1. Family Medicine and Public Health Clerkship Rotation University of Manitoba 2010 - 2011 Amanda Condon MD CCFP Introduction to Quality Improvement

2. Objectives • Define and understand basic quality terminology: quality and continuous quality improvement (CQI) • List 4 main concepts of CQI and provide clinical CQI examples • List and describe elements of PDSA cycle • Introduce tools and methods for improving quality of care • Construct and present an idea for a CQI project

3. Concepts of Continuous Quality Improvement • Quality can be defined by how well we meet the needs of those we serve • Most problems are in process not people • Unintended variation in processes can lead to unwanted variation in outcomes • Continual improvement can be achieved through serial experimentation

4. Quality • In health care, quality defined as: “doing the right thing, the first time, in the right way at the right time” • “Right thing, for every patient, every time” • Quality = extent to which health services increase likelihood of desired health outcome and are evidence based (Institute of Medicine)

5. The Institute for Healthcare Improvement (IHI): different measures

6. Aims for improvement • Safe • Effective • Patient-Centred • Timely • Efficient • Equitable

7. 9 categories of change • eliminate waste • improve work flow • optimize inventory • change the work environment • enhance the producer/customer relationship • manage time • manage variation • design systems to avoid mistakes • focus on the product or service Langley, Nolan, Nolan, Norman & Provost 1999

8. Examples of QI initiatives • DPIN • MIMS • Breast Cancer Screening Program • Cervical Cancer Screening Program • Colorectal Cancer Screening Program • Care Maps (asthma, ACS etc.) • Standing Orders • Medication Reconciliation • Bridging Specialist and Generalist Care

9. Examples of QI Initiatives (cont’d) • Store and Forward • Physician Integrated Network • EMR/EPR/EHR/PACS

10. The improvement process • Project Phase • Diagnostic Phase • Intervention Phase • Plan a change • Do it in a small test • Study its effects • Act on the result • Impact Phase • Sustaining Improvement Phase Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement

11. Intervention Phase Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf) Identify appropriate interventions Implement changes identified in the diagnostic phase Undertake one or more PDSA cycles Interventions phase Decide on interventions Undertake one or more PDSA cycles

12. How to use the PDSA Cycle • use plan-do-study-act cycles to conduct small-scale tests of change in real settings • plan a change • do it in a small test • study its effects • act on what learned • team uses and links small PDSA cycles until ready for broad implementation

13. The quality improvement model-the PDSA cycle • What are we trying to accomplish? • How will we know that a change is an improvement? • What changes can we make that will result in an improvement?

14. The model for improvement What are we trying to accomplish? How we will know that a change is an improvement? What change can we make that will result in an improvement? ACT PLAN STUDY DO Langley, Nolan, Nolan, Norman & Provost 1999

15. The PDSA cycle Determines what changes are to be made Change or test ACT PLAN STUDY DO Summarizes what was learned Carry out the plan Langley, Nolan, Nolan Norman & Provost 1999

16. Impact and implementation phase • Measure impact of changes/interventions • Record the results • Revise the interventions • Monitor impact NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf

17. Sustaining the Improvement • Standardization of systems and processes • Documentation of policies, procedures, protocols and guidelines • Measurement and review of practice to ensure that change has become “standard” • Training and education of staff NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

18. Quality improvement initiative Proposal • Identify an area for improvement, based on clinical experience • Prepare proposal for initiative implementation following PDSA method • Present proposal to clerkship group

19. Choosing an area for improvement • What irritates people, slows them down or costs them money? Target your efforts at relieving the worst of these problems. • Design a "best guess" solution -- a new process model based on the best practice your community has to offer. • Ensure that the new process won't irritate people, slow them down or cost them money.

20. The model for improvement What are we trying to accomplish? How we will know that a change is an improvement? What change can we make that will result in an improvement? ACT PLAN STUDY DO Langley, Nolan, Nolan, Norman & Provost 1999

21. References NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement(www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf) Jain, Manoj. Road Map for Quality Improvement – A guide for doctors. WHO Patient Safety Curriculum - Topic 7: Introduction to quality improvement methods. Djuricich, Alexander. Curriculum in Continuous Quality Improvement for Residents. Indiana University School of Medicine, 2006.