Quality Quality Improvement Improvement

MethodsMethodsGreg Randolph, MD, MPHGreg Randolph, MD, MPH

Healthcare Quality Healthcare Quality DefinedDefined

 ” ”The degree to which health The degree to which health services for individuals and services for individuals and

populations increase the populations increase the likelihood of desired health likelihood of desired health

outcomes and are consistent with outcomes and are consistent with current professional knowledge.”current professional knowledge.”

--Institute of Medicine, 2001--Institute of Medicine, 2001

ExerciseExercise In pairs, define Quality In pairs, define Quality

Improvement (3 minutes)Improvement (3 minutes) Be prepared to share (2 Be prepared to share (2

minutes)minutes)

UNC Pediatrics Residency UNC Pediatrics Residency QI Program QI Program

“A systematic approach of measuring and identifying gaps between actual and desired quality of care and applying tools and improvement methods (e.g., PDSA cycles) to make changes to the system that result in measurable improvements (i.e., closing the gap)”

Quality Improvement Quality Improvement FocusFocus

Patient-centeredPatient-centered - care that is responsive to - care that is responsive to patient preferences, needs, valuespatient preferences, needs, values

EffectiveEffective - providing services based on - providing services based on scientific knowledge to all who could benefit scientific knowledge to all who could benefit and refraining from providing to those not and refraining from providing to those not likely to benefit likely to benefit

EquitableEquitable - providing care that does not vary - providing care that does not vary in quality because of personal characteristicsin quality because of personal characteristics

TimelyTimely - reducing waits and delays for care - reducing waits and delays for care EfficientEfficient - avoiding waste - avoiding waste SafeSafe - avoiding injuries to patients from care

--Institute of Medicine, 2001--Institute of Medicine, 2001

Fundamental Questions for Fundamental Questions for ImprovementImprovement

What are we trying to What are we trying to accomplish?accomplish?

How will we know that a How will we know that a change is an improvement?change is an improvement?

What changes can we make that What changes can we make that will result in an improvement?will result in an improvement?

Model for ImprovementModel for Improvement AimAim

MeasuresMeasures

Ideas/Change Ideas/Change ConceptsConcepts

What are we trying to accomplish?

How will we know that changes are an improvement?

What changes can we make that will result in

an improvement?

Model for ImprovementModel for Improvement

AIMAIM: : What are we What are we trying to accomplish?trying to accomplish?

MEASURESMEASURES:: How will we know that How will we know that changes are an changes are an improvement?improvement?

IDEASIDEAS:: What changes can What changes can we make that will result in we make that will result in an improvement?an improvement?

What is an Aim Statement?What is an Aim Statement?

AimAim:: A written statement of the A written statement of the accomplishments expected accomplishments expected

from from improvement effortimprovement effort

Key components:Key components: A general description of aim - should answer, “what are A general description of aim - should answer, “what are

we trying to accomplish?”we trying to accomplish?”

Rationale/importance Rationale/importance

Some guidance for carrying out the work Some guidance for carrying out the work

Specify target population and time periodSpecify target population and time period

Measurable goalsMeasurable goals

Goals Should Be:Goals Should Be:

MeasurableMeasurable NumericNumeric Preferably absolute rather than Preferably absolute rather than

relative relative

A stretch, not business as usualA stretch, not business as usual Achievable, not impossibleAchievable, not impossible

ExerciseExercise In pairs, critique aim In pairs, critique aim

statement – are key statement – are key components present (3 components present (3 minutes)minutes)

Then pick a problem and write Then pick a problem and write your own (5 minutes)your own (5 minutes)

Be prepared to share (2 Be prepared to share (2 minutes)minutes)

Model for ImprovementModel for Improvement

AIMAIM: : What are we trying to accomplish?What are we trying to accomplish?

MEASURESMEASURES: : How will we know that How will we know that changes are an changes are an improvement?improvement?

IDEASIDEAS: : What changes can we make What changes can we make that will result in an that will result in an

improvement?improvement?

