Discussion Topics Improving Elderly Care Prepared by Robert Lloyd, PhD Executive Director Performance Improvement Jonkoping, Sweden 14 May 2013 The messiness of life! Defining the system of care The Quality Measurement Journey Selecting and building measure Operational definitions Data collection The sequence of improvement
So, here is how you reduce avoidable readmissions Not really, because you have to deal with the Messiness of Life! X Give all patients and families a booklet that describes how to prevent readmissions Y Reduce Readmissions and Harm Some problems are so complex that you have to be highly intelligent and well informed just to be undecided about them. --Laurence J. Peter Is life this simple? A good reference on this topic is Wicked Problems and Social Complexity by Jeff Conklin, Ph.D., Chapter 1 in Dialogue Mapping: Defragmenting Projects through Shared Understanding. For more information see the CogNexus Institute website at http://cognexus.org, 2004. 4
Independent Variables Which looks more like this There are numerous direct effects between the independent variables (the Xs) and the dependent variable (Y). Age X1 Gender X2 Current health status X3 Coordination of Care X4 Communication amongst care X5 givers Time 1 Time 2 Y Time 3 Reduce Readmissions and Harm 5 Well actually, the messiness of life looks more like this In this case, there are numerous direct and indirect effects between the independent variables and the dependent variable. For example, X1 and X4 both have direct effects on Y plus there is an indirect effect due to the interaction of X1 and X4 conjointly on Y. R1 R2 Current health status R3 Gender X1 Age X2 X3 Communication amongst care givers Coordination of care X4 X5 R5 R4 Time 1 Time 2 Time 3 R = residuals or error terms representing the effects of variables not included in the model. Y RY Reduce Readmissions and Harm 6
Start by Defining the System of Care A system has an aim or purpose. The network of factors that lead to outcomes of value to stakeholders. Factors comprise structures, processes, culture, personnel, geography, and much more. A System is Dynamic: it is in motion not static! A system is perfectly designed to achieve the results it gets! Improving outcomes requires understanding the dynamics of the system. Population Health Organizations or service groups Individuals who provide direct patient care and related services Types of Systems Macro-systems (e.g. a city, a region, province, a county, or a country) Meso-systems (e.g. hospitals, clinics, home care organizations, or visiting nurses) Micro-systems (e.g. unit nurses, critical care staff, home care workers, pharmacists, physical therapists)
Driver Diagrams The Driver Diagram is a tool to help us understand the system, its outcomes and the processes that drive the outcomes. It helps us understand the messiness of life! 10 A Theory of How to Improve a System Outcome Aim: Expresses stakeholder value! Result Primary Drivers P. Driver P. Driver Drivers 10 Secondary Drivers (processes, norms, structures) S. Driver 1 S. Driver 2 S. Driver 3 S. Driver 1 S. Driver 2 Changes Change 1 Change 2 Change 3 Cause
Key Concepts to Change System S + P = O Structure + Process = Outcomes Source: Donabedian, A. Explorations in Quality Assessment and Monitoring. Volume I: The Definition of Quality and Approaches to its Assessment. Ann Arbor, MI, Health Administration Press, 1980. National or even regional indicators are typically focused on outcomes. But, the outcomes will never change unless someone is focused on the structures and processes that drive the outcomes. Two Main Categories of Drivers Primary Drivers System components which will contribute to moving the primary outcome(s). Secondary Drivers Elements of the associated Primary Drivers. They can be used to create projects or a change package that will affect the Primary Drivers and ultimately the Outcome(s).
