Fundamentals of Quality Improvement Lisa Price, MD

Agenda Why does quality matter? Why does quality matter? Brief detour into history of quality management Brief detour into history of quality management Principles of quality management and how does it apply to the world of medicine Principles of quality management and how does it apply to the world of medicine

Why does quality matter? Institute of Medicine 2000 Institute of Medicine 2000 CO + UT and NY studies– adverse events 2.9 and 3.7% of hospitalizations CO + UT and NY studies– adverse events 2.9 and 3.7% of hospitalizations ‘97 there were 33.6 mil admissions ‘97 there were 33.6 mil admissions Observed adverse events resulted in death 6.6 – 13.6% of time. Extrapolated 44,000 to 98,000 deaths every year due to medical error Observed adverse events resulted in death 6.6 – 13.6% of time. Extrapolated 44,000 to 98,000 deaths every year due to medical error 8 th leading cause of death 8 th leading cause of death Ahead of AIDS, breast cancer and MVA’s Ahead of AIDS, breast cancer and MVA’s

Why does quality matter? Population Health Per capita cost Experience of care The Triple Aim=Survival

What is Quality? qual-i-ty qual-i-ty An inherent or distinguishing characteristic An inherent or distinguishing characteristic A degree or grade of excellence A degree or grade of excellence

A Brief History of Quality Management Shewhart DemingOhno

What are the principles of Quality Management and how do they apply to the world of medicine?

1. Work is a series of processes. supplierprocessorcustomer Who is your customer?

2. Strong supplier-customer relationships are critical for good quality management

3. The majority of quality failure is due to a problem in the process.

Why Do Errors Occur? Questions to Ask Questions to Ask Has this happened before? Has this happened before? Would another person have done the same thing? Would another person have done the same thing? Could this have been anticipated? Could this have been anticipated? If “yes” to any of these = System Error If “yes” to any of these = System Error 94% of errors belong to the system 94% of errors belong to the system Responsible people are necessary but not sufficient to ensure quality in complex systems Responsible people are necessary but not sufficient to ensure quality in complex systems

4. Poor quality is expensive. 2 types of quality improvement - improve features and reduce defects 2 types of quality improvement - improve features and reduce defects Defects/errors result in costs Defects/errors result in costs Discarding defective product Discarding defective product Costly surveillance programs Costly surveillance programs Rework Rework Workarounds add complexity and not value Workarounds add complexity and not value Dissatisfied customers result in loss of market share Dissatisfied customers result in loss of market share Litigation Litigation

5. Understanding process variability is key. True understanding of a process True understanding of a process Ability to separate out change in outcome due to process change from “noise” Ability to separate out change in outcome due to process change from “noise” Unpredictable processes are inherently flawed Unpredictable processes are inherently flawed

6. Quality control should focus on the most vital processes. Creation of “robust” processes at critical steps can dramatically improve quality. Creation of “robust” processes at critical steps can dramatically improve quality. Resources are finite. How do you identify where to get the most “bang for your buck?” Resources are finite. How do you identify where to get the most “bang for your buck?” Value stream mapping - documents steps in a process, how long each takes, and identifies waste Value stream mapping - documents steps in a process, how long each takes, and identifies waste

7. Fundamentals of quality improvement are basic scientific thinking. Do StudyAct Plan

8. Universal employee involvement is critical. Quality Committee Culture of Quality Quality Committee Culture of Quality Train all employees on basic quality methods and empowering them to identify waste and create solutions. Train all employees on basic quality methods and empowering them to identify waste and create solutions. Steering committees Steering committees Project teams Project teams Work done across departments and levels Work done across departments and levels

Summary Errors most often come not from workers but systems. A culture of blame, shame and exhortations to be “more careful” will not improve the system. Errors most often come not from workers but systems. A culture of blame, shame and exhortations to be “more careful” will not improve the system. QI is a managerial science guided by theory, statistics and psychology QI is a managerial science guided by theory, statistics and psychology It is the continuous search for small opportunities to reduce waste, rework and unnecessary complexity It is the continuous search for small opportunities to reduce waste, rework and unnecessary complexity The greatest asset of any system is its human thinkers, who with proper leadership can identify these opportunities and act The greatest asset of any system is its human thinkers, who with proper leadership can identify these opportunities and act

Next Steps-QI In Action 1. Understand the problem 1. Understand the problem 2. Identify areas of improvement 2. Identify areas of improvement 3. State the goal 3. State the goal 4. Implement the change 4. Implement the change 5. Measure 5. Measure 6. Hold the gain and extend the improvement. 6. Hold the gain and extend the improvement.

Health Care Problem Addressed Names of Team Members

1.Understanding the Problem What do you already know about the problem? What is the BUSINESS DRIVER behind the problem? Are you aware of any data available about your problem? What has been your experience with the problem? Who are the stakeholders in this process? Use a Cause-and-Effect Diagram to describe your problem in more detail

Cause-and-Effect diagram Materials and EquipmentPeople and management EnvironmentProcess Effect

2.Identify Areas for Improvement Looking back at your cause and effect diagram, what are areas for improvement? Which areas could result in the most change if improved? What would the ideal process look like?

3. Measuring progress What are the metrics that can help you assess improvement for your process?

4. Explicitly State Your Goals Remember: they should result in meaningful improvement, they should be something that you really could influence, and should be non-controversial. State your goals in SMART format. Specific Measurable Attainable Relevant Time-bound

5. Effective Solutions What are the solutions that can effect the changes/improvement you are hoping to achieve? Remember, usually more than one change is needed and try to prioritize stronger intervention.

6.Building on Success How could improvement be sustained long term?