Introduction to
Quality Improvement in
Health Care
Kevin C. Shannon, MD, MPH, FAAFP
Associate Professor
Department of Family Medicine
Loma Linda University
Who am I (professionally)?
•
•
•
•
•
•
•
From northern Illinois, so:
Wheaton/U of IL (MD/MPH)
But then Karen, so Brown U.
FQHCs: Lawrence, MA & Chicago, IL (~ QI)
Academics U of IL (~ QI) / Dartmouth *QI
Missions: Kenya (academics/med dir) *QI
Public Health: Uganda *QI
Common Progression
•
•
•
•
Intern: “I can’t kill a patient!” (afraid)
2nd year: “I can’t kill a patient!” (overconfident)
Senior resident: “The system is broken!”
First year in practice: “It’s me, It’s me, O Lord,
standing in the need of prayer – for the buck
stops with me!”
• A couple years into practice: “The system is
broken!”
Three Attitudes Toward Systems
1. Kermudgeon (Maureen)
2. Changer (Kevin)
3. Laid Back (Karen)
• Pick (2) or (3) – for your benefit and the
benefit of your patients and staff
“Every system is perfectly designed
to get the results it gets”
• So… the challenge for change agents:
understand a system well enough to
accurately guess what aspect of the system
needs changing to accomplish the
improvement desired
Natural Course of a QI Project:
• Form an Improvement Team
• Assess your system:
5 P’s: Purpose, People, Professionals,
Processes, Patterns
• Diagnose
Based on assessment, identify your
general theme for improvement, and then
choose a specific AIM
• Treat
Choose measures and changes
(Innovation)
Start improving, using PDSA cycles (Pilot –
Intervention – Spread)
The Model for Improvement
What are we trying
to accomplish?
Aim
How will we know that a
change is an improvement ?
Measurement
What change can we make
that will result in improvement?
Act
Study
Plan
Do
Change
Cycle for Learning
and Improvement
Langley, Nolan, Nolan, Norman, Provost;
7
Improvement Guide, 1996
Setting an Aim—What are we
trying to accomplish?
• List problems/opportunities for change
• Prioritize – what is important to work on?
• What is practical to do?
– What do we have to resources to do?
– What do we have the time to do?
• Have a team discussion to agree on an aim
An Aim…
• Should be SMART:
– Specific-Measurable-AttainableRelevant-Timely
• It should specify:
– patient population/system
– numeric goals
– time frame
Examples of Specific Aims
• “Increase the % infants born in our
coverage area who get their 1st dose of
DPT by 2 months of age from 40% to 80%
by July 2012”
• “Increase the % of adults with DM II in our
practice who have at least 2 HbA1c tests
per year from 65% to 90% by December
2012”
The Model for Improvement
What are we trying
to accomplish?
Aim
How will we know that a
change is an improvement ?
Measurement
What change can we make
that will result in improvement?
Act
Study
Plan
Do
Change
Cycle for Learning
and Improvement
Langley, Nolan, Nolan, Norman, 11
Provost;
Improvement Guide, 1996
How will we know that a change is
an improvement?
• Measurement tells you whether you are
making improvement or not
• Use measurement to monitor your
performance to adjust it as you go forward
with improvement
• Use measurement for improvement, not just
for evaluation/judgment (look through the
windshield, not at the rear-view mirror)
How will we know that a change is
an improvement?
•
•
•
•
•
•
Identify measures related to aims
Patient eligibility, denominator, numerator
Intelligent sampling required
Keep measures simple and practical
Balancing measures needed
Develop operational definitions
13
Examples of Measures
• % of babies born in village who get first DPT dose
by 8 weeks of age
• Number of children attending each outreach
clinic for immunization
• % of DM II patients in our practice who get two
HbA1c tests within last 12 months
• Average satisfaction scores of DM II patients in
our practice over last 6 months
14
Operationally Defining a Measure
• What is the phenomenon?
• What aspect will you measure?
• Does the measure reflect the
phenomenon faithfully?
Exercise:
What is a “Clean Room”?
Create an operational definition of “cleanliness”
for the following scenarios:
– A Teenage Boy’s Bedroom
– An Operating Room in a Hospital
The Model for Improvement
What are we trying
to accomplish?
Aim
How will we know that a
change is an improvement ?
Measurement
What change can we make
that will result in improvement?
