Chapter 4 Formation,Problem Identification, Prioritization Basic final.pptx

Chapter 3 Quality Improvment Models _Basic final.pptx

1. 1 Team Dynamics and problem solving Chapter 4 12 January 2024 QI Training

2. Team formation, Problem Identification, Prioritization and Aim Setting

3. Outline Introduction QI Team formation and composition of QI teams. Roles and Responsibilities of Quality Improvement Teams Stages of team development Identify Quality Gaps/Identify Problems using Data Prioritization Tools Problem Statemen and Aim Statement Quality Improvement Project Work – Section I Summary 3 12 January 2024 QI Training

4. Enabling Objectives Discuss team formation: QIT establishment, composition their roles and responsibilities, and QI team meetings Identify problems using the dimensions of quality, Data and Donabedian framework. Apply tools to prioritize problems. Develop problem statement. Develop SMART aim statement for identified problems . 4 12 January 2024 QI Training

5. QI Team Formation and Functionality

6. Activity 1: Reflection questions What is team and its difference with a group? Who should be included in a QI team? How big should the team be? How frequent should the team meet? Time allowed-10 min 6 12 January 2024 QI Training

7. What is a team? A team is a group of two or more individuals who: Interact dynamically Have a common goal/Objective Have been assigned specific tasks for each Who have a limited lifespan of membership. Who have been each assigned specific roles or functions to perform 7 12 January 2024 QI Training

8. Difference between group and team Group Team Individual goals Shared goals Individual accountability Individual and mutual accountability Individual work Collective work Individual success or failure Collective success or failure Discussion , decision, delegation of a work for each individuals Discussion, decision and sharing of work 8 12 January 2024 QI Training

9. During Team Formation Things Should Be Considered Those interested in QI and/or those who are involved in the area that needs improvement The team should be multidisciplinary and relatively small (6-10) Client representation on the team is encouraged 9 12 January 2024 QI Training

10. 10 Composition of QI team 12 January 2024 QI Training

11. Example: QI team If your QI team focus is on MNCH you probably will have a core team that includes representatives of: Maternity and Pediatric Wards, Laboratory, Pharmacy, Management, and Clinician/ Pediatrician/ Obstetric Gynecologist. Any change targeting on improving MNCH is likely to impact on some of the care processes of these units/ departments. Often senior staff of the unit or the unit in-charge is selected to be part of the core team,. This situation would result in a core QI team of 6-10 members. 11 Reflect question What do you observe from the above examples ??? 10 minutes 12 January 2024 QI Training

12. Key positions/roles of a QI team System leader(Facility leader): Agree on the improvement topic and aim Identify the leader of the QI team. Stay informed about the progress of the QI effort Communicate with boards for decision making issues Provide necessary resources as required Attend learning sessions and provide guidance Stay informed about the progress of the QI effort. 12 12 January 2024 QI Training

13. Key positions/roles …… Unit Head (Day-to-day Leader): Keep the team focused on the aim and charter. Plan and organize team meetings. Identify needs for and request additional support. Assign responsibilities to team members. Liaise with the management team. Represent the team during the learning sessions. Develop an implementation plan for the Changes. Serve as coaches to new teams during the Scale-up process 13 12 January 2024 QI Training

14. Key positions/roles …… Subject matter expert Though this role is often covered by the systems leader or day-to-day leader, But we may also require the relevant subject matter experts when trying to make change to the system. Moreover, this person should have a good working relationship with colleagues and have interest in driving change. 14 12 January 2024 QI Training

15. Key positions/roles …… Clients and Beneficiaries (often part of the QI team) Identify issues of access and service quality, and communicate these to the QI team. Engage in problem analysis, change idea development Identify changes in patient behavior and promote them through a network of patients. Attend learning sessions. (Clinical audit reports, Death audit reports….) Report on progress to peers 15 12 January 2024 QI Training

16. Innovators of Improvement Identify and prioritize problems Develop and test change ideas - PDSA Get results – early wins Involve colleagues Convince early adopters 12 January 2024 QI Training 16

17. Leadership Engagement/Buy-in At some point the team may need additional resources to test a change idea Change is not always well accepted by all individuals Leadership can give additional support the team’s idea by instructing staff to cooperate to testing the change 17 12 January 2024 QI Training

