How to do it! A short course on Quality Improvement › fis2013 › Final FIS PDF...This can tell you if you have really achieved an improvement, or if a stable process has deteriorated

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How to do it! A short course on

Quality Improvement

Dr Emma Donaldson Gastroenterology SpR

Dr Imran Qureshi Microbiology SpR

+ How I became involved in QI

and how I was supported

+ How do you engage with

trainees to work on QI?

+ Why do you think trainees don’t

engage with QI

Don’t know what it is

Do not feel empowered to get involved

Don’t think that getting involved will amount to anything

Laziness

Do not feel that is has anything to do with them

Selfishness

‘What will I get out of it?’

+ How do we get trainees to engage

with QI?

We tell people about it – an appeal to altruism

We explain the benefits over audit

Some people are forced – never a good idea

Mostly we resort to bribery

Certificates

Posters

Presentations

Other opportunities

+ DAPS Global

QI Program

Summer School

Safety Tour

DAPS Relay

Awards

www.dapsglobal.com

+ Going through a QIP

Practically

+ What is Quality Improvement

Research:

Provides the evidence

Tells us the RIGHT THING TO DO

Quality Improvement:

Helps us develop systems to deliver care

Ensures we are DOING THE THING RIGHT

Audit:

Provides assurance of excellent care

CONFIRMS WE ARE DOING THE RIGHT THING, RIGHT

+

Every system is perfectly designed to get the results that it gets

+ Where we are now is where we got as a result of:

lots of clever, committed, caring people

who know their work

trying as hard as they can

+

+

Moving on from where we are now, therefore, needs new tools that we haven’t used before

+

Model for Improvement

Model for Improvement

+ Start with the aim…

The solutions come last

Let solutions come from the team

If you have a good idea, the team will have it too

Then they’ll own it

If they have a bad idea, let them test it

+ A Good Aim

S pecific

M easurable

A chievable

R elevant

T ime limited

Stre-e-e-e-e-e-e-e-e-e-etch

+ Aim statements

1 – provide adequate pain control to all patients.

2 – 90% of patients who report that they had pain will

respond “yes” to “did staff do all they could to control your

pain” by June 2012

+ AIM

To increase/decrease …………………

by ……… %

by date ………….

+

“The greatest danger for most of us is not that our aim is too high and

we miss it, but that it is too low and we reach it.”

Michelangelo

+ A Driver Diagram

Reinforces the aim statement as the goal

Clarifies the big picture

Identifies primary system components

Aids in development of measurement

Most importantly: Helps teams to articulate

their contribution to the overall aim and

avoid missing important system components

50% reduction in

acute central line

infections in ICU,

MHDU and Renal

(G3/Renal Unit)

by June 2009

•Nominate 2 clinical leads from your ward

•Introduce systems for:

• competency training

• quality assurance

• encouraging reporting for learning

Leadership, Governance & Staff Education

Process

Standardisation

Patient Involvement

•Introduce system of assessment for most appropriate line

•Paired insertion of central lines mandatory throughout

•Mandatory use of care pathways

•Daily review for removal

•Consider recruiting patient champion

•Introduce system of appropriate communications

•Involve patients in early identification of infection

Measurement

•Present data in ward area

•Introduce reporting system

•Celebrate success

•Develop system for measuring catheter days

Central Lines

+ Key Learning Points

How do you know if something is a primary driver?

if you take the driver out then the whole goal is unlikely to be achieved

Most people focus on one or two system components (primary drivers) and then wonder why the project hasn’t succeeded

Teams can share learning by working in different areas of the driver diagram and sharing learning

+ Limitations of drivers

Not a perfect science

Will require ongoing amendment

Interplay between drivers

Contribution of each driver is unlikely to be equally

distributed

Model for Improvement

The 3 reasons for measurement

Measurement for

Improvement

Source: Robert Lloyd IHI 2006

+ C-Diff Measures

Aim: To reduce the incidence of c-diff on the elderly care wards by 50% by December 2007

Outcome Measures

The number of c-diff cases per year

Process Measures

% compliance to hand hygiene

Balancing Measures

The number of complications arising from inadequately treated infections

+ Stroke Measures

Aim: To achieve a score of 95% on the Sentinel audit by October 2008

Outcome Measures

Audit score

The mortality rate of stroke patients

Process Measures

The % of patients receiving a brain scan within 24hrs

Balancing Measures

Time spent by ward staff completing forms

Wait time for other patients requiring

brain scan

+

Using the data

+

The project

Did we achieve anything, are things better?

Ways to display data: Static

View…

Ways to display data: Dynamic View…

+ Average Before=8 hours delay

Average After=3 hours delay

DG 1-11/12

+ Run Charts

Viewing TIME ORDERED DATA is a powerful way of detecting change

It can tells us when a real change has occurred

The pattern contains additional useful information

+

So in Quality Improvement we are concerned with plotting data over time in order to

understand variation in processes

“If I had to reduce my message for management to just a few words, I’d say it all had to do with reducing

variation”

