Download Quality Improvement Part 1

QUALITY IMPROVEMENT
PART 1
1
Rebecca S. (Suzie) Miltner, PhD, RN, CNL, NEA-BC
University of Alabama at Birmingham
Birmingham, AL
Brant J. Oliver, PhD, MS, MPH, APRN-BC
MGH Institute of Health Professions
Boston, MA
OBJECTIVES



Describe basic steps in understanding process
variation.
Use common QI tools to generate ideas for
solutions to problems.
Describe the structure of a QI Aim Statement.
2
QUALITY IMPROVEMENT (QI)
Definition: Use data to monitor the outcomes of care processes and use improvement methods to design
and test changes to continuously improve the quality and safety of health care systems.
Knowledge
Skills
Attitudes
Describe strategies for learning about
the outcomes of care in the setting in
which one is engaged in clinical
practice
Seek information about outcomes of care
for populations served in care setting
Seek information about quality
improvement projects in the care setting
Appreciate that continuous
quality improvement is an
essential part of the daily work
of all health professionals
Recognize that nursing and other
health professions students are parts
of systems of care and care
processes that affect outcomes for
patients and families
Give examples of the tension
between professional autonomy and
system functioning
Use tools (such as flow charts, cause-effect Value own and others’
contributions to outcomes of
diagrams) to make processes of care
care in local care settings
explicit
Participate in a root cause analysis of a
sentinel event
Explain the importance of variation
and measurement in assessing
quality of care
Use quality measures to understand
performance
Use tools (such as control charts and run
charts) that are helpful for understanding
variation
Identify gaps between local and best
practice
Appreciate how unwanted
variation affects care
Value measurement and its
role in good patient care
Describe approaches for changing
processes of care
Design a small test of change in daily work
(using an experiential learning method such
as Plan-Do-Study-Act)
Practice aligning the aims, measures and
changes involved in improving care
Use measures to evaluate the effect of
change
Value local change (in
individual practice or team
practice on a unit) and its role
in creating joy in work
3
Appreciate the value of what
individuals and teams can to do
to improve care
QUALITY IMPROVEMENT (QI)
Definition: Use data to monitor the outcomes of care processes and use improvement methods to design
and test changes to continuously improve the quality and safety of health care systems.
Knowledge
Skills
Attitudes
Describe strategies for learning
about the outcomes of care in the
setting in which one is engaged in
clinical practice
Seek information about outcomes of care for
populations served in care setting
Seek information about quality improvement
projects in the care setting
Appreciate that continuous
quality improvement is an
essential part of the daily
work of all health
professionals
Recognize that nursing and other
health professions students are
parts of systems of care and care
processes that affect outcomes for
patients and families
Give examples of the tension
between professional autonomy
and system functioning
Use tools (such as flow charts, causeeffect diagrams) to make processes of
care explicit
Participate in a root cause analysis of a
sentinel event
Value own and others’
contributions to outcomes of
care in local care settings
Explain the importance of
variation and measurement in
assessing quality of care
Use quality measures to understand
performance
Use tools (such as control charts and run
charts) that are helpful for understanding
variation
Identify gaps between local and best practice
Appreciate how unwanted
variation affects care
Value measurement and its
role in good patient care
Describe approaches for
changing processes of care
Design a small test of change in daily
work (using an experiential learning
method such as Plan-Do-Study-Act)
Practice aligning the aims, measures and
changes involved in improving care
Use measures to evaluate the effect of
change
Value local change (in
individual practice or team
practice on a unit) and its role
in creating joy in work
4
Appreciate the value of what
individuals and teams can to do
to improve care
Our focus
today over
the next two
sessions.
TOOLS AND TECHNIQUES TO
INCORPORATE INTO YOUR COURSES

Process Mapping

Brainstorming

Affinity Diagrams

Multi-Voting

Tests of Change

Using Data to Understand Processes

Using Data to Evaluate Change Interventions
5
TOOLS AND TECHNIQUES TO
INCORPORATE INTO YOUR COURSES

