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Quality 101You can do this!

Windy Stevenson, MDMedical Director, Doernbecher Quality Program

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How do you feel about QUALITY?

Quality is not rocket science.

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How do you feel about QUALITY?

Quality is not some lurking danger to avoid.

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Maybe this?

Quality is not someone else’s job.

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This is probably the most common…

Quality is not about working harder.

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Quality is about this

Quality is what we all do every day to provide the best care to kids and families

in the most efficient way we can.

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Quality Improvement makes the right thing for the patient

easy and cost effective. It makes your job easier!

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If I do my job, by the end of this session,

You will get why quality improvement is important

You will understand that quality improvement is part of your job

You will see that you are already doing it

You will OWN one model for facilitating improvement

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Why do we care?

U.S. outcomes are pitiful for the amount we spend on healthcare

For every dollar the U.S. government spends on traditional biomedical research, it spends a penny on research to ensure patients actually receive the interventions identified through biomedical research

Loscalzo J. The NIH budget and the future of biomedical research. N Engl J Med. 2006; 354: 1665

Traditional models of vigilance and education aren’t working; Health care reform will require us to behave differently

There is an urgent need for system improvement NOW

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How has quality evolved?

1800’s: Quality Assurance- credentialing, accreditation Did the dog get fed? Who forgot to feed the dog?

1900’s (mid): Statistical Quality Control & CQI- variations, profilingHow many times a week do we forget? Who’s the worst offender?

1900’s(late) : Outcomes analysis- systems thinking, patient focusedIs the dog maintaining a healthy weight? Is Johnny right for the job? Can we make it easy for Johnny to feed the dog? Is the dog being fed the cat’s food?

2000’s: Rise of Big ManagementIf we hire a consultant and report our results to the whole neighborhood, will the dog get fed more often?

Today: Quality Cacophony- seeking the sweet spot of transparency, efficiency, outcomes, and patient centeredness

Does data demonstrate that we transparently, accountably, efficiently, effectively, safely, timely, equitably provide canine sustenance in a dog-friendly way? (Tammy or Anja, can EPIC get me that data? )

Concepts courtesy Donald Fetterolf, President of the American College of Medical Quality

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Your brain is incredible!

Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer inwaht oredr the ltteers in a wrod are, the olny iprmoatnt tihng is taht the frist and lsat ltteer be in the rghit pclae. The rset can be a taotl mses and you can sitll raed it wouthit a porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. Amzanig huh?

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Your brain is incredible!

You have (at least) two jobs!

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OK. You work, and you improve how you work. Now what?

IOM Dimensions of Quality (STEEEP) For what system issue do you have passion?

Curiosity? What can you try next Tuesday? Don’t get paralyzed by how much there is to do

Start before you are ready.

Godfrey et al; clinical Microsystems part 3; The Joint Commission Journal on Quality and Patient Safety

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What is a system?

Stop driving the systems to work harder, and start intentionally creating better systems.

• Medication administration • Evening sign-out

How do you understand a system?

Every system is perfectly designed to achieve the results it gets.

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Where do you start?

You already do

this every day!

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Let’s say we have a new mascot

Go! Noon

Conference!

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But we have an issue

Pablo has gained a whole pound in the 6 weeks we’ve had him!

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This is your aim statement:

WHY?

Aim:

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Is our Aim Statement SMART?

Specific we chose ONE thing! Measurable we can prove we’ve impacted it Actionable there are no known insurmountable barriers Realistic it’s within our scope Timely we’ll do it within a time frame

Aim:

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WHY? The Doernbecher Purpose…

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Measurement

We MEASURE!Outcomes measuresProcess measuresBalancing measures

When we try to improve a system we do not need perfect inference about a pre-existing hypothesis: we do not need randomization, power calculations, and large samples. We need just enough information to take a next step in learning.

– Donald Berwick

AIM:

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Measurement

AIM:

Outcomes measures:Are we getting there?

