1. QUALITY IMPROVEMENT METHODOLOGY: CHANGING PROCESSES TO IMPROVE OUTCOMES Sarah Gimbel, RN, MPH Assistant Clinical Professor Department of Global Health University of Washington Technical Advisor Monitoring & Evaluation Health Alliance International

2. Quality Improvement Methodology Late 1990s: Major transformation  Measuring mistakes process redesign  Traditional outcomes research tools Before and after Intervention and control groups Rigorous statistical analysis  Emphasis on rapid assessment, dynamic implementation, & simple techniques to measure progress in closing quality gaps  Far less academic and more results-oriented

3. Coming Together: Changes in Medicine & Other Industries 1. Evidence-based medicine 2. Lean Methodology (Toyota)  Institute for Health Care Improvement (IHI) Breakthrough Collaboratives*  HIVQUAL- National and International *handouts on Breakthough Collaboratives available

4. 1. Evidence-based Medicine  “The conscientious, explicit and judicious use of the best current evidence” 1  While the standards for what was considered high quality evidence have gone way up, the methods for applying it have been based more on individual practice/experience  And in the words of David Eddy:  If it works, do it  If it doesn’t work, don’t do it  When there is insufficient evidence to decide, be conservative 1-Sackett D, BMJ 1996;312:71-72 (13 January)

5. 2. Lean Methodology-Toyota model  Within healthcare services the core idea is to maximize patient value while minimizing waste  Lean approach changes the focus of management from optimizing separate technologies, assets, and vertical departments to optimizing the flow of products and services through entire system  Map out processes and identify value and non- value added steps, and eliminate waste.

6. 2. Lean – Some Key Principles  Base decisions on long-term philosophy at the expense of short term financial goals  Create continuous flow to bring problems to the surface  Use “pull” systems to avoid over production  Level out the work load  Build a culture of stopping to fix problems  Standardized tasks and processes are the foundation for continuous improvement and employee empowerment

7. 3. IHI Model for Improvement  “Every process is perfectly designed to give you exactly the outcome that you get.”  Step 1: The Three Questions:  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 an improvement?

8. Step 2: PDSA Cycle—Testing Change in a Real World Setting  Plan:  Design workflow changes;  Identify tools to support the new workflow;  Decide what to measure & how  Do: Implement plan  Study: Look at what was measured; figure out what it means  Act: Fix the things didn’t work the first time and retest until it works right

9. One PDSA Cycle isn’t enough The cycles are linked for continuous improvement *Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.The Improvement Guide: A Practical Approach to Enhancing Organizational Performance **The Plan-Do-Study-Act cycle was developed by W. Edwards Deming (Deming WE. The New Economics for Industry, Government, Education.).Deming WE. The New Economics for Industry, Government, Education

10. But what do we measure?  Don’t waste time trying to get perfect data  Don’t wait for the technology  Learn to navigate on minimal data points  Use quick and dirty samples if necessary  Examples:  Wait times  Number of tests ordered  Ask the people affected what worked and what didn’t

11. Spread  It isn’t enough to simply do a demonstration  Spread across the organization/district/province/country  Leadership is essential  Replicate the process of education  Replicate the data collection  Replicate the PDSA cycles Begin with the perfected workflow from the pilot Try it in other areas, but be prepared to modify as needed

12. The Collaborative Concept - 1995  Short 6-15 month learning sessions bringing teams from different settings all seeking improvement on a focused clinical area  Team of 3 usually attend 3 learning sessions and report back to additional team members at the local organization  Examples of goals:  Reduce ED wait times by 50%  Reduce hospitalization for CHF Pts by 50%  Reduce worker absenteeism by 25%

13. Collaborative Improvement Model © 2002 Institute for Healthcare Improvement Select Topic Planning Group Identify Change Concepts Participants Prework LS 1 P S AD P S AD LS 3 LS 2 Supports E-mailVisits PhoneAssessments Senior Leader Reports