A Theory for Weight Loss A Theory for Weight Loss Outcome Primary Drivers Secondary Drivers Ideas for Process Changes Outcome Primary Drivers Secondary Drivers Ideas for Process Changes Calories In Limit daily intake Substitute low calorie foods Track Calories Plan Meals Calories In Limit daily intake Substitute low calorie foods Track Calories Plan Meals AIM: A New ME! Avoid alcohol Drink H2O Not Soda AIM: A New ME! Avoid alcohol Drink H2O Not Soda Every system is perfectly designed to achieve the results that it gets Calories Out 13 Exercise Fidgiting Work out 5 days Bike to work Hacky Sack in office Every system is perfectly designed to achieve the results that it gets Calories Out 14 Exercise Fidgiting Work out 5 days Bike to work Hacky Sack in office
Execution Ideas Will Key Strategies for Reducing Readmissions Interventions for Reducing Rehospitalizations Aim: Reduce readmissions to the hospital in States, regions or countries Outcome Measures: 1. All-cause 30 day re-hospitalization rates (reduce by 3) 2. Patient and family satisfaction with: transition out of the hospital ( increase) coordination of care in community ( increase) Who Multi-stakeholder Coalitions Hospital Associations Integrated Health Care Systems Payers and Purchasers Communities Clinicians / Providers of Care How to Build Will Aligned Incentives, Policy Change and Payment Reform Transparent State-wide Measurement Optimizing the transitions to community care settings after acute care hospitalizations Providing enhancements / supplements to routine care for patients at high-risk for rehospitalizations Engaging consumers and their family caregivers in their own care (and medication management) Leadership, support for improvement and oversight/learning system o at the state or regional level o at the community level o within clinical settings Community activation and cooperation across organizational boundaries and clinical settings (cross-continuum teams) Micro-system quality improvement capability (ability to test, implement & spread process improvements; use of process and outcome measures to guide quality improvement work) Aim: Reduce readmissions to the hospital in States, regions or countries Outcome Measures: 1. All-cause 30 day re-hospitalization rates (reduce by 3) 2. Patient and family satisfaction with: transition out of the hospital ( increase) coordination of care in community ( increase) Optimizing the transitions to community care settings after acute care hospitalizations Providing enhancements / supplements to routine care for patients at high-risk for rehospitalizations Engaging consumers and their family caregivers in their own care (and medication management) Redesigning/Optimizing Core Processes: Transition out of the hospital Transition back into primary care Transition to the skilled nursing facility Transition to home care Enhancements: Primary Care Models Home Care Programs Skilled Nursing Home Models Disease-Specific Programs Supplemental Care: APN Transitional Care Coaching Model Case Management Models (for patients at home and in skilled nursing facilities) Integrated Models of Clinical Care and Social Support Consumer Engagement : Medication Management Proactive Advanced Directives/ Palliative Care Patient-Owned Care Plans Health Literacy
Exercise: Drivers of Improvement Påverkansanalys Bättre liv för sjuka äldre Bättre liv för sjuka äldre 2013 Make a list of potential improvement drivers for Avoidable Inpatient Admissions or Re-admissions. Create a driver diagram for this topic Aim & Outcomes Primary and Secondary Drivers causing the Outcome En meny av möjligheter Mål/målområde Bättre liv för sjuka äldre Primära påverkansfaktorer Områden Sammanhållen vård och omsorg Preventivt arbetssätt God vård vid demenssjukdom Utskrivning från sjukhus Ordnad process primärvård/hemsjukvård/omsorg Mångbesökare på sjukhus Åstadkomma förbättringar Sekundära påverkansfaktorer Strategier Aktiv patient- och brukarinvolvering Hmmmm. am I a primary or a secondary driver? God läkemedelsbehandling för äldre God vård i livets slutskede 17 ihi
