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Quality Improvement

Part 1: Quality Improvement (QI) and the Importance of QI

Part 2: Before Beginning - Establish an Organizational Foundation for QI

Part 3: QI Programs - The Improvement Journey

Part 4: Supporting the QI Program - Keep the Momentum Going

Part 5: References

Part 6: Additional Resources

Part 3: QI Programs - The Improvement Journey 

When the QI team is assembled and prepared to integrate quality improvements into its organization, the focus then becomes the actual implementation. This section describes QI processes at a high operational level. The content is intended to provide answers for these reflection questions, as an organization makes specific decisions about what it wants to improve and how to actually accomplish the work:

  • What are the desired improvements?
  • How are changes and improvements measured?
  • How is staff organized to accomplish the work?
  • How can QI models be leveraged to accomplish improvements effectively and efficiently?
  • How is change managed?

More detailed and advanced content can be accessed by clicking on specific links to other modules. 

What Are the Desired Improvements?

In a health care organization, team members may suggest multiple areas that need ongoing measurement or improvement. The first task is to focus on one or more improvement areas, but it is recommended that no more than a few be selected. The following may be considered during the process of selecting opportunities for improvement:

  • What are the funding agency's expectations; e.g., Bureau of Primary Health Care (BPHC)?
  • What are the regulatory or monitoring agency's requirements; e.g., OSHA and accreditations agencies?
  • What are the patients' issues and concerns?
  • What are the staff's issues and concerns?
  • What are the leadership's priorities?

An organization's processes that are weighted more heavily for improvement have one or more of the following characteristics:

  • High volume, affecting a large number of patients
  • High frequency
  • High risk, placing patients at risk for poor outcomes
  • Longstanding
  • Multiple unsuccessful attempts to resolve in the past
  • Strong and differing opinions on cause or resolution of the problem

Brainstorming is a valuable approach for generating ideas on additional opportunities for improvement. When performed in a structured manner, in a lively roundtable session led by a facilitator, it allows ideas to flow freely without debate or judgment. Subsequently, the ideas are reviewed, discussed, and clarified. During this stage, ideas are considered based on their projected time and resource requirements. Data collection efforts that may involve staff members outside the team are also taken into account. Then the team members rank and prioritize the areas based on organizational goals and needs, and a list of areas for improvement is identified.

For most teams, choosing improvement opportunities is an iterative process. After an organization creates a prioritized list using the methods described, it performs as many areas as feasible, considering the reality of its available resources and organizational constraints.

How Are Changes and Improvements Measured?

Data Infrastructure, Monitoring, and Evaluation

The first principle, QI Work as Systems and Processes, discussed in Part 1: Principles of QI, involves changes to the health system to improve performance. As patient outcomes may be affected, an organization wants to ensure that changes applied are true improvements. An effective way to accomplish this is to apply the fourth principle, Focus on Use of the Data.

An organization may already have existing data to track improvement. It needs to monitor the data that accurately reflects how a particular system is functioning, which requires an organization to focus on specific and well-defined data sets when monitoring QI.

To know which data to use and how to use it, understanding these three related concepts is important. The terminology for the concepts is introduced here, and more detail can be found in the Performance Management and Measurement module.

  • Performance measures in a health care setting are derived from practice guidelines. Data that is defined into specific measurable elements provides practitioners with a meter to measure the quality of their care. Performance measures are designed to measure systems of care.(3)
  • Performance measurement is a process by which an organization monitors important aspects of its programs, systems, and processes. In this context, performance measurement includes the operational processes used to collect data necessary for the performance measure(s).
  • Performance management is a forward-looking process used to set goals and regularly check progress toward achieving those goals. In practice, this involves goal setting, looking at the actual data for performance measures, and acting on results to improve the performance toward those goals.

Used together, these three concepts form the basis for a QI data infrastructure. An organization should choose performance measures that reflect the care system targeted for improvement, and then set up a data collection system to document its performance. After the data is collected, then an organization analyzes the performance data and acts on that information. The ongoing process of collecting data, analyzing the data, introducing change based on that analysis, and again collecting data, is referred to as the improvement cycle.

Before choosing performance measures, a QI team first reviews its organizational topics of interest, as discussed in the previous section, What Are the Desired Improvements? In addition, it needs to consider parameters specific to its organization, such as, resources, constraints, and the population served. Good performance measures are always:

  • Relevant and based on a condition that frequently occurs and/or has a great impact on the patients at their facility
  • Measurable and can be realistically and efficiently measured with the facility's finite resources
  • Accurate and based on accepted guidelines or developed through formal group decision-making methods
  • Feasible and can realistically be improved given the capacity of the organization's clinical services and patient population

Once measures are identified, an organization then determines its data collection frequency and sampling. More frequent data collection allows an organization to focus its QI efforts more aggressively. Monthly data collection is suggested, but collection on a quarterly basis is adequate, if necessary. A more advanced discussion on data collection and sampling considerations can be found in the Managing Data for Performance Improvement module.

An organization's processes and procedures needs to be established for consistent reviews and analyses of the performance measurement data by the staff. The data is analyzed to identify trends and progress toward an organization's goals. This type of analysis also identifies opportunities for improvement, allowing the QI team to focus its efforts and ensure that system changes result in improvement. Additional information, including tools and resources to assist an organization with data analysis, can be found in the Managing Data for Performance Improvement module.

