Topic 7

Introduction to methods for

quality improvement
 Learning objective

• the objectives of this topic are to:

– describe the basic principles of quality improvement

– introduce students to the methods and tools for improving the
quality of health care
 Performance requirement

• know how to use a range of improvement activities

and tools
 Knowledge requirements

• the science of improvement

• the quality improvement model
• change concepts
• two examples of continuous improvement methods
• methods for providing information on clinical care
 The science of improvement

• appreciation of a system
• understanding of variation
• theory of knowledge
• psychology
W Edwards Deming
 The Institute for Healthcare
Improvement (IHI): different measures
Measurement for research Measurement for learning
and process improvement

Purpose To discover new knowledge To bring new knowledge into

daily practice
Tests One large "blind" test Many sequential, observable
tests
Biases Control for as many biases as Stabilize the biases from test to
possible test

Data Gather as much data as possible, Gather "just enough" data to

"just in case" learn and complete another
cycle

Duration Can take long periods of time to "Small tests of significant

obtain results changes" accelerate the rate of
improvement
Three types of measures

• outcome measures
• process measures
• balancing measures
 The quality improvement model-the
PDSA cycle
• 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?
 The model for improvement

What are we trying to accomplish?

How we will know that a change is an improvement?

What change can we make that will result in an improvement?

ACT PLAN

STUDY DO

Langley, Nolan, Nolan, Norman & Provost 1999

 The PDSA cycle

Determines what
Change or test
changes are to be made

ACT PLAN

STUDY DO

Summarizes what
Carry out the plan
was learned

Langley, Nolan, Nolan Norman & Provost 1999

 Change concepts …

… are general ideas, with proven merit

and sound scientific or logical foundation
that can stimulate specific ideas for
changes that lead to improvement.

Nolan & Schall, 1996

 9 categories of change

• eliminate waste
• improve work flow
• optimize inventory
• change the work environment
• enhance the producer/customer relationship
• manage time
• manage variation
• design systems to avoid mistakes
• focus on the product or service
Langley, Nolan, Nolan, Norman & Provost 1999
 Two continuous improvement
methods
• clinical practice improvement methodology (CPI)
• root cause analysis
 The improvement process

Project mission
Ongoing monitoring
Project team
Outcome
Future plans
Project Conceptual flow of
phase process
Sustaining
improvement Customer grid
phase Data
1 -fishbone
1 month 5
Diagnostic -Pareto chart
Annotated Impact 2 -run charts
4 phase
run chart phase -SPC charts
SPC charts
3
Intervention
A phase 2 months
S P D S
2 months D S A Plan a change
A P A
D P A S P Do it in a small test
S P D Study its effects
D Act on the result

Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(
www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

SPC – statistical process control

 Interventions phase
Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

Identify appropriate interventions

Implement changes identified in the diagnostic phase
Undertake one or more PDSA cycles

Interventions phase
Decide on interventions

Undertake one or more PDSA

cycles
 How to use the PDSA Cycle

• use plan-do-study-act cycles

to conduct small-scale tests ACT PLAN
of change in real settings • What changes
can be made for
• Objective
• Prediction
– plan a change the next cycle
(adapt change, • Plan for change (who,
another test, what, when, where)
– do it in a small test implementation
cycle?)
• Plan for data collection
(who, what, when, where)
– study its effects
STUDY DO
– act on what learned • Complete analysis
of data • Carry out the change

• team uses and links small • Compare results

to predictions
• Document observations
• Record data
PDSA cycles until ready for • Summarize
knowledge gained

broad implementation

NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement

(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
 PDSA cycle - single test

PDSA Cycles – single test

D S Changes that
S result in
A P A improvement
A D
P
S P
A P
D
S D
Hunches,
theories
and ideas

Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement
(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
 PDSA cycle – multiple tests

D S D S D S

P A P A P A

S S S
D A D A D A
P P P

A P A P A P
S D S D S D

Test 1 Test 2 Test 3

PDSA Cycles – multiple tests

NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement

(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
Impact and implementation phase

