Download Quality improvement: which tools and techniques to use in practice

Quality Improvement:
Which tools and techniques to use
in practice
Kevin Gibbs
Clinical Pharmacy Manager
Maureen Bisognano
Chief Executive Officer
Institute for Healthcare Improvement
2012
Aims and learning outcomes
• Aim
▫ Discuss some tools and measurement techniques that
support quality improvement within the workplace
• Learning outcomes: At the end of this session
participants will be able to:
▫ Explain the principles behind the elimination of waste
using Lean
▫ Select appropriate tools to use in local quality
improvement initiatives
▫ Apply the Model for Improvement to any quality
improvement measure
…the Chief Executive of NHS England
has called for ‘the unleashing of
creative energy and the mobilising of
collective action’ for change…
…the Chief Executive
of Monitor advocates ‘turbocharging’ change in the NHS…
…commentators warn that the
NHS must ‘change or die’…
…the King’s Fund concludes
that the greatest transformational
force for change will come from
within the NHS…
…the NHS Leadership
Academy advocates ‘collective’
leadership styles, shifting power
to front line staff and patients…
Getting involved in improvement….
• Isn't this just for
Managers?
• What can I do?
• Doesn’t this
need lots of
resources?
• How can one
person do this?
Darzi Report. 2008.
<https://www.gov.uk/government/uploads/system/uploads/
attachment_data/file/228836/7432.pdf>
Continuous
improvement
– Can it work?
Team
Sky
‘Performance by the
aggregation of marginal gains’
▫ It means taking the 1% from
everything you do; finding a 1%
margin for improvement in everything
you do
▫ If a mechanic sticks a tyre on, and
someone comes along and says it
could be done better, it's not an insult
- it's because we are always striving
for improvement
http://www.teamsky.com/article/0,27290,17547_5792058,00.html#FYXpi3JIGadPVtaX.99
http://blog.bufferapp.com/what-would-happen-if-you-improved-everything-by-1-thescience-of-marginal-gains
Quality improvement approaches and tools
Lean
▫
▫
▫
▫
▫
Process mapping
Identification & elimination of waste working
5S workplace organisation
Visualisation / Visual management
Standardisation of procedures
Model for improvement
▫ Plan - Do - Study - Act
▫ Measurement for Improvement
Other tools
▫ Failure Modes and Effects Analysis (FMEA)
▫ Programme Theory
Challenges in “Improvement”
Analysis of Health Foundation
improvement programmes. 2012
Crossing the Quality Chasm.
US Institute of Medicine . 2001.
1.
1.
2.
Convince people there is a
problem
2. If you do it, will it work?
3. Data collection and monitoring
4. Project goals must be realistic
and achievable
5. Communication to staff and
support
6. Project must be owned,
common goals
7. Leadership
8. Incentivising participation / staff
motivation
9. Securing sustainability
10. Side effects of change counterbalancing
Adapted from: BMJ Qual Saf 2012;1-9 doi:10.1136/bmjqs-2011-000760 (@
3.
4.
5.
6.
link)
Redesigned care processes
Effective use of information
technologies
Knowledge and skills
management
Development of effective
teams
Coordination of care across
patient conditions, services and
settings over time
Use of performance and
outcome measurement for
continuous quality
improvement and
accountability
Lean
• Lean provides a way to do more ands more with less
and less – less human effort, less equipment, less
time & less space
• Lean is a set of tools and techniques, a philosophy
and a leadership culture
Lean started in the automotive industry but is widely
applicable in Healthcare; often re-badged:
“IHI-approach”
“Vanguard method”
Systems thinking
Build a paper aeroplane
• Two groups
▫ Follow the instructions and build a paper aeroplane
▫ You have 5 minutes
▫ Launch your plane……….
• Now your Airbus A380 is built and test-flown…..
▫
▫
▫
▫
▫
How many of your group successfully built their plane?
How productive were you with your SOP?
What do you think about standardising your procedures?
Did the visual aspect of the SOP help?
Do you think you can learn from this regarding your own
SOPs?
Improving flow in the patient journey and
eliminating waste
“Waste” is any problem that interferes with people doing their work
effectively or any activity that does not provide value for the customer
Five principles of lean thinking enhance the quality of healthcare1
Specify value
Value is
defined by
the
customer
Identify the
value stream or
patient journey
Make the
process and
value flow
Core set of
actions to
deliver
value for
patients
Facilitate
the smooth
flow of
patients and
information
Let the
customer pull
Every step
pulls towards
it, one at a
time, when
needed
Pursue
perfection
Continuous
development
-No mistakes
-No delay
-On time
1: University of Warwick. Going Lean in the NHS. NHS Institute for Innovation and Improvement. 2007.
