Quality Improvement 101

1. Quality Improvement 101 Barbara DeBaun, RN, MSN, CIC Kathleen Carrothers, MPH, CPHQ Cynosure Health

2. Today’s Objectives • Describe the elements of process design • Explain how to flow chart a process • Describe the Model for Improvement • Demonstrate 2 Performance Improvement tools

3. How Hazardous Is Health Care? (Leape)

5. 2001

6. 2003: Duke University Medical Center

7. 2007

8. Complexity of Healthcare • 90,000 people in an ICU every day • Five million Americans will receivecare in an ICU in a year • Average LOS in ICU is 4 days • Survival rate is 68% • Average patient requires 178 individual actions per day (suctioning, medication, wound care, etc.) • An error is made 1% of the time • Average of 2 errors/day/patient • Gawande, A. (2007, December 10). The checklist: If something so simple can transform intensive care, what else can it do? The New Yorker.

9. Why We Come To Work • Pick a dot • Goals, measure, current performance • Move the dot • Select intervention, PDSA • Share the dot Share a Story Data Drives Decisions The Heart Motivates

10. 10 Years Ago Central Line Blood Stream Infections were a part of doing business Ventilator Associated Pneumonia was an unfortunate consequence of being sick Sepsis was defined as shock from infection and carried a 50% mortality rate

11. 2012: Zero Tolerance

12. The Tennis Ball Exercise

13. How To Play • Break up into groups of 4-5 people • Select - Timer, Scribe, Leader • Using your tennis balls, spend 5 minutes designing a process that meets the following specifications: • Each ball must be touched by each person at least one time • The ball cannot be passed to the person directly next to you • The balls must be moved from person to person • Time your process • The goal is to build a process that meets the design specifications in the shortest amount of time • After 5 minutes we will get the best time from each team • You will then have another 5 minutes to improve your process

14. What Did You Do? • Formed a team • Designated roles • Brainstormed • Designed a process • Measured its performance • Benchmarked its performance • Analyzed the process design • Redesigned your process • Measured your new process, etc.

15. Learning PI From Tennis Balls • Before you can improve a process you need to know how it works • Listen to all members of your team • Especially those who are closest to the process • Share improvement ideas • Try them

16. More Learning’s • If at first you don’t succeed, try, try again • Look at others who perform the process well both within and externally • Borrow their ideas • Keep going • It’s the best process not the best people

17. Performance Improvement Tools

18. Facts About Flowcharts • Used to visually explain a process and the interrelationship between process steps • Allows analysis and better understanding of a process • Great way for a workgroup to better understand their environment • Excellent training documents

19. Commonly Used Flowchart Shapes Indicates starting or ending points of process Names or describes an individual task or procedure Indicates a conditional branch; a question or a decision; a variation in the process Start or End Start or End Task or Procedure Branch

20. Start Yummy Example Gather ingredients Preheat oven to 325 F Prepare baking pan… Blend water, oil, and eggs in medium bowl Add mix Stir until moistened Spoon batter into prepared pan Spread evenly Bake as directed below Cool completely in pan Cut and serve

21. Start Gather ingredients Spoon batter into prepared pan Preheat oven to 325 F Spread evenly Prepare baking pan… Pan type? Bake 40-45 minutes Bake 45-50 minutes Glass Blend water, oil, and eggs in medium bowl Metal Add mix Are you at high altitude? Add ¼ cup flour and add’l 2 Tbsps. water Yes Cool completely in pan No Cut and serve Stir until moistened

22. Flowcharts • Identifies parts of the process where data can be collected • Serves as a training tool to understand the complete process

23. Flowchart Analysis • What does your process look like? • What does the desired process look like? • Compare both charts, looking for areas where they are different • Focus improvement efforts on the differences or areas of rework and delays

24. Call between MDs office & OR Room is booked MD’s office faxes paper work Complete? Office called & reminded Pt. arrives Paperwork checked again Pt. held in pre-op for MD to complete paperwork Complete? Pt. taken to OR

25. Give It a Try • At your table pick one of the following processes to flowchart: • Packing for the last trip you took • Preparing the last meal you cooked • Getting here today • Determine the start and ending point of the process

26. Decisions to Make • Decide on the level of detail • Simple macro-flowchart shows only the general process flow • Detailed flowchart shows all actions and decision points

27. Go For It • Identify the major steps in the process • Write each step on a post-it note • Arrange the post-it notes in the desired sequence • Add directional arrows and decision diamonds • Keep all yes choices in the same direction

28. Flowchart Analysis • What does your process look like? • What does the desired process look like? • Consider flowcharting to compare the ‘real world’ with ‘the policy’ • Focus improvement efforts on the differences or areas of rework and delays

29. Fishbone • Also called cause-and-effect diagram • Can reveal key relationships among various variables, and the possible causes provide additional insight into process behavior • Often used in root cause analysis • People • Processes • Equipment

30. Investigating Practices to Prevent CR-BSI

31. The Model for Improvement So You Think You Can Change?

32. While all changes do not lead to improvement, all improvement requires change. • Thomas Nolan, The Improvement Guide

33. Model For Improvement What are we trying to AIM accomplish? How will we know that a MEASURE change is an improvement? Whatchangecan we make that Selecting Change willresult in improvement? Act Plan Small Tests of Change Study Do

34. What Are We Trying to Accomplish? • Developing the team’s Aim Statement

35. FromAlice in Wonderland • One day Alice came to a fork in the road and saw a Cheshire Cat. • “Which road do I take?” she asked. • His response was a question: “Where do you want to go?” • “I don’t know, “ Alice answered. • “Then,” said the cat, “it doesn’t matter.” • Lewis Carroll

36. BIG BOLD

37. WHAT? WHERE? HOW MUCH?

38. By WHEN?

40. Clear and Unambiguous Target

41. AIM Statements • Reduce heart failure mortality rate by 40% by September 1, 2012 • Reduce falls with injury on 4 West to zero by November 30, 2012

42. What Are You Trying to Accomplish? • At your tables, for the next 5-10 minutes create an AIM Statement for a project you are working on or planning to start

43. Evaluation and Sharing • Did your AIM statement: • Have a clear numerical goal? • Have a bold but realistic goal? • Clearly articulate what you want to achieve and by when? • Can your AIM statement be given in any elevator? • Would you change your AIM statement? • If so, what would you change and why?

44. How do you know if a change is an improvement?

45. Model For Improvement What are we trying to AIM accomplish? How will we know that a MEASURE change is an improvement? Whatchangecan we make that Selecting Change willresult in improvement? Act Plan Small Tests of Change Study Do

46. Why Measure? • How else will you know that the change(s) you made resulted in improvement?

47. Limitations One Voice Sample Useful, not perfect

48. Select right measures Rapid results Adapt interventions

49. Types of Measures

50. Process Measures Outcome Measure What you get What you do Balance Measures