QI 101: Introduction to Health Care Improvement
Which of these questions is most strongly related to the "appreciation of a system" component of Deming's System of Profound Knowledge? What are your predictions about the system's performance? What is the whole system that you're trying to manage? What motivates people to act as they do? What is the variation in results trying to tell you about the system?
"What is the whole system you're trying to manage?" is the best answer. Deming defined a system as a network of interdependent components that work together to try to accomplish the aim of the system. He said that the aim for any system should be that everybody gains, not that one part of the system gains at the expense of any others.
List the six dimensions of health care, and the aims for each, outlined by the Institute of Medicine (IOM) in 2001. It said 44,000 to 98,000 Americans were dying due to medical errors each year.
1. Safety 2. Effectiveness (matching science to care) 3. Patient centeredness (Control their own care) 4. Timeliness (avoiding delay of care) 5. Efficiency (avoiding waste) 6. Equity (closing the gap) "STEEP"
"When one of my coworkers is late for the carpool in the morning, it affects the traffic we hit, what roads we can take, what parking space we can get, and, ultimately, the time we arrive at work." Understanding variation Theory of knowledge Psychology (human behavior) Appreciation of a system
Appreciation of a system: You're thinking about how the different parts of your system interact with and rely on one another.
How is safety defined?
Avoid injuries to patients from the care that is intended to help them
How is efficient defined?
Avoid waste, including waste of equipment, supplies, ideas, and energy
Timely and effective care
How often or how quickly hospitals provide care that research shows gets the best results for patients with certain conditions, and how hospitals use outpatient medical imaging tests (like CT scans and MRIs).
Psychiatric unit services
How often or how quickly inpatient psychiatric facilities give recommended treatments and services known to get the best results for people with mental health conditions, substance abuse, and other health conditions
Unplanned hospital visits
How often patients return to the hospital after being discharged or come to the hospital after an outpatient procedure and how long they stay
Survey of patients' experiences
How patients responded to a national survey about their hospital experience; for example, how well a hospital's doctors and nurses communicate with patients and how well they manage their patients' pain
What is scientific improvement?
Improvement Methodologies: Implementation Science Healthcare Delivery Science Systems Engineering Heath Systems Strengthening Lean Six Sigma Lean Six Sigma
Equitable Example HealthPartners, an integrated health system in Minnesota, US, has been working on improving health disparities.
In one year, the pink ticket program helped achieve more than 6,000 same-day mammograms, which helped contribute to IHI's Triple Aim: better care to improve the health of populations at a lower cost
Payment and value of care
Information about how much Medicare pays hospitals
Who is W. Edwards Deming?
Introduced Total Quality Management, made the idea that held the process of whatever happens is more important then the product
What is System of Profound Knowledge?
It's not a "system" in the sense of a systematic set of procedures, but a framework for understanding the key aspects of any system you need to consider in order to bring about improvement. He described it best in his last book, The New Economics, published shortly before his death in 1993.
Which of the following countries has had a relatively inexpensive universal health insurance system for more than 50 years? Germany The United States Chile Japan
Japan Japan has had a relatively inexpensive universal health insurance system for more than 50 years. Germany made health insurance mandatory for its entire population in 2009. Chile has given all Chileans access to a basic health care package since 2005.
Which of the following improvement efforts is the best example of making care more patient centered? Improving the percent of clinic patients achieving their targeted blood pressure by instituting a series of reminders for providers about evidence-based processes Decreasing unnecessary surgical procedures by helping patients reduce their pain through physical activity Improving patient experiences by providing reading materials in the waiting room Better identifying patient concerns and values
Better identifying patient concerns and values by instituting quarterly patient focus groups The best answer is implementing focus groups. Patient-centered care means providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
How is equitable defined?
Care shouldn't vary in quality because of personal characteristics
What is Deming's Theory of Knowledge?
Deming believed knowledge is based on theory, and that theories need to be developed, applied, and tested in order to advance knowledge in a systematic fashion. (Learn how this relates to something called PDSA cycles, which allow you to test ideas for change on a small scale, in QI 102: How to Improve with the Model for Improvement.) Consider: What are your predictions about the system's performance? What are the theories that form the basis for these predictions?
What is Deming's Psychology (Human Behavior)?
Deming believed that people are fundamentally different, with varied strengths, beliefs, and motivations. Because people are fundamental components of the systems in which they work, all these human factors will affect systems outcomes. Consider: What are the important interactions among people in the system? How do people in a system react to change? What motivates people to act as they do?
What is Deming's Appreciation of a system?
