Quality Improvement
Neil Houston
GP Clinical Lead SPSP – PC
Associate Adviser NES
Aims
•
•
•
•
What is QI
A method of how to do it
Develop your own ideas
Preparing for the real world
Insanity: doing the same thing
over and over again and
expecting different results.
Albert Einstein, (attributed)
US (German-born) physicist (1879 - 1955)
What is QI?
“the combined and unceasing efforts of everyone—healthcare
professionals, patients and their families, researchers,
payers, planners and educators—to make the changes that
will lead to:
better patient outcomes
better system performance
better professional development”
Healthcare will not realise its full potential
unless change making becomes an
intrinsic part of everyone’s job, every day,
in all parts of the system.
Doing the work and working on the work
The Model for Improvement
‘This model is not magic, but it is
probably the most useful single
framework I have encountered in
twenty years of my own work on
quality improvement’
Dr Donald M. Berwick
Former Administrator of the Centres for Medicare &
Medicaid Services
Professor of Paediatrics and Health Care Policy
at the Harvard Medical School
Question 1: What are we trying to accomplish?
Aim Statements
Specific
Measurable
Achieveable
Realistic
Timely
“I want to be seen at or near to
my appointment time”
Aims
95% of patients attending the Opthalmology outpatient
department at Forth Valley Royal Hospital will be seen by a
clinician within 15 minutes of their appointment time by
October 2016
Developing an Aim
Statement
Team name:
Aim statement
You should review your Aim Statement frequently to make sure
it is consistent and that everyone involved with the initiative
has a common understanding of what is to achieved.
How will this be measured ?
By when?
“In God we trust.
All others bring
data.”
W. E. Deming
Change vs Improvement
Of all changes I’ve observed, only
about 5% were improvements, the
rest, at best, were illusions of progress
W. Edwards Deming
Why are we measuring?
Judgement
The answer to this question will guide our entire
measurement journey
Measurement for judgement
% waiting over 4 hours in A&E
England by week 2003/04
25.00
20.00
target
15.00
10.00
35
33
29
27
25
23
The week
Trusts were
measured for
performance
ratings
21
19
17
15
13
11
9
7
5
3
1
51
49
47
45
43
41
39
37
35
0.00
31
5.00
So why measure?
• To enable us to ‘see’ how we are doing
• To enable us to ‘see’ the variation that lives in
our daily processes
• To tell us whether we are getting closer to our
aims?
• What are we doing well? Why
• What are we not doing so well? why?
Three Types of Measures
Outcome Measures: Voice of the customer or patient. How is the
system performing? What is the result?
Warfarin Control – Reduction in number of strokes
Process Measures: Voice of the workings of the system. Are the
parts/steps in the system performing as planned?
Warfarin – are patients in therapeutic range and appear for bloods
tests
Balancing Measures: Looking at a system from different
directions/dimensions. What happened to the system as we
improved the outcome and process measures? (e.g. unanticipated
consequences, other factors influencing outcome)
Warfarin – number of blood tests taken
What could you measure?
”
• Patients will be seen within 15 minutes of their
appointment time
• Data for average time after appointment time that patients
are called into the clinicians room
• How
• IT
• Observation
• Questionnaire
What could you measure
How often should you measure?
We have 2 quarterly data points – is this an improvement?
Executive Time Series
Something Important
100
80
60
40
20
0
Higher is
better
J
F
M
A
M
J
J
Months
A
S
O
N
D
Are we assuming something like this?
Executive Time Series - linear trend
Something Important
100
80
60
40
20
0
J
F
M
A
M
J
J
Months
Measurement for Improvement
A
S
O
N
D
But it could be like this ...
Executive Time Series - no trend
Something Important
100
80
60
40
20
0
J
F
M
A
M
J
J
Months
Measurement for Improvement
A
S
O
N
D
Or this ...
Executive Time Series - seasonal dip
Something Important
100
80
60
40
20
0
J
F
M
A
M
J
J
Months
A
S
O
N
D
Or this!
Executive Time Series - one month blip
Something Important
100
80
60
40
20
0
J
F
M
A
M
J
J
Months
A
S
O
N
D
PLOT Data over time
Run chart
• A run chart is the simplest of charts. It is a single line
plotting some value over time. A run chart can help
you spot upward and downward trends and it can
show you a general picture of a process.
