Transcript The Science of Improvement and Creating Reliable Systems

The Science of Improvement:
Creating Reliable Health Systems
Debbie Barnard,MS,CPHQ
SHN Project Manager, CPSI
October / November 2007
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Introduction
Current State of Healthcare
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Canadian Experience
• Canadian Adverse Events Study (Hospital
settings)
(Baker, R. & Norton, P. et al. (2004)
– Incidence rate of 7.5% in hospitals (2000)
– 70,000 preventable adverse events (est.)
– 9,000 - 24,000 preventable AE deaths in Canada (2000)
• One in 9 acquire infection in hospital
• One in 9 given wrong medication
• More deaths occur due to adverse events than
from breast cancer, vehicle accidents and HIV
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How Hazardous Is Health Care? (Leape)
DANGEROUS
(>1/1000)
Total lives lost per year
100,000
REGULATED
ULTRA-SAFE
(<1/100K)
HealthCare
Driving
10,000
1,000
Scheduled
Airlines
100
Mountain
Climbing
Bungee
Jumping
10
Chemical
Manufacturing
Chartered
Flights
European
Railroads
Nuclear
Power
1
1
10
100
1,000
10,000
Number of encounters for each fatality
100,000
1,000,000 10,000,000
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How Hazardous Is Health Care?
(Leape)
DANGEROUS
(>1/1000)
Total lives lost per year
100,000
REGULATED
ULTRA-SAFE
(<1/100K)
HealthCare
Driving
The Goal
10,000
1,000
Scheduled
Airlines
100
Mountain
Climbing
Bungee
Jumping
10
European
Railroads
Nuclear
Power
Chemical
Manufacturing
Chartered
Flights
1
1
10
100
1,000
10,000
100,000
1,000,000 10,000,000
Number of encounters for each fatality
Copyright 2002 Institute for Healthcare Improvement
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Seeing Differently
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“The real act of discovery is not
in finding new lands, but in
seeing with new eyes”.
Marcel Proust (1871-1922)
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Nine Box Puzzle
• On your sheet there are nine dots arranged in a set of
three rows. Your challenge is to draw four straight lines
which go through the middle of all of the dots without
taking your pen off the sheet of paper.
• You can start from any position on the paper and draw
the lines one after the other without moving your pen
from the paper.
• Each line must start where the last line finishes.
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System of Profound Knowledge
The System has four parts
• Appreciation for a system
• Knowledge about variation
• Theory of knowledge
• Psychology
Source: Horn, Steve, “Deming's System of Profound Knowledge”
http://home.clara.net/hornsc/spk/spk_intro.htm [Accessed October 2007]
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Lens of Profound Knowledge
“The system of profound
knowledge provides a
lens. It provides a new
map of theory by which
to understand and
optimize our
Theory of
organizations.”
Appreciation
of a system
Knowledge
Psychology
Deming, The New
Economics, 1993
Understanding
Variation
Provost, L.; Godlee, F., “Connecting the Science of
Improvement to Medical Research” International Forum on
Quality and Safety in Health Care [Online Access Oct. 2007]
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Deming’s System of Profound
Knowledge
APPRECIATION
OF A SYSTEM
THEORY OF
KNOWLEDGE
PSYCHOLOGY
UNDERSTANDING
VARIATION
Source: Margolis,P & Lannon L; NRSA AHRQ Workshop:
Quality and Quality Improvement
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Understanding Systems
APPRECIATION
OF A SYSTEM
THEORY OF
KNOWLEDGE
PSYCHOLOGY
UNDERSTANDING
VARIATION
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What is a System?
“A system is a network of interdependent
components that work together to try to
accomplish the aim of the system.”
W Edwards Deming,
The New Economics, p. 50
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System
Source: Horn, Steve, “Deming's System of Profound Knowledge”
http://home.clara.net/hornsc/spk/spk_intro.htm [Accessed October 2007]
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Common View of a System
CEO
Assistant
VP
VP
Director
Director
Manager
Director
RN
RN
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Common Conception of a System
CEO
Assistant
VP
VP
Director
Director
Manager
Director
RN
NO!!!! According to Deming
RN
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Slide
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System of Improvement - Five
Activities for Leaders
Source: Harries, Bruce: Presentation to SHN Education Resources Committee – January
2007Quality as a Business Strategy Associates in Process Improvement (API), Austin Texas copy write
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Types of Processes
• Mainstay processes - those processes
that directly relate to the mission of the
organization and add value to the external
customers of the organization.
Source: Quality as a Business Strategy - Associates in Process Improvement API,
Austin Texas pages 1-26, 1-27 copy write 8/2006
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Types of Processes
• Driver processes - those processes that
"drive" the mainstay of the organization.
These processes are usually associated
with the need that the organization intends
to fulfill (from the mission statement of the
organization).
• Examples:
– customer feedback, planning, research,
development, budgeting, etc.
