Quality 2.pdf

Quality Part/2 Dr. Mais Alkhalli Community Medicine Common Measures of Quality and Improvement 9 Creasure) # · complexi llvy skilgigskill. Sis I. measurement...

Quality Part/2 Dr. Mais Alkhalli Community Medicine Common Measures of Quality and Improvement 9 Creasure) # · complexi llvy skilgigskill. Sis I. measurement &i 1 errors Measures) II. process variation III. statistical process control  S1 i 165 Measurement -- ·ji ✓ The most basic concept in quality improvement is that of measurement and the metrics associated with it. Measurement is the translation of observable events into e & is & (tools) el quantitative terms Metrics are the means actually used to record these observable events. All quality improvement efforts require numerical data because “you can't manage what you can't measure.” In this way, quality improvement is driven by data-based evidence rather than subjective judgments or opinion se i ↳ - is His is  las) case definition -- is Ass - case definition of I dirrated d diarrhea is Measurement increase the volume & frequency of the stool ▪ Good measurement begins with the rigorous definition of the concept to be measured (defined in very specific terms) ▪ An[operational definition] is indicated. Operational definitions are concrete statements about how to implement terms and operational procedures in measurement or data collection definition ▪ Ideally the operational definition includes how it is measured, - This definition should be written and should include the unit of measure —For example, wait times could be defined as the time 198 interval between the arrival of a patient at the office and the time he or she is first seen by the doctor. The unit of measure is time, but the !+- -- start and end points are important for assessing the reliability and validity of the measure. How it's measured  & I Soha wil $ e * & 26 j -Sl Measurement i S Reliable or valid I Reliability means that if a measure is taken at several points over time or by various people, the measure will generally be consistent (that is, not vary too much).  The measure will be consistent, or reliable if: every recorded wait time starts with examples the arrival of the patient and ends with the patient’s first encounter with the ↳ ⑪ doctor. ②  If a person takes his or her temperature each morning, it should be close 2 to 98.6 degrees Fahrenheit each time, assuming that the person is not ill. If it substantially deviates from 98.6, then that person is ill, the thermometer is broken and not giving consistent readings.  If two nurses in a practice are measuring wait times but use different definitions of waiting, then their measurement of waiting time will not be consistent (reliable). different definition wait time I i & F ↳The measurement will be Not Reliable $ & Measure 1 16. Measurement is glad 2 jjS riss Is · /I valid * j, ! Validity is the extent to which the 9. ? Not validit measure used actually measures the & 14 concept (the accuracy of the measure).  If two nurses use the same stopwatch to record waiting times, as long ji, line as the clock itself is accurate and the nurses adhere to the same definition of waiting, the wait times should be accurate. In other ↓ 110j51 words, As with reliability, having a rigorous definition and method of data collection will yield a valid measure. mid - valid  Measurement  The use of a measurement methodology that yields reliable (consistent) and valid (accurate) measures of the concept is vital. < valid II I & Reliable So it's So it's is & Reliable [ & ] > - jale So it's valid Not valid & Not Reliable I Not valid  Process Variation and Statistical Process Control (SPC)  Process variation is the range of values that a quality metric can take as a result of different causes within the process.  As Shewhart noted, these causes can take two forms: & "A [Special-cause variation3 [common-cause variation& Dis sij - :& J glas is jusual is wait time. wait jl , time Is due to unusual, infrequent, is due to the usual or natural or unique events that cause causes of variation within a the quality metric to deviate process. from its average by a statistically significant degree.  to improve quality we should to eleminating special-cause & common cause variation Following Shewhart, quality improvement now involves (1) detecting and eliminating special-cause variation in a process. & Tasogd (2) detecting and reducing, whenever feasible, common-cause variation within a process. · 3. $ Normal Distribution  > - process variation tool ill.9 Statistical Process Control (SPC)  Statistical Process Control (SPC) is a method by which process variation is measured, tracked, and controlled in an effort to improve the quality of the process.  SPC is a branch of statistics that involves time series analysis with graphic data display.  The advantage of this method lies in the use of a visual display, which is intuitive for most decision-makers.  