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Continuous qualityimprovementContinuous qualityimprovementTRISASI LESTARI 2017
Continuous qualityimprovementContinuous qualityimprovement
What is Quality?What is Quality?What is Quality?What is Quality?
Seandainya praktek klinis bisasesederhana ini
XPasienkonsultasidg Dokter
XPasienkonsultasidg Dokter
Seandainya praktek klinis bisasesederhana ini
YPasiensembuhdan puas
YPasiensembuhdan puas
Banyak faktor yang mempengaruhiX1 Usia
X2 Gender
X4 Koordinasipelayanankesehatan
X2 Gender
X3 Statuskesehatan X5 Komunikasi
Time 1 Time 2
Banyak faktor yang mempengaruhiX4 Koordinasipelayanankesehatan
Y Outcomepasien (sembuh,perbaikanfungsional ataukepuasan)
X5 Komunikasi
Y Outcomepasien (sembuh,perbaikanfungsional ataukepuasan)
Time 2 Time 3
Kenyataannya seperti ini
X1 UsiaX4 Koordinasipelayanankesehatan
R1
R2
R4
X2 Gender
X3 Statuskesehatan X5 Komunikasi
Time 1 Time 2
R3
R5
Kenyataannya seperti iniX4 Koordinasipelayanankesehatan
Y Outcomepasien (sembuh,perbaikanfungsional ataukepuasan)
X5 Komunikasi
Y Outcomepasien (sembuh,perbaikanfungsional ataukepuasan)
Time 3
Mind the GapMind the Gap
IDENTIFY GAP ANDCHALLENGESIDENTIFY GAP ANDCHALLENGESIDENTIFY GAP ANDCHALLENGESIDENTIFY GAP ANDCHALLENGES
WHAT DO YOUWANT TO CHANGEWHAT DO YOUWANT TO CHANGEWRITE YOUR ANSWER IN A PIECE OF PAPER
WHAT DO YOUWANT TO CHANGEWHAT DO YOUWANT TO CHANGEWRITE YOUR ANSWER IN A PIECE OF PAPER
Quality Improvement
A systematic approach to analyzing (current)performance in an organization
ANDdesigning, testing and monitoring interventions that
bridge the gap
A systematic approach to analyzing (current)performance in an organization
ANDdesigning, testing and monitoring interventions that
bridge the gap
Quality Improvement
A systematic approach to analyzing (current)performance in an organization
ANDdesigning, testing and monitoring interventions that
bridge the gap
A systematic approach to analyzing (current)performance in an organization
ANDdesigning, testing and monitoring interventions that
bridge the gap
The Quality Gurus
W. Edwards Deming(1900-1993)
Walter Shewhart(1891-1967)
The Quality Gurus
Walter Shewhart(1891-1967)
Joseph M. Juran(1904 - 2008 )
W.Edwards Deming
“If I had to reduce mymessage for managementto just a few words, I’d say
it all had to do withreducing variation”.
“If I had to reduce mymessage for managementto just a few words, I’d say
it all had to do withreducing variation”.
“If I had to reduce mymessage for managementto just a few words, I’d say
it all had to do withreducing variation”.
“If I had to reduce mymessage for managementto just a few words, I’d say
it all had to do withreducing variation”.
W.Edwards Deming
“If I had to reduce mymessage for managementto just a few words, I’d say
it all had to do withreducing variation”.
“If I had to reduce mymessage for managementto just a few words, I’d say
it all had to do withreducing variation”.
“If I had to reduce mymessage for managementto just a few words, I’d say
it all had to do withreducing variation”.
“If I had to reduce mymessage for managementto just a few words, I’d say
it all had to do withreducing variation”.