W.E.Deming

+ Types of Variation

Common Cause

Is due to natural and regular causes

Results in a ‘stable’ process

Also known as random variation

Special Cause

Is due to irregular or unnatural causes that are not inherent to the process

Results in an ‘unstable’ process that is not predictable

Also know as non-random variation

+ Understanding variation

The outcome of every process is affected by lots of little

things

Each of these little things varies naturally

All these little variances add up

This makes the process vary over time

+

Wait to see doc Time to get

CXR Time to XR

review Time to

prescription Time to draw up

Time to admin

0

20

40

0

50

100

0

50

100

+

0

50

100

150

200

250

1 2 3 4 5 6 7 8

Antibiotic drawn up

Antibiotic prescribed

Xray seen

Xray

Porters

Order Xray

Clerk/exam

See doc

+

0

50

100

150

200

250

1 2 3 4 5 6 7 8

Antibiotic drawn up

Antibiotic prescribed

Xray seen

Xray

Porters

Order Xray

Clerk/exam

See doc

+ Common Cause Variation

0

5

10

15

20

25

30

+

A system can also be affected by a big, unusual influence

The size of the change produced is BIG in relation to the

common cause variances

It happens much less frequently than the common cause

variances

+

0

50

100

150

200

250

300

350

400

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Antibiotic drawn up

Antibiotic prescribed

Xray seen

Xray

Porters

Order Xray

Clerk/exam

See doc

Major Incident

+ Special Cause Variation

+

+

+

Engineering science uses a robust approach to detect

deviations from the usual pattern

This can tell you if you have really achieved an improvement,

or if a stable process has deteriorated

+ %

Of

Patients

% Of Patients Receiving Swallow Screen Within 24hrs

Month

Mean

LCL

June

'07

July '0

7

Aug

ust '

07

Sep

tem

ber '

07

Octobe

r '07

Nov

ember

'07

Dec

ember

'07

Janu

ary '0

8

Februa

ry '0

8

Mar

ch '0

8

Apr

il '08

May

'08

June

'08

July '0

8

Aug

ust '

08

Sep

tem

ber '

08

0

10

20

30

40

50

60

70

80

90

100

8 datapoints

above the mean =

special cause

variation

+ Examples – Length of Stay

+

+

“All improvement will require change,

but not all change will result in improvement”

50% reduction in

acute central line

infections in ICU,

MHDU and Renal

(G3/Renal Unit)

by June 2009

•Nominate 2 clinical leads from your ward

•Introduce systems for:

• competency training

• quality assurance

• encouraging reporting for learning

Leadership, Governance & Staff Education

Process

Standardisation

Patient Involvement

•Introduce system of assessment for most appropriate line

•Paired insertion of central lines mandatory throughout

•Mandatory use of care pathways

•Daily review for removal

•Consider recruiting patient champion

•Introduce system of appropriate communications

•Involve patients in early identification of infection

Measurement

•Present data in ward area

•Introduce reporting system

•Celebrate success

•Develop system for measuring catheter days

Central Lines

+ The PDSA Cycle

Plan

• What are you going to

test?

• What do you predict

will happen?

• Develop the test

(Who? What? When?

Where? Data?)

Do

• Try out the test on a small

scale

• Observe & document results

Study

• Analyse data

• Study the results

• Compare results &

predictions

Act

What will you

do next?

• Adapt

• Adopt

• Abandon

Hunch

Workable

solution

+ Why test change before implementing it?

It involves less time, money and risk

The process is a powerful tool for learning; from both ideas that work and those that don't

It is safer and less disruptive for patients and staff

Because people have been involved in testing and developing the ideas, there is often less resistance

+ Successful PDSA Cycles

Think ahead

Small scale

Predict

Test with willing staff

Don’t ask permission or for consensus

Data and documentation

+ What PDSAs Are Not…

A radical change to a system /process

Full blown trust-wide implementation

Mini projects

Top down directives

‘PDSA’s ‘test’ a proposed change

+ PDSA principles

Initial ideas usually don’t work

If a PDSA “fails”, then the idea would not work reliably

But lots can be learnt during the process

+ Small Scale Tests of Change on:

One clinic

One patient

One doctor

One nurse

One day / shift

+ Stakeholder Engagement

Another critical aspect of improving care

Delivering high-quality patient care is a TEAM effort

Interventions often require other healthcare professionals to

be involved in their implementation

Make sure you identify and consult relevant stakeholders

before you finalise your intervention

Imposition is never welcome, discussion is!

These people will be key at roll-out

+ Roll-out

Have you demonstrated that you have made an

improvement?

Numbers are essential

Cost-savings are even better!

Co-operation of colleagues in roll-out is a winner

Directorate approval is key

The rest is ‘usually’ plan-sailing

+

The Spread

1 3 5 All

+ Conclusion - 1

Always start with the aim

Never the solution

Spend time working out measures

+ Conclusion - 2

Gather information, set up measurement system

Drivers, cause effects, theory of change

Only then solutions

+ Conclusion - 3

Test solutions with PDSA

Need serial PDSAs

Monitor effect with oucome

Start small, very small

+ BMJ Quality &

IHI Open School

Nov 14th 16th 20th • QI Brainstorm • Projects selected

Autumn: • Projects identified

Jan/ Mar/ May: • Project presentation updates

•Grand Round •Appraisal

Aug: • Introduce concept • ‘Keep eyes open’

Summer Continuous: • Project group meetings with ST facilitators • Intranet communications • QI support

2011 - 2012

Unlocking the Potential Enabling junior doctors to lead quality improvement

NHS Tayside 2013-14

+ Features

Online workbook

Learning modules – CPD

Mentor integration

Multiple authors

Useful tools

Automatic publication production

Quick peer-review turnaround

+ Challenges of supporting

trainees in QI

+ Challenges

Dedicated teaching time

Dedicated time to undertake QI

Poor mentor:mentee

Lack of understanding around QI

Reversion to audit

Lack of support

Egos

+

Take-home Message