March of Dimes Improvement Model Presentation and QI Tools ...

10/31/2016

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Continuous Quality

Improvement in the

Healthcare Setting

March of Dimes: Learning for Babies Conference

November 03, 2016

Terri Crutcher, DNP, RN

Assistant Professor

Vanderbilt University School of Nursing

Susie Leming-Lee, DNP, RN, CPHQ

Assistant Professor

Vanderbilt University School of Nursing

Objectives

• Describe quality improvement basic principles and concepts

• Differentiate quality improvement, evidence based practice,

and research

• Identify and describe commonly used quality improvement

tools

Comparison: Quality Improvement,

Evidence Based Practice, ResearchQI

(Quality Improvement)

EBP

(Evidence Based Practice)

Research

Method PDSA Level of Evidences Qualitative, Quantitative

Sample Unit Level Patient Population Representative

Human Subjects ? IRB ? IRB Need IRB

Data Collection Evaluation Search & Appraise Validity

Results Improve process Impact Add to body of knowledge

Implications Process change Practice change Understanding change

Dissemination Unit/Agency Practice standards Scientific community

Adapted from Dimitroff, L.J. Nursing Research Alliance 7th Annual Conference, April 2011, Comparing and Contrasting

Nursing Research, Evidence Based Practice, and Quality Improvement: A Differential Diagnosis. Capital District Nursing

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The Science of Improvement

• Knowledge of general truths or the operation of general laws, especially those obtained and tested through the scientific method

• Concerned with how knowledge of specific subject matter is applied in diverse situations

The Science of Improvement

A primary aim of the

science of improvement

is to increase the chance

that a change will actually

result in sustained

improvement from the

viewpoint of those

affected by the change.

The Art of Improvement

Improvement requires change

Change implies a newness, a creative aspect

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The Science and Art of Improvement

Science:

• The idea is tested first on a small scale

• The change does not require undue restrictions

• Moving improvement from Trial-and-error process to Trial-and-learning process

Art:

• Innovation

• Creativity

• Communication

Improvement

While all

improvements

require change,

not every change

will result in

improvement

What is the PDSA Cycle?

“The cycle is a flow diagram for learning,

and for improvement of a product or a

process”

Deming, 1994

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Knowledge to Support the Model

The route to transformation is what

Dr. Deming calls “Profound

Knowledge” composed of:

• Appreciation for a system

• Knowledge of variation

• Theory of knowledge

• Psychology

The Model for Improvement

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in an improvement?

Plan

DoStudy

Act

Rapid Cycles of Change

Langley, et al., 2009

The Model for Improvement

• What are we trying to accomplish?

• How will we know that a change is an improvement?

• What changes can we make that will result in an improvement?

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The Model for Improvement - PDSA

PDSAPlan

• State objectives of the test

• Make predictions

• Develop a plan to carry

out test

Langley et al., 2009


PDSA

Do • Carry out test

• Document problems and

unexpected observations

• Begin analysis of the data

Langley et al., 2009Rapid Cycles of Change


PDSA

Study• Complete the analysis of

the data

• Compare data to predictions

• Summarize what was learned


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The Model for Improvement -PDSA

PDSAAct

• Adopt the change or

• Abandon the change or

• Run through the cycle again,

possibly under different conditions,

different materials, different people

or different rules


The Model for Improvement - PDSAWhat are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in an improvement?

Plan

DoStudy

Act

• State objectives of the test

• Make predictions

• Develop a plan to carry

• out test

• Carry out test

• Document problems and

• unexpected observations

• Begin analysis of the data

• Complete data analysis

• Compare data to predictions

• Summarize what was

learned

• Adopt the change

• Abandon the change

• Run through the cycle

again, possibly under

different conditions,

materials, people or

rules

Langley et al., 2009Rapid Cycles of Change

Principles of Improvement

• Know why you need to improve

• Have a way to get feedback to let you know if

improvement is occurring

• Develop a change that may result in improvement

• Test a change before any attempts to implement

Langley, et al., 2009

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Principles of Improvement

• Customer Driven

• System Optimization and Alignment

• Continual Improvement and Innovation

• Continual Learning

• Management through Knowledge

• Collaboration and Mutual Respect

Massey, et al., 2007

Why is This Important?

Insanity –

Doing the same thing

the same way and

expecting a different

result

Albert Einstein

Quality Improvement Tools

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Quality Improvement Tool Box• Data Collection/Check Sheet

• Root Cause Analysis/Cause &

Effect/Ishikawa/Fishbone Diagram

• Process Flow Chart

• Brainstorming

• Affinity Analysis

• System Modeling

• Force Field Analysis

• Failure Mode Effects Analysis

(FMEA)

• Gantt Chart

• Bar & Pie charts

• Run Charts (statistical tool)

• Pareto Charts (statistical tool)

• Control Charts (statistical tool)

• Histograms (statistical tool)

• Scatter Diagram (statistical tool)

• Lean Tools:

• 5S

• Value Stream Mapping

• Jidoka: (stop the line)

• Just in Time

• Poka Yoke: Mistake Proofing

• Heijunka: Smoothing the Process

Why Do We Use QI Tools?

