Performance Improvement in Health Care
Question 1
With your understanding of the PDCA Cycle, for this week's assignment, apply the PDCA principles to improve/solve a problem or process that you've experienced in your (family, work, or school) life recently.
Create a PDCA diagram, summarize the problem/process, and then describe/summarize each of the 4 steps as it applies to the problem/process that you've set out to improve.
Lastly, answer the question of whether using the PDCA principles helped you to improve/solve the problem or process you presented–or not.
Video must watch
(I work Full-time as a Senior Admin Assistant for Emergency Medicine Department and school full-time, and I am married and a family oriented person)
APA Format
PDSA: Plan-Do-Study-Act
Also Called: Rapid Cycle Improvement, PDCA (Plan-Do-Check-Act)
What is PDSA? Stage 1: Plan Stage 2: Do Stage 3: Study Stage 4: Act Examples More Information
What is PDSA?
PDSA, or Plan-Do-Study-Act, is an iterative, four-stage problem-solving model used for improving a process or carrying out change.
When using the PDSA cycle, it's important to include internal and external customers; they can provide feedback about what works and what doesn't. The customer defines quality, so it would make sense to also involve them in the process when appropriate or feasible, to increase acceptance of the end result. (If you're unsure about, who your customers are, you may want to create a customer chain to assist in identification.)
In applying PDSA, ask yourself three questions:
1. What are we trying to accomplish?
2. How will we know that a change is an improvement?
3. What changes can we make that will result in an improvement?
Stage 1: Plan
A. Recruit Team
Assemble a team that has knowledge of the problem or opportunity for improvement. Consider the strengths each team member brings—look for engaged, forward-thinking staff.
After recruiting team members, identify roles and responsibilities, set timelines, and establish a meeting schedule.
B. Draft an Aim Statement
Describe what you want to accomplish in an aim statement . Try to answer those three fundamental questions:
1. What are we trying to accomplish?
2. How will we know that a change is an improvement?
3. What change can we make that will result in improvement?
C. Describe Current Context and Process
Brainstorm
Examine your current process. Start by asking the team these basic questions:
· What are we doing now?
· How do we do it?
· What are the major steps in the process?
· Who is involved?
· What do they do?
· What is done well?
· What could be done better?
You might have already answered the last two questions if you have performed a SWOT analysis .
Try a Swim Lane Map
You may find it helpful to construct a swim lane map to visually describe your process.
Creating a process flow or at least depicting the current process can be very useful. If your team runs into road blocks, you might have found where the problem is occurring—or maybe the right person for identifying a missing step is not at the table.
Gather More Detail
Once the general structure is completed, these can be some more helpful questions to ask:
· How long does the process currently take? Each step?
· Is there variation in the way the process is currently completed?
D. Describe the Problem
Using the aim statement created in Step B, state your desired accomplishments, and use data and information to measure how your organization meets/does not meet those accomplishments.
For example: If your objective is to maximize your staff's quality of work life, you might find evidence by surveying employees on workplace stressors.
Write a Problem Statement
Write a problem statement to clearly summarize your team's consensus on the problem. You may find it helpful to prioritize problems, if your team has identified more than one, and/or include a justification of why you chose your problem(s).
E. Identify Causes and Alternatives
Analyze Causes
For the problem in your problem statement, work to identify causes of the problem using tools such as control charts , fishbones , and work flow process maps (e.g., flowcharts , swim lane maps ). The end of the cause analysis should summarize the cause analysis by describing and justifying the root causes.
Examine your process, and ask:
· Is this process efficient? What is the cost (including money, time, or other resources)?
· Are we doing the right steps in the right way?
· Does someone else do this same process in a different way?
Develop Alternatives
Try to mitigate your root causes by completing the statement,
"If we do __________, then __________ will happen."
Choose an alternative (or a few alternatives) that you believe will best help you reach your objective and maximize your resources.
