Quality Improvement Models: PDSA
- 1. Quality Improvement Models: PDSA Rebecca S. (Suzie) Miltner, PhD, RN Associate Professor, School of Nursing
- 2. UAB Mission To improve the health and well-being of society, particularly the citizens of Alabama, by providing innovative health services of exceptional value that are patient- and family-centered, a superior environment for the education of health professionals, and support for research that advances medical science.
- 3. UAB Mission To improve the health and well-being of society, particularly the citizens of Alabama, by providing innovative health services of exceptional value that are patient- and family-centered, a superior environment for the education of health professionals, and support for research that advances medical science.
- 4. And we have opportunities for improvement…
- 5. Opportunities for improvement… Admission process/Bed assignment Equipment availability Training and competency Prioritization Supervision/Oversight
- 6. In the “past”… People were disciplined (maybe terminated) New rules came down from managers/leaders Everyone had to sign the inservice sheet as a record that they knew the new policy. No changes within system…just waiting for the next incident.
- 7. What do you do to change a process to make it better?
- 8. The Quality Foundation Avedis Donabedian, MD, MPH (1919-2000) Father of quality assessment Structure-process-outcome framework for QI and health services research Famous quotes: “People have a big problem understanding the relationship between quality and systems. System management doesn’t get taught in medical school or nursing school.’’ ‘‘There’s lip service to quality and, goodness knows, propaganda, but real commitment is in short supply.’’ ‘‘Systems awareness and systems design are important for health professionals, but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system’s success. Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession, you have to love your God. If you have love, you can then work backward to monitor and improve the system.’’
- 9. What IS Quality Improvement? -9-
- 10. What IS Quality Improvement? Quality Improvement is a data-driven, formal approach to the analysis of performance and the systematic efforts to improve it.
- 11. What IS Quality Improvement? The combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners, administrators, educators – to make changes that will lead to better patient outcomes, better system performance, and better professional development. -11- Batalden P, Davidoff F. Qual. Saf. Health Care 2007;16;2-3
- 12. Quality Improvement: Bridging the Implementation Gap Implementation Gap Scientific understanding Patient care Progress Time
- 13. 13 Rubenstein, L. & Pugh, E. 2006. Strategies for Promoting Organizational And Practice Change by Advancing Implementation Research. Journal of General Internal Medicine, 21, S58-64. What is Quality Improvement?
- 15. Frameworks or Models? Essentially, all models are wrong, but some are useful. Box, George E. P.; Norman R. Draper (1987). Empirical Model- Building and Response Surfaces, p. 424, Wiley. ISBN 0471810339.
- 16. Why Use Frameworks or Models? System of rules, ideas or beliefs that is used to plan or decide something A supporting structure around which something can be built A way to operationalize abstract concepts Visually depict how something should work Frame of reference and common language when working in a group
- 17. Improvement Models Plan-Do-Study-Act (PDSA) Total Quality Management/Continuous Quality Improvement Model for Improvement Six Sigma Lean / Toyota Production System Lean Six Sigma 17
- 18. The Quality Foundation Walter Shewhart (1891 – 1967) Western Electric Co. Variation and statistical control Designed to assist Bell telephone in their efforts to improve reliability and reduce frequency of repairs Developed the Plan-Do-Check-Act (PDCA) cycle
- 20. 20 FOCUS-PDSA ► Focus Find an opportunity ► Organize A team ► Clarify Understand process / problem ► Understand Variation, root causes, barriers ► Select Opportunity and strategy ► Plan Intervention ► Do Intervention ► Study Measure the results ► Act To hold gains continue to improve
- 22. What is Lean? Goes by many names (e.g. Lean manufacturing, Toyota Production System Key theory is removal of waste Emphasis is on work flow Key steps Identify which features create value Identify the sequence of activities called the value stream Let the customer pull the product or service through the process Perfect the process 22 Bevan et al, (2005). Lean Six Sigma: Some Basic Concepts. NHS Institute for Innovation and Improvement
- 23. Method developed in industry at Motorola in the 1980s under the leadership of Bob Galvin. Won the Baldrige Award in 1988. Further popularized by General Electric under Jack Welch and became the company’s operating strategy in 1995. Goal is to achieve defect-free performance at the level of 3 or fewer defects per million (6 sigma) What is Six Sigma?
