Quality Improvement Society of Hospital Medicine

QI Theory:
Quality Improvement in the Hospital

Goals for this Primer
• Understand fundamental concepts in
quality improvement
• Identify the environment and key steps for
a successful quality improvement project
• Become familiar with several quality
improvement tools and their use
Quality Improvement:
Bridging the Implementation Gap
Progress
How good is American healthcare?
Patient care
Time
Progress
We get it right 54% of the time.

-Brent James, MD, MStat
Executive Director, Intermountain Health Care
Patient care
Time
Scientific
understanding
Implementation
Progress
Gap
Patient care
Time
Hospitalists and Quality Improvement
• Complex process problems need multidisciplinary

solutions
• We are at the frontlines seeing system failures,
process errors, and performance gaps with our
own eyes -- which is our competitive advantage
• Improved quality delivers:
 better patient care…
 at lower costs…
 with potentially higher reimbursements (pay-for-
performance)…
And it can make our jobs more interesting, fun, and
rewarding.
Section I:
Quality Improvement and Change
in the Hospital Atmosphere
Definition of Quality
• Meeting the needs and exceeding the

expectations of those we serve
• Delivering all and only the care that the patient

and family needs
“Definition” of Improvement
It is NOT…
 yelling at people to work harder, faster, or safer
 creating order sets or protocols and then failing to
monitor their use or effect
 traditional Quality Assurance
 research (but they can co-exist nicely)
Principle #1:
Improvement Requires Change
Every system is perfectly designed to achieve

exactly the results it gets
To improve the system, change the system…

Principle #2:
Less is More
You cannot destroy productivity
When changing the system, keep it simple

Illustrating Principle #2: Less Is More
Probability of Performing Perfectly
No. Probability of Success, Each Element

Elements 0.95 0.99 0.999 0.999999
1 0.95 0.99 0.999 0.999999

25 0.28 0.78 0.98 0.998
50 0.08 0.61 0.95 0.995
100 0.006 0.37 0.90 0.99
Understanding Change in the Hospital
Atmosphere
• Change = not just doing something different, but

engineering something different
• at least one step in at least one process
• Hospital Atmosphere = hospitals tend to be viscous,

complex systems with default levels of performance
• change engineered to improve performance can be a foreign
concept - or even overtly resisted
Atmosphere
A Common Strategy Which Commonly Fails:
• Experts design a comprehensive protocol using EBM
over several months
• Protocol is presented as a finished, stand alone
product
• Customization of protocol is discouraged
• Compliance depends on vigilance and hard work
• Monitoring for success or failure is the exception to
the rule (with failures coming to light after patients
are harmed)
• Flawed implementation leads to repetitive efforts
down the road
Atmosphere
High-Reliability Strategies Commonly Succeed:
• Build a “decision aide” or reminder into the system
• Make the desired action the default action (not doing
the desired action requires opting out)
• Build redundancy into responsibilities (e.g. if one
person in the chain overlooks it, someone else will
catch it)
• Schedule steps to occur at known intervals or events
• Standardize a process so that deviation feels weird
• Take advantage of work habits or reliable patterns of
behavior Build at least one - if not more - of these high-
reliability strategies into any changed process.
Atmosphere
Change engineered to drive improvement depends on…

• Workplace Culture: personnel must be receptive to change
• Awareness: administrative and medical staffs must care
about performance and support its improvement through
change
• Evidence: local experts must identify which research to
translate into practice
• Experience: a skilled team must choose, implement, and
follow up changes to ensure:
1) improvement efforts are ongoing and yielding better
performance
2) productivity is preserved
An Atmosphere for Change
AWARENESS EXPERIENCE
OF THE LOCAL PERFORMANCE GAP WITH SIMILAR IMPROVEMENT
Patient EFFORTS
Medical Staff Hospitalist Quality Officer
Administrative Support Multidisciplinary Team Members
Success Stories From Other Institutions
EVIDENCE WORKPLACE CULTURE