Quality is reducingvariationQuality is reducingvariation
Dr Walter Shewhart
Perkembangan ilmu murni dan ilmu terapan terusmendorong kebutuhan akan akurasi dan presisi. Akantetapi ilmu terapan jauh lebih membutuhkan akurasi
dan presisi dibandingkan dengan ilmu murni
Perkembangan ilmu murni dan ilmu terapan terusmendorong kebutuhan akan akurasi dan presisi. Akantetapi ilmu terapan jauh lebih membutuhkan akurasi
dan presisi dibandingkan dengan ilmu murni
Perkembangan ilmu murni dan ilmu terapan terusmendorong kebutuhan akan akurasi dan presisi. Akantetapi ilmu terapan jauh lebih membutuhkan akurasi
dan presisi dibandingkan dengan ilmu murni
Perkembangan ilmu murni dan ilmu terapan terusmendorong kebutuhan akan akurasi dan presisi. Akantetapi ilmu terapan jauh lebih membutuhkan akurasi
dan presisi dibandingkan dengan ilmu murni
Dr Walter Shewhart
Perkembangan ilmu murni dan ilmu terapan terusmendorong kebutuhan akan akurasi dan presisi. Akantetapi ilmu terapan jauh lebih membutuhkan akurasi
dan presisi dibandingkan dengan ilmu murni
Perkembangan ilmu murni dan ilmu terapan terusmendorong kebutuhan akan akurasi dan presisi. Akantetapi ilmu terapan jauh lebih membutuhkan akurasi
dan presisi dibandingkan dengan ilmu murni
Perkembangan ilmu murni dan ilmu terapan terusmendorong kebutuhan akan akurasi dan presisi. Akantetapi ilmu terapan jauh lebih membutuhkan akurasi
dan presisi dibandingkan dengan ilmu murni
Perkembangan ilmu murni dan ilmu terapan terusmendorong kebutuhan akan akurasi dan presisi. Akantetapi ilmu terapan jauh lebih membutuhkan akurasi
dan presisi dibandingkan dengan ilmu murni
Komponen Ilmu Terapan
Berfokus padacustomer
Berfokus padaproses
Berfokus padacustomer
Berfokus padacustomer
Berfokus padaproses
Berfokus padaproses
Komponen Ilmu Terapan
Berfokus padaproses
Menggunakan datauntuk mengambil
keputusan
Berfokus padaproses
Berfokus padaproses
Menggunakan datauntuk mengambil
keputusan
Menggunakan datauntuk mengambil
keputusan
Crosby (1979)
Quality is FreeQuality is FreeQuality is FreeQuality is FreeQuality is FreeQuality is FreeQuality is FreeQuality is Free
Principles of QualityImprovementPrinciples of QualityImprovementPrinciples of QualityImprovementPrinciples of QualityImprovement
Quality is everyone’s business!(W. Edwards Deming)
Quality is everyone’s business!(W. Edwards Deming)
Quality is a team effortsQuality is a team efforts
Focus of improvement is on process,not individualsFocus of improvement is on process,not individuals
QI must be data drivenQI must be data driven
The QI Process is best whenbased on an established, acceptedmodel
The QI Process is best whenbased on an established, acceptedmodel
Malcolm Baldrige ModelMalcolm Baldrige Model
The QI processmust becommunicable
The QI processmust becommunicable
“If you always do what you havealways done, you will always get
what you have always got!”Don Berwick
“If you always do what you havealways done, you will always get
what you have always got!”Don Berwick
“If you always do what you havealways done, you will always get
what you have always got!”Don Berwick
“If you always do what you havealways done, you will always get
what you have always got!”Don Berwick
Changing Systems/Changingpeople
Change is threatening“Its always been done this way”
Change is time-consuming“what’s the point it will only disrupt the system”
Change means testing out things in your own setting“some people are never happy, no matter what you do,
so what’s the point”
Change is threatening“Its always been done this way”
Change is time-consuming“what’s the point it will only disrupt the system”
Change means testing out things in your own setting“some people are never happy, no matter what you do,
so what’s the point”
Changing Systems/Changingpeople
Change is threatening“Its always been done this way”
Change is time-consuming“what’s the point it will only disrupt the system”
Change means testing out things in your own setting“some people are never happy, no matter what you do,
so what’s the point”
Change is threatening“Its always been done this way”
Change is time-consuming“what’s the point it will only disrupt the system”
Change means testing out things in your own setting“some people are never happy, no matter what you do,
so what’s the point”
Always speak tosomeone different
Didn’t specify whatI wanted properly
GettingGettingInformationInformation
Set impossibletimescales
Defining the Problem
Set impossibletimescales
Am I dealing withreally urgent work?
Other deadlinesOther deadlines
Haven’t plannedtime available well
Not sharingworkload
Didn’t specify whatI wanted properly
Didn’t checkoften
enough
Not got anaccurate
brief
Defining the Problem
Haven’t plannedtime available well
Didn’t checkoften
enough
Waiting for lineWaiting for linemanagers approvalmanagers approval
Not got anaccurate
brief
Didn’t givemanager
enough time
Three fundamental questions forimprovement( Nolan Questions )What are we trying to achieve?