Project MeasuresProject Measures

Goal

Project MeasuresProject Measures

The question: The question: How will we know that a How will we know that a change is anchange is an improvement? - improvement? - usually requires usually requires more than one measure. more than one measure.

A balanced set of measures helps assure that A balanced set of measures helps assure that the the systemsystem is improved: is improved: Related to aim’s measurable goalsRelated to aim’s measurable goals

Easy to collectEasy to collect

Show improvement quickly and include outcomesShow improvement quickly and include outcomes

Can display them graphically over timeCan display them graphically over time

Run charts Run charts

Balancing MeasuresBalancing Measures

Are we improving parts of our Are we improving parts of our system at the expense of others? system at the expense of others?

Usually not one of goalsUsually not one of goals

Great source is to listen to Great source is to listen to skeptics… “Yes, but…”skeptics… “Yes, but…”

Example of Measure SetExample of Measure Set

The delay for routine appointmentsThe delay for routine appointments

% of patient visits with the patient’s primary % of patient visits with the patient’s primary clinician clinician

Practice average cycle timesPractice average cycle times

% of patients rating the overall visit as excellent % of patients rating the overall visit as excellent

% of visits that are “no show/missed”% of visits that are “no show/missed”

Usual Display of Usual Display of MeasuresMeasures

0102030405060708090

100

Imm Rate

Before

After

QI Measures: Annotated QI Measures: Annotated Run ChartsRun Charts

Reduced appt

delays

Reminder system

Practice wide guidelines

Clinician education

Model for ImprovementModel for Improvement

AIMAIM: : What are we trying to What are we trying to accomplish? accomplish?

MEASURESMEASURES: How will we know that : How will we know that change is change is an improvement? an improvement?

IDEASIDEAS: : What changes can we make What changes can we make that will result in that will result in

an an improvement?improvement?

““PDSA Cycles”PDSA Cycles”

PDSA Cycles help teams adapt good PDSA Cycles help teams adapt good ideas to their specific situation:ideas to their specific situation: Force us to think smallForce us to think small

Force us to be methodical, make Force us to be methodical, make predictionspredictions

Allow rapid adaptation and Allow rapid adaptation and implementation of changes in busy implementation of changes in busy healthcare settings healthcare settings

The PDSA Cycle

Act Plan

• What changes are to be made?

• Next cycle?

• Objective• Questions and

predictions • Plan to carry out the

cycle (who, what, where, when)

Study Do• Complete the

analysis of the data• Compare data to

predictions•Summarize what was learned

• Carry out the plan• Document problems

and unexpected

observations

Example PDSA Cycle

Changes to bemade: Test 2 more days- Dr. R on time; nurse to bring charts for prescheduled

Objective: Test huddlesQuestions: Will they uncover capacity? Prediction: Yes Plan: Dr. R care team, huddle 5 mins in AM for 2 days at schedule

4 unused visits identified; took 15 minutes due to late arrivals; charts would be helpful

Mon and Tues - document problems, Unexpected observations; count uncovered capacity

Act Plan

Study Do

Key Points for PDSA CyclesKey Points for PDSA Cycles

Do initial cycles on smallest scale possibleDo initial cycles on smallest scale possible

Think baby steps…a “cycle of one” usually bestThink baby steps…a “cycle of one” usually best ““Failed” cycles are good learning opportunities when Failed” cycles are good learning opportunities when

small small

Successful testsSuccessful tests

As move to implementation, test under as many As move to implementation, test under as many conditions as possibleconditions as possible

Special situations (e.g., busy days)Special situations (e.g., busy days)

Factors that could lead to breakdowns (e.g., different staff or Factors that could lead to breakdowns (e.g., different staff or physicians involved)physicians involved)

Things “naysayers” worry about (e.g., “It will not work when Things “naysayers” worry about (e.g., “It will not work when Dr. Noonan is not here”)Dr. Noonan is not here”)

Questions?Questions?