Source: Quality as a Business Strategy - Associates in Process Improvement API,
Austin Texas pages 1-26, 1-27 copy write 8/2006
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Types of Processes
• Support processes - those processes
that are necessary to support the mainstay
processes.
• Examples for a healthcare organization
are IT, HR, Communications, etc.
Source: Quality as a Business Strategy - Associates in Process Improvement API,
Austin Texas pages 1-26, 1-27 copy write 8/2006
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EXAMPLE
Systems View of SHN Campaign
Wednesday Updated: Sunday, January 28, 2007
Purpose of Camgaign
Enabling providers to work with
patients on selected topics to
reduce preventable harm in Canada
DRIVERS
Coordination
Partnership
and
Alliance
Needs
Assessment
Planning
Funding
and
Budgets
Governance
Communication
Measurement
Evaluation
Learning
from
Teams
Feedback
MAINSTAY
Building
Relationships
(infrastructure)
Nodes,
Clinical &
Campaign
Supports
SUPPORT
Maintain
and
Manage IT
Education/
Training
Workshops,
Conference
calls,Website,
Getting
Started Kits
Caring for
each other
Recognition
Future leaders
Psychosocial
support
Support staff
Social events
Purpose of CPSI
Provide national leadership to
improve safety in Canada
HR
Getting
people to
the right
place
Clinical
supports
Nodes/
SIA’s
Purpose of CPSI Secretariat
Provide funding, co-ordination
and communication to enable
the campaign to reduce harm.
Page 1
Harries, Barnard, Hoffman 2006
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Understanding Variation
APPRECIATION
OF A SYSTEM
THEORY OF
KNOWLEDGE
PSYCHOLOGY
UNDERSTANDING
VARIATION
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“In God we trust. All others
bring data.”
W.E. Deming, Ph.D.
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Measurement Has Two Purposes
• Helps you to know:
– Where you are?
– Where you are going?
• “Without measurement it is
impossible to know whether you
have improved”
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Types of Measures
Type of measure
Examples
Outcome measures
Rates
Failures
Re-admits
Mortality, LOS
Process measures
% use order set, guideline, etc
% treated in required time
% receiving 100% of ‘bundle’
Times, durations
Etc
Balancing measures
Costs
Delays
Resources
% detected by redundant process
Etc
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Process vs. Outcome
Measures
Outcome = Voice of customer/patient:
• How is the system performing?
• What is the result of systems?
• How is the health of patients affected?
Process = Voice of workings of the system:
• Are the parts/steps in the system performing as
planned?
• Are key changes being implemented?
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Common Terms
• Variation - difference in the output of a process (or
inputs to a process) over time. Variation consists of
common cause variation, special cause variation and
structural variation (and some include tampering).
• Common Cause Variation - variation resulting from the
system. Every system will have some amount of
variation of results.
• Special Cause Variation - variation resulting from a
assignable cause. Special causes should be addressed
by finding the special cause and taking action..
Source: Horn, Steve, “Deming's System of Profound Knowledge”
http://home.clara.net/hornsc/spk/spk_intro.htm [Accessed October 2007]
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Common Terms
• Structural Variation - trends within the
data. They often take the form of seasonal
variation and growth or decline
• Tampering - taking action based on the
belief that a common cause is a special
cause.
– Most variation (97% +) is common cause
variation
Source: Horn, Steve, “Deming's System of Profound Knowledge”
http://home.clara.net/hornsc/spk/spk_intro.htm [Accessed October 2007]
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Understanding Variation
Stable Process - one in statistical
control.
Source: Horn, Steve, “Deming's System of Profound Knowledge”
http://home.clara.net/hornsc/spk/spk_intro.htm [Accessed October 2007]
Unstable Process - a process not in
statistical control.
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Common Cause Variation
• Variation exists in all aspects of life
– People’s Behavior
– Weight
– Stress
– Time required to travel to work
– People – “how they learn”, intelligence
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Psychology
APPRECIATION
OF A SYSTEM
THEORY OF
KNOWLEDGE
PSYCHOLOGY
UNDERSTANDING
VARIATION
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Psychology
• This is Deming’s language for the
dynamics of people in the workplace, team
performance, learning styles and
organizational culture. Deming opines that
managers need to know how people
interact, their individual needs, their
working and learning styles.
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Theory of Knowledge
APPRECIATION
OF A SYSTEM
THEORY OF
KNOWLEDGE
PSYCHOLOGY
UNDERSTANDING
VARIATION
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Knowledge for Improvement
Subject Matter
Knowledge
Profound Knowledge
Improvement:
Learn to combine
subject matter
knowledge and
profound knowledge
in creative ways to
develop effective
changes for
improvement.
Improvement
Provost, L.; Godlee, F., “Connecting the Science of
Improvement to Medical Research” International Forum on
Quality and Safety in Health Care [Online Access Oct. 2007]
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Introduction to PDSA
• Deming argued that inspection at the end
of the process is too late and too
expensive.
