Transcript English - LLU Global Health Institute

QUALITY / PATIENT SAFETY
IN HEALTH PROFESSIONAL
EDUCATION
Dwight C. Evans, M.D. FACP
October 2016
Pursuit of Clinical Quality:
The Science of Improvement
Building on S. of I. Background
Often Healthcare Doesn’t Add “Value”
• Too often Medical interventions are:
• Overused
• Underused
• Used inappropriately
• Medical Care is too often:
• Inaccessible
• Inefficient
• Even harmful
• The ability of your HC system to meet societal needs is
now dependent on improving the quality and value of the
care delivered while reducing costs
Quality and Patient Safety
• For the purposes of discussion, consider them
interchangeable
• Why? Because they share the same vision and
approach to make patient care and supporting
processes better:
• Measure the magnitude of the problem
• Identify root causes & measure importance of each cause
• Find solutions for the most important causes
• Prove the effectiveness of the solutions
• Deploy programs to ensure sustained improvement
• Thus a Safety Culture is the same as a Quality
Improvement Culture
What Drives Improvement
Waste,
Unevenness
Overburden
Mission,
People,
Outcomes
Eliminating Waste is only part of the battle
High Reliability Organizations (HROs)
• HRO’s design work systems to:
• Anticipate
• Contain and
• Recover from Mishaps
• HROs use:
• Science of Improvement tools to shape the behavior of
HC staff to avoid mishaps
• Human failure mode effect analyses,
• Hazard and operability studies
• Standard routines to reduce uncertainty
High Reliability Organizations
• HROs:
• Seek an ideal of perfection, but never expect to achieve it
• Demand complete safety, but never expect it
• Dread surprise, but always anticipate it
• Deliver reliability, but never take it for granted
• They understand that High Reliability is an endless Journey rather
than a simple destination
• Journey Examples:
• Huddles and incident reports
• Standardized protocols and checklists
• Pre and post-procedure briefings
• Goal: a comprehensive operating management system –
organization-wide integrated approach to manage risk
and to achieve safe and reliable performance
The Business Case
• Administrative processes in health care are just
as broken as clinical processes
• HR, IT, Contracting, Billing, Supply chain, etc.
• RPI can directly improve margins
• Quality improvements often don’t save $$
• Learning how to do Rapid Process Improvement
allows organizations to solve their own
problems, eliminate consultants
• Generate positive ROI now while learning how
to redesign care processes for the future (low
hanging fruit)
Culture
• Culture is the frame of reference for meaning and action that
encompasses the skills, beliefs, assumptions, norms, customs
and language that members of a group develop over time
• Culture unobtrusively controls staff’s decision basis-their
expectations about the consequences of particular behaviors
• Risk-taking
• Procedure violation or
• Unsafe behaviors
• Bypassing hand washing
• Reporting of errors
• A safety culture leads to increased patient safety by fostering,
with minimal surveillance, an efficient and reliable workforce
sensitized to safety issues.
Safety (Improvement) Culture
• Aim is a “system-first” culture, but not a “blame-
free” culture
• HROs separate blameless errors (for learning)
from blameworthy ones (for discipline,
equitably applied to all groups)
• Prerequisites for safety culture in health care
• Eliminate intimidating behaviors
• Hold everyone accountable for consistent
adherence to safety practice
• HROs balance learning and accountability
What is Quality Improvement (QI)?
• The combination and unceasing efforts of everyone in HC
(professionals, patients, families, researchers, educators)
to make the changes that will lead to better patient
outcomes (health) and better professional development
(learning)
• QI is:
• A philosophy of continuous performance improvement and
• A set of discrete technical tools and managerial methods
• Value is defined by the “customer”
• May be the Patient [HC exists to serve patients] / Family
• May be a different part of your HC system
• “Value” Must include patient (customer) input as well as the needs of
your HC professionals in order to ensure quality safety and
appropriate service
Lean in Healthcare QI/Pt Safety
• Lean: a QI methodology focused on identifying and
eliminating waste from the HC system
• Value stream mapping/analyzing flow to ID delays, waiting times, errors,
inappropriate procedures
• Standard work
• 5 S (sorting, setting in order, systematic cleaning, standardizing
and sustainment); example: all exam rooms - standard
• Rapid Cycle Improvement via many PDSA cycles
• Once a process is stabilized: SDSA cycles
• Where are you on your journey to become a “High
Reliability Organization?”