TO TRANSLATE INTO PRACTICE READY TO ACCEPT CHANGE
“Bedside” Teaching Task Load
Didactic Teaching Sessions Culture of Improvement
Local Expertise in Disease Literature Culture of Negative Expectations
AWARENESS  Patient
At mercy and increasingly aware of
OF THE LOCAL PERFORMANCE GAP underperforming status quo
Patient Now can access a new resource promoting
Medical Staff transparency in hospital performance:
Hospital Administration www.hospitalcompare.hhs.gov
 Hospital Administration  Medical Staff

Understands status quo is unacceptable Has professional responsibility to improve
(IOM, Leapfrog, NQF, JCAHO) Knows all too well where system fails
Sees fiscal health tied to performance Recognizes that professional livelihood will
against national benchmarks, ability to depend on paying attention to outcomes:
reduce costs & LOS, improve margins, Pay-for-Performance
and competitive reputation in the
community
Hospitalist Team Facilitator  EXPERIENCE

Technical expert on Quality Improvement
theory and tools WITH SIMILAR IMPROVEMENT EFFORTS
Owns the team process, enforces ground Hospitalist Team Facilitator
rules, helps judge feasibility Multidisciplinary Team Members
Teaches the team while doing Successful Strategies Used By Others
Successful Strategies Used By Others  Multidisciplinary Team Members 

Learn from mistakes of others Chosen for hands-on, fundamental
Adapt successes of others (tools and knowledge of key processes
methods): steal shamelessly Inclusive, open, & consensus seeking
Get specific advice in ’Ask the Expert’ Impact not only the change(s) but the
forums or other consortiums that collect implementation
and share experience
“Bedside” Teaching Didactic Teaching Sessions

To an audience of residents or students To an audience of peers, administrators,
To build cadre of “experts” (and to help nurses, or support staff
meet ACGME requirements) To boost awareness, knowledge,
Download teaching pearls from SHM enthusiasm, and support
resource rooms Download slide sets from SHM resource
rooms
 
Local Expertise in Disease Literature
EVIDENCE Decide what changes to make based on
TO TRANSLATE INTO PRACTICE the level of evidence
“Bedside” Teaching Establishes team’s credibility
Didactic Teaching Sessions Extends team’s authority when local sub-
Local Expertise in Disease Literature specialists or experts participate in
selecting and implementing change

Task Load Culture of Improvement

Be sensitive about piling new tasks onto Extend it, one person and one project at a
over-tasked personnel time
Use the input of personnel who will be Advertise successes
responsibile for implementing Use or adapt this online ‘cultural survey:’
Make it easy and desirable to do the right http://www.patientsafetygroup.org/program/step1c.cfm
thing  
Culture of Negative Expectations

Overcome it, one person and one project WORKPLACE CULTURE
at a time READY TO ACCEPT CHANGE
Attach pride to balance between Task Load
performance successes and failures
Culture of Improvement vs.
Consider using a ‘cultural survey’ to
identify problems and address them Culture of Negative Expectations
through proper channels 
Section II:
The Multidisciplinary Team

The Driving Force for Change
THE MULTIDISCIPLINARY TEAM
Leverages frontline expertise and experience.