Påverkansanalys för sammanhållen vård och omsorg Påverkansanalys En meny av möjligheter Primära påverkansfaktorer Strategier Identifiera patienter med särskilda behov Sekundära påverkansfaktorer Koncept En meny av möjligheter Primära påverkansfaktorer Koncept Sekundära påverkansfaktorer Idéer för genomförande - förbättringsarbeten Mål/ Målområde Sammanhållen vård och omsorg Minska onödiga inläggningar på sjukhus - Undvikbar sjukhusvård 6 3 2 1 - Andel patienter återinlagda 6 3 2 1 6 3 2 1 6 3 2 1 6 3 2 1 Utskrivning från sjukhus Idé - Antal patienter som fått/inte fått säker utskrivning Ordnad process primärvård/ hemsjukvård/omsorg Idé - Antal patienter/månad som följt/inte följt rutin för ordnad process Mångbesökare på sjukhus Idé - Antal patienter som kommer för tredje gången inom två månader Åstadkomma förbättringar Involvera patient och närstående genom tydlig information och dokumentation Underlätta nästa steg genom tydlig information och dokumentation till andra vård- och omsorgsgivare Standardisera utskrivningsförfarandet för alla patienter Följ upp hur det gått hemma eller motsvarande Identifiera patienter med särskilda behov Erbjud bedömning och planering i hemmet Underlätta nästa steg genom tydlig information och dokumentation till andra vård- och omsorgsgivare Arbeta i team i vård och omsorg tillsammans Identifiera patienter med särskilda behov Bygg relation genom regelbunden patientkontakt Skapa tydliga planer med patientens fokus Kontinuerlig resultatåterkoppling som grund för att identifiera förbättringsarbete och följa dess effekter Mål/målområde Strategi Utskrivning från sjukhus (säker utskrivningsprocess) Antal patienter som inte fått säker utskrivning 6 3 2 1 6 3 2 1 6 3 2 1 6 3 2 1 6 3 2 1 Identifiera patienter med särskilda behov Involvera patient och närstående Underlätta nästa steg till andra vård- och omsorgsgivare Standardisera utskrivningsförfarande Bedömning sker utifrån standardiserat underlag baserat på förmåga och omgivning Bedömning sker utifrån patientens ålder och diagnos Bedömning sker utifrån kända drivers Bedömningsmall (Word) Standardiserat utskrivningssamtal med Teach back genomförs Länk till instruktion: Teach back Patienten får ett standardiserat hemgångsmeddelande Patienten får den aktuella läkemedelslistan i handen Standardiserad samordnad vårdplan, SIP, skapas Standardiserad epikris skickas Aktuell läkemedelslista förmedlas till andra En utskrivningsansvarig sjuksköterska har tillsatts Skapa checklista för vad som behöver göras inför hemgång 6 3 2 1 6 3 2 1 Idé - Antal enheter som har handlingsplan med resultat Aktiv patient- och brukarinvolvering Idé - Antal redovisade exempel på patient/brukarinvolvering/enhet Ta fram modeller för att öka patient/brukare/närståendes involvering i sin egen vård och omsorg och i utvecklingen av den Utveckla nya arbetssätt och en kultur där patient/brukare/närståendes upplevelser tas tillvara på ett bra sätt ihi 6 3 2 1 Följ upp hur det gått hemma eller motsvarande Ring upp patienten <72 timmar enligt rutin Webbkollen hemma ihi
En meny av möjligheter Påverkansanalys Mål/målområde Koncept Involvera patient och närstående Antal patienter som upplever att de inte känt sig delaktiga och välinformerade Webbkollen 6 3 2 1 6 3 2 1 6 3 2 1 6 3 2 1 Primära påverkansfaktorer Förbättringskoncept Standardiserat utskrivningssamtal med Teach back genomförs Länk till instruktion: Teach back Antal patienter som fått/inte fått Teach-back samtal Patienten får ett standardiserat hemgångsmeddelande Antal patienter som fått/inte fått standardiserat hemgångsmeddelande Patienten får den aktuella läkemedelslistan i handen Antal patienter som fått/inte fått LM-lista i handen Sekundära påverkansfaktorer Genomförande - hur ihi Exercise: Drivers of Improvement Review the 3 Primary Drivers for the Involvera patient och närstående driver diagram. Work by yourself to identify the Secondary Drivers that you think influence or drive the 3 Primary Drivers (5 minutes). Discuss with those are your table the Secondary Drivers and agree on a common set of Secondary Drivers (10 minutes). Write each Secondary Driver on a post-it note an hold onto these for now.
