Quality Improvement Part II

what is SIX SIGMA

"A statistical concept that measures a process in terms of defects --The term comes from the use in statistics of the Greek letter sigma to denote standard deviation from the mean Six sigma is equivalent to 3.4 defects or errors per million The Six Sigma philosophy focuses on eliminating defects through practices that emphasize understanding, measuring and improving processes"

QUALITY IMPROVEMENT IS NOT...

......not research... Quality Improvement --Intent is to improve practice --Assess within existing standards of care --Primary audience is the organization Research --Intent is to provide generalizable knowledge --Testing new methods or interventions --Primary goal is to publish --Requires IRB approval

U: UNDERSTAND

At this point, if the team has completed 'C', they must stop and consider 'U' For example, understand/accept some process variation at your facility when dealing with lateness "U" allows team to understand precisely where the clinical actions resulting in lateness fall short and why Not looking for WHO went wrong, but rather looking for WHAT went wrong or isn't going as well as it could be at your facility Still gathering info --No plan wanted/needed/possible at this point CQI is not a quest for unrealistic perfection Ask appropriate questions... --Do cultural issues contribute to problem? --Will it make our care more/less patient centered to take action on this issue? --Is the issue a result of the large system or a sign of lax staff behavior? --What is our facility philosophy toward patients? --Any departmental changes that might have recently worsened issue?

FOCUS: PDCA

F=Find a process to improve O=Organize a team that knows process C=Clarify the current knowledge of process U=Understand causes of process variation S=Select the process improvement desired PDCA= Plan, do, Check, Act

COMPARISONS of FOCUS/PDCA, six sigma, and FADE:

FOCUS / PDCA --Find-Organize-Clarify-Understand-Select --Plan-Do-Check-Act SIX SIGMA --Define-Measure-Analyze-Improve-Control --Define-Measure-Analyze-Design-Verify FADE --Focus-Analyze-Develop-Evaluate-Execute All have common themes of analysis, implementation and review Choose the best one for your clinical needs

'PDCA' ARISES FROM 'FOCUS' ANALYSIS

FOCUS: Complete FOCUS process first GOAL: Identify issue/element to track PDCA: Plan - Do - Check - Act --Decide which part of issue needs to be addressed --Maximize efficiency by manipulating a part to change the outcome of the whole

Another quality improvement program is FADE:

FOCUS: Define and verify the process to be improved ANALYZE: Collect and analyze data to establish baselines, identify root causes and point toward possible solutions DEVELOP: Based on the data, develop action plans for improvement, including implementation, communication, and measuring/monitoring EXECUTE: Implement the action plans, on a pilot basis as indicated, and EVALUATE: Install an ongoing measuring/monitoring (process control) system to ensure success.

C: CHECK

No matter how well things went, you must check the outcomes to see if change is needed The planning/doing are over....check now! Ask this question: --Was our original decision concerning which aspect of the overall process should be changed correct? (If no, return to the Ishekawa chart and reconsider the elements If yes, did our proposed plan turn out to be the most efficient and cost effective one?) What if a) the result of the plan is unsatisfactory because of overlooked factors or b) is effective but too costly? --RETHINK the (P) and (D) steps! Common problems with this stage of CQI implementation: --Unwilling to do the work to rethink weak plan --Unrealistic cost estimates --Breakdown of team interactions and effectiveness

PLANNING THEN TURNS TO ACTION

--After FOCUS, we know WHAT process to go through to identify issues of less than desired levels of quality --REMEMBER: Without enough FOCUS, any plan is doomed to either fail or waste valuable time --NEXT... PDCA: HOW to structure the process of implementing change --The first action plan is often not the version that actually is effective in the end

AS A MANAGER......

