Informatics 8: Quality Improvement

Question 1

quality reviews

Answer 1

• every 1 patient we do good by we only gain one patient back
• no more no less
• every patient you do wrong by you lose 5 patients
• people are more likely to leave bad reviews

Question 2

quality improvement theory

Answer 2

• quality improvement in the hospital goals for this primer
• understnad fundamental concepts in quality improvement
• identify the environment and key steps for a successful quality improvement project
• become familiar with several quality improvement tools and their use

Question 3

quality improvement: bridging the implementation gap

Answer 3

• direct relationship between progress and time -> patient care
• scientific understanding and IT can decrease the implementation gap
• patient care is slow increasing slope :(
• we get it right 54% of the time -> not good

Question 4

hospitalists and quality improvement

Answer 4

• complex process problems need multidisciplinary solutions
• all departments work together
• we are at the frontlines seeing system failures process errors, and performance gaps with our own eyes -> which is our competitive advantage
• teaching people how to use EMR wrong -> snow ball effect -> people take it out on other things
• improved quality delivers:
• better pt care**
• at lower costs
• with potentially higher reimbursements (pay-for-performance)
• and it can make our jobs more interesting, fun, and rewarding

Question 5

quality

Answer 5

• meeting the needs and exceeding the expectations of those we serve
• delivering all and only the care that the patient and family needs
• we do this to better patient care

Question 6

improvement

Answer 6

• it is NOT:
• yelling at people to work harder, faster, or safer
• creating order sets or protocols and then failing to monitor their use or effect- follow up
• traditional quality assurance-
• research (but they can co-exist nicely)- trying a new durg

Question 7

improvement requires change

Answer 7

• principle #1
• every system is perfectly designed to achieve exactly the results it gets
• to improve the system, change the system*…
• change= not just doing something different, but engineering something different -> at least one step in at least one process

Question 8

clinical research

Answer 8

• trying something new in the real word
• monitor to see if its working
• and then put it in true clinical practice

Question 9

less is more

Answer 9

• principle #2
• you cannot destroy productivity
• when changing the system, keep it simple

Question 10

change

Answer 10

• not just doing something different, but engineering something different
• at least one step in at least one process

Question 11

understanding change in the hospital atmosphere

Answer 11

• high reliability strategies commonly succeed:
• build a “decision aide” or reminder into the system
• make the desired action the default action (not doing the desired action requires opting out)
• build redundancy into responsibility (e.g. if one person in the chain overlooks it, someone else will catch it)
• schedule steps to occur at known intervals or events
• standardize a process so that deviation feels weird
• take advantage of work habits or reliable patterns of behavior
• build at least one- if not more- of these high reliability strategies into any changed process

Question 12

improving quality

Answer 12

-can increase or decrease cost depending on the situation

Question 13

understanding change in the hospital atmosphere

Answer 13

• change engineered to drive improvement depends on…
• workplace culture
• awareness
• evidence
• exerience

Question 14

workplace culture

Answer 14

• personnel must be receptive to change

- ready to accept change

Question 15

awareness

Answer 15

-administrative and medical staffs must care about performance and support its improvement through change

Question 16

evidence

Answer 16

-local experts must identify which research to translate into practice

Question 17

experience

Answer 17

• a skilled team must choose, implement, and follow up changes to ensure:
• improvement efforts are ongoing and yielding better performance
• productivity is perserved

Question 18

an atmosphere for change

Answer 18

-

Question 19

the driving force for change: the multidisciplinary team

Answer 19

-a team is not the same as a committee

Question 20

committee

Answer 20

• individuals bring representation
• productive capacity = single most able member
• sum of the whole is greater than the individual

Question 21

team

Answer 21

• individuals bring fundamental knowledge

- productive capacity = synergistic (more than the sum of all individual team members together)

Question 22

hospital atmosphere

Answer 22

• hospitals tend to be viscous, complex systems with default levels of performance
• change engineered to improve performance can be a foreign concept or even overtly resisted

Question 23

consensus

Answer 23

• finding a solution acceptable enough that all members can support it
• no member opposes it
• you need to wholeheartedly agree when you vote
• very hard to do
• everyone agrees but it may not be their first choice
• it is NOT:
• a unanimous vote (consensus may not represent everyone’s first priority)
• a majority vote (in a majority vote, only the majority gets something they are happy with, people in the minority may get something they dont want at all, which is not what consensus is all about)
• everyone it totally satisfied

Question 24

3 types of team members

Answer 24

• team leader
• team facilitator
• process owners (members with operational, hands-on fundamental knowledge of the process)

Question 25

team leader

Answer 25

• schedules and chairs team meetings
• sets the agenda (printed at each meeting)
• records team activities (working documents in binder)
• reports to management (steering team)
• often a member of steering team

Question 26

team facilitator

Answer 26

• own the team process (enforces ground rules)
• body guard, cop
• technical expert on QI theory and tools
• assists team leader
• teaches while doing within team

Question 27

process owners

Answer 27

• chosen for fundamental knowledge
• will help implement
• should become leaders (so choose wisely)

