Informatics 8: Quality Improvement Flashcards
1
Q
quality reviews
A
- every 1 patient we do good by we only gain one patient back
- no more no less
- every patient you do wrong by you lose 5 patients
- people are more likely to leave bad reviews
2
Q
quality improvement theory
A
- quality improvement in the hospital goals for this primer
- understnad fundamental concepts in quality improvement
- identify the environment and key steps for a successful quality improvement project
- become familiar with several quality improvement tools and their use
3
Q
quality improvement: bridging the implementation gap
A
- direct relationship between progress and time -> patient care
- scientific understanding and IT can decrease the implementation gap
- patient care is slow increasing slope :(
- we get it right 54% of the time -> not good
4
Q
hospitalists and quality improvement
A
- complex process problems need multidisciplinary solutions
- all departments work together
- we are at the frontlines seeing system failures process errors, and performance gaps with our own eyes -> which is our competitive advantage
- teaching people how to use EMR wrong -> snow ball effect -> people take it out on other things
- improved quality delivers:
- better pt care**
- at lower costs
- with potentially higher reimbursements (pay-for-performance)
- and it can make our jobs more interesting, fun, and rewarding
5
Q
quality
A
- meeting the needs and exceeding the expectations of those we serve
- delivering all and only the care that the patient and family needs
- we do this to better patient care
6
Q
improvement
A
- it is NOT:
- yelling at people to work harder, faster, or safer
- creating order sets or protocols and then failing to monitor their use or effect- follow up
- traditional quality assurance-
- research (but they can co-exist nicely)- trying a new durg
7
Q
improvement requires change
A
- principle #1
- every system is perfectly designed to achieve exactly the results it gets
- to improve the system, change the system*…
- change= not just doing something different, but engineering something different -> at least one step in at least one process
8
Q
clinical research
A
- trying something new in the real word
- monitor to see if its working
- and then put it in true clinical practice
9
Q
less is more
A
- principle #2
- you cannot destroy productivity
- when changing the system, keep it simple
10
Q
change
A
- not just doing something different, but engineering something different
- at least one step in at least one process
11
Q
understanding change in the hospital atmosphere
A
- high reliability strategies commonly succeed:
- build a “decision aide” or reminder into the system
- make the desired action the default action (not doing the desired action requires opting out)
- build redundancy into responsibility (e.g. if one person in the chain overlooks it, someone else will catch it)
- schedule steps to occur at known intervals or events
- standardize a process so that deviation feels weird
- take advantage of work habits or reliable patterns of behavior
- build at least one- if not more- of these high reliability strategies into any changed process
12
Q
improving quality
A
-can increase or decrease cost depending on the situation
13
Q
understanding change in the hospital atmosphere
A
- change engineered to drive improvement depends on…
- workplace culture
- awareness
- evidence
- exerience
14
Q
workplace culture
A
- personnel must be receptive to change
- ready to accept change
15
Q
awareness
A
-administrative and medical staffs must care about performance and support its improvement through change
16
Q
evidence
A
-local experts must identify which research to translate into practice
17
Q
experience
A
- a skilled team must choose, implement, and follow up changes to ensure:
- improvement efforts are ongoing and yielding better performance
- productivity is perserved
18
Q
an atmosphere for change
A
-
19
Q
the driving force for change: the multidisciplinary team
A
-a team is not the same as a committee
20
Q
committee
A
- individuals bring representation
- productive capacity = single most able member
- sum of the whole is greater than the individual
21
Q
team
A
- individuals bring fundamental knowledge
- productive capacity = synergistic (more than the sum of all individual team members together)
22
Q
hospital atmosphere
A
- hospitals tend to be viscous, complex systems with default levels of performance
- change engineered to improve performance can be a foreign concept or even overtly resisted
23
Q
consensus
A
- finding a solution acceptable enough that all members can support it
- no member opposes it
- you need to wholeheartedly agree when you vote
- very hard to do
- everyone agrees but it may not be their first choice
- it is NOT:
- a unanimous vote (consensus may not represent everyone’s first priority)
- a majority vote (in a majority vote, only the majority gets something they are happy with, people in the minority may get something they dont want at all, which is not what consensus is all about)
- everyone it totally satisfied
24
Q
3 types of team members
A
- team leader
- team facilitator
- process owners (members with operational, hands-on fundamental knowledge of the process)
25
team leader
- schedules and chairs team meetings
- sets the agenda (printed at each meeting)
- records team activities (working documents in binder)
- reports to management (steering team)
- often a member of steering team
26
team facilitator
- own the team process (enforces ground rules)
- body guard, cop
- technical expert on QI theory and tools
- assists team leader
- teaches while doing within team
27
process owners
- chosen for fundamental knowledge
- will help implement
- should become leaders (so choose wisely)
28
team ground rules
- all team members and opinions are equal
- team members will speak freely and in turn we will listen attentively to others, each must be heard, no one may dominate
- problems will be discussed, analyzed, or attacked (not people)
- all agreements are kept unless renegotiated
- once we agree, we will speak with "one voice" (especially after leaving the meeting)
- honestly before cohesiveness
- consensus vs. democracy: each gets his say, not his way
- silence equals agreement
- members will attend regularly
- meetings will start and end on time
29
defining an approach to change
- will the team target "all" patients in the inpatient bell curve, or just a sub-group considered "at-risk" (depicted in the outlying tail)
- is the quality of inpatient care which is not in the tail somehow acceptable
30
engineering change
hospitals have 2 dynamic levels impacting performance:
1. processes- tasks performed in series or in parallel, impacting patient care and potentially patient outcomes
2. personnel- skilled people with hearts and minds, with variable levels of attention, time, and expertise
31
what variables impact quality outcomes of care?
