PERFORMANCE & PROCESS IMPROVEMENT

PERFORMANCE IMPROVEMENT INTRODUCTION

■ PERFORMANCE IMPROVEMENT INTRODUCTION

■ THE QPI PROCESS
■ FACTORS ENSURE SUCCESSFUL QPI
■ QPI MODELS
– FOCUS PDCA
– HFMEA
– SIX SIGMA
– LEAN ENTERPRISE
– KAIZEN
 PERFORMANCE MEASURES
 EVIDENCE BASED PRACTICE
 INTRODUCTION

■ Performance Improvement (PI) is a method for analyzing performance

problems and setting up systems to ensure good performance.

■ QPI uses a systematic methodology and tools to find the root causes of a
performance problem and then implement a plan to correct these
problems.

Note: Always use the concept “Area of potential improvement”

instead of “Problem”
 Rules in performance improvement (QPI) prioritization
■ The first approach: it should be aligned with organization’s strategic priorities and mission. If a
quality improvement is not aligned with the scope of the organization and the business goals and
objectives, then we will not start designing any process related to this quality initiative

■ The second approach; criteria-based approach considering risk, volume, safety, cost,..etc.
■ Prioritization should be based on qualitative and quantitative data available.
■ The initiative that have the most opportunity for improvement are often tackled first
■ High risk process usually takes priority. The level of risk determined based on potential
consequences of injury and the frequency.
■ Learning from successful teams is one of the main QPI aspects. This could happen internally or
externally
■ Prioritization Matrix is the best tool to prioritize group of initiatives.

■ Examples of priority performance improvement topics

 Sentinel Events
 Hospital-Acquired infections
 Medication Safety
 Nurse-Sensitive Safety Measures e.g. Pressure Ulcer
 QA & QI – They are not the same

–Quality Assurance (QA):

– Reactive, works on problems after they occur
– Led by management
– One point in time

–Quality Improvement (QI):

■ Proactive – works on processes before problems occur
■ Led by staff
■ Continuous

Note: Nowadays focus shifted from the performance of individuals (Quality Assurance) to
the performance of organization’s system and process (Quality Improvement). And
the focus shifted from identifying poor performers to improving group performance
 THE QPI PROCES

■ Stage 1: Consider Institutional Context: The facilitator must be aware of the goals of the larger
organization and maintain a consistent direction when defining performance targets. Familiarity
with organizational goals helps to ensure the sustainability of the interventions.

■ Stage 2: Obtain and Maintain Stakeholder Agreement: In the initial stage, the Pl facilitator, the
client and the stakeholders meet to discuss and define the desired outcomes of the activity.

■ Stage 3: Define Desired Performance: The stakeholder group creates verbal statements that define
desired performance in specific, observable and measurable terms. These statements of desired
performance address the quality, quantity and timeliness of performance project.

■ Stage 4: Describe Actual Performance: Once desired performance described, current levels of
performance are assessed using the same indicators developed to describe desired performance.

■ Stage 5: Describe Performance Gaps: After describing desired and actual levels of performance, the
difference (gap) between them should be described using the same indicators that were employed
to describe desired and actual performance and in objective terms.
 THE QPI PROCES
■ Stage 6: Find Root Causes: Once performance gaps have been described, the next step is to
determine the cause of those gaps. Using the performance factors as a starting point, the
stakeholder group participates in a root cause analysis to uncover the factors that are
impeding good performance.

■ Stage 7: Select and Design Interventions: The stakeholder group next elects interventions that
will address the root causes discovered during the previous stage. Each intervention or set of
interventions must address at least one root cause.

■ Stage 8: Implement Interventions: During the implementation stage, the team recruits
additional expertise as needed, assures organizational readiness, applies the interventions.
and helps enable and monitor organizational change.

■ Stage 9: Monitoring and Evaluation: In this step, the team measures the change in the
performance gaps identified during gap analysis and evaluate the improvement. Monitoring
happens on an ongoing basis and it should be on organizational objectives
 Important Messages:
 The goal of performance management is to ensure meeting the
organizational visions
 We start quality performance improvement (QPI) projects mainly for
identified areas of improvement to improve it, not only for
accreditation.
 Before starting/ adopting QPI be sure it’s applicable and consistent
with organizations strategic plan even if its success somewhere else
 QPI steps can be summarized in five steps
1. Check applicability
2. Make commitment
3. Data Collection
4. Implementation
5. Evaluation
 FACTORS THAT ENSURE SUCCESSFUL QPI
1. Ensure leadership support and commitment.
 To have a successful team, you should include (senior leaders) in the
team, ALWAYS
 One of the best leadership commitment features for new projects is
through allocating resources for the process
2. Assess priority and feasibility of QPI initiative based on
prioritization rules.
 Prioritization matrix is the best tool for prioritization, otherwise you
can use multi-voting or other tools
3. Identify the aim of conducting QPI initiative.
 FACTORS THAT ENSURE SUCCESSFUL QPI

