Transcript Doing Well By Doing Good: The Physician Business Case for Quality

"Quality Improvement
(QI) in Healthcare
Department of Family Medicine Faculty Meeting
November 12, 2008
Why should we get involved?
 Number of patients who die from breast
cancer every year: 42,297
 Number who die from automobile
accidents: 43,458
 Number who die from medical errors:
44,000 – 98,000
Why should we get involved?
% of Americans who report they or a
family member experienced a medical
error: 22
Annual cost of preventable patient injury
resulting from medical errors:
$17-29 billion
Why should we get involved?
% of health care workers who don’t wash
their hands between patients: 50-80
# pts who acquire infections in US
hospitals each year: 1.7 million
Why should we get involved?
Rank of US among major industrialized
nations in per capita spending: # 1
Rank of US in death rates from conditions
we know how to prevent: # 1
Why should we get involved?
 ACGME Core Competencies
•
•
•
•
•
•
PATIENT CARE
MEDICAL KNOWLEDGE and SKILLS
INTERPERSONAL AND COMMUNICATION SKILLS
PROFESSIONALISM
SYSTEM-BASED PRACTICE
PRACTICE-BASED LEARNING AND IMPROVEMENT
are also now JC requirements for credentialing!
 MOC – maintenance of certification
 INTRODUCTION
 The proposed project will develop and
implement a formal curriculum and
experiential learning process to train
residents in quality improvement (QI) of
primary care . . . through two major
objectives
Objective 1: Incorporate Evidence-Based Quality Improvement
Process into the curriculum to (2) Prepare family medicine residents
with the knowledge, skills and attitudes to utilize an evidence-based
quality improvement process in their medical practice
Tentative Topics / Content
1. Basics of QI (definition of terms)
2. History of QI and why now in health care
3. Basic tools of QI
4. Nationally recognized resources for QI
5. Analyzing quality data
6. Patient-centered approach to QI (Chronic Disease Model)
7. Role of information technology in QI
8. Discussion of outcomes measures and QI
9. Association of QI and patient safety, reduced costs, etc.
10. QI applied to different cultures and healthcare
disparities
What is "Quality Improvement"?
 Quality Improvement (QI) is a method that
organizations use to increase the quality and
value of their goods or services.
 By understanding the basic principles and
tools of QI and applying them to your work,
quality and excellence will become a part of
your everyday life.
"We are what we repeatedly do. Excellence, then, is not an
act, but a habit."
-- Aristotle
Barriers to Improvement
“Inertia”
“Good enough?
“Every system is perfectly
designed to achieve the
results it gets.”
Donald Berwick, M.D.
Quality Improvement and Excellence rely on both the
system and the individual.
The system is responsible to the individual and the individual is
responsible to the system (i.e., interdependence).
"The achievements of an organization are the results
of the combined effort of each individual."
-- Vince Lombardi
Today’s Focus:
Brief overview and introduction to
approaches to and models for
quality improvement
Underlying Principle
 Quality improvement, in order to be
implemented and effective, must
incorporate principles that support a
simple, common sense approach to
problems.
Quality Improvement “Models/Models”
 Organizational Frameworks / Quality Management
Models



Baldrige Evaluation Process
ISO 9001 Certification
Balanced Scorecard Approach
 Quality Improvement Methods




Six Sigma
Human Factors
Lean or TPS (Toyota Production System)
PDCA / PDSA Cycles or Model for Improvement
 Quality Improvement Theories


Reliability Theory
Spread Theory
Review of the Main Concepts
 Baldrige:  Performance Excellence (value/quality service)
 ISO 9000:  Performance Excellence (internal processes)
 Balanced Scorecard:
 Performance Excellence
(measurement of business processes and external
outcomes)
 Lean:
 Waste;  Efficiency (internal processes)
 Human Factors:
 Performance; 
Variation (staff
abilities)
 Six Sigma:
 Performance;  Variation
business goals)
 MFI:
 Processes
(cost saving,
Design of health care systems and processes
Elements configured by ‘designers’ include:

People – education, training, orientation, …

Materials – medications, supplies, …

Tools – medical equipment, information
technology, forms, communication media, …

Methods – procedures, diagnostic and treatment
processes, management practices, policies,
communications practices, coordination of effort,
Sources of design failure in complex systems
Design flaws are expected because (for example):
 Actual operations are more complex than our design





models
System elements interact in unexpected ways
Procedures, tools, and materials are used in ways not
anticipated
Multiple designers with potentially different goals and
assumptions
Safety features, defenses become degraded over time
Environmental conditions, expectations, and demands
change over time
The world points out our design flaws to us
In the course of actual operations, design flaws will
produce:
 Errors, unsafe acts, procedure violations
 Glitches
 Near-misses
 Accidents
 Injury
 Sentinel events/catastrophes
(We may also learn from other people’s failures)
Model for Improvement (MFI)
Definition
 The MFI is based on a “trial and learning” approach. This trial
and learning approach revolves around three questions.

What are we trying to accomplish? (AIM)

How will we know that a change is an improvement?
(Criteria or Measures)

What changes can we make that will result in
improvement? (Testing Changes)
 Focusing on these questions accelerates the building of
knowledge by emphasizing a framework for learning, the use of
data and the design of effective tests or trial.
Setting Aims
Improvement requires setting aims. The aim should be time-specific and
measurable; it should also define the specific population of patients that
will be affected.
Establishing Measures
Teams use quantitative measures to determine if a specific change
actually leads to an improvement.
Selecting Changes
All improvement requires making changes, but not all changes result in
improvement. Organizations therefore must identify the changes that
are most likely to result in improvement.
The Plan-Do-Study-Act (PDSA)
Cycle
Testing Changes
The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change
in the real work setting — by planning it, trying it, observing the
results, and acting on what is learned. This is the scientific method
used for action-oriented learning.
Steps in the PDSA Cycle
Step 1: Plan - Plan the test or observation, including a plan for
collecting data.
•State the objective of the test.
•Make predictions about what will happen and why.
•Develop a plan to test the change. (Who? What? When? Where?
What data need to be collected?)
Step 2: Do - Try out the test on a small scale.
•Carry out the test.
•Document problems and unexpected observations.
•Begin analysis of the data.
Steps in the PDSA Cycle
Step 3: Study - Set aside time to analyze the data and study the
results.
•Complete the analysis of the data.
•Compare the data to your predictions.
•Summarize and reflect on what was learned.
Step 4: Act - Refine the change, based on what was learned from the
test.
•Determine what modifications should be made.
•Prepare a plan for the next test.
“MFI” vs. “Scientific Method”
 P - Hypothesis
 D - Methods
 S - Results
 A - Conclusions
Ideas for change
 Can come from a variety of sources:
 Critical thinking about the current system
 Creative thinking
 Observation of the process
 A hunch
 Scientific literature
 Insight gleaned from a completely different
situation
Develop and pilot test a change
 The plan for the test should cover who will do
what, what they will do, and where it will be
done.
 Testing a change allows a preview of the effect
that one or more changes would have if they
were implemented.
Testing changes is an iterative process: the completion of each
Plan-Do-Study-Act (PDSA) cycle leads directly into the start of
the next cycle.
We learn from the test — What worked and what didn't work?
What should be kept, changed, or abandoned? — and uses the
new knowledge to plan the next test. The team continues linking
tests in this way, refining the change until it is ready for broader
implementation.
Continue and Reinforce changes that
lead to an improvement
 Previously labeled "trial-and-error",
these cycles of implementing change
and reviewing the effects should be
thought of as "trial-and-success" or
"trial-and-learning".
 METRIC stands for Measuring, Evaluating
and Translating Research Into Care.

It is an innovative online practice improvement
program that allows you to earn CME credit in
your office, while improving patient care. The
program is designed to assist family physicians in
fulfilling the requirement for Part IV of
Maintenance of Certification.
Resources
 Institute for Healthcare Improvement
 http://www.ihi.org/ihi
 IHI Open School
 http://www.ihi.org/IHI/Programs/IHIOpenSchool/IHIOpen
SchoolforHealthProfessions.htm
 AAFP Clinical QI Resources
 http://www.aafp.org/online/en/home/practicemgt/quality.h
tml
 AHRQ
 http://www.ahrq.gov/