Quality results from studying and changing
the system, not inspecting the product
Measurements used to monitor the
processes
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Model for improvement
Aims
What are we trying to
accomplish?
Measurement
How will we know that a
change is an improvement?
Ideas, evidence,
hunches,
Other people etc.
The fourth
question:
how to make
changes
What changes can we make that will
result in the improvements we seek ?
Act
Plan
Study
Do
The
three
fundamental
questions for
improvement
Langley, Nolan et al 1996
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Repeated Use of the PDSA Cycle
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
A P
What change can we make that
will result in improvement?
S D
Changes That
Result in
Improvement
Implementation
of Change
A P
S D
Theories
Ideas
Very Small
Scale Test
Followup Tests
Wide-Scale
Tests of
Change
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Why Test
• Why Not Just Implement then
Spread?
 Increase degree of belief
 Document expectations
Build a common understanding
Source: IHI
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Why Test
Evaluate costs and side-effects
Explore theories and predictions
Test ideas under different
conditions
Learn and adapt
Source: IHI
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We Know That…
• Every system is perfectly
designed to get the results it
gets.
• If we want different results, we
must change (transform) the
system
Source: Maher,L. and Plsek, P. “Bringing Creativity and Innovation to Health Services” Presented at the Quality
Improvement in Healthcare Forum, Prague, April 2006
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Reliability in Healthcare
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Why reliability?
• Implementing reliability concepts has been
found to reduce defects in care, increase the
consistency with which appropriate care is
delivered and improve patient outcomes.
( IHI 2004)
• “Reliability means keeping a promise”
(Don Berwick)
Source: Murkin, J. “Reliability Theory in Action”.
www.nhsscotlandevent.com/.../1330%20wed%20alsh%20%20Reliability%20Theor
y%20in%20Action%20FULL%20SESSION.ppt [Accessed Oct. 2007]
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Reliability Rates in Healthcare
A large study in US health care using detailed case notes
review concluded that the “defect rate” in the technical quality
of American healthcare is approximately -
45%
(McGlynn, et al The quality of healthcare delivered to adults in the
United States NEJM 2003; 348)
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3 Steps Towards Reliability
1. Prevent failure (a breakdown in operations or
functions).
2. Identify and Mitigate failure: Identify failure
when it occurs and intercede before harm is caused, or
mitigate the harm caused by failures that are not
detected and intercepted.
3. Redesign the process based on the
critical failures identified.
Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper.
Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org)
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Reliability Equation
Reliability =
Number of actions
that achieve the intended result
÷
Total number of actions taken
Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper.
Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org)
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Reliability
What does the system look like?
Less than
10-1
Chaotic, ad hoc, no system
(<80%, out of
control)
10-1
Intent, vigilance, hard work
10-2
Design informed by reliability science
and human factors
(80 – 95%
success)
(95 – 99.5%
success)
10-3 or more Design of ‘High Reliability
(<5 per 1000
Organisations’
failures)
(Nolan, after Weick)
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10-1 performance
• Standard tools and techniques used at the
10-1 performance level include:
Use of common equipment brands
Standard order sheets and guidelines
Memory aids such as checklists
Feedback mechanisms regarding
compliance with standards
Awareness-raising and training
Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper.
Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org)
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10-2 performance
• Standard tools and techniques used at the
10-2 performance level include:
“Opt-out” – The desired action = flow of work
Standardize processes
Create redundancies and time lapses
Build design aids into the system
Make the desired action the default
Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper.
Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org)
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10-2 Performance Principles
• Constraints: Constraints restrict or limit the
performance of certain actions. For example,
computers that signal an alarm when two
medications prescribed for the same person
should not be taken together serve as a
constraint.
• Affordances: An affordance provides clear
visual or other sensory clues that lead the user
to use a product or tool correctly, or perform the
correct action. An outward-swinging door with a
pushplate but no handle is an example.
Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper.
Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org)
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10-2 performance
• Reminders: Examples include calling patients the day
before their appointments to reduce no-shows and late
arrivals, and using checklists or alarms to prompt
specific actions.
• Differentiation: To reduce confusion when actions,
parts, or numbers are similar, patterns are broken by
color coding, sizing parts differently, numbering items in
easily distinguishable ways, or separating similar items.
.
Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper.
Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org)
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10-3 performance
• Failure Modes and Effects Analysis (FMEA)
Failure modes (What could go wrong?)
Failure modes (Why would the failure
happen?)
Failure modes (What would be the
consequences of each failure?)
Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper.
Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org)
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Questions/Comments
Debbie Barnard, MS, CPHQ
Project Manager Safer Healthcare Now!
Canadian Patient Safety Institute
Suite 1414, 10235 101 Street
Edmonton, Alberta T5J3G1
Phone: 780-498-7259 or 1-866-421-6933
Fax: 780-409-8098
Email: [email protected]
Website: www.patientsafetyinstitute.ca
The Canadian Patient Safety Institute would like to acknowledge funding
support from Health Canada. The views expressed here do not necessarily
represent the views of Health Canada
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