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 (most patient care outcomes or services result

from a complex system of interaction between health-care professionals, treatment
procedures and medical equipment) it is important to understand the
interdependencies and relationships among all of these components, increasing the
accuracy of predictions about any impact that changes may have on the system.
• understanding of variation(Variation is the differences between two or
more similar things such as different rates of success for appendectomies in two
W Edwards Deming
different parts of the country, . Shortages of personnel, drugs or beds can lead to
variations of care
• theory of knowledge (requires us to make predictions that any changes we
make will lead to an improvement, Predicting the results of a change is a necessary
step to enable a plan to be made even though the future is certain

• Psychology (The last component is the importance of understanding the

psychology of how people interact with each other and the system. Making a change
whether it is small or large will have an impact and knowledge of psychology helps to
understand how people might react, and why they might resist change.

• Measurement is an essential component of quality improvement because it

forces people to look at what they do and how they do it. Most activities in
health care can be measured, yet currently they are not. There is strong
evidence to show that when people use the appropriate Quality
improvement activities require health professionals to collect and analyze
data generated by the processes of health care
 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: Examples of outcome measures
include patient satisfaction surveys
-Some specific examples include:
-access: time waiting for surgery
-critical care: number of deaths in the emergency department;
- medication systems: the number of medication dosing or administration
errors

* When there’s uncertainly about the outcome of the process with presence of
guidelines and experienced staff, the process is considered complex
• process measures:refer to measurements about the workings of the
system. These measures are usually used when a clinician or manager
wants to find out how well a part or aspect of a health service or system is
working or being performed.
-Some specific examples:
-access: number of days the ICU is full and has no spare beds;
-surgical care: number of times swab count completed

• balancing measures: This measure is used to ensure that any

change does not create additional problems. It seeks to examine the service
or organization from a different perspective
-A specific example is:
-reducing the length of stay in hospital: ensure readmission rates are not
increasing.
 The quality improvement model-the
PDSA cycle
• The quality improvement model is a combination of building and
applying knowledge to make an improvement by asking three
questions and using the PDSA (plan, do, study,act) cycle developed
by Deming.

• What are we trying to accomplish?

The idea behind this question is to guide and focus the efforts of the health-
care team doing the improvement. It is important that the team agrees that a
problem exists and that it is worthwhile fixing.

• How will we know that a change is an improvement?

An improvement can only be confirmed when the measures show things were
improved over time
• What changes can we make that will result in an
improvement?
• This last question involves the team testing the different
interventions used to make the improved over time.
• Their version of quality improvement is different from other change
models in that it seeks to accelerate improvement. Hundreds of
health-care organizations have successfully used the model to
improve healthcare processes and outcomes.
 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

• One of the rules of quality improvement is regular testing
of any changes introduced because unexpected things
may happen. The cycle begins with a plan and ends with
an action. The study section is designed to build new
knowledge.

• The application of the model can be simple or complex,

formal or informal. It can be used to improve waiting
times in the clinic or decrease surgical infection rates in
theatres. A formal improvement activity may require
detailed documentation, more complex tools for data
analysis or more time for discussion and team meetings.
The PDSA model depends on a format that repeats
steps over and over until an improvement has been
effected and sustained.
 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: Look for ways of eliminating any activity or resource
in the hospital or clinic that does not add value to patient care
• improve work flow:Improving the flow of work in processes is an
important way to improve the quality of patient care delivered by
those processes
• optimize inventory: Inventory of all types is a possible source of waste
in organizations
• change the work environment
• enhance the producer/customer relationship
• manage time:An organization can get more achieved by reducing
the time to deliver health care, develop new ways of delivering
health care, reducing waiting times for services and cycle times for
all services and functions in the organization
• manage variation: Reducing variation improves the predictability
of outcomes and helps reduce the frequency of adverse outcomes
for patients.

• design systems to avoid mistakes: Organizations can reduce

errors by redesigning the system to ensure that there is redundancy
i.e. multiple checks and balances to combat human error.

• focus on the product or service: service Although many

organizations focus on ways to improve processes, it is also
important to address improvement of products and services
Example: change concept
• A health-care team may want to adhere to the WHO protocol Clean hands
are safer hands. Infection control is a good idea and the WHO guidelines
are based on evidence, expert opinion and the literature. One could predict
that if the guidelines were implemented then an improvement would be
made, i.e. a decrease in the transmission of infection via hands.
Implementing a guideline is an example of an abstract concept.
 Two continuous improvement
methods
• clinical practice improvement methodology (CPI): CPI
methodology is used by health-care professionals to improve the
quality and safety of health care

• root cause analysis: Many hospitals and health services are

now using a process called root cause analysis to determine the
underlying causes of adverse events or incidents. A root cause
analysis is used after an incident has occurred to uncover the
primary possible causes.
• A root cause analysis is a defined process that seeks to explore all
of the possible factors associated with an incident by asking what
happened, why it occurred and what can be done to prevent it from
happening again.
 The improvement process

Project mission
Ongoing
Project team
monitoring
Outcome
Future plans Project Conceptual flow
of process
Sustaining phase
improveme Customer grid
nt phase Data
1 -fishbone
1 month 5
Diagnosti -Pareto chart
Annotated Impact 2 -run charts
4 c phase
run chart phase -SPC charts
SPC
3
charts
Intervention
A phase 2
S P D S months
2 D S A Plan a change
A P A
months 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

ACT PLAN
• use plan-do-study-act cycles What• changes • Objective

to conduct small-scale tests can be made for the

next cycle (adapt
• Prediction
change, another • Plan for change (who,
of change in real settings test,
implementation
what, when, where)
• Plan for data collection
cycle?)
– plan a change (who, what, when,
where)

– do it in a small test
STUDY DO
– study its effects
• Complete
– act on what learned analysis of data • Carry out the change
• Document
• Compare
observations
• team uses and links small •
results to
predictions • Record data
Summarize
PDSA cycles until ready for 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)
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

• 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
improvements need to be sustained
2. This may involve:
phase
• standardization of existing
systems and processes
• documentation of policies,
procedures, protocols and
guidelines
•
• measurement and review of
interventions to ensure that Sustain the standardizatio
change becomes past of gains n
“standard” practice
• training and education of staff
•
documentatio
n
•
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: focuses deeply about the problem(s) and not

the solutions
• cause and effect diagrams (Ishikawa/fishbone): a cause
and effect diagram helps the team to stay focused on all of
the possible causes rather then fixate on the one cause
• Pareto charts :” to describe a large proportion of quality
problems being caused by a small number of causes
• run charts: . A run chart helps the team know if a change
is an improvement over time
 Evidence for there being
a problem worth solving

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 Surgical ward

practitioner care

Investigations Operating theatre Allied

Surgical team
health
Pain team
Referral to Pre-op ward Discharge planner
surgeon

Referral to Admitted to
Community health/
Hospital hospital
Peripheral hospital
Hospital Preoperative
admission clinic
Return to life Home
Admissions office
 Customer and expectations list

• surgical ward staff Multidisciplinary meeting

to:
• post-op anaesthetic care staff
• physiotherapy dept -ask opinion
-brainstorm process of
• dietitian care
• peri-operative unit staff -how to improve the
• private hospital staff process
• pain team -who to include in the
• anaesthetists process of change
• surgeons -how to communicate
• intensivist progress
standardization
Evidence-based
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 Staff attitudes Complications

issues
LOS poor pain control
home support
mobilization wound complications
often weak pain control
family support weak/malnourished
nutrition
infection

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

100
80
76
67
57

42

24
 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 condition
• measure and calculate monthly average cases
• 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