- 24. Sigma calculation is related to number of defects. 6 sigma = 3 defects per million (99.99966%) 5 sigma = 233 defects per million (99.98%) 4 sigma = 6210 defects per million (99.4%) 3 sigma = 66807 defects per million (93.3%) 2 sigma = 308537 defects per million (69.1%) 1 sigma = 691462 defects per million (30.85%) Goal for any individual measure is set (specification limit) and this is used to determine if there is a defect or not. Six Sigma Measure
- 25. Lean and Six Sigma 25 Specify Value Understand Demand Flow Level Perfection Improved efficiency and speed Lean: Focuses on dramatically improving flow in the value stream and eliminating waste. Six Sigma: Focuses on eliminating defects and reducing variations in processes. Define Measure Analyse Improve Control Improved effectiveness Bevan et al, (2005). Lean Six Sigma: Some Basic Concepts. NHS Institute for Innovation and Improvement
- 26. Lean Six Sigma Combines lean and six sigma concepts Define, measure, analyze, improve, control Sigma yield decreases as complexity increases, so first reduce complexity (steps in the process), then improve sigma per part or step
- 27. Comparison of different models 27
- 28. Quality Improvement Quality Improvement is a data-driven, formal approach to the analysis of performance and the systematic efforts to improve it.
- 29. Plan Do Study Act Identify a problem Organize a team Define the process Understand process performance - data Choose a process change • This framework serves as the basis for most improvement methodologies • QI tools are the enablers for these components. They allow efficient, effective completion. • QI is a team sport. All stakeholders are key to understanding the process and choosing rational interventions
- 30. 30 CQI elements Key features systematic data guided activities designing with local conditions in mind iterative development Rubenstein et. al. 2013. How can we recognize CQI?
- 31. Improvement Tools Team building Group decision making techniques Brainstorming Affinity diagrams Multi-voting Nominal group technique Process mapping Aim statements Developing measures (metrics) Analyzing (and displaying) data Tests of change (PDSA) 31
- 34. 34 PDSA Cycle Plan Define the aim, question, and predictions Plan your data collection to answer the questions Do Try out the change idea and collect data Study Analyze the data and compare to your predictions Act Plan the next cycle Can you implement the change?
- 35. 35 Stage Description Steps Plan Plant the test or observation, including a plan for collecting data. 1) State the object of the test. 2) Make predictions about what will happen and why. 3) Develop a plan to baseline the current process and test the change. (Who? What? When? Where? What data need to be collected?) Do Try out the test on a small scale 1) Carry out the test. 2) Document problems and unexpected observations. 3) Begin analysis of the data. Study Analyze the data and study the results. 1) Complete analysis of the data. 2) Compare the data to your predictions. 3) Summarize and reflect on what was learned. Adapt, Adopt or Abandon? Act Refine the change based on what was learned from the test. 1) Determine what modifications should be made. 2) Prepare a plan for the next test. PDSA Cycle
- 36. PDSA Cycle Example Note: • Prediction • Measures • Responsible Persons
- 37. P D S A Ideas Changes in the system resulting in improvement Modify the protocol and make it standard practice Use the protocol with all the patients Modify the protocol and try with other patients Create a protocol and try with a few patients PDSA Cycles: Iterative Process
- 38. Tomolo A M et al. Qual Saf Health Care 2009;18:217-224 Revised conceptual model of rapid cycle change.
- 39. LEARNING BY DOING An improvement simulation exercise *Thanks to my colleague, Brant Oliver, PhD, MS, MPH, at the Dartmouth Institute
- 40. Learning Objectives After completing this simulation exercise, participants will be able to: (1) describe the IHI Model for Improvement, including the Plan-Do-Study-Act Cycle; (2) conduct simple PDSA cycles in a simulated environment; (3) create simple data displays for performance measurement; and (4) describe and interpret Run Charts.
