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Two Kinds of People

Two Kinds of People. Two Kinds of People. Two Kinds of People. Quality Improvement in Healthcare. Manu K. Malhotra, MD Henry Ford Hospital Mar 3, 2016. Quality Improvement. I. What is QI? II. Why do you need to know about it? III. Process improvement techniques IV. Root Cause Analysis.

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Two Kinds of People

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  1. Two Kinds of People

  2. Two Kinds of People

  3. Two Kinds of People

  4. Quality Improvement in Healthcare Manu K. Malhotra, MD Henry Ford Hospital Mar 3, 2016

  5. Quality Improvement • I. What is QI? • II. Why do you need to know about it? • III. Process improvement techniques • IV. Root Cause Analysis

  6. What is Quality Improvement? • Methodical approach to measuring performance and the effort to improve it.

  7. QA vs. QI • QA: Quality Assurance • A primarily retrospective review of processes and making sure they are followed and work as intended. • QI: Quality Improvement • A prospective and retrospective look at results and processes with a focus on how to improve them.

  8. Why do I need to know about QI? • Continually improve your ability to care for patients. • Make the world a better place • Empower yourself • And…

  9. Why do I need to know about QI? • Core Competencies • Patient care • Medical knowledge • Interpersonal skills and communication • Professionalism • Systems-based practice • Practice-based learning

  10. Why do I need to know about QI? • SBP: Systems Based Practice • …and improve their patient care practices. • PBLI: Practice Based Learning and Improvement • …effectively call on system resources to provide care that is of optimal value.

  11. Why do I need to know about QI? • Remain EM Board Certified • Patient Care Practice Improvement Activity (PI)

  12. Why do I need to know about QI? • Meet existing and future performance guidelines/mandates. • E.g. Sepsis, ACS guidelines • Sentinel events (Root Cause Analysis) • Hospital Acquired Conditions

  13. What is quality?

  14. What is quality? • Quality in Healthcare • Mortality • Morbidity • Complications • Quality of Life • Perception of Care (wait times, etc) • …

  15. Process Improvement • In many cases, Quality can be improved by improving processes (eg. sepsis). • Throughput • Time to see a doctor • Time from admission to bed • …

  16. Process Improvement Techniques • Total Quality Management • Process Re-Engineering • Constraint management • Six Sigma • Lean Systems

  17. Lean Manufacturing • Attributed to Taichii Ohno of Toyota, but actually, the ideas are rooted in the work of Henry Ford and the Model T factory…

  18. Lean Manufacturing • Basic concepts: • Empower front-line workers to affect change • Remove “waste” (errors and delays) • Seamless flow of work/products • Understand the current process first! • Value Stream Maps • Use Japanese words

  19. Types of Waste (Muda) • Transportation • Inventory • Motion • Waiting • Over-processing • Over-production • Defects

  20. HFH ED history with Lean • 2010: MHA Keystone: ED project • Multihospital project to improve healthcare delivery in MI • Lean used as a tool • HFH ED created a Lean team comprised of 4 nurses, one doctor and one clinical quality specialist.

  21. Assess the Current Process • “Current State” value stream map created for the Door to Doc process • Map was then “socialized” • Reworked, more details added • “Gemba” walks • “Muda” identified • All done by clinicians who work in the ED

  22. Current State

  23. Future State Map • All ideas and findings incorporated and changes to be made identified (“Kaizan bursts”) • Future State map created

  24. HFH Emergency Department Door to Provider Time

  25. HFH Emergency Department Door to Provider Time

  26. But how do you decide what to improve? • Data collection • Consensus • Mandates • Adverse Events

  27. Adverse Events • Sentinel events • Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) mandated the use of RCA (root cause analysis) in the investigation of sentinel events in all accredited hospitals starting in 1997. • M & M • QA Process

  28. M&M • Provider Centered • Defensive • Retroactive

  29. QI Process • Patient Centered • Quality Directed • Proactive

  30. Root Cause Analysis (RCA) • Root Cause Analysis • Try to get at the cause of the problem instead of just dealing with the symptoms, or putting out fires or placing blame. • Data Collection • Reconstruction of the events • Analysis • Recommendations

  31. RCA • Problem: • Patient and family complaining (loudly) about waiting too long to be seen • Expeditious Solution: • Go talk to patient and family and “get things going” on the patient • Result: • Someone else ends up waiting a little longer

  32. RCA • This solution treats the symptoms, but not the problem.

  33. Reaching the Root cause • The 5 whys • Fishbone (Cause and effect)Diagrams • Causal Factor Chart

  34. The 5 whys • 1. Why is the patient upset? • He’s been waiting for 3 hrs to be seen. • 2. Why has he been waiting 3 hrs? • He just got back from triage. That’s how long the wait is. • 3. Why is the wait so long? • There ain’t no beds, so the ED is crammed. • 4. Why are there no inpatient beds? • Our transfer volume is on the rise. • 5. Why are we taking transfers when our patients are waiting?

  35. 5 whys • Incoming transfers are preferentially placed in beds over ED patients.

  36. Or may more than 5… • 6. Why are incoming transfers preferentially placed in beds over ED patients. • Because there is a belief that critically ill patients in our ED are safer than patients waiting at St. Elsewhere • 7. Why do we think that? • Because it’s true

  37. Fishbone Diagram Facility Resources Too noisy Waiting too long Smells bad Vending machine not working Laying in hallway Patient is upset Pt. worried about dx Nurse was mean Lost her job Doctor was rude Personal Staff

  38. RCA • 5 whys is more useful for linear problems, but is not well-suited for multifactorial problems. • Fishbone diagrams/Causal Charts can be more useful when many causes need to be explored and evaluated.

  39. RCA • Root cause analysis is a part of the problem definition phase of almost all process improvement systems. • Find a solution that not only solves the problem, but prevents its recurrence.

  40. Take-home points • QI will be a part of your life • Lean Healthcare uses value stream mapping and empowers front-line workers to eliminate waste • Root cause analysis is the first step in addressing an adverse event • Five Whys and Fishbone diagrams can be used to assess the root cause

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