RUN CHART RULES (RCRs)
The key rules indicating special cause variation are:
Measure or Characteristic
Rule 1: SHIFT
A shift in the process is six or more consecutive points either all above or all
below the median line. Values that fall on the median line do not count
towards or break a shift – skip values on the median and continue counting.
Rule 1
25
20
15
10
5
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
How big a sample?
Little and often
What would your measurement
plan look like ?
What changes are
to be made?
Next cycle?
Compare/analyse
data, Summarise
learning
Aim & plan the cycle
(who, what, when &
how)
Carry out the plan
Document problems
Anyone for tennis?
Instructions
• At your tables 6 - 9 people
• Assign a time keeper
• Assign a number to each of the other people at your
table
Break out Exercise
• Your current process involves tossing the tennis ball
(provided) from person to person, following the sequence
provided on the next slide
Practice your process one time
Time keeper please:
• Time how long the team takes to complete the process (in
seconds)
•The number of times they drop the tennis ball
Exercise Sequence
9 people
8 people
•6 people
5 people
1
3
1
4
4
8
3
2
5
1
1
6
3
4
1
7
5
2
1
5
7 people
4
6
2
5
1
1
3
7
5
2
6
1
9
3
7
2
6
4
8
1
Time?
Drops?
How low can you get?
Break out Exercise
Team Aim: We aim to reduce the time taken for every person
to touch the ball in sequence.
We also aim to reduce our ball drops
Rules:
• The initial sequence as provided must be adhered to
• You may only test one change idea at a time
• Record the time and ball drops after each change
Exercise Sequence
•9 people
•8 people
•7 people
•6 people
•5 people
1
4
8
7
3
6
3
2
4
1
3
5
2
1
1
4
4
5
5
1
1
6
2
5
1
1
3
7
5
2
6
1
9
3
7
2
6
4
8
1
How did you get on ?
Fastest Time ?
Breakthrough Changes?
What changes are
to be made?
Next cycle?
Compare/analyse
data, Summarise
learning
Aim & plan the cycle
(who, what, when &
how)
Carry out the plan
Document problems
Building Knowledge with PDSA Tests
Breakthrough
Results
A P
S D
Wide-scale tests
of Change
Tests under new conditions
(Quantitative data)
A P
Hunches,
Theories,
Best
Practices
S D
Follow-up Tests
Very Small Scale Test
(Qualitative/Quantatiative Data)
Improvement Guide, Chapter 7, p. 146
A typical approach
Reinertsen JL, Bisognano M, Pugh MD. Seven Leadership Leverage Points for
Organization-Level Improvement in Health Care (Second Edition). Cambridge,
Massachusetts: Institute for Healthcare Improvement; 2008. Available:
www.ihi.org p26
An Applied Science Approach
Reinertsen JL, Bisognano M, Pugh MD. Seven Leadership Leverage Points for
Organization-Level Improvement in Health Care (Second Edition). Cambridge,
Massachusetts: Institute for Healthcare Improvement; 2008. Available: www.ihi.org p26
You can only learn as quickly as you
test.
The Value of “Failed” Tests
“I did not fail one
thousand times; I found
one thousand ways
how not to make a light
bulb.”
Thomas Edison
Start
• 1 patient
• 1 day
• 1 admission
• 1 clinician
Small
PDSA - Improve Compliance of Patients Attending Monthly Blood Monitoring
Ensure patients prescribed Methotrexate or
Azathoprine attend a monthly review for
blood monitoring
Patients complying by attending blood
monitoring will increase
Using a variety of engagement methods
Patients engaging
5 Stop repeat prescription until
they attend
4 Restrict the amount of repeat prescription
available to them to encourage attendance
3 Put a note on patients repeat prescription
2 Send information stating reasons for why it is important to attend
1 Invite patients who have
failed to comply by telephone
PATIENT SAFETY IN PRIMARY CARE WHY BOTHER?
• Adverse events in primary care cause:
– 1 in 20 deaths in hospital
– 6.7% of admissions linked to adverse reaction to
medication
– 4% of hospital bed capacity
– 1-2% of consultations in Primary care have
potential for harm
To Err is Human 1999
Howard et al Br J pharmacology 2006
Zhang et al BMJ 2009
Howard et al qshc 2003
Process mapping
How are you going to go back and engage
with your team?