How Is Staff Organized to Accomplish the Work?

QI is a method for continuously finding ways to provide better patient care and services, and at its core, QI is a team process. Most QI initiatives benefit from having a team of individuals who are focused and accountable for clearly-defined improvement aims. Under the right circumstances, a team applies the knowledge, skills, and perspectives of different individuals to make lasting improvements. A diverse QI team is even more effective, because its members bring their varying backgrounds, viewpoints and experiences to the QI process. A small QI team of six or fewer members also works well and is easier to manage. When recruiting new members for a team, selecting enthusiastic members who are interested in QI produces better outcomes. In a smaller organization, it is common for one individual to fill multiple roles on the QI team. A more advanced discussion on developing a QI team can be found in the Improvement Teams module.

How Can QI Models Be Leveraged to Accomplish Improvements Effectively and Efficiently?

After an organization identifies opportunities for performance improvement through data analysis, it then can make changes to the underlying system targeted for improvement. Using quality improvement (QI) models, either alone or in combination, is an effective approach for categorizing potential changes to an organization's system, and identifying changes that worked in other similar settings. QI models help an improvement team to focus on changes that have already proven to be effective, and they also provide guidance on different ways to approach change. This section provides a brief introduction to specific models that many health care organizations use to successfully shape their quality program infrastructures and guide their QI activities to improve care for their patients.

Introduction to QI Models

There are a variety of QI models currently in use and five are highlighted here. Two of the models highlighted, Care Model and Lean Model, provide a framework to improve patient care. The other three models, Model for Improvement, FADE, and Six Sigma, focus on processes that monitor the results of measures: 

  1. Care Model: There are six fundamental aspects of care identified in the Care Model, which creates a system that promotes high-quality disease and prevention management. It does this by supporting productive interactions between patients, who take an active part in their care, and providers, who have the necessary resources and expertise.
  2. Lean Model: This model defines value by what a customer (i.e., patient) wants. It maps how the value flows to the customer (i.e., patient), and ensures the competency of the process by making it cost effective and time efficient.
  3. Model for Improvement: This model focuses on three questions to set the aim or organizational goal, establish measures, and select changes. It incorporates Plan-Do-Study-Act (PDSA) cycles to test changes on a small scale.
  4. FADE: There are four broad steps to the FADE QI model:
    • Focus?define process to be improved
    • Analyze?collect and analyze data
    • Develop?develop action plans for improvement
    • Execute?implement the action plans, and Evaluate?measure and monitor the system to ensure success
  5. Six Sigma: Six Sigma is a measurement-based strategy for process improvement and problem reduction. It is completed through the application of the QI project and accomplished with the use of two Six Sigma models: 1) DMAIC (define, measure, analyze, improve, control), which is designed to examine existing processes, and 2) DMADV (define, measure, analyze, design, verify) which is used to develop new processes.

Note: Experts are beginning to combine Six Sigma and Lean models into the one term, Lean Six Sigma. This is because they both require a focus on analyzing processes, and use mapping as a means to achieve improvement.

While it is not essential for an organization to understand all of the QI models listed in this module, a thorough understanding ensures a more versatile approach to QI. Each QI model and method offers a systematic approach for assessing and improving care services.

How Is Change Managed?

Improvement requires change, but not every change is an improvement. The approach used by most organizations is to adopt a strategy for managing change and train their staff to facilitate the improvement process. There are a number of change processes being used, including:

  • Trial-and-error or jumping to solutions without sufficient study
  • Extensive study of a problem which can lead to "analysis paralysis"
  • Best practices by adopting someone else's success
  • Top-down - leaders decide what changes are made

All of these change strategies have pros and cons and work under certain situations. When dealing with the high stakes of clinical care, a prudent approach has gained popularity with QI teams around the globe. The Model for Improvement is a strategy to systematically and effectively manage change, which stemmed from the work of William Edwards Deming, also known as the founder of continuous QI. The model has two parts, which are depicted in Figure 3.1: Model for Improvement:

  • Part 1 presents three fundamental questions, which can be addressed in any order:
    • 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 improvement?
  • Part 2 is the Plan-Do-Study-Act (PDSA) cycle to test and implement changes in real-work settings. The PDSA cycle guides the test of change to determine if the change is an improvement.

Figure 3.1: Model for Improvement.

Adapted from Institute for Health care Improvement Exit Disclaimer.)
Figure 3.1: Model for Improvement

Note: Testing changes is an iterative process: the completion of each test cycle leads directly into the start of the next cycle. A team learns from the test; i.e., What worked and what didn't work? What should be kept, changed, or abandoned? The team uses the new knowledge to plan the next test, and continues linking tests in this way, refining the change until it is ready for broader implementation.

**It is important to note that the Model for Improvement, and associated techniques for small changes tested over time, is strongly encouraged as a change methodology.

Tips for Testing Changes

The following suggestions may be used for effectively testing changes:

  • Keep the changes small but continue to test
  • Involve care teams that have a strong interest in improving care
  • Study the results after each change. All changes are not improvements, so discontinue testing of anything that does not work.
  • If help is needed, involve others who do the work?even if they are not on the improvement team
  • Ensure overall performance is improving; changes in one part of a complex system may adversely affect another

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