The Science of Improvement: Creating Reliable Health Systems Debbie Barnard,MS,CPHQ SHN Project Manager, CPSI October / November 2007

Introduction Current State of Healthcare

Canadian Experience Canadian Adverse Events Study (Hospital settings) (Baker, R. & Norton, P. et al. (2004) Incidence rate of 7.5% in hospitals (2000) 70,000 preventable adverse events (est.) 9,000 - 24,000 preventable AE deaths in Canada (2000) One in 9 acquire infection in hospital One in 9 given wrong medication More deaths occur due to adverse events than from breast cancer, vehicle accidents and HIV

How Hazardous Is Health Care? (Leape)

How Hazardous Is Health Care? (Leape) The Goal Copyright 2002 Institute for Healthcare Improvement

Seeing Differently

“The real act of discovery is not in finding new lands, but in seeing with new eyes”. Marcel Proust (1871-1922)

Nine Box Puzzle On your sheet there are nine dots arranged in a set of three rows. Your challenge is to draw four straight lines which go through the middle of all of the dots without taking your pen off the sheet of paper. You can start from any position on the paper and draw the lines one after the other without moving your pen from the paper. Each line must start where the last line finishes.

System of Profound Knowledge The System has four parts Appreciation for a system Knowledge about variation Theory of knowledge Psychology Dr. W. Edwards Deming stressed the importance of studying four areas to become more effective in leading improvement: Appreciation of a system Understanding variation Theory of knowledge Psychology Deming called the interplay of these four areas “Profound Knowledge” Knowledge of Variation, that is, a knowledge of common cause and special variation. Knowledge of Systems, that is, understanding that all the parts of a business are related in such a way that if you focus on optimizing one part, other parts may suffer. Knowledge of Psychology, that is, what motivates people. Theory of Knowledge, that is, how we learn things. Source: Horn, Steve, “Deming's System of Profound Knowledge” http://home.clara.net/hornsc/spk/spk_intro.htm [Accessed October 2007]

Lens of Profound Knowledge “The system of profound knowledge provides a lens. It provides a new map of theory by which to understand and optimize our organizations.” Deming, The New Economics, 1993 Appreciation of a system Theory of Knowledge Psychology Understanding Variation Aim or Values Provost, L.; Godlee, F., “Connecting the Science of Improvement to Medical Research” International Forum on Quality and Safety in Health Care [Online Access Oct. 2007]

Deming’s System of Profound Knowledge Source: Margolis,P & Lannon L; NRSA AHRQ Workshop: Quality and Quality Improvement

Understanding Systems

What is a System? “A system is a network of interdependent components that work together to try to accomplish the aim of the system.” W Edwards Deming, The New Economics, p. 50

System Source: Horn, Steve, “Deming's System of Profound Knowledge” http://home.clara.net/hornsc/spk/spk_intro.htm [Accessed October 2007]

Common View of a System

Common Conception of a System NO!!!! According to Deming

Slide

System of Improvement - Five Activities for Leaders Source: Harries, Bruce: Presentation to SHN Education Resources Committee – January 2007Quality as a Business Strategy Associates in Process Improvement (API), Austin Texas - copy write

Types of Processes Mainstay processes - those processes that directly relate to the mission of the organization and add value to the external customers of the organization. Source: Quality as a Business Strategy - Associates in Process Improvement API, Austin Texas pages 1-26, 1-27 copy write 8/2006

Types of Processes Driver processes - those processes that "drive" the mainstay of the organization. These processes are usually associated with the need that the organization intends to fulfill (from the mission statement of the organization). Examples: customer feedback, planning, research, development, budgeting, etc. Source: Quality as a Business Strategy - Associates in Process Improvement API, Austin Texas pages 1-26, 1-27 copy write 8/2006

Types of Processes Support processes - those processes that are necessary to support the mainstay processes. Examples for a healthcare organization are IT, HR, Communications, etc. Source: Quality as a Business Strategy - Associates in Process Improvement API, Austin Texas pages 1-26, 1-27 copy write 8/2006

EXAMPLE Harries, Barnard, Hoffman 2006

Understanding Variation

“In God we trust. All others bring data.” W.E. Deming, Ph.D.