Value
1. Value Adding Activities
▫ These are activities that “add value” to our customers. A
“value adding” activity is anything we do to transform
materials or information into something that our customers
require.
2. Necessary Non Value Adding Activities
▫ A “non value adding” activity is something that consumes
resources, does not create any value for the customer but
is still currently necessary to supply the service.
3. Waste
▫ Waste is any activity that consumes resources, but does not
create any value for the customer
Lean building blocks: 8 wastes
Waiting for queries to be answered
Waiting for staff, materials, information, prescriptions
Checkers waiting dispensing
Patient’s waiting time
Not empowering
Not utilising
expertise, talent or
creativity of staff
Not acting on ideas
Movement of people
or information
around the
department
organisation
Items not in reach
Stock levels inaccurate
More info then
needed
Excess stock
Not using
resource
Waiting
or delay
Overproduction
Transport or
Conveyance
Motion
Stock &
Materials
Making more,
earlier or faster than
the next process requires
Defects
incl
rework
Overprocessing
Wrong drug / admind dose
Dispensing errors
Moving materials
unnecessarily
What is your
workflow around the
department
Delivery of drugs to
clinical areas
Extra effort adding no
value to the product /
service for the customer
Lean building blocks: 5 S
A place for everything and everything in it’s place
• Sort
▫ Do we need it? How frequently
▫ How accessible?
• Set in order
▫ Position things so everyone knows where to find it
• Shine
▫ Clean the area
• Standardise
▫ Agree  Communicate  Follow
▫ (Re-)Order levels
• Sustain
▫ Become daily routine, continually improve
▫ Long-term, a ‘mindset’
The 6th S
Safety
5S: Sort
• Eliminating unnecessary items from the work area
• Removing waste
▫ Waste caused by irregular workflow
 Untrained staff
▫ Waste associated with overly strenuous work
 Working conditions, training
▫ Waste of overproduction and inventory
 8 wastes
• ‘One is Best’
▫ One pen, One SOP, One ream of paper, One hour for
meetings
Sort: Identifying waste
• Inventory
▫ Too much work in progress or
stock
 Do I need these items for the
task in hand?
 How many do I really need?
 Does this item improve my
productivity and efficiency?
 When did I last use this piece of
equipment?
 When will I next use this piece
of equipment?
▫ Conduct a video ‘Waste walk’
Sort: Reducing workplace variation and waste
•
•
•
•
•
Poor layout
Poor workplace organisation
Inadequate training
Not following procedures
Poor workplace environment
▫ Light, cleanliness, clutter etc.
• Map the flow of people and
material around the workplace
▫ Is this efficient?
▫ Are there any ‘choke’ points?
5S: Set in Order / Straighten
• Everything is placed to
ease the flow of work
• Visual management
▫ Everything and it’s place
is clearly identifiable
 30 second rule
 Photographs
 Labels
 Remove doors
▫ How are you doing?
 3 second rule
TTA
VTE
● Not done ● In progress ● Complete
Shadow board
Set positions outlined on
the floor and labelled
https://wallcontrol.com/catalog/hooks/hookscatpg21.htm
Lean 6S Training – Presentation Mercy Medical Centre.
2009.
http://www.lean.org/fusetalk/forum/messageview.cfm?catid
=46&threadid=4343&STARTPAGE=2&FTVAR_FORUMVIEWTM
P=Linear
Productive Ward Examples
For more on the
‘Productive’ series
of ideas
<http://www.institu
te.nhs.uk/quality_a
nd_value/productivi
ty_series/the_produ
ctive_series.html>
5S: Straighten - 2
• Process mapping
▫
▫
▫
▫
Are all processes of equal value?
How long does each process take?
Do these activities add value?
Do any subtract value?
• Working to order
▫ Operator A works to satisfy and please operator B
▫ Don’t ‘push’ work e.g. batch and queue
▫ ‘Pull’ downstream e.g. milk bottles = ‘Just-in-time’
system (JIT)
5S: Shine
• Ensure the area remains clean and tidy to remain
efficient
▫ Workplace storage
▫ Equipment
▫ Estates / space
 Walls, notice boards, walkways
• A daily routine not an occasional task
▫ e.g.- Putting away at the end of the day
▫ Creates ownership for work areas
▫ Identifies broken equipment etc.