Impacts not only the change/interventions,
but also the implementation
The Driving Force for Change:
The Multidisciplinary Team
A team is not the same as a committee…
Committee
• individuals bring representation
• productive capacity = single most able member
Team
• individuals bring fundamental knowledge
• productive capacity = synergistic (more than the sum of all
individual team members together)
Features of a good team…
• Safe (no ad hominem attacks)
• Inclusive (values all potential contributors including
diverse views; not a clique)
• Open (considers all ideas fairly)
• Consensus seeking
Consensus…
• definition: finding a solution acceptable enough
that all members can support it; no member
opposes it
• It is not:
 A unanimous vote (consensus may not represent
everyone’s first priorities)
 A majority vote (in a majority vote, only the majority
gets something they are happy with; people in the
minority may get something they don’t want at all,
which is not what consensus is all about)
 Everyone totally satisfied
Three types of team members…
1) Team Leader
2) Team Facilitator
3) Process Owners (members with operational, hands-on
fundamental knowledge of the process)
Team Leader…
• schedules and chairs team meetings
• sets the agenda (printed at each meeting)
• records team activities (working documents in
binder)
• reports to management (Steering Team)
• often a member of Steering Team
Team Facilitator…
• owns the team process (enforces ground rules)
• technical expert on QI theory and tools
• assists Team Leader
• teaches while doing, within team
Process Owners…
• chosen for fundamental knowledge
• will help implement
• should become leaders (so choose wisely)
Team Ground Rules…
• All team members and opinions are equal
• Team members will speak freely and in turn
 We will listen attentively to others
 Each must be heard
 No one may dominate
• Problems will be discussed, analyzed, or attacked (not people)
• All agreements are kept unless renegotiated
• Once we agree, we will speak with "One Voice" (especially after leaving the meeting)
• Honesty before cohesiveness
• Consensus vs. democracy: each gets his say, not his way
• Silence equals agreement
• Members will attend regularly
• Meetings will start and end on time
A Brief Digression into Quality
Improvement Theory
Defining an Approach to Change
Will the team target ‘all’ patients in the
inpatient bell curve, or just a sub-group
considered ‘at-risk’ (depicted in the
outlying tail)? Is the quality of inpatient
care which is not in the tail somehow
‘acceptable?’
Before
Bell Curve:
Inpatient Population
Tail
worse
If the team can identify and define an inpatient sub-group
‘at-risk,’ then improvement efforts could conceivably
focus just on these ‘at-risk’ patients - this is similar to After
traditional Quality Assurance. Note that even if tail
events are eliminated, the quality of care for the rest of
the inpatient population (depicted by the unchanged
position and shape of the bell curve) does not improve at
all. While the mean does move toward better care, this is
due only to eliminating statistical outliers.
Before
Bell Curve: worse Quality
Tail
worse
If the team identifies a performance gap applicable to a
wider patient population, the team may design changes in
After
processes with the potential for dramatic effect:
improvement and standardization in processes reduces
variation (narrows the curve) and raises quality of care for
all (shifts entire curve toward better care). This radical
change is what defines Quality Improvement.
Before
Bell Curve: worse Quality
Tail
better
worse
worse Quality
Section III:
Tools for Engineering Change
Engineering Change
• Hospitals have two dynamic levels impacting

performance:
1) Processes
• tasks performed in series or in parallel, impacting patient care
and potentially patient outcomes
2) Personnel
• skilled people with hearts and minds, with variable levels of
attention, time, and expertise
Engineering Change:
What Variables Impact Quality Outcomes of Care?
Structure Processes Outcomes of Care
Inputs Steps Outputs
•Patients •Inventory Methods •Physiologic