Process Mapping

Brainstorming
QI Workshop Part 1

Affinity Diagrams

Multi-Voting

Tests of Change

Using Data to Understand Processes

Using Data to Evaluate Change Interventions
6
MODEL FOR IMPROVEMENT
Aim
Change Ideas
Measurement
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PROBLEM IDENTIFICATION
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FIRST, WE (ALWAYS) NEED TO BETTER
UNDERSTAND THE PROCESS…
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PROBLEM: FALLS


Falls are a common patient safety problem
Falls can have devastating effects (injuries,
increased LOS, death)

Falls are expensive

Falls are “never events”
Cox, Thomas-Hawkins, Pajarillo, DeGennaro, & Cadmus, 2015
Dean, 2012
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FALLS AT AMC
 FY15

2.42 falls/1000 patient days
 Estimated
Financial Impact:
$1.5 million+
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WE DO HAVE EVIDENCE OF THINGS THAT WORK:
FALL PREVENTION BUNDLE OF CARE








Leadership support
Use of a standard fall risk assessment tool
Fall risk assessments on admission and at regular
intervals (to include, medications, mentation, mobility,
and history)
Use of visual aids (fall risk bracelets)
Patient & family education
Communication with the healthcare team
Frequent Rounding on patients
Monitoring compliance & performance with falls
interventions.
(Agency for Healthcare
Research and Quality, 2012)
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GATHERING DATA TO UNDERSTAND A
PROCESS: SUGGESTED STEPS
1.
Observe processes (formal and informal)
2.
Interview key personnel
3.
Collect data
4.
Create a process map
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1. PROCESS OBSERVATION
What can you really
see when you just
look around you?
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WHAT DID WE OBSERVE?
Falls Protocol: Not implemented about 50% of the
time
 Workload: Not possible to round every hour on
every patient and meet patients’ other needs.
 Geography: Pts assigned for continuity, RN
experience, patient acuity, but not geography (i.e. lots
of extra walking)
 Technology: Bed alarms don’t connect to call
system; nurses turn off frequently
 Risk Assessment: Every patient at risk
 Rooms: Rooms are small and full of obstacles

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2. INTERVIEW KEY PERSONNEL
What did the
stakeholders tell us?
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INTERVIEW RESULT THEMES
Geography: Layout of the unit is a barrier; difficult
to move patient room closer
 Patient Factors: Patient’s with cognitive issues and
impaired judgment are most difficult; patient’s not
engaged
 Technology: Bed alarms don’t connect to call
system, used to have video monitoring
 Risk Assessment: low specificity
 Equipment: difficult to get walkers

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3. COLLECT DATA: HOW BAD IS IT?
ABC Unit
AMC: 2.42 per 1000 patient days
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3. COLLECT DATA
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4. CREATE PROCESS MAP
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4. CREATE PROCESS MAP
Why?
 Provides a common picture of a process for the
whole team.
 Helps identify which parts of the system are
important to measure.
 Helps generate ideas for change. (Define,
standardize or find areas for improvement in a
process.)
How?
 Use symbols to represent steps in the process
 Start with big picture and develop detail later
 Need to have people who do the process involved
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PROCESS MAP SYMBOLS
Oval: Denotes the
Start or Stop point in
the process
Diamond:
Denotes a
decision
point in the
process
Rectangle: Denotes a
step in the process or
instructions
Arrow: Denotes direction
Triangle:
Measurement
point
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4. CREATE A
PROCESS MAP
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ANOTHER IMPORTANT NOTE…
Don’t confuse ideal process with the
actual process.
24
QI Part 2 will talk more about collecting
and analyzing data.
Let’s focus more on process maps right
now….
25
BREAKOUT: PROCESS MAPPING
 Divide
into groups of 6-8 people.
 You
are going to create a process map of a
medication administration process.

You need to decide the setting and start point.

