1. Implementing Quality Improvement Introduction to PDSA cycles

2. Objectives After this session participants will: Understand how to do a gap analysis Understand the main steps in implementing a change to improve quality Understand the concepts of PDSA

3. You’ve done the measurement. What should you do with all that data?

4. Your data shows: Only 70% of eligible patients are routinely screened for TB. How can you improve this?

5. How do we improve a problem? Some general principles Need to ensure there is an atmosphere of improvement The discussion is not accusatory or seeking to blame The problem is in the process not the individual – Clinic procedures, information, materials/supplies, equipment

6. QI methods Many approaches, some overlaps, but all with the same goal: Improve a gap Some basic questions that the team must ask – Why does the gap exist? – How can we close the gap? – Did we succeed? 6

7. Introduction to PDSA A process that helps us to organize how we will improve a gap Plan Do Study Act

8. Remember the link between measurement and QI Measure quality Work to address the gap: QI Identify a gap Understand why gap exists

9. PDSA cycles focuses on the highlighted areas Measure quality Work to address the gap: QI Identify a gap Understand why gap exists Adapted from JSI

10. PDSA cycles focuses on the highlighted areas Measure quality Work to address the gap: QI Identify a gap Understand why gap exists ActPlan* StudyDo

11. Act Does the intervention need to be modified? OR Is the change ready to expand and integrate? Plan* Understand why gap exists Make a plan to fix the gap Decide how to implement plan (who, what, where, when) Study Did the measurement show the expected difference? Were other changes seen? Share with team Do Carry out the plan on small scale Document problems Begin analysis The PDSA cycle *Plan as response to identified gap Adapted from IHI, HIVQUAL JSI and others Expand and integrate Identify a gap

12. So how do you plan what your change (QI project) will be?

13. Step 1: Planning to improve a quality gap 1.Understand where in the system things are not working: 1.Make a Flow chart 2.Brainstorm - Where do we think problems are? 3.Cause and Effect (Fishbone) 2.Develop the solution 3.Make a plan to fix the gap 4.Decide how the plan will be implemented (discussed in next talk)

14. Make a flow chart A map of what should happen Work with the QI team and others as needed Draw out each of the detailed steps required to have the desired outcome – An eligible patient is started on ART Start with patient registering to clinic, end with patient started on ART. – Patient receives Cotrimoxazole prophylaxis Start with patient comes into clinic and end with patient leaving clinic with CTX pills

15. Flow chart 1: TB screening, diagnosis and referral for treatment at the OPC Patient Document in the registration book & patients chart: - Check pt’s ID card -Stamp TB screening (if used) - Physical examination -TB screening: check questions Lab: smear or culture Get result Three sputum: - 1: on-site - 2: morning after - 3: on-site BK positive Giving to the registration nurse for documentation Refer to TB unit for treatment Any suspected symptom 2 days 1-5 days Doctor Registration nurse Lab: taking specimens

16. Brainstorming Refer to the flow chart as a guide List all potential causes of the quality gap Work as a team and continue until you have exhausted all ideas Categorize into potential groups – Human resources – Patient factors – System/protocols – Guidelines – Infrastructure – Resources – Other factors

17. Flow chart 2: List all the possible gaps Patient Document in the registration book & patients chart: - Check pt’s ID card - Weight, temperature, BP - Stamp TB screening (if used) - Physical examination -TB screening: check questions - Baseline tests: CBC, CD4, LFT, HBV, HCV, VDRL Lab: smear or culture Get result Three sputum: - 1: on-site - 2: morning after - 3: on-site BK positive Giving to the registration nurse for documentation Refer to TB unit for treatment Any suspected symptom 2 days 1-5 days 1 Stamp not available Forget to stamp chart 2 Forget to ask about symptoms Forget to document Doctor Registration nurse Lab: taking specimens 3 Do not take sputum 4 Lost or poor specimens 5 No result Result not documented

18. Cause and effect/Fishbone Developed by Ishikawa Helps to categorize the potential causes of the gap – Ex. those developed by brainstorming Guides where you might try to improve

19. Systems and guidelines Resources Other factors Physical Infrastructure Staff Gap Patients

20. Guidelines and systems Screening guidelines not clear Charts not well organized Resources Stamp lost Other factors Physical Infrastructure: Inadequate space, Too crowded Staff Too few Not trained MDs get called away Patient not screened for TB Patients Come late to appointment

21. Step 1 Plan - Some tips Work as a team. Every voice counts. Start with a flow chart, then brainstorm possible gaps in each step of the process. – The “change” or first QI project may be found after this step. Categorizing into systems will help to further organize and guide where the change can be focused. Ask representative from leadership to join and develop the detailed plan

22. Step 1: Example of a plan to improve TB screening from 70% to 90% of patients After discussion of the possible causes, the clinic decides the biggest problem is that nurses and doctors forget to ask about symptoms and a reminder is needed. Solution: Place signs on the desk and use a stamp that had been provided, but not regularly used.

23. Step 2: Do The PDSA Cycle Do Carry out the plan Document problems Begin analysis

24. Do: Principles Is there something easy that another clinic has already done? Start small and simple – What can we change by next week? Test it out – don’t be afraid to just try something small to see if it works Document what happens, both good and bad. – Do a mini chart review – Note any affects on resources or other systems The PDSA Cycle Ref. National Quality Center

25. Example simple solution

26. Step 3: Study The PDSA Cycle Study Did the measurement show the expected difference? Were other changes seen? Share with team

27. Did the stamp improve TB screening? 13%70% TB screening stamp with symptom put on doctor’s desk Quick review of 10 charts: 9 screened for TB Minimal work for nurses

28. Step 3: Study The PDSA Cycle Study Did the measurement show the expected difference? Were other changes seen? Share with team Yes! This plan worked No effects on resources

29. Step 4: Act The PDSA Cycle Act Did the plan work? Yes: How will you expand or sustain it? No: What will you try next?

30. Act: What Will We Do (Based on What We Learned)? In our example: 1)we will continue to use the stamp 2)make sure that it has a secure place to stay 3)add signs to remind staff and patients about TB screening 4)continue to monitor. The PDSA Cycle

31. Example: TB screening 13%70%90% - Remind staff about TB screening in staff meeting - Make a paper reminder put on the desk in front of the doctor TB screening stamp with symptom put on doctor’s desk Goal: 90%

32. Another example Clinic ABC found that many patients were missing clinic visits. After writing out a flow chart and brainstorming potential causes they decided the core cause was many patients had barriers to keeping appointments

33. Plan: Tool to improve on time visits. Objective: screen HIV patients for issues that might affect their ability to come to clinic on time. Prediction: adding a screening tool will add time to the patient visit, but we can keep this to a minimum Steps: Nurse Thuy and Counselor Ngoc researched and identified possible tools that were reviewed by Ngoc and Dr. Phuong. They selected one tool for Dr. Phuong to use with at least three patients in the clinic on Thursday Necessary tasks: 1. Identify tool. 2. Copy tool and place in patients' charts. 3. Dr. Phuong reviews instructions for using tool. 4. Explain tool to patient. 5. Use tool Adapted from the National Quality Center

34. Do: Implementing the adherence tool Dr. Phuong used the tool on one patient the next day The PDSA Cycle

35. Study: What happened with the tool? The tool was 5 pages long Added 35 minutes to the patient’s visit The next patient waiting for the doctor was late for work so had to leave his appointment We made things worse! The PDSA Cycle

36. Act: What happened with the tool? The clinic team sat down again to come up with a new plan to screen patients for barriers.

37. Emphasis point All improvements require change, however, all changes don’t lead to improvement

38. Summary Goal of QI is to improve Requires team approach Many approaches exist – most use incremental and continuous change Start small Measure before, during and after to make sure there is improvement Make sure the change is institutionalized so the change is sustained.

39. Summary slides - Quality Improvement: first step Guidelines and standards Performance goal Actual performance Quality Indicators Performance gap Quality Improvement Intervention Adapted from JSI and EGPAF 95% 80%

40. Actual performance Performance gap Performance goal Second QI Intervention Quality Indicators Guidelines and standards Quality Improvement: second intervention Adapted from JSI and EGPAF 95% 85% 90%

41. Resources NationalQualityCenter.org HIVQUAL John Snow International Institute for Healthcare Improvement Partners in Health Resources