1. Two Kinds of People

2. Two Kinds of People

3. Two Kinds of People

4. Quality Improvement in Healthcare
Manu K. Malhotra, MD
Henry Ford Hospital
Mar 3, 2016

5. Quality Improvement I. What is QI?
II. Why do you need to know about it?
III. Process improvement techniques
IV. Root Cause Analysis

6. What is Quality Improvement?
Methodical approach to measuring performance and the effort to improve it.

7. QA vs. QI QA: Quality Assurance QI: Quality Improvement
A primarily retrospective review of processes and making sure they are followed and work as intended.
QI: Quality Improvement
A prospective and retrospective look at results and processes with a focus on how to improve them.

8. Why do I need to know about QI?
Continually improve your ability to care for patients.
Make the world a better place
Empower yourself
And…

9. Why do I need to know about QI?
Core Competencies
Patient care
Medical knowledge
Interpersonal skills and communication
Professionalism
Systems-based practice
Practice-based learning

10. Why do I need to know about QI?
SBP: Systems Based Practice
…and improve their patient care practices.
PBLI: Practice Based Learning and Improvement
…effectively call on system resources to provide care that is of optimal value.

11. Why do I need to know about QI?
Remain EM Board Certified
Patient Care Practice Improvement Activity (PI)

12. Why do I need to know about QI?
Meet existing and future performance guidelines/mandates.
E.g. Sepsis, ACS guidelines
Sentinel events (Root Cause Analysis)
Hospital Acquired Conditions

13. What is quality?

14. What is quality? Quality in Healthcare Mortality Morbidity
Complications
Quality of Life
Perception of Care (wait times, etc) …

15. Process Improvement
In many cases, Quality can be improved by improving processes (eg. sepsis).
Throughput
Time to see a doctor
Time from admission to bed …

16. Process Improvement Techniques
Total Quality Management
Process Re-Engineering
Constraint management
Six Sigma
Lean Systems

17. Lean Manufacturing
Attributed to Taichii Ohno of Toyota, but actually, the ideas are rooted in the work of Henry Ford and the Model T factory…

18. Lean Manufacturing Basic concepts:
Empower front-line workers to affect change
Remove “waste” (errors and delays)
Seamless flow of work/products
Understand the current process first!
Value Stream Maps
Use Japanese words

19. Types of Waste (Muda) Transportation Inventory Motion Waiting
Over-processing
Over-production
Defects

20. HFH ED history with Lean
2010: MHA Keystone: ED project
Multihospital project to improve healthcare delivery in MI
Lean used as a tool
HFH ED created a Lean team comprised of 4 nurses, one doctor and one clinical quality specialist.

21. Assess the Current Process
“Current State” value stream map created for the Door to Doc process
Map was then “socialized”
Reworked, more details added
“Gemba” walks
“Muda” identified
All done by clinicians who work in the ED

22. Current State

23. Future State Map
All ideas and findings incorporated and changes to be made identified (“Kaizan bursts”)
Future State map created

25. HFH Emergency Department Door to Provider Time

26. HFH Emergency Department Door to Provider Time

27. But how do you decide what to improve?
Data collection
Consensus
Mandates
Adverse Events

28. Adverse Events Sentinel events M & M QA Process
Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) mandated the use of RCA (root cause analysis) in the investigation of sentinel events in all accredited hospitals starting in 1997.
M & M
QA Process

29. M&M
Provider Centered
Defensive
Retroactive

30. QI Process
Patient Centered
Quality Directed
Proactive

31. Root Cause Analysis (RCA)
Try to get at the cause of the problem instead of just dealing with the symptoms, or putting out fires or placing blame.
Data Collection
Reconstruction of the events
Analysis
Recommendations

32. RCA Problem: Expeditious Solution: Result:
Patient and family complaining (loudly) about waiting too long to be seen
Expeditious Solution:
Go talk to patient and family and “get things going” on the patient
Result:
Someone else ends up waiting a little longer

33. RCA
This solution treats the symptoms, but not the problem.

34. Reaching the Root cause
The 5 whys
Fishbone (Cause and effect)Diagrams
Causal Factor Chart

35. The 5 whys 1. Why is the patient upset?
He’s been waiting for 3 hrs to be seen.
2. Why has he been waiting 3 hrs?
He just got back from triage. That’s how long the wait is.
3. Why is the wait so long?
There ain’t no beds, so the ED is crammed.
4. Why are there no inpatient beds?
Our transfer volume is on the rise.
5. Why are we taking transfers when our patients are waiting?

36. 5 whys
Incoming transfers are preferentially placed in beds over ED patients.

37. Or may more than 5…
6. Why are incoming transfers preferentially placed in beds over ED patients.
Because there is a belief that critically ill patients in our ED are safer than patients waiting at St. Elsewhere
7. Why do we think that?
Because it’s true

38. Fishbone Diagram Facility Resources Too noisy Waiting too long
Smells bad
Vending machine not working
Laying in hallway
Patient is upset
Pt. worried about dx
Nurse was mean
Lost her job
Doctor was rude
Personal
Staff

40. RCA
5 whys is more useful for linear problems, but is not well-suited for multifactorial problems.
Fishbone diagrams/Causal Charts can be more useful when many causes need to be explored and evaluated.

41. RCA
Root cause analysis is a part of the problem definition phase of almost all process improvement systems.
Find a solution that not only solves the problem, but prevents its recurrence.

42. Take-home points QI will be a part of your life
Lean Healthcare uses value stream mapping and empowers front-line workers to eliminate waste
Root cause analysis is the first step in addressing an adverse event
Five Whys and Fishbone diagrams can be used to assess the root cause