Measurement Has Two Purposes Helps you to know: Where you are? Where you are going? “Without measurement it is impossible to know whether you have improved” The organization experiences higher costs of operation because management is unable to isolate the cause of the variation (Deming, 1986).

Types of Measures Type of measure Examples Outcome measures Process measures Balancing measures Rates Failures Re-admits Mortality, LOS % use order set, guideline, etc % treated in required time % receiving 100% of ‘bundle’ Times, durations Etc Costs Delays Resources % detected by redundant process

Process vs. Outcome Measures Outcome = Voice of customer/patient: How is the system performing? What is the result of systems? How is the health of patients affected? Process = Voice of workings of the system: Are the parts/steps in the system performing as planned? Are key changes being implemented?

Common Terms Variation - difference in the output of a process (or inputs to a process) over time. Variation consists of common cause variation, special cause variation and structural variation (and some include tampering). Common Cause Variation - variation resulting from the system. Every system will have some amount of variation of results. Special Cause Variation - variation resulting from a assignable cause. Special causes should be addressed by finding the special cause and taking action.. The reduction of variation has profound impacts on the reduction of costs and increase in customer satisfaction. Common Cause Variation - variation resulting from the system. Every system will have some amount of variation of results. The way to improve common cause variation is to change the system. Special Cause Variation - variation resulting from a assignable cause. Special causes should be addressed by finding the special cause and taking action. Special Causes can be beneficial, in which case identify the cause and seek to incorporate it in the standard practice. Source: Horn, Steve, “Deming's System of Profound Knowledge” http://home.clara.net/hornsc/spk/spk_intro.htm [Accessed October 2007]

Common Terms Structural Variation - trends within the data. They often take the form of seasonal variation and growth or decline Tampering - taking action based on the belief that a common cause is a special cause. Most variation (97% +) is common cause variation Structural Variation - trends within the data. They often take the form of seasonal variation and growth or decline (where the data has, for example, a underlying trend of increasing 4% annually). Tampering - taking action based on the belief that a common cause is a special cause. The tendancy to take action, often leads to action without reason which causes more problems than it fixes. Dr. Deming stated that most variation (97% plus) was common cause variation not due to special causes. Tampering can also be considered a form of variation. Source: Horn, Steve, “Deming's System of Profound Knowledge” http://home.clara.net/hornsc/spk/spk_intro.htm [Accessed October 2007]

Understanding Variation Stable Process - one in statistical control. Unstable Process - a process not in statistical control. Source: Horn, Steve, “Deming's System of Profound Knowledge” http://home.clara.net/hornsc/spk/spk_intro.htm [Accessed October 2007]

Common Cause Variation Variation exists in all aspects of life People’s Behavior Weight Stress Time required to travel to work People – “how they learn”, intelligence

Psychology

Psychology This is Deming’s language for the dynamics of people in the workplace, team performance, learning styles and organizational culture. Deming opines that managers need to know how people interact, their individual needs, their working and learning styles.

Theory of Knowledge

Knowledge for Improvement Improvement: Learn to combine subject matter knowledge and profound knowledge in creative ways to develop effective changes for improvement. Subject Matter Knowledge Profound Knowledge Improvement Provost, L.; Godlee, F., “Connecting the Science of Improvement to Medical Research” International Forum on Quality and Safety in Health Care [Online Access Oct. 2007]

Introduction to PDSA Deming argued that inspection at the end of the process is too late and too expensive. Quality results from studying and changing the system, not inspecting the product Measurements used to monitor the processes Prevention by process improvement: Deming argued that inspection at the end of the process is too late and too expensive. Rather, he stipulates process analysis, control and improvement. Thus, according to Deming, quality results from studying and changing the system, not inspecting the product. Measurements are used to monitor the processes to ensure that the possibility of producing unacceptable variability from the stable system’s products or services.

The three fundamental questions for improvement Model for improvement 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 the improvements we seek ? Aims The three fundamental questions for improvement Measurement Ideas, evidence, hunches, Other people etc. Act Plan Study Do The fourth question: how to make changes Langley, Nolan et al 1996

Repeated Use of the PDSA Cycle What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement Changes That Result in Improvement A P S D DATA D S P A Implementation of Change A P S D Wide-Scale Tests of Change A P S D Follow-up Tests Theories Ideas Very Small Scale Test

Why Test Why Not Just Implement then Spread? Increase degree of belief Document expectations Build a common understanding Source: IHI

Why Test Evaluate costs and side-effects Explore theories and predictions Test ideas under different conditions Learn and adapt Source: IHI

Every system is perfectly designed to get the results it gets. We Know That… Every system is perfectly designed to get the results it gets. If we want different results, we must change (transform) the system Source: Maher,L. and Plsek, P. “Bringing Creativity and Innovation to Health Services” Presented at the Quality Improvement in Healthcare Forum, Prague, April 2006

Reliability in Healthcare

Why reliability? Implementing reliability concepts has been found to reduce defects in care, increase the consistency with which appropriate care is delivered and improve patient outcomes.   ( IHI 2004) “Reliability means keeping a promise” (Don Berwick) Source: Murkin, J. “Reliability Theory in Action”. www.nhsscotlandevent.com/.../1330%20wed%20alsh%20%20Reliability%20Theory%20in%20Action%20FULL%20SESSION.ppt [Accessed Oct. 2007]

Reliability Rates in Healthcare A large study in US health care using detailed case notes review concluded that the “defect rate” in the technical quality of American healthcare is approximately - 45% (McGlynn, et al The quality of healthcare delivered to adults in the United States NEJM 2003; 348)

3 Steps Towards Reliability 1. Prevent failure (a breakdown in operations or functions). 2. Identify and Mitigate failure: Identify failure when it occurs and intercede before harm is caused, or mitigate the harm caused by failures that are not detected and intercepted. 3. Redesign the process based on the critical failures identified. Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org)

Reliability = Reliability Equation Number of actions that achieve the intended result ÷ Total number of actions taken Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org)

What does the system look like? Less than 10-1 Reliability What does the system look like? Less than 10-1 (<80%, out of control) Chaotic, ad hoc, no system 10-1 (80 – 95% success) Intent, vigilance, hard work 10-2 (95 – 99.5% success) Design informed by reliability science and human factors 10-3 or more (<5 per 1000 failures) Design of ‘High Reliability Organisations’ (Nolan, after Weick)

10-1 performance Standard tools and techniques used at the 10-1 performance level include: Use of common equipment brands Standard order sheets and guidelines Memory aids such as checklists Feedback mechanisms regarding compliance with standards Awareness-raising and training Creation and use of a standardized approach to care for patients. Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org)

10-2 performance Standard tools and techniques used at the 10-2 performance level include: “Opt-out” – The desired action = flow of work Standardize processes Create redundancies and time lapses Build design aids into the system Make the desired action the default Creation and use of a standardized approach to care for patients. Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org)

10-2 Performance Principles Constraints: Constraints restrict or limit the performance of certain actions. For example, computers that signal an alarm when two medications prescribed for the same person should not be taken together serve as a constraint. Affordances: An affordance provides clear visual or other sensory clues that lead the user to use a product or tool correctly, or perform the correct action. An outward-swinging door with a pushplate but no handle is an example. An affordance is the design aspect of an object that suggests how the object should be used Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org)

10-2 performance Reminders: Examples include calling patients the day before their appointments to reduce no-shows and late arrivals, and using checklists or alarms to prompt specific actions. Differentiation: To reduce confusion when actions, parts, or numbers are similar, patterns are broken by color coding, sizing parts differently, numbering items in easily distinguishable ways, or separating similar items. . Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org)

10-3 performance Failure modes (What could go wrong?) Failure Modes and Effects Analysis (FMEA) Failure modes (What could go wrong?) Failure modes (Why would the failure happen?) Failure modes (What would be the consequences of each failure?) Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2004. (Available on www.IHI.org)

Questions/Comments Debbie Barnard, MS, CPHQ Project Manager Safer Healthcare Now! Canadian Patient Safety Institute Suite 1414, 10235 101 Street Edmonton, Alberta T5J3G1 Phone: 780-498-7259 or 1-866-421-6933 Fax: 780-409-8098 Email: dbarnard@cpsi-icsp.ca Website: www.patientsafetyinstitute.ca The Canadian Patient Safety Institute would like to acknowledge funding support from Health Canada. The views expressed here do not necessarily represent the views of Health Canada