Improvement Science Made Simple Dr. Moza Alishaq-Ph.D Dr. Jameela - - PowerPoint PPT Presentation

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Improvement Science Made Simple

• Dr. Moza Alishaq-Ph.D
• Dr. Jameela Alajmi-MD

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Objective :

To gain an understanding of:

• Quality
• Quality improvement
• Profound Knowledge
• Model of change
• Describe the basic principles of quality improvement
• introduce the methods and tools for improving the quality of

health care by using Model for Improvement, PDSA and its Journey

• Creativity thinking & Improvement in Decision Making

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• UNDERSTAND QUALITY :

Institute of Medicine, is often used:

• [QUALITY is] the degree to which health

services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

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HOW OTHERS LOOK AT QUALITY `Institute for Healthcare Improvement (IHI): “Quality- is as outcomes management, minimizing unnecessary variation so that outcomes become more predictable and certain.

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What does quality in healthcare means?

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The Institute of Medicine has identified six dimensions of healthcare quality.

These state that healthcare must be:

Therefore, leaders need to actively consider these six dimensions when setting their priorities for improvement.

Safe Effective Patient Centered Timely Efficient Equitable

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WHAT DO YOU THINK IS QUALITY IMPROVEMENT

Quality improvement. it as a systematic approach that uses specific techniques to improve quality. The conception of improvement better patient experience and

• utcomes achieved through

changing provider behaviour and organisation through using a systematic change method and strategies. They are combination of a ‘change’ (improvement) and a ‘method’ (tools), in order to achieve better outcomes.

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How can we improve a system to achieve better results in the dimensions of quality

You need to :

• Know the place of care/service
• Know your patients
• understand the system is failing –Identify what is wrong.
• make sure it is the step that needs fixing.
• `Identify processes that can be improved and lead to

better quality of care.

`Then you can implement a change to the “system”.

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What would improve quality?

4 1 2 3

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1

Understanding the problem, what the data tell you - understanding the processes and systems within the

• rganisation –patient pathway

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Analysing The demand, capacity and flow of the service

1

2

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choosing the tools to bring about change, and include:

• leadership and
• clinical engagement,

skills development,

• staff and patient

participation

1

3

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Evaluating and measuring the impact of a change

4 1 2 3

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Enhance the relationship

Manage Time Manage variation

9 Categories of Change for Quality Improvement

eliminate waste improve work flow

change work environment

design systems to avoid mistakes focus on the product/service

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Knowledge Of a System Knowledge Of Variation Knowledge Of Psychology Theory Of Knowledge

The Deming System Of Profound Knowledge

• Appreciation of a system : understanding the overall

processes involving suppliers, Producers, and customers ( or recipients ) of goods and services ( explained below );

• Knowledge of variation : the range and causes of

variation in quality, and use of statistical sampling in measurements;

• Theory of knowledge : the concepts explaining

knowledge and the limits of what can be known.

• Knowledge of psychology : concepts of human nature .

W Edwards Deming

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Common Variation=is always present Is inherent in the process Special cause =It is irregular causes that are not inherent in the design of process

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Group Activity

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Appreciation of a system

What are the resources required to improve system?

Knowledge of variation What is your predication about type of variation? Theory of knowledge

What are the ideas you would like to implement to reduce waiting time?

Knowledge of psychology How are you going to reward the team?

Reduce Outpatient Waiting Time

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Five Deming Principles That Help Healthcare Process Improvement

• 1. Quality improvement is the science of process

management .

• 2. If you cannot measure it…You cannot improve it .
• 3. Managed care means managing the processes of care,

not managing physicians and nurses .

• 4. The right data in the right format at the right time in

the right hands.

• 5. Engaging the “smart cogs” of healthcare .

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Exercise on Quality

What is the benefit for:

Patients Staff

Organization

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What is ‘‘quality improvement’’ and how can it transform healthcare

• better patient outcomes (health),
• better system performance (care) and
• better professional development (learning).

Everyone

Better Professional development (Learning) Better patient (and population ) Outcomes (Health) Better System Performance (Care)

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Enter

The Stages Of Change Model

Precontemplation (Not yet

acknowledging that there is a problem behavior that needs to be changed) Contemplation (Acknowledging that there is a problem but not yet ready or sure of wanting to make a change) Preparation/Determination (Getting ready to change) Action/Willpower (Changing behavior) Maintenance (Maintaining the behavior change) Relapse (Returning to older behaviors and abandoning the new changes)

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Exercise

• Thinking of not smoking but not now I still thinking

about it

• Stop Smoking didn’t help me to be healthy there is

no difference

• I am thinking of stop smoking, can you help how to

do this?

