Quality Improvement Methods Greg Randolph, MD, MPH

Healthcare Quality Defined ”The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” ”The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” --Institute of Medicine, 2001

Exercise In pairs, define Quality Improvement (3 minutes) In pairs, define Quality Improvement (3 minutes) Be prepared to share (2 minutes) Be prepared to share (2 minutes)

UNC Pediatrics Residency QI Program “A systematic approach of measuring and identifying gaps between actual and desired quality of care and applying tools and improvement methods (e.g., PDSA cycles) to make changes to the system that result in measurable improvements (i.e., closing the gap)”

Quality Improvement Focus Patient-centered - care that is responsive to patient preferences, needs, values Patient-centered - care that is responsive to patient preferences, needs, values Effective - providing services based on scientific knowledge to all who could benefit and refraining from providing to those not likely to benefit Effective - providing services based on scientific knowledge to all who could benefit and refraining from providing to those not likely to benefit Equitable - providing care that does not vary in quality because of personal characteristics Equitable - providing care that does not vary in quality because of personal characteristics Timely - reducing waits and delays for care Timely - reducing waits and delays for care Efficient - avoiding waste Efficient - avoiding waste Safe Safe - avoiding injuries to patients from care --Institute of Medicine, 2001

Fundamental Questions for Improvement What are we trying to accomplish? What are we trying to accomplish? How will we know that a change is an improvement? How will we know that a change is an improvement? What changes can we make that will result in an improvement? What changes can we make that will result in an improvement?

Model for Improvement Aim Measures Ideas/Change Concepts What are we trying to accomplish? How will we know that changes are an improvement? What changes can we make that will result in an improvement?

Model for Improvement AIM: What are we trying to accomplish? MEASURES:How will we know that changes are an improvement? IDEAS:What changes can we make that will result in an improvement?

What is an Aim Statement? What is an Aim Statement? Aim:A written statement of the accomplishments expected from improvement effort Key components: A general description of aim - should answer, “what are we trying to accomplish?” A general description of aim - should answer, “what are we trying to accomplish?” Rationale/importance Rationale/importance Some guidance for carrying out the work Some guidance for carrying out the work Specify target population and time period Specify target population and time period Measurable goals Measurable goals

Goals Should Be: Measurable Measurable Numeric Numeric Preferably absolute rather than relative Preferably absolute rather than relative A stretch, not business as usual A stretch, not business as usual Achievable, not impossible Achievable, not impossible

Exercise In pairs, critique aim statement – are key components present (3 minutes) In pairs, critique aim statement – are key components present (3 minutes) Then pick a problem and write your own (5 minutes) Then pick a problem and write your own (5 minutes) Be prepared to share (2 minutes) Be prepared to share (2 minutes)

Model for Improvement AIM: What are we trying to accomplish? MEASURES: How will we know that changes are an improvement? IDEAS: What changes can we make that will result in an improvement?

Project Measures Goal

Project Measures The question: How will we know that a change is an improvement? - usually requires more than one measure. The question: How will we know that a change is an improvement? - usually requires more than one measure. A balanced set of measures helps assure that the system is improved: A balanced set of measures helps assure that the system is improved: Related to aim’s measurable goals Related to aim’s measurable goals Easy to collect Easy to collect Show improvement quickly and include outcomes Show improvement quickly and include outcomes Can display them graphically over time Can display them graphically over time Run charts Run charts

Balancing Measures Are we improving parts of our system at the expense of others? Are we improving parts of our system at the expense of others? Usually not one of goals Usually not one of goals Great source is to listen to skeptics… “Yes, but…” Great source is to listen to skeptics… “Yes, but…”

Example of Measure Set The delay for routine appointments The delay for routine appointments % of patient visits with the patient’s primary clinician % of patient visits with the patient’s primary clinician Practice average cycle times Practice average cycle times % of patients rating the overall visit as excellent % of patients rating the overall visit as excellent % of visits that are “no show/missed” % of visits that are “no show/missed”

Usual Display of Measures

QI Measures: Annotated Run Charts Reduced appt delays Reminder system Practice wide guidelines Clinician education

Model for Improvement AIM: What are we trying to accomplish? MEASURES: How will we know that change is an improvement? IDEAS: What changes can we make that will result in an improvement?

“PDSA Cycles” PDSA Cycles help teams adapt good ideas to their specific situation: PDSA Cycles help teams adapt good ideas to their specific situation: Force us to think small Force us to think small Force us to be methodical, make predictions Force us to be methodical, make predictions Allow rapid adaptation and implementation of changes in busy healthcare settings Allow rapid adaptation and implementation of changes in busy healthcare settings

The PDSA Cycle Act Plan What changes are to be made? Next cycle? Objective Questions and predictions Plan to carry out the cycle (who, what, where, when) Study Do Complete the analysis of the data Compare data to predictions Summarize what was learned Carry out the plan Document problems and unexpected observations

Example PDSA Cycle Changes to be made: Test 2 more days- Dr. R on time; nurse to bring charts for prescheduled Objective: Test huddles Questions: Will they uncover capacity? Prediction: Yes Plan: Dr. R care team, huddle 5 mins in AM for 2 days at schedule 4 unused visits identified; took 15 minutes due to late arrivals; charts would be helpful Mon and Tues - document problems, Unexpected observations; count uncovered capacity Act Plan Study Do

Key Points for PDSA Cycles Do initial cycles on smallest scale possible Do initial cycles on smallest scale possible Think baby steps…a “cycle of one” usually best Think baby steps…a “cycle of one” usually best “Failed” cycles are good learning opportunities when small “Failed” cycles are good learning opportunities when small Successful tests Successful tests As move to implementation, test under as many conditions as possible As move to implementation, test under as many conditions as possible Special situations (e.g., busy days) Special situations (e.g., busy days) Factors that could lead to breakdowns (e.g., different staff or physicians involved) Factors that could lead to breakdowns (e.g., different staff or physicians involved) Things “naysayers” worry about (e.g., “It will not work when Dr. Noonan is not here”) Things “naysayers” worry about (e.g., “It will not work when Dr. Noonan is not here”)

Questions?