5S: Standardise
• Embedding 5S into the workplace
• How to manage continuous 5S
▫ Incorporate 5S in the organisation’s cultural values and
beliefs
▫ Not slip back into old established habits
• This should be fluid and dynamic, as things improve
so new standards are set, ---- by you…
5S: Sustain
• The hardest part……
▫ Estimated that 70% of Lean initiatives fail after 5 years
• Not sustaining will affect quality, staff morale etc
• Engage staff
▫ Empowerment
▫ Communicate
Benefits achieved
Change events planned
▫ Use suggestion boxes / emails etc
• Leadership and vision
▫ Encourage - Listen – Motivate
▫ Managers should regularly plan to “walk the floor”
▫ Embed Lean as “the way we do things”
Process mapping exercise
• In groups of 4-5 map a process
• Pick a process, e.g.
Screening a TTA in the dispensary
Getting ready to go to work
Identify each step in the process
Identify which steps do not add any value
Identify any issues / problems with each step
Other Lean building blocks
• Visual controls
▫ All needed information, material, and indicators are in
plain view
• Standard work
▫ Consistent performance of a task, according to
proscribed methods / SOPs, without waste and
focussed on human movement (ergonomics)
• Batch size reduction
▫ One-piece flow - “Make one and move one”
• Teams
▫ Emphasis on team working
• Quality at source
▫ Ensuring the product / information that is passed on to
the next process is of an acceptable quality
• Using the “one-point
lesson” in training/SOPs
▫ Visual tool
▫ Train someone on how to
do one thing in 10 min or
less
▫ Also suitable for complex
tasks if broken down into
steps
Lean Kaizen. A Simplified approach to process management.
Alukal G, Manos A. ASQ Quality Press.2006
• A key to successful
quality improvement
= Measurement of
progress and success
• Performance
indicators
• PDSA cycle – Model
for improvement
• Controlled (but rapid)
experimentation
PDSA cycle
http://www.scotland.gov.uk/publications/2008/01/14161
901/3
• Plan – Do – Study - Act
• A method to test ideas
safely
Starting small and
building on the results of
the cycle
With each cycle you
gather more knowledge
to help make the next
improvement
Allows measurement of
the effect of the change
over time
Testing and spreading
• Testing: 1510spread
▫ One patient then 5 patients
then 10 patients then a
ward…
• At the end of each ‘try’ go
into a huddle with those
trying out the change
▫
▫
▫
▫
What worked
What didn't work
Change as necessary
Test again tomorrow
 Document decisions
Rapid Test Cycles
Spreading the change
• Identify a leader who is responsible for the spread
▫ Be able to remove obstacles
• Identify the target population for the spread
▫ Which wards / units etc.
• What did you learn from the pilot areas(s) where you
tests your change?
 What key messages will explain the new system / idea to
the target population?
▫ Patient stories / Show results / Individual testimonies
from those who have benefitted from the change
• Good communication
“All improvement will require change
but not all change will result in
improvement”
Langley G, et.al. The Improvement Guide. 2nd edn. Pub: JoseyBass. 2009
ISBN 978-0-470-19241-2
Levels of measurement
1. Outcome measures
▫
How the overall system is improving - the end result
2. Process measures
▫
How the individual parts of the system are working
3. Balancing measures
▫
What happens elsewhere in the system when you
make the change - other consequences
• Consider sampling e.g. 5 patients per ward
per week
Measurement for improvement
Measurement for Research
Measurement for Learning and
Process 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 Gather "just enough" data to learn
in case"
and complete another cycle
Duration Can take long periods of time to
obtain results
"Small tests of significant changes"
accelerates the rate of improvement
From: Institute for Healthcare Improvement
<http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx>
Run charts
• Graph your results
• These can be statistical or visual
• Annotate your results with your changes to see their
influence
Percentage of patients with one or more critical drugs missed in the preceding 72 hours, split by
month and ward
AUG 2012 - non-critical delayed (any drug not given
30%
JULY 2013 missed doses
campaign
1. Re-launch magazine rack
2. New drug bulletin
3. Divisional safety team
support
within 90mins but given within 12 hours) medication
taken out of data collection.
SEPT 2012
Interventions
25%
- Feedback form introduced
- Departmental education
Feb 14
SEPT 2013 – More
specific strategy
to engage band 5
nurses
JAN/FEB 2013
20%
Understaffing
(nursing) and
excessive bed
pressure?