• Know exactly what you are trying to do – have clear aims and objectives
How will we know that change is an improvement?How will we know that change is an improvement?• Measuring processes and outcomes
What changes can we make that will result in an improvement?• What have others done? What hunches do we have? What can we learn as
we go along?
Three fundamental questions forimprovement( Nolan Questions )What are we trying to achieve?
• Know exactly what you are trying to do – have clear aims and objectives
How will we know that change is an improvement?How will we know that change is an improvement?
What changes can we make that will result in an improvement?• What have others done? What hunches do we have? What can we learn as
we go along?
The DOING part of the ImprovementModelThe DOING part of the ImprovementModel
PDSA Cycle
A structured approach for making small incremental changes to systems
A full cycle for planning, implementing, testing and identifying further changesA 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
PDSA Cycle
A structured approach for making small incremental changes to systems
A full cycle for planning, implementing, testing and identifying further changesA 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
PLANWhy do this? What are the
objectives?
What are theexpected results?
What exactly willwe do?
How will wecommunicate our
results?
Does it fit overallmission, values,
plans?
Who needs toparticipate?
For how long willwe engage in this
activity?
How will wemeasure success?
(baseline/outcomeperformance)
For how long willwe engage in this
activity?
How will wemeasure success?
(baseline/outcomeperformance)
How will wecommunicate our
results?
DO = Testing in a small scaleUse interviews or calculations to test feasibilityUse interviews or calculations to test feasibility
Use volunteers or team members to do the testsUse volunteers or team members to do the testsUse volunteers or team members to do the tests
Use a small sub-populationUse a small sub-population
Use one locationUse one location
Conduct the test for a short period of time. Ideally over one week.Conduct the test for a short period of time. Ideally over one week.
DO = Testing in a small scaleUse interviews or calculations to test feasibilityUse interviews or calculations to test feasibility
Use volunteers or team members to do the testsUse volunteers or team members to do the testsUse volunteers or team members to do the tests
Use a small sub-population
Use one location
Conduct the test for a short period of time. Ideally over one week.Conduct the test for a short period of time. Ideally over one week.
The principles of PDSAs
Breaks down change into manageable, bite-sized time-limited chunks
Not audits – snap shots in timeA PDSA cannot be too small!!!!!!
It can be too bigSmall changes can be tested without causing upheaval to the whole system
Tell others what you are doingIf it doesn’t work, try something different based on your learning
Document what did/didn’t work
Breaks down change into manageable, bite-sized time-limited chunks
Not audits – snap shots in timeA PDSA cannot be too small!!!!!!
It can be too bigSmall changes can be tested without causing upheaval to the whole system
Tell others what you are doingIf it doesn’t work, try something different based on your learning
Document what did/didn’t work
The principles of PDSAs
Breaks down change into manageable, bite-sized time-limited chunks
Not audits – snap shots in timeA PDSA cannot be too small!!!!!!
It can be too bigSmall changes can be tested without causing upheaval to the whole system
Tell others what you are doingIf it doesn’t work, try something different based on your learning
Document what did/didn’t work
Breaks down change into manageable, bite-sized time-limited chunks
Not audits – snap shots in timeA PDSA cannot be too small!!!!!!
It can be too bigSmall changes can be tested without causing upheaval to the whole system
Tell others what you are doingIf it doesn’t work, try something different based on your learning
Document what did/didn’t work
Why test?
To learn whether the change will result in an improvementTo predict the amount of improvement possibleTo learn how to adapt the change to different environmentsTo understand the costs and impact of changeTo reduce resistance
To learn whether the change will result in an improvementTo predict the amount of improvement possibleTo learn how to adapt the change to different environmentsTo understand the costs and impact of changeTo reduce resistance
To learn whether the change will result in an improvementTo predict the amount of improvement possibleTo learn how to adapt the change to different environmentsTo understand the costs and impact of changeTo reduce resistance
To learn whether the change will result in an improvementTo predict the amount of improvement possibleTo learn how to adapt the change to different environmentsTo understand the costs and impact of changeTo reduce resistance
What can we learn from testingchanges...
Taking action as a result of learning from the last testsPlanning multiple tests around each changeThinking a couple of tests aheadReally scaling down the sizeMaking sure there is agreement before testing
Taking action as a result of learning from the last testsPlanning multiple tests around each changeThinking a couple of tests aheadReally scaling down the sizeMaking sure there is agreement before testing
Source: Berwick
What can we learn from testingchanges...