Complexity Multiple Primary Drivers One Secondary Driver Levels of Ambition Department-level Priority Sponsor Resources Pilot Unit Department Institution Intitution System Scope Significant system level Priority Sponsor Resources What AIM will your team choose? It will help to Prioritize the Drivers Limitations of resources, attention, and consensus usually mean we cannot work on everything. What to Measure? What to Change? Where is the impact? Which secondary drivers do we believe will deliver the biggest impact? Which secondary drivers will be easiest to work on? Are some beyond our control? What is our current level of performance on the secondary drivers? 24
Status Oral Health Clinic (OHC) Project Caries Control (all active caries restored) Timely Scheduling of Appointments Treatment Planning & Execution Patient Sense of Urgency, Acceptance of Protocol Oral Health Care Prioritization Process WELL defined 4 3.5 Risk Assess Prev Care At OHC over 16 months, we will Ability/Willingness to Pay 3 1) increase the % of pts completing caries control within 2 month by X% and 2) decrease the % of risk management pts who need treatment for new caries by Y% (active pt = 18+ w/ >=1 visit in past 2 years, not withdrawn) Risk Management (no active caries) Population Management Patient Self Management (hygiene & preven. Products) Patient Diet Patient Education & Support Risk assessment, communication of risk status Process NOT defined 2.5 2 1.5 1 0.5 Diet Ability Pay Scheduling Pt Ed Pt Involved Popn Mgmt Tx Self Mgmt Timely Resore 0 2.5 3 3.5 4 4.5 5 Impact Source: Richard Scoville, Ph.D. Risk-based preventive care (cleaning, etc) Lower Impact High Impact 25 Timely restorative care for new caries 26
What s The Status of This Driver/Process? What Is It s Predicted Impact? LEVEL 0 1 DRIVER STATUS DEFINITION Driver is not defined or status is unknown There is an informal understanding about the driver by some of the people who do the work. No widely recognized or formal written description of the driver. APPROXIMATE RELIABILITY LEVEL 0 1 PREDICTED IMPACT DEFINITION This driver has no impact or does not apply to our system of care This driver has only minimal or indirect impact on patient services and outcomes 2 Driver is documented. driver description includes all required participants (including families where appropriate). The driver is understood by all. 2 This driver will improve services for our patients, but other driveres are more important 3 4 5 27 The driver is well-defined, and enacted reliably. Quality measures are identified to monitor outcomes of the driver and may be in use by few/some. Ongoing measures of the driver are monitored routinely by key stakeholders and used to improve the driver. Documentation is revised as the driver is improved. driver outcomes are predictable. driveres are fully embedded in operational systems. The driver consistently meets the needs and expectations of all families and/or providers. 95% 99% 3 4 5 28 This driver has significant impact on outcomes for our patients This driver is necessary for delivering patient services It has a major, direct impact on the outcomes. This driver is absolutely essential for achieving results. Improvement in this driver alone will have a direct, immediate impact on outcomes
Status Status Results of OHC Prioritization Results of OHC Prioritization Process WELL defined 4 3.5 3 2.5 2 1.5 1 0.5 Diet Ability Pay Risk Assess Scheduling Prev Care Pt Ed Pt Involved Popn Mgmt Tx Self Mgmt Timely Resore Process WELL defined 3.5 3 High impact, not 2.5 well defined processes 2 are key targets for 1.5 improvement! 4 1 0.5 Diet Ability Pay Risk Assess Scheduling Prev Care Pt Ed Pt Involved Popn Mgmt Tx Self Mgmt Timely Resore Process NOT defined 0 2.5 3 3.5 4 4.5 5 Impact Process NOT defined 0 2.5 3 3.5 4 4.5 5 Impact Lower Impact High Impact Lower Impact High Impact 29 30
Exercise: Prioritizing Drivers Påverkansanalys En meny av möjligheter Primära påverkansfaktorer Förbättringskoncept Sekundära påverkansfaktorer Genomförande - hur Use the Prioritizing Drivers Worksheet. Number each secondary driver for the Involvera patient och närstående and place this number on the worksheet based on your assessment of: (1) how well each driver is defined, and (2) the level of impact that the driver can have. Do this by yourself (5 minutes). Then discuss with those at your table your priorities for the Secondary Drivers (10 minutes). Reach table consensus on which Secondary Drivers go into which square on the worksheet. Mål/målområde Koncept Involvera patient och närstående Antal patienter som upplever att de inte känt sig delaktiga och välinformerade Webbkollen 6 3 2 1 1 2 3 6 6 3 2 1 6 3 2 1 Standardiserat utskrivningssamtal med Teach back genomförs Länk till instruktion: Teach back Antal patienter som fått/inte fått Teach-back samtal Patienten får ett standardiserat hemgångsmeddelande Antal patienter som fått/inte fått standardiserat hemgångsmeddelande Patienten får den aktuella läkemedelslistan i handen Antal patienter som fått/inte fått LM-lista i handen ihi Finally, place your post-it notes on the big worksheet on the wall.
