6quality improvement gimbel
Post on 03-Apr-2018
225 Views
Preview:
TRANSCRIPT
-
7/28/2019 6quality Improvement Gimbel
1/34
INTRODUCTION TO QUALITY
IMPROVEMENT TOOLS:CHANGING PROCESSES TOIMPROVE OUTCOMES
Sarah Gimbel
Seattle, WAJuly 2011
1
-
7/28/2019 6quality Improvement Gimbel
2/34
-
7/28/2019 6quality Improvement Gimbel
3/34
From Industry: Lean Methodology
Within healthcare services the core idea is tomaximize patient value while minimizingwaste
Lean approach changes the focus ofmanagement from optimizing separate
technologies, assets, and vertical departmentsto optimizing the flow of products and servicesthrough entire system
Map out processes and identify value and non-
3
-
7/28/2019 6quality Improvement Gimbel
4/34
Lean Some Key Principles
Base decisions on long-term philosophy at theexpense of short term financial goals
Create continuous flow to bring problems to thesurface
Level out the work load
Standardized tasks and processes are the
foundation for continuous improvement andem lo ee em owerment
4
-
7/28/2019 6quality Improvement Gimbel
5/34
Improvement: Process Mapping &
PDSAEvery process is perfectly designed toget
the results it gets-Paul Batalden
The Three Questions:
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?
-
7/28/2019 6quality Improvement Gimbel
6/34
Process Mapping
Whenever there is a health outcomefor a patient, there is a process.
Our challenge lies in seeing it.
5
-
7/28/2019 6quality Improvement Gimbel
7/34
What is Process Mapping? (aka: Value Streammapping)
Its a tool used to identify value and reduce
waste (muda)
Muda?Muda is the Japanese word for waste. But not
waste defined in a traditional way. Waste isanything that does not provide value to thepatient, for example: waiting, travel,misdiagnosis, stock-outs
Process Mapping?7
-
7/28/2019 6quality Improvement Gimbel
8/34
How does Process Mapping help?
Problem Identification
Generating Solutions
Test
Disseminate
7
-
7/28/2019 6quality Improvement Gimbel
9/34
Benefits of Process Mapping
Puts a spotlight on waste
Streamlines work processes
Defines and standardizes the steps and sequence
Promotes deep understanding Builds consensus
Key tool for continuous quality improvement
Process Mapping can help us reach our goals ofimproving health outcomes by improving quality
through increased communication between health
facility managers and staff
9
-
7/28/2019 6quality Improvement Gimbel
10/34
Look for areas for improvement
Is the process standardized, or are the peopledoing the work in different ways? Eg. Prenatalcare
Are steps repeated or out of sequence?
Are there steps that do not add value to theoutput?
Are there steps where errors occur frequently?
10
-
7/28/2019 6quality Improvement Gimbel
11/34
-
7/28/2019 6quality Improvement Gimbel
12/34
map
An example from Mozambique
We chose to map the flow of patientswho had been identified as HIV+ and
were referred to the HIV/AIDStreatment clinic for assessment. Wefollowed these patients through their
care pathway as they received careand treatment for the HIV/AIDSinfection.
12
-
7/28/2019 6quality Improvement Gimbel
13/34
Step 2: Collect information & create acurrent process map
The process as it currently exists
Starting when the HIV positive patient comes to theclinic and the patient is registered by the
receptionist we followed the path that each patienttakes. We talked to the staff responsible at eachpoint. Detailed note taking is necessary.
Next, we draw the map first by hand and then onthe computer.
13
-
7/28/2019 6quality Improvement Gimbel
14/34
-
7/28/2019 6quality Improvement Gimbel
15/34
Process Mapping the Initial Workflow
HIV Positive
Patient comes
to Clinic
Enrollment
Process
with RN
Patient
scheduled
to see MD
Registration
Process with
Receptionist
Patient
returns to
clinic for
appointment
Patient
registers
Pt has
access to
ARVs?
Intervention: Counselling
CD4 test not
ordered
Intervention:
Counselling
CD4 testing
ordered
Lab
open?
Yes
NoNo
Yes
Patient
scheduled
for CD4
count
Blood for CD4
count drawn
Patient
schedules
appointment to
review results of
CD4 count
Patient
returns to lab
for
appointment
Patient
returns to
clinic forappointment
Patient
registers
Patient seen
by Physician
Patient seen
by Physician
Treatment
plan is
developed.