Deming defined a system as a network of interdependent components that work together to try to accomplish the aim of the system. The aim for any system should be that everybody gains, not that one part of the system gains at the expense of any others. Consider: What is the whole system that you're trying to manage? How do the different parts interact with and rely on one another?
When you are applying Deming's System of Profound Knowledge, which of the following statements is true? You can't think about any one component of the System of Profound Knowledge completely in isolation. You need to fully understand each component of the System of Profound Knowledge to gain any benefit. It helps to visualize the System of Profound Knowledge as a tree. All of the above
Deming emphasized that it is the relationships among the four parts of the System of Profound Knowledge (which is often depicted as a lens) that provide insights for improvement; you can't think about any one area completely in isolation because they all intersect and interact. According to Deming, "One need not be eminent in any part nor in all four parts in order to understand and apply it."
What is Deming's Understanding Variation?
Deming said there are two causes of variation: those that are intrinsic to the system and typical (common causes), and those that are the result of an unusual event, outside the typical operation of the system (special causes). To make improvements, you need to measure your results and be able to recognize and distinguish between both types of variation. Consider: What is the variation in results trying to tell you about the system? Why did something go wrong? Why are results so poor? How can you repeat successful results?
Which of the following statements is true: During the past 15 years, the cost of care has been a growing problem for many developed nations. During the past 15 years, most countries around the world have used similar approaches to improve health care quality and access. Among industrialized nations, there is a perfect correlation between quality rankings and the number of dollars spent on health care. All of the above
During the past 15 years, the cost of care has been a growing problem for many developed nations. The cost of care has been a growing problem throughout developed nations during the last 15 years. For example, across 34 nations that make up the Organization for Economic Cooperation and Development (OECD), the average per capita health care expenditure increased by more than 70 percent between 2000 and 2010. However, the biggest spenders — such as the US — don't necessarily have the highest quality in many areas. Today, countries around the world with vastly different political, economic, and cultural makeups are working toward the goals of improving quality and access in different ways.
Effective Example Claxton-Hepburn Medical Center in Ogdensburg, New York, didn't know exactly what they should be doing to prevent pressure ulcers
Established a skin and wound care team and started researching pressure ulcer prevention.
6 categories of waste (Efficient)
Failures of: 1. Care delivery 2. Care coordination 3. Overtreatment 4. Administrative complexity 5. Pricing failures 6. Fraud and abuse
What is W. Edward's Deming System of Profound Knowledge
Four areas when to make a change within a system: Appreciation of a system Variation Theory of Knowledge Human Behavior
Patient-Centered Example an innovative tool the Mayo Clinic and other institutions are using to turn this old, unilateral decision-making process on its head:
Here is a tool that is a graphical, cardboard tool, and patients are invited to consider which aspects of their next diabetes medicine, for instance if they're going to add a medicine to their current program, which aspect of their next diabetes medicine would they like to consider first? So patients may see this, and they may be interested, for instance, in the effect of the medicine on their weight. So the clinician takes that card and hands it over to the patient, which of course has a very important ritual meaning: "Here's information; it's in your hands."
Describe common challenges for health care systems around the world.
High adverse event rates Too few and poorly trained providers Limited diagnostic tools and equipment Delays in accessing medications and other treatments The need to effectively treat growing numbers of patients with non-communicable diseases, such as cancer, heart disease, and diabetes
Complications and deaths
How likely it is that patients will suffer from complications while in the hospital, and how often patients in the hospital get certain serious conditions that might have been prevented if the hospital followed procedures based on best practices and scientific evidence
Timely Example Staff at Margret Marquart Catholic Hospital in Kpando, Ghana — one of the initial hospitals participating in a nationwide improvement initiative in Ghana called Project Fives Alive! Mortality rate for children under five was 33 per 1,000 admissions - most deaths d/t malaria, anemia, and neonatal disease (asphyxia and prematurity) Two causes: delays in patients seeking care and delays in clinicians providing appropriate care upon arrival at the hospital
Key changes included: 1. Community education on the importance of seeing care early 2. Triage and fast-tracking: identifying acutely ill patients and providing prompt treatment 3. Blood bank readiness: blood donation campaigns amongst the youth and requiring all elective surgery cases to bring two blood donors Achieved: 31% reduction in under-five mortality 37% reduction in post-neonatal infant mortality 35% reduction in under-five malaria case fatility
IHI Model for Improvement Steps
Lean: Eliminating Waste Six Sigma: Highly reliable Systems Engineering: Systems dynamics As Dr. Goldmann said, most of the problems in health and health care are not due to mistakes by uninformed or lazy people, but, rather, can be traced to problems with the systems in which they have to work. To change the statistics you've been learning about, you have to error-proof your systems
Dhruv, a 65-year-old retiree, is brought to the hospital after developing chest pain while gardening. He is quickly diagnosed with an acute myocardial infarction (heart attack). He waits almost two hours to get to the catheterization lab; suffering heart damage. The hospital where Dhruv is recovering reviews its patient satisfaction survey results in order to improve its care and patient outcomes. Which aim is the hospital generally achieving? Timely Effective Efficient Patient-Centered
Patient-centered care is defined by the IOM as "care that is respectful of and responsive to individual patient preferences, needs, and values" and that ensures "patient values guide all clinical decisions." These high satisfaction rates are consistent with being patient-centered.