• QI Tools allow us to gather data for effective problem-

solving that is data driven. Data is impersonal; opinions

are not.

• Experience is gained quickest by collecting and analyzing

data using QI tools.

• The tools provide common methods of analysis to help

problem solving teams operate effectively.

• Operations problems – usually may be solved by these

tools.

Data Collection

• Where in the process can we get this data?

• Who in the process can give us this data?

• How can we collect this data from these people with minimum effort and chance of error?

• What additional information do we need to capture for future analysis, reference, and traceability?

Juran Institute

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Check Sheet

Description:

A simple data collection form

consisting of multiple

categories with definitions.

Data are entered on the form

with a simple tally mark each

time one of the categories

occurs.

• Use during the: Plan and Do

phase of the PDSA cycle

ASQ, 2016

Leming-Lee, 2015

Process FlowchartHigh Level View

Description:

A flowchart is a

picture of the

separate steps of

a process in

sequential order.

• Use during the:

Plan and Do

phase of the

PDSA cycle.

“Picturing the Process”

Micro Level View

Process Flowchart

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IHI, 2016

Run ChartDescription:

A graphical tool to

monitor important

process variables

over time.

A helpful tool in

identifying trends

and cycles.

One of the most

important tools for

assessing the

effectiveness of change

• Use during the: Plan,

Do, and Study phase

of the PDSA cycle.

“Tracking Trends”

Pareto DiagramDescription:

A Pareto chart is a bar graph. The

lengths of the bars represent

frequency and are arranged with

longest bars on the left and the

shortest to the right. In this way

the chart visually depicts which

situations are more significant.

Often called the 80-20 Rule.

Principle: quality problems are

the result of only a few problems.

The Pareto principle implies 80%

of process problems can be

accounted for by 20% of process

factors.


phase of the PDSA cycle.https://www.google.com/search?q=image+of+quality+improvement+tools,+scatter+diagram&espv=2&biw=1280&bih=633&tbm=isch&tbo=

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“Focus on Key Problems”

Cause and Effect Diagram(Fishbone or Ishikawa)

Description:

The fishbone diagram

identifies many possible

causes for an effect or

problem.

It can be used to structure a

brainstorming session. It

immediately sorts ideas

into useful categories.

• Use during the: Plan

and Do phase of the

PDSA cycle

“Find and Cure Causes,

NOT Symptoms”

Brassard & Ritter, 1994

Used with permission from Susie Leming-Lee

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Control ChartDescription:

The control chart is a graph used to

study how a process changes over time.

Data are plotted in time order.

A control chart always has a central line

for the average, an upper line for the

upper control limit, and a lower line for

the lower control limit. These lines are

determined from historical data.

By comparing current data to these

lines, you can draw conclusions about

whether the process variation is

consistent (in control) or is

unpredictable (out of control, affected

by special causes of variation).

• Use during the: Plan, Do, Study


ASQ, 2016

“Recognizing Sources of Variation”


LS1

Histogram Description:

A frequency distribution shows

how often each different value

in a set of data occurs. A

histogram is the most

commonly used graph to show

frequency distributions. It looks

very much like a bar chart, but

there are important differences

between them.

• Use during the: Plan, Do,

and Study phase of the

PDSA cycle.

https://www.bing.com/images/search?q=image+histogram+tool&view=detailv2&qpvt=image+histogram+tool&id=C9A8639FB28DEBDFCD6724ECB6E6C300032C8397&selecte

dIndex=9&ccid=8V3pER39&simid=608050517127333569&thid=OIP.Mf15de9111dfda2533ffd4ac44ef7844ao0&ajaxhist=0

“Process Centering, Spread,

and Shape”

Scatter DiagramDescription:

The scatter diagram graphs

pairs of numerical data, with

one variable on each axis, to

look for a relationship between

them. If the variables are

correlated, the points will fall

along a line or curve. The better

the correlation, the tighter the

points will hug the line.



https://www.google.com/search?q=image+of+quality+improvement+tools,+


“Measuring Relationships Between

Variables”

Slide 31

LS1 Leming-Lee, Susie, 10/11/2016

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Teams

Your Most Important Quality Improvement Tool

The Team is the Engine that Drives Quality Improvement!

A team is “a group of people working together to

achieve a common purpose for which they hold

themselves mutually accountable”

The team is the most powerful tool in your toolbox!!

What is a Team?