Question 28

team ground rules

Answer 28

• all team members and opinions are equal
• team members will speak freely and in turn we will listen attentively to others, each must be heard, no one may dominate
• problems will be discussed, analyzed, or attacked (not people)
• all agreements are kept unless renegotiated
• once we agree, we will speak with “one voice” (especially after leaving the meeting)
• honestly before cohesiveness
• consensus vs. democracy: each gets his say, not his way
• silence equals agreement
• members will attend regularly
• meetings will start and end on time

Question 29

defining an approach to change

Answer 29

• will the team target “all” patients in the inpatient bell curve, or just a sub-group considered “at-risk” (depicted in the outlying tail)
• is the quality of inpatient care which is not in the tail somehow acceptable

Question 30

engineering change

Answer 30

hospitals have 2 dynamic levels impacting performance:

1. processes- tasks performed in series or in parallel, impacting patient care and potentially patient outcomes
2. personnel- skilled people with hearts and minds, with variable levels of attention, time, and expertise

Question 31

what variables impact quality outcomes of care?

Answer 31

• structures/inputs- patients, equipment, supplies, training, environment
• processes/steps- invent`ory methods, coordination, physician orders, nursing care, ancillary staff, housekeeping, transport
• outcomes of care/outputs- physiologic parameters, functional status, satisfaction, cost

Question 32

the 2 most dynamic levels impacting performance

Answer 32

• this is the most important parts
• process/steps:
• inventory methods
• coordination
• physician orders
• nursing care*
• ancillary staff*
• housekeeping*
• transport*
• • -> also personnel
• • most important areas

Question 33

processes

Answer 33

• all those affecting relevant aspects of patient care
• clinical decision making, order writing, admission intake, medication delivery, direct patient care, discharge planning, PCP communication, discharge follow-up, etc.

Question 34

Where?

Answer 34

• where are the processes to improve?
• brainstorming
• multivoting and nominal group technique
• affinity group
• where do we start?
• cause and effect diagrams (ishikawa or fishbone diagrams)
• tally sheets
• pareto charts
• flow (conceptual flow, decision flow) chart
• run charts
• SPC charts
• scatter charts

Question 35

cause and effect diagram

Answer 35

• sometimes also called a fishbone or ishikawa diagram
• graphically displays list of possible factors, focused on one topic or objective
• used to quickly organize and categorize ideas during a brainstorming session, often as an interactive part of the session itself (the added organization can help produce balanced ideas during a brainstorming session)

Question 36

tools for engineering change: pareto chart

Answer 36

• graph chart
• graphical display of the relative weights or frequencies of competing events, choices, or options
• a bar chart, sorted from greatest to smallest, that summarizes the relative frequencies of events, choices, or options within a class
• often includes a cumulative total line
• used to focus within a broad category containing many choices, based on factual or opinion-based information
• can combine factors that contribute to each items practical significance

Question 37

sketching processes or flow***

Answer 37

• macro process maps- biggest thing in health care -> decision charts
• decision flow diagrams- flows down the process

Question 38

improve incrementally. learn through action

Answer 38

• PDSA- plan do study act
• test your changes
• assess their effect
• then re-work the changes and do it again…and again…

Question 39

PDSA (the benefits of repeated cycles)

Answer 39

• increases belief that change will result in improvement
• allow opportunities for “failures” without impacting performance
• provides documentation of improvement
• adapts to meet changing environment
• evaluates costs and side-effects of the change
• minimizes resistance upon implementation
• ideas are great, but “how” is on trial

Question 40

PDSA: overview

Answer 40

• scientific method for action-oriented learning: shorthand for testing a change in the real world setting
• test a change by: planning it, trying it, measuring its results… and then trying to do it better the next time
• multiple rounds of changes – some failures and some successes - should lead to improved aggregate outcome

Question 41

PDSA: principles for success

Answer 41

• Start new changes on the smallest possible scale, e.g. one patient, one nurse, one doctor
• run just as many PDSA cycles as necessary to gain confidence in your change- then expand
• expand incrementally to more patients
• expand to involve more nurses, more doctors, more departments
• balance changes within system to ensure other processes not adversely stressed

Question 42

PDSA: question

Answer 42

• what do we want to achieve
• what changes will drive our progress
• how will we measure our progress
• how should we modify our latest changes

Question 43

PDSA: what do we want to achieve?

Answer 43

-set an outcome aim
-it should be ambitious
-must be measurable
-must specify a time period and a definite population in your hospital
FUNCTION EXPANSION
-list the outcome aim again, then:
-ask why 3 times
-ask how 3 times
-loos at the new aim statements
-pick the best one
-

Question 44

PDSA: what changes will drive our progress?

Answer 44

• select changes to your system, the ones most likely to improve outcomes
• recognize that not all changes improve outcomes or offer balance

Question 45

PDSA: how will we measure our progress

Answer 45

• define what you will measure quantitatively

- collect data, chart measures regularly over specified time period, and chart against benchmarks and goal lines

Question 46

3 types of measures: PDSA

Answer 46

• outcomes
• process
• balancing measures- use a balanced set of measures for all improvement efforts

Question 47

principle of measurement

Answer 47

• seek usefulness, not perfection
• integrate measurement into the daily routine
• use qualitative and quantitative data
• use sampling
• plot data over time