Topic 7

Introduction to methods for

quality improvement
Learning objective
the objectives of this topic are to:

describe the basic principles of quality improvement
introduce students to the methods and tools for improving the
quality of health care
Performance requirement
know how to use a range of improvement activities
and tools
Knowledge requirements
the science of improvement
the quality improvement model
change concepts
two examples of continuous improvement methods
methods for providing information on clinical care
W Edwards Deming
The science of improvement
appreciation of a system
understanding of variation
theory of knowledge
psychology
Measurement for research

Measurement for learning
and process improvement

Purpose
To discover new knowledge To bring new knowledge into
daily practice
Tests
One large "blind" test Many sequential, observable
tests
Biases
Control for as many biases as
possible
Stabilize the biases from test to
test
Data

Gather as much data as possible,
"just in case"
Gather "just enough" data to
learn and complete another
cycle
Duration

Can take long periods of time to
obtain results
"Small tests of significant
changes" accelerate the rate of
improvement
The Institute for Healthcare
Improvement (IHI): different measures
Three types of measures
outcome measures
process measures
balancing measures

The quality improvement model-the
PDSA cycle
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?
ACT PLAN
What are we trying to accomplish?
How we will know that a change is an improvement?
What change can we make that will result in an improvement?
DO STUDY
The model for improvement

Langley, Nolan, Nolan, Norman & Provost 1999
ACT PLAN
DO STUDY
Determines what
changes are to be made
Summarizes what
was learned
Change or test
Carry out the plan
Langley, Nolan, Nolan Norman & Provost 1999
The PDSA cycle
Change concepts

are general ideas, with proven merit
and sound scientific or logical foundation
that can stimulate specific ideas for
changes that lead to improvement.


Nolan & Schall, 1996
9 categories of change

eliminate waste
improve work flow
optimize inventory
change the work environment
enhance the producer/customer relationship
manage time
manage variation
design systems to avoid mistakes
focus on the product or service
Langley, Nolan, Nolan, Norman & Provost 1999
Two continuous improvement
methods

clinical practice improvement methodology (CPI)
root cause analysis
D
P A
S
3
Intervention
phase
Diagnostic
phase
2
1
Project
phase
4
5
Sustaining
improvement
phase
Impact
phase
Project mission
Project team
Conceptual flow of
process
Customer grid
Data
-fishbone
-Pareto chart
-run charts
-SPC charts
2 months
Plan a change
Do it in a small test
Study its effects
Act on the result
2 months
1 month
Annotated
run chart
SPC charts
D
P
A
S
D
P
A
S
D
P
A
S
D
P
A
S
Ongoing monitoring
Outcome
Future plans
Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
SPC statistical process control
The improvement process
Identify appropriate interventions
Implement changes identified in the diagnostic phase
Undertake one or more PDSA cycles
Interventions phase
Decide on interventions
Undertake one or more PDSA
cycles
Interventions phase
Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
ACT
What changes
can be made for
the next cycle
(adapt change,
another test,
implementation
cycle?)

PLAN
Objective
Prediction
Plan for change (who,
what, when, where)
Plan for data collection
(who, what, when, where)

Carry out the change
Document observations
Record data

DO
Complete analysis
of data
Compare results
to predictions
Summarize
knowledge gained







STUDY
How to use the PDSA Cycle
use plan-do-study-act cycles
to conduct small-scale tests
of change in real settings
plan a change
do it in a small test
study its effects
act on what learned
team uses and links small
PDSA cycles until ready for
broad implementation
Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
PDSA Cycles single test
Changes that
result in
improvement
Hunches,
theories
and ideas
A
S D
P
A
S
D
P
A
S
D
P
A
S D
P
PDSA cycle - single test
PDSA Cycles multiple tests
A
S D
P A
S D
P A
S D
P
P
D A
S
P
D A
S
P
D A
S
D
P A
S
D
P A
S D
P A
S
Test 1 Test 3 Test 2
PDSA cycle multiple tests
NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

1. Measure impact of changes/interventions
2. Record the results
3. Revise the interventions
4. Monitor impact

Impact and implementation phase
Implement the changes
Measure impact
Annotated run chart
SPC charts
Other graphs
Impact and implementation phase
NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