Process measuresAre we doing the right things to get there?

Balancing measuresAre we messing things up by getting there?

Arrival time

DM complic.

Routes, departure timeHbA1c checks

Breakfast

Clinic delays

MEASURES:

Not everything that can be counted counts, and not everything that counts can be counted.

Albert Einstein, US (German-born) physicist (1879 - 1955)

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Measurement

Outcomes measures

Process measures

Balancing measures

AIM:

MEASURES:

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Testing

Outcomes measures

Process measures

Balancing measures

MEASURES:

TEST: Email reminder not to give Pablo donuts

AIM:

No donuts

for Pablo.

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Testing

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Testing

Outcomes measures

Process measures

Balancing measures

MEASURES:

TEST: Music Therapy

TEST: Email

AIM:

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Testing

Outcomes measures

Process measures

Balancing measures

MEASURES:

TEST: Music TherapyTEST: 2nd years take over Pablo’s fitness program

TEST: Email reminder not to give Pablo donuts

AIM:

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You don’t have to be perfect …to be damn good.

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Another example- from your work @ DCH

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WHY? The Doernbecher Purpose…

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Don’t get paralyzed when there’s lots to do

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Driving change is not easy…

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Not all barriers are insurmountable.

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Using Six Sigma and Lean methodologies, I will invoke Deming and Shewart’s approaches while conducting a Kaizen event to reduce the muda through process mapping, aggregate patient-level data, and reliability analysis to create a standardized deliverable.

Be as smart as you can, but remember that it is always better to be wise than to be smart - Alan Alda

I know a way to make this system work better tomorrow.

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Take Home Points

Real (sustainable) change comes from changing systems, not changing within systems

Be specific about what you want to accomplish, and why

Focus on patients

Start before you think you are ready

Don’t get paralyzed by lack of research-level data or by how much there is to do

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What if you want to know more?

IHI Open School– http://ihi.org/IHI/Programs/IHIOpenSchool/WhatstheIHIOpenSchool.htm

Call me, page me, email me– 4-1321– 15763– lammersw@ohsu.edu

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Remaining slides are extras

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Don’t get paralyzed!

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GO!QUALITY!

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Don’t get paralyzed when no one else seems to be worried about doing it right

“STEVE’S TRUCK + VAN LETTERING”

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Don’t get paralyzed when there is no $

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Maybe this?

Quality is not a myth.

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Some people think of this…

Quality is not a bunch of Japanese words.

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Why do we care?

HBR Jeff Levin-ScherzApril 2010

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So, what do we do?

Start small Keep it simple Learn together Realize our power

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What are we aiming for? IOM (Institute of Medicine) dimensions

STEEEP—Safe, Timely, Effective, Efficient, Equitable, and Patient-centeredSafe: This means much more than the ancient maxim "First, do no harm," which makes it the individual caregiver’s responsibility to somehow try extra hard to be more careful (a requirement modern human factors theory has shown to be unproductive). Instead, the aim means that safety must be a property of the system. No one should ever be harmed by health care again.

Timely: Unintended waiting that doesn’t provide information or time to heal is a system defect. Prompt attention benefits both the patient and the caregiver.

Effective: It should match science, with neither underuse nor overuse of the best available techniques—every elderly heart patient who would benefit from beta-blockers should get them, and no child with a simple ear infection should get advanced antibiotics.

Efficient: constantly seeking to reduce the waste—and hence the cost—of supplies, equipment, space, capital, ideas, time, and opportunities.

Equitable: Race, ethnicity, gender, and income should not prevent anyone in the world from receiving high-quality care. We need advances in health care delivery to match the advances in medical science so the benefits of that science may reach everyone equally.

Patient-centered: The individual patient’s culture, social context, and specific needs deserve respect, and the patient should play an active role in making decisions about his or her own care. That concept is especially vital today, as more people require chronic rather than acute care.