What is Quality Improvements

The purpose of this module is to help you understand and apply principles and practices of Quality Improvement (QI). It will cover:
a) Measures of quality
b) Models of QI
c) The differences between QI and research



Objectives: By the end of this program, participants will be able to:
- Explain the difference between structure, process, and outcome indicators.
- Describe methods for measuring performance and assessing quality.
- Describe the FADE and PDSA models of Quality Improvement.
- Compare and contrast Quality Assurance and Quality Improvement.
- Distinguish between Quality Improvement projects and research.
- Apply the FADE or PDSA model to analyze and improve a clinical or administrative process.



The module has 5 sections:
Introduction - Brief intro to QI, stated importance and highlight issues.
Part 1 – Measurement: Process and outcome indicators
Part 2 - Methods of Quality Improvement
Part 3 – Things Quality Improvement is NOT
Summative Experience: Application level FADE and PDSA
Each section will include comprehension questions or exercises for your use to verify you have understood the material.



What is QI?
Quality Improvement is a formal approach to the analysis of performance and systematic efforts to improve it. There are numerous models used. Some commonly discussed include:
+ FADE
+ PDSA
+ Six Sigma (DMAIC)
+ CQI: Continuous Quality Improvement - http://deming.eng.clemson.edu/pub/tutorials/
+ TQM: Total Quality Management - http://www.mapnp.org/library/quality/tqm/tqm.htm
These models are all means to get at the same thing: Improvement. They are forms of ongoing effort to make performance better.

In industry, quality efforts focus on topics like product failures or work-related injuries.
In administration, one can think of increasing efficiency or reducing re-work.
In medical practice, the focus is on reducing medical errors and needless morbidity and mortality.

The first 3 models will be discussed in this module. For information on the other two, please select the relevant links above.



Contrasting QI and QA: Many people are familiar with the term Quality Assurance (QA), as it was a common term for many years.

Quality Assurance – QA was reactive, retrospective, policing, and in many ways punitive. It often involved determining who was at fault after something went wrong. This term is older and not as likely to be used today.

Quality Improvement – QI involves both prospective and retrospective reviews. It is aimed at improvement -- measuring where you are, and figuring out ways to make things better. It specifically attempts to avoid attributing blame, and to create systems to prevent errors from happening.

QI activities can be very helpful in improving how things work. Trying to find where the “defect” in the system is, and figuring out new ways to do things can be challenging and fun. It’s a great opportunity to “think outside the box.”

An effective QI program can really help make your life better.

Short Example of QI vs. QA
From the following statements, which do you think have a QA focus and which have a QI focus?

1. Which staff member failed to transfer the call to the correct extension?
2. Are we creating an environment encouraging technicians to report errors?
3. How do we reduce errors or rejections on the production line?
4. Patient had a bad outcome; were the designers or engineers at fault?
5. What could we do to increase the efficiency of chart filing?

If you think you have a good comprehension of the difference between QA and QI try to look at the QA statements and see if you could reword them to have a QI focus. Alternately you can also change the QI statements to QA. The main difference between QI and QA is that QI’s focus is on Improvement. The focus makes all the difference in how people respond to a quality project.



How Do You Define Quality?

The definition of quality often depends on the stakeholders. Stakeholders are, as the name implies, people with some stake or concern in the process.

In manufacturing, the definition of quality can be fairly straightforward. Products should work as intended with a minimum number of faults or failures. Stakeholders might be:

Management, who wants to see improved production numbers with acceptable quality.
Union officials, who want the best conditions and highest pay for employees
Employees, who want consistent work in a safe environment.
Customers/purchasers, who want value for their money.
In service industries, customer satisfaction is often the primary measure.

Example: John is the manager of a local Sleep-E Motel. He has just received the second quarter report from his national headquarters which shows his cost per room has been rising over the last year. John and his staff are given bonuses based on maintaining or lowering costs. Who/what are the stakeholders he should consider in assessing ways to lower his costs?

The answer is:
Employees – Want bonuses and continued job security in a nice workplace.
Customers – Want the lowest cost for the highest quality and most amenity.
Corporate – Want to see the highest profit for the lowest total cost.

In this example John has to take into account the stakeholders and their interests to correctly identify the “quality” component he should work to change. He could lower his costs by cutting staff but that would mean more work and a sense of insecurity for the remaining staff. He could raise the room costs, which may lead to lower customer satisfaction. Taking time to understand stakeholder concerns help clarify his options.



Methods of Quality Improvement: The FADE Model (Organizational Dynamics Institute, Wakefield, MA). There are 4 broad steps to the FADE QI model:

1. FOCUS: Define and verify the process to be improved
2. ANALYZE: Collect and analyze data to establish baselines, identify root causes and point toward possible solutions
3. DEVELOP: Based on the data, develop action plans for improvement, including implementation, communication, and measuring/monitoring
4. EXECUTE: Implement the action plans, on a pilot basis as indicated, and
5. EVALUATE: Install an ongoing measuring/monitoring (process control) system to ensure success.



FADE Model in Action

Example: Back to John at the Sleep-E Motel: Using a FADE model John FOCUSed on the linens cycle of housekeeping. He ANALYZEd the way linens were handled and found that the laundering process seemed to be inefficient. He DEVELOPed a step-by-step process for washing, drying, folding, and storing the linens which he expected would speed up the process and eliminate wasted effort. He then EXECUTed the process with his staff and will EVALUATE for effectiveness on a weekly basis.