•Equipment •Coordination parameters
•Supplies •Physician orders •Functional status
•Training •Nursing Care •Satisfaction
•Environment •Ancillary staff •Cost
•Housekeeping
•Transport
Engineering Change:
What Variables Impact Quality Outcomes of Care?
The two most dynamic levels impacting performance
Processes
Steps
•Inventory Methods
•Coordination
•Physician orders
•Nursing Care
•Ancillary staff
•Housekeeping Personnel
•Transport
Engineering Change
• Processes
 all those affecting relevant aspects of patient
care
• clinical decision making, order writing, admission
intake, medication delivery, direct patient care,
discharge planning, PCP communication,
discharge follow-up, etc
Engineering Change
• Personnel
 anybody who touches the patient or a relevant
process in the system
• departments, physicians, clerks, pharmacy,
nursing, RT, PT/OT/ST, care technicians,
phlebotomist, patient transport, administration
Engineering Change:
The Multidisicplinary Team Asks “What?”
• What?
 is the right thing to do?
 will make the system more effective?
Engineering Change:
The Multidisicplinary Team Asks
“Where?”
• Where?
 are the processes to improve?
• Brainstorming
• Multivoting & nominal group technique
• Affinity grouping
 do we start? (dissect and understand the processes)
• Cause and effect diagrams (Ishikawa or ‘fishbone’ diagrams)
• Tally sheets
• Pareto charts
• Flow (conceptual flow, decision flow) charts
• Run charts
• SPC charts
• Scatter charts
Tools for Engineering Change:
Cause-and-Effect Diagram
• sometimes also called a ‘fishbone’ or Ishikawa diagram
• graphically displays list of possible factors, focused on
one topic or objective
• used to quickly organize and categorize ideas during a
brainstorming session, often as an interactive part of the
session itself (the added organization can help produce
balanced ideas during a brainstorming session)
Cause-and-Effect Diagram
Example: Adverse Drug Events (ADE)
Drug
Nurse
Ordering Physician
Administration
Physician Errors Pharmacy
Errors
Pharmacist Nurse/Clerk
Rate Transcribing
Dilution
Spelling
Route
Dosage
Place outcome here
Time Route
Nurse Scheduling
Order Missed
Wrong
Drug
Dose
Age
Weight
Unforeseen ADE
Psychiatric Gender Expected
Drug/Drug
Renal
Cognitive Electrolyte
Drug/Food Pharmacokinetics
Past Allergic
Compliance Hepatic Reaction
Drug/Lab
Absorption Pharmacodyamics
Race
Patient Physiologic Pharmocologic

Errors Factors Factors Pharmacist
Patient
Patient Physician
Dietician
Pareto Chart
• graphical display of the relative weights or frequencies of competing
events, choices, or options
• a bar chart, sorted from greatest to smallest, that summarizes the
relative frequencies of events, choices, or options within a class
• often includes a cumulative total line
• used to focus within a broad category containing many choices, based
on factual or opinion-based information
• can combine factors that contribute to each item's practical
significance
Pareto Chart
Causes Contributing to Adverse Drug Events
100
90
80
70
60
Contributing
Percent
50
40
30
20
10
0
Causes
Causes
Sketching Processes or Flow
• Macro Process Maps

• Decision Flow Diagrams
The patient is Macro Process Map
admitted to the
hospital
Example: Heart Failure Core Measures 2-3
The patient is
clinically identified
as having heart
failure
The patient is The patient is

prescribed an ACEI prescribed an ACEI
The ejection fraction in hospital at discharge
is evaluated
The ejection fraction
< 40%
is documented in the
The contraindication
chart The patient is not
for an ACEI is
prescribed an ACEI
documented in the
in hospital
chart
> 39%
The patient is
excluded from the
target population
Decision Flow Diagram
Deep Post-Op UTI Pneumonia Bacteremia Other
Wound Infection
Contributing layer dissected: Contributing layer dissected:

Prevention Prevention Prophylactic Antibiotics
Patient Prophylaxis
Prevention Preparation
Patient
Selection
Prophylactic
Antibiotics
Detection Antibiotic
Selection
- Duration
Surgery
- Sterile Technique
- Operative Findings
Treatment
Delivery
- Timing
For iatrogenic infections, any Post-Op
given type of infection can be Wound Care Calling out the contributing layers
dissected into the hierarchy of helps the team think through the steps
contributing layers. ripest for change.
Run Charts
• Our brains understand graphics better than tables
• Tabular information doesn’t convey trends over time very
well
• Keep it simple
• In center of horizontal axis place: baseline mean
performance
• In center of vertical axis place: implementation point
• Can add upper and lower control limits, but usually not
needed
Run Charts
Percent Sliding Scale Insulin Only
80
70
60
50 10/20/03
Percent
New Order Set
40
30 01/20/04
CPOE - TH
20
10
0
03
04
03
04
03
04
03
04
2
3
2
3
-0
-0
-0
-0
n-
n-
g-
g-
b-
b-
r-
r-
ec
ec
ct
ct
Ap
Ap
Ju
Ju
Au
Au
Fe
Fe
O
O
D
D
Run Charts
Percent with Frank Hypoglycemic Events
16
14
12
10
Percent
8
10/20/03
New Order Set
6
March 2003
4 Team Forms CPOE
TH - 1/04
HC - 8/04
2
0
03
04
03
04
03
04
05
03
04
2
4
2
4
-0
-0
-0
-0
-0
-0
n-
n-
g-
g-
b-
b-
b-
r-
r-
ec
ec
ec
ct
ct
ct
Ap
Ap
Ju
Ju
Au
Au
Fe
Fe
Fe
O
O
D
D
Run Charts
Percent with Optimal/Acceptable Glucose Readings
100
90
80
70
60
Percent
10/20/03
50 New Order Set
CPOE
March 2003
Team Forms TH - 1/04
40 HC - 8/04
30
20
10
0
03
04
03
04
03
04
05
03
04
2
4
2
4
-0
-0
-0
-0
-0
-0
n-
n-
g-
g-
b-
b-
b-
r-
r-
ec
ec
ec
ct
ct
ct
Ap
Ap
Ju
Ju
Au
Au
Fe
Fe
Fe
O
O
D
D
Engineering Change:
The Multidisicplinary Team Asks “How?”
• How?
 can you make it easy to do the right thing?
• You cannot destroy productivity
– Changes must maintain, or enhance, workplace efficiency or balance
• You must devote as much attention to fitting changes into clinical

work flow as you do to the evidence-based guideline
– Changes must be blended into the flow of clinical care
– Important variables to consider: staffing, training, supplies, physical
layout, information flow, and educational materials
Engineering Change
Improve incrementally. Learn through action.
Plan Do Study Act

PDSA PDSA  PDSA  PDSA PDSA  PDSA
Test your changes. Assess their effect.

Then re-work the changes and do it again…and again…
Engineering Change:
PDSA
(the Benefits of Repeated Cycles)
• Increases belief that change will result in

improvement
• Allows opportunities for “failures” without
impacting performance
• Provides documentation of improvement
• Adapts to meet changing environment
• Evaluates costs and side-effects of the change
• Minimizes resistance upon implementation
Engineering Change:
PDSA
• Overview:
 scientific method for action-oriented learning:
shorthand for testing a change in the real world setting
 test a change by: planning it, trying it, measuring its
results… and then trying to do it better the next time
 multiple rounds of changes – some failures and some
successes - should lead to improved aggregate
outcome
Engineering Change:
PDSA
• Principles for Success:
 start new changes on the smallest possible scale, e.g.
one patient, one nurse, one doctor
 run just as many PDSA cycles as necessary to gain
confidence in your change – then expand
 expand incrementally to more patients
 expand to involve more nurses, more doctors, more
departments
 balance changes within system to ensure other
processes not adversely stressed
What do we want to achieve?
What changes will drive our progress?
How will we measure our progress?
How should we modify our latest changes?
modified from: The Foundation of Improvement by Thomas W. Nolan et. al

Engineering Change
What do we want to achieve?

Set an outcome aim.
(It should be ambitious, must be measurable and must
specify a time-period and a definite population in your
hospital.)
List the outcome aim again, then:

– ask “why” three times, “Function
– ask “how” three times,
– look at the new aim statements, and
Expansion”
– pick the best one

Engineering Change
What changes will drive our progress ?

Select change(s) to your system, the one(s) most likely to
improve outcomes.
(Recognize that not all changes improve outcomes or offer
balance.)

Engineering Change
Principles of Measurement:
Seek usefulness, not perfection.
Integrate measurement into the daily routine.
Use qualitative and quantitative data.
Use sampling.
Plot data over time.
How will we measure our progress?

Define what you will measure quantitatively.
(Collect data, chart measures regularly over specified
time-period, and chart against benchmarks & goal lines.)
Three Types of Measures:
1) Outcomes
2) Process
3) Balancing measures
(Use a balanced set of measures for all
improvement efforts.)
Engineering Change
How should we modify our latest changes?