- 41. In this exercise we will simulate the model for improvement… IHI (2004)
- 43. Simulation Exercise: Mr. Potato Head A scene from “Toy Story” (Pixar Studios) Credits: • Original program: Institute for Healthcare Improvement (IHI), Cambridge, MA (2004) • Adapted by Steve Harrison, Sheffield MCA, Sheffield, UK (2013) • Adapted for collaborative simulation with real time measurement dashboard and registry (B. Oliver, 2015, 2016) & playbook (M Godfrey (2015).
- 44. Imagine that building Mr. Potato Head is improving the quality of falls prevention in an academic medical center... 0 2 4 6 8 10 12 14 16 Jan-… Mar… May… Jul-04 Sep… Nov… Jan-… Mar… #MeetingCriteria # Patients Meeting Criteria 20 30 40 50 60 70 80 Jan-04 Mar-… May… Jul-04 Sep-… Nov-… Jan-05 Mar-… %MeetingCriteria % Of Patients Meeting Criteria
- 45. Your Evidence Based Practice Bundle of Care: Potato Head
- 46. 46 What we aim to achieve… • “Build it right” (adhere to the evidence based practice guideline) • “Build it fast” (optimize access to care) • “Do it consistently” (optimize reliability) • “Continuously improve” (optimize value)
- 47. Facility Teams for the PDSA Simulation… • Unit Nurse Manager • Staff RN: Timer • Staff PCT: Recorder • PT/PharmD/MD: Observer(s)
- 48. Falls Prevention Program Components Hat = Risk Assessment Glasses = individual care plan Tongue = medication s Mustache = orthostatic HTN Nose = interprofessional team Right ear = mobility program Left ear = feet/footwear Eyes = vision Pants = hip protectors Left arm = environment Right arm = goal setting/feedback
- 49. We have to pretend! We can’t do all these interventions, so… Accuracy will represent getting the right preventive measures to the right patient Speed of putting the parts together will represent efficiency
- 50. How will we measure our success? Accuracy = score 0-3 How does the scoring work? Let’s figure that out! 0 = xxx 3 = xxx Speed = time measured with stopwatch on smart phone
- 51. We will simulate a facility level improvement collaborative… • 1 Baseline cycle and successive PDSA cycles • Simulate rapid cycle improvement in separate microsystems • Track performance (building speed and accuracy score) using Run Charts and descriptive displays • Cascade measures and simulate an improvement collaborative
- 52. P D S A Ideas Changes in the system resulting in improvement Modify the protocol and make it standard practice Once you are happy, try the set of interventions with all the patients Modify the interventions and try with more patients Try one set of interventions on 5 patients PDSA Cycles: Iterative Process
- 54. PDSA Plan Time Accuracy 1 Baseline 2 3 4 0 20 40 60 80 100 120 140 Time 0 0.5 1 1.5 2 2.5 3 Accuracy
- 55. Common Cause Variation caused by chance causes, by random variation in the system, resulting from many small factors. Example: Variation in work commute due to traffic lights, pedestrian traffic, parking issues. Special Cause Variation caused by special circumstances or assignable cause not inherent to the system. Example: Variation in work commute impacted by flat tyre, road closure, heavy frost/ice. Types of Variation Statistically significant 56
- 56. Common Cause Variation Reduce Variation (Increase Precision): Make the process even more reliable. Sub-Optimal Average Performance: Redesign process to get a better result. Special Cause Variation Identify the Cause: If Positive: “Maximize, optimize, replicate, or standardize.” If Negative: “Minimize or eliminate” 57 Application – Responding to Variation
- 57. Benchmarking helps to empower improvement collaboratives…
- 58. Potato Head “Best Practice” Flow Diagram to Standardize for Playbook
- 60. The “light” side
- 62. Final Thought: Our job is not only to DO our work, but also to IMPROVE our work – ultimately to improve patient care quality. -Paul Batalden