1. Once an intervention has been
introduced, the intervention and any
improvements need to be sustained
2. This may involve:
standardization of existing
systems and processes
documentation of policies,
procedures, protocols and
guidelines
measurement and review of
interventions to ensure that
change becomes past of
standard practice
training and education of staff


Sustaining
improvement phase
Sustain the gains
standardization
documentation
measurement
training
Sustaining the improvement phase
NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
Root cause analysis
a multidisciplinary team
the root cause analysis effort is directed towards finding
out what happened
establishing the contributing factors of root causes
Performance requirements

Know how to use a range of improvement activities and tools

flowcharts
cause and effect diagrams (Ishikawa/fishbone)
Pareto charts
run charts

0
2
4
6
8
10
12
14
LOS days
Hospital NSW Health Kehlet et.al
At the same time LBH executives and staff expressed a desire to improve LOS.
NSW New South Wales.
Evidence for there being
a problem worth solving
Flow chart of process
Something amiss
Referral to Hospital
Visit to general
practitioner
Referral to surgeon
Investigations
Hospital admission









Admissions office
Operating theatre
Admitted to hospital
Preoperative clinic
Post anaesthetic care
Allied health
Surgical ward
Surgical team
Discharge planner
Pre-op ward
Pain team
Home
Community health/
Peripheral hospital
Return to life
Accelerated Recovery Colectomy Surgery (ARCS)
Jenni Prince
Area CNC Pain Management
North Coast Area Health Service
NCHI Sydney Australia

Multidisciplinary meeting to:
-ask opinion
-brainstorm process of care
-how to improve the process
-who to include in the process
of change
-how to communicate progress
standardization
Evidence-based
practice
team approach
Customer and expectations list
surgical ward staff
post-op anaesthetic care staff
physiotherapy dept

dietitian
peri-operative unit staff
private hospital staff
pain team
anaesthetists
surgeons
intensivist




Cause and effect diagram
Social issues

Staff attitudes Complications
Procedure
Patient perception
Post discharge support
Prolonged
LOS
surgery
mobilization
nutrition
nil by mouth
LOS
mobilization
pain control
nutrition
expect long LOS
home support
often weak
poor understanding
of procedure
little knowledge of
support services
pain control
locus of control
family support
poor pain control
wound complications
weak/malnourished
community health
general practitioner
infection
family
colon care nurse
Accelerated Recovery Colectomy Surgery (ARCS)
Jenni Prince
Area CNC Pain Management
North Coast Area Health Service
NCHI Sydney Australia

45
34
28
18
16
8
38
0
5
10
15
20
25
30
35
40
45
p
o
o
r

p
a
t
ie
n
t
k
n
o
w
le
d
g
e
n
o
n
-
s
t
a
n
d
a
r
d
iz
e
d

p
a
in
c
o
n
t
r
o
l
im
b
e
d
d
e
d

s
t
a
ff

a
t
t
it
u
d
e
s

p
o
o
r
ly

c
o
o
r
d
in
a
t
e
d
d
is
c
h
a
r
g
e
s
lo
w

to

m
o
b
il
iz
e
u
n
d
e
r
n
o
u
r
i
s
h
e
d

p
a
t
ie
n
t
s
e
tc
24
57
42
76
67
80
100
Pareto chart

surgical incision trial of transverse incision
pain control wound infusion for transverse incisions

then

patient information booklet
surgeon pathway
anaesthetic pathway
ARCS clinical pathway - surgical technique

- pain control

- bowel prep/care
- nutrition
- mobilization





1
surgeon
10
patients
1
surgeon
1-6
patients
PDSA cycles - implementation
Average LOS (days) per month
0
10
20
30
40
50
60
1 2 3 4 5 6 7 8 9 10 11 12
month
d
a
y
s
Run chart
Made change here
Strategies for sustaining
improvement
document and report each patient LOS
measure and calculate monthly average LOS
place run chart in operating theatre, update run chart
monthly
bimonthly team meetings to report positives and
negatives
continuously refine the clinical pathways
report outcomes to clinical governance unit
Spread - all surgeons
- left hemicolectomy
- all colectomy surgery
- throughout North Coast Area Health Service