Taking action as a result of learning from the last testsPlanning multiple tests around each changeThinking a couple of tests aheadReally scaling down the sizeMaking sure there is agreement before testing
Taking action as a result of learning from the last testsPlanning multiple tests around each changeThinking a couple of tests aheadReally scaling down the sizeMaking sure there is agreement before testing
STUDY
Collect relevant baseline and outcome dataCollect relevant baseline and outcome data
AnalyzeAnalyze
compare with past performance and with external resources.compare with past performance and with external resources.
Collect relevant baseline and outcome dataCollect relevant baseline and outcome data
Analyze
compare with past performance and with external resources.compare with past performance and with external resources.
Study (past tense - outcome)
Study the outcome of your measuresWhat worked? Do you need to carry out another PDSA? Do youneed 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 theoriginal pdsa?
Study the outcome of your measuresWhat worked? Do you need to carry out another PDSA? Do youneed 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 theoriginal pdsa?
Study the outcome of your measuresWhat worked? Do you need to carry out another PDSA? Do youneed 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 theoriginal pdsa?
Study the outcome of your measuresWhat worked? Do you need to carry out another PDSA? Do youneed 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 theoriginal pdsa?
AnalyzeEvaluate the resultsInterpretDiscuss◦is the new process/ strategy/improvement useful?◦practical?◦cost-effective?
Evaluate the resultsInterpretDiscuss◦is the new process/ strategy/improvement useful?◦practical?◦cost-effective?
Evaluate the resultsInterpretDiscuss◦is the new process/ strategy/improvement useful?◦practical?◦cost-effective?
Evaluate the resultsInterpretDiscuss◦is the new process/ strategy/improvement useful?◦practical?◦cost-effective?
ACT
If it works, implement, disseminate,publicize, do training and in-service,
and maintain gains.
If it works, implement, disseminate,publicize, do training and in-service,
and maintain gains.
If it works, implement, disseminate,publicize, do training and in-service,
and maintain gains.
If it works, implement, disseminate,publicize, do training and in-service,
and maintain gains.
Act (present / future tense)
What changes are you going to make based onyour findings?This will inform your next PDSA cycleDocument the change you are going to make andidentify future plans
What changes are you going to make based onyour findings?This will inform your next PDSA cycleDocument the change you are going to make andidentify future plans
What changes are you going to make based onyour findings?This will inform your next PDSA cycleDocument the change you are going to make andidentify future plans
What changes are you going to make based onyour findings?This will inform your next PDSA cycleDocument the change you are going to make andidentify future plans
Repeated use ofthe PDSA cycle
Testing andrefining ideas
Implementing newprocedures & systems- sustaining change
Brightidea!
Implementing newprocedures & systems- sustaining change
Create Multiple PDSA Ramps
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DS
P
DS
A
P
DS
A
DS
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A
receptionist porters Nurses
Create Multiple PDSA Ramps
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DS
A
DS
Nurses
Scottish Primary Care CollaborativeBorders GP Practice
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% of Diabetes Patients with a BP<140/80
Diabetes (blood pressure)Improvements with PDSAs
PDSAs to improve shareddiabetes information with
Secondary CarePDSAs toValidateDiabetesRegister
Scottish Primary Care CollaborativeBorders GP Practice
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% o
f Peo
ple
with
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bete
s
% of Diabetes Patients with a BP<140/80
PDSAs to improve shareddiabetes information with
Secondary Care
PDSA to contact allPatients who have not hada BP check in the last year
PDSAs toValidateDiabetesRegister
Scottish Primary Care CollaborativeBorders GP Practice
0
10
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80
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% o
f Peo
ple
with
Dia
bete
s
% of Diabetes Patients with a BP<140/80
Diabetes (blood pressure)Improvements with PDSAs
PDSAs to improve shareddiabetes information with
Secondary Care
PDSAsPDSAs PDSAs
PDSAs to improvecurrent patient recall
system
Scottish Primary Care CollaborativeBorders GP Practice
0
10
20
30
40
50
60
70
80
90
Baseli
ne
Month
1
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% o
f Peo
ple
with
Dia
bete
s
% of Diabetes Patients with a BP<140/80
PDSAs to improve shareddiabetes information with
Secondary Care
PDSA to contact allPatients who have not hada BP check in the last year
PDSAs to improvecurrent patient recall
system
“If you always do what youhave always done, you willalways get what you have
always got!”Don Berwick
“If you always do what youhave always done, you willalways get what you have
always got!”Don Berwick
“If you always do what youhave always done, you willalways get what you have
always got!”Don Berwick
“If you always do what youhave always done, you willalways get what you have
always got!”Don Berwick
Quality Improvementmeans CHANGE but notall changes areimprovement
Quality Improvementmeans CHANGE but notall changes areimprovement
Quality Improvementmeans CHANGE but notall changes areimprovement
Quality Improvementmeans CHANGE but notall changes areimprovement
Pertanyaan 2: Bagaimana kitatahu bahwa perubahan yangterjadi adalah suatu perbaikan?