- structures/inputs- patients, equipment, supplies, training, environment
- processes/steps- invent`ory methods, coordination, physician orders, nursing care, ancillary staff, housekeeping, transport
- outcomes of care/outputs- physiologic parameters, functional status, satisfaction, cost
32
the 2 most dynamic levels impacting performance
- this is the most important parts
- process/steps:
- inventory methods
- coordination
- physician orders
- nursing care*
- ancillary staff*
- housekeeping*
- transport*
- * -> also personnel
- * most important areas
33
processes
- all those affecting relevant aspects of patient care
- clinical decision making, order writing, admission intake, medication delivery, direct patient care, discharge planning, PCP communication, discharge follow-up, etc.
34
Where?
- where are the processes to improve?
- brainstorming
- multivoting and nominal group technique
- affinity group
- where do we start?
- cause and effect diagrams (ishikawa or fishbone diagrams)
- tally sheets
- pareto charts
- flow (conceptual flow, decision flow) chart
- run charts
- SPC charts
- scatter charts
35
cause and effect diagram
- sometimes also called a fishbone or ishikawa diagram
- graphically displays list of possible factors, focused on one topic or objective
- used to quickly organize and categorize ideas during a brainstorming session, often as an interactive part of the session itself (the added organization can help produce balanced ideas during a brainstorming session)
36
tools for engineering change: pareto chart
- graph chart
- graphical display of the relative weights or frequencies of competing events, choices, or options
- a bar chart, sorted from greatest to smallest, that summarizes the relative frequencies of events, choices, or options within a class
- often includes a cumulative total line
- used to focus within a broad category containing many choices, based on factual or opinion-based information
- can combine factors that contribute to each items practical significance
37
sketching processes or flow***
- macro process maps- biggest thing in health care -> decision charts
- decision flow diagrams- flows down the process
38
improve incrementally. learn through action
- PDSA- plan do study act
- test your changes
- assess their effect
- then re-work the changes and do it again...and again...
39
PDSA (the benefits of repeated cycles)
- increases belief that change will result in improvement
- allow opportunities for "failures" without impacting performance
- provides documentation of improvement
- adapts to meet changing environment
- evaluates costs and side-effects of the change
- minimizes resistance upon implementation
- ideas are great, but "how" is on trial
40
PDSA: overview
- scientific method for action-oriented learning: shorthand for testing a change in the real world setting
- test a change by: planning it, trying it, measuring its results… and then trying to do it better the next time
- multiple rounds of changes – some failures and some successes - should lead to improved aggregate outcome
41
PDSA: principles for success
- Start new changes on the smallest possible scale, e.g. one patient, one nurse, one doctor
- run just as many PDSA cycles as necessary to gain confidence in your change- then expand
- expand incrementally to more patients
- expand to involve more nurses, more doctors, more departments
- balance changes within system to ensure other processes not adversely stressed
42
PDSA: question
- what do we want to achieve
- what changes will drive our progress
- how will we measure our progress
- how should we modify our latest changes
43
PDSA: what do we want to achieve?
-set an outcome aim
-it should be ambitious
-must be measurable
-must specify a time period and a definite population in your hospital
FUNCTION EXPANSION
-list the outcome aim again, then:
-ask why 3 times
-ask how 3 times
-loos at the new aim statements
-pick the best one
-
44
PDSA: what changes will drive our progress?
- select changes to your system, the ones most likely to improve outcomes
- recognize that not all changes improve outcomes or offer balance
45
PDSA: how will we measure our progress
- define what you will measure quantitatively
| - collect data, chart measures regularly over specified time period, and chart against benchmarks and goal lines
46
3 types of measures: PDSA
- outcomes
- process
- balancing measures- use a balanced set of measures for all improvement efforts
47
principle of measurement
- seek usefulness, not perfection
- integrate measurement into the daily routine
- use qualitative and quantitative data
- use sampling
- plot data over time