Status Process WELL defined Process NOT defined Prioritizing Drivers Worksheet 4 3.5 3 2.5 2 1.5 1 0.5 Diet Ability Pay Risk Assess Scheduling Prev Care Pt Ed Pt Involved Popn Mgmt Tx Self Mgmt Timely Resore 0 2.5 3 3.5 4 4.5 5 Impact Don t forget that Drivers and Processes are linked! Outcome AIM: A New ME! Primary Drivers Calories In Calories Out List days cooking v. leftovers Secondary Drivers Limit daily intake Substitute low calorie foods Avoid alcohol Exercise Fidgiting Ideas for Changes Track Calories Plan Meals Drink H2O Not Soda Work out 5 days Bike to work Hacky Sack in office List dishes to prepare List ingredients Improving the reliability, consistency, usability or efficiency of processes is central to improving system outcomes Ingredient on hand? YES NO Add item to list Shop from list 33 Lower Impact High Impact 34 Set aside for meal
Outcome Finally remember that Primary Drivers Secondary Drivers Ideas for Process Changes The Model for Learning and Change AIM: A New ME! than Outcome Measures! Calories In Calories Out Process Measures change Limit daily intake Substitute low calorie foods Avoid alcohol Exercise Fidgiting Track Calories Plan Meals Drink H2O Not Soda Work out 5 days Bike to work When you combine the 3 questions with the PDSA cycle, you get Hacky 35 more quickly Sack in The Improvement Guide, API, 2009 office the Model for Improvement.
Measurement is Central to the Team s Ability to Improve The purpose of measurement in QI work is for learning not judgment! All measurement has limitations, but the limitations do not negate its value for learning. Build a balanced set of measures that reflect the VOC and VOP. All measurement should be linked to the team s Aim. Measurement should be used to guide improvement and test changes. Measurement should be integrated into the team s daily routine. Data should be plotted over time on annotate graphs. Focus on the Vital Few! The Quality Measurement Journey AIM (How good? By when?) Concept Measure Operational Definitions Data Collection Plan Data Collection Analysis ACTION Source: R. Lloyd. Quality Health Care: A Guide to Developing and Using Indicators. Jones and Bartlett Publishers, 2004. 38
The Quality Measurement Journey AIM (How good? By when?) Concept Measure Operational Definitions Data Collection Plan Data Collection Analysis ACTION Source: R. Lloyd. Quality Health Care: A Guide to Developing and Using Indicators. Jones and Bartlett Publishers, 2004. Moving from a Concept to a Measure Hmmmm how do I move from a concept to an actual measure? Every concept can have MANY measures. Which one is most appropriate? 39
Every concept can have many measures Source: R. Lloyd. Quality Health Care: A Guide to Developing and Using Indicators. Jones and Bartlett, 2004. A Family of Measures Concept Hand Hygiene Medication Errors Ventilator Associated Pneumonias (VAPs) Potential Measures Ounces of hand gel used each day Ounces of gel used per staff Percent of staff washing their hands (before & after visiting a patient) Percent of inpatients with C.Diff Percent of errors Number of errors Medication error rate Percent of patients with a VAP Number of VAPs in a month The number of days without a VAP Compliance with the ventilator bundle Outcome Measures: Voice of the customer or patient. How is the system performing? What is the result? Process Measures: Voice of the workings of the system. Are the parts/steps in the system performing as planned? Balancing Measures: Looking at a system from different directions/dimensions. What happened to the system as we improved the outcome and process measures (e.g. unanticipated consequences, other factors influencing outcome)? 41
Outcome What Changes Can We Make? Understanding the System for Weight Loss Primary Drivers Secondary Drivers Ideas for Process Changes Potential Set of Measures for Producing a New Me AIM: A New ME! Every system is perfectly designed to achieve the results that it gets Calories In Calories Out Limit daily intake Substitute low calorie foods Avoid alcohol Exercise Fidgiting Track Calories Plan Meals Drink H2O Not Soda Work out 5 days Bike to work Hacky Sack in office Topic A New Me! (Lose some weight) Outcome Measures Weight BMI Body Fat Waist Size Process Measures Daily calorie count Exercise calorie count Average drinks per week Percent of meals off plan Balancing Measures Money spent on healthy food Number of days not exercising due to injuries Family and friends satisfaction Richard Scoville & I.H.I.
