Two Kinds of People

Two Kinds of People

Two Kinds of People

Quality Improvement in Healthcare Manu K. Malhotra, MD Henry Ford Hospital Mar 3, 2016

Quality Improvement I. What is QI? II. Why do you need to know about it? III. Process improvement techniques IV. Root Cause Analysis

What is Quality Improvement? Methodical approach to measuring performance and the effort to improve it.

QA vs. QI QA: Quality Assurance QI: Quality Improvement A primarily retrospective review of processes and making sure they are followed and work as intended. QI: Quality Improvement A prospective and retrospective look at results and processes with a focus on how to improve them.

Why do I need to know about QI? Continually improve your ability to care for patients. Make the world a better place Empower yourself And…

Why do I need to know about QI? Core Competencies Patient care Medical knowledge Interpersonal skills and communication Professionalism Systems-based practice Practice-based learning

Why do I need to know about QI? SBP: Systems Based Practice …and improve their patient care practices. PBLI: Practice Based Learning and Improvement …effectively call on system resources to provide care that is of optimal value.

Why do I need to know about QI? Remain EM Board Certified Patient Care Practice Improvement Activity (PI)

Why do I need to know about QI? Meet existing and future performance guidelines/mandates. E.g. Sepsis, ACS guidelines Sentinel events (Root Cause Analysis) Hospital Acquired Conditions

What is quality?

What is quality? Quality in Healthcare Mortality Morbidity Complications Quality of Life Perception of Care (wait times, etc) …

Process Improvement In many cases, Quality can be improved by improving processes (eg. sepsis). Throughput Time to see a doctor Time from admission to bed …

Process Improvement Techniques Total Quality Management Process Re-Engineering Constraint management Six Sigma Lean Systems

Lean Manufacturing Attributed to Taichii Ohno of Toyota, but actually, the ideas are rooted in the work of Henry Ford and the Model T factory…

Lean Manufacturing Basic concepts: Empower front-line workers to affect change Remove “waste” (errors and delays) Seamless flow of work/products Understand the current process first! Value Stream Maps Use Japanese words

Types of Waste (Muda) Transportation Inventory Motion Waiting Over-processing Over-production Defects

HFH ED history with Lean 2010: MHA Keystone: ED project Multihospital project to improve healthcare delivery in MI Lean used as a tool HFH ED created a Lean team comprised of 4 nurses, one doctor and one clinical quality specialist.

Assess the Current Process “Current State” value stream map created for the Door to Doc process Map was then “socialized” Reworked, more details added “Gemba” walks “Muda” identified All done by clinicians who work in the ED

Current State

Future State Map All ideas and findings incorporated and changes to be made identified (“Kaizan bursts”) Future State map created

HFH Emergency Department Door to Provider Time

HFH Emergency Department Door to Provider Time

But how do you decide what to improve? Data collection Consensus Mandates Adverse Events

Adverse Events Sentinel events M & M QA Process Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) mandated the use of RCA (root cause analysis) in the investigation of sentinel events in all accredited hospitals starting in 1997. M & M QA Process

M&M Provider Centered Defensive Retroactive

QI Process Patient Centered Quality Directed Proactive

Root Cause Analysis (RCA) Try to get at the cause of the problem instead of just dealing with the symptoms, or putting out fires or placing blame. Data Collection Reconstruction of the events Analysis Recommendations

RCA Problem: Expeditious Solution: Result: Patient and family complaining (loudly) about waiting too long to be seen Expeditious Solution: Go talk to patient and family and “get things going” on the patient Result: Someone else ends up waiting a little longer

RCA This solution treats the symptoms, but not the problem.

Reaching the Root cause The 5 whys Fishbone (Cause and effect)Diagrams Causal Factor Chart

The 5 whys 1. Why is the patient upset? He’s been waiting for 3 hrs to be seen. 2. Why has he been waiting 3 hrs? He just got back from triage. That’s how long the wait is. 3. Why is the wait so long? There ain’t no beds, so the ED is crammed. 4. Why are there no inpatient beds? Our transfer volume is on the rise. 5. Why are we taking transfers when our patients are waiting?

5 whys Incoming transfers are preferentially placed in beds over ED patients.

Or may more than 5… 6. Why are incoming transfers preferentially placed in beds over ED patients. Because there is a belief that critically ill patients in our ED are safer than patients waiting at St. Elsewhere 7. Why do we think that? Because it’s true

Fishbone Diagram Facility Resources Too noisy Waiting too long Smells bad Vending machine not working Laying in hallway Patient is upset Pt. worried about dx Nurse was mean Lost her job Doctor was rude Personal Staff

RCA 5 whys is more useful for linear problems, but is not well-suited for multifactorial problems. Fishbone diagrams/Causal Charts can be more useful when many causes need to be explored and evaluated.

RCA Root cause analysis is a part of the problem definition phase of almost all process improvement systems. Find a solution that not only solves the problem, but prevents its recurrence.

Take-home points QI will be a part of your life Lean Healthcare uses value stream mapping and empowers front-line workers to eliminate waste Root cause analysis is the first step in addressing an adverse event Five Whys and Fishbone diagrams can be used to assess the root cause