Efficient Example The National Health System (NHS) in England was facing the same problem as many countries' health systems: Health care costs were growing, but their budget wasn't. To begin to deal with this, they set a goal: By April 2013, all patients would be cared for in the most productive environment possible
Promoted The Productive Series, a series of programs based upon improvement methodology such as Lean and Six Sigma. These programs helped multidisciplinary health care professionals identify waste in their different industries and streamline their work
How is Patient Centered defined?
Provide care that is respectful and responsive to individual patients
How is effectiveness defined?
Provide the appropriate level of services based on scientific knowledge
Which of the following is a trend in modern health care across industrialized nations? Providers are becoming more specialized. The disease burden is shifting toward acute conditions. There is growing demand for complicated procedures. Providers are becoming more specialized AND There is growing demand for complicated procedures.
Providers are becoming more specialized AND There is growing demand for complicated procedures. As medical information and technology increases, demand for complicated procedures is increasing, and providers are becoming more and more specialized (and fragmented). The burden of disease is shifting toward chronic conditions.
"My coworkers and my husband are resistant to my improvement idea (and my coworkers are routinely late for the carpool) because they are tired in the morning." Understanding of variation Appreciation of a system Psychology (human behavior) Theory of knowledge
Psychology (human behavior): You're thinking about how people in your system react to your change, and what motivates them act as they do.
How is timely defined?
Reduce waits and sometimes harmful delays for patients and providers
Why was it important for the Institute of Medicine (IOM) to develop its six aims for health care? So that accreditation organizations would be better able to evaluate hospitals So that health care organizations would have a better idea of what they needed to improve So that lawmakers could focus their attention upon specific areas when working on health care reform All of the above
So that health care organizations would have a better idea of what they needed to improve Just as defining dimensions of good performance helps employees, defining the aims (or dimensions of quality) of health care helped hospitals and other organizations understand what to focus on when improving their care.
Safety Example Scottish Patient Safety Programme (SPSP) is a national initiative that aims to improve the safety and reliability of health care. Jason Leitch, National Clinical Director of Healthcare Quality for the Scottish government, describes why the SPSP program set an ambitious goal to reduce mortality by 15 percent across the countr
Started in the acute care setting in 2008 and has spread to maternity and child care, mental health, and primary care. As of 2014, by introducing systemic changes such as surgical pauses, pre-operative briefings, and leadership safety walk rounds, the program has been able to report the following improvements: 15.9% reduction in the Hospital Standardized Mortality Ratio 25.5% reduction in surgical mortality 80% decrease in Clostridium Difficile rates in patients over age 65 89% decrease in MRSA cases
Which of the following statements is a reason for improving the US health care system? The US has fallen behind in biomedical innovation. The US lacks the means to measure health care quality and access. The US government and citizens alike are struggling to afford the cost of care. All of the above
The US government and citizens alike are struggling to afford the cost of care. The US government and citizens alike are struggling to afford the cost of care. We've seen in this lesson the US has the means to measure health care quality — the results just often are not what one would hope! Although the US remains a leader in biomedical innovation, even the most advanced biomedical science and technology can't guarantee high-quality care.
Transcendental Nursing Home is working on decreasing its rates of catheter-associated urinary tract infections (UTIs) among its residents. While reviewing data, the improvement team notices that the UTI rate on Floor 3 is half that of the rest of the floors. They decide to visit the unit and find out what it is doing differently.After speaking with caregivers on Floor 3, the improvement team discovers that there is a particularly dedicated head nurse on the unit whose mother died after a catheter-associated UTI. This nurse orients all new providers and also provides feedback when she sees that catheters are being placed unnecessarily in patients. Which component of Deming's System of Profound Knowledge do this nurse's actions best represent? Theory of knowledge Appreciation of a system Understanding of variation Psychology (human behavior)
The answer is psychology (human behavior). This nurse is very particular about preventing UTIs because of the way this kind of infection has affected her life. This, in turn, has a strong effect on the way the entire unit works.
