Richard J. Banchs - The Quality Improvement Challenge

1 Cover

2 Title Page The Quality Improvement Challenge A Practical Guide for Physicians Richard J. Banchs, MD Associate Professor of Anesthesiology Associate Head, Department of Anesthesiology Director, Quality and Safety University of Illinois Hospital and Health Sciences System USA Michael R. Pop, SSMBB, MBA Director of Business Process Improvement Omron Automation Americas USA

3 Copyright Page

4 Dedication Page

5 Why This Book?

6 About the Authors

7 List of Stories, Examples, Exercises and Case Studies

8 About the Companion Website

9 PART I: THE BASICS CHAPTER 1: The Problem with HealthcareSO, WHAT’S THE PROBLEM? HOW DID WE GET HERE? THE CHALLENGES TO IMPROVE HEALTHCARE WHAT IS THE PHYSICIAN’S ROLE IN PROCESS IMPROVEMENT? REFERENCES CHAPTER 2: We Need to Improve the Way We ImproveWHAT’S THE GOAL OF A QI PROJECT? A BETTER IMPROVEMENT STRATEGY GUIDING PRINCIPLES THE FIVE “RS” OF EVERY QI PROJECT THE CHANGE SPACE REFERENCES

10 PART II: THE FIRST “R”: THE RIGHT PROJECT CHAPTER 3: The Project Selection ProcessWHERE DO I START? THE PROJECT SELECTION PROCESS THE PROJECT SELECTION MATRIX: A TOOL TO PRIORITIZE QI PROJECTS A PROJECT TYPE FOR EVERY PROBLEM PROJECT TYPES FROM THE LENS OF CHANGE HOW TO ESTABLISH YOUR PROJECT’S TIMELINES CHAPTER 4: Frame Your ChallengeSTORIES FROM THE FRONT LINES OF HEALTHCARE: MARTHA SANCHEZ, THE HEAD OF HOUSEKEEPING THE PROBLEM STATEMENT THE PROBLEM STATEMENT IS YOUR “ELEVATOR SPEECH” THE PROJECT CHARTER EXERCISE: A PROBLEM STATEMENT AND PROJECT CHARTER FOR YOUR QI PROJECT

11 PART III: THE SECOND “R”: THE RIGHT PEOPLE CHAPTER 5: Don’t Go at It AloneSTORIES FROM THE FRONT LINES OF HEALTHCARE: TURN‐AROUND TIME FOR X‐RAYS IN THE ED THE PRIMARY SPONSOR WHO SHOULD BE YOUR PRIMARY SPONSOR? REVIEW QUIZ REFERENCES CHAPTER 6: Organize Your QI Team and Select the Team LeaderTHE QI TEAM WHO SHOULD BE ON YOUR QI TEAM? THE TEAM LEADER THE TRUE ROLE OF THE QI TEAM THE FIRST TOLLGATE REVIEW EXERCISE: THE QI TEAM AT HEART MEDICAL CENTER REFERENCES

12 PART IV: THE THIRD “R”: THE RIGHT PROBLEM CHAPTER 7: What Is the Scope of the Project? The SIPOC DiagramYOU NEED TO KNOW YOUR PROJECT’S SCOPE AND BOUNDARIES THE TOOL: A SIPOC DIAGRAM HOW TO DRAW A SIPOC DIAGRAM CHAPTER 8: Who Are the “Customers,” and What Do They Need?IN HEALTHCARE, WE ALSO HAVE “CUSTOMERS” THE “CUSTOMER CONTINUUM” THE VOICE OF THE CUSTOMER (VOC) HOW DO WE COLLECT THE VOC? CRITICAL‐TO‐QUALITY (CTQ) THE CRITICAL‐TO‐QUALITY TREE EXERCISE: CTQS FOR THE NEW WOMEN’S CENTER CHAPTER 9: Who Are the “Stakeholders,” and What Challenges Do They Have?THE FRONTLINE STAKEHOLDERS THE VOICE OF THE STAKEHOLDERS THE CRITICAL NEEDS OF THE STAKEHOLDERS THE SECOND TOLLGATE REVIEW

