The first step when considering an improvement project is to ask yourself four important questions:

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1 Quality 101 Quality Improvement Date posted: 11/16/2010 The first step when considering an improvement project is to ask yourself four important questions: 1. What process do we want to improve and why? 2. How will we know if a change results in improvement? 3. What changes could we make that might result in improvement? 4. Who should be on the improvement team? 1. What process do we want to improve and why? What are we trying to accomplish? When answering this question, it is important to keep the answer concise. It doesn t have to be the perfect definition of the problem; rather, the answer will serve as a starting point for our work, which will keep us focused Don t include the solution in the problem statement. For example, a sandwich shop owner facing long customer wait times might try to answer the question with we want to add tables to our shop. However, this is not an appropriate improvement project definition, it is a predefined solution to a perceived problem Don t assign blame in the problem statement Project aims should be measurable and time-specific, if possible Project Definition examples: CORRECT: We want to shorten wait time in line to less than five minutes for our customers by July 15th INCORRECT: We want to shorten wait times for our customers (not time-specific, less measurable) INCORRECT: We want to add tables to our sandwich shop to shorten wait times for our customers (predefined solution)

2 INCORRECT: We want to shorten wait times for our customers which have been long due to lack of tables (assigning blame) 2. How will we know if a change results in improvement? When answering this question, it is important to determine objective ways of measuring improvement. Typically it is easiest if measures can be defined on a numeric scale. Consider how you will use the data you collect before collecting it. Will you plot it on a graph over time? Will you want to divide it into groups? Consider using sampling, such as measuring the wait time for every tenth customer, instead of measuring for every customer. Measures example: CORRECT: Number of people in line at noon; Highest number of people in line during the lunch rush of 11:30-12:45; Longest individual customer wait time in line between 11:30 and 12:45; Average customer wait time in line between 11:30 and 12:45; Percentage of customers indicating that the wait time is acceptable on a customer survey INCORRECT: Line length (not specific as to when or how often to measure); People will wait in line less (not specific as to how many people to measure); Customers will complain about wait time less often (not specific as to less ) 3. What changes could we make that might result in improvement? When answering this question, it is often helpful to get ideas from a variety of perspectives, including management, employees, customers, and industry research. Change concepts to help generate ideas for changes include 1 : a. Eliminate Waste 1 The Improvement Guide (Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. San Francisco, California, USA: Jossey-Bass Publishers, Inc.; 1996)

3 b. Improve Work Flow c. Optimize Inventory d. Change the Work Environment e. Producer/Customer Interface f. Manage Time g. Focus on Variation h. Error Proofing i. Focus on the Product or Service 4. Who should be on the improvement team? Teams will vary in the number and type of people included. The team should be composed to suit the project s needs. It may be helpful to keep core membership to 7 or less people to make it easier to schedule meetings. First, review the project definition and what we are trying to accomplish. Second, consider what processes will be affected by the improvement efforts. Make sure people who participate in or are affected by these processes are involved in the improvement team. Ensure that the team includes members familiar with all the different parts of the process managers and administrators as well as those who work in the process, including physicians, pharmacists, nurses, and front-line workers Now that you have learned about the four important questions regarding project definition, measures, potential changes, and team, you are ready to move on. The second step when considering implementation of an improvement project is review the Plan Do Study - Act Cycle, often referred to as PDSA. This scientific model for implementing change, popularized by W. Edwards Deming 2, allows you to track and respond to the success of your improvements. 2

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5 Step 1: PLAN Select a change to focus on first. Implementing more than one change simultaneously may make it difficult to determine which change is responsible for any improvements. To determine which change to try first, ask yourself the following questions: How easy would it be to implement this change? What steps do I need to take in order to try it? What resources do I need to try this change? (FTEs, money, equipment, training, outside expertise, knowledge, skills, policies, protocols) Are there enough people to staff the improvement team for this change without negatively affecting the organization s day-to-day work? What do I think will happen when the change is implemented? What is the predicted likelihood of success? Who is responsible for each step of implementing the change and when will these steps be performed? How will you measure the effect of the change? What measure(s) will you track?

6 Step 2: DO Implement the change. Here are a few tips for successful implementation 3 o Scale down the scope of the test of change you don t need hundreds of data points to make it a good test o Pick willing volunteers pick people who want to participate in a pilot, not those you have to convince o Avoid the need for consensus, buy-in, or political solutions. Save these for later stages. When possible, choose changes that do not require a long process of approval, especially during the early testing phase o Don t reinvent the wheel. Research changes that have been implemented elsewhere successfully and consider modifying them for your own institution o Overcome technical barriers. Don t wait for the new computer system to start your pilot; you can conduct a small test of change using paper and pencil instead o Remember that not all changes will lead to improvement that is why it is called a test. You may need to discontinue some of your changes o Document unexpected observations. You may learn the most about your process from these situations 3

7 Step 3: STUDY In the Study phase, it is not enough to simply say yes, there was an improvement or no, there was not an improvement It is important to describe the results achieved by a change, and analyze how the actual results compare to the predicted results This analysis will help you build additional knowledge about the process you are working to improve There are several techniques for data analysis you can utilize in the Study phase Impact/Effort Matrix Process Mapping Pareto Charts Control Charts Step 4: ACT The ACT phase is when you will review the results of your small test of change. What can you do to improve and refine the change and improvement? Here are some reasons we test changes. These may help you decide how to refine your change in the ACT phase 4 To increase your belief that the change will result in improvement To decide which of several proposed changes will lead to the desired improvement To evaluate how much improvement can be expected from the change To decide whether the proposed change will work in the actual environment of interest 4

8 To decide which combinations of changes will have the desired effects on the important measures of quality To evaluate costs, social impact, and side effects from a proposed change In addition, collecting testing data and results that you can present to your coworkers may reduce resistance upon implementation. Small Cycles of Change The improvement process is not necessarily over just because you have reached the ACT phase of your project. Several natural progressions of your project may present themselves at this time: If you piloted on one unit or with just a few patients or clinicians, roll the change out to additional units, patients, or providers. This is when you will need to sell the change to people who have not been involved in the project from the start. If you piloted a change with an informal support structure, it may be necessary to formalize that structure now that your change will be permanent. Consider structure around training, documentation, and standardization. Now you can consider whether implementing another change would further improve the process. Start again by asking the four questions, and then begin again with Plan Do Study Act. In the subsequent cycles, it is important to consider how the individual changes interact to affect the process as a whole.

9 In summary, quality improvement is about measuring, making a change, and measuring again to know whether your change created improvement. The Plan Do Study Act approach is a scientifically-based method to implement changes to improve quality. It allows us to quickly understand if the change we have made is responsible for improvement in the outcomes, and to correct course if the change does not result in improvement. Recommended Resources The Improvement Guide (Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. San Francisco, California, USA: Jossey-Bass Publishers, Inc.; 1996). An easy to follow book about quality improvement methods. The Institute for Healthcare Improvement Website Free, high-quality information about quality improvement methods. AHRQ Innovations Exchange Review projects other institutions have implemented. AHRQ Patient Safety Primers Learn more about patient safety focus areas.

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