Test your changes.
(Run PDSA cycles to learn from the work setting.)

Engineering Change:
Hints for Success
• Empower nursing
• Expedite order set and protocol passage through appropriate medical staff committees
• Better to implement an imperfect, compromise change than no change at all
• Pilot newest changes on smallest scale
• Provide hot line or support for difficult implementation situations
• Use your new system as a shared baseline, with clinicians free to vary based on individual patient
needs
• Follow metrics continuously as you implement
• Feed metrics back into subsequent PDSA cycles
• Measure, learn, and over time eliminate variation arising from professionals; retain variation arising
from patients
• Keep big picture in mind
• Negotiate ‘speed bumps’
 Time delays in getting data
 Incomplete buy-in
 Go around obstacles instead of through them (can always go back to them later)
 Some who disagree with you may be correct
 Make changes painless as possible: make it easy to do the right thing
QI Theory:
Quality Improvement in the Hospital
• Suggested next steps:

1) Share this primer in QI Theory with other hospitalists in
your group
2) Identify an important QI project at your hospital
3) Lead the QI project using all available resources
4) Learn from your experience and be among the first to
mentor other hospitalists
Use SHM’s topic-specific resource rooms to ask questions,

share experiences & tools, review the literature, and to
download presentations to help you educate others.
Acknowledgments
• Brent James, MD, MStat (Intermountain Health Care's Institute for
Health Care Delivery Research): concepts, content, figures
• Thomas Nolan, PhD (Institute for Healthcare Improvement): concepts,
content, figures
• Greg Maynard, MD, MSc (University of California, San Diego):
editorial composition and review
• Jason Stein, MD (Emory University School of Medicine): editorial
composition

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QI Theory:

Quality Improvement in the Hospital

How good is American healthcare?

We get it right 54% of the time.

• Complex process problems need multidisciplinary

• Meeting the needs and exceeding the

• Delivering all and only the care that the patient

Every system is perfectly designed to achieve

To improve the system, change the system…

You cannot destroy productivity

When changing the system, keep it simple

No. Probability of Success, Each Element

1 0.95 0.99 0.999 0.999999

• Change = not just doing something different, but

• Hospital Atmosphere = hospitals tend to be viscous,

Change engineered to drive improvement depends on…

EVIDENCE WORKPLACE CULTURE

 Hospital Administration  Medical Staff

Hospitalist Team Facilitator  EXPERIENCE

Successful Strategies Used By Others  Multidisciplinary Team Members 

“Bedside” Teaching Didactic Teaching Sessions

Task Load Culture of Improvement

Culture of Negative Expectations

The Multidisciplinary Team

THE MULTIDISCIPLINARY TEAM

Leverages frontline expertise and experience.

• Hospitals have two dynamic levels impacting

Structure Processes Outcomes of Care

Inputs Steps Outputs

•Patients •Inventory Methods •Physiologic

Patient Physiologic Pharmocologic

• Macro Process Maps

The patient is The patient is

Contributing layer dissected: Contributing layer dissected:

New Order Set

• You must devote as much attention to fitting changes into clinical

Improve incrementally. Learn through action.

Plan Do Study Act

Test your changes. Assess their effect.

• Increases belief that change will result in

What changes will drive our progress?

How will we measure our progress?

How should we modify our latest changes?

modified from: The Foundation of Improvement by Thomas W. Nolan et. al

What do we want to achieve?

List the outcome aim again, then:

modified from: The Foundation of Improvement by Thomas W. Nolan et. al

What changes will drive our progress ?

modified from: The Foundation of Improvement by Thomas W. Nolan et. al

How will we measure our progress?

How should we modify our latest changes?

modified from: The Foundation of Improvement by Thomas W. Nolan et. al

• Suggested next steps:

Use SHM’s topic-specific resource rooms to ask questions,

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