Quality Improvement Methods Welcome to the Quality Improvement Methods. This is lecture a. Quality Improvement Methods Lecture a This material (Comp 12 Unit 6) was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024. This material was updated by Normandale Community College, funded under Award Number 90WT0003. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/

Quality Improvement Methods Learning Objectives Describe strategies for Quality Improvement Describe the role of Leadership in Quality Improvement The objectives for this lecture are to: Describe strategies for quality improvement, and Describe the role of Leadership in Quality Improvement

Quality Improvement in the Health Care Setting Quality Improvement – an approach to improvement of service systems and processes through the routine use of health and program data to meet patient and program needs (Chang, 1999) Examples of Quality Improvement Projects Redesigning a Clinical Office Reducing the time for patient intake Redesigning the information flow in a laboratory Increasing the access to care Remember the IOM defined Quality of Care as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Quality Improvement is a method of evaluating and improving processes of patient care which emphasizes a multidisciplinary approach to problem solving, and focuses not on individuals, but systems of patient care which might be the cause of variations. Quality improvement methods can be used to improve health outcomes of all types and sizes. Some examples of Quality Improvement Projects: Redesigning a Clinical Office, Reducing the time for patient intake, and Redesigning the information flow in a laboratory. Increasing access to care, for example by increasing the percentage of time patients can get same day visits when needed

Putting Quality Into Practice The "Putting Quality Into Practice" video series demonstrates the effects of workflow, resource and systems reviews, electronic medical records (EMRs) implementation and other quality improvement efforts on a practice. This series is an eight-part series that plays in a loop. There is approximately 60 minutes of video. The series was produced by the ABIM Foundation, a non-profit foundation. http://www.abimfoundation.org/Resource-Center/Video/PQIP.aspx The "Putting Quality Into Practice" video series emerged as part of a larger project that documented physician engagement in quality improvement projects. The series demonstrates the effects of workflow, resource and systems reviews, electronic medical records (EMRs), implementation and other quality improvement efforts on a practice. In the video, physicians describe their quality improvement process including the following: Motivation and first steps, Systems, measurement and tools, External resources, and Barriers and solutions. This series is an eight-part series that plays in a loop. There is approximately 60 minutes of video. The series was produced by the ABIM Foundation, a non-profit foundation. Pause the slides and click on the http link to listen to this video. Pause the slides now.

Duke Databank for Cardiovascular Disease In the National Roundtable on health care Quality’s “The Urgent Need to Improve Health Care Quality,” the Institute of Medicine highlighted the deficiencies in the U.S. health care system. This is the ultimate improvement project and the reason for the current emphasis on HIT implementation and process improvement.   An example of this in action is the Duke Databank for Cardiovascular Disease, created through the vision of Dr. Eugene Stead, chair of the Duke Department of Medicine from 1946 to 1967. “His vision was that the computer be used hospital-wide as a ‘computerized textbook of medicine,’ replacing a doctor's fallible memory of how to treat a condition or disease with a computer's infallible memory of each patient treated in the hospital” (The Duke Databank for Cardiovascular Disease - Overview. (n.d.)). The databank ultimately became a major part of a cycle of care improvement that started with identifying problems from aggregate data, testing ideas for improvement – including in clinical trials, incorporating that new knowledge into the medical literature and eventually into new care guidelines – adherence of which could then be measured through the databank. Images reprinted from http://digitaldukemed.mc.duke.edu/databank/Images/

Three Major Concepts Quality is a Measurable Phenomenon Safety Six dimensions : Safe, effective, timely, patient-centered, efficient, equitable Safety Errors are definable and measurable The right plan is defined on the basis of professional standards To avoid errors, you must decide on the best plan in the context of professional standards, and the plan must be executed Accountability Measurable performance with consequences Currently lies primarily with physicians Physicians will increasingly be held accountable for performance at the microsystem level In a keynote address presented at the Texas Heart Institute’s symposium “Evolving Standards in Cardiovascular Care: What Have We Learned? Where Are We Going?” (Califf, 2005) Dr. Robert Califf added three major key concepts to the thinking of the cycle of bench to bedside for performance measures. He said, “First, we do the clinical trials. Then we develop guidelines from what the clinical trials showed. Clinical practice guidelines, if properly constructed, provide the evidence to show which of our options is most effective in a particular clinical situation. Then, in order to be sure that we are exercising the ‘best option,’ we have to be able to measure what we are doing. And finally, we close the loop by providing education and feedback to the practicing community. If we are successful in all of this, outcomes can improve.” He presented three key concepts, shown in the slide. “The 1st is that quality is a measurable entity. The Institute of Medicine has defined quality in terms of six dimensions: Is it safe, effective, timely, patient-centered, efficient, and equitable? It’s no longer enough to provide quality in your own individual clinical universe, because that universe overlaps other areas. Patients are exposed to a variety of practitioners and environments during an episode of care, so the responsibility for quality includes proper coordination across practices. The 2nd concept is safety—with safety now defined in terms of “freedom from error.” Errors are definable and measurable . . . an error is defined as having the wrong plan or failing to execute the right plan. . . . The 3rd concept is something that is really being stressed by the Institute of Medicine this year: Accountability. Obviously, we must then have systems in place to document that what we are doing is the right thing.” And this brings us back to the need for efficient and accurate HIT systems.