1. Magazine rack with bike
light
2. Red dots re-launched
3. Drug Bulletin Issue2
4. Spread to ward 12 and 4
15%
10%
MARCH - MAY 2013
New drug cupboards
installed
Jan 14
New
medical
model
of care
NO
DATA
5%
0%
MAU critical drugs
Ward 4 critical drugs
Ward 12 critical drugs
Using the model for improvement
• From your process mapping
▫ Are there any areas you would wish to try out a
change?
▫ Using the project template provided design a rapid test
cycle
 Part of the day job
Engagement and empowerment
• “Quality improvement is
everyone’s priority”
• “We want your ideas and
suggestions for
improvement”
 Problems and
countermeasures sheets
 Capture ideas and issues
 Show progress to
resolution of the issue
• Problems are not solved
in the meetings room,
they are solved at the
workplace
Failure Modes and Effects Analysis
• FMEA is an effective way of using a multidisciplinary
team to analyse a process to see where there are
areas of concern
• Failure modes
▫ What could go wrong?
• Failure causes
▫ Why could the failure happen?
• Failure effects
▫ What would be the consequences of each failure?
Occurrence scale
Scoring description of each FMEA step
Severity scale
Detection scale
1 - Remote:
No known occurrence
or/ Happens < 10% of the time
1 - No effect
1 – Very high
Error almost always detected
or/ We’ll catch it 9 times out of 10
3 - Low:
Possible, but no known data
Or/ Happens 10-30% of the time
2 - Slight annoyance
May affect the patient
3 – High
Error likely to be detected
or/ We’ll catch it 7 times out of 10
5 - Moderate:
Documented but less frequent
Or/ Happens 40-60% of the time
3 – Moderate system problem
May affect the patient
5 – Moderate
Moderate likelihood of detection
or/ We’ll catch it 5 times out of 10
7 - High
Documented and frequent
Or/ Happens 70-80% of the time
5 – Major system problem
May affect the patient
8 – Low likelihood of detection
or/ We’ll catch it 2 times out of 10
10 - Very high:
Documented, almost certain
o/r Happens 90-100% of the time
7 – Minor injury
Temporary patient harm
10 – Detection not possible at any
point
or/ We’ll never catch it!
9 – Major injury
Permanent lessening of body function,
surgical intervention required,
disfigurement
10 – Terminal injury or death
http://www.ihi.org/resources/Pages/Tools/FailureModesandEffectsAnalysisScoringSystem.aspx
FMEA example – Medicines reconciliation in admissions
1
4
5
2
3
6
7
Record online at IHI.org using an interactive tool
<http://app.ihi.org/Workspace/tools/fmea/>
Programme theory and Action Effect
Model
Reed JE, et al. BMJ Qual Saf 2014;0:1–9. doi:10.1136/bmjqs-2014-003103
Review of learning outcomes
• We have
• Explain the principles behind elimination of waste in
using Lean
• Select appropriate tools to use in local quality
improvement initiatives
• Apply the Model for Improvement to any quality
improvement measure
On Monday
• Identify two areas of waste in your workplace
• Map a process that you or colleagues feel is either
▫ Wasteful
▫ Inefficient
▫ That could highlight concerns / patient risk
• Discuss running a FMEA on a high risk process with
your Trust’s Medication Safety Officer
Any questions?


[email protected]
0117 923 0000 bleep 2268
Woodrow Wilson
Sir Winston Churchill
Further information
<http://w
ww.nhsiq.
nhs.uk/>
<http://www.pharmacyqs.com/>
<http://www.ihi.org/Pages/default.aspx>
<http://www.changemodel.nhs.uk/pg/dashboard>
• Process mapping using Excel
▫ http://www.leanhealthcareacademy.co.uk/Page/About/lean_tools
• You Tube videos
▫ Mayo Clinic Introduction to Quality Improvement
 https://www.youtube.com/watch?v=f-FbIA3ezBw
▫ Introduction to Lean Kaizen, DMAIC and Six Sigma
 https://www.youtube.com/watch?v=WA3t20upCHI
▫ … lots more on You Tube!
• Scoville R. Little K. Comparing Lean and Quality
Improvement. IHI White Paper. 2014. www.ihi.org
• Reed JE, McNicholas C, Woodcock T, Issen L, Bell D.
Designing quality improvement initiatives: the action
effect method, a structured approach to identifying
and articulating programme theory. BMJ Quality &
Safety Online First. 15 Oct 2014, 10.1136/bmjqs2014-003103.
• The how-to-guide for measurement for
improvement. Patient Safety First. 2005
▫ http://www.patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/How-to-guides-2008-0919/External+-+How+to+guide+-+measurement+for+improvement+v1.2.pdf