1. Changing Process to Improve Clinical Quality: Hardwiring Plan/Do/Study/Act Kathryn M Harmes MD, Grant M. Greenberg MD, MA, MHSA Department of Family Medicine University of Michigan Medical School

2. Disclosures None to report for either speaker

3. Objectives Recognize standard methodology and tools for rapid cycle problem solving. Prepare and utilize Plan Do Study Act (PDSA) cycles for daily process change. Practice methods of conducting root cause analysis and relate its importance for successful Quality Improvement.

4. What went wrong: problem solving is not simple We come across issues every day in clinical practice When things don’t go exactly right, do we always understand why?

7. Typical Problem Solving Good people wanting to do the right thing and get work done, jumping to conclusions about perceived problems based on gut instinct and hearsay, applying poor fixes that are doomed to fail over the long-term.

8. Problems are Opportunities “No problem is problem” - Ohno, Toyota “I haven't failed, I've found 10,000 ways that don't work.” - Thomas Edison

9. Finding a Problem for Improvement “If you don’t have standard work first, don’t expect any improvement” -Dave Lagozzo Start by evaluating the current state Required: consensus on desired outcome “If we don’t know who owns the problem, it won’t get solved.” John Shook “Success depends on leadership having conversation around the problems, not the outcome” Steven Spear

10. Structured Problem Solving Continuous Improvement Adjust / Act Plan Check Do Grasp the Situation 10

11. Structured Problem Solving Continuous Improvement Adjust / Act Plan Check Do Grasp the Situation Identify countermeasures Select countermeasures Develop plan for experiments Run the experiment Monitor the experiment Evaluate results Capture learnings Keep or adjust the change Identify next gap Select problem Scope problem Develop background statement Observe at the gemba Map / draw the current state Collect current state data Analyze the current state Develop problem statement Establish goals Analyze root causes Start here 11

12. Root Cause Analysis 5 Why’s Flowcharts Fishbone

13. 5 Why Example Behind on Rx Refill Requests High Volume of Requests This week No Clinic Appointments Everybody at STFM Mtg It’s a great meeting I get to go to a workshop on PDCA Why

14. Flowcharts Visual display of every step in a process Can help identify: redundancy, complexity, delay, and waste in a process and answer the question “does each step add value?” Value Stream Mapping - LEAN

15. Value Stream Map Example

16. Flowchart - UDS

17. Fishbone Diagram People, Process, Equipment, Materials, Environment It helps teams understand that there are many causes that contribute to an effect It graphically displays the relationship of the causes to the effect and to each other

18. Fishbone Diagram Problem People Process Equipment Material/SuppliesEnvironment

19. Diabetic Foot Exam Not Done! Doctor forgets Done, not updated in EHR to capture data Monofilament broken Monofilament not in exam room Patient not in clinic for diabetes PeopleProcess Equipment Environment (culture)Material/Supplies

20. Know Normal From Abnormal. Right Now

21. Once you know the problem…then and only then can you work to solve it Plan Do Study/Check Act/Adjust http://www.ihi.org/knowedge/Pages/HowtoImprove/default.aspx http://www.innovations.ahrq.gov/content.aspx?id=2398

22. Plan “A plan is an experiment you run to see what you don’t understand about the work” -Stephen Spear “If you want to make God laugh, tell him your plans”. -Woody Allen “When you’re not sure what to do next, that’s a good time to try something”. -John Long, MD

23. PLAN (with a capital P) Have a well defined goal Form a team Clearly define your intervention List tasks needed to implement Assign responsibility, due dates Predict what will happen, determine how you will you define success

24. Data to Drive Change: Key Characteristics Objective Believable Reproducible Relevant Accessible/Transparent

25. “DO” Run the test Suggest: small scale, pilot before larger scale if feasible “Just Do It” -Nike advertising campaign

26. Study/Check How do the results compare to the predictions? Reflection If results differ from predictions, ask why? –Consider re-evaluating the original root cause analysis

27. Act/Adjust Based on the P/D/S portions of the cycle: –What modifications need to be made for the next cycle? –What did you learn? –IF the plan is working…set a time frame for re-evaluation (e.g. 30/60/90 days) –Streamline (eliminate wasted effort)

28. Final Thoughts Make success understandable and doable Make it easy to see problems Make it clear what to do when a problem is encountered Make it clear what will happen after notifying supervisor of a problem

30. STEP 1 Generate a list of root causes that might contribute to low Chlamydia Screening rates –Use the technique of asking "why" 5 times, and/or use a fishbone diagram to evaluate for causes stemming from one of the main categories of problems: people, material, machine, method or motive, means opportunity. No Solutions!

31. STEP 2 What are your root causes?

32. STEP 3 Root Causes 1. Provider unaware of availability and reliability of urine testing 2. External labs not being captured into EMR 3. Providers not ordering at time of service 4. Providers uncomfortable ordering test due to sensitive nature of discussion 5. Patient not sexually active/declines testing NOW: Develop a PDSA plan using the worksheet

33. STEP 4/5 Look at your data. Discuss with your small group: Did your intervention have its intended impact? Why or why not? What might you do as a next step? What might you do differently next time?

34. Discussion Why does standard work matter? Did you find the “right root cause”? Did you have consensus? What will you try when you return to your own clinic/setting?

35. Contact Info Katy Harmes MD jordankm@umich.edu Grant Greenberg MD, MA, MHSA ggreenbe@umich.edu http://medicine.umich.edu/dept/family-medicine/ 734-232-6222 (for both of us!) https://twitter.com/GrantG_MD

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