Quality Improvement “Knowing is not enough; we must apply. Willing is not enough; we must do.” - Goethe Goethe, considered by many to be the most important writer in the German language, and one of the most important thinkers in Western culture, stated that: “Knowing is not enough; we must apply. “Willing is not enough; we must do.”   Quality improvement enables us to move from the knowledge presented in the 1999 report by the Institute of Medicine, which “estimated that 98,000 or more people die annually in the US due to medical errors” to “doing” the improvement which must be done. (Kohn, 2000)

Focus You have been introduced to concepts and practices that will enable you to: Identify and document the processes in a health care setting, Collect and analyze information about processes in the health care setting, and Redesign the workflow processes and streamline this redesign Quality Improvement methods and tools enable you to: Collect and compile information on an ongoing basis, Analyze the information for root causes, Make decisions on how to eliminate these problems (process improvement), Change processes based on this analysis, and Redesign (strategic change), and set timetable for these steps. For this lecture it is important to focus on where we are in the process improvement. In Component 10, Health Care Workflow Process Improvement, you were introduced to concepts and practices that enable you to identify the processes that control how a health care process is working, collect and analyze information about processes in the health care setting, and redesign the workflow processes and streamline this redesign. This unit will introduce you to Quality Improvement methods and tools that enable practitioners to collect and compile information on an ongoing basis, analyze the information for root causes, make decisions on how to eliminate these problems (process improvement), change processes based on this analysis and redesign (strategic change), and set timetables for these steps.

Quality Improvement in Health Care Settings In 2004 Stephen Shortell likened the U.S. health care system to a “shoddily constructed building located in the pathway of an impending natural disaster“ Quality can be improved in the Health Care Setting by understanding the Foundations and Methods Quality Improvement. For purposes of this lecture we will review a limited number of QI methods and tools that the analyst may encounter in the health care setting. We will briefly compare and contrast the quality improvement methodologies and tools and their appropriate uses in the health care setting.   In 2004, Stephen Shortell likened the U.S. health care system to a “shoddily constructed building located in the pathway of an impending natural disaster” (Ransom, 2004) and many have noted in the last few years that quality can be improved in the health care setting by understanding the foundations and methods of quality improvement. The analysts are likely to see many of these methods as they move through the health care arena. It is important to recognize what the methods are and where to find additional information. It is not the intent of this lecture to teach one how to perform the quality improvement.

Foundations of Quality Improvement Walter Shewhart W. Edwards Deming Joseph M. Juran Three of the primary thought leaders who formed the foundation of quality improvement are Walter Shewhart, W. Edwards Deming, and Joseph M. Juran. In ensuring the reliability of the national system of telephone exchanges and the production of the telephone, Shewhart used his knowledge of statistics to design a tool, the control chart, in 1924 to guide change actions in response to statistical variation. His other contributions included “operational definitions” ensuring that common operations were used to define what was measured. (Ransom, 2004) Deming, also a statistician, used his knowledge gained from working with Shewhart and others to develop a “Theory of Improvement” and “a system of profound knowledge” in the 1970s. He described this system as an understanding of four components: 1. Variations (Shewhart’s influence) 2. Theory of knowledge 3. Appreciation for a system 4. Psychology and the interactions between the components.(Ransom, 2005)

PDSA Cycle Edward Deming derived what became known as the Deming Wheel, Deming cycle, or Deming circle, from Walter Shewart’s 1939, straight line, three-step scientific process of specification, production and inspection. Deming presented it as a circle to stress “the importance of constant interaction among the four steps of design, production, sales and research” The PDCA (Plan-Do-Check-Act) cycle is often attributed to Deming and Shewart, but Deming has denied this connection. However, in 1993 Deming presented an evolved version of the cycle as the “Shewart Cycle for Learning and Improvement”, as a method for improving a product or process and called it the PDSA (Plan-Do-Study-Act) cycle. (Moen, 2011)

Quality Improvement Methods Summary – Lecture a Strategies for quality improvement (QI) Need for aggressive QI in health care Role of leadership in creating a culture that supports QI This concludes Lecture a of Quality Improvement Methods. In this lecture, we introduced high level strategies for quality improvement to point you to areas for further learning. We discussed the need for aggressive quality improvement in health care, and we described the role of leadership in creating a culture that supports QI. A good starting point and resource for learning how to apply the strategies, methods and tools introduced in this lecture is the American Society for Quality (ASQ) at asq.org.

Quality Improvement Methods References – Lecture a Califf, R. M. (2006). Translating Clinical Trials into Practice (keynote). Tex Heart Inst J., 33(2), 192-196. Chang, R. Y. (1999). Continuous Process Improvement (Rev ed.). San Francisco, CA: Jossey-Bass Pfeiffer. Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). Institute Of Medicine: To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press. Ransom, S. B., Joshi, M. S., & Nash, D. (Eds.). (2004). The Healthcare Quality Book: Vision, Strategy, and Tools (1 ed.). Chicago, IL: Health Administration Press. Tague, N.R,  (2004) The Quality Toolbox, Second Edition, ASQ Quality Press, 390-392. Images Slide 5: Dr. Eugene A Stead, Jr. [photo]. Retrieved from: http://digitaldukemed.mc.duke.edu/databank/Images/stead_eugene_thumbnail.jpg Slide 5: Hardware Configuration [image]. Retrieved from: http://digitaldukemed.mc.duke.edu/databank/Images/hardware_configuration_1971.jpg No audio.

Quality Improvement Methods Lecture a This material was developed by Duke University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024. This material was updated by Normandale Community College, funded under Award Number 90WT0003. No audio. Health IT Workforce Curriculum Version 4.0