CD4 count
reviewed with
patient, and
significance
explained.
Patient Leaves Clinic
Patient Leaves Clinic
Patient Leaves Clinic
15
-
7/28/2019 6quality Improvement Gimbel
16/34
local managers and frontline healthprofessionals
Assessing the current process map with the goal of improvingpatient flow by looking for steps that:
i) Definitely add valueii) Add no value, but are unavoidable
iii) Add no value, but are avoidable(Source: Womack and Jones)
After making a process map, the next day we return
to the health center and discussed it with health workers toensure its accuracy. Together we consider how the mapcould be used to make improvements to the system.
16
-
7/28/2019 6quality Improvement Gimbel
17/34
Process Mapping: Potential Areas forImprovement
HIV Positive
Patient comes
to Clinic
Enrollment
Process
with RN
Patient
scheduled
to see MD
Registration
Process with
Receptionist
Patient
returns to
clinic for
appointment
Patient
registers
Pt has
access to
ARVs?
Intervention: Counselling
CD4 test not
ordered
Intervention:
Counselling
CD4 testing
ordered
Lab
open?
Yes
NoNo
Yes
Patient
scheduled
for CD4
count
Blood for CD4
count drawn
Patient
schedules
appointment to
review results of
CD4 count
Patient
returns to lab
for
appointment
Patient
returns to
clinic forappointment
Patient
registers
Patient seen
by Physician
Patient seen
by Physician
Treatment
plan is
developed.
CD4 count
reviewed with
patient, and
significance
explained.
Patient Leaves Clinic
Patient Leaves Clinic
Patient Leaves Clinic
17
-
7/28/2019 6quality Improvement Gimbel
18/34
Change
Create future process map and work towards it byimplementing tests of change. (Plan-Do-Study-Actor PDSA cycles)
Use the map and the data as a guide to figureout where change can be most effective. Trackchanges in indicators to determine the effects ofthe change as the process moves forward
18
-
7/28/2019 6quality Improvement Gimbel
19/34
The PDSA CycleTesting Changein a Real World Setting
Plan: Design workflow changes;
Identify tools to support the newworkflow;
Decide what to measure & how
Do: Implement plan
Study: Look at what wasmeasured; figure out what itmeans
Act: Fix the things didnt work the
first time and retest until it works
19
Step 5: One PDSA Cycle isnt
-
7/28/2019 6quality Improvement Gimbel
20/34
Step 5: One PDSA Cycle isntenough (continuous quality
improvement)The cycles are linked for continuousimprovement
*Langley GL, Nolan KM, Nolan TW, Norman CL, ProvostLP. The Improvement Guide: A Practical Approach to
Enhancing Organizational Performance.**The Plan-Do-Study-Act cycle was developed by W.
Edwards Deming (Deming WE. The New Economics for
Industry, Government, Education.).20
http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Literature/The+Improvement+Guide+A+Practical+Approach+to+Enhancing+Organizational+Performance.htmhttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Literature/The+Improvement+Guide+A+Practical+Approach+to+Enhancing+Organizational+Performance.htmhttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Literature/NewEconomicsforIndustryGovernmentEducation.htmhttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Literature/NewEconomicsforIndustryGovernmentEducation.htmhttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Literature/NewEconomicsforIndustryGovernmentEducation.htmhttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Literature/NewEconomicsforIndustryGovernmentEducation.htmhttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Literature/The+Improvement+Guide+A+Practical+Approach+to+Enhancing+Organizational+Performance.htmhttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Literature/The+Improvement+Guide+A+Practical+Approach+to+Enhancing+Organizational+Performance.htm -
7/28/2019 6quality Improvement Gimbel
21/34
21
Process Mapping/PDSA Steps
Current State
Future State
Next Future State
Original State
-
7/28/2019 6quality Improvement Gimbel
22/34
-
7/28/2019 6quality Improvement Gimbel
23/34
PDSA Cycle in Beira, Mozambique
What were we trying to accomplish?All HIV positive patients would have a CD4 count
within 1 month of presenting to the clinic
How would we know that a change was animprovement?