Develop an action plan, including necessary staff/resources and a timeline. Try to account for risks you might face as you implement your action plan.
Stage 2: Do
Start to implement your action plan. Be sure to collect data as you go, to help you evaluate your plan in Stage 3: Study. Your team might find it helpful to use a check sheet , flowchart , swim lane map , or run chart to capture data/occurrences as they happen or over time.
Your team should also document problems, unexpected effects, and general observations.
Stage 3: Study
Using the aim statement drafted in Stage 1: Plan, and data gathered during Stage 2: Do, determine:
· Did your plan result in an improvement? By how much/little?
· Was the action worth the investment?
· Do you see trends?
· Were there unintended side effects?
You can use a number of different tools to visually review and evaluate an improvement, like a Pareto chart , control chart , or run chart .
Stage 4: Act
Reflect on Plan and Outcomes
· If your team determined the plan resulted in success, standardize the improvement and begin to use it regularly. After some time, return to Stage 1: Plan and re-examine the process to learn where it can be further improved.
· If your team believes a different approach would be more successful, return to Stage 1: Plan, and develop a new and different plan that might result in success.
The PDSA cycle is ongoing, and organizations become more efficient as they intuitively adopt PDSA into their planning.
Celebrate Improvements and Lessons Learned
· Communicate accomplishments to internal and external customers
· Take steps to preserve your gains and sustain your accomplishments
· Make long-term plans for additional improvements
· Conduct iterative PDSA cycles when needed
More Information
The ABCs of PDCA and PDSA Flowchart (PDF) Public Health Foundation
Embracing Quality in Local Public Health (PDF) Michigan Local Public Health Accreditation Program
Baldrige Performance Excellence Program National Institute of Standards and Technology, US Dept. of Commerce
PDSA [Note: Video will autoplay] Institute for Healthcare Improvement
Whiteboard: The PDSA Cycle (Part 1) [Note: Video will autoplay] Whiteboard: The PDSA Cycle (Part 2) [Note: Video will autoplay] Institute for Healthcare Improvement
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Chapter 1: The Global Evolution of Continuous Quality Improvement: From Japanese Manufacturing to Global Health Services
Outline
Introduction
Definitions
Characteristics / Elements of CQI
Evolution of CQI in Health Care
Broad-Based Approaches to CQI
Introduction
Continuous quality improvement (CQI) has evolved over time and across countries
Substantial progress has been made in the diffusion of CQI in health, e.g., in public heath
The need for greater diffusion of CQI continues, particularly due to greater complexity in health care systems
Quality and safety problems persist in health care and new techniques are available to address these
Definition of Quality in Health
The WHO definition of quality of care is “the extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centered.”
Components of Health (WHO)
Safe. Delivering health care that minimizes risks and harm to service users, including avoiding preventable injuries and reducing medical errors.
Effective. Providing services based on scientific knowledge and evidence-based guidelines.
Timely. Reducing delays in providing and receiving health care.
Efficient. Delivering health care in a manner that maximizes resource use and avoids waste.
Equitable. Delivering health care that does not differ in quality according to personal characteristics such as gender, race, ethnicity, geographical location or socioeconomic status.
People-centered. Providing care that takes into account the preferences and aspirations of individual service users and the culture of their community
Quality Assurance(QA)
QA focuses on conformance quality, which is defined as “conforming to specifications; having a product or service that meets predefined standards” (McLaughlin & Kaluzny, 2006, p. 37).
QA is sometimes the primary goal of accreditation processes.
Definition of CQI in Health Care
CQI is defined as a structured organizational process for involving personnel in planning and executing a continuous flow of improvements to provide quality health care that meets or exceeds expectations
Common Characteristics of CQI
• a link to key elements of the organization’s strategic plan;
• a quality council made up of the institution’s top leadership;
• training programs for personnel;
• mechanisms for selecting improvement opportunities;
formation of process improvement teams;
• staff support for process analysis and redesign;
• personnel policies that motivate and support staff participation in process improvement;
• application of the most current and rigorous techniques of the scientific method and statistical process control.
