6quality Improvement Gimbel

7/28/2019 6quality Improvement Gimbel

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INTRODUCTION TO QUALITY

IMPROVEMENT TOOLS:CHANGING PROCESSES TOIMPROVE OUTCOMES

Sarah Gimbel

Seattle, WAJuly 2011

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From Industry: Lean Methodology

Within healthcare services the core idea is tomaximize patient value while minimizingwaste

Lean approach changes the focus ofmanagement from optimizing separate

technologies, assets, and vertical departmentsto optimizing the flow of products and servicesthrough entire system

Map out processes and identify value and non-

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Lean Some Key Principles

Base decisions on long-term philosophy at theexpense of short term financial goals

Create continuous flow to bring problems to thesurface

Level out the work load

Standardized tasks and processes are the

foundation for continuous improvement andem lo ee em owerment

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Improvement: Process Mapping &

PDSAEvery process is perfectly designed toget

the results it gets-Paul Batalden

The Three Questions:

What are we trying to accomplish?How will we know that a change is an

improvement?

What changes can we make that will result in an

improvement?


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Process Mapping

Whenever there is a health outcomefor a patient, there is a process.

Our challenge lies in seeing it.

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What is Process Mapping? (aka: Value Streammapping)

Its a tool used to identify value and reduce

waste (muda)

Muda?Muda is the Japanese word for waste. But not

waste defined in a traditional way. Waste isanything that does not provide value to thepatient, for example: waiting, travel,misdiagnosis, stock-outs

Process Mapping?7


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How does Process Mapping help?

Problem Identification

Generating Solutions

Test

Disseminate

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Benefits of Process Mapping

Puts a spotlight on waste

Streamlines work processes

Defines and standardizes the steps and sequence

Promotes deep understanding Builds consensus

Key tool for continuous quality improvement

Process Mapping can help us reach our goals ofimproving health outcomes by improving quality

through increased communication between health

facility managers and staff

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Look for areas for improvement

Is the process standardized, or are the peopledoing the work in different ways? Eg. Prenatalcare

Are steps repeated or out of sequence?

Are there steps that do not add value to theoutput?

Are there steps where errors occur frequently?

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map

An example from Mozambique

We chose to map the flow of patientswho had been identified as HIV+ and

were referred to the HIV/AIDStreatment clinic for assessment. Wefollowed these patients through their

care pathway as they received careand treatment for the HIV/AIDSinfection.

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Step 2: Collect information & create acurrent process map

The process as it currently exists

Starting when the HIV positive patient comes to theclinic and the patient is registered by the

receptionist we followed the path that each patienttakes. We talked to the staff responsible at eachpoint. Detailed note taking is necessary.

Next, we draw the map first by hand and then onthe computer.

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Process Mapping the Initial Workflow

HIV Positive

Patient comes

to Clinic

Enrollment

Process

with RN

Patient

scheduled

to see MD

Registration

Process with

Receptionist

Patient

returns to

clinic for

appointment

Patient

registers

Pt has

access to

ARVs?

Intervention: Counselling

CD4 test not

ordered

Intervention:

Counselling

CD4 testing

ordered

Lab

open?

Yes

NoNo

Yes

Patient

scheduled

for CD4

count

Blood for CD4

count drawn

Patient

schedules

appointment to

review results of

CD4 count

Patient

returns to lab

for

appointment

Patient

returns to

clinic forappointment

Patient

registers

Patient seen

by Physician

Patient seen

by Physician

Treatment

plan is

developed.

CD4 count

reviewed with

patient, and

significance

explained.

Patient Leaves Clinic



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local managers and frontline healthprofessionals

Assessing the current process map with the goal of improvingpatient flow by looking for steps that:

i) Definitely add valueii) Add no value, but are unavoidable

iii) Add no value, but are avoidable(Source: Womack and Jones)

After making a process map, the next day we return

to the health center and discussed it with health workers toensure its accuracy. Together we consider how the mapcould be used to make improvements to the system.

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Process Mapping: Potential Areas forImprovement

HIV Positive

Patient comes

to Clinic

Enrollment

Process

with RN

Patient

scheduled

to see MD

Registration

Process with

Receptionist

Patient

returns to

clinic for

appointment

Patient

registers

Pt has

access to

ARVs?

Intervention: Counselling

CD4 test not

ordered

Intervention:

Counselling

CD4 testing

ordered

Lab

open?

Yes

NoNo

Yes

Patient

scheduled

for CD4

count

Blood for CD4

count drawn

Patient

schedules

appointment to

review results of

CD4 count

Patient

returns to lab

for

appointment

Patient

returns to

clinic forappointment

Patient

registers

Patient seen

by Physician

Patient seen

by Physician

Treatment

plan is

developed.

CD4 count

reviewed with

patient, and

significance

explained.




