Quality Improvement Methods

1. Quality Improvement Methods Greg Randolph, MD, MPH

2. Healthcare Quality Defined  ”The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” --Institute of Medicine, 2001

3. Exercise • In pairs, define Quality Improvement (3 minutes) • Be prepared to share (2 minutes)

4. UNC Pediatrics Residency QI Program “A systematic approach of measuring and identifying gaps between actual and desired quality of care and applying tools and improvement methods (e.g., PDSA cycles) to make changes to the system that result in measurable improvements (i.e., closing the gap)”

5. Quality Improvement Focus • Patient-centered - care that is responsive to patient preferences, needs, values • Effective - providing services based on scientific knowledge to all who could benefit and refraining from providing to those not likely to benefit • Equitable - providing care that does not vary in quality because of personal characteristics • Timely - reducing waits and delays for care • Efficient - avoiding waste • Safe - avoiding injuries to patients from care --Institute of Medicine, 2001

6. Fundamental Questions for Improvement • 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 an improvement?

7. Model for Improvement What are we trying to accomplish? • Aim • Measures • Ideas/Change Concepts How will we know that changes are an improvement? What changes can we make that will result in an improvement?

8. AIM: What are we trying to accomplish? MEASURES: How will we know that changes are an improvement? IDEAS: What changes can we make that will result in an improvement? Model for Improvement

9. What is an Aim Statement? Aim: A written statement of the accomplishments expected from improvement effort Key components: • A general description of aim - should answer, “what are we trying to accomplish?” • Rationale/importance • Some guidance for carrying out the work • Specify target population and time period • Measurable goals

10. Goals Should Be: • Measurable • Numeric • Preferably absolute rather than relative • A stretch, not business as usual • Achievable, not impossible

11. Exercise • In pairs, critique aim statement – are key components present (3 minutes) • Then pick a problem and write your own (5 minutes) • Be prepared to share (2 minutes)

12. AIM: What are we trying to accomplish? MEASURES: How will we know that changes are an improvement? IDEAS: What changes can we make that will result in an improvement? Model for Improvement

13. Project Measures Goal

14. Project Measures • The question: How will we know that a change is animprovement? - usually requires more than one measure. • A balanced set of measures helps assure that the system is improved: • Related to aim’s measurable goals • Easy to collect • Show improvement quickly and include outcomes • Can display them graphically over time • Run charts

15. Balancing Measures • Are we improving parts of our system at the expense of others? • Usually not one of goals • Great source is to listen to skeptics… “Yes, but…”

16. Example of Measure Set • The delay for routine appointments • % of patient visits with the patient’s primary clinician • Practice average cycle times • % of patients rating the overall visit as excellent • % of visits that are “no show/missed”

17. Usual Display of Measures

18. QI Measures: Annotated Run Charts Clinician education Reduced appt delays Practice wide guidelines Reminder system

19. AIM: What are we trying to accomplish? MEASURES: How will we know that change is an improvement? IDEAS: What changes can we make that will result in an improvement? Model for Improvement

20. “PDSA Cycles” • PDSA Cycles help teams adapt good ideas to their specific situation: • Force us to think small • Force us to be methodical, make predictions • Allow rapid adaptation and implementation of changes in busy healthcare settings

21. The PDSA Cycle Act Plan • Objective • Questions and predictions • Plan to carry out the cycle (who, what, where, when) • What changes are to be made? • Next cycle? Study Do • Complete the analysis of the data • Compare data to predictions • Summarize what • was learned • Carry out the plan • Document problems and unexpected • observations

22. Example PDSA Cycle Act Plan Changes to be made: Test 2 more days- Dr. R on time; nurse to bring charts for prescheduled Objective: Test huddles Questions: Will they uncover capacity? Prediction: Yes Plan: Dr. R care team, huddle 5 mins in AM for 2 days at schedule Study Do Mon and Tues - document problems, Unexpected observations; count uncovered capacity 4 unused visits identified; took 15 minutes due to late arrivals; charts would be helpful

23. Key Points for PDSA Cycles • Do initial cycles on smallest scale possible • Think baby steps…a “cycle of one” usually best • “Failed” cycles are good learning opportunities when small • Successful tests • As move to implementation, test under as many conditions as possible • Special situations (e.g., busy days) • Factors that could lead to breakdowns (e.g., different staff or physicians involved) • Things “naysayers” worry about (e.g., “It will not work when Dr. Noonan is not here”)

24. Questions?