4. Involve all the right interdisciplinary team (cross-functional) to

implement change.
 This is the best type of team
 Highly needed when issue affecting several areas across organization
 To facilitate involvement of physicians and nurses in QPI, remember:
 Explain the program to the team then ask for feedback
 Don’t give them mass document and enforce them to self read it
 For physicians, don’t explain many QPI theories to them
5. Identify the measures to enable managing (M2M: Measure to Manage)
6. Educate the staff on the desired change.
7. Collect, analyze, and evaluate data on the redesigning process.
 FACTORS THAT ENSURE SUCCESSFUL QPI
8. Report and display results to reward staff for improvement.
 Dissemination of organization’s performance indicators result should
be to entire staff
 For any QPI (e.g. fall in ICU, Needle stick in ER), unit’s staff must be
notified first before any body else
 If the report is for governance or top leaders:
 Number one focus is team achievement
 Don’t include individual practice pattern in report. Instead of reporting to
top leaders, practice pattern should be disseminated to the practitioners
them self to promote their behavioral changes in PI concerned areas
 Use graphic display (easy to interpret, especially in presentations)
 You may include objectives, methodology but not the meeting minutes
 Write overview of quality program, specially the effect on patient care
 FACTORS THAT ENSURE SUCCESSFUL QPI
9. Compare performance internally and externally.
10. Celebrate success internally and externally.
 Display outcome data is one of the most effective ways to disseminate QPI information and
results. On the other hand, using MEMO is one of the least effective ways
 QUALITY PERFOREMANCE IMPROVEMENT (QPI)
MODELS

■ The following are examples of QPI models:

 FOCUS PDCA
 HFMEA
 Lean
 Six Sigma Model
 Rapid Cycle Improvement (PDSA)
 Kaizen
 FOCUS PDCA

■ FOCUS PDCA is a methodology that is used to identify improvement

opportunities and creates a systematic approach to implementing
changes.
Steps Description Tools to use
F Find a Process to Improve: 1) Patient Surveys
 Prioritize opportunities based on patient/internal customer input, clinical monitoring, 2) Brainstorming’
and/or strategic direction. 3) Observations Tool
O Organize a Team: 1)Agenda/Meeting Summary
 Select a team/individual who has the content knowledge of what you hope to improve 2) Communication
(Define team member roles)
C Clarify the Current State: 1)Flowchart
 Understand the current problem and current process steps 2) Observations
 Identify the people/resources involved in the process steps 3) Data Collection
 Collect necessary data in the current state
U Understand Root Causes: 1)Brainstorming
 Understand root causes in order to identify why the process isn’t working effectively 2) 5 Why’s
3) Fishbone Diagram
S Select the Improvement: 1)Aim Statement
 Establish a goal regarding what you will improve
P Plan the Improvement: 1)Flowchart
 Plan to carry out the cycle (who,what,when,how) 2) Action Plan
 Create a data collection plan 3) Data Collection Plan
 Focus on small tests of change 4)Decision Making
D Do the Improvement: 1)Actions plan
 Carry out the plan to make change 2) Data Collection Plan
 Document problems or unexpected observations 3) Check Sheet
 Measure the impact of the change 4) Observations Tool
5)Communication Plan
C Check the Results: 1)Run Chart
 Examine data to determine whether the change led to the expected improvement 2) Check Sheet
(Summarize finding results) 3)Surveys
A Act and Determine Next Steps: 1)Action Plan
 Use finding to determine and act upon next steps: 2) Storyboard
o Holds the gains 3) Charter
o Develop plan to monitor data
o Revise change idea and begin new PDCA cycle
o Start another FOCUS-PDCA on a new improvement
 HEALTHCARE FAILURE MODE AND EFFECTS ANALYSIS
(HFMEA)

■ “Failure modes” means the ways, or modes, in which something might fail. Failures are
any potential or actual defects.
■ “Effects analysis” refers to studying the consequences of those failures. Failures are
prioritized according to its frequency and seriousness.

■ Failure Modes and Effects Analysis is a systematic, proactive method for evaluating a
process to identify where and how it might fail and to asses the relative impact of
different failures, in order to identify the parts of the process that are most in need' of
change.
 FMEA includes review of the following:

■ Steps in the process

■ Failure modes (What could go wrong")
■ Failure causes (Why would the failure happen?)
■ Failure effects (What would be the consequences of each failure?)