The percent of patients with CD4 count would risefrom 10% and approach 100%
What changes could we make that would resultin an improvement?
Remove barriers to testing
Remove non-value added steps from the workflow
23
-
7/28/2019 6quality Improvement Gimbel
24/34
Steady enrollment growth
Adults enrolled each month
0
100
200
300
400
500
600
700
Feb
-03
May-03
Aug-03
Nov-03
Feb
-04
May-04
Aug-04
Nov-04
Feb
-05
May-05
Aug-05
Nov-05
Feb
-06
May-06
24
-
7/28/2019 6quality Improvement Gimbel
25/34
Outcome of a process perfectly
-
7/28/2019 6quality Improvement Gimbel
26/34
Outcome of a process perfectlydesigned get 10% CD4 Testing
26
-
7/28/2019 6quality Improvement Gimbel
27/34
-
7/28/2019 6quality Improvement Gimbel
28/34
Remove the barrier
HIV Positive
Patient comes
to Clinic
Enrollment
Process
with RN
Patient
scheduled
to see MD
Registration
Process with
Receptionist
Patient
returns to
clinic for
appointment
Patient
registers
Intervention:
Counselling
CD4 testing
ordered
Lab
open?
No
Yes
Patient
scheduled
for CD4
count
Blood for CD4
count drawn
Patient
schedules
appointment to
review results ofCD4 count
Patient
returns to lab
forappointment
Patient
returns to
clinic for
appointment
Patient
registers
Patient seen
by Physician
Patient seen
by Physician
Treatment
plan is
developed.
CD4 count
reviewed with
patient, and
significance
explained.
Patient Leaves Clinic
Patient Leaves Clinic
Patient Leaves Clinic
Value
Added Step
Value
Added Step Value
Added Step
Non-Value
Added Step
Non-Value
Added Step
Non-Value
Added Step Non-Value
Added Step
Value
Added StepValue
Added Step
Non-ValueAdded Step
Non-Value
Added StepNon-Value
Added Step
Value
Added Step
Non-Value
Added Step
Non-Value
Added Step
Non-ValueAdded Step
Non-Value
Added Step ValueAdded Step Value
Added Step
Value
Added Step28
-
7/28/2019 6quality Improvement Gimbel
29/34
-
7/28/2019 6quality Improvement Gimbel
30/34
Outcome after ART barrier isremoved
% with CD4
-
7/28/2019 6quality Improvement Gimbel
31/34
Task shift CD4 ordering to nurses
HIV Positive
Patient comes
to Clinic
Enrollment
Process with
RN
Patient
scheduled
to see MD
Registration
Process with
Receptionist
Patient
returns to
clinic for
appointment
Patient
registers
Lab
open?
No
Yes
Patient
scheduled
for CD4
count
Blood for CD4
count drawn
Patient returns
to lab for
appointment
Patient seen by
Physician
Treatment plan
is developed.
Intervention:
Counselling
CD4 count reviewed with
patient,significance explained.
Patient Leaves Clinic
RN orders
CD4 Count
Blood for CD4
count drawnPatient Leaves Clinic
Value
Added Step
Value
Added Step ValueAdded Step
ValueAdded Step
ValueAdded Step
Value
Added StepValue
Added Step
Value
Added Step
Non-Value
Added Step
Non-Value
Added Step
Non-Value
Added Step
Non-Value
Added Step
Non-Value
Added StepNon-Value
Added Step
Non-Value
Added Step
31
-
7/28/2019 6quality Improvement Gimbel
32/34
Outcome after CD4 count orderis automatic
% with CD4
-
7/28/2019 6quality Improvement Gimbel
33/34
What would Toyota do?
HIV Positive
Patient comes
to Clinic
Enrollment
Process
with RN
Registration
Process with
Receptionist
includes
order for CD4
count
Patient seen
by Physician
Treatment
plan is
developed.
Intervention:
Counselling
CD4 count reviewed with
patient,significance
explained.
Rapid CD4
Drawn On-Site
Result of
CD4 returns
Value
Added Step
Value
Added Step Value
Added Step
Value
Added StepValue
Added Step
Value
Added Step Value
Added Step
Value
Added Step
33
-
7/28/2019 6quality Improvement Gimbel
34/34
QUESTIONS?
34
OR course, MOH, Dili, Timor Leste, 11/2010
top related