Act
Study
Plan
Do
Change
Cycle for Learning
and Improvement
Langley, Nolan, Nolan, Norman, 17
Provost;
Improvement Guide, 1996
Assess your system, then consider
changes that are likely to improve it:
• Use the 5 P assessment to find problems
• Understand the ‘forces that are holding the
unchanged present in place’ before selecting
changes
• For every problem, understand
– The potential causes
– The facilitators
– The barriers
What Causes Problems:
•
•
•
•
•
Machines -- test equipment, data bases
Materials -- supplies, input information
Methods -- processes, protocols, techniques
Measurements -- bias, inaccuracy in data itself
People -- physicians, nurses, technicians, patients
Constructing a Fishbone
Cause and Effect Diagram
– Get the right people in the room
– State and clarify the “effect”
– Brainstorm list for 4 Ms/P involved in the
process or effect interested in
– Brainstorm causes for each of these
– For each cause ask “why” 5 times to get to
underlying causes
Where do Ideas for Improvement
Come From?
•
•
•
•
•
•
•
Understanding of processes and causes
Evidence-based medicine, guidelines
Benchmarking – superior performers
Brainstorming, judgment, ‘best-guess’
Creative thinking, innovation
Expert opinion
“Change concepts” e.g. alter sequence
Generating Ideas for Changes in a
Specific Clinical Area:
• “7As of RI Improvement Opportunity”:
– Acceptability; Accessability; Accountability;
Affability; Affordability; Availability; Awareness
CHANGE !
Develop and test a change:
• Test on a SMALL SCALE
• Collect data to test the effect of change
ACT
STUDY
PLAN
DO
Plan-Do-Study-Act Cycle
• Change ideas are not guaranteed to lead to
improvement – they have to be tested
• Process of testing a change is called a
Plan-Do-Study-Act (PDSA) cycle
• Changes are studied using the measures
previously chosen
• Every PDSA cycle is a form of learning in action,
and a sophisticated, demanding way to achieve
learning and change in complex systems
Plan-Do-Study-Act Cycles:
“Trial and Learning”
• Plan: State objective, make predictions, be
specific: who, what, when, how much
• Do: Carry out test, collect data and note the
unexpected problems
• Study: Compare data to predictions,
summarize lessons learned
• Act: Choose a change to make next cycle,
based on what you have learned.
26
Exercise:
Paper Airplane Quality Improvement
• By the end of the session you will:
– Know how begin an improvement effort with a
small test of change.
– Understand how to learn from this first test
and use that knowledge to design new tests
that become more effective over time
– Appreciate the role of team work in this effort.
– Begin to see how to apply these concepts
TASK: create the paper airplane
that will fly the farthest
after 4 PDSA cycles
Four Steps (three stations):
• “Plan” station: design/create paper airplane;
1st time only the paper; then anything on table
• “Do” station: one test flight, plot result
• “Study”/”Act” station: discuss result of the
flight (good/bad); then determine the next
type of change to make to airplane design
Airplane Design Report Outs
• What did you learn during each cycle?
• Small cycles of change: does this approach
have good potential for improving health
care?
“Hare Saves People”
•
•
•
•
•
Story from Bagandan Oral Tradition (agrarian)
Leopard & Hare live on same compound
pattern repeated every rainy season: ants
People prepared but L…; asked Hare for help
Hare assessed pattern & Leopard; introduced
change, successfully distracting him;
• Hare was rewarded for working to solve
problem
• Leopard died b/c he tried to “reap where he
did not sow”
Plan-Do-Study-Act Cycles:
“Trial and Learning”
• Plan: State objective, make predictions, be
specific: who, what, when, how much
• Do: Carry out test, collect data and note the
unexpected problems
• Study: Compare data to predictions,
summarize lessons learned
• Act: Choose a change to make next cycle,
based on what you have learned.
31
Focus on
populations, not
individuals
Emphasis on
using DATA to
inform change
Months - years
to properly
design /
complete
Not touching
patients
PH Research
QI
Yes
Yes
Yes
Yes
Yes
NO !
often…
NO !
Plan-Do-Study-Act Cycle
• Whether you achieve positive results or not, the
most important thing is to learn:
– Why did you succeed?
– Why did you fail?
– What further changes do you now need to
make in order to succeed?
• By doing a series of PDSA cycles and learning
from each effort at improvement, you can
achieve lasting improvements
Sequential Cycles on a “Ladder”
Changes that
result in
improvement
Knowledge
Theories
and ideas
Time