Data from a particular process are graphed across time. When enough data are available, the amount of variation that is occurring can be measured. For example: A manager of an ambulatory clinic tracked an increase in complaints about patient wait time from quarterly patient satisfaction surveys. For the next month, the wait time for each patient was collected, and the daily average was graphed. At the same time, data were collected about why waiting time increased, and the clinic manager found the special-cause variation was driven by: (1) The number of medically complex, time-consuming patients each day. (2) The training needs of a new LPN and receptionist. (3) The overscheduling of new patients. According to these findings, the manager was able to work with both clinical and administrative personnel to address these concerns and reduce both the variability and the average wait time.  Bedsid soned · resontal control -- · 5.Si out of control Flag - of 19 & 9 control &i - - wait time 599. &Sig & S & complex case,% it's Cout of - control) & is 1 complex cases d 15% Sod 96 , in Control & TWO L Continuous Quality Improvement. APPROACHES TO QUALITY IMPROVEMENT: - Six Sigma. (patient-centered) 1961 : /& S :16 2/28. CQI-Continuous Quality Improvement  · (1) Continuous Quality Improvement An organizational process in which employee teams identify and &1s address problems in their work processes. - &2 When CQI is applied across the organization, it creates a - > continuous flow of process improvements that meet or exceed &, customer or patient expectations. &oj  5) dimension I approach S Five dimensions of CQI:.. - Process focus. Customer focus Employee empowerment Data-based decision making Organization-wide impact 1. Process Focus & Sigji6. process ? g  CQI focuses on the process part of Donabedian's quality conception as key to developing high quality health care. &  Specifically, CQI promotes the view that understanding and addressing the factors that create variation in an administrative or clinical process (e.g., long wait times, high rehospitalization rates) examples : will produce superior patient care quality and organizational S performance.  Quality improvement should not be a one-time activity, it should be * a normal activity, resulting in a continual flow of Improvements.  Underpinning this approach are the concepts and tools of statistical process control (SPC) that Shewhart developed.  & customers in Sis 2. Customer Focus customers /  Every effort in the organization must be taken in order to “delight the customer.” patient a S is the main  CQI : Defines who a customer is in broad terms. customer Normally, patients are thought of as the main customers in health care. CQI's view, is that any person, group, or organization that is impacted by a process at any point is a customer. For example:  a doctor ordering an MRI can be considered a customer because she receives the service of the radiology department.  Thus, CQI takes the position that each process has a variety of both internal and external customers. The customer focus is best exemplified in the widespread use of patient satisfaction surveys by hospitals and physician groups. N 9 /140 -gl 3. Data-based Decision Making ·  It is an emphasis on using data to make all quality improvement decisions. data 11 Ji -  The foundation of SPC, rests on the collection, analysis, and use of is accurate data to improve processes and monitor the success of process interventions. ·i · gl  The use of carefully collected data reduces both uncertainty and the dependence on uninformed impressions or biases for improving an organizational process.  · 12 Mis  It also provides good evidence to convince skeptics that a process problem exists.  In the prior example, the collected data on waiting times enabled not only the clinic manager to understand the special-cause factors creating waiting times but also helped physicians, nurses, and front desk and other staff understand the sources of the problem & Kale r data ju 8 Olg.  i 9i wa 4. Employee Empowerment &As SNsIds is 9  This empowerment is manifested by the widespread use of 1, quality improvement teams. 3  The typical CQI team will consist of hourly employees whose day- to-day work gives them a unique perspective and detailed lis knowledge of patient care processes. * &  Another important individual for a CQI team is the facilitator, - obs > - 9 · jS who typically provides training on CQI tools and philosophy. Bas &  Members of the CQI team are not only empowered to improve their work environment but can also become advocates for & change, overcoming resistance among other employees. Pain assis &r i s 5  In the prior example, the clinic manager worked with both clinical employees (e.g., RNs, LPNs, and the nurse supervisor) and administrative employees (e.g., receptionists, admission and billing clerks, and their supervisor) to decrease the wait times and improve patients' satisfaction with the clinic.  (Quality) isS 5. Organization-wide Impact 2 N (i) Leadership)  Strategic use across the organization, accomplished through the coordinated and continuous improvement of various operational processes across organizational levels.  