Scholtes, Joiner, Streibel, 2010

• Members have a shared work product

• Carry out quality improvement activities

• Work across functions or departments to improve complex

processes

• Usually consist of five to seven members

• Should represent everyone who works on the process in need

of improvement

• Use quality tools to improve processes

• Generate ideas for change!Scholtes, Joiner, Streibel, 2010

Key Elements of a Team

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Brainstorming

Brainstorming is used to create a high volume of

ideas on any topic by creating a process that free

of criticism and judgement.


Brainstorming

(IHI, 2016)

Tools for Generating Ideas:

• Cause and effect diagram/Ishikawa diagram

• Affinity Grouping: is a brainstorming method in which

participants organize their ideas and identify common

themes

• Multi-voting: is a structured series of votes by a team, in

order to narrow down a broad set of options to a few.

Nominal group technique – write ideas in silence, report

out with ideas on newsprint

“While all changes do not lead to improvement, all improvement requires change”

• Eliminate waste - Lean

• Improve work flow

• Optimize inventory

• Change the work environment

• Enhance customer relationship

• Manage time

• Manage variation

• Design systems to avoid

mistakes

• Focus on the product or service

• Minimize handoffs

• Move steps closer to the

process

• Find and remove bottlenecks

• Change the order of process

steps

• Use automation

• Give people access to

information

• Implement cross-training

• Reduce wait time

• Standardization

Change Concepts

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Conclusion

Thank You!

ReferencesAmerican Society for Quality. (2016). Pareto chart. Retrieved from http://asq.org/learn-about-quality/cause-analysis-

tools/overview/pareto.html

American Society for Quality. (2016). Control chart. Retrieved from http://asq.org/learn-about-quality/data-collection-analysis-

tools/overview/control-chart.html

American Society for Quality. (2016). Brainstorming. Retrieved from http://asq.org/learn-about-quality/idea-creation-

tools/overview/brainstorm.html

American Society for Quality. (2016). Check sheet. Retrieved from http://asq.org/learn-about-quality/data-collection-analysis-

tools/overview/check-sheet.html

American Society for Quality. (2016). Fishbone (Ishikawa) diagram. Retrieve from http://asq.org/learn-about-quality/cause-analysis-

tools/overview/fishbone.html

Deming, W.E. (1994). The new economics for industry, government, education (2nd ed.). Cambridge, MA: Massachusetts Institute of

Technology Center for Advanced Engineering Study.

High-Performance Community Health Centers: Learning, Measuring, and Achieving. A Guide for Health Center Staff and Boards. Found

at /www.caplink.org/images/stories/Resources/publications/Pub-High-Performance-Community-Health-Centers.pdf

Institute for Healthcare Improvement (2012). How to improve. Retrieved from http://www.ihi.org/knowledge/Pages/

HowtoImprove/default.aspx

Institute for Healthcare Improvement. (2016). Science of improvement: Establishing measures.

http://www.ihi.org/resources/pages/howtoimprove/scienceofimprovementestablishingmeasures.aspx

Institute for Healthcare Improvement. (2016). Idea generation tools: Brainstorming, Affinity grouping, and multivoting

http://www.ihi.org/resources/Pages/Tools/BrainstormingAffinityGroupingandMultivoting.aspx

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Institute for Healthcare Improvement. (2016). Using change concepts for improvement. Retrieved from

http://www.ihi.org/resources/Pages/Changes/UsingChangeConceptsforImprovement.aspx

Inozu, B. Chauncey, D., Kamataris, V., & Mount, C. (2012). Performance Improvement for Healthcare, Leading Change with Lean,

Six Sigma and Constraint Management. New York: McGraw Hill.

Langley, G., Moen, R., Nolan, K., Nolan, T., Norman, C. & Provost, L. (2009). The improvement guide: A practical approach to

enhancing organizational performance (2nd ed.). San Francisco, CA: Jossey-Bass.

Massy, W. F., Graham, S. W., & Short, P. M. (2007). Academic quality work: A handbook for improvement. Bolton, Mass: Anker

Pub. Co.

McMahon, T. (2008). A lean journey: The quest for true north. Problem Solving and basic quality tools. Retrieved from

http://www.aleanjourney.com/2011/09/seven-basic-tools-of-quality.html

Rickards, T., & Moger, S. (2000). Creative leadership processes in project team development: an alternative to Tuckman's stage

model. British journal of Management, 11(4), 273-283.

Plsek, P.E. (2016). Accelerating health care transformation with lean and innovation: The virginia mason experience. Retrieved

from https://innovations.ahrq.gov/article/using-tools-idea-generation. Agency for Healthcare Research and Quality

Scholtes, P. R., Joiner, B. L., Streibel, B. J. (2010). The team handbook (3rd ed.). Middleton, WI: Advertisers Press, Inc.

Walton, M. (1990).Deming management at work. New York: G.P. Putnam’s Sons.

References

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