Introduction to methods for quality improvement Topic 7 Introduction to methods for quality improvement When Rabia first mentioned this conference to me in September 2007 I was impressed with her commitment, vision and energy for this international event. But frankly, I was a little nervous at how much work was needed to deliver such an ambitious programme in such a short time. It is an amazing testament to Rabia, Mustafa and other members of the organising committee and staff that this impressive programme has been realised here in this fantastic venue. I am delighted to be able to support this congress and the initiatives that are being shared to improve patient safety globally In my presentation I will draw on the global work on patients safety, reflecting on how patient safety affects us all how we should and can learn from error the work of the WHO World Alliance for Patient Safety and the personal experience of some clinicians, professionals, policy makers and patients in their efforts to make healthcare safer across the world I will be expending on this introduction in two interactive workshop sessions, one on Patients for Patient Safety and patient engagement and the other, a Learning from Error workshop

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 Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its 2008-09 Forward programme shortly.

Performance requirement know how to use a range of improvement activities and tools Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its 2008-09 Forward programme shortly.

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 Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its 2008-09 Forward programme shortly.

The science of improvement appreciation of a system understanding of variation theory of knowledge psychology W Edwards Deming Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its 2008-09 Forward programme shortly.

The Institute for Healthcare Improvement (IHI): different measures 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 Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its 2008-09 Forward programme shortly.

Three types of measures outcome measures process measures balancing measures Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its 2008-09 Forward programme shortly.

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? Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its 2008-09 Forward programme shortly.

The model for improvement 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? ACT PLAN STUDY DO Langley, Nolan, Nolan, Norman & Provost 1999

The PDSA cycle ACT PLAN STUDY DO Determines what changes are to be made Change or test ACT PLAN STUDY DO Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its 2008-09 Forward programme shortly. Summarizes what was learned Carry out the plan Langley, Nolan, Nolan Norman & Provost 1999

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 Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its 2008-09 Forward programme shortly.

Langley, Nolan, Nolan, Norman & Provost 1999 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 Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its 2008-09 Forward programme shortly.

The improvement process 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 1 month Annotated run chart SPC charts Ongoing monitoring Outcome Future plans Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its 2008-09 Forward programme shortly. 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

Interventions phase 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) Identify appropriate interventions Implement changes identified in the diagnostic phase Undertake one or more PDSA cycles Interventions phase Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its 2008-09 Forward programme shortly. Decide on interventions Undertake one or more PDSA cycles

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 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 NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

PDSA cycle - single test PDSA Cycles – single test D S Changes that result in improvement S A P A A D P S P A P D S D Hunches, theories and ideas Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

PDSA cycle – multiple tests PDSA Cycles – multiple tests NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

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

Sustaining the improvement phase Once an intervention has been introduced, the intervention and any improvements need to be sustained 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 standardization documentation measurement training Sustain the gains 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 Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its 2008-09 Forward programme shortly.

Performance requirements Know how to use a range of improvement activities and tools flowcharts cause and effect diagrams (Ishikawa/fishbone) Pareto charts run charts Launched in 2004 following the WHA Resolution which called for Member States to "pay the closest possible attention to the problem of patient safety" Promote awareness and political commitment Expert-led technical programmes to improve patient safety worldwide The Alliance will be publishing its 2008-09 Forward programme shortly.

Evidence for there being a problem worth solving At the same time LBH executives and staff expressed a desire to improve LOS. NSW – New South Wales.

Flow chart of process Something amiss Visit to general practitioner Accelerated Recovery Colectomy Surgery (ARCS) Jenni Prince Area CNC Pain Management North Coast Area Health Service NCHI Sydney Australia Something amiss Visit to general practitioner Post anaesthetic care Surgical ward Operating theatre Investigations Allied health Surgical team Pain team Referral to surgeon Pre-op ward Discharge planner Referral to Hospital Admitted to hospital Community health/ Peripheral hospital Hospital admission Preoperative clinic Return to life Home Admissions office

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

Pareto chart 24 57 42 76 67 80 100

PDSA cycles - implementation 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 surgeon10 patients 1 surgeon1-6 patients

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