Five Lean Principles
1.
Value:
• Value is determined by the end customer – the patient
2.
Value Stream – Mapping processes:
• Linking processes or steps that provide value to the pt
3.
Value flows without interruption:
• Identify ideal patient experience – streamline process and eliminate
waste to achieve “value”
4.
Allow patient to “pull” value from process:
• Available when the patient wants it- one piece flow
5.
Continuous pursuit of perfection:
• Reliable and sustainable systems redesign
Value from the Patient’s perspective…
• No delays in access to service or care, no scheduled
•
•
•
•
•
•
•
waiting
Accurate, consistent, satisfying outcomes
Service flexibility
No delays in receiving test results, medications, products,
services or care
Evening and weekend clinic or service appointments
Expedient assessment and treatment
Competent, caring and professional staff
Clean, welcoming, and aesthetically pleasing facilities
Three Categories of Waste

Mura

Muda
Muri

Muda – waste;
activities that do not
add value
Muri – overburdening
people or equipment
Mura – unevenness in
demand (unbalanced
workflow)
Non-Value Added Steps - MUDA
• Typically 95% of health care process time is non-value
added!
• MUDA: the eight forms of Waste:
• Defects
• Overproduction
• Waiting
• Not utilizing human potential
• Transportation
• Inventory
• Motion
• Extra processing
First group of improvements result from eliminating waste
MURA - Unevenness
• Needs and demands have natural variation which we
often make worse:
• No standardization
• Handoffs
• Delaying
• Economies of scale
• Lack of skills and training
• Second order of improvements result from reducing
variation
MURI - Overburden
• Overburden occurs when the human element of a work
process is not:
• Safe
• Stress free
• Engaging at the same level
• Causes of Overburden are many but typically stem from:
• Too much waste
• Too much to do and not enough time to do it
• Poor ergonomics
• Tolerating overburden demonstrates a lack of respect for people!
5 “S” Principle
5 S Results:
Before 5S
After 5S
Emergency Department - Supplies
Before 5S
After 5S
The Power of Lean
• When properly deployed
• Senior Management as well as Process Improvement model
• Lean:
• Becomes a continuous improvement system to improve work and
outcomes
• A system to execute day-to-day clinical processes
• A management system of how to lead and empower people
• Organizations who utilize Lean:
• Organize jobs into smooth sequences
• Create a balance of human and machine utilization
• Improves physical layout to support employee efficiency
• Provide process control and reduce variation
Health Professional (HP) Education
• We are training the HP for the 2020’s:
• All health professionals should be educated to
deliver patient-centered care:
[via the Science of Improvement]
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Members of an interdisciplinary team
Emphasizing evidence-based practice
Emphasizing quality improvement
With enhanced Informatics infrastructure
• GME: residency programs must demonstrate that
their graduates are competent in systems-based
practice and practice-based learning and
improvement
QI Challenges/Suggestions
in Academic Settings
• Do you have competent senior or mid-level faculty to
serve as role models for your students/residents?
• Are you having to report significant number of quality
metrics?
• Who collects this data?
• Who hires the data analysts?
• Does your academic promotion system legitimize QI/PS
activity similar to research/teaching/clinic activity?
• Is your HC system built to improve/increase the:
• Value you deliver to your patients?
vs.
• Volume of care you deliver?
Coleman et al, “Strategies for Developing and Recognizing Faculty Working in
QI/PS” Academic Med 2016.
QI Challenges/Suggestions
in Academic Settings
Challenges
1. Gap in trained Faculty
QI Mentors
2. Data Bottlenecks
3. Who pays?
Possible Suggestions
1. Junior Faculty join QI
2.
3.
4.
4. Academic Recognition?
5. New model: reward
value not volume
5.
teams
Dedicated QI/PS data
Analysts
Central Funding?
