Norma A. Atienza, BSN, MPA, RN, CIC, CPHQ October 26, 2011 Performance Improvement: Making It Simple for the Creative (Busy) Minds.

Norma A. Atienza, BSN, MPA, RN, CIC, CPHQ

October 26, 2011

Performance Improvement: Making It Simple for the Creative (Busy) Minds

Quality / Performance Improvement

Definitions:

A planned, systematic, approach to monitor, analyze and improve performance, thereby continually improving the quality of patient care and services provided and the likelihood of desired patient outcomes.

The continuous study and adaptation of a healthcare organization’s functions and processes to increase the probability to better meet the needs of individuals and other users of services.

Quality / Performance Improvement Process

• PI Projects are identified / approved by the governing body as initiatives that are important to support the mission and the strategic goals of the organization

• Projects are also identified based on high volume, high risk and those that affect patient care that potentially will have negative outcomes.

• Infection Control – looking at processes and outcomes that supports the goals of the practice aligning to the strategic goals of the institution.

Why Performance Improvement?

The quest for Quality has become relentless especially with the advent of health care reform

Quality initiatives have become more prominent not only with government initiatives that set specific benchmarks to improve patient care but also among other health care insurers.

Common PI Methodologies or Approaches:Shewart Cycle / PDCA or PDSA CyclePDCA was developed by Walter Shewhart in the 1920s and

Edwards Deming adapted the process and called it PDSA Cycle– Plan

• Plan change• Study a process by collecting necessary data• Evaluate the results• Formulate a plan for improvement

• Set goals and target• Determine methods for reaching goals

– Do• Implement the plan (trial, house-wide)• Educate / train

– Check or Study• Gather data and evaluates results of the change• Determine success of action taken• Modifications needed

– Act• Implement the plan changes• Not successful, abandon the plan and rework the cycle

FOCUS - PDCA Model

Originated with the Hospital Corporation of America now HCA Healthcare. It assumes that a PI or a QI process is already in place to improve.• F = Find a process to improve

– define the process, identify the process– who will benefit from the improvement– how the process fits w/in the org priorities

• O = Organize a team that knows the process– people knowledgeable about and involved in the process– manageable team size, appropriate members– method to document team progress (WWW)

• C = Clarify current knowledge of the process– gather and review current knowledge – analyze to distinguish between expected and actual performance

• U = Understand variable and causes of variation– Plan and implement data collection– Measure using appropriate indicators

• Select = the process improvement– Identify action to improve

Other Approaches to Performance Improvement

• Change Acceleration Process (CAP)– A process that proactively plans for change

acceptance for successful implementation – Streamlines “traditional QI approaches– Requires top leadership support to succeed

• Work-Out– Promotes rapid problem solving via involvement

and accountability– Flowchart, cost/benefit of solutions– Test period or pilot

• Lean– Focused on eliminating waste through detailed

analysis of workflow

Six Sigma Strategy

• Was a strategy developed by Motorola in the mid-1980s and implemented successfully in GE and Allied Signal (manufacturing) as a way to reduce common cause variation and error rates.

• Driven by statistical analysis of data to identify causes of unwanted variation and defects

Sigma Value

DPMO

Defects / million opportunities

Quality Yield

(% quality standards achieved)

COQ/COPQ

Cost as % of total

1δ & 2δ 700,000/308,537

(non-competitive)

Poor High

3δ 66,807 93.3% 25-40%

4δ 6210 99.4% 15-25%

5δ 233 99.98% 5-15%

6δ 3.4

(world Class

99.999% <1%

Adapted from: Caldwell, Brexler, Gillem. Lean-Six Sigma for Healthcare

The DMAIC Approach

D: Define• Define the problem• Set the goals• Identify the customers• Who are your team members

M: Measure• How is the process performed• Identify the metrics• What data will be collected • Methodology in collecting the data

The DMAIC Approach

A: Analyze• Review data, what have the PI tools revealed

(fishbone, flowchart, etc.)• Identify or diagnose root cause• What is the data telling us

I: Improve• Improve the process• Identify actions needed to achieve the

performance goal• Apply WWW process as needed• Implement actions for improvement• Review and compare old and new process,

what was changed

The DMAIC Approach

C: Control

• In control only when goal is reached – then maintain and monitor the improvements Review data, what have the PI tools revealed (fishbone)

• If not, go back to data analysis. Review improvement processes in-placed, are they effective?

