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Pamela S. Gillam, MPA
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Quality Quality ImprovementImprovement– What – What Is it and How Can It Help Is it and How Can It Help
Me?Me?Pamela S. Gillam, MPAPamela S. Gillam, MPA
OBJECTIVES:OBJECTIVES:
Recognize the definition of Quality Recognize the definition of Quality Improvement (QI)Improvement (QI)
Understand the difference b/w QI and Understand the difference b/w QI and Quality Assurance (QA)Quality Assurance (QA)
Demonstrate the use of the Model for Demonstrate the use of the Model for Improvement/PDSA CycleImprovement/PDSA Cycle
Why You Should Care About QIWhy You Should Care About QI
If you plan to be a:If you plan to be a: Health Educators- It is an effective approach for Health Educators- It is an effective approach for
implementing evidence based practices!implementing evidence based practices! Researcher-- Evaluation is a required Researcher-- Evaluation is a required
component of most research grants and QI component of most research grants and QI enhances it; Funders (Feds!) are counting on itenhances it; Funders (Feds!) are counting on it
Administrator– Hospitals are using it; Administrator– Hospitals are using it; Reimbursement depends on it; many Reimbursement depends on it; many organizations are in desperate need for it!!!!organizations are in desperate need for it!!!!
What is Quality?What is Quality?
American Society for Quality (ASQ) American Society for Quality (ASQ) definition—definition—
1. the characteristics of a product or service 1. the characteristics of a product or service that bear on its ability to satisfy stated or that bear on its ability to satisfy stated or implied needs; implied needs;
2. a product or service free of deficiencies. 2. a product or service free of deficiencies.
“Fitness for Use”- Joseph Juran “Conformance to Requirements”- Philip Crosby
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What is Quality?What is Quality?
Quality is a never-ending Quality is a never-ending cycle of continuous cycle of continuous
improvement.improvement.
-Deming
66
The Quality JourneyThe Quality Journey
Quality Assurance
Quality Improvement
Rapid Cycle Quality Improvement
77
Quality Alphabet SoupQuality Alphabet Soup
lean
Quality ImprovementQuality Improvement
Aimed at improvement -- measuring where Aimed at improvement -- measuring where you are, and figuring out ways to make you are, and figuring out ways to make things betterthings better
Specifically attempts to avoid attributing Specifically attempts to avoid attributing blameblame
Attempts to create systems to prevent Attempts to create systems to prevent errors from happeningerrors from happening
Models for QIModels for QISix Sigma (6s) Lean Model for Improvement
Focus on Critical-to-Customer Quality Focus- Identify Value
Focus- Improvement through Small Scale Testing
Focus- Culture and Infrastructure Eliminate Waste Test ideas to meet overarching goals
Reducing VariationIncrease Processing Speed/Reduce WIP
Test ideas under a variety of conditions
Remove Causes of Defects Process Mapping, Takt time PDSA
DMAIC, Cpk
Use this when you have ideas of what can be done or adapting EBP
Use this when you don't know what to do
Common across all three:Need to understand the process flows
Need to understand the overall goal and strategy of Operations Need for leadership and organizational buy-in
Importance of the “voice of the customer” (internal and external)Need for data and measurements, i.e., evidence-based changes
Use of teams
Common QI ToolsCommon QI Tools
Control Charts, Pareto Charts, GANTT Control Charts, Pareto Charts, GANTT chartscharts
Plan Do Study Act (PDSA) CyclePlan Do Study Act (PDSA) Cycle Root Cause Analysis- Ishikawa/Fishbone Root Cause Analysis- Ishikawa/Fishbone
DiagramDiagram Nominal Group TechniqueNominal Group Technique Flow chartsFlow charts FMEAFMEA
QI is QI is ALWAYS ALWAYS
about about THE THE
CUSTOMER!!!CUSTOMER!!!
An Integrated Approach To ImprovementAn Integrated Approach To Improvement
Top down
Bottom up
Leadership level• Determine aims• Identify resources (staff/$$)• Continuous support
Strategies for Improvement:
Make changes in other areas Use collaborative model in other areas Fundamental change in how the organization/division does business Local incremental improvements Control what’s going to happen
Local level• Understand capacity needs• Knows what will work/won’t work
Results
Reduce cost/improve productivity
Provide different/ new services
Improve quality
1313
QA vs. QIQA vs. QI
Quality AssuranceQuality Assurance Conform to Conform to
standardsstandards Relies on Relies on
inspectioninspection Focus on itemsFocus on items Quality is separate Quality is separate
functionfunction Departmental Departmental
functionfunction
Quality ImprovementQuality Improvement Improved Improved
performanceperformance Monitor over timeMonitor over time System orientationSystem orientation Quality integrated Quality integrated
in organizationin organization Interdisciplinary Interdisciplinary
functionfunction
QA vs. QI (cont’d)QA vs. QI (cont’d)
Quality AssuranceQuality Assurance
Focus on improving Focus on improving
individual's faultsindividual's faults
ReactionaryReactionary
Use of “minimum” Use of “minimum”
standardsstandards
Time-limitedTime-limited
Quality ImprovementQuality Improvement
Focus on systems and Focus on systems and process improvementprocess improvement
Proactive Proactive
Use of “benchmark” and Use of “benchmark” and “best practices”“best practices”
ContinuousContinuous
Short Example of QI vs. QAShort Example of QI vs. QA
From the following statements, which do you think From the following statements, which do you think have a QA focus and which have a QI focus?have a QA focus and which have a QI focus?
