Quality Improvement in Healthcare seminar.pptx

Quality Improvement in Healthcare

1. Seminars on QI in Healthcare

2. Programme Welcome and Housekeeping Background & Principles of Quality Improvement The Model for Improvement - aims and drivers - measuring for improvement - ideas for change - plan, do, study, act Putting your project together Resources for QI Summary and Close

3. Group activity Marshmallow and Spaghetti Challenge You have 7 minutes The Challenge Build the tallest free standing structure One entire marshmallow should be placed at the top Use as much or as little of the kit – no additional items will be provided

4. Background Principles of Quality Improvement Ravi Chetan

5. Health care is delivered in a complex environment Healthcare is facing challenges Everyone is finding it too ‘difficult’ & morale is low

6. 1900-1993

7. What does QUALITY mean to you? Safe Reliable Consistent Timely Premium Inclusive Efficient

8. Group activity What is Quality Think of the best service you have ever had? How did it make you feel?

9. The Implementation Gap

10. Clinical Audit & Quality Improvement- what is the difference Quality improvement (QI) is NOT separate from clinical audit QI is Beyond Audit i.e. free from the rigid constrains and rigours of audit QI is the wider overarching umbrella under which clinical audit can sit

11. Two concepts vital to understanding QI An interconnected approach that unites human beings and their job functions into one integrated system in which we live and work Systems Approach Improvement Science Good to Great

12. Improvement science Walter A. Shewhart and W. Edwards Deming , statisticians and engineers Bell’s laboratories 1920-1940 Their theoretical work laid the foundations of this new science to better visualise and understand the interdependent components of a system Improvement science is the foundation of Quality Management theory Leadership in any organisation anywhere in the world Educational institutions, businesses , government agencies, charities or nonprofit organisations , and Healthcare providers around the world  

13. Shewhart & Deming Distinction between Pure science  (e.g. Fleming’s discovery of antibiotics) Applied science  The concept of PDSA cycles Run charts (Shewhart charts) Knowledge is based on theory Theories need to be developed, applied and tested in order to advance knowledge Life is messy and nonlinear Whenever you make a change in one part of a system, that change will affect other parts of your system – positively or adversely

14. Interconnecting systems in work place are hard to understand! Service delivery Finance Workforce & Job Plan Medicines Technology Information Communication Deming’s System of Profound Knowledge helps: It can help break down complex quality issues into smaller, more understandable parts . By breaking down a problem into its component parts, you can better analyze it and find ways to improve it

15. Systems Approach Four aspects: Theory of Knowledge Appreciation of a System Variation Human Behaviour

16. The basic principles of Systems Approach E very system is perfectly designed to get the results it gets When an error occurs in a complex system the system is still perfectly designed for that error , or another one like it, to occur again and again To avoid errors, a conscious effort must be made to identify the problem in the system and to improve the system

17. Compassion Care and Respect Information & Communication Clinical Knowledge & Skills Technology & Medications QUALITY Patient care using Systems Approach Good to Great

18. How do we define QI in the NHS? Healthcare that is: Safe Timely Effective Efficient Equitable Patient Centred Quality is everyone’s responsibility

19. Questions and Answers

20. Summary The aim of healthcare is to ensure every person receives exactly the right care, every time There is an implementation gap Health care takes place in a complex environment made up of several interconnected elements Healthcare can be viewed as a p rocess and a s ystem A systems approach helps improve delivery of healthcare This is based on a science called Improvement science The components of Quality can be understood by the mnemonic ‘STEEP’ Quality Improvement provides us the knowledge and tools to refine, change or develop the systems we need to deliver the healthcare

21. Model For Improvement - AIMS Tracy Turner

22. PDSA Cycle Pioneered by W. Edwards Deming in 1950s Designed to put industrial processes in a continuous feedback loop to improve Simple but effective approach to testing before committing to full implementation.

23. https :// www.youtube.com/watch?v=SCYghxtioIY Model for Improvement

24. Start small: Trial it on one ward initially; Up to 4-5 patients for two days only Review: Check and report findings, what went well, what could be improved Revise & Implement: Make any changes needed and re-trial Increase the scale of the test: More shifts, more patients, more wards Model for Improvement Example in a healthcare setting A project to trial a new pro forma in patient records following low compliance with record-keeping standards

25. Model for Improvement

26. “If you don't know where you are going, any road will get you there.” Good to Great

27. Raise awareness of Quality Improvement

28. To introduce Quality Improvement tools to Southend University Hospital staff by Q4 of 2016

29. The QI team will facilitate an introductory QI learning session for at least 16 SUH staff by 1 December 2016 S pecific? M easurable? A chievable? R ealistic? T imed?

30. Over to you Improve hand washing on the wards To increase hand washing rates by 20% across all inpatient wards by 1st December 2018.