The end point is when person gets medication.
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TIPS FOR PROCESS MAPPING



Ask what happens first, next, and then what
happens next.
 If DEPENDS, then pick the most common next
step and follow what happens after, and then
go back to follow the other one.
Keep it simple
Turn the list of steps into a flow chart using
symbols
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PROBLEM SOLVING:
TOOLS TO IDENTIFY SOLUTIONS
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Most of our common problems in nursing
do not have easy solutions.
How do we get creative and figure out new
ideas to try?
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BRAINSTORMING AND
DECISION MAKING TOOLS
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BRAINSTORMING
Creativity
 Large number of ideas
 All team members involved
 Sense of ownership in decisions
 Input to other tools

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BRAINSTORMING
Common Guidelines
 Write down ALL IDEAS exactly as spoken; one idea
per post-it note/index card.
 Avoid interpreting
 Encourage participation by all members
 No “good” or “bad” ideas
 No discussion
 Can build on other’s ideas
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FALLS CASE STUDY




ABC unit is a 30 bed medical unit that is also the internal
medicine teaching unit at Academic Medical Center (AMC).
There are 4 different teaching teams on the unit on any given day.
The unit’s average daily census is 29. There is an average of 10
discharges and admissions every day.
The model of care on this unit is all RN with each nurse taking 34 patients in an assignment. Approximately 35% of the patients
on any day are total care. Staff satisfaction is high on this unit,
but the average staff nurse only has about 2.5 years of
experience. After a few years of experience on this unit, many
nurses move to ICUs or move on to APN roles after completing
their MSN.
The Nurse Manager is experienced, well respected, and has a
reputation for turning around troubled units. In fact, the falls
rate is only indicator that is above the benchmark at AMC.
What can we do to decrease the falls rate on this unit?
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BREAKOUT: BRAINSTORMING
What’s the problem?
 Break into groups of 6-8 people.
 Work individually for 3-5 minutes and list 6 or more
ideas for solutions
 After 3-5 minutes, go around your group and share
your ideas. Place post it notes on the board as you
share.
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DECISION MAKING TOOLS
 Affinity
Diagrams
 Multi-voting
35
AFFINITY DIAGRAMS
 Designed
to sort a large number of ideas,
process variables, concepts, and opinions into
naturally related groups.
36
GENERATING SOLUTIONS: BRAINSTORMING AND
AFFINITY ANALYSIS
Either list can
be rank-ordered
37
AFFINITY BREAKOUT
Without speaking, sort the cards into "similar"
groups based on your gut reaction.
 If you don't like the placement of a particular
card, move it. Continue until consensus is
reached.
 Create headers consisting of a concise 3-5 word
description
 Discuss the groupings and try to understand how
the groups relate to each other.

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MULTI-VOTING
 Multi-voting
is a group decision-making
technique used to reduce a long list of items to
a manageable number by means of a
structured series of votes.
39
HOW TO DO MULTI-VOTING
Work from a large list
 Assign a label to each item
 Vote for 1/3 to ½ of the items
 Tally the votes
 Repeat until down to a small number of items

If < 5 team members: remove items with < 2 votes.
 If 6-15 team members: remove items with < 3 votes.
 If > 15 team members: remove items with < 4 votes.

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FINAL COMMENTS




Quick solutions to complex problems do not
work.
Systematic understanding of the process can
lead to better solutions to the problems.
There are tools that can facilitate your work to
understand the process and find solutions to
problems.
Use them in practice and in the classroom!
41
TOOLS AND TECHNIQUES TO
INCORPORATE INTO YOUR COURSES

Process Mapping

Brainstorming

Affinity Diagrams

Multi-Voting

Tests of Change

Using Data to Understand Processes

Using Data to Evaluate Change
Interventions
QI Workshop
Part 2
42
PROCESS MAPPING
SUGGESTIONS FOR CLINICAL COURSES

Assign students to write up and/or map one of
the following processes they performed or
observed during their last clinical:






Medication administration process for routine
medication
Medication administration process for IV medication
Initial shift assessment
Rounding
Care bundle (falls, CAUTI, CLABSI)
Almost anything!
43
INTEGRATING AN IMPROVEMENT PROJECT
INTO A ONE SEMESTER CLASS

Rapid Cycle Quality Improvement (RCQI) can be
incorporated into both didactic and clinical
courses over a semester.
Prelicensure programs
 Graduate programs


Types of projects:
Personal improvement projects
 Care bundle compliance (falls, CAUTI, pressure ulcer
prevention)
 Larger microsystem or mesosystem changes

44
DATA COLLECTION SHEET



Most tools and
resources came
from
www.cautiout.org
They recommend
two weeks (M-F?)
of baseline data
collection, then
again after
interventions.
Could be modified
for other bundles
such as fall
prevention,
45
CLABSI, etc.
46