 Teams use FMEA to evaluate processes for possible failures and to

prevent them by correcting the processes proactively rather than
reacting to adverse events after failures have occurred.
 Uses of FMEA
1. To plan actions to reduce harm from failure modes

A. If the failure mode is likely to occur:

■ Evaluate the causes and see if any or all of them can be eliminated.
■ Consider adding a forcing function (that is, a physical constraint that makes committing an error impossible, such as medical gas
outlets design)
■ Add a verification step, such as independent double-checks for medications.

B. If the failure is unlikely to be detected:

■ Identify other events that may occur prior to the failure mode and can serve as "flags" that the failure mode might happen.
■ Consider technological alerts such as devices with alarms to alert users when values are approaching unsafe limits.

C. If the failure is likely to cause severe harm:

■ Identify early warning signs that a failure mode has occurred, and train staff to recognize them for early intervention.
■ Provide information and resources, such as a reversal agents or antidotes, at points of care for events that may require
immediate action.
 Uses of FMEA

2. To evaluate the potential impact of changes under consideration.

■ Teams can use FMEA to discuss and analyze each change under consideration and calculate the change in
Risk Priority Number (RPN) if the change were implemented. This allows the team to "verbally simulate" the
change and evaluate is impact in a safe environment, prior to testing it in a patient care area.

3. To monitor and track improvement over time.

■ Teams should consider calculating a total RPN for the process as described above and then set a goal for
improvement. For example, a team may set a goal of decreasing the total RPN for the medication ordering
process by 50% from the baseline.
 Failure Mode and Effects Analysis
(FMEA) steps
Step One Select a process to Use FMEA in processes which don’t have too many sub-process (e.g.
Evaluate with FMEA instead of conducting FMEA on entire medication process, you may
select electrolyte replacement process)

Step two Recruit a multidisciplinary Be sure to include everyone who is involved at any point in the process.
team
Step Three Review the process Number/enumerated every step of the process (Flowcharting can be a
helpful tool) for outlining the steps. When you are finished, be sure to
obtain consensus from the group about steps accuracy.

Step Four List failure modes and For each step in the process, list all possible “failure modes.” Then, for
causes and its effect each failure mode listed, identify all possible causes.
on patients
Step Five Assign Risk Priority To assign RPN, answer the following: Occurrence: How likely is it that
Number (RPN) this failure mode will occur?
Detection: If this failure mode occurs, how likely is it that the failure will
be detected?
Severity: If this failure mode occurs, how likely is it that harm will occur?
RPN=Severity X Occurrence X Detection
Severity (1=Not Severe, 10= Very Severe)
Occurrence (1=Not Likely, 10 = Very Likely)
Detection (1=Easy to Detect, 10= Not easy to Detect)
Step Six Evaluate the results The score will be 1-1,000, Identify the failure modes with the
highest RPNs. These are the ones the team should consider first
as improvement opportunities.

Step Seven Create actions to reduce Failure modes with high RPNs are the most important to focus
risks improvement efforts. In this step, create actions to reduce harm
from failure modes:

Step Eight Assign responsibility for Assign responsibilities for implementing corrective actions and
actions determine project completion date

Step Nine Re-assign risk codes Determine what is RPN after actions implementation (residual risk)
(residual risk) to assist the team in prioritizing actions and to determine if the
actions were effective

Step Ten Monitor the actions and Monitor to evaluate if the risk reduction strategies have reduced risk
risk reduction and take additional actions, if necessary, to further reduce risk
 HFMEA

What are the benefits of calculating RPN or Hazard Scoring Matrix

■ Whenever more than one risk identified, hazard scoring matrix or RPN can help in
two things
– Prioritization
– Assessment: assess the severity/ risk pre and post interventions
 Current Healthcare Quality Management Approaches

■ Six Sigma:

 The Six Sigma approach to improving quality can be used to address many of the
challenges facing healthcare, including resource utilization, patient safety, appropriate
use of technology, and increasing market share, using data and statistical analysis to
measure and improve performance, in addition, six sigma provide better approach to
achieve long-term results. Quality is improved by eliminating errors in production and
service related processes.