Quality must be recognized as a strategic priority requiring executive leadership. Supporting this priority is substantial training in quality methods and tools supported by an organizational culture that values quality.  In order to make specific quality improvements, the Shewhart/Deming cycle of PDCA is generally used in manufacturing and other industries.  However, during the early 1980s, the Hospital Corporation of America (HCA) modified the PDCA cycle to create the FOCUS—PDCA framework, which has become the most commonly used quality improvement framework in the healthcare industry.  The addition of FOCUS clarifies the steps that need to be done prior to the implementation of any process change. The changes in the process will then be guided by the PDCA cycle u  L FOCUS—PDCA framework  Brusse[-  Find means identifying a process problem, preferably a “high- pain” one, to address. wait time is i 54 [  Organize means to organize a team of people who work on the FOCUS (Find, [ process. These people would then be trained on process improvement skills and tools. Organize, tools 5 deprocess & " gig Clarify,  [ Clarify results in the team moving to clarify the process Understand, ↳. is problem through some type of process mapping (flowcharting). mi I  Understanding the process problem comes next. It involves and Select) measurement and data collection of key metrics to document the dimensions of the process problem and to provide a benchmark for goal setting. · is win · Wi / [  Select means to identify a set of process improvements and ↳ then select from them for implementation. & IS 1 As &  E  Plan means to take the process improvement from the S Mes phase of FOCUS and create a plan for its implementation. I & H E it &  Do means to actually implement the process improvement. Check means to check whether the process is involved [ using  PDCA(Plan, the measures identified and measured in the U phase of FOCUS. ↳ plan & Mili Do, Check, ↳ [Result(1g is plans D I - A and Act) [Act  L means to determine whether the process improvement ↳ did was successful. 200 S If the process improvement was successful, the cycle  terminates. If the process improvement was not successful, then the cycle continues back to the planning stage to identify and plan the implementation of another process is · 15 3 9 %$65 improvement. , * the plan , succesful & the cycle terminate  If the process improvement was successful, the cycle terminates— If the process improvement was not successful, then the cycle continues back to the planning stage to identify and plan the implementation of another process improvement. It is important to emphasize the iterative nature of repeated PDCA cycles. That is, if something is not working, one does not wait for an extended period of time, rather another plan is formulated and the cycle repeats until the process is back in control  2 data/ &. Six Sigma variation 11 & Is an extension of Joseph Juran's approach to quality improvement and was developed by Motorola and popularized by Jack Welch at General Electric. Y R It has been defined as a “data-driven quality methodology that seeks to eliminate variation from a process”(Scalise,2001). Six Sigma, like CQI, is a resource-intensive tool requiring ] & + 550S substantial up-front training in quality improvement tools and.. concepts, time and personnel resources to carry out quality > - personal & tools improvement projects, and long-term management resources commitment. -  *Handm For these reasons, Six Sigma is best applied to important, - costly issues in key processes. ↳ Ple in Six Sigma employs a structured process called DMAIC &blog - out of control is 15   Define includes delimiting the scope of work, determining due dates, and mapping the future state of the process, including improvements. · S DMAIC (Define, [  Measure encompasses both the creation of measures or metrics and their application to determine how well a process is performing. Measure, · i process iss 1955 Analyze, [  Analyze further breaks down the understanding of the process and often includes flowcharting the process. Improve, and - /MIS Control).  Improve specifies the steps that will be taken to meet the goals outlined during the define step. similW  Control is about ensuring that the improvements are permanent rather than temporary. & sl &is m - (d variation) 39 6 sigma DMAIC process  :61s B  While DMAIC guides the actual improvement project, Six Sigma also features major training and human resource components. ] > - Stools & S., j Because of these components, many large hospitals and health Six Sigma A& systems have begun adopting Six Sigma as a way to change the organization and establish a culture of quality. Such change & organization? Igi begins with a CEO who supports the method; without top High Quality e use management support, efforts like this generally flounder. High Quality &, Leadershipis QUALITY IMPROVEMENT TOOLS: - $ s Hooks /1% 8 proaches a DATA COLLECTION MAPPING ANALYZING PROCESSES PROCESSES  tool Col DATA COLLECTION  & The check sheet Collection - - i event J is  The check sheet is a simple data collection form in which the occurrence of some event ↓ or behavior is tallied.  