A Guide to Quality Improvement

Transcription

1 A Guide t Quality Imprvement What is quality imprvement? Quality imprvement (QI) is abut imprving patient (and ppulatin) utcmes, system perfrmance and prfessinal develpment. 1 The Institute f Healthcare Imprvement (IHI) have develped the Mdel fr Imprvement (MFI) which is ne type f QI methdlgy. 2 The MFI is being successfully adpted in many healthcare settings t imprve patient care. Mre than the methdlgy, QI is abut a change in behaviurs, wrking tgether, change cming frm the bttm up, creative thinking, and fundamentally, using measurement t guide imprvement. QI is distinctly different t audit and has been shwn t bring abut mre sustained imprvement. What is the Mdel fr Imprvement? The Mdel fr Imprvement cnsists f the 3 questins belw. These questins shuld act as guide when planning yur prject and yu shuld refer back t them during the running f yur prject t ensure yu are n track. Mdel fr Imprvement What are we trying t Hw will we knw that a change is an imprvement? What changes can we make that will result in imprvement? Hw t interpret each questin? Set yur aim & then plan yur prject with a prcess map and driver diagram Regular real time measurement will infrm yu if changes yu test bring abut imprvement Develp ideas & test them using PDSA cycles Act Study Plan D

2 1. Batalden D, Davidff F. What is quality imprvement and hw can it transfrm healthcare. Qual Saf Health Care 2007;16:2-3 di: /qshc Langley GL, Nlan KM, Nlan TW, Nrman CL, Prvst LP. The Imprvement Guide: A Practical Apprach t Enhancing Organizatinal Perfrmance (2nd editin). San Francisc: Jssey-Bass Publishers 2009 Hw d I frm the right team? T ensure success & sustainability f yur wrk, it is vital yu get the right team tgether. The team shuld include everyne wh has a stakehlder interest in yur prject. It shuld be multi-disciplinary, include smene with enugh senirity t make key decisins, have permanent members f staff t ensure sustainability, include peple with specialist knwledge as well as frntline staff wh will champin yur wrk. Aim Setting Having the right aim is a fundamental part f starting yur prject. The right aim will prvide clarity, engage stakehlders, generate enthusiasm and enable measurement. The aim shuld be a stretch aim ie. an aspiratin, nt a target yu reached within a week. The aim shuld be SMART: Specific wh, what, where, when Measureable numeric gals, by hw much? Achievable within yur influence Realistic/relevant t stakehlders and rganisatin Timely by when, give a precise date WEAK AIM Why is it a weak aim? STRONG AIM Reduce the number f resident falls in a care hme Residents must have a nutritin plan within 48 hurs 95% f residents will have their medicatins in a timely manner S: which care hme, type f fall (all r injurius?) M: reduce by hw much? T: by when? S: Is it all residents r just the new nes r a six mnthly review? Within 48 hurs f what? Newly welcmed r thse back frm hspital? R: Relevant? D all residents need a nutritin plan? T: by when S: Which medicatins prescribed r PRN? M: What d we mean by timely? At the exact time r within 30 minutes/60 minutes T: give an actual date! Reduce the n. f injurius falls 4 by 50% in XXX care hme by 31 st Dec 2015 All new residents at XXX care hme will have a full nutritin assessment, plan and cmmunicated t all staff within 48 hurs f arriving by Octber 2014 All residents will receive their prescribed medicatins within 30 minutes f the time prescribed by 1 st Octber 2014 at XXX care hme.

3 Prcess Mapping A prcess map sets ut exactly what ccurs in the system at the mment. It maps ut the current pathway and can be used t identify prblem areas, stakehlders and ideas fr change. Driver Diagrams A driver diagram sets ut the plan fr yur prject in a visual and effective diagram The diagram includes yur smart aim and the primary and secndary drivers needed t reach that aim. Primary drivers: essential factrs that need t be addressed in rder t achieve the aim Secndary drivers: what factrs lead t yur primary drivers Nb. A secndary driver shuld directly lead t a primary driver, which shuld be essential t achieving yur aim. Each primary driver must be essential t yur prject, ie, withut it, yur prject wn t succeed Driver diagrams help identify the measures fr yur prject as well as yur t d list T start yur driver diagram, have a sessin with yur team where yu brainstrm n pst-its, all the factrs needed t meet yur aim then grup the factrs int primary and secndary drivers Eg.AIM: AIM: T reduce all falls by 50% in all residents at XXXX care hme by December 2015 Step 1: Brainstrm-what factrs need t be in place t achieve this aim? Awareness f falls Resurces Risk assess Time Pathway Team buy-in Cmputer Training Named persn respnsible Falls Interventins