31. Questions and Answers

32. Good to Great

33. Model for Improvement Ideas What change can we make that will result in improvement? How will we know change is an improvement? What are we trying to accomplish? Aims and Drivers Measures

34. “We but mirror the world. All the tendencies present in the outer world are to be found in the world of our body. If we could change ourselves, the tendencies in the world would also change. As a man changes his own nature, so does the attitude of the world change towards him. This is the divine mystery supreme. A wonderful thing it is and the source of our happiness. We need not wait to see what others do .”

35. Change ideas should be directed by your aim Relative advantage Simplicity Compatibility Trailibility Observability

36. Techniques for coming up with Ideas for Change Critical thinking about the current system Benchmarking Using technology Creative thinking Using change concepts

37. Guide for determining test size based on degree of belief and potential consequences

38. Drivers AIM Primary Driver Primary Driver Primary Driver Secondary Driver Secondary Driver Secondary Driver Secondary Driver Secondary Driver Secondary Driver Secondary Driver

39. Example: Calorie intake Exercise Attitude & behaviour Knowledge and understanding of calories and food Opportunity to access healthy food Can afford healthy food Capable of obtaining/cooking healthy food Understand ‘burning’ calories benefits Physically be capable to exercise Have opportunity to exercise Motivation Reduce stresses (methods?) Stay focused on meals/drinking habits Inform friends & family (gain support) AIM I will lose 10kg weight in 6 months Primary Drivers Secondary Drivers

40. Your turn to do a driver diagram SMART AIM “ To increase hand washing rates by 20% across all inpatient wards by 1 st December 2018 ”

41. Driver diagram

42. A process map ( or flow chart ) Helpful in collection and analysis of data on how a system works If you do it before introducing a change it gives you baseline data And Points you as to where changes may be needed

43. Fishbone diagram Cause and effect diagram (or an Ishikawa Chart) A tool that can help teams identify root causes of a problem

44. Questions and Answers

45. 10 mins

46. Good to Great

47. Model for Improvement Ideas What change can we make that will result in improvement? How will we know change is an improvement? What are we trying to accomplish? Aims and Drivers Measures

48. Why Measure? 1. Do you know how good you are ? 3. Do you understand variation? 2. Do you know how good you are relative to the best? 4. Can you demonstrate improvement over time?

49. Defining Measures Clearly define each measure Define the goal of the measure How to display the measure Project-level measures monitor your progress toward your overall goals ( e.g rate of HACI) PDSA-level measures monitor the results of specific tests of change toward those goals. ( e.g % time staff wash hands before encounters with patients)

50. Types of Measures in QI Outcome measure What you ultimately want to improve Process measure Are parts or steps in the system performing as planned (PDSA measures) Balancing measure Not directly related to the aim but assess whether changes are creating other problems

51. Example

52. Group Activity 2 Identify the type of measure Aim: To increase hand washing rates by 20% across all inpatient wards by 1 st December 2018 . Percentage of staff washing their hands Number of staff receiving hand washing instruction Occupational health referrals for hand skin conditions Rate of hospital acquired infections Cost of hand washing equipment

53. Collecting Data Ask the following questions: Who is responsible for collecting the data? Is data already available? How often will data be collected, e.g . hourly, daily, or weekly? What/who is to be included or excluded , e.g . include only inpatients or include inpatients and outpatients? How will data be collected , e.g. manually or by an automated system? Establish the nature of sampling . Is it random, stratified or Judgement based Tip: You should integrate measurement into the daily routine as much as possible

54. Measuring and Displaying Data over Time: Run Charts X axis , for plotting time The basic elements of a run chart : Y axis , for plotting the variable you’re measuring Goal line , indicating the result you're working toward Annotations , showing when the team made specific process changes or noteworthy events occurred PDSA 1 PDSA 2 Median line, the data point half way between the highest and the lowest data point

55. Example of Run Chart Aim: To increase hand washing rates by 20% across all inpatient wards by 1 st July 2017 Outcome measure: Percentage of staff washing their hands Would you say the changes the team is testing are leading to improvement ? Training given to staff

56. Measurement in QI vs Audit The differences? Sample Size and type Data frequency Purpose

57. Questions to ask about the data Is there an improvement? Is any improvement due to the intervention? Is the improvement sustained ? What would the data tell you if you had carried out a snap shot audit?

58. How does Measuring for QI differ from Measuring for Research? Quality Research Quality Improvement Purpose Proof of effectiveness Sustained improvement Data collection Gather enough data to authoritatively study for effect and control for all known confounders Gather just enough data to information improvement and only collect data on 1-2 confounders as needed Method One large test with a fixed hypothesis, control bias as much as possible Rapid sequential tests with a hypothesis that changes as learning takes place, no effort to control bias Results Evaluation Pre and post assessment Regular assessment with run charts

59. Shewhart chart   (also called a control chart) Similar to a run chart BUT has a number of differences Need to have 20 or more data point An average for the data (rather than the median) An upper control limit (UCL) and a lower control limit (LCL). Control limits  allow you to determine if the process is stable (containing only common cause variation) or not stable (containing special cause variation )  

