1. Introduction to Quality
Introduction to QualityImprovement
Improvement
Ahmad Thanin
Ahmad Thanin

2. Objectives
0 To gain an understanding of what quality
improvement is
0 To present the Model for Improvement and PDSA
cycle
0 To introduce measurement in quality improvement
0 To introduce flowcharts

3. What is Quality
Improvement?
0 A formal approach to the analysis of performance and
systematic efforts to improve it
0 Different from Quality Assurance

4. Quality Improvement versus
Quality Assurance
Quality Improvement Quality Assurance
What can we do to improve? What went wrong?
Proactive Reactive
Avoids blame Often Punitive
Fosters System change Tries to find who was at fault
Focuses on the entire
system
Focuses on the specific
incident

5. What is quality?
0 Definition of quality depends on stakeholders
0 The client/customer (the patient)
0 The provider/employer (health care providers)
0 Management (hospital management)
0 Payer (Ministry of Health)

6. 6 Pillars of Quality
0 Safety
0 Timely Access
0 Equitable
0 Efficacy
0 Efficient
0 Patient Centered

7. “Every system is perfectly
designed to get the results it
gets”
0 How can you improve a system to achieve better results
in the 6 pillars of quality?

8. To improve a system…
0 You need a good understanding of the system
0 You need to understand where it is failing -
Identify what is wrong
0 Make sure it is the step that needs fixing
0 Then you can implement a change to the “system”

9. What is a system?
0 System = any assembly of procedures, resources and
routines to carry out a specific activity

10. System
0 To understand a system and identify what is wrong
with it Map it out!

11. How do you map out a
system?
0 Use a flow chart/diagram
0 Use different perspectives (a doctor’s perspective is
different to a nurse’s or a porter’s to a patient’s
perspective)

12. Quality Improvement Models
0 Model for Improvement = Three questions + PDSA cycle
0 FADE = Focus, Analyze, Develop, Execute and Evaluate
0 Six Sigma
0 CQI = Continuous Quality Improvement
0 TQI = Total Quality Management
0 7 step method

13. Model for ImprovementModel for Improvement
= Three questions + PDSA cycle= Three questions + PDSA cycle

14. The Three Questions
0 The Model for Improvement begins with three
fundamental questions
0 1.1. The Aim:The Aim: What are we trying to accomplish? (How
good do we want to get and by when?)
0 2.2. The MeasuresThe Measures: How will we know a change is an
improvement?
0 3.3. The Changes:The Changes: What change can we make that will
result in improvement?

15. PDSA Cycle
0 PPlan a change
0 DDo the change
0 SStudy the results
0 AAct on the results
STUDY
ACT PLAN
DO

16. PDSA Cycle
0 Enables rapid testing and learning
0 Allows for incremental testing
0 Instead of spending weeks or months planning out a
comprehensive change, then putting it into practice
only to find that it is fundamentally flawed

17. PDSA Cycle
0 Can aid you in:
0 Developing a change
0 Testing a change
0 Implementing a change

18. 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?
MODEL FOR IMPROVEMENT
STUDY
ACT PLAN
DO

19. Executing the Model forExecuting the Model for
ImprovementImprovement
Let’s do an example

20. The Problem
0 Patient’s at XY - Hospital emergency department
are often in pain
0 We want to change that
0 So…how do we do that?

21. Executing the Model for
Improvement0 Form a team
0 Three Questions: The Aim,
The Measures, The changes
0 Test changes - PDSA Cycle
0 Implement changes that
work
0 Spread the changes to other
areas
The Aim
The Measure
The Change
STUDY
ACT PLAN
DO

22. You need a team
0 Why?
0 Need different
perspectives
0 It’s a lot of work
0 Increased buy-in by staff
0 Different levels of support
(e.g. management)
0 To come up with the
right team you have to
have an idea of what
your aim is…

23. The AimThe Aim
What are we trying to accomplish?

24. The Aim
0 A strong, measurable
aim with a clear time
frame will help keep
your project on course
0 It has to be important to
those involved
The Aim
The Measure
The Change
STUDY
ACT PLAN
DO

25. The Aim
0 A good aim:
0 Is Specific
0 Is Measurable
0 Determines a time frame
0 Addresses who the change is for, and what has to be
achieved
0 Is Sustainable

26. The Aim
0 I will become a good runner
0 I will run 10 kilometers per week by May 31st
0 I will run more often
Which one of the above is a good aim?Which one of the above is a good aim?