Promotion Committee to
grant credit for QI/PS
time
Obtain payment models
that reward outcomes
Stevens CD, “5 Tactics to Build QI/PS capacity Acad med 2016
What is the status of QI/Pt Safety in your
HP Education program?
• Is QI/Patient Safety an “add-on” subject? Sending a clear
message that QI/Pt Safety is less important relative to other
clinical topics
• Do your Attendings see QI/Pt Safety as part of their
professional identity?
• Do you have a core of academic physicians that can lead and
promote QI/Pt Safety initiatives?
• What do you need to do so that there is social and academic
legitimization of doing QI/ Pt Safety training to HP students and
residents?
• Publish QI / Pt Safety initiatives in peer-reviewed journals
• Research seed monies to start QI/ Pt Safety projects
• Provide protected time for QI/Pt Safety projects
• Academic Promotion: include QI/Pt Safety as essential components for
advancement
Role of HP Schools in Teaching QI/PS
• Similar to “life-long learning” is the concept of
“life-long Quality Improvement”
• If a HP Student learns this, then he/she will
continue doing QI for the rest of his/her
professional life.
• Basic QI learning tool:
• Institute for Healthcare Improvement’s “Open School”
• Successful HP Education QI teaching is:
• Didactic (acquiring new knowledge)
• Experiential-learning by doing (with coaching)
• Competency-Based
QI/Pt Safety training
• How do we create clinically based improvement learning
for all HC students?
• Suggested pattern for QI/Pt Safety training:
• Initial exposure: Web-based modules (IHI’s Open School) for core
concepts
• Classroom exploration of core QI/Pt Safety concepts
• Practice in simulation labs
• Application in clinical settings
• Repeated key finding: lack of critical mass of clinically
based faculty members ready to teach QI/Pt Safety
• Are your HP Students learning to be team leaders?
• Are your students developing the “competencies” of QI/Pt
Safety?
Examples of HP School QI training
• Dartmouth:
• Year one: introduce the student to basic concepts of QI
• Year two:
• Learn and use techniques that can describe people, structures within
•
•
•
•
the HC microsystem
Learn how HC systems are measured and effects of measurement
Learn how to analyze data over time from a system
Learn the basic tools of QI: Aim, flow diagrams, cause-effect diagrams,
Through small groups: (with a coach)
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•
•
•
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Create a play for change in a system
Identify gaps between local and best practices
Use measurement to understand performance variation in a system of care
Learn how to work effectively in groups – learning team leadership skills
Prepare a poster for presentation
Dartmouth example - 2
• Year four:
• Two capstone courses that review
• How healthcare systems work
• The Science of Improvement
• System vulnerabilities
• Safe Prescribing practices
Medical College of Wisconsin Example
• Quality Improvement and Patient Safety Scholarly
Pathway
• One afternoon a week of protected time (non-core time)
• Core sessions• Didactic component: 5 three hour session – year one; 7 in year two
• Content:
• Systems and Systems theory
• Patient Safety Principles
• QI methodology
• Small group experiences (teaching QI methodology) via case work
• Last hour of the session: (guided by a faculty coach)
• 15 min on a core QI methodology
• Then Apply QI methodology (IHI’s Model for Improvement) to that day’s case
• A mentored scholarly project focused on QI or Pt Safety topic
Medical College of Wisconsin Example - 2
• Learning Objectives for QI
• Year One:
• Define safety in systems and human factor science
• Describe the concept of process mapping (HC)
• Create a flow map of a current process
• Explain the importance of systems design in decreasing the potential for
human error
• Evaluate the strength of different types of QI improvement methods
• Demonstrate through role-playing the skills needed to work in a
multidisciplinary team
• Explain why physicians are integral to QI team efforts
Medical College of Wisconsin Example - 3
• Year two:
• Describe the interactions between systems of care and their impact on
a patient with chronic disease
• Describe how patient experience is integral to health system design
• Recognize the impact of an adverse event on the patient, family and
the patient’s physicians
• Define ‘Root Cause Analysis” and explain its importance to QI
• List three types of QI Tools- describe how each one works
• Learn to balance your individual patient care responsibility with that of
being a team member in shared decision making
• Define “medical hierarchy” and “Culture of Safety”
• Describe how a HP Student can bring an error or ‘near miss’ to the
attention of a supervisor
• List and practice three skills to improve resilience and prevent burnout
in med school
• Describe challenges of engaging physicians in QI efforts
• Demonstrate how to disclose an adverse event to a patient
Quality Improvement in Clinical Years
UC - San Francisco
• Year three begins the important concept of “Socialization”
• Emulation of behavior of their residents and Attending
• Learn the norms that are stated or hidden in their clinical setting
• A positive “Culture of Safety”
• Continued need for improvement in safety culture – barriers to student
engagement in patient safety behaviors
• Errors in communication
• Fear of Punitive response to errors: are HC team members encouraged to
disclose patient safety events?