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Change

Create future process map and work towards it byimplementing tests of change. (Plan-Do-Study-Actor PDSA cycles)

Use the map and the data as a guide to figureout where change can be most effective. Trackchanges in indicators to determine the effects ofthe change as the process moves forward

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The PDSA CycleTesting Changein a Real World Setting

Plan: Design workflow changes;

Identify tools to support the newworkflow;

Decide what to measure & how

Do: Implement plan

Study: Look at what wasmeasured; figure out what itmeans

Act: Fix the things didnt work the

first time and retest until it works

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Step 5: One PDSA Cycle isnt


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Step 5: One PDSA Cycle isntenough (continuous quality

improvement)The cycles are linked for continuousimprovement

*Langley GL, Nolan KM, Nolan TW, Norman CL, ProvostLP. The Improvement Guide: A Practical Approach to

Enhancing Organizational Performance.**The Plan-Do-Study-Act cycle was developed by W.

Edwards Deming (Deming WE. The New Economics for

Industry, Government, Education.).20
http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Literature/The+Improvement+Guide+A+Practical+Approach+to+Enhancing+Organizational+Performance.htmhttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Literature/The+Improvement+Guide+A+Practical+Approach+to+Enhancing+Organizational+Performance.htmhttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Literature/NewEconomicsforIndustryGovernmentEducation.htmhttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Literature/NewEconomicsforIndustryGovernmentEducation.htmhttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Literature/NewEconomicsforIndustryGovernmentEducation.htmhttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Literature/NewEconomicsforIndustryGovernmentEducation.htmhttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Literature/The+Improvement+Guide+A+Practical+Approach+to+Enhancing+Organizational+Performance.htmhttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Literature/The+Improvement+Guide+A+Practical+Approach+to+Enhancing+Organizational+Performance.htm


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Process Mapping/PDSA Steps

Current State

Future State

Next Future State

Original State


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PDSA Cycle in Beira, Mozambique

What were we trying to accomplish?All HIV positive patients would have a CD4 count

within 1 month of presenting to the clinic

How would we know that a change was animprovement?

The percent of patients with CD4 count would risefrom 10% and approach 100%

What changes could we make that would resultin an improvement?

Remove barriers to testing

Remove non-value added steps from the workflow

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Steady enrollment growth

Adults enrolled each month

0

100

200

300

400

500

600

700

Feb

-03

May-03

Aug-03

Nov-03

Feb

-04

May-04

Aug-04

Nov-04

Feb

-05

May-05

Aug-05

Nov-05

Feb

-06

May-06

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Outcome of a process perfectly


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Outcome of a process perfectlydesigned get 10% CD4 Testing

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Remove the barrier

HIV Positive

Patient comes

to Clinic

Enrollment

Process

with RN

Patient

scheduled

to see MD

Registration

Process with

Receptionist

Patient

returns to

clinic for

appointment

Patient

registers

Intervention:

Counselling

CD4 testing

ordered

Lab

open?

No

Yes

Patient

scheduled

for CD4

count

Blood for CD4

count drawn

Patient

schedules

appointment to

review results ofCD4 count

Patient

returns to lab

forappointment

Patient

returns to

clinic for

appointment

Patient

registers

Patient seen

by Physician

Patient seen

by Physician

Treatment

plan is

developed.

CD4 count

reviewed with

patient, and

significance

explained.




Value

Added Step

Value

Added Step Value

Added Step

Non-Value

Added Step

Non-Value

Added Step

Non-Value

Added Step Non-Value

Added Step

Value

Added StepValue

Added Step

Non-ValueAdded Step

Non-Value

Added StepNon-Value

Added Step

Value

Added Step

Non-Value

Added Step

Non-Value

Added Step

Non-ValueAdded Step

Non-Value

Added Step ValueAdded Step Value

Added Step

Value

Added Step28


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Outcome after ART barrier isremoved

% with CD4


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Task shift CD4 ordering to nurses

HIV Positive

Patient comes

to Clinic

Enrollment

Process with

RN

Patient

scheduled

to see MD

Registration

Process with

Receptionist

Patient

returns to

clinic for

appointment

Patient

registers

Lab

open?

No

Yes

Patient

scheduled

for CD4

count

Blood for CD4

count drawn

Patient returns

to lab for

appointment

Patient seen by

Physician

Treatment plan

is developed.

Intervention:

Counselling

CD4 count reviewed with

patient,significance explained.


RN orders

CD4 Count

Blood for CD4

count drawnPatient Leaves Clinic

Value

Added Step

Value

Added Step ValueAdded Step

ValueAdded Step

ValueAdded Step

Value

Added StepValue

Added Step

Value

Added Step

Non-Value

Added Step

Non-Value

Added Step

Non-Value

Added Step

Non-Value

Added Step

Non-Value

Added StepNon-Value

Added Step

Non-Value

Added Step

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Outcome after CD4 count orderis automatic

% with CD4


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What would Toyota do?

HIV Positive

Patient comes

to Clinic

Enrollment

Process

with RN

Registration

Process with

Receptionist

includes

order for CD4

count

Patient seen

by Physician

Treatment

plan is

developed.

Intervention:

Counselling

CD4 count reviewed with

patient,significance

explained.

Rapid CD4

Drawn On-Site

Result of

CD4 returns

Value

Added Step

Value

Added Step Value

Added Step

Value

Added StepValue

Added Step

Value

Added Step Value

Added Step

Value

Added Step

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QUESTIONS?

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OR course, MOH, Dili, Timor Leste, 11/2010

6quality Improvement Gimbel

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