4 Step 2: Use yur driver diagram t grup int primary and secndary drivers Primary Drivers Secndary Drivers Reliably risk assess Risk assessment frm Training hw t assess falls risk Respnse plicy AIM: T reduce all falls by 50% fr all Respnd - Reliably Identify the risks Infrm bth resident and sister in charge Decide n a plan Implement the plan Review medicatins Implement interventins ie anti-slip Training Train bth the staff and residents Identify time fr training Resurce t pay fr the training Step 3: Frm this yu can nw develp measures and yur t-d list. Measures: AIM: Number f falls Examples f ther measures: The number f staff and residents wh have been trained The number f fully cmpleted risk assessments perfrmed Measurement fr Imprvement Rigrus, real time measurement is a key part f QI and shuld drive yur prject. There are 4 types f measures needed: 1. Outcme measure: this is yur aim and shuld relate directly t the patient/ppulatin 2. Prcess measures: measuring the integral aspects f yur system eg. percentage pathways cmpleted 3. Balancing measures: the knck n effects f yur prject 4. Financial measures: these shuld nt drive yur prject, but need t be understd

5 Eg. Aim: Reductin f inpatient pressure ulcers by 50% 1. Outcme measure: N. f residents falls 2. Prcess measure: The number f cmpleted falls risk assessments Balancing measure: Are mre residents develping pressure ulcers as a result f decreased mbility t prevent the falls 3. Financial measures: csting attributed t reductin f falls Key rules f measurement fr imprvement: Measure at weekly r mnthly intervals (little but ften a sample will d) Ensure measurement is in real time Make it easy t understand Make it part f yur wrking rutine and s easy t cllect Anntate yur charts with the tests f change yu have tried, s yu can learn frm what yu have tried and understand what has made a difference Sample size: needs t be gd enugh, nt perfect. This is nt research! Yu nly need a sample size large enugh t identify if yu have a prblem in yur system. Displaying yur measurement: use run charts ie. time series charts Examples f QI run charts: AIM: T reduce all falls by 50% in all residents at XXXX care hme by December 2015

6 Tests f change T imprve a system, changes need t be tested t see if they make an imprvement. Testing invlves rigrus real time measurement, t see if there is an imprvement. All imprvement will require change, but nt all change will result in imprvement. P Batalden Testing change is dne using PDSA cycles (see diagram belw). PDSA cycles shuld be carried ut fr each test undertaken. Fr each test f change, run the PDSA cycle as fllws: 1. Plan: What test f change d yu want t try? Where are yu ging t try it and n wh? What d yu expect t happen? Hw will yu measure it? 2. D: Carry ut the test and measure 3. Study: Analyse yur results. What happened when yu ran the test? Did it meet yur expectatins? 4. Act: Adpt, adapt r reject the change. Perhaps test it n mre patients? Try a new test f change. Features f PDSAs Keep tests small s failures cause minimal damage Measure, s yu understand the impact f any change Anntate yur run charts with yur tests f change Dn t change the system till yu understand the impact f changes

7 Retest the change in each new envirnment eg, dn t assume a pathway which has been tested in ne clinic will wrk in the next clinic Give team members wnership f different tests Celebrate failures, this is useful infrmatin t Eg. Aim: 95% discharge summaries are sent n day f discharge in Basildn Hspital. Start small, take ne team n ne ward. Get it t 95% with that team first, befre mving t the whle team r care hme. CYCLE PLAN DO STUDY ACT 1 -Hld a teaching sessin with the team and residents -Hld the teaching sessin -Measure weekly the n f falls What did the measurements shw? -Adpt, reject r redesign the teaching sessin -Trial it again -Try anther 2 Re-design the falls assessment frm -Trial n ne day with ne resident Ask fr feedback and respnd -Adpt, reject, adapt the system 3 Intrduce an alert system which enables residents t say if they feel at risk f falling Intrduce a safety huddle fr each handver -Trial it n ne week with a grup f residents Try it ne day Analyse the results Ask fr feedback frm the team -Adpt, adapt, reject Yu can then develp yur run chart by anntating the changes yu have tested

8 Other Useful Resurces Useful article: Batalden D, Davidff F. What is quality imprvement and hw can it transfrm healthcare. Qual Saf Health Care 2007;16:2-3 di: /qshc A yu tube summary f the mdel fr imprvement: Scttish Imprvement Hub prvides a useful cllectin f resurces: Resurces fr cre medical trainees ding a QI prject: The Institute f Healthcare Imprvement has useful resurces as well as sme nline curses: