Topic 7

1. Topic 7 Introduction to methods for quality improvement

2. LEARNING OBJECTIVE • the objectives of this topic are to: • describe the basic principles of quality improvement • introduce students to the methods and tools for improving the quality of health care

3. PERFORMANCE REQUIREMENT • know how to use a range of improvement activities and tools

4. KNOWLEDGE REQUIREMENTS • the science of improvement • the quality improvement model • change concepts • two examples of continuous improvement methods • methods for providing information on clinical care

5. THE SCIENCE OF IMPROVEMENT • appreciation of a system • understanding of variation • theory of knowledge • psychology W Edwards Deming

6. THE INSTITUTE FOR HEALTHCARE IMPROVEMENT (IHI): DIFFERENT MEASURES

7. THREE TYPES OF MEASURES • outcome measures • process measures • balancing measures

8. THE MODEL FOR IMPROVEMENT What are we trying to accomplish? How we will know that a change is an improvement? What change can we make that will result in an improvement? PLAN ACT STUDY DO Langley, Nolan, Nolan, Norman & Provost 1999

9. THE PDSA CYCLE Determines what changes are to be made Change or test PLAN ACT STUDY DO Summarizes what was learned Carry out the plan Langley, Nolan, Nolan, Norman & Provost 1999

10. CHANGE CONCEPTS … … are general ideas, with proven merit and sound scientific or logical foundation that can stimulate specific ideas for changes that lead to improvement. Nolan & Schall, 1996

11. 9 CATEGORIES OF CHANGE • eliminate waste • improve work flow • optimize inventory • change the work environment • enhance the producer/customer relationship • manage time • manage variation • design systems to avoid mistakes • focus on the product or service Langley, Nolan, Nolan, Norman & Provost 1999

12. TWO CONTINUOUS IMPROVEMENT METHODS • clinical practice improvement methodology (CPI) • root cause analysis

13. THE IMPROVEMENT PROCESS Project mission Project team Ongoing monitoring Outcome Future plans Project phase • Conceptual flow of process • Customer grid • Data • fishbone • Pareto chart • run charts • SPC charts Sustaining improvement phase 1 1 month 5 Diagnostic phase Annotated run chart SPC charts Impact phase 2 4 3 Intervention phase A 2 months P S D S D 2 months S Plan a change Do it in a small test Study its effects Act on the result P A A A D A S P P S P D D Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf) SPC – statistical process control

14. INTERVENTIONS PHASE Identify appropriate interventions Implement changes identified in the diagnostic phase Undertake one or more PDSA cycles Interventions phase Decide on interventions Undertake one or more PDSA cycles Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

15. HOW TO USE THE PDSA CYCLE • use plan-do-study-act cycles to conduct small-scale tests of change in real settings • plan a change • do it in a small test • study its effects • act on what learned • team uses and links small PDSA cycles until ready for broad implementation ACT PLAN • What changes can be made for the next cycle (adapt change, another test, implementation cycle?) • Objective • Prediction • Plan for change (who, what, when, where) • Plan for data collection (who, what, when, where) STUDY DO • Complete analysis of data • Compare results to predictions • Summarize knowledge gained • Carry out the change • Document observations • Record data Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

16. PDSA CYCLE - SINGLE TEST PDSA Cycles – single test D S Changes that result in improvement S A P A D A P S P A P D S D Hunches, theories and ideas Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

17. PDSA CYCLE – MULTIPLE TESTS D S D S D S P A P A P A S S S D A D A D A P P P A P A P A P S S D D S D Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

18. IMPACT AND IMPLEMENTATION PHASE • Measure impact of changes/interventions • Record the results • Revise the interventions Impact and implementation phase • Annotated run chart • SPC charts • Other graphs Measure impact Implement the changes

19. ROOT CAUSE ANALYSIS • a multidisciplinary team • the root cause analysis effort is directed towards finding out what happened • establishing the contributing factors of root causes

20. PERFORMANCE REQUIREMENTS Know how to use a range of improvement activities and tools • flowcharts • cause and effect diagrams (Ishikawa/fishbone) • Pareto charts • run charts

21. EVIDENCE FOR THERE BEING A PROBLEM WORTH SOLVING At the same time LBH executives and staff expressed a desire to improve LOS. NSW – New South Wales.

22. FLOW CHART OF PROCESS Something amiss Post anaesthetic care Surgical ward Visit to general practitioner Allied health Surgical ward Operating theatre Investigations Pain team Pre-op ward Referral to surgeon Surgical ward Admitted to hospital Referral to Hospital Community health/ Peripheral hospital Preoperative clinic Hospital admission Return to life Admissions office Home Accelerated Recovery Colectomy Surgery (ARCS) Jenni Prince , Area CNC Pain Management, North Coast Area Health Service, NCHI Sydney Australia

23. CUSTOMER AND EXPECTATIONS LIST • surgical ward staff • post-op anaesthetic care staff • physiotherapy dept • dietitian • peri-operative unit staff • private hospital staff • pain team • anaesthetists • surgeons • intensivist • Multidisciplinary meeting to: • ask opinion • brainstorm process of care • how to improve the process • who to include in the process of change • how to communicate progress • Standardization • Evidence-based practice • team approach

24. CAUSE AND EFFECT DIAGRAM Social issues Staff attitudes Complications poor pain control LOS home support wound complications mobilization often weak weak/malnourished pain control infection nutrition family support Prolonged LOS nutrition expect long LOS general practitioner poor understanding of procedure mobilization community health nil by mouth little knowledge of support services family surgery colon care nurse pain control locus of control Procedure Patient perception Post discharge support Accelerated Recovery Colectomy Surgery (ARCS) Jenni Prince , Area CNC Pain Management, North Coast Area Health Service, NCHI Sydney Australia

25. PARETO CHART

26. PDSA CYCLES - IMPLEMENTATION • surgical incision trial of transverse incision • pain control wound infusion for transverse incisions 1 surgeon 10 patients • patient information booklet • surgeon pathway • anaesthetic pathway • ARCS clinical pathway • surgical technique • pain control • bowel prep/care • Nutrition • mobilizatioN 1 surgeon 1-6 patients

27. RUN CHART

28. STRATEGIES FOR SUSTAINING IMPROVEMENT • document and report each patient LOS • measure and calculate monthly average LOS • place run chart in operating theatre, update run chart monthly • bimonthly team meetings to report positives and negatives • continuously refine the clinical pathways • report outcomes to clinical governance unit • Spread – all surgeons • left hemicolectomy • all colectomy surgery • throughout North Coast Area Health Service