• Medical Hierarchy: low position of power for HP Student and steep authority
gradients – hinder open communication
• Need for curriculum focused on safe handoffs and error disclosure
Ways the LL Academic Healthcare Center has
Implemented Quality / Patient Safety Program?
• Handoff Training
• TeamSTEPPS training
• IHI Open School
• Patient-Centered Bedside Rounds
• Whole Person Care Culture
• Two Quality and Patient Safety Chief Residents – Int Med
• Block rotations for 2nr or 3rd year residents in QI/PS
• Pre and Post rotation surveys
• Continuity IM Residents work on PI teams in their area
Interdisciplinary QI/Patient Safety
• Are your medical and nursing schools working together to
integrate HC improvement and patient safety content into
their curricula?
• How can you create learning experiences in QI/Pt Safety
for both medical and nursing students?
• Experiential learning
• Didactic
• Small Group exercises
• Simulations
• Barriers:
• Lots of scheduling difficulties
• Are students engaged? (lack of knowledge, lack of interest, etc.)
• Different age of students
• Difficult in creating meaningful clinical experiences in QI/Pt Safety for
more than small groups of students
Interdisciplinary QI/Pt Safety training
• Programs that work:
• SBAR Tool – a framework for communication among HC team
members about a patient’s condition
• Situation
• Background
• Assessment
• Recommendation
• TeamSTEPPS (from AHQR)
• Strategies and tools to enhance performance and patient safety training
• Interprofessional clinical simulation based on
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•
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Leadership
Situation monitoring
Mutual support
communication
Trainees’ Future roles
• Trainees need to learn how to present QI data
(“information”) to their healthcare “Board” / Senior
Management
• While “run-charts” (time-series) are excellent graphs, a better
representation is to use “Control Charts”
• Board member may need to be educated as to how Control Charts
are to be interpreted (interpretation skill level)
• Can Board members rapidly interpret key data? To decide what, if any,
actions are needed.
• Time-series representations (Run and control charts) inform:
• Is the performance acceptable? Is the level of variation expected?
• Is the time between metrics allow for action between time points?
• Are the process changes we made working?
• Does this area need greater or different focus? Or resource input?
Trainees’ Future roles - 2
• Trainees need to understand that they need to establish
and help flourish a “culture of QI” in their future
organizations
• Trainees need to understand that they need “buy-in” from
their “Stakeholders” (i.e. Boards)
• Need for “Political Skill” to manage how QI info is presented and
acted upon
Ways to Implement a Hospital-Based
Quality / Patient Safety ( P & PS) Program
• Large Facilities:
• Quality Management Program:
• Quality Assurance (external and internal)
• Process Improvement Program
• Patient Safety Program
• Small Facilities:
• “Quality & Patient Safety” responsibility may be a “Collateral” duty
for one staff member
• Modified Morbidity & Mortality/Process Improvement Committee
Conference
• Attendees: Physicians, Nurses, Pharmacists, Students, Residents,
etc.
Faculty Development Strategies
• Make QI/PS critical to the success of each Dept.