14. IHI in Developing Countries  Projects use the classic IHI improvement strategies  Model for improvement  Breakthrough Collaborative Series  Chronic Illness Care Model including spread

15. Example: IHI-Niger Background  Post partum hemorrhage leading cause of maternal death & one of the highest maternal mortality risks in the world  Attributing common factors: high incidence of home births, poverty/malnutrition, lack of access to quality skilled maternal health care Intervention: Focus on AMTSL  On-site trng for all maternal health providers by regional trainers  Quarterly regional learning sessions for midwives & MDs to share innovations (eg. 24-hr call schedule to assure skilled birth attendance at births, purchase of coolers in delivery areas made for oxytocin provision)

16. Niger: Challenges  Lack of medical records (no paper?!)  Unfamiliarity with data collection and analysis  Lack of skilled HR  Low quality of existing HR (nurse/midwife has 2yrs professional training after equivalent of middle school education)  Lack of basic supplies  Weak infrastructure & health system  Lack of updated standards for evidence-based high impact care

17. Large scale systems improvement is universally applicable: IHI/Post Partum Hemorrhage in Niger

18. Niger: Lessons Learned  Bring representatives from sites together regularly at learning sessions (cross-fertilization of ideas and best practices)  Pick a few focused pieces to gradually phase in. Don’t try to do everything at once.

19. 3. HIVQUAL-US  Build capacity and capability among Ryan White Title III and IV grantees to sustain QI in HIV care (1995)  Goals & Objectives  Improve the quality of care for persons with HIV receiving care in Title III and IV-supported programs  Promote QI activities  Promote self-reporting of HIV performance measurement data based on clinical guidelines  Provide site-specific consultation to build quality improvement capacity which is responsive to the specific organizational needs of grantees

20. HIVQUAL Model Using the results of specific indicators to measure care elements to ensure sustained success over time 1. Review, collect and analyze baseline data 2. Develop a project team workplan 3. Project team investigates the process 4. Project team plans and tests changes 5. Project team evaluate results with key stakeholder 6. Systematize change

21. HIVQUAL US Performance Data

22. HIVQUAL International  2003 Thailand: Pilot implementation in 12 sites, as of 2008 over 900 sites have integrated HIVQUAL-T frameworks into services to improve quality of HIV care  2006 Mozambique: Pilot implementation in 36 sites in 2007 followed by quality improvement trainings in 2008  Other countries in early process: Namibia, Guyana, Uganda, Rwanda, Nigeria, Haiti

23. Pilot results: HIVQUAL-T measurement in 12 hospitals, 2002-2005

24. Example: Using QI Methodology to improve outcomes in Beira, Mozambique (2004)  Approximately 500 HIV positive patients newly enrolled each month and increasing  Only 10% were having their CD4 counts done within 1 month of enrollment  A registry existed to track patients  Resources to buy reagents for CD4 testing were scarce  Only those patients with resources to obtain ART were CD4 tested

25. PDSA Cycle in Beira, Mozambique  What were we trying to accomplish?  All HIV positive patients would have a CD4 count within 1 month of presenting to the clinic  How would we know that a change was an improvement?  The percent of patients with CD4 count would rise from 10% and approach 100%  What changes could we make that would result in an improvement?  Remove barriers to testing  Remove non-value added steps from the workflow

26. Steady enrollment growth

27. Mapping the Initial Workflow

28. Outcome of a process perfectly designed get 10% CD4 Testing

29. Major System Barrier to CD4 Testing: Drugs!

31. Step 1: Remove the barrier

32. Outcome after ART barrier is removed

33. Step 2: Task shift CD4 ordering to non-physician provider

34. Outcome after CD4 count order is “automatic”

35. What would Toyota do?

36. Recap of the tools used in this model  Evidence-based medicine: – target was designed to identify everyone who needs ART as early as possible  Improvement Methodology:  Clear articulation what we are trying to accomplish  Changes tried out, adjusted to get them to work better, all of them required overcoming resistance,  Measurement to track improvement  Spread to other clinics

37. QUESTIONS?