• It is not the time for me to stop Smoking
• It is my time to keep doing exercise and follow up

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S P O

• Facilities
• Staff
• Equipment
• Evolutions
• Treatments
• What gets done to

patients

• Survival
• Degree of health
• Time to recovery
• Disability due to care
• Sustainability of health
• Long-term adverse

consequences of care

Donabedian Quality Framework

Structure Outcome Process

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The Patient Journey Through Hospital System

Emergency Department

Theatre P.I.C.U Ward Specialist Clinics

Pharmacy Medical Imaging Pathology Allied Health Support Services

The Patient experience is a direct result of how the different hospital systems interact and the way staff work within these systems to provide patient care.

Please note : The purpose of this diagram is to demonstrate the large number of systems that a patient could pass through on their healthcare journey.

Patient Arrives

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Interaction

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A female patient 23 years old was admitted to the medical intensive care unit at MBX hospital due to sudden loss of consciousness and seizures. At the time of admission

• bserved lack of consciousness, seizures and severe critical condition was
• bserved. Meningitis and septic shock were diagnosed. Based on computed

tomography performed on the first day--inflammation of the sinuses soft tissues was diagnosed. Suspected cause of infection was performed 6 weeks earlier surgical correction of the nasal septum. In the next stage of treatment on the seventh day after admission the functional endoscopic sinus surgery was performed. Due to massive tissue hypoperfusion the necrosis in the skin of the lower limbs

• ccurred. Due to the lack of effectiveness antimicrobial therapy use of intravenous

ceftaroline was administrated. Effective treatment allowed in day 11 to wean the patient from the ventilator. At the day 26 the patient was transferred to a hospital in the place of residence.

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Break Time 15 Minutes

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• Have you ever attempted to make a change in your personal or professional life and failed;

perhaps a New Year’s resolution?

• Your failure to improve was probably not due to a lack of motivation or a desire to improve,

but rather to a lack of utilizing a good method proven to be effective at implementing change.

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We all work with and within systems:

Systems of communication

1

Reporting systems

2

Systems for complaints

3

Systems for distributing information

4

Systems for issuing prescriptions or medication

5

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How it has been done so far…

What is the best way to approach change that results in improvement?

Trial & Error? Chaos Too much action, not enough thinking “Something must be done, this is something, therefore we must do it…” Detailed prior study? Paralysis Too much thinking, not enough action “We can’t do anything until we know exactly what to do…”

“Trial and Learning” Approach

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Trial and Learning’ Component Parts

• Setting challenging aims
• Identifying principles/change ideas

what has worked for someone? What might work for us?

• Measuring progress

knowing what’s happening

• Testing changes

starting small; reducing risk

• Implementing and sustaining change

change in systems and routines; developing skills and abilities

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Embedded PowerPoint Video

By PresenterMedia.com

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Three fundamental questions for model of improvement

THE THINKING PART

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The 3 Questions

The Model for Improvement begins with three fundamental questions:

• What are we trying to

accomplish? (How good do we want to get and by when?)

• 1. The Aim:

How will we know a change is an improvement?

• 2. The Measures:

What change can we make that will result in improvement?

• 3. The Changes:

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PDSA CYCLE : The Doing Part of the Improvement Model

( test changes)

Plan a change Do the change Study the results Act on the result

Walter Shewhart was the first person to propose a version of the PDSA cycle.

• W. Edwards Deming modified Shewhart's cycle to PDSA, replacing "check" with "study.

P D C A P D C A

P

D

C A

Higher Quality

Rotation 1 Rotation 2 Rotation 3

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What is a PDSA?

• A structured approach for making small incremental changes to systems
• A full cycle for planning, implementing, testing and identifying further changes
• A common sense, easy to understand tool for bringing about change
• A tool which can reduce anxiety to change

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PLAN DO STUDY ACT

What changes are we going to make based on our findings

What were the results? What exactly are we going to do? When and how did we do it?

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Process Of Applying Model of Improvement Example: Quality Improvement Project on Antimicrobial Stewardship Heart Hospital-HMC

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PLAN DO STUD Y ACT

What are we trying to accomplish ? How will we Know if a change is an Improvement?

What changes can we make that will result in improvement ?