27. The Aim
0 Back to the Problem: Patients at XY - Hospital
emergency department are often in pain
0 We decide to focus on emergency department
patients with fractures

28. The Aim
0 All emergency department patients with fractures
0 We will provide analgesia to 100% of our pts with a
suspected fracture within 15 minutes of arrival to the
emergency department by the end of December 2013.

29. Choose your teamChoose your team

30. Choose your team
0 Consider the system that relates to the aim i.e. what
processes will be affected by the improvement efforts
0 Involve members familiar with all different parts of
processes

31. Back to our example
0 All emergency department
patients with fractures
0 We will provide analgesia to
100% of our patients with a
suspected fracture within 15
minutes of arrival to the
emergency department by
the end of June 2011.
0 What processes will be
affected?

32. Back to our example
0 All emergency department
patients with fractures
0 We will provide analgesia to
100% of our patients with a
suspected fracture within 15
minutes of arrival to the
emergency department by
the end of June 2011.
0 What processes will be
affected?
0 Nursing/Triage
0 Pharmacy
0 Stocking
0 Doctors
0 Registration
0 ED chief/director/
manager

33. Choose your team
0 Effective teams require three kinds of expertise
0 System leadership for authority
0 Clinical -Technical expertise
0 Day to day leadership - Project leader

34. Your team
0 Team leader: Medical director of the emergency
department
0 Technical expert: Hospital Quality Management
member
0 Day to day leader (project leader): an emergency
doctor or nurse
0 Additional team members: pharmacist, person
responsible for stocking, charge nurse, registration
clerk

35. Revisit the Aim
0 Once you have chosen your team, review and modify
the aim based on their input

36. MeasurementMeasurement
How will we know that a change is an
improvement?

37. Measurement
0 Measurement is critical
for testing and
implementing changes
0 Different from
measurement for
research
The Aim
The Measure
The Change
STUDY
ACT PLAN
DO

38. Measurement
Measurement for
Research
Measurement for
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 possible
Stabilize the biases from test to
test
Data Gather as much data as
possible, just in case
Gather just enough data to learn
and complete another cycle
Duration Can take a long time Short duration

39. Measurement
0 3 types of measures for quality improvement
0 Outcome measures
0 Process measures
0 Balancing measures
0 (+/- Structure Measures)

40. Outcome Measure
0 = Where are we ultimately trying to go
0 Are your changes actually leading to improvement

41. Process Measures
0 = Are we doing the right things to get there?
0 To affect an outcome you have to improve your
processes
0 Are the parts/steps in the system performing as
planned

42. Balancing Measures
0 Tells you if changes designed to improve one part of
the system are causing new problems in other parts of
the system
Examples for our case scenario: Complications fromExamples for our case scenario: Complications from
analgesics (allergic reactions, hypotension,analgesics (allergic reactions, hypotension,
infections at IM injection sites); increased times toinfections at IM injection sites); increased times to
nursing assessments for all other patients othernursing assessments for all other patients other
than those with fracturesthan those with fractures

43. The ChangeThe Change
What change can we make that will lead to
improvement?

44. Developing Changes
0 Depends what you are
trying to change The Aim
The Measure
The Change
STUDY
ACT PLAN
DO

45. Basic Techniques
0 Critical ThinkingCritical Thinking
0 Flow Chart/Diagram
0 BenchmarkingBenchmarking
0 Compare to best practice
0 Using TechnologyUsing Technology
0 Barcodes for medications
0 Creative ThinkingCreative Thinking
0 Become a patient for a day
0 Using Change ConceptsUsing Change Concepts

46. Critical Thinking
0 Use a Flow Chart/Diagram
0 A flow chart allows to “visualize” the system you are
trying to change
0 Allows ALL to see the system the same way

47. Flow Chart/Diagram
0 It helps to clarify complex processes
0 It identifies steps that do not add value to the
internal or external customer, including:
0 Delays
0 Needless storage and transportation
0 Unnecessary work, duplication, and added expense
0 Breakdowns in communication

48. Flow Chart/Diagram
0 It helps team members gain a shared
understanding of the process and use this
knowledge to collect data, identify problems,
focus discussions, and identify resources.
0 It serves as a basis for designing new
processes.