--Define quality for your practice --Ensure quality is part of clinic vision --Identify the steps in each process critical to quality --Manage the process to achieve quality --Involve and support clinical and administrative staff in the quality improvement process --Effectively measure quality --Communicate the process measurements and outcomes routinely to entire staff --Lead with questions --Live the vision

AHRQ report included the following:

--Effects of bundled payment systems on health care spending and quality of care (Bundled Payment) --Patient-centered medical home (PCMH) --Quality improvement interventions to address health disparities (Disparities) --Comparative effectiveness of medication adherence interventions (Medication Adherence) --Public reporting as a quality improvement strategy (Public Reporting) --Prevention of healthcare-associated infections (HAI) --Quality improvement measurement of outcomes for people with disabilities (Disability Outcomes) --Interventions to improve health care and palliative care for advanced and serious illness (Palliative Care)

Key points of six sigma:

--Goal setting --Planning --Foundation is customer service --Ongoing process review --Supported by management --Employee participation is critical --Team approach --Recognize need to ↓ defects, ↓ costs, ↑customer service --Ongoing quality improvement

Organizations with a quality focus are where...

--Improving outcomes is recognized --Questions are part of everyday practice --Evidence supports clinical decisions --Patient satisfaction is valued --Teamwork is essential

F: FIND What type of issue to track? Usual Sources for Issues:

--Incident reports --HIPPA complaints --Patient satisfaction forms --Billing/collections monthly reports --Staff productivity records --Listen to staff complaints at meetings for 'hot-button' topics

C: CLARIFY CURRENT KNOWLEDGE What should we do to handle this issue? Potential sources to get this answer...

--Policy and procedure manual --State law --Contracts of employment (if applicable) --Limits of licensure --Guide to PT Practice/Guide to OT Practice --Current literature --Patient Bill of Rights --Patient satisfaction surveys --Exit interviews --Fluctuations in staffing/administration --Hospital demographics for patient mix --Logistical changes: Hours, staff ratio, traffic pattern, need for pt supervision

Six Sigma's approach is similar to that of good medical practice used since the time of Hippocrates

--Relevant information is assembled followed by careful diagnosis --After a thorough diagnosis is completed, a treatment is proposed and implemented --Finally, checks are applied to see if the treatment was effective --There are two Six Sigma models...

S: SELECT

--Select the process improvement desired --Now can answer the question: What component of the issue can I change, modify, improve, or delete to make the biggest impact on our satisfaction level with the issue? --What if you still can't decide? --Don't go forward into planning/acting phase until you can

O: ORGANIZING THE TEAM Once the issue is selected, ask:

--Who has experience in CQI initiatives? --Who has the biggest 'problem' with the issue? --Who works well in groups? --Who has knowledge/history of the issue?

There are two Six Sigma models...

1. DMAIC Is an improvement system for existing processes falling below specification and looking for incremental improvement The five phases involved are... Define Measure Analyze Improve Control 2. DMADV Is an improvement system used to develop new processor products at Six Sigma quality levels The five phases involved are... Define Measure Analyze Design Verify

Agency for Healthcare Research & Quality [AHRQ]: CLOSING THE QUALITY GAP

2013 report analyzing current issues regarding quality improvement in health care This report is based on research conducted by the RAND Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ) The analysis is intended to help health care decision makers, including patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services Looks at the evidence about strategies aimed at closing the "quality gap," the difference between what is expected to work well for patients based on known evidence and what actually happens in day-to-day clinical practice across populations of patients The eight topics selected for this series are relevant to ongoing initiatives in health care reflected in the Patient Protection and Affordable Care Act and are consistent with previously identified national priority areas on health care quality

How can we limit the amount of tries before we "get it right" WITH our plan?

80% of the PDCA process: ...the initial analysis and planning 20% of the PDCA process: ...doing , checking and redoing the action

GUIDING PRINCIPLES

Achieving quality outcomes is a group process and will require all of us working together in commitment to improve quality and safety of patient care

A: ACT

Act to implement the change in original plan... Is it possible that the revised plan may not provide results at acceptable level? --YES (especially if planning process is rushed or does not have complete team buy-in) What should you do? --Return to P and D steps again NOTE: Discovery that it is a really poor plan or facing a change in team may result in a return to FOCUS step again Can the plan ever achieve desired level of results the first time? Or, after only minor revision? YES What should you do ? --Notify stakeholders about outcomes --Implement permanent policies --Arrange time to f/u on issue --Info gathered when reviewing productivity records; patient, staff, or nursing complaints; or sign-in logs can alert staff to possible need for earlier review

A POSITIVE APPROACH TO CHANGE

Appreciative Inquiry: --Is a flexible process for engaging people in building the kind of organization in which they want to work --Seeks a focus on what is right rather than focusing on gap analysis or what is wrong, what is missing

What if staff focus on a pet peeve rather than the big picture?