• Have the QI/PS faculty member report to Dept. Chair
• Ensure QI/PS faculty have authority to lead organizational
•
•
•
•
change
Hold all faculty accountable for meeting the 6 IOM Quality
domains
Resources: Funding and time allocation
Establish “Science of Improvement” core in HP Student
curriculum (at least equal to Biostatistics/Evidence-based Medicine)
Establish a “learning community” in QI/PS across your
system
Faculty Development Strategies
• Establish a faculty mentoring program in QI/PS
• Hold Seminars:
• How to start a QI/PS program
• Determinants of a successful QI/PS program
• How to recognize QI/PS work as scholarship and tenure track
• How to facilitate spread of QI/PS through out your HC system
• How to Mentor/teach QI/PS to your students/residents
• Consider HC System/HP Faculty pilot grants to start
QI/PS program and QI/PS projects
CAMEL Suggestion:
• Is CAMEL organization maturing enough to begin:
• “Communities
of Practice”?
[On-line meetings, blogs, Frequently Asked Question sheets, etc.]
• Religion class format and content
• QI and Patient Safety
• _________
• Develop Leadership positions in QI/Pt Safety?
• Develop Chief Resident positions in QI/Pt Safety?
• Create “Chief Patient Safety” Officer concept?
Lean A3 Thinking
• A standardized approach to problem solving:
• For Executive Leadership- very helpful in Strategic Planning
• For front-line staff – very helpful in solving unit-based problems
• A step by step direction to problem solving
• Continuous Improvement (Quality: patient care and Systems)
• The A3 provides a clear, concise, one page overview
• It can consolidate large amounts of information in an
understandable format using visual display
• The A3 process should become the “default” way of
strategic planning/improvements
Strategic Planning Focus – A3
• The A3 process can be used for your annual Strategic
Planning Conference/event to create the:
• Vision
• Goals
• High-level implementation plan for the next year
• By defining “True North” you insure that your entire
organization is strategically aligned
A3 Box 1 Reason for Action
• What is the problem
statement?
• What is the scope of
the problem?
• What are the
boundaries you will
set?
A3 – Box 2 Current State
• What does the
organization look like right
now?
• Data/Business case for need:
• What are the
current/upcoming changes
you wish to initiate?
• Have you personally visited
the site you want to change?
• Gemba Walk
• Identify what are the core
process?
• Flow Map the core processes
• Identify (high-level) major
issues (Kapowie’s)
A3 – Box 3 Future (Target) State
• What do we want the
organization to look like
at:
• 1 year
• 3 years
• 5 years from now?
• What does “Good” look
like?
• How will we know when
we have made an
impact?
A3 – Box 4 Gap Analysis
• What are the big
differences (gaps to be
closed) between the
current and future state?
• What impact do these
gaps have on our ability to
be successful or reach our
target state?
• How much control /
influence do we have over
these gaps?
• What are some of the
potential root causes of the
gaps?
A3- Box 5 Solution Approach
• What ideas / strategies
do we have for closing
the gap?
• Which of the core
processes have the
most potential to close
gaps (attain target)
• What have others done
to close the gaps?
• How easy or difficult are
the solutions being
proposed?
A3 – Box 6 Rapid Experiments
• Proposed countermeasures to
address each root cause
• Predicted results for each
countermeasure
• Do multiple PDSAs
• Assessment Q:
• Are there clear countermeasure
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•
•
•
•
steps identified?
Do the countermeasures link to the
Root Cause of the prob.?
Who is responsible for what, by
when (5 whys – I how clear)
Will these action items prevent
recurrence of the problem?
Is the implementation order clear
and reasonable?
How will the effects of the
countermeasure be verified?
A3 – Box 7 Implementation
• Table to document how
you will do the different
PDSA cycles you do in
closing the gaps
• Who (who leads task)
• What (task)
• When (completion date)
• Where
• Learn and improve as
you go
(PDSAs/RPIWs)
A3 – Box 8 Confirmed State
• Accomplishments
• Metrics (data)
• run charts, control
charts, etc.
• Document quantified
change (% improvement
or % no longer
happening, etc.)
A3 – Box 9 Insights
• What have you learned
from this process?
• How can we make it
better next time
• Summary:
Why Promote A3 Thinking?
• A structured cycle of improvement
• A framework for organizing thinking
• Can be used for any type of problem
• Individual and teams (and systems) – a living,
dynamic document
• Eliminates the waste of debating method
• Reveals the issues, problems and previous ways of
thinking
• Makes problem solving visual
• Tells a Story
A Key tool in becoming a High Reliability Organization