1. 1. Which staff member failed to transfer the call to the Which staff member failed to transfer the call to the correct extension? correct extension?
2.2. Are we creating an environment encouraging clinicians Are we creating an environment encouraging clinicians to report errors?to report errors?
3.3. How do we reduce billing errors by our staff?How do we reduce billing errors by our staff?
4. 4. Patient had a bad outcome; were the doctors or Patient had a bad outcome; were the doctors or nurses at fault? nurses at fault?
5. 5. What could we do to increase the efficiency of chart What could we do to increase the efficiency of chart filing?filing?
The Model for The Model for ImprovementImprovement
Testing Testing
and Implementing and Implementing ChangesChanges
Model for Improvement
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?
Act Plan
DoStudy
From: Associates in Process Improvement
AIM
MEASURE
CHANGES
Aim StatementAim Statementaka “What are you trying to aka “What are you trying to
improve?”improve?” Involve senior leadersInvolve senior leaders Focus on issues that are important to your Focus on issues that are important to your
organizationorganization Connect the team Aim statement to the Connect the team Aim statement to the
Strategic PlanStrategic Plan Build on the work of others (Steal Build on the work of others (Steal
Shamelessly!)Shamelessly!)
Measures- 3 TypesMeasures- 3 Types
1.1. Outcome MeasuresOutcome Measures- Voice of the Customer. How - Voice of the Customer. How is the system performing? What is the result?is the system performing? What is the result?
2.2. Process MeasuresProcess Measures- Voice of the workings of the - Voice of the workings of the system. Are the parts/steps in the system system. Are the parts/steps in the system performing as planned?performing as planned?
3.3. Balancing MeasuresBalancing Measures- Looking at a system from - Looking at a system from different directions. What happended to the different directions. What happended to the system as we improved the outcomes/process system as we improved the outcomes/process (e.g. unanticipated consequences, other factors (e.g. unanticipated consequences, other factors influencing outcome)?influencing outcome)?
ChangesChanges
Practices from other industriesPractices from other industries Evidence-based PracticesEvidence-based Practices Promising PracticesPromising Practices Ideas from staffIdeas from staff
Model for Improvement
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?
Act Plan
DoStudy
From: Associates in Process Improvement
AIM
MEASURE
CHANGES
PDSA Cycle for Learning and PDSA Cycle for Learning and Improvement: Use it All!Improvement: Use it All!
Plan• Objective
• Questions and Predictions (Why?)
• Plan to carry out the cycle (who, what, where, when)
Do• Carry out the plan• Document problems
and unexpected observations
• Begin analysis
of the data
Study• Complete the
analysis of the data
• Compare data to predictions
• Summarize what was learned
Act• What
changes are to be made?
• Next cycle?
What will happen if we
try something different?
Let’s try it!!Did it work?
What’s next?
Use the PDSA Cycle for :Use the PDSA Cycle for :
Testing or adapting a change Testing or adapting a change ideaidea
Implementing a changeImplementing a change
Spreading the changes to the Spreading the changes to the
rest of your systemrest of your system
Why Test?Why Test? Increase your belief that the change will Increase your belief that the change will
make improvementmake improvement Predict how much improvement you can Predict how much improvement you can
expect from the changeexpect from the change Learn how to adapt the change in your Learn how to adapt the change in your
settingsetting Figure out the costs and side-effects of the Figure out the costs and side-effects of the
changechange Minimize resistance upon implementationMinimize resistance upon implementation
To be considered a real testTo be considered a real test
Test was planned, including a plan for Test was planned, including a plan for collecting datacollecting data
Plan was carried out and data were Plan was carried out and data were collectedcollected
Time was set aside to analyze data and Time was set aside to analyze data and study the resultsstudy the results
Action was based on what was learnedAction was based on what was learned
Repeated Use of the PDSA CycleRepeated Use of the PDSA Cycle
Hunches Theories
Ideas
Changes That Result in
Improvement
A P
S D
APS
D
A P
S D
D SP A
DATA
Very Small Scale Test
Follow-up Tests
Wide-Scale Tests of Change
Implementation of Change
Aim: Aim: Reduce smoking rates by implementing Reduce smoking rates by implementing the 2 A’s and R CPG standardthe 2 A’s and R CPG standard
Conducting 2 A’s and R will
increase Fax Referrals
Reduced Smoking Rate
A P
S D
APS
D
A PS D
D SP A
DATAD S
P A
Cycle 1: Test the 2 A’s and R with 5 patients on Tuesday.
Cycle 2: Change forms, process.
Cycle 3:
Cycle 4: Standardize process
Cycle 5: Educate staff in new process
Test new form, process with 10 patients.
Let’s practice!!!Let’s practice!!!