Avoid over-controlling Staff buy-in might be more important Allow staff to brainstorm any issues that negatively impact patient care in terms of... --Frustration --Cost --Time

D: DO

Carrying out the plan... At the end, you need to answer "yes" to 2 Q: 1. Did we follow through with creating and carrying out the plan? 2. Did the team make its best effort to carry out the plan as designed?

CQI Creativity + Teamwork=

Change

CONSIDERATIONS

Focus on quality improvement in healthcare organizations Improves patient care outcomes Helps improve the work environment People want to work in organizations that emphasize quality

KEY POINTS for quality improvement:

Identify the root cause before making changes Be creative in developing solutions Measurement and improvement are possible Improving healthcare quality is our responsibility

What is APPRECIATIVE INQUIRY?

Is about appreciating and valuing --Recognizes the best in people and the organization, affirms strengths Is about inquiring --Explores, discovers, asks questions, sees new potential Looks at root causes for success and designs ways to replicate --Root cause analysis looks for deficits and causes of failure

PDCA PROCESS

P: Plan D: Do C: Check/Consider/Change A: Act Act again with modified plan or (if issue met minimum level for improvement), arrange time to revisit in future for possible action

POSSIBLE TIMELINES

Quick action/expect quick results --No outsiders involved; no cost to require pre-approval Quick action/expect slow results --Many influencing factors; no requirement for patients to cooperate; schedule changes are easy to plan/hard to consistently implement Slow action/expect quick results --Difficult issue so coming up with a plan that hasn't already failed will take time; a 'hard to pin down' problem so staff might not easily agree on best plan—once the plan is in place, things will change Slow action/expect slow results --Imposing an external efficiency standard (therapy's standard for timeliness) on a service (nursing)with other priorities

C: CHECK & CHANGE AS NEEDED

Revising the plan: Choices... --Change original plan or pitch and start over? --Change individual responsibilities? --Change timeline? --Change minimum acceptable level of improvement? Caution... --Avoid tinkering to give illusion of progress—must have reasons for changes

Institute of Medicine (IOM) defined six key dimensions of high-quality care:

Safe Effective Patient centered Timely Efficient Equitable

WHAT COMES AFTER FOCUS

Team decides not to proceed b/c timing is wrong or financial/staff support not forthcoming --Inform staff; inform any essential stakeholders --Document decision; target for review later Team decides to proceed: Next step... --Select model for developing action plan --We are currently using the FOCUS-PDCA model so team will now progress to PDCA......

P: PLAN

Team must target the most ineffective or inefficient part of the processes that is within your power to change Make sure the resulting plan actually addresses the identified part Are you sure that's the most important element? Evaluate selected element by asking 3 Q to get 3 "yes" 1. Is this process element w/in PT and OT control to change? 2. Are there adequate time/resources to address this element? 3. Will changing this part have much impact on the overall process? And do we value the resulting impact? Actions: What is the plan? Responsibility: Who does what? Timeline: What are the deadlines? Minimum acceptable level of change: How much improvement must occur before we are satisfied? Finalize plan Make sure everyone understands the plan Assigning responsibility Use team members identified during FOCUS Setting timeline Things to consider

THE CALL TO LEADERSHIP

To change practice calls for transformational leadership to achieve the collective purpose Ordinary methods will not create behavior change What is in your tool kit to create new work environments where quality is valued?

All health professionals should be educated to deliver.....

patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, informatics and quality improvement approaches NOTE: These are the expectations of the Affordable Care Act

how does the US score on quality measures?

pretty low....