HOSPITAL QUALITY IMPROVEMENT

▪ Processes ▪ Outcomes
HIGHEST QUALITY HOSPITAL CARE
What do you care more
about?

Processes vs Physicians

Is one more effective?

HIGHEST QUALITY HOSPITAL CARE
Processes vs Physicians

If your hospital lacks a specific

process to drive a specific outcome,
do individual physicians fill the gap?
 HIGHEST QUALITY HOSPITAL CARE
Optimal Process: Optimal Outcome:
identify correctable problem correct correctable problem

identify preventable problem prevent preventable problem

 Quality Improvement:
Bridging the Implementation Gap

How good is American healthcare?

We get it right 54% of the time.

Progress

-Brent James, MD, MStat

Executive Director, Intermountain Health Care

Patient care

Time
 Quality Improvement:
Bridging the Implementation Gap

Scientific
understanding
Implementation
Progress

Gap

Patient care

Time
 HOSPITALISTS AND QUALITY
IMPROVEMENT
▪ Complex process problems need multidisciplinary
solutions
▪ We are at the frontlines seeing system failures,
process errors, and performance gaps with our own
eyes -- which is our competitive advantage
▪ Improved quality delivers:
▪ better patient care…
▪ at lower costs…
▪ with potentially higher reimbursements (pay-for-
performance)…
And it can make our jobs more interesting, fun, and rewarding.
▪ Meeting the needs and exceeding the
expectations of those we serve
DEFINITION OF QUALITY
▪ Delivering all and only the care that the
patient and family needs
▪ It is NOT…
▪ yelling at people to work harder, faster, or
safer
▪ creating order sets or protocols and then
failing to monitor their use or effect
▪ traditional Quality Assurance
▪ research (but they can co-exist nicely)
 Every system is perfectly designed to achieve exactly the results
PRINCIPLE #1:
it gets
IMPROVEMENT REQUIRES CHANGE
➢To improve the system, change the system…

You cannot destroy productivity

➢When changing the system, keep it simple

▪ Change = not just doing something different, but
engineering something different
▪ at least one step in at least one process

▪ Hospital Atmosphere = hospitals tend to be

viscous, complex systems with default levels of
performance
▪ change engineered to improve performance can be a foreign
concept - or even overtly resisted
Change engineered to drive improvement depends on…
UNDERSTANDING CHANGE
▪ Workplace Culture: IN THE
personnel HOSPITAL
must be receptive to change
ATMOSPHERE
▪ Awareness: administrative and medical staffs must care about
performance and support its improvement through change
▪ Evidence: local experts must identify which research to
translate into practice
▪ Experience: a skilled team must choose, implement, and
follow up changes to ensure:
1) improvement efforts are ongoing and yielding better
performance
2) productivity is preserved
AN ATMOSPHERE FOR CHANGE

AWARENESS EXPERIENCE
OF THE LOCAL PERFORMANCE GAP WITH SIMILAR IMPROVEMENT
Patient EFFORTS
Medical Staff Hospitalist Quality Officer
Administrative Support Multidisciplinary Team Members
Success Stories From Other
Institutions

EVIDENCE WORKPLACE CULTURE

TO TRANSLATE INTO PRACTICE READY TO ACCEPT CHANGE
“Bedside” Teaching Task Load
Didactic Teaching Sessions Culture of Improvement
Local Expertise in Disease Culture of Negative Expectations
Literature
 THE MULTIDISCIPLINARY TEAM
THE DRIVING FORCE FOR CHANGE

Leverages frontline expertise and experience.

Impacts not only the change/interventions,
but also the implementation
THE DRIVING FORCE FOR CHANGE: THE MULTIDISCIPLINARY TEAM
A team is not the same as a committee…
Committee
▪ individuals bring representation

▪ productive capacity = single most able member

Team
▪ individuals bring fundamental knowledge

▪ productive capacity = synergistic (more than the sum of all individual team
members together)

Features of a good team…

▪ Safe (no ad hominem attacks)

▪ Inclusive (values all potential contributors including

diverse views; not a clique)
▪ Open (considers all ideas fairly)

▪ Consensus seeking
 Three types of team members…
1) Team Leader
THE DRIVING FORCE FOR CHANGE:
2) Team Facilitator
THEOwners
3) Process MULTIDISCIPLINARY TEAM
(members with operational, hands-on fundamental knowledge
of the process)

Team Leader… Team Facilitator…

▪ schedules and chairs team meetings
▪ sets the agenda (printed at each meeting)
▪ records team activities
(working documents in binder)
▪ owns the team process (enforces ground
rules)
▪ technical expert on QI theory and tools
▪ assists Team Leader

▪ teaches while doing, within team

▪ reports to management (Steering Team)

▪ often a member of Steering Team

Process Owners…

▪ chosen for fundamental knowledge

▪ will help implement

▪ should become leaders (so choose wisely)

Team Ground Rules…

THE DRIVING FORCE FOR CHANGE:

▪ All team members and opinions are equal
▪ Team members will speak freely and in turn
THE MULTIDISCIPLINARY TEAM
▪ We will listen attentively to others
▪ Each must be heard
▪ No one may dominate
▪ Problems will be discussed, analyzed, or attacked (not people)
▪ All agreements are kept unless renegotiated
▪ Once we agree, we will speak with "One Voice" (especially after leaving the meeting)
▪ Honesty before cohesiveness
▪ Consensus vs. democracy: each gets his say, not his way
▪ Silence equals agreement
▪ Members will attend regularly
▪ Meetings will start and end on time
Hospitals have two dynamic levels impacting performance:
1) Processes
ENGINEERING
▪ tasks performedCHANGE
in series or in parallel, impacting patient
care and potentially patient outcomes
2) Personnel
▪ skilled people with hearts and minds, with variable levels
of attention, time, and expertise

Structure Processes Outcomes of Care

Inputs Steps Outputs

•Patients •Inventory Methods •Physiologic

•Equipment •Coordination parameters
•Supplies •Physician orders •Functional status
•Training •Nursing Care •Satisfaction
•Environment •Ancillary staff •Cost
•Housekeeping
•Transport
▪ Processes
▪ all those affecting relevant aspects of patient care
▪ clinical decision making, order writing, admission intake, medication delivery,
direct patient care, discharge planning, PCP communication, discharge follow-
up, etc
ENGINEERING CHANGE
▪ Personnel
▪ anybody who touches the patient or a relevant process in the system
▪ departments, physicians, clerks, pharmacy, nursing, RT, PT/OT/ST, care
technicians, phlebotomist, patient transport, administration

▪ What?
▪ is the right thing to do?
▪ will make the system more effective?

▪ Where?
▪ are the processes to improve?
▪ Brainstorming
▪ Multivoting & nominal group technique
▪ Affinity grouping
▪ do we start? (dissect and understand the processes)
▪ Cause and effect diagrams (Ishikawa or ‘fishbone’ diagrams)
▪ Tally sheets
▪ Pareto charts
▪ Flow (conceptual flow, decision flow) charts
▪ Run charts
▪ SPC charts
▪ Scatter charts
 Tools for Engineering Change:
Run
▪ Our brains understand Charts
graphics better than tables
▪ Tabular information doesn’t convey trends over time
very well
▪ Keep it simple
▪ In center of horizontal axis place: baseline mean
performance
▪ In center of vertical axis place: implementation point
▪ Can add upper and lower control limits, but usually not
needed