60. Shewhart chart   (also called a control chart)

61. Questions and Answers

62. Ravi Chetan

63. What do we need in order to improve Quality?

64. How willing are you? Diffusion of Innovation Not everyone has the same motivation for adopting a new idea!

65. Population distribution of ADOPTERS How embedded Is the change (%) How many does it need to embed a change?

66. How can you come up with ideas? 2. Critical Thinking about the system currently in place Mapping Pathway Evaluate flow charts 3. Benchmarking Compare your service with standards of best practice ( this is Audit ) 1. Creative Thinking 4. Technology inspired E-Prescribing Imaging Network platforms

67. Cheat / copy / follow tried and tested methods used by others Associates for Process Improvement API have 70 proven concepts available online Change Concepts A. Eliminate Waste E. Enhance the Producer/Customer Relationship Eliminate Things That Are Not Used Eliminate Multiple Entry Reduce or Eliminate Overkill Reduce Controls on the System Recycle or Reuse Use Substitution Reduce Classifications Remove Intermediaries Match the Amount to the Need Use Sampling Change Targets or Set Points 38. Listen to Customers 39. Coach Customers to Use Product/Service 40. Focus on the Outcome to a Customer 41. Use a Coordinator 42. Reach Agreement on Expectations 43. Outsource for “Free” 44. Optimize Level of Inspection 45 Work with Suppliers F. Manage Time 46. Reduce Setup or Startup Time 47. Set up Timing to Use Discounts B. Improve Work Flow 48. Optimize Maintenance Synchronize Schedule into Multiple Processes Minimize Handoffs Move Steps in the Process Close Together Find and Remove Bottlenecks Use Automation Smooth Work Flow Do Tasks in Parallel consider People as in the Same System Use Multiple Processing Units Adjust to Peak Demand 49. Extend Specialist’s Time 50. Reduce Wait Time G. Manage Variation 51. Standardization (Create a Formal Process) 52. Stop Tampering 53. Develop Operational Definitions 54. Improve Predictions 55. Develop Contingency Plans 56. Sort Product into Grades 57. Desensitize 58. Exploit Variation C. Optimize Inventory H. Design System to Avoid Mistakes Match Inventory to Predicted Demand Use Pull Systems Reduce Choice of Features Reduce Multiple Brands of Same Item 59. Use Reminders 60. Use Differentiation 61. Use Constraints 62. Use Affordances D. Change the Work Environment I. Focus on the Product or Service Give People Access to the Information Use Proper Measurements Take Care of Basics Reduce Demotivating Aspects of Pay System Conduct Training Implement Cross-Training Invest More Resources in Improvement Forcus on Core Processes and Purpose Share Risks Emphasize Natural and Logical Consequences Develop Alliance/Cooperative Relationships Mass Customize Offer Product/Service Anytime Offer Product/Service Anyplace Emphasize Intangibles Influence or Take Advantage of Fashion Trends Reduce the Number of Components Disguise Defects or Problems Differentiate Product Using Quality Dimensions

68. PDSA Cycle …… the tool for Action oriented ( Experiential) Learning and Quality Improvement

69. Small steps lead to big changes One basic tenet of PDSA is that we start small ! A small-scale test of change enables you to observe the test while minimizing potential risks Your   Degree of belief   i.e . how likely you believe the change is to lead to improvement, & the potential consequences if the change does not lead to improvement

70. Scale & Scope Scale  refers to the timespan, number of patients or events included in a test cycle — e.g. more patients, more time, more events Scope  refers to the variety of conditions under which your tests occur – e.g. different patients, different times, different staff, & different wards/areas T he 5X rule to increase Scale 1 525125 625

71. Running Concurrent Test Cycles Small, Rapid tests of Change Testing and Adapting

72. How to use the PDSA

73. Putting your project together Ravi Chetan Good to Great

74. The Four Phases of a Quality Improvement Project Innovation coming up with new ideas for change Pilot testing a change on a small scale Implementation making the change the new standard process in a defined setting Spread implementing the change in several settings :

75. Barriers to change (Herbert Kaufman) Adopter personality People naturally react differently to change

76. Not everyone has the same degree of motivation for Adopting a new idea!

77. What type of an ADOPTER are you? Diffusion of Innovation How embedded Is the change (%)

78. How Change Spreads – 3 Stages

79. When do you know a change has been implemented? W hen you could have 100% staff turnover of the people who were involved in the original tests and studies, and the change would still remain in place as part of the system .

80. Questions and Answers

81. Good to Great

82. Information and Support

83. Finding Information

84. Where next? Theory and Practice of QI

85. Questions and Answers

86. Summary of the day What health care looks like today, and why it needs improvement Basic improvement methodology - Model for Improvement : H ow to set an aim How to select measures, collect data, and display data in run charts to learn from visual patterns T est changes A ct on the results of the tests of change using Plan-Do-Study-Act (PDSA) cycles