Can Quality Improvement Be Improved

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Can Quality Improvement Be Improved?

• Effective Diagnosis of Performance Gaps
• March 12, 2004
• Kevin Kennedy, MHS
• Donna Thorson, MS

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Presentation Objectives

• Define error understand the Big 3 categories
  of performance gaps
• Compare contrast the Big 3
• Understand how the Big 3 affect performance gap

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In the Beginning

• All of us have used quality improvement (QI)
  techniques
• How can we go one step further?
• Can QI activities be improved?
• Can Human Factors help?

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What Is Human Factors?

• The science of designing tools, tasks,
  information, and work systems to be compatible
  with abilities of human users both physical
  mental.

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Human Factors

• Includes the study of human error
• Airline accidents, car accidents, Columbia
• So, what is an error?

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Definition of Error

• Planned sequence of mental/physical activities
  fails to achieve desired outcome

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Personal Example
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Why an Error?

• Sequence of actions did not achieve desired
  outcome filling up my tank and leaving safely
  with car/gas pump in one piece
• I forgot to remove the nozzle prior to leaving
• What factors contributed to this?

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Friends vs. Human Factors

• Friends How could someone do this?
• HF What were conditions situation like when
  getting gas? What are characteristics of the task?

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Diagnosis of Error

• Filled up my car thousands of times before
  without any problems routine task
• Forgot to execute one step in the process
• Distractions contributed to forgetting to remove
  the nozzle

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So What?

• When a gap exists, helpful to assess why prior to
  developing interventions
• If we do not understand reasons, interventions
  may not be effective
• Go beyond trial error

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Things to Consider

• Are there different types of errors?
• What are violations?
• How are violations different from errors?
• Who cares?

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The Big 3 Categories of Performance Gaps?

• Plan is not executed properly (execution errors)
• The plan itself was inadequate to achieve desired
  outcome (planning errors)
• Deliberate departure from safe practice
  (violations)

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What Is a plan?

• Means (includes mental/physical activities) to
  achieve an objective
• Peanut butter jelly example
• Not having a plan is a plan

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The Big 3 Categories of Performance Gaps

• 1. Plan was not executed properly (execution
  errors)
• My gas station story
• Injecting the entire vial of medicine when
  distracted
• Patient not assessed for pain due to
  interruptions
• Immunization order given upon admission to be
  given at discharge, forgotten in the interim

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The Big 3 Categories of Performance Gaps

• 2. The plan itself was inadequate to achieve
  desired outcome (planning errors)
• Decided to drive to my favorite station 5 miles
  away and ran out of gas
• Not giving immunizations to residents with a cold
• Foot exams given to all patients with diabetes
  who take off shoes socks

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The Big 3 Categories of Performance Gaps

• 3. Violations deliberate, not necessarily
  reprehensible, deviations from those practices
  deemed necessary (by managers, designers) to
  maintain safe operation

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The Big 3 Categories of Performance Gaps

• 3. Violations
• Knowing speed limit is 65 and driving 80, seat
  belts
• Cutting corners, skipping steps, do not read
  manual before using equipment
• Omit foot exam since patient wearing boots it
  will take too much time to take them off
• Accept a verbal statement of weight vs. weighing
  to save time

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Violations

• Act itself is deliberate
• Negative consequences are not intended
• Certain conditions more likely to produce
  violations

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Violation Producing Conditions
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Summary - Violations

• Important to recognize that everyone commits
  violations at some point
• Need to understand why and not just blame
  individual
• Still a systems approach

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Errors vs. Violations

• Errors involve individual thought processes
• Unintentional
• Can be product of system design

• Violations involve social context (procedures,
  rules)
• Intentional
• Can be product of system design

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What are the Big 3 Categories of Performance
Gaps?

• Plan is not executed properly (execution errors)
• The plan itself was inadequate to achieve desired
  outcome (planning errors)
• Deliberate departure from safe practice
  (violations)

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Why Care About the WHY?

• Different Problems Different
  Solutions

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Execution Errors

• What May Not Work
• 1. Punishment
• 2. Rewards
• 3. Training or Education of Skilled Operators
• Why? Intended to correctly complete task.

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Execution Errors

• What May Work
• Prompts
• Reminders
• Memory Aids

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Planning Errors

• What May Not Work
• 1. Punishment
• 2. Rewards
• 3. Reminders
• Why? They believe they are acting correctly.

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Planning Errors

• What May Work
• Memory Aids
• Training or Education
• Creating a process

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Violations

• What May Not Work
• 1. Training and Education
• 2. Reminders
• 3. Prompts
• 4. Memory Aids
• 5. Punishment
• Why? Violations are a product of consequences and
  positive consequences are strongest.

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Violations

• What May Work
• Redesign work to eliminate frustrations
• Using policies and rules only when necessary
• Positive feedback for desired behavior

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Possible Solutions

• Execution Errors
• Prompts
• Reminders
• Memory Aids
• Planning Errors
• Memory Aids
• Training/Education
• Process Changes

• Violations
• Redesign Work
• Using policies only when necessary
• Positive Feedback

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Group Exercise

• Aim apply the Big 3 reasons for performance
  gaps to specific scenarios
• ID a scribe and a reporter
• Choose 1 of the 4 scenarios and list potential
  reasons for gaps in performance (10 minutes)

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Group Exercise

• After making your list categorize the reasons
  (plan not executed, wrong plan, violation)
• Each table will be asked to report two reasons
  for gap and then their classification from the
  Big 3

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Scenario 1

• Patients with diabetes do not always get an
  annual foot exam in the outpatient setting.
• Why not?

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Scenario 2

• Patients in the hospital who are eligible for PPV
  do not always receive it.
• Why not?

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Scenario 3

• Pressure sores in nursing homes are not always
  treated based on available science.
• Why not?

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Scenario 4

• Care planning patient teaching for post-op
  orthopedic patients do not include instruction
  for pain management during activity/exercise.
• Why not?

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The Big 3 Categories of Performance Gaps

• Plan is not executed properly (execution errors)
• The plan itself was inadequate to achieve desired
  outcome (planning errors)
• Deliberate departure from safe practice
  (violations)

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Discussion
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Case Study 1

• Operating Room
• Focused on retention of foreign objects
• Diagnosed reasons why not all objects were
  discovered before closing
• Interventions implemented focused on human
  factors concepts (planning, execution errors)

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Case Study 2

• Home health
• Improvement in Pain Interfering with Activity
• Diagnosis MD not notified
• Solution Scripted dialogue for communication
• Results - 24.8 relative improvement

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Take Home Ideas

• The Big 3 provide a useful model to understand
  why performance gaps exist a gap may have
  multiple causes
• The Big 3 are important to consider when
  choosing interventions
• Human Factors concepts supplement traditional
  QI activities