13 PART V: THE FOURTH “R”: THE RIGHT CAUSE CHAPTER 10: To Understand a Process, You Need to “Go See” and Create a MapSTORIES FROM THE FRONT LINES OF HEALTHCARE: ANDREA, THE QI PROJECT MANAGER THE FIRST STEP IS TO “GO SEE” AT THE GEMBA YOU SEE THE SYSTEM IT’S ALL ABOUT THE PROCESS THE PROCESS MAP BASIC PROCESS FLOW MAP THE SWIM LANE CHART THE VALUE STREAM MAP PROCESS DATA FOR THE VSM EXERCISE: MAPPING “ORDERING BLOOD FROM THE BLOOD BANK” CHAPTER 11: Get a Quick Win: Identify and Eliminate “Waste”WASTE IS THE OPPOSITE OF VALUE WHY TARGET WASTE? WHO IS TIM WOOD? TOOLS TO IDENTIFY AND ELIMINATE WASTE MAPPING TECHNIQUES TO IDENTIFY WASTE EXERCISE: IDENTIFYING WASTE IN THE PEDIATRIC UNIT CHAPTER 12: Measure What MattersMEASUREMENTS METRICS WHO DECIDES WHAT WE NEED TO MEASURE? THE TWO TYPES OF METRICS USED IN QI PROJECTS WHAT DOES A “GOOD” PROJECT METRIC LOOK LIKE? METRICS ARE EXPRESSED AS TWO TYPES OF DATA COMMON METRICS USED IN QI PROJECTS REFERENCE CHAPTER 13: Practicalities for Planning and Collecting Baseline DataWHY DO WE NEED TO COLLECT DATA? WHERE CAN I FIND THE DATA THAT I NEED? WHAT MAKES DATA SO HARD TO GET? THE KEY TO DATA COLLECTION IS TO START WITH A GOOD DATA COLLECTION PROCESS THREE RULES OF DATA COLLECTION MAKE YOUR DATA COLLECTION MORE EFFECTIVE WITH A DATA COLLECTION PLANNER CHAPTER 14: Define Baseline PerformanceHOW DO I ASSESS A PROCESS’S BASELINE PERFORMANCE? WHY DO WE NEED A COMBINATION OF NUMBERS AND PICTURES? GRAPHS ARE THE BEST TOOLS TO INTERPRET DATA DO I NEED TO HAVE DATA NORMALLY DISTRIBUTED? THE GRAPHICAL ANALYSIS THE HISTOGRAM: A TOOL TO GET A SNAPSHOT WITH CONTINUOUS DATA ADDITIONAL GRAPHS YOU CAN USE WITH CONTINUOUS DATA THE BAR CHART: A TOOL TO GET A SNAPSHOT WITH DISCRETE DATA ADDITIONAL CHARTS YOU CAN USE WITH DISCRETE DATA CASE STUDY: IMPROVING RTA TIME AT ST. MICHAEL’S HOSPITAL THE ANSWER TO THE PROBLEM OF VARIATION IS A GRAPH OF TIME‐ORDERED DATA VARIATION GUIDES THE IMPROVEMENT STRATEGY TIPS WHEN PRESENTING DATA REFERENCES CHAPTER 15: Tools to Characterize the Type of VariationWHAT IS A RUN CHART? MAKING A RUN CHART INTERPRETING THE RUN CHART REFERENCE CHAPTER 16: Tools to Characterize the Type of VariationTHE CONTROL CHART THE INDIVIDUALS AND MOVING RANGE (I‐MR) CHART THE UPPER AND LOWER CONTROL LIMITS OF THE INDIVIDUALS CHART UPPER CONTROL LIMIT OF THE MOVING RANGE (MR) CHART HOW TO DETECT SPECIAL CAUSE VARIATION WITH THE I‐MR CHART THE I‐MR CHART GUIDES THE IMPROVEMENT STRATEGY ADDITIONAL CONTROL CHARTS CASE STUDY: DOOR‐TO‐INFUSION (DTI) TIME AT HURON MEDICAL CENTER REFERENCES CHAPTER 17: Define Baseline PerformanceIS THE PROCESS MEETING THE NEEDS OF THE CUSTOMER? PROCESS CAPABILITY CASE STUDY: THE NEW BALLOON ANGIOPLASTY CATHETER AT UIC CAPABILITY INDICES PROCESS CAPABILITY FOR DISCRETE DATA THE PROCESS SIGMA OR SIGMA METRIC PUTTING IT ALL TOGETHER: IS THE PROCESS STABLE? IS IT CAPABLE? CHAPTER 18: How to Identify and Prioritize the Most Likely Cause of the ProblemSTORIES FROM THE FRONT LINES OF HEALTHCARE: WAIT TIME IN THE ORTHOPEDIC OUTPATIENT CLINIC THE THINGS WE DO THAT STIFLE OUR ANALYTICAL THINKING CRUCIAL INTERACTION OF ACTIONS AND CONDITIONS THE PATH TO THE ANALYSIS OF Y TOOLS TO IDENTIFY THE POSSIBLE CAUSE(S) OF THE PROBLEM TOOLS YOU CAN USE TO FILTER AND PRIORITIZE THE MOST LIKELY CAUSE EXERCISE: IN‐TRAINING EXAMINATION AT MASS GENERAL HOSPITAL CHAPTER 19: Before Proceeding, Confirm the Cause‐and‐Effect RelationshipTHE CAUSE‐AND‐EFFECT RELATIONSHIP THE SCATTERPLOT: IS THERE A RELATIONSHIP? THE CORRELATION COEFFICIENT: WHAT IS THE STRENGTH OF THE RELATIONSHIP? REGRESSION ANALYSIS HYPOTHESIS TESTING THE THIRD TOLLGATE REVIEW