How Will We Know We Are Improving? Understanding the System for Weight Loss with Measures Outcome AIM: A New ME! Weight BMI Body Fat Waist size Primary Drivers Calories In Daily calorie count Exercise calorie count Calories Out Secondary Drivers Limit daily intake % of Substitute opportunities used low calorie foods Avoid alcohol Exercise Avg cal/day Avg drinks/ week Ideas for Process Changes Track Calories Running calorie total Plan Meals offplan/week Drink H2O Not Soda Sodas/ week Work out 5 days Days between workouts System for Improving Oral Health (with Measures) Outcome Reduce burden of dental disease % pts with new cavitation % pts complaining of pain % of pts with OR Tx Primary Drivers Active, informed families Reliable delivery of evidence based preventive & restorative care Secondary Drivers % patients with high oral literacy Patient oral health literacy Patient self management % patients with self Improved diet mgmt plan Improved hygiene Community support CHCs, private dentists, pediatricians, PCPs Payers Early, regular risk-based evaluation & guidance % patients assesed for risk % patients with regular care Use of conservative procedures % patients with Fluoride exposure timely ART, Fluoride ART Measures let us Monitor progress in improving the system Identify effective changes Fidgiting Bike to work Percent of days on bike Hacky Sack in office Etc... Richard Scoville & Catalyst Institute Improved patient access: Dental Home % patients with dental home Qualified OR Tx Coordination with PCPs: referrals Team-based care % patients with timely OR Tx Balancing demand Time and to 3 rd available capacity appt
Improve Transition from Hospital to Home Percent of discharges with readmission for any cause within 30 days HCAHPS (Hospitalwide data) Communication Questions #3 and #7 Discharge Questions #19 and #20 Perform an enhanced assessment of post-hospital needs Provide effective teaching and facilitate enhanced learning Ensure posthospital care follow-up Provide real-time handover communications Involve the patient, family caregiver(s), Percent of admissions and community where provider(s) patients and as family full partners in completing an caregivers assessment are of included the patient s in assessing home-going post needs discharge needs Reconcile medications upon admission Percent of admissions where community providers are included in assessing post discharge needs Identify the patient s initial risk of readmission Create a customized discharge plan based on the assessment Involve all learners in patient education Percent of observations of nurses Redesign the patient education teaching process patient or other identified learner where Teach Back is used to assess understanding Redesign patient teaching print materials Percent of observations of doctors teaching patient or other identified Use Teach Back learner where Teach Back is used to assess understanding Reassess the patient s medical and social risk for readmission Schedule timely and appropriate follow-up Percent of care patients discharged who had a follow-up visit scheduled before being discharged in accordance with their risk assessment Give patient and family members a patient-friendly posthospital care plan that includes a clear medication list Provide customized, real-time critical information to the next clinical Percent care of provider(s). patients discharged who receive a customized care plan written in patient-friendly language at the time of discharge Warm handover for high-risk patients Percent of time critical information is transmitted at the time of discharge to the next site of care (e.g., home health, long term care facility, rehab care, physician office) Exercise Hanging Measures on your Driver Diagram! On your driver diagram, hang the outcome and process measures you will need to track improvement in your system or project. Make sure that these are the most appropriate measures for the concepts you wish to measure.
En meny av möjligheter Påverkansanalys Mål/målområde Koncept Involvera patient och närstående Antal patienter som upplever att de inte känt sig delaktiga och välinformerade Webbkollen 6 3 2 1 6 3 2 1 6 3 2 1 6 3 2 1 Primära påverkansfaktorer Förbättringskoncept Standardiserat utskrivningssamtal med Teach back genomförs Länk till instruktion: Teach back Antal patienter som fått/inte fått Teach-back samtal Patienten får ett standardiserat hemgångsmeddelande Antal patienter som fått/inte fått standardiserat hemgångsmeddelande Patienten får den aktuella läkemedelslistan i handen Antal patienter som fått/inte fått LM-lista i handen Sekundära påverkansfaktorer Genomförande - hur ihi The Quality Measurement Journey AIM (How good? By when?) Concept Measure Operational Definitions Data Collection Plan Data Collection Analysis ACTION Source: R. Lloyd. Quality Health Care: A Guide to Developing and Using Indicators. Jones and Bartlett Publishers, 2004. 50
You have performance data. Now what do you do with it? If I had to reduce my message for management to just a few words, I d say it all had to do with reducing variation. W. Edwards Deming 51 52
Measure The Problem The average of a set of numbers can be created by many different distributions Aggregated data presented in tabular formats or with summary statistics, will not help you measure the impact of process improvement/redesign efforts. Aggregated data can only lead to judgment, not to improvement! Time X (CL) 53 54
If you don t understand the variation that lives in your data, you will be tempted to... Deny the data (It doesn t fit my view of reality!) See trends where there are no trends Try to explain natural variation as special events Blame and give credit to people for things over which they have no control Distort the process that produced the data Kill the messenger! 55 What is the variation in one system over time? Walter A. Shewhart - early 1920 s, Bell Laboratories 56 Static View Static View Dynamic View UCL time Every process displays variation: LCL Controlled variation stable, consistent pattern of variation chance, constant causes Special cause variation assignable pattern changes over time
Types of Variation Common Cause Variation Is inherent in the design of the process Is due to regular, natural or ordinary causes Affects all the outcomes of a process Results in a stable process that is predictable Also known as random or unassignable variation Special Cause Variation Is due to irregular or unnatural causes that are not inherent in the design of the process Affect some, but not necessarily all aspects of the process Results in an unstable process that is not predictable Also known as non-random or assignable variation A Stable Process A predictable process has only common causes or random variation in play.! 57
Pounds of Red Bag Waste But Stable OK So, the Key questions for Understanding Variation are A process may be operating in a stable, predictable fashion but still produce unacceptable results! All the shops in Soviet Union were limited to 2-3 types of merchandise, all over country, in every city or a small village the same things were sold, produced on a few Russian state owned plants. Source: www.englishrussia.com 60 Is the process stable? Is the process predictable? Is the process capable? 6.00 5.75 5.50 5.25 5.00 4.75 Median=4.610 4.50 4.25 4.00 3.75 3.50 3.25 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Point Number
Per cent C- sect ions Num ber of M edic at ions Er r or s per 1000 Pat ient Days 35. 0 30. 0 25. 0 20. 0 15. 0 10. 0 5. 0 0. 0 2 2. 5 2 0. 0 1 7. 5 1 5. 0 1 2. 5 1 0. 0 7. 5 5. 0 2. 5 0. 0 12/ 95 2/ 96 4/ 96 6/ 96 8/ 96 10/ 96 12/ 96 2/ 97 4/ 97 6/ 97 8/ 97 m ont h 10/ 97 W eek 12/ 97 2/ 98 4/ 98 6/ 98 8/ 98 10/ 98 12/ 98 2/ 99 4/ 99 6/ 99 UCL = 2 7. 7 0 1 8 CL=18. 0246 L CL = 8. 3 4 7 3 UCL = 1 3. 3 9 4 6 1 CL = 4. 4 2 0 4 8 L CL = 0. 0 0 0 0 0 Attributes of a Leader Who Understands Variation Leaders understand the different ways that variation is viewed. They explain changes in terms of common causes and special causes. They use graphical methods to learn from data and expect others to consider variation in their decisions and actions. They understand the concept of stable and unstable processes and the potential losses due to tampering. Capability of a process or system is understood before changes are attempted. Exercise Common and Special Causes of Variation Select several measures which your organization tracks regularly. Do you and the leaders of your organization evaluate these measures according the criteria for common and special causes of variation? If not, what criteria do you use to determine if your measures are improving or getting worse? Percent of Cesarean Sections Perform ed Dec 95 - Jun 99 M ed ica tio n Erro r Ra te
Measure Pounds of Red Bag Waste 63 How do we analyze variation for quality improvement? Run and Control Charts are the best tools to determine if our improvement strategies have had the desired effect. 6.00 5.75 5.50 5.25 5.00 4.75 4.50 4.25 4.00 3.75 3.50 3.25 Elements of a Run Chart Time 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Point Number Four simple run rules are used to determine if special cause variation is present The centerline (CL) on a Run Chart is the Median Median=4.610 ~ X (CL)
Measure Number of Complaints Elements of a Control Chart The Quality Measurement Journey 50.0 45.0 40.0 35.0 30.0 25.0 20.0 15.0 10.0 An indication of a special cause 5.0 Jan01 Mar01 May01 July01 Sept01 Nov01 Jan02 Mar02 May02 July02 Sept02 Nov02 Time Month UCL=44.855 (Upper Control Limit) A B C CL=29.250 C B A X (Mean) LCL=13.645 (Lower Control Limit) 66 AIM (How good? By when?) Concept Measure Operational Definitions Data Collection Plan Data Collection Analysis ACTION Source: R. Lloyd. Quality Health Care: A Guide to Developing and Using Indicators. Jones and Bartlett Publishers, 2004.