Pertanyaan 2: Bagaimana kitatahu bahwa perubahan yangterjadi adalah suatu perbaikan?
Sulitnya mengukur mutu
Makan waktu, menambah pekerjaanMakan waktu, menambah pekerjaan
Harus memastikan akurasi data dan konsistensi metode pengambilan dataHarus memastikan akurasi data dan konsistensi metode pengambilan data
Terlalu banyak indikator, tapi bukan indikator yang tepatTerlalu banyak indikator, tapi bukan indikator yang tepatTerlalu banyak indikator, tapi bukan indikator yang tepatTerlalu banyak indikator, tapi bukan indikator yang tepat
Indikator terima jadi, tanpa ada proses diskusiIndikator terima jadi, tanpa ada proses diskusi
Bagaimana menggunakan data yg sudah dikumpulkanBagaimana menggunakan data yg sudah dikumpulkan
Pengumpulan data manual atau otomatisPengumpulan data manual atau otomatis
Hasil analisis tidak sesuai dengan pendapat manajemenHasil analisis tidak sesuai dengan pendapat manajemen
Sulitnya mengukur mutu
Makan waktu, menambah pekerjaan
Harus memastikan akurasi data dan konsistensi metode pengambilan dataHarus memastikan akurasi data dan konsistensi metode pengambilan data
Terlalu banyak indikator, tapi bukan indikator yang tepatTerlalu banyak indikator, tapi bukan indikator yang tepatTerlalu banyak indikator, tapi bukan indikator yang tepatTerlalu banyak indikator, tapi bukan indikator yang tepat
Indikator terima jadi, tanpa ada proses diskusiIndikator terima jadi, tanpa ada proses diskusi
Bagaimana menggunakan data yg sudah dikumpulkanBagaimana menggunakan data yg sudah dikumpulkan
Pengumpulan data manual atau otomatis
Hasil analisis tidak sesuai dengan pendapat manajemenHasil analisis tidak sesuai dengan pendapat manajemen
“The more effort you put into understandingand utilizing data, the more you will berewarded in terms of solving the right
problem in the right way”.(The Victorian Quality Council Safety and Quality in Health)
“The more effort you put into understandingand utilizing data, the more you will berewarded in terms of solving the right
problem in the right way”.(The Victorian Quality Council Safety and Quality in Health)
“The more effort you put into understandingand utilizing data, the more you will berewarded in terms of solving the right
problem in the right way”.(The Victorian Quality Council Safety and Quality in Health)
“The more effort you put into understandingand utilizing data, the more you will berewarded in terms of solving the right
problem in the right way”.(The Victorian Quality Council Safety and Quality in Health)
Useful linksInstitute of Healthcare Improvementwww.ihi.orgA Guide to Service Improvementwww.scotland.gov.ukImprovement & Support Team Toolkithttp://member.goodpractice.net/ContinuousImprovementToolkit/Welcome.gpImprovement Leaders Guideswww.modern.nhs.uk/improvementguides
Institute of Healthcare Improvementwww.ihi.orgA Guide to Service Improvementwww.scotland.gov.ukImprovement & Support Team Toolkithttp://member.goodpractice.net/ContinuousImprovementToolkit/Welcome.gpImprovement Leaders Guideswww.modern.nhs.uk/improvementguides
Institute of Healthcare Improvementwww.ihi.orgA Guide to Service Improvementwww.scotland.gov.ukImprovement & Support Team Toolkithttp://member.goodpractice.net/ContinuousImprovementToolkit/Welcome.gpImprovement Leaders Guideswww.modern.nhs.uk/improvementguides
Institute of Healthcare Improvementwww.ihi.orgA Guide to Service Improvementwww.scotland.gov.ukImprovement & Support Team Toolkithttp://member.goodpractice.net/ContinuousImprovementToolkit/Welcome.gpImprovement Leaders Guideswww.modern.nhs.uk/improvementguides
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