This is a cyclic process. Once you’ve made a change, you start all over again:

You Evaluate the impact of your change
You Focus down further
You Analyze the problem to find the root cause(s)
Then Develop methods for further improvement
And Execute and Evaluate again!
Repeat the process until the goal is achieved.





This is the model in graphic form, including a little more detail of what can be included in each step. As you can see there are many parts within each of the basic four steps. Start in the middle of the circle and move out in each phase to see the sequential flow of the FADE process.

The small details are less important than the 4-step cycle.




PDSA: Another commonly used QI model is the PDSA cycle:

PLAN: Plan a change or test of how something works.
DO: Carry out the plan.
STUDY: Look at the results. What did you find out?
ACT: Decide what actions should be taken to improve.

Repeat as needed until the desired goal is achieved

PDSA Example
Issue: Ineffective team meetings that were causing more problems than they would resolve.

Cycle 1
PLAN – Took suggestions from group and used the suggestions to plan implementation of changes to improve the meetings effectiveness.

Fewer meetings
Follow an agenda
Assigning tasks prior to meeting

DO – Documented the process and passed out to group members for commentary and commitment to changes.
STUDY – Group members were worried about their assignments and agenda items to submit, today’s topic may not be the “hot” issue when the meeting was held.
ACT – Decided to proceed with the changes in spite of the concerns due to perception that the concerns were unfounded and based on fear of change.

Cycle 2
PLAN – New process initiated but only one topic submitted for agenda.

DO – He created an agenda with one topic and one regarding the lack of agenda items, assigned roles and held the meeting.

STUDY – Meeting was short for the wrong reason. People did not know what format to use when submitting agenda items. Also, concerned about how items would be used.

ACT – A form was created for submitting agenda items. Everyone was assigned to submit one item using the form for the next meeting.

Any further process issues would be addressed in the same manner.




Six Sigma: Six Sigma is another model for improvement. The term comes from the use in statistics of the Greek Letter (sigma) to denote Standard Deviation from the mean. 6 sigma is equivalent to 3.4 defects or errors per million.

Six Sigma is a measurement-based strategy for process improvement and problem reduction completed through the application of improvement projects. This is accomplished through the use of two Six Sigma models: DMAIC and DMADV.

DMAIC (define, measure, analyze, improve, control) is an improvement system for existing processes falling below specification and looking for incremental improvement.

DMADV (define, measure, analyze, design, verify) is an improvement system used to develop new processor products at Six Sigma quality levels.

Emergency Department example of Six Sigma use: The ED is often the first entry point for a community to the hospital, thus it is the place where positive or negative perceptions of the hospital initially may be formed. North Shore University Hospital in Forest Hills, N.Y., addressed this issue by initiating a Six Sigma project aimed at improving the patient experience in its Emergency Department. The project team took on the problem of excessive wait times in the ED while struggling at the same time with rising Healthcare costs and increasing volumes of patients. The results have been impressive

Cardiac Cath Lab use of Six Sigma: Cardiac catherization labs represent a significant capital investment for many hospitals. Realizing a return on this investment is increasingly challenging, given the introduction of advanced technologies and limitations in reimbursement. To meet the challenges and maintain fiscal health, hospitals are pursuing strategies such as Six Sigma, lean and change management techniques to improve throughput, maximize equipment utilization and increase efficiency.

Reducing Coding Errors with Six Sigma: Like a detective, Pam Thomson probed the mysteries of CPT coding errors in the pulmonary medicine department at University of Virginia (UVA) Medical Center, looking for hard evidence of what went wrong and why. Were coding errors correlated with the time of day, day of the week, or workload? Was something amiss in the physician/coder interaction that produced the code? Were errors related to some fundamental misunderstanding of a specific type of code that caused consistent overcoding or undercoding?


A Comparison of the Models


FADE PDSA DMAIC DMADV
Focus Define Define
Analyze Measure, Analyze Measure, Analyze
Develop Plan Design
Execute Do Improve
Evaluate Study Control Verify
Act

Each model reflects a common thread of analysis, implementation, and review. As in the graphic for the FADE model, each also has deeper meaning (further levels of analysis) for the headings. Using a methodology ensures that you are not missing any of the critical steps. No one method is best for everyone or all situations.

Pick a method that makes sense to you and follow it.



Quality Improvement is NOT Performance Improvement: The terms quality improvement and performance improvement are sometimes used interchangeably. Performance Improvement means a change in the system performance.




Research: The distinction between QI and research is an important one. There is a spectrum, and it can be blurry sometimes, but there are some key points (with legal implications!).

QI:
Intent is to improve current practice. For internal use only.
By definition, the data is confidential.
Action is within existing standards of care.
Institutional Review Board (IRB) approval is not necessary.


Research:
Intended to create generalized knowledge.
Desire to publish or present.
Testing new methods.
Needs IRB approval!



Summary
+ Improving quality is our responsibility.
+ Measurement and improvement are possible.
+ Identify the root cause before making changes.
+ Be creative in developing solutions.


"THINK OUTSIDE THE BOX!"