1. Measure impact of changes/interventions

2. Record the results
3. Revise the interventions
4. Monitor impact

Impact and implementation phase

Measure impact • Annotated run chart

• SPC charts
• Other graphs

Implement the changes

NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement

(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
Sustaining the improvement phase

Sustaining
1. Once an intervention has been
introduced, the intervention and any improvement phase
improvements need to be sustained
2. This may involve:
• standardization of existing
systems and processes
• documentation of policies,
procedures, protocols and
guidelines
• measurement and review of • standardization
interventions to ensure that Sustain the gains
change becomes past of • documentation
“standard” practice
• training and education of staff • measurement
• training

NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement

(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)
 Root cause analysis

• a multidisciplinary team
• the root cause analysis effort is directed towards finding
out what happened
• establishing the contributing factors of root causes
 Performance requirements

Know how to use a range of improvement activities and tools

• flowcharts
• cause and effect diagrams (Ishikawa/fishbone)
• Pareto charts
• run charts
 Evidence for there being
a problem worth solving
14
12
10
8
LOS days
6
4
2
0
Hospital NSW Health Kehlet et.al

At the same time LBH executives and staff expressed a desire to improve LOS.

NSW – New South Wales.

Flow chart of process
Accelerated Recovery Colectomy Surgery (ARCS)
Jenni Prince
Area CNC Pain Management
North Coast Area Health Service
NCHI Sydney Australia

Something amiss

Visit to general Post anaesthetic care Surgical ward

practitioner

Investigations Operating theatre Allied health Surgical team

Pain team
Referral to surgeon Pre-op ward Discharge planner

Referral to Hospital Admitted to hospital

Community health/
Peripheral hospital
Hospital admission Preoperative clinic

Return to life Home

Admissions office
 Customer and expectations list

• surgical ward staff Multidisciplinary meeting to:

• post-op anaesthetic care staff -ask opinion
• physiotherapy dept -brainstorm process of care
-how to improve the process
• dietitian
• peri-operative unit staff -who to include in the process
• of change
private hospital staff
• pain team -how to communicate progress
• anaesthetists standardization
• surgeons Evidence-based
• intensivist practice
team approach
 Accelerated Recovery Colectomy Surgery (ARCS)
Jenni Prince

Cause and effect diagram

Area CNC Pain Management
North Coast Area Health Service
NCHI Sydney Australia

Social issues Staff attitudes Complications

LOS poor pain control
home support
mobilization wound complications
often weak pain control
family support weak/malnourished
nutrition
infection
Prolonged
LOS
nutrition expect long LOS
mobilization poor understanding of
procedure general practitioner
nil by mouth
surgery little knowledge of community health
support services family
pain control
locus of control colon care nurse
Procedure
Patient perception Post discharge support
 Pareto chart

45
40 100
45 80
35
76
30 67
57 38
25 34

20 42 28

15
18
10 16
24 5 8
0
l s ts
ge tro de rge iliz
e n e tc
le d co
n itu ch
a b tie
ow att s
om
o pa
kn a in f f d i
t ed
en
t
ed
p sta te d w sh
a ti iz d ina slo uri
r p a rd d de o rd
e rn o
p oo a nd be co nd
-st im ly u
n or
no po
 PDSA cycles - implementation
1
 surgical incision trial of transverse incision surgeon
 pain control wound infusion for transverse incisions 10
patients

then

• patient information booklet

• surgeon pathway
• anaesthetic pathway
• ARCS clinical pathway - surgical technique 1
surgeon
- pain control 1-6
- bowel prep/care patients

- nutrition
- mobilization
 Run chart

Average LOS (days) per month

60
50
40 Made change here
days

30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12
m onth
 Strategies for sustaining
improvement
• document and report each patient LOS
• measure and calculate monthly average LOS
• place run chart in operating theatre, update run chart
monthly
• bimonthly team meetings to report positives and
negatives
• continuously refine the clinical pathways
• report outcomes to clinical governance unit
• Spread - all surgeons
- left hemicolectomy
- all colectomy surgery
- throughout North Coast Area Health Service