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

2. Introduction Current State of Healthcare

3. 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 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

4. How Hazardous Is Health Care? (Leape)

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

6. Seeing Differently

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

8. 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.

9. 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” [Accessed October 2007]

10. 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]

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

12. Understanding Systems

13. 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

14. System
Source: Horn, Steve, “Deming's System of Profound Knowledge” [Accessed October 2007]

15. Common View of a System

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

17. Slide

18. 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

19. 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

20. 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

21. 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

22. EXAMPLE
Harries, Barnard, Hoffman 2006

23. Understanding Variation

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

25. 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).

26. 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

27. 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?

28. 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” [Accessed October 2007]

29. 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” [Accessed October 2007]

30. 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” [Accessed October 2007]

31. 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

32. Psychology

33. 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.

34. Theory of Knowledge

35. 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]

36. 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.

37. 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

38. 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

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

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

41. 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

42. Reliability in Healthcare

43. 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”. [Accessed Oct. 2007]

44. 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)

45. 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; (Available on

46. 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; (Available on

47. 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)

48. 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; (Available on

49. 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; (Available on

50. 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; (Available on

51. 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; (Available on

52. 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; (Available on

53. Questions/Comments Debbie Barnard, MS, CPHQ
Project Manager Safer Healthcare Now!
Canadian Patient Safety Institute
Suite 1414, Street
Edmonton, Alberta T5J3G1
Phone: or
Fax:
Website:
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