49. Flow Chart/Diagram
0 High-level flowchart, showing six to 12 steps, gives a
panoramic view of a process
0 Detailed flowchart is a close-up view of the process,
typically showing dozens of steps. These flowcharts
make it easy to identify rework loops and complexity
in a process.

50. Example: High Level Flow
Chart

51. Example: Detailed Flow Chart

52. 7Change Concepts
0 Eliminate Waste - an activity or resource that does
not add value
0 Improve Work Flow
0 Optimize Inventory - is your work being held up
because items are not properly organized or available

53. Change Concepts
0 Change the Work Environment (does the work
culture enhance or impede change)
0 Manage Time
0 Focus on Variation - what aspect of the system
vary and make your outcomes unpredictable
0 Focus on Error Proofing (checklist)

54. Testing Changes:
Testing Changes:
PDSA CyclePDSA Cycle
All improvement will require change, but not all
change will result in improvement.

55. Testing Changes
0 Why test changes (even if they are already proven
elsewhere)?
0 To learn how to adapt the change to the particular
conditions in your setting
0 To evaluate the costs and side effects
0 To minimize resistance when implementing the change
in the organization
0 Increase your belief that the change will result in
improvement
To test your change use the PDSA cycleTo test your change use the PDSA cycle

56. PDSA Cycle
0 PlanPlan
0 Objectives
0 Questions and predictions
0 Plan to carry out the cycle
(who, what, where, when)
0 Plan for data collection
The Aim
The Measure
The Change
STUDY
ACT PLAN
DO

57. PDSA Cycle
0 DoDo
0 Carry out the plan
0 Document problems and
unexpected results
0 Begin Analysis
The Aim
The Measure
The Change
STUDY
ACT PLAN
DO

58. PDSA Cycle
0 StudyStudy
0 Complete analysis of the
data
0 Compare data to prediction
0 Summarize what was
learned
The Aim
The Measure
The Change
STUDY
ACT PLAN
DO

59. PDSA Cycle
0 ActAct
0 What changes are to be
made
0 Next cycle?
The Aim
The Measure
The Change
STUDY
ACT PLAN
DO

60. Testing Changes
0 Much can be learnt
from a failed test
PDSA
PDSA
PDSA
PDSA
PDSA
STUDY
ACT PLAN
DO
STUDY
ACT PLAN
DO
STUDY
ACT PLAN
DO

61. What happens when you
identify what works?
0 Are you done?
0 Once you identify what works, change has to be
SUSTAINED. Implementing a change is the hardest
part.

62. How easily is change
adopted?
0 Process of “Normalization”
0 People have a tendency to fall into old habits
0 People have a tendency to resist change
0 People may feel threatened by a change

63. Executing the Model for
Improvement0 Form a team
0 Three Questions: The Aim,
The Measures, The changes
0 Test changes - PDSA Cycle
0 Implement changes that
work
0 Spread the changes
The Aim
The Measure
The Change
STUDY
ACT PLAN
DO

64. ImplementationImplementation

65. Implementation
0 Usually comes after a series of successful tests
0 It requires that staff and leaders build the change
into formal plans, job definitions, training,
and explicit reviews
0 The change does not depend on the individuals
doing the work, but on the way the work is
organized - as part of the system.

66. Implementing Change
0 “Hard-wire” the change into the system
RememberRemember
The implementation phase is the most commonThe implementation phase is the most common
area where process improvements fails.area where process improvements fails.

67. Hardwire Change
0 Market your change
0 Train everyone involved
0 Make changes to job descriptions, policies, procedures, forms
0 Addressing supply and equipment issues
0 Assigning day-to-day ownership for the maintenance of the
new process
0 Have senior leaders remove any barriers

68. Social System
0 Social System - understand the relationship among the
people who will be adopting the new ideas
0 Remember there is an emotional component to change
0 Stress of learning and executing something new
0 Initial disruption to workflow
0 Maybe they feel their job/position is threatened

69. Social System
0 Those who are supportive
0 Enlist on your side
0 Those who are not supportive
0 Don’t try to change their attitude
0 Listen to what concerns them, identify barriers
0 Those who don’t really care, and will follow when others
do

70. SummarySummary
0 In this modules we have presented an introduction to:
0 Quality Improvement
0 The Model of Improvement
0 3 questions (What is your aim, measures, change) and PDSA
cycle
0 Types of Measures
0 Change and Implementation

71. Thank YouThank You