Learning by Doing: Linking Quality Improvement Theory and

PracticeBoel Andersson Gäre, MD, PhD, Professor

Johan Thor MD, MPH, PhD, Director

The Jönköping Academy for Improvement of Health and Welfare

Jönköping University, Sweden

Who are you?

• Health professionals

• Researchers and teachers

• Students

• Managers

• Policy makers

• Quality professionals

• Others

Better systemperformance

(quality, safety, value)

Everyone

Batalden P, Davidoff F. What is ”quality improvement” and how can it transform healthcare?Qual.Saf.Health Care 2007;16;2-3

Better outcomes(individual, population)

Better professional

development(competence, values,

pride, joy)

Batalden & Stoltz, 1993, after Deming.

Multiple knowledge systems are involved…

Generalizable

scientific

evidence

+Particular

context

Measured

performance

improvement

control for

contextinquire into

particular

identity

balanced

measures

over time

choosing

best

plan

executing

locally

Batalden & Davidoff, 2007

A Model for Improvement

1. What are we trying to accomplish? (Aim)

2. How will we know if a change is an improvement? (Measurement)

3. What changes can we make that will result in improvement?

P

S D

A

Plan-Do-Study-Act

Langley GJ, et al. The Improvement

Guide: a Practical Approach to

Enhancing Organizational

Performance. 2nd ed. San

Francisco: Jossey-Bass; 2009.

Case: what do they need to know?

Two clinical managers – a head nurse and a physiotherapist – work with hip and knee arthroplasty care Helena Sundquist, RN Sofia Persson, PT

Värnamo

Hospital

Case: what do they need to know?

• The managers wish to reduce the (unusually long) Length of Stay (LOS) for these patients* – to enhance efficiency and reduce the risk of complications – while maintaining the good clinical outcomes and high patient satisfaction at their hospital

• How should they go about achieving that?

* Hip replacement LOS 7.9 days (national average 6 days, range 3-9 days);

knee replacement LOS 8.4 days (national average 5 days, range 3-9 days)

The Jönköping Master’s Program on Quality Improvement and Leadership in Health and

Welfare Services

The purpose of the program is to contribute to improvement in health, healthcare and social care.

The Master’s program is intended to strengthen participants’ ability to lead and achieve improvement of health and social care leading to gains in health and welfare as well as good economizing of resources.

1. Health care

as process,

system.

2. Variation and

measurement.

3. Customer /

Beneficiary

knowledge.

4. Leading,

following and

making changes

in health care.

5. Collaboration.

6. Social

context &

accountability.

7. Developing

new locally

useful

knowledge.

8. Professional

subject matter.

Institute for Healthcare Improvement, IHI, (www.ihi.org), 1998

Magister- masterprogrammet

Improvement Knowledge I

(5 ECTS)

Drivers &

Sources of

Inspiration for

QI (5 ECTS)

Perspective of

the Patient/

Client

(5 ECTS)

Systems thinking; Organizing,

Leadership and Management

(10 ECTS)

Spring (January-June)Fall (August-January)Ye

ar

1Ye

ar

2Ye

ar

3 Practicum (30 ECTS)

Completion of 2-year Master’s Thesis (30 ECTS)

Project planning

(7,5 ECTS)

1-year Master’s thesis

(15 ECTS)Quality,

Measurement,

and Learning

(7,5 ECTS)

Care Logistics

& Informatics

(7,5 ECTS)

1-year Master students

Improvement Knowledge II

(5 ECTS)

Electives

(7,5 ECTS)

�1-year Master’s Degree

2-year Master students

�2-year Master’s Degree

2-year Master students

Design Principles for the Master’s Program

• Action learning

• Interprofessional interaction

• ”Blended” learning

• Reflection

• Writing

Action and Learning

“If you want truly to understand something, try to change it”

Kurt Lewin (1890-1947)

Concrete experience

Observations and

reflections

Notice

Formation of abstract

concepts and generalizations

Make

senseImplications

for setting,

context

Testing implications

of concepts in new

situations

Anticipate

requisite

assessment

David Kolb

Action Learning

Design Principles for the Master’s Program

• Action learning – linking theory and practice

• Interprofessional collaboration

• ”Blended” learning

• Reflection

• Writing

Nurses

Physiotherapists

Occupational

therapists

Physicians

Biomedical analysts

Social workers

Finance people

Web designer

Engineers

Psychologists

Dentist

Managers

Working Groups

Self-selected based on the following criteria:

• 5-7 members/group

• Both sexes

• At least 2 professions represented

• Members born in at least two different decades

Blended Learning

• Campus sessions: 2 days every 5 weeks

• Synchronous sessions over the web

• Asynchronous distance learning: readings and assignments carried out ”at home”

• Combine with regular work in health or social care

The value of reflection

“Reflection is the process of stepping back from experience to process what the experience means, with a view to planning further action [ref.s]. It is the critical link between concrete experience, the interpretation and taking new action.”

Coghlan D, Brannick T. Doing action research in your own organization. London:

SAGE; 2001, p. 31.

Design Principles for the Master’s Program

• Action learning – linking theory and practice

• Interprofessional collaboration

• ”Blended” learning

• Reflection

• Writing

Nurses

Physiotherapists

Occupational

therapists

Physicians

Social workers

Finance people

Web designer

Engineers

Psychologists

Dentist

Managers

EXEMPLARY CARE AND LEARNING SITES (ECLS)

Starting early to introduce improvement knowledge in health professional education and training

can both be excellent?

if we deliver better care, are we delivering better education?

if we deliver excellent education, does care improve?

how are these concepts linked?

complementary concepts?

learning care delivery

An ECLS produces patient-centered care in a way that continuously improves patient outcomes, system performance,& professional developmentHeadrick LA, Shalaby M, Baum KD, Fitzsimmons AB, Hoffman KG, Höglund PJ, Ogrinc G, Thörne K. Acad Med. 2011 Nov;86(11):e6-7.

Futurum – the Academy for Health and Care

Jönköping County Council hosts:• Students from 14 different professions• from 5 different universities• providing 8000 ”student weeks” yearly of

practice based learning

Exploration, improvement and learning!

- Students in improvement work

Pilot project, Geriatric ward, Jönköping, Jönköping County Council, Sweden

Pär Höglund, MD, PhDDaniel Gustafsson, MD (resident), Student supervisor, Geriatric ward

Intended goals

• To help 5th year medical students to gain knowledge of the logistics and the situation outside the hospital for senior patients.

• To present at least three improvement suggestion to the ward.

The Geriatric project

-documentation and reflection around the discharge of Roy

Maria Lorentz and Jakob Ström, Med School Year 5, Linköping, Sweden

Photo

Who is Roy?

• Previously a well-functioning individual • Fall injury four months ago, head/neck

injury• Been hospitalized since his injury• Roy feels constant pain, primarily in his

neck

Discharge planning the day before

• 13.30-13.40: Nurse to Nurse phone report from Geriatric ward to a short term nursing home

• 13.45-13.48: A nurse visits Roy and his wife to inform about a transfer tomorrow to the nursing home

11.0

7-11

.26

Assisted transport to the nursing home

Time line – the day of discharge10

.30-

10.4

5

Packing his belongings, the RN does som last-minute checking

11.2

7-12

.05

Introduction to the nursing home by CNA

12.1

4-12

.20

RN talks to wife about medications, and nurse student talks with Roy

12.2

0-12

.26

RN chitchats with Roy.

The students’ presentation at the doctors’ morning meeting

The Good Parts

• Nurse to Nurse phone report. The template seems ok (but could be more structured)

• RN preparations the day before• RN checklist with admission paper that

should be sent to the nursing home• Friendly reception at the nursing home

and short waiting time for the RN

Improvements suggestions

• Template for the RN final discharge meeting and/or discharge meeting with the physician– Additional information to the patient and their family,

about for instance future planning

• Short written notice from the doctor to the patient about what the patient has been treated for, follow up etc.– Information useful for the family.– Information may increase adherence?– Time requirement 3 minutes

How did the clinic benefit from the project?

• Illuminates the students’ capacity• Additional knowledge about nursing

homes• Specific improvements areas and project

were discussed (also during coffee breaks the following week)

• Suggestion from the doctors about other areas to explore and improve.

What was in it for the student(s)?