Model For Improvement

Step.1

• 1. Define the problem
• 2. What exactly are you trying to achieve
• 3. Refer to the Nolan questions (thinking )

AIM The aim should be time-specific and measurable; it should also define the specific population of patients that will be affected, applicable to specific system. MEASURE Working out what to measure, How to measure and collect it SELECT CHANGES Organizations therefore must identify the changes that are most likely to result in improvement. In this section you will

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• A Performance Measure is a quantitative tool that provides an indication of an
• rganization’s performance in relation to a specified process or outcome.
• Set goals for measures:

A SMART goal is a goal that is specific, measurable, attainable, relevant and time based.

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Process Compliance with checklist Outcome Infection rate Balance Cost reduction

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• BASELINE MEASURES

OUTCOME MEASURES:

• The number of VAP/1000 device days will be calculated in monthly basis by using infection control

surveillance form, microbiology lab, and CDC, NHSN standards/guideline

PROCESS MEASURES:

• % compliance with VAP bundle
• % Hand Hygiene
• % adhered to the respiratory therapy and sedation vacation protocol.
• % of adherence to intubation guidelines.
• Average Reduce LOS related to VAP.

BALANCEE MEASURES:

• Average Patient/relative satisfaction

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Main Issue 1 Factor Factor Factor Main Issue 2 Factor Factor Factor Main Issue 3 Factor Factor Factor Factor Factor Factor Main Issue 4 Factor Factor Factor Main Issue 5 Factor Factor Factor Main Issue 6 Problem

• r Effect

FISH DIAGRAM – Up to 6 Causes

Scenario-Fishbone

You are working with group of staff from an outpatient clinic wanted to understand what caused the common problem of long waiting times for outpatient appointments. The facilitator ask the team involved in the outpatient clinic to meet together and to write the fishbone analysis tool to clearly on a flipchart and document all the causes of waiting times

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Antibiotic stewardship infrastructure Preauthorization & Restriction Develop ( clinical Audit ) strategy Data Monitoring & surveillance

Global Aim Implementation antibiotic stewardship program Specific Aim Timely and appropriate use of antibiotic in acute care setting by 100% by End of Dec2015

Outcome measures: prevalence of MDRO Incidence of CD Process Measures: Compliance % to surgical prophylaxis Utilization rate of ( promoted and restricted antibiotics) % De-scalation Balance Measure: Mortality rate Cost reduction %

• Develop anti stewardship multi-displinary team Create Clean lines of accountability:
• Between chief executive
• Clinical governance
• Therapeutic committee
• Infection prevention and control committee
• Periodic release of anti-biogram
• Share surveillance with point of care
• Education point of care
• Develop Antimicrobial review methods
• Use of diagnostic tools
• Audit and direct feedback to prescribers
• Formulary restrictions / approval system
• Antimicrobial Prescribing Policy
• Care pathway /Checklist

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To test your change use the PDSA cycle. step.2

Start with a PLAN  Who?  What?  Where?  When?  How?  Predication of the answers to the questions  What are you going to measure? Data collection Do: the action part of the process Observations are made and recorded include things that were not part of the plan

CONTINUOUS IMPROVEMENT

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Step.2 Aim : Right drug, right dose, right time, right duration for Surgical patients .

Review in line with HMC guidelines with H.H OR

S A P D P D S A S A P D P D S A P D S A

Cycle 5: Implement in other all surgical cases Cycle 1: Testing

prescribing in CABG pilot population based

• n local policy

Cycle 2: Testing administration

in anesthetic room

Cycle 3: Testing recording timings ; Surgical

prophylaxis ONE DOSE within 60 minutes before knife to skin

Cycle 4: Testing repeat and /or postoperative doses –

pharmacist /surgeon

*A repeat dose of prophylaxis may be required for prolonged procedures or where there is significant blood

• loss. A treatment course of antibiotics may also need to be given in cases of dirty surgery or infected wounds.

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Study

• Study the outcome of your measures What worked? Do you need to carry out another PDSA?
• Do you need to involve more people?
• Do you need to generate more ideas?
• What didn’t work and why?

Do you need to change the plan? Do you need to tweak the original PDSA?