The Model for Learning and Change The Sequence of Improvement When you combine the 3 questions with the Test under a variety of conditions Make part of routine operations Implementing a change Sustaining improvements and Spreading changes to other locations PDSA cycle, you get the Model for Improvement. Theory and Prediction Developing a change Testing a change Act Study Plan Do The Improvement Guide, API, 2009
Focus on Relationships S + P + C* = O Structure + Process + Culture = Outcomes Source: Donabedian, A. Explorations in Quality Assessment and Monitoring. Volume I: The Definition of Quality and Approaches to its Assessment. Ann Arbor, MI, Health Administration Press, 1980. *NOTE: The Culture Component (C) has been added by R. Lloyd and R. Scoville to make this a more visible aspect of what it takes to actually move and outcome. National or even regional indicators are typically focused on outcomes. But, the outcomes will never change unless someone is focused on the structures and processes that drive the outcomes. The Primary Drivers of Improvement Having the Will (desire) to change the current state to one that is better Developing Ideas that will contribute to making processes and outcome better Ideas Will QI Execution Having the capacity to apply CQI theories, tools and techniques that enable the Execution of the ideas
How prepared is your Organization? Key Components* Will (to change) Ideas Execution Low Low Low Self-Assessment Medium High Medium High Medium High *All three components MUST be viewed together. Focusing on one or even two of the components will guarantee suboptimized performance. Systems thinking lies at the heart of CQI! A closing thought It must be remembered that there is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than the creation of a new system. For the initiator has the hatred of all who would profit by the preservation of the old institution and merely lukewarm defenders in those who would gain by the new one. Machiavelli, The Prince, 1513
General References on Quality References on Measurement The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers., San Francisco, 1996. Quality Improvement Through Planned Experimentation. 2nd edition. R. Moen, T. Nolan, L. Provost, McGraw-Hill, NY, 1998. The Improvement Handbook. Associates in Process Improvement. Austin, TX, January, 2005. A Primer on Leading the Improvement of Systems, Don M. Berwick, BMJ, 312: pp 619-622, 1996. Accelerating the Pace of Improvement - An Interview with Thomas Nolan, Journal of Quality Improvement, Volume 23, No. 4, The Joint Commission, April, 1997. 73 Brook, R. et. al. Health System Reform and Quality. Journal of the American Medical Association 276, no. 6 (1996): 476-480. Carey, R. and Lloyd, R. Measuring Quality Improvement in healthcare: A Guide to Statistical Process Control Applications. ASQ Press, Milwaukee, WI, 2001. Lloyd, R. Quality Health Care: A Guide to Developing and Using Indicators. Jones and Bartlett Publishers, Sudbury, MA, 2004. Nelson, E. et al, Report Cards or Instrument Panels: Who Needs What? Journal of Quality Improvement, Volume 21, Number 4, April, 1995. Provost, L. and Murray, S. The Data Guide. Jossey-Bass Publishers, 2011. Solberg. L. et. al. The Three Faces of Performance Improvement: Improvement, Accountability and Research. Journal of Quality Improvement 23, no.3 (1997): 135-147. 74
References on Spread Gladwell, M. The Tipping Point. Boston: Little, Brown and Company, 2000. Kreitner, R. and Kinicki, A. Organizational Behavior (2 nd ed.) Homewood, Il: Irwin, 1978. Lomas J, Enkin M, Anderson G. Opinion Leaders vs Audit and Feedback to Implement Practice Guidelines. JAMA, Vol. 265(17); May 1, 1991, pg. 2202-2207. Myers, D.G. Social Psychology (3 rd ed.) New York: McGraw-Hill, 1990. Prochaska J., Norcross J., Diclemente C. In Search of How People Change, American Psychologist, September, 1992. Rogers E. Diffusion of Innovations. New York: The Free Press, 1995. Wenger E. Communities of Practice. Cambridge, UK: Cambridge University Press, 1998. Thank you! Good luck with your Quality Journey! Contact Information: Bob Lloyd: rlloyd@ihi.org 75 76