14 PART VI: THE FIFTH “R”: THE RIGHT SOLUTION CHAPTER 20: Develop and Prioritize Your Improvement IdeasBARRIERS TO CREATIVE THINKING SETTING THE RIGHT CONDITIONS FOR CREATIVE THINKING THE CREATIVE SCAFFOLD DIVERGENT THINKING: DEVELOPING IDEAS USING EXISTING SOLUTIONS DIVERGENT THINKING: FINDING NEW SOLUTIONS CONVERGENT THINKING: USING THE TEAM’S KNOWLEDGE TO PRIORITIZE IDEAS CONVERGENT THINKING: PRIORITIZE IDEAS BY COMPARING OPTIONS CONVERGENT THINKING: PRIORITIZE IDEAS USING ASSESSMENT CRITERIA CASE STUDY: DECREASING UNPLANNED READMISSIONS AFTER TONSILLECTOMY ASSESSING RISK: FAILURE MODE AND EFFECTS ANALYSIS (FMEA) USING THE FMEA WITHOUT THE RISK PRIORITY NUMBER (RPN) REFERENCES CHAPTER 21: Test the Effectiveness of Your Ideas with a PilotTHE PILOT STUDY THE BEST‐KNOWN PILOT IS THE PDSA CYCLE ADVANTAGES OF THE PDSA CYCLE THE PDSA CYCLE IS A “LEARNING RAMP” REFERENCES CHAPTER 22: Improve “Flow” and Work ConditionsPROCESS FLOW STRATEGY FOR CREATING PROCESS FLOW STEPS AND SEQUENCE TO CREATE FLOW WHAT IS STANDARD WORK? THE CRITICAL ROLE OF WORK CONDITIONS 5S TO OPTIMIZE YOUR WORKSPACE VISUAL MANAGEMENT MISTAKE‐PROOFING SYSTEMS REFERENCES CHAPTER 23: Now Roll‐Out Your Improvement Ideas and Make Them “Stick”STORIES FROM THE FRONT LINES OF HEALTHCARE: THE EARLY DISCHARGE QI PROJECT AT MEMORIAL HOSPITAL BEFORE YOU ROLL‐OUT, YOU NEED AN IMPLEMENTATION PLAN ASSESS THE POTENTIAL IMPACT OF YOUR IMPROVEMENT IDEAS ASSESS THE POTENTIAL FOR PUSHBACK: THE STAKEHOLDER ANALYSIS YOUR STAKEHOLDER ENGAGEMENT STRATEGY ASSESS THE LEVEL OF SUPPORT: THE LOCAL SPONSOR ANALYSIS THE LOCAL SPONSOR STRATEGY THE MONITORING AND CONTROL PLAN THE FOURTH TOLLGATE REVIEW PROJECT CLOSURE REFERENCES