 Six Sigma is based on the concept of the normal distribution and the belief that there is
a point, six standard deviations from the mean, where there should be almost zero
defects. Therefore, error rates should not exceed 3.4 defects per million opportunities
(DPMO).
 Lean and Six Sigma
Attitude and Discipline

Customer Focus
View Quality externally from the customer’s perspective
Measure the same way that the customer does
Meet customer expectations every time
Continuous improvement cycle
Systematic
Scientific
Fact-based
Data-driven
Process focus

Customers Have All The Votes Concerning

Extent Of Satisfaction And Value
 Roles & Responsibilities

• Owns vision, direction, • Leads change

integration, results

Executive
• Support Six Sigma • Supports Black Belts by
• Ensure success of participating on project
GB/BB projects teams
Yellow Belts Green Belts
• Develops All • Apply Breakthrough
deployment and Employees Strategy to specific
Strategy (White Belts) projects, lead and
• Supports cultural direct teams to
change execute
• Understand vision
Champion / projects
• Apply concepts to their Black Belts
Sponsor job and work area

• Owns the process in which

GB/BB works • Trains and coaches Black
• Challenges GB findings Process Master Belts , Green Belts and
leaders
Owner Black Belt
 Six Sigma DMAIC Cycle

DEFINE

CONTROL
MEASURE

IMPROVE ANALYSE
Current Healthcare Quality Management Approaches
 Define: Practitioners begin by defining the process. They ask who the customers
are and what their problems are. They identify the key characteristics important
to the customer along with the processes that support those key characteristics.
They then identify existing output conditions along with the process elements.

 Measure: Next, the focus is on measuring the process. Key characteristics are
categorized, measurement systems are verified, and data are collected.

 Analyze: The intent of analysis is to convert the raw data into information that
provides the most important causes of the defects or problems.

 Improve: Results of process changes are seen and the company can judge
whether the changes are beneficial or if another set of changes is necessary.

 Control: If the process is performing at a desired and predictable level, it is put

under control. The process is monitored to ensure that no unexpected changes
 Current Healthcare Quality Management Approaches
■ Lean Enterprise
Lean enterprise includes the application of value stream analysis (a tool for exposing
waste), root cause analysis (which is a method for pursuing perfection). and the use of
new technologies to facilitate more efficient practices.
7 (8) Wastes
■ Intellect
■ Scrap / Rework / Defect/
Errors
■ Waiting
■ Inventory
■ Motion / Movement
■ Transportation
■ Over processing
■ Overproduction
 Current Healthcare Quality Management Approaches

■ Lean Enterprise
One of the major difference between the lean approach and traditional quality
improvement is its emphasis on investigating new ways of getting things done and
making the changes in the short period of time. The basic idea is to identify new
procedures that should be more effective than existing systems in the eliminating
waste. Quality improvement has typically used the incremental change model, but lean
enterprise is more about total redesign. A key element of success is the commitment
and the involvement of workers in change process
 Current Healthcare Quality Management Approaches

■ Reengineering

 There was typically a focus on restructuring systems and departments into more efficient processes.
For example, hospitals experimented with creating new positions that combined work from several
different areas. A focus on cross-functional capabilities led to the dissolution of departmental "silos".

 Many hospitals thought that reengineering would increase profit margins and create financial stability.
The problem was that reengineering often became associated with downsizing and layoffs. When this
happened, employee morale declined and productivity suffered. Because of these negative
connotations, reengineering has fallen out of vogue and been replaced by other improvement models
and initiatives. The newer approach is to consider adopting the lean enterprise method to increase
financial stability by eliminating waste.
 Current Healthcare Quality Management Approaches

■ Rapid Cycle Improvement

 Rapid Cycle Improvement

The IHI developed the "collaborative" approach, termed the "Breakthrough Series," to bring about
rapid cycle improvements. Fundamental to the collaborative approach is the acceptance model and
establishment of infrastructure through which collaborating organizations can identify and prioritize
aims for improvement and gain access to methods, tools, and materials that will enable them to
conduct individually. The key elements of success are enlisting a broad range of “partners" utilizing
evidence-based practice and developing toolkits that contain essential information and resources for
change. At the core of the collaborative approach are PDCA cycles. The real benefits to organizations
that participate in the Breakthrough Series are that they can learn from other organizations’
successes and failures.
 Current Healthcare Quality Management Approaches

■ Kaizen

■ Kaizen: The word Kaizen mean “continuous improvement” or good change. It comes
from the Japanese word “Kai” which means “change” and “zen” which means “good”.
■ Kaizen: is a system of continuous improvement in quality, technology, processes,
company, culture, productivity, safety and leadership, aims to eliminate waste
■ Kaizen in a system that involves every employee – from upper management to the
cleaning crew. Everyone is encouraged to come up with small improvement
suggestions on a regular basis. Kaizen is based on making little changes on a regular
basis, always improving productivity, safety and effectiveness while reducing waste
 PERFORMANCE MEASURES

■ There are several types of performance measures. Before selecting a

measure, one must understand the purpose of each measure.
 Process Measure
 Outcome Measures
 Structural Measures
 Dashboard: and balanced scorecards

■ Dashboards and balanced scorecards (BSC) are approaches to monitor

the progress of performance against strategic goals.