The Transcendental Nursing Home is working on decreasing its rates of catheter-associated urinary tract infections (UTIs) among its patients. The improvement team predicts that if they begin providing intensive training to staff on how to place the catheters, the infection rates will improve. They devise a plan to test this idea. After three months of testing its improvement idea, the Transcendental team notices that infection rates on one unit are much higher than any other unit. Frustrated, leadership decides to replace all the providers on that unit except the three with the highest seniority. What is the likely outcome, and why? Infection rates will not change because the leaders have not changed the system of care. Infection rates will get better because the leaders have fixed the system. Infection rates will not change because the three caregivers with seniority are probably negligent, like their peers who were
The most likely answer is that infection rates will not change because the leaders have not changed the system of care. Removing individual "offenders" from a system should not be expected to magically make infection rates will go down. The best way to implement improvement is to examine and change the system of care itself.
"If I can convince my husband and coworkers to go to bed earlier at night, they won't mind getting up earlier, and we will all get to work 30 minutes earlier and be happier and more productive." Psychology (human behavior) Theory of knowledge Appreciation of a system Understanding variation
Theory of knowledge: You have several theories based upon which you have made a prediction about the system's performance. You will have to test these theories before they become knowledge.
Transcendental Nursing Home is working on decreasing its rates of catheter-associated urinary tract infections (UTIs) among its residents. While reviewing data, the improvement team notices that the UTI rate on Floor 3 is half that of the rest of the floors. They decide to visit the unit and find out what it is doing differently. Which component of Deming's System of Profound Knowledge is the team about to harness? Theory of knowledge Appreciation of a system Understanding variation Psychology (human behavior)
They are working at understanding variation. By noting a unit that outperforms the others — a significant variation — the nursing home can now study that unit and attempt to spread its practices throughout the organization.
Which of the following improvement efforts is the best example of increasing the equity of care? Decreasing adverse drug events by having a pharmacist on rounds in the intensive care unit Shortening wait times at a clinic by allowing patients to self-register on a computer in the waiting room Instituting quarterly focus groups of patients seen in the emergency department to better identify patient concerns Through staff development and weekly feedback, equalizing the likelihood that a patient w
Through staff development and weekly feedback, equalizing the likelihood that a patient will receive the appropriate amount of pain medication regardless of their race The best answer is equalizing the likelihood that a patient will receive pain medication as indicated regardless of race, ethnicity, or education. Equity is about making sure patients receive appropriate, high-quality care regardless of gender, race, ethnicity, socioeconomic status, geographic location, sexual orientation, and other individual characteristics.
Dhruv, a 65-year-old retiree, is brought to the hospital after developing chest pain while gardening. He is quickly diagnosed with an acute myocardial infarction (heart attack). However, he waits almost two hours to get to the catheterization lab and have his blocked coronary artery opened. Ultimately, he suffers permanent damage to his heart. Which of the IOM aims has this hospital FAILED to meet? Timely Effective Safe Efficient
Timely Dhruv's care was not timely. He did not receive care when it was needed, without delays.
"On one day no one was late and it was school vacation week so there were no buses to hold us up — we got to work earlier than any other day!" Appreciation of a system Psychology (human behavior) Theory of knowledge Understanding of variation
Understanding variation: You are looking at a variation in results, and how it related to your system. The fact that it was school vacation week was unusual, meaning it was a "special cause" of variation.
In regard to health disparities around the world, which of the following statements is most true? Inequitable medical care is the primary driver of health disparities. Where a child is born significantly affects his or her life expectancy. The root causes of health disparities are complex. Where a child is born significantly affects his or her life expectancy AND The root causes of health disparities are complex.
Where a child is born significantly affects his or her life expectancy AND The root causes of health disparities are complex. Where a child is born and raised can significantly change the life expectancy. The root causes of this and other health differences we see around the world are deeply complex and by no means begin or end in the clinical setting.
Who is Walter Shewhart?
contributed to understanding of process variability Walter Shewhart made a distinction between what he called pure science (for example, Fleming's discovery of antibiotics) and applied science (for example, ensuring antibiotics are available to all, and neither under- nor overprescribed to any patient). He made the bold claim that the latter type of science could be even more challenging than the former.1
IHI Model for Improvement
includes the PDSA cycle to improvement, plan, do, study, act. ask 3 questions. what are we trying to accomplish? how will we know change is leading toward improvement? what changes can we make that will result in improvement?
