Practice-based Quality Improvement Session 1 PCFDP October 15, 2010 Sally Kraft, MD, MPH Stephanie Berkson, MPA - PowerPoint PPT Presentation


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Practice-based Quality Improvement Session 1 PCFDP October 15, 2010 Sally Kraft, MD, MPH Stephanie Berkson, MPA


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Title: Practice-based Quality Improvement Session 1 PCFDP October 15, 2010 Sally Kraft, MD, MPH Stephanie Berkson, MPA

Practice-based Quality Improvement Session
1 PCFDP October 15, 2010 Sally Kraft, MD,
MPH Stephanie Berkson, MPA
  1. In a small group, review the performance data on
    colorectal cancer screening.
  2. Together discuss the following questions
  3. Does the data demonstrate variation in
    performance? What are the implications of the
    observed variation in performance?
  4. What are potential causes of variation?
  5. How would you use the data to achieve
    improvements in performance rates?

Session Objectives
  1. Develop an understanding of health system levels
    and how these levels impact performance and
  2. Develop an understanding of the core concepts of
    performance improvement.
  3. Develop an understanding of the model of
  4. Gain experience analyzing variation, using
    process maps, brainstorming and creating affinity

Current UW Health Organizational Performance in
Size of the bubble is correlated to the number of
eligible patients at each organization
UW Health Primary Care Clinics Performance in
Colorectal Cancer Screening
UW Health Colorectal Cancer Screening Rates by
UW Health Colorectal Cancer Screening Rates by
Size of the bubble is correlated to the number of
eligible patients at each clinic
Physician Screening Rates At a Single Clinic
Screening rates based on panel age 50 75
Levels of improvement
Performance at any level of the healthcare
system, may be influenced by factors at another
level in the system
- Berwick. Health Affairs 2002
Berwick. Health Affairs 2002
Quality Improvement Improving Performance at the
Frontline of Care
A True North The experience of the patient and their loved ones
B Microsystems Small units of care delivery
C Organizations The systems that supports small units of delivery
D Environment Policy, payment, regulation, accreditation the factors that shape behavior, interests and opportunities
Berwick. Health Affairs 2002
Institute of Medicine Definition of Quality
  • The degree to which health services for
    individuals and populations increases the
    likelihood of desired health outcomes and are
    consistent with current professional knowledge.
  • Chassin and Galvin JAMA 1998 The Urgent Need to
    Improve Health Care Quality

What is Quality Improvement (QI)?
  • The combined and unceasing efforts of
  • everyone health care professionals, patients
  • and their families, researchers, payers,
  • planners, educators to make changes that
  • will lead to better
  • patient outcomes
  • professional development
  • system performance
  • Practice based QI focus on improving the quality
    of care delivered to a group of patients
    receiving care in a practice.

(Presentation by Dr. Batalden IOM Workshop Jan 07)
Institute Of Medicine Six Aims for Quality
Health Care
  • Safety
  • Timely
  • Effectiveness
  • Efficiency
  • Equity
  • Patient-Centered

Berwick. Health Affairs 20022180-90
Improving Performance by Understanding Variation
  • Variation in quality means that every patient is
    not receiving the best care every time. Our data
  • UW Health performs poorly compared to other
    Wisconsin provider groups on most of the publicly
    reported measures
  • There is significant variation in performance
    between UW Health primary care clinics
  • There is significant variation between
    physicians, even physicians practicing at the
    same clinic
  • Variation related to patient factors is
    appropriate. Our goal is to decrease
    inappropriate variation.
  • Inappropriate variation can be decreased by
    standardizing the clinical practices that produce
    superior performance (steal best practices from
    top performers!)