• Make changes as needed.

Metrics

• Outcome

• Process

• Person Centered

• Structure

Developing Goals

S – specific

M – measurable

A – attainable

R – relevant

T – time based

C – clearly understood

A – agreed upon

R – re-negotiated

Judy L’s

Examples:

1. To decrease HA CAUTI by 10% by the end of FY2012 from that of 2011.

2. By June 30, 2012, improve Core Measure aggregate perfect care score to 95%.

3. Reduce department expenses by maintaining no more than 1.8% (of total Salaries) in overtime expenses each month as reported in Visionware.

Review of Common

Graphs

and

Charts

Line Graph or Run Chart: provides a running record of a process overtime

Saint Clare's HospitalsFalls Data - July 2010 to April 2011

per 1000 Patient Days

2.95

2.492.71

3.76

1.48

3.10

1.45

2.29

2.66

4.02

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

Jul

Aug Sep Oct

Nov

Dec Jan

Feb

Mar

Apr

Month

Fal

l Rat

e

Goal Ave = 2.70

Line Graph

Saint Clare's Hospital

3.30

4.22

1.852.27

2.03

1.441.17 1.25

1.65

1.10

1.852.09

1.11

1.80

0.981.43

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

Jan Feb Mar Apr May Jun Jul Aug

Mortality '10 RRT '10

Mortality rate continues to decrease in 2010 except for the couple of months. Again if RRT is decreased, mortality rate increased

Pie Chart or Circle Graph: used to display parts of a whole (proportional relationships)

Saint Clare's HospitalSite of CVAD Insertions

January to December 2010

26%

5%

38%

31% Subclavian

Femoral

IJ

Upper arm (PICCs)

Control Chart: a display of normal variations and “out of control” variations over time

3/113/

93/7

3/3

3/1

2/25

2/23

2/21

2/17

2/15

2/112/

92/7

2/3

2/1

1/28

1/25

1/21

1/19

1/17

1/13

1/111/

71/5

1/3

80

70

60

50

40

30

20

10

0

date1

Indiv

idual V

alu

e

_X=30.34

UCL=53.46

LCL=7.23

1

Denville TAT

Bar Chart: comparisons between different groups

0

20

40

60

80

100

Saint Clare's HospitalHandwashing Compliance

Hospital-Wide Discipline Specific

2009 2010

2009 73.5 96 91 78.6 69.6 88 77.8 80.4 67.7 31.9 66 42.1 83.9

2010 98.4 95 92.9 75 78.9 100 92.5 96.3 73.1 60 92.2 56.1 94

Phys Nsg NAs APNCM/S

WAnc. Tech

RespPT/OT

/STEnv.

Transport

Rad Techs

Phleb Other

22

Pareto: offers a comparison of causes of problems in a process and rank-order (prioritizes). Determine where to focus improvement efforts.

Count 132 95 13 11 3Percent 52.0 37.4 5.1 4.3 1.2Cum % 52.0 89.4 94.5 98.8 100.0

CommentsOther

PowerForm

missi

ng date/tim

e

PowerForm

miss

ing MD name

PowerForm

missi

ng MD nam

e/date

/time

PowerForm

not pres

ent

250

200

150

100

50

0

100

80

60

40

20

0

Count

Perc

ent

Pareto Chart of Critical Values PowerForm Audit

Realize that change is not always a process

improvement. Sometimes it’s a process of invention!

Wendy Kopp Founder of Teach for America

? Questions