At the end of the data collection period, they are added up. The best check sheets are those that are simple and have well-defined categories of what constitutes a particular event or behavior.  2 & checksheet i chart abstractions or chart audits S 11 , & (patient record) is  In this process, a check sheet is used to collect information from a patient's medical * record. Often this is a manual process that involves an individual looking at the medical record and finding the requested information and recording it on a check sheet. *  The use of electronic medical records may take some or all of the labor out of this process, as pertinent medical information can be collected more easily or, better yet, a complete report can be produced at the click of a mouse  3 Geographic mapping infectious diseases * & outbreak  Is a pictorial check sheet in which an event or problem is plotted on a map. This is often used in epidemiological studies to plot where victims of certain diseases live, work, play, etc.  For example, the Sudden Acute Respiratory Syndrome (SARS) outbreak initially occurred in China and, via air travel, quickly spread to a number of cities. Analysis by government public health agencies (e.g., U.S. Centers for Disease Control and Prevention) and the World Health Organization pinpointed the suspected origin of the outbreak and helped to direct prevention and treatment efforts. :D Bin Corigin) /I  tool t MAPPING PROCESS ·big  Flowcharting is the main way that processes are mapped. A flowchart is a picture of the sequence of steps in a process. ·I -- Different action steps within the process are denoted by various geometric shapes · is 4 A basic flowchart outlines the major steps in a process. A detailed flowchart is often more useful in quality improvement. & jigig A top-down flowchart is often used for providing an overview of - large or complex processes. It shows the major steps in the process and lists, below each major step, the sub-steps. The development flowchart adds another dimension. Often it is tuseful for tracking the flow of information between people. That is, & w the development flowchart shows the steps of the process carried out by each person, unit, or group involved in a process. , je4)  -geographic.. & processing  A marriage of geographic and processing mapping is the workflow diagram.  Simply put, this reflects the movements of people, materials, documents, or information in a process. Plotting these movements on the floor plan of a building or around a paper document can present a very vivid picture of the inefficiency of a process. With the advancement of information technology, increasingly sophisticated geographic mapping and tracking programs have become available, making this complex task easier to do. + /  - S Workflow diagram  tool fi ANALYZING PROCESSES  The cause-and-effect diagram helps to identify and organize the possible cause for a problem in a $ structured format. ① It is commonly referred to as a fishbone diagram for Left Right its resemblance to a fish. It is also called an Ishikawa diagram, in honor of - - Kaoru Ishikawa, who developed it. I (1) The diagram begins with the problem under - investigation described in a box at the right side of the diagram. The fish's spine is represented by a long O ↳ fish arrow within the box. The major possible causes of wid the problem are arrayed as large ribs along the spine. · spine These are broad categories of causes to which - smaller ribs are attached that identify specific causes (54(1) of the problem. - gr  2 A Pareto chart is a simple frequency chart. The frequency of each problem, reason, etc. is listed on the x-axis, and the number or percent of occurrences is listed on the y-axis.* * This analysis is most useful in identifying the major problems in a process and their frequency of occurrence.  continuous variable & frequency/1.4 Another version of the frequency chart is the histogram, which shows the range and frequency of values for a measure. When complete, it shows the complete distribution of some variable. This is often useful in basic data analysis $ Histogram A $ in discrete ⑲ variable j # j (continuous I Bar variable) chart  As mentioned earlier, quality improvement has its greatest impact if it becomes a part of the strategic mission of a healthcare organization. When that occurs, it is then possible to look beyond the boundaries of the organization and to consider ways in which the healthcare system at the local, regional, and national levels could be improved.  5 CONCLUSION: Quality, along with access and cost, are the three core policy issues for our healthcare system. Improving quality in a system that will be undergoing a vast expansion of is [access via health insurance reform and the continued cost pressure will be a challenge. The models and tools presented above show that quality can be dramatically improved, even in a challenging environment.