Societal Cost of Poor Quality
Crosby: Cost of quality (“Quality is free”, 1979)
Cost of (poor) quality = cost of nonconformance
Poor quality care has an impact on the patients directly affected, the services which provide that care, and society at large
unnecessary costs associated with waste and wasted effort when work is not done correctly the first time.
includes the costs of identifying errors, correcting them, and making up for the customer dissatisfaction that results.
This view leads naturally to a broadening of the definition of quality by introducing the concept of adding value, in addition to ensuring the highest quality of care.
Quality/Accountability/Value
Improving quality involves three aims (“The triple aim: Care, health, and cost”: Berwick et. al, 2008: 759):
Improving the experience of care
Improving the health of populations
Reducing the per capita costs of health care
At a more micro level, improving quality also involves professional responsibility and development
An example of the evolution continuing in the 21st Century
These concepts have evolved further in the second decade of the 21st century to include a fourth aim directed at ensuring the well being of health care providers
See Chapter 2 (Bodenheimer & Sinsky, 2014)
Rationale for Implementation of CQI in Health Care
Health care organizations embark on CQI for a variety of reasons, including:
Engagement in true process improvement
Give customers (patients) the quality care they deserve
AND / OR
Accreditation requirements,
Cost control,
Competition for customers, and
Pressure from employers and payers
Characteristics/Functions of Health Care CQI
(1) Understanding and adapting to the external environment;
(2) empowering clinicians and managers to analyze and improve processes;
(3) adopting a norm that the term customer includes both patients and providers and that customer preferences are important determinants of quality in the process;
(4) developing a multidisciplinary approach that goes beyond conventional departmental and professional lines;
Characteristics/Functions of Health Care CQI
(5) adopting a planned, articulated philosophy of ongoing change and adaptation;
(6) setting up mechanisms to ensure implementation of best practices through planned organizational learning;
(7) providing the motivation for a rational, data-based, cooperative approach to process analysis and change; and
(8) developing a culture that promotes all of the above.
CQI: Philosophy and Process
CQI is simultaneously two things: a management philosophy and a management method.
It is distinguished by the recognition that customer requirements are the key to customer quality and that customer requirements ultimately will change over time because of changes in evidence-based practices and associated changes in education, economics, technology, and culture.
In health care such changes, in turn, require continuous improvements in the administrative and clinical methods that affect the quality of patient care and population health.
Elements of CQI in Health Care
Philosophical Elements
Structural Elements
Health Care Elements
Philosophical Elements of CQI
Strategic Focus
Customer Focus.
Systems View
Data-driven (evidence-based) Analysis
Implementer Involvement
Multiple Causation
Solution Identification
Process Optimization
Continuing Improvement.
Organizational Learning
Structural Elements of CQI
Use of process improvement teams
Use of CQI tools
Creation of parallel organization (Quality Council) to monitor CQI
Gain commitment from top management
Utilize statistical analysis
Develop and review customer satisfaction measures
Use benchmarking
Engage in redesign of processes
Examples of CQI Tools
Flow charts
Run charts
Control charts
Cause and effect diagrams
Frequency
charts
Checklists
Pareto charts
Healthcare Elements of CQI
Use of epidemiological and clinical studies (evidence based medicine)
Involvement of staff in governance and peer review
Use of risk-adjusted outcome measures
Use of cost-effectiveness analysis
Use of quality assurance and risk management data and techniques
Evolution of CQI
From Japan(post-WW II) to US (1960s) to the World (21st century)
Most recently: to low and middle income countries
From TQM to CQI
Pioneers
Deming (14 points)
Shewhart
Juran
Feigenbaum
Crosby
Donabedian
Continuing Evolution in Japan
Taguchi
Ishikawa
Deming’s 14 Points
Deming’s 14-Point Program
Reprinted from The New Economics for Industry, Government, Education by W. Edwards Deming by permission of MIT and W. Edwards Deming. Published by MIT, Center for Advanced Engineering Study, Cambridge, MA 02139. Copyright © 1993 by W. Edwards Demig.