CONTINUOUS IMPROVEMENT

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Act

• What changes are you going to make based on your

findings? This will inform your next PDSA cycle

• Document the change you are going

to make and identify future plans

CONTINUOUS IMPROVEMENT

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Months

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P D C A P D C A P D C A

Higher Quality

P D C A P D C A P D C A P D C A P D C A P D C A P D C A P D C A P D C A

Create Multiple PDSA Ramps

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Scottish Primary Care Collaborative Borders GP Practice

10 20 30 40 50 60 70 80 90 B a s e l i n e M

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t h 2 4 % of People with Diabetes % of Diabetes Patients with a BP<140/80

Diabetes (blood pressure) Improvements with PDSAs

PDSAs to improve shared diabetes information with Secondary Care

PDSA to contact all Patients who have not had a BP check in the last year

PDSAs PDSAs PDSAs

PDSAs to improve current patient recall system PDSAs to Validate Diabetes Register

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• Step. 3

Implementing Changes After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the team may implement the change on a broader scale — for example, for an entire pilot population or on an entire unit. e.g.: Antibiotic prophylaxis in all CBAG patients in TICU

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• Step. 4

Spreading Changes After successful implementation of a change or package of changes for a pilot population or an entire unit, the team can spread the changes to other parts of the organization or in other organizations

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The Principles Of PDSAs

• Breaks down change into manageable, bite-sized time-limited chunks

Not audits – snap shots in time

• Small changes can be tested without causing upheaval to the whole system

Tell others what you are doing

• If it doesn’t work, try something different based on your learning

Document what did/didn’t work

D P A S

3 Intervention phase Diagnostic phase 2 1 Project phase 4 5 Sustaining improvement phase Impact phase Project mission Project team Conceptual flow of process Customer grid Data

• fishbone
• Pareto chart
• run charts
• SPC charts

2 months Plan a change Do it in a small test Study its effects Act on the result 2 months 1 month Annotated run chart SPC charts

D P A S D P A S D P A S D P A S

Ongoing monitoring Outcome Future plans

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

The improvement process

1. Once an intervention has been introduced, the intervention and any improvements need to be sustained 2. This may involve:

• standardization of existing systems

and processes

• documentation of policies,

procedures, protocols and guidelines

• measurement and review of

interventions to ensure that change becomes past of “standard” practice

• training and education of staff

Sustaining improvement phase

Sustain the gains

• standardization
• documentation
• measurement
• training

Sustaining the improvement phase

NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

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Ali Baba Game

Description: Ali Baba is going to the market to sell all his stock But he need your help to load his crazy dromedary Learning Objectives: At the end of this activity, you will be able to describe how assembling Ali Baba stocks with a team can help teach the value of iterative tests of change. Discussion Questions:  Why is assembling something such as with Ali Baba with a team a valuable way to learn about iterative tests of change?  Why is measurement a critical component of PDSA cycles?  Did you find Ali Baba it effective? Why or why not?

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Break time for 15 minutes

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The Six Thinking Hats

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Six Thinking Hats – Team Decision Making



Early in the 1980s Dr. de Bono invented the Six Thinking Hats method



The six hats represent six modes of thinking and are directions to think rather than labels for thinking. That is, the hats are used proactively rather than reactively



The method promotes fuller input from more people. In de Bono's words it "separates ego from performance".



The key theoretical reasons to use the Six Thinking Hats are to:

 encourage Parallel Thinking  encourage full-spectrum thinking  separate ego from performance

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Logical Positive Think of sunshine: this stands for

• ptimism and the logical positive view
• f things

The yellow hat looks for feasibility and how something can be done Example:

• This might work if we moved the

production plant nearer to the customers

• The benefit might come from repeat

purchases

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Feelings & intuitions Color of fire Has to do with feeling, emotions, and high intuitions The red hat gives permission to put these forward without apology or explanation Example:

• this is what I feel about this project,…
• I don’t like the way that this is being done

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Critical Judgement This is the caution hat Th black hat prevents us from making mistakes or doing silly things Example

• The regulation don’t permit us to do

that

• We don’t have the production capacity

to do that

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Creative Thinking Is the color of vegetation The green hat is for creative idea, new idea, additional alternative Example

• We need some new ideas here….
• Are their any additional alternative?

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Information & Data The white hat is neutral: it caries information. it has to do with data and information. Example What information do we have here? What information is missing? How we are going to get the information?

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Control of thinking process Think of the sky Blue hat is for process control This hat ask about how we are thinking the blue hat set the agenda for thinking, summary, conclusion, decision,….. Example

• Could we have a summary
• Could we have decision

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Main benefits of Six Thinking Hats Methods:

1.Allow to say things without risk 2.Create awareness that there are multiple perspectives on the issue at hand 3.Convenient mechanism for “switching gears” 4.Rules for the game of thinking 5.Focus Thinking 6.Lead to more creating thinking 7.Improve communication 8.Improve decision making

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• Scenario:

Increase numbers of surgical site infection post Cesarean section from Jan 2016- April 2017

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1 2 3 4 5 6 7

leadership for change spread of innovation improvement methodology transparent measurement system drivers engagement to mobilise rigorous delivery

Change Model, highlights the following key areas for consideration: