Some Fundamentals on Quality Improvement in Health and Social Care Towards a Shared Understanding EPSO, Reykjavik, 2017-09-26 Johan Thor, MD, MPH, PhD Associate Professor E-mail: johan.thor@ju.se
The death rate among the patients was worst in February 1855 at 42.7% of all soldiers admitted. After her sanitary reforms, which started on 17 March 1855, the death rate fell to 2.2% by June 1855. She showed a causal link between the sanitary reforms and this dramatic fall in mortality. Florence Nightingale, (1820 1910) Neuhauser D. Florence Nightingale gets no respect: as a statistician that is. Qual Saf Health Care. 2003;12(4):317.
Change: Difficult, yet Inevitable Most organizational change initiatives fail to achieve intended outcomes (not only in health and social care) Without successful change, organizations risk failing to fulfill their mission and going out of business
Fundamentals Improvement rarely happens spontaneously it typically requires deliberate efforts. If we want our services to perform better and yield better outcomes, we need to change our ways of working since performance is an inherent property of a system. Every system is perfectly designed to get the results it gets. Batalden P, Splaine M. What will it take to lead the continual improvement and innovation of health care in the twenty first century? Quality management in health care. 2002;11(1):45 54.
Fundamentals All improvement is change but not all change is improvement. Improvement Change Berwick DM. A primer on leading the improvement of systems. BMJ. 1996; 312(7031):619 22. Don Berwick, MD, MPP
Fundamentals The mere knowledge that there is a better way of working does not automatically cause everyone to start to work that way. (Remember Semmelweis!) You also need to manage the process of change. Then, a methodology can be helpful. This is where improvement knowledge comes in!
W. Edwards Deming Professor Paul Batalden Batalden PB, Stoltz PK. A framework for the continual improvement of health care: building and applying professional and improvement knowledge to test changes in daily work. The Joint Commission journal on quality improvement. 1993;19(10):424 47; discussion 48 52.
Quality improvement is the combined and unceasing efforts of everyone healthcare professionals, patients and their families, researchers, payers, planners and educators to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development. Batalden PB, Davidoff F. What is quality improvement and how can it transform healthcare? Quality and Safety in Health Care. 2007; 16:2 3. Better health and welfare Better care Better professional development, learning, joy in work
A Model for Improvement 1. What are we trying to accomplish? (Aim) 2. How will we know if a change is an improvement? (Measurement) 3. What changes can we make that will result in improvement? (Change) A P S D Plan Do Study Act Langley GJ, et al. The Improvement Guide: a Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco: Jossey Bass; 2009.
Juran s Quality Trilogy Meet patients, clients and other stakeholders needs; Evidence based practice Monitor performance, feed back to relevant actors, prompt corrective action Quality Planning Designing services to meet quality requirements Quality Control Managing services to reliably meet quality requirements Quality Improvement Changing services to better meet quality requirements Reduce quality deficiencies; make services more reliable (and less costly) Joseph Juran (1904 2008)
Nelson EC, Batalden PB, Godfrey MM. Quality by design: a clinical microsystems approach. 1st ed. San Francisco: Jossey Bass/Wiley; 2007.
Consistency Taking a consistent and systematic approach probably matters more than which specific method you choose Organizations that switch their method often likely get less out of their improvement efforts Walshe K, Freeman T. Effectiveness of quality improvement: learning from evaluations. Qual Saf Health Care 2002;11:85 87.
Measurement and Improvement Reliable measurement [of quality indicators] is important for the ability to conduct, and evaluate, improvement efforts. Thor J. Getting Going on Getting Better: How is Systematic Quality Improvement Established in a Healthcare Organization? Implications for Change Management Theory and Practice. [PhD-thesis] Stockholm: Karolinska Institutet; 2007, p. 25. Available electronically at: http://diss.kib.ki.se/2007/978-91-7357-274-3/
Three Dimensions of Quality Structure Buildings, equipment, human resources Process Outcomes of health and care services Activities; what we do in health and care Outcome Donabedian A. Evaluating the quality of medical care. 1966. Milbank Q. 2005;83(4):691 729.
Example: Diabetes Care Structure Regular eye examination; laser treatment when needed Availability of photographic eye examination Process Maintained eye sight; incidence of retinopathy Outcome
Measurement and Improvement Not all purposes with quality measurement can be satisfied with the same measurements some purposes are incompatible and need to be addressed separately
Counterproductive mixing We are increasingly realizing not only how critical measurement is to the quality improvement we seek but also how counterproductive it can be to mix measurement for accountability or research with measurement for improvement. Improvement Research Accountability Solberg LI, Mosser G, McDonald S. The three faces of performance measurement: improvement, accountability, and research. Jt Comm J Qual Improv. 1997 Mar;23(3):135 47.
Data to Support Improvement Patterns that can guide improvement efforts are best revealed by plotting data over time Levett JM, Carey RG. Measuring for improvement: from Toyota to thoracic surgery. Ann Thorac Surg. 1999 Aug;68(2):353 8.
Walter Shewhart Shewhart s data presentation rules: Data have no meaning apart from their context. Data contain both signal and noise. To be able to extract information, one must separate the signal from the noise within the data. Walter Shewhart 1891 1967 1. Best M, Neuhauser D. Walter A Shewhart, 1924, and the Hawthorne factory. Qual Saf Health Care. 2006;15(2):142 3. 2. http://en.wikipedia.org/wiki/walter_a._shewhart, accessed 2014 09 01.
Variation in Health Care Variation can signal that care is not consistently in line with the best available evidence Variation can also indicate success in improving care by changing work practices Misinterpretation of variation can cause worse quality and higher cost
There is Room for Improvement Patients are harmed by contemporary care Effective care is not provided consistently Human dignity is not sufficiently honored There is widespread waste inefficiency in health and social care systems There is widespread unwanted variation inequity in health and welfare; in access to care and to health information
Dimensions of goodness Safety Timeliness Effectiveness Efficiency Equity Patient- Centeredness Who can do what, where and how? What do/ will you do? Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC, USA: National Academies Press; 2001
Suggested Literature Batalden PB, Stoltz PK. A framework for the continual improvement of health care: Building and applying professional and improvement knowledge to test changes in daily work. The Joint Commission Journal on Quality Improvement. 1993; 19 (10):424-47. Berwick DM. Controlling variation in health care: a consultation from Walter Shewhart. Med Care. 1991;29(12):1212-25. Berwick DM. A primer on leading the improvement of systems. BMJ. 1996 Mar 9;312(7031):619-22. Batalden PB, Davidoff F. What is quality improvement and how can it transform healthcare? Quality and Safety in Health Care. 2007; 16:2-3. Staines A, Thor J, Robert G. Sustaining improvement? The 20- year Jönköping quality improvement program revisited. Qual Manag Health Care. 2015;24(1):21-37.
Suggested Literature Langley GJ, et al. The Improvement Guide: a practical approach to enhancing organizational performance. 2nd edition. San Francisco: Jossey-Bass; 2009. Nelson EC, Batalden PB, Godfrey MM. Quality by design: a clinical microsystems approach. 1st ed. San Francisco: Jossey- Bass/Wiley; 2007. Bate P, Mendel P, Robert G, Nuffield Trust. Organizing for quality: the improvement journeys of leading hospitals in Europe and the United States. Abingdon: Radcliffe; 2008. Batalden PB, Foster T, (eds). Sustainably improving health care: creatively linking care outcomes, system performance, and professional development. London: Radcliff; 2012. Walshe, K. and J. A. Smith, Eds. (2016). Healthcare management. London, McGraw-Hill Education/Open University Press.
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Table Conversation Topics 1. What do supervisory organizations do today to improve quality and safety in health and social care? 2. What could supervisory organizations do to further promote improvement of quality and safety in health and social care? 3. What are the desirable limits to what supervisory organizations should do to promote improvement of quality and safety in health and social care? What should they NOT do (and why)?
Switching Tables Between Rounds Topic 1 Topic 2 Topic 3 One Table Host stays at each table for all 3 rounds. All other participants move between topics. Try to mix with as many new people as possible at each new round.