Cross Disciplinary Thinking
Cross-Disciplinary Strategic Thinking
Industrial Versus Health Care Quality
Cons
Ignores complexities patient-practitioner relationship;
Downplays competencies and motivation of the practitioner;
Ignores quality-cost trade-offs;
Gives less to clinical activities than to supportive ones;
Limited perspective on mechanisms for influencing professional behavior such as “education, retraining, supervision, encouragement and censure”
Pros
Importance of health care quality traditions.
Greater attention to consumers
Greater attention to system designs and processes
Expansion of self-monitoring, self-governing tradition to all staff
Greater role by management in CQI
Development of appropriate applications for health care monitoring.
Greater education and training in CQI for all staff
Evolution of CQI in Health Care
From hospitals to all segments of healthcare
From doctors and managers to all staff
From specialized knowledge to generalized competencies
From localized activities to national and international regulatory and accrediation agencies
The Big Bang of CQI
Institute of Medicine
To Err is Human (2000)
Crossing The Quality Chasm (2001)
Data already know, but these report galvanized the press, the public, professional groups and regulators
Increased demands for accountability and professional responsibility
Transfer of concerns from managerial responses, to across the board responsibility
Revised Boynton & Victor Model for Health Care From Industrialization to Personalization
Revised Boynton and Victor Model for Health Care
Mass Personalization
Personalization must not be mixed up with customization. While customization relates to changing, assembling or modifying product or service components according to customers’ needs and desires, personalization involves intense communication and interaction between two parties namely customer and supplier. Personalization in general is about selecting or filtering information objects for an individual by using information about that individual (the customer profile) and then negotiating the selection with the individual….
(Tseng and Piller, 2003, p.7)
Examples of Personalization in Health Care
Increased accessibility of data and information leading to increased patient and family participation in decision making
Possibility of personalized medicine – right drug at the right dose at the right time
Focus on individual rather than (chronic) condition, including evidence based medicine and self management
Recent Evolutionary Trends in CQI
The integration of CQI into public health activities
The integration of CQI into nursing education (QSEN)
The expanding role of accreditation.
The global spread of CQI across countries and health services
Greater understanding and use of broad–based applications and methods
PDSA/PDCA
PDSA Plan-Do-Study-Act
Shewhart (PDSA) cycles “provide a structure for iterative testing of changes to improve quality of systems…The pragmatic principles of PDSA cycles promote the use of a small scale iterative approach to test interventions, as this enables rapid assessment and provides flexibility to adapt the change according to feedback to ensure fit-for-purpose solutions are developed” (Taylor et al. 2014, pp.290-291).
PDCA is an alternate definition of PDSA
Used interchangeably
C:Check is equivalent to S:Study
Shewhart (PDSA) Cycle
Shewhart (PDSA) Cycle
Reprinted from The New Economics for Industry, Government, Education by W. Edwards Deming by permission of MIT and W. Edwards Deming. Published by MIT, Center for Advanced Engineering Study, Cambridge,
MA 02139. Copyright © 1993 by W. Edwards Demig.
Key Features of PDSA
The use of repeated iterative cycles
Prediction-based test of change (developed in the plan stage)
Small-scale testing (build as confidence grows – adapting according to feedback and learning)
Use of data over time (to understand the impact of change)
Documentation (to support local learning and transferability to other settings)
Source: Taylor et al. 2014, p.293.
FOCUS-PDCA
The FOCUS–PDCA Cycle
FOCUS-PDCA
FOCUS-PDCA creates common language and an orderly sequence for implementing CQI. It focuses on the answers to 9 questions (Batalden and Stoltz, 1993):
1. What are we trying to accomplish?
2. How will