18. Leadership Engagement/Buy-in Leaders engagement could be beneficial To guide on how to analyze the current performance of the HF To help create a burning platform (agendas) To align QI aims with facility goals 18 The frog in the burning platform 12 January 2024 QI Training

19. E ffective T eam Clear communication among all members Regular brainstorming sessions with all members participating Problem solving done by the team Commitment to the project and the other team members Regular team meetings that are effective and inclusive 19 12 January 2024 QI Training

20. Conducting regular QI Team Meetings New QI teams should meet at least every other week (twice per month) Experienced teams should have monthly meetings Each meeting should be documented; meeting minutes serve as reference material for the QI team, QI coach and (senior) leadership. QI teams should debrief/ update leadership regularly (preferably every month but at least once a quarter). 20 A QI team in action 12 January 2024 QI Training

21. QI Team Meetings What it should be : focused on aims identifying barriers to reaching aims creating or sourcing change ideas planning PDSAs reviewing PDSAs & change ideas What it should not be : a team meeting a meeting where every problem in the facility is addressed a complaining session without the generation of change ideas disconnected from previous meetings Green C. 2010 12 January 2024 QI Training 21

22. Stages of Team Development : Tuckman Model 22 12 January 2024 QI Training

23. Problem Identification, Prioritization

24. Activity – 2: Plenary Discussion You have had an ongoing problem with frequently occurring maternal mortalities (more than 3 per month) in your facility. You have been tasked to bring a solution to this problem. What should be done differently to reduce maternal mortality in the facility? Time: 5 minutes 24 12 January 2024 QI Training

25. Introduction A problem is “ the difference between things as perceived and things as desired” Gause and Weinberg (1989) “ the gap between the existing state and the desired state of a process” Health Quality Ontario 25 12 January 2024 QI Training

26. Problem Identification 26 12 January 2024 QI Training

27. Identifying Quality Gaps What to improve? Need to identify the opportunity for improvement Safety issues: system fails to detect risks and adverse events that will eventually harm the patient or provider Effectiveness issues: system does not deliver according to performance expectations Efficiency issues: system uses too many resources to deliver its performance Responsiveness issues: the system does not address the needs of its clients to their satisfaction. Federal Democratic Republic of Ethiopia, Ministry of Health (2017), HSTQ, QI-TC Participants Manual 27 12 January 2024 QI Training

28. Identifying Quality Gaps… People-centered : the system does not respond to the individual’s, family and caretaker needs and values. The care is not considerate of the patient and family choices. Timely : the system is unable to use the time efficiently. Equitable: the system is designed in a way where clients are favored based on personal characteristics. Integration: The system fails to provide coordinated and comprehensive care. 28 12 January 2024 QI Training

29. Identify Problems in Quality of Care 29 Seven Healthcare Quality Dimensions 12 January 2024 QI Training

30. Donabedian’s Model: Evaluating QoC 30 STRUCTURE Physical and organization c haracteristics where healthcare occur s PROCESS Focus on the care delivered to patient e.g. services, diagnostics or treatment OUTCOME Effect of healthcare on the status of patient and population 12 January 2024 QI Training

31. Donabedian’s Model Donabedian , A (1966). Evaluating the quality of medical care. Milbank Quarterly, 44 (Suppl.), 166-206. 12 January 2024 QI Training 31

32. Activity 3: Small Group Exercise Instruction: Form group of 3-5 participants per facility/department Think about existing performance gaps in your facility/department using Dimensions of Quality of care Data: Mortality and Morbidity reports Donabedian’s model Present the existing performance gaps Time: 30 minutes 32 12 January 2024 QI Training

33. Problem identification: What Tools to Use? Common tools for problem identification, Data from various sources Conducting audit Comparing performance with targets: Review Observation / Walk through Patient Compliant Others 33 12 January 2024 QI Training

34. Compare Performance with Target 34 12 January 2024 QI Training

35. Observation 35 Clinical skills 12 January 2024 QI Training

36. Using Data sources –Registers 36 12 January 2024 QI Training

37. Data sources Audit Data Quality 37 Chart audit 12 January 2024 QI Training

38. Walk-through Is repeated real-time observation of patients and families as they move through each step of their healthcare journey. Enables providers to better understand the true care pathway, experience of care from the patients’ and families’ point of view It generates data that address the total experience of the patient including frustrations, confusion, anxiety Adapted from Institute for Healthcare Improvement, Walk-through Tool 38 12 January 2024 QI Training

39. Prioritization Tools Pareto Chart Vilfredo Pareto If you’re Noah, and your ark is about to sink, look for the elephants first, because you can throw over a bunch of cats, dogs, squirrels, and everything else that is just a small animal and your ark will keep sinking. But if you can find one elephant to get overboard, you’re in much better shape. 12 January 2024 QI Training 39

40. Pareto Principle A small amount of effort accounts for most of the results. 80/20 rule 40 12 January 2024 QI Training

41. What is a Pareto Chart? A graphical tool that helps to prioritize efforts to where they will have the most impact. It is made up of three (3) key components: Bar/Column chart – representing categories/frequencies displayed in order of size Line graph – representing the cumulative percentage Two vertical (y-) axis 41 12 January 2024 QI Training

42. Steps for Constructing a Pareto Chart List all the possible categories/groups Collect the data – how many of each Arrange the categories/groups from the highest to the lowest frequency/impact Calculate the total, add up the frequencies Calculate percentage for each category/group 42 12 January 2024 QI Training

43. Steps for Constructing… 6. Calculate the cumulative percentage 7. Draw the axes – horizontal: categories/groups vertical left: frequencies/ ‘raw’ data vertical right: cumulative percentage Plot the data in your graph Label the axes and annotate the graph (specifying the vital few and useful many) 43 12 January 2024 QI Training

44. Prepare Pareto Chart (30 min.) 44 Contributing factor (Causes of Neonatal deaths) Frequency Percentage Cumulative Percentage Prematurity 49 32.2% 32.2% Birth Asphyxia 45 29.6% 61.8% Neonatal Sepsis 31 20.4% 82.2% Congenital Abnormalities 11 7.2% 89.5% Pneumonia 9 5.9% 95.4% Tetanus 4 2.6% 98.0% Malnutrition 1 0.7% 98.7% Diarrhea 1 0.7% 99.3% Birth injury 1 0.7% 100% Total 152 100% 12 January 2024 QI Training

45. Pareto Chart on Neonatal deaths Causes of neonatal deaths in the scenario facility Useful many Vital few 45 12 January 2024 QI Training

46. Activity 4: Small Group Exercise Instruction: Prepare pareto chart using your facility data of Neonatal death C omplete the table and construct the complete Pareto Chart Allow 3 groups to present using flip chart Time: 30 minutes 46 12 January 2024 QI Training

47. Priority Matrix Which identified problem should be prioritized? Common criteria used to prioritize problems Cost and/or gains when resolved Availability of solutions Availability of resources (staff, time, equipment, etc.) Urgency of solving Size of problem Adapted from National Association of Country & City Health Officials (NACCHO), First Things First 47 12 January 2024 QI Training

48. Step-by-Step Instructions Adapted from National Association of Country & City Health Officials (NACCHO), First Things First 48 12 January 2024 QI Training

49. Example of Prioritization Matrix *Rating Scale used: 0-5 49 Problem or Opportunity Impact Frequency Feasibility Alignment with Strategic Goals Total priority Score Low rates of immunization coverage 4 5 4 4 17 High rates of maternal mortality 5 4 4 5 18 Low rates of antenatal care utilization 4 3 4 4 16 Lack of access to essential maternal and child health services in rural areas 5 5 4 5 19 High prevalence of stunting among children 5 3 3 3 14 In adequate access to prenatal care 4 3 3 2 12 12 January 2024 QI Training

50. Activity 5: Small Group Exercise Work in your previous groups (per facility, department, organization) Brainstorm with your group about prevailing health problems in your work place List the problems and the criteria you use to rank them Use prioritization tools and prioritize performance gaps Present to the plenary Time: 20 minutes 50 12 January 2024 QI Training

51. Sn List of identified problems Within control/Feasibility Frequency of the problem Cost Total score 1 2 3 4 5 6 7 8 9 10 11 12 51 Problem prioritization matrix : Group exercise(20 min) 12 January 2024 QI Training

52. Problem Statement

53. Components of Problem Statement What is the problem? What is not functioning as desired? What are the boundaries? ( Size ) How do we know it is a problem? How long has it been a problem ( time ) ? What are the effects ( impact ) of this problem? Where does the problem exist? How will we know the problem is resolved ? 53 12 January 2024 QI Training

54. What it does NOT include… Causes Actions or corrections required Assign blame Address more than one problem 54 12 January 2024 QI Training

55. Guiding Questions Example A team at a dream hospital noted a shortage in medication for Acute Respiratory Infections (ARI) for under five children. What is the problem? A shortage of ARI drugs for children under five How do you know it is a problem? Drugs run out by the third week of the month How frequently does it occur? This shortage has occurred every month for the past nine months What are the effects of this problem? Patients develop complications causing an increase in referrals to a first-level facility How will you know when it is resolved? The problem will be solved when ARI drugs last until the end of the month Federal Democratic Republic of Ethiopia, Ministry of Health (2017), HSTQ, QI-TC Participants Manual 55 12 January 2024 QI Training

56. Examples Problem Statement Problem Statement Strong? 1. There are many errors in our data 2. Over the past 2 years, only 50% of ANC clients was tested for HIV in Dream Hospital, leading to high-risk deliveries with potential risk for baby and health workers to be exposed 3. Maternal client's satisfaction is low 4. For 3 months Dream Hospital had a closed OR and an increase in referrals, so far 150 clients were referred 56 12 January 2024 QI Training

57. Setting Aim Statement

58. 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 improvement? Model for Improvement Act Plan Study Do © 2004 Institute for Healthcare Improvement The Model for Improvement was developed by Associates in Process Improvement. Aim 12 January 2024 QI Training 58

59. Purpose of Aim Statement 1 st Principle of Improvement – know why to improve An Aim Statement is an explicit description with specific actions or focus An internal and external communication tool for the work to be done 59 12 January 2024 QI Training

60. Components of Aim Statement SMART aim template Specific Be specific about what you want to improve. Where and for who? Measurable Include a measurement that will evidence improvement. create a baseline performance Achievable Set a numerical target that can be realistically achieved Relevant Your aim to the facility goals and will improve patient care, experience and outcomes. Time-bound Include a timeframe for your project thinking about when you might see the outcomes 60 12 January 2024 QI Training

61. Aim Statement Date: I/we,_________________,aim to improve/reduce/initiate/redesign_______________________from_________________to__________by______________. 61 12 January 2024 QI Training

62. Example: Aim statement Date: Problem: Babies are cold at one hour following birth We will reduce the % of newborns with low temperature (<36.5 C ) from the current 50% to less than 10% within six weeks Who (which patients) - Newborns What (the outcome) - low temperature (<36.5 C ) How much (the amount of desired improvement ) - from 50% to less than 10% By when (time over which improvement will occur) - within 6 weeks 12 January 2024 QI Training 62

63. Examples of Aim Statements S M A R T We Emergency OPD QI team at Tena Lehulum Hospital aim to reduce the length of stay of cardiac patients from 72 hours to 48 hours in Adult Emergency department from May 20, 2022, to August 30, 2022 To increase number of 4 th ANC from 50% to 85% at Tena Lehulum Hospital by the end of June 2022 To increase the percentage of inpatient referral feedback given from 20% to 50% from June 23/2022 to Jan 7/ 2023G.C. 63 12 January 2024 QI Training

64. Quality Improvement Project Work Section I – Problem identification, prioritization and aim statement Develop a problem statement and a SMART aim statement for a problem identified in your facility/organization use the prioritized problem from the priority matrix exercise Present your work Document in your project workbook, subsequent sessions will build on this (Annexed) Time: 30 minutes 64 12 January 2024 QI Training

65. Summary . 65 Team is group of individuals who work together to achieve common goal QI teams should constitute system leaders, day to day leadership and subject matter experts Tuchman's models of stage of team are forming,storming,normingand performing Conducting regular QI meeting is key role of team improving quality 12 January 2024 QI Training

66. Summary… 66 12 January 2024 QI Training

67. THANK YOU! 67 12 January 2024 QI Training