■ Dashboards and BSC can be used at organizational and/or departmental

level since each department (unit) has its own goals and objectives.
 Dashboards

■ Dashboards provide overview of an organization.

■ Dashboards are an easy access computer program integrates a variety of
performance /key indicators into one display, usually with graphs or
charts.
■ Dashboards provide a running picture of a departmental / organizational
status at any point of time.
 Balanced Scorecards (BSC)

■ BSC provide comprehensive view of organizational performance rather than depending on

few choice indicators.
■ BSC helps organizations to better link long-term strategy with short-term activities.
■ BSC provide performance measures in relation to strategic plan (mission, vision, goals)
■ BSC approach views the organization from four different perspectives:

 Financial (How do we look to providers of financial resources?)

 Customer (How do our customers see us?)
 Internal process (At what must we excel?)
 Learning and growth (Can we continue improve and create value for customers?)
 Balanced Scorecards (BSC)

■ In Healthcare, the most common adjustment to the traditional balanced scorecard is

the extra emphasis on patient results and customer satisfaction

■ If the scorecard is adequately balanced, it will reflect both the needs and priorities of
the organization itself, and also those of the community and customers it service
 Balanced Scorecards (BSC)

Important Note:
■ The main difference between a dashboard and a scorecard is that a scorecard describes
past performance, while a dashboard depicts performance in real time.
 BENCHMARKING

■ Benchmarking: is the comparison of an organizations or practitioner’s

results against a reference point (Best Practice) which give shape for
shapeless raw data and enable organizations or individuals to set a target
or goal.

■ Comparison of some outcome measures such as mortality and length of

stay cannot be made without risk adjustment and severity adjustment.
 Risk Adjustment

■ Technique used to control the fact that different patients with the same diagnosis may have
additional conditions that can affect how they respond to treatment.

■ It is a statistical process used to identify and adjust for variation in patient outcomes that stem
from differences in patient characteristics across healthcare organizations (comparing outcome
without risk adjustment can be misleading).

■ To benchmark organizational data, we have to compare the result with similar facilities e.g. to
compare surgical site infection (SSI) in a hospital, it should be compared with SSI in similar facility

■ Benchmarking is an essential element of clinical pathway development.

 Type of benchmarking

 Internal (e.g. time to antibiotic in septic shock, ER vs. ICU at X hospital)

 External (eg. CLABSI, ICU at X hospital vs. NHSN)
 Zero-incidence (e.g. wrong site surgery, X hospital vs. zero incidence)
 EVIDENCE:- BASED PRACTICE AND CLINICAL PATHWAYS

■ Evidence Based Practice

 Evidence-based Medicine: conscientious, explicit and judicious use of current best evidence in making
decisions about the care of individual patients.

 From healthcare quality perspective. Evidence-Based Practice (EBP) is more appropriate than Evidence-
Based Medicine.

 EBP promotes patient safety through the provision of effective and efficient healthcare, resulting in
standardization and less variation.

 Evidence-based quality management is based on two type of research:

 Clinical research, which evaluates the impact of intervention on patient outcomes.
 Health services research, which evaluates health system at the micro and macro level.
 EVIDENCE:- BASED PRACTICE AND CLINICAL
PATHWAYS

■ Evidence Based Practice and professional standards helps in

1. Reduce assignable variation

2. Reduce waste of time
3. Reduce waste of resources
4. Improve communication
5. Ensure quality care for the individual client
 Clinical Pathways

■ Clinical guidelines: are consensus statements developed to assist in

clinical management decisions.

■ Clinical Pathways; are tools to manage quality outcomes and cost of care
based on clinical guidelines and current evidence.
 Clinical pathways characteristics and benefits

1. It is document based tools (knowledge translation tool)

2. Enhances standardization and reduces variation of clinical practice.
3. Improve communication and teamwork between interdisciplinary.
4. Does not substitute clinical personal judgment.
5. More applicable in non-complicated illness (e.g. surgical procedures)
rather than medical complications
NGC

■ NGC: The National Guidelines Clearinghouse and AHRO initiative is a publicly

available database of evidence – based clinical practice guidelines and related
documents. NGC updated weekly to provide an objective and detailed information
on clinical practice guidelines for physicians and other health professionals