• Had a purpose – will be used in the clinic• Expectations from the doctors• A great deal of positive feedback – both on

the content and on the presentation.• Will be remembered after medical school • Knowledge about the logistics and

cooperation between the county and muncipality.

Integration?

Based on these examples and models, what are your thoughts about how to integrate* research, quality improvement, and implementation of evidence-based practice, student involvement and cultural change?

*Integration: the combining and coordinating of separate parts or elements into a unified whole (Merriam-Webster, Medical Definition of ~)

MAKING IMPROVEMENT AND STUDYING IMPROVEMENT

Improvement Science in Practice

Improvement Science

• Making improvement is not the same as studying improvement, but they have a generative relationship

• Improvement science is an emerging field

• Learn more about the evolution of this field at the Health Foundation: http://www.health.org.uk/areas-of-work/improvement-science/

Improvement Knowledge I

(5 ECTS)

Drivers &

Sources of

Inspiration for

QI (5 ECTS)

Perspective of

the Patient/

Client

(5 ECTS)

Systems thinking; Organizing,

Leadership and Management

(10 ECTS)

Spring (January-June)Fall (August-January)Ye

ar

1Ye

ar

2Ye

ar

3 Practicum (30 ECTS)

Completion of 2-year Master’s Thesis (30 ECTS)

Project planning

(7,5 ECTS)

1-year Master’s thesis

(15 ECTS)Quality,

Measurement,

and Learning

(7,5 ECTS)

Care Logistics

& Informatics

(7,5 ECTS)

1-year Master students

Improvement Knowledge II

(5 ECTS)

Electives

(7,5 ECTS)

�1-year Master’s Degree

2-year Master students

�2-year Master’s Degree

2-year Master students

The Jönköping Master’s Program

Improving and Studying

• How did you improve what you improved?

• How did you study (inquire into, reflect upon, measure) the improvement process, outcomes?

Paul Batalden, 2012

SQUIRE Guidelines(Standards for QUality Improvement Reporting Excellence)

A. Clear and accurate information for finding, indexing, and scanning your paper?1) Title2) Abstract

B. Why did you start? (I)3) Background knowledge4) Local problem5) Intended improvement6) Study question

C. What did you do? (M)7) Ethical issues8) Setting9) Planning the intervention

C. What did you do? (cont’d)10) Planning the study of the intervention11) Methods of evaluation12) Analysis

D. What did you find? (R)13) Outcomes

E. What do the findings mean? (D)14) Summary15) Relation to other evidence16) Limitations17) Interpretation18) Conclusions

F. Were other factors relevant to conduct and interpretation of the study?

19) Funding

See: www.squire-statement.orgDavidoff F, Batalden P, Stevens D, Ogrinc G, Mooney S. Publication guidelines for

quality improvement in health care: evolution of the SQUIRE project. Quality &

Safety in Health Care. 2008 Oct;17 Suppl 1:i3-9.

The improvement project and the study of the project

IMPROVEMENT

PROJECT

Improvementleader/author

•planning•organizing

Patients•interviews•feedback

•touch points

Staff•interviews•feedback

•touch points

Co-designgroup•meeting

•touch points•planning

improvements

Co-designteam

•follow-upmeetings

Co-designteam

follow-upmeetings

Co-designgroup•reunion

•reporting•celebration

The

STUDY

ofthe

IMPROVEMENT

Experiencequestionnaires

Experiencequestionnaires

Experiencequestionnaires

Experiencequestionnaires

Experiencequestionnaires

Focus group interview

Concludingquestionnaire

Bergerum C, 2012

Back to the Athroplasty ProjectProportion

of patients

who got up

on their legs

on the day

of surgery

Better systemperformance

(quality, safety, value)

Everyone

Batalden P, Davidoff F. What is ”quality improvement” and how can it transform healthcare?Qual.Saf.Health Care 2007;16;2-3

Better outcomes(individual, population)

Better professional

development(competence, values,

pride, joy)

Name, occupation/job, location

The Mission of Jönköping Academy

To promote health and welfare by providing and helping put to good use knowledge on improvement and leadership within health and social care. The Jönköping Academy undertakes education and research through collaboration between university, health and social care partners. Decision-makers and staff in health and social care constitute the Academy's primary audience.

www.jonkopingacademy.se