Which Process is Better? Which Will be Easier to
Managing Variation is Key to Improvement
Ideal Quality/Process Improvement Scenario 1.
Assess need to address variation within the
process 2. Decrease variation if necessary 3.
Concentrate efforts on improving average of
improved process
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How do we understand variation in Colorectal
Cancer screening data?
  • Start by defining the current process.
  • Improvement Tool Process map
  • Exercise
  • Define start and end points of the process
  • Identify all current steps in the process

Process Map Basics
  • Definition
  • Illustration of steps in a process using symbols
    and arrows
  • Purpose
  • Understand existing processes
  • Identify non-value added steps
  • Clarify complex processes
  • Identify improvement opportunities
  • Generate alignment and agreement
  • Train new staff

Where are the opportunities for improvement in
this process?
  • Problem Identification
  • What do we do that is valuable?
  • What do we do that isnt valuable?
  • Lean Thinking (from Toyota improvement model)
    Seeing and eliminating waste, i.e. eliminating
    anything that doesnt add value to the process

Learning from Toyota
  • When my grandfather brought Toyota into the auto
    business in 1937, he created a set of principles
    that has always guided how we operate. We call it
    the Toyota Way, its pillars are respect for
    people continuous improvement.
  • - Akio Toyoda, president Toyota Motor
  • But, when customers are overlooked

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Patient-centered customers first! (making a
U-turn for the better)
  • I am convinced that the only way for Toyota to
    emerge stronger from
  • this experience is to adhere more closely to
    (these core principles)
  • Yet it is clear to me that in recent years we
    didn't listen as carefully as
  • we should or respond as quickly as we must to
    our customers' concerns
  • This is why I am taking the company back to
    basics. Across Toyota, we
  • are putting our customers, the values on which
    our company was founded,
  • front center
  • We are listening more closely to our customers'
    concerns, gathering
  • information faster, responding more effectively
    when there's an issue.
  • - Akio Toyoda, president Toyota Motor

Types of waste
Waiting Patients waiting for providers, providers
waiting for patients to be roomed, waiting for
lab, x-rays, results etc.
Over Production Producing more than is needed
(ordering unnecessary tests)
Transportation Unnecessary movement of materials
or patients from one place to another
Intellect Any failure to fully utilize the time
and talents of people (providers escorting
patients through clinic)
Motion Worker motion that does not add value
(i.e. supplies kept in central cabinet rather
than room)
Inventory any more than the minimum to get the
job done
Over Processing Adding more value than the
customer is paying for
Defects/Rework Product or service not meeting
customer requirement (Health ed materials only in
What steps does the patient value? Acute care
appointment example
Lead Time Reduction Chart
Non-Value-Added Value-Added
Patient arrives and checks in (3 mins)
Patient sits in waiting room (10 mins)
Patient is weighed and taken to exam room (2 mins)
History of current problem described to nurse/MA (5 mins)
Wait for physician (10 mins)
History of current problem described to physician (5 mins)
Physician exam, discussion of treatments, write Rx (10 mins)
Total NVA Time 25 mins Total VA Time 20 mins
Example Urgent Care Process Map
  • Identify non-value added steps then
  • Eliminate
  • Combine
  • Simplify

Where is the waste in the Colorectal Cancer
screening process?
  • Exercise
  • 1. Indentify the value added steps that deliver
    satisfaction or value
  • 2. Identify the non-value added steps that
    generate costs or waste

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QI foundation Plan-Do-Check-Act
Multiple small improvement projects, each one
building from the earlier project.
  • 1 Find a process to improve
  • 2 Organize a team
  • 3 Clarify current knowledge
  • 4 Understand causes of problem
  • 5 Select the improvement
  • Plan Do Check Act

What are the causes of waste in Colorectal Cancer
Start by Finding a specific process to improve,
then Organize your team. Improvement Tool
How do we make sense of our brainstorming results?
  • Start by organizing your findings into themes.
  • Improvement Tool Affinity Diagram

How do we choose what to improve in the process?
  • After you Clarify the situation and Understand
    the causes, Select a process to improve within
    your level of improvement.

Take Home Lessons
  • Levels of the health system
  • Understand the relationship between the levels
    and potential impact on improvement work
  • Inappropriate variation is an opportunity for
  • Standardize care processes
  • Identify best practices
  • Our model for improvement FOCUS PDCA
  • Improvement tools
  • Process map
  • Brainstorming
  • Cause and effect diagrams/affinity diagrams

Well do a deeper dive into applying the PDCA
cycle in Session 2.
  • Skills we will practice at the Nov session
  • Writing a specific aim statement
  • Facilitating an improvement team
  • Collecting improvement data
  • Continuing the momentum to roll uphill