Section 4: Ways To Approach the Quality Improvement Process (Page 2 of 2) | Agency for Healthcare Research and Quality

Contents

Page 1 of 2
4.A. Focusing on Microsystems
4.B. Understanding and Implementing the Improvement Cycle

Page 2 of 2
4.C. An Overview of Improvement Models
4.D. Tools To Enhance Quality Improvement Initiatives
References

4.C. An Overview of Improvement Models

To succeed in improving patients’ experiences, it is important to use a systematic, structured approach that gives feedback on your progress. If your organization has already adopted an established quality improvement model, you will be able to apply its system and methods to improve patient experience and your organization’s CAHPS survey scores. If not, you can learn about and adapt one of the models described below to pursue improvements:

• The Institute for Healthcare Improvement’s Model for Improvement
• Lean
• Six Sigma

Established QI models share several common features, including:

• Emphasis on leadership to hold people accountable, communicate the vision and strategy, and eliminate cultural and other barriers to improvement.
• Clear goals.
• Use of measurement and analysis to identify issues and guide decisions.
• Emphasis on stakeholders as participants and audiences for the improvement processes.
• Use of structured, iterative processes to implement improvement interventions.
• Use of many of the same tools to support analysis and implementation.
• Monitoring of front-line clinical activity through observations and the collection and reporting of process data as feedback on the effect of changes or to track the progress of the implementation process.
• Transparent metrics.

As you work with any QI method, the key is to carefully choose strategies that have the best chance to improve how your organization interacts with patients.

4.C.1. The Model for Improvement

The Institute for Healthcare Improvement (IHI) Model for Improvement is a simple, yet powerful model that focuses on setting aims and selecting or developing measures to indicate if a change resulted in improvement. At the heart of the Model for Improvement is the Plan-Do-Study-Act (PDSA) cycle (see Figure 4-1).

The first part of the Model for Improvement is based on a “trial and learning” approach using rapid cycle improvement (RCI; see box below). During this first part, a QI team guides development of its strategy and action plan by answering the following 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 improvement?

In the second part of the model, the QI team uses RCI and the PDSA cycle to implement its action plan with small-scale interventions introduced rapidly to test the changes, learns from these tests, and then modifies the intervention for implementation in another cycle.

What Is Rapid Cycle Improvement (RCI)?

RCI is a practical and real-time approach that involves testing interventions on a small scale (e.g., one physician), permitting experimentation, and discarding unsuccessful tests. Numerous small cycles of change can successfully accumulate into large effects. For example, a medical practice could improve quality by working on a series of cumulative and linked PDSA cycles in different aspects of care at the same time, e.g., medication use, diagnostic testing, and patient scheduling. RCI also limits measurement to what is sufficient to track progress.

4.C.2. Lean

Lean, which is sometimes referred to as the Toyota Production System, is a tool used by businesses to streamline manufacturing and production processes. The main emphasis of Lean is on cutting out unnecessary and wasteful steps in the creation of a product or the delivery of a service so that only steps that directly add value are taken. One core principle of Lean is the need to provide what the internal or external customer wants, i.e., to provide “value” to the customer, with minimal wasted time, effort, and cost. Another is that any part of a process that does not add value is simply removed from the equation, leaving a highly streamlined and profitable process that will flow smoothly and efficiently, creating additional capacity and hence enhanced performance. In health care, Lean “thinking” involves a clear understanding of the process under review, including every step involved, eliminating unnecessary steps, and basing the redesigned process on the “pull” needs of the patient.12

Lean uses a technique called Value Stream Mapping (VSM). In VSM, a QI team creates a visual map of each step in the flow of the current process. To do that, the team will have to discuss and agree on the current process’s sequential steps from beginning to end. VSM is extremely useful for mapping the steps that a patient will take when visiting a clinician’s office. Another example would be mapping the flow of a medication prescription, fill, and dispense. Using this technique, QI teams can find steps in the process that result in waste, poor flow, low value, and/or errors.

The next step in Lean is to do 5S organization. During 5S workplace organization, team members systematically review each environment to:

1. Sort,
2. Simplify (set in order),
3. Standardize,
4. Sweep/shine, and
5. Initiate self-controls that will sustain the order of standardization.

The purpose of 5S is to improve space organization and to eliminate the time or “motion waste” of “searching” for things or getting prepared to work. VSM coupled with 5S are proven tools to create processes that are “leaner,” offer more value to those involved in the process, and increase the success rate of sustained process improvement.

In a Lean culture, the focus is on interdisciplinary teams, where leaders are coaches and enablers. There is a strong patient focus and decisions are data and process driven. Rewards accrue to the team or group; however, the focus remains on the customer’s needs and expectations. For example, from the patient perspective, a process with value would include no unnecessary delays in access to care, error-free process, no long wait times, and a satisfactory outcome. From the provider perspective, a process with value would result in readily available charts, equipment, labs and essential patient data.

Examples of Organizations Using Lean

Three Federally Qualified Health Centers applied Lean techniques to improve the patient visit process. In May 2009, Altarum Institute launched partnerships with three FQHCs in Virginia, Michigan, and Maine through the Community Health Center Innovation Mission Project. The goal of this project was to apply innovative systems change methods to strengthen FQHC operations.

Over an approximately 18-month period, Altarum and its FQHC partners worked together to improve operations using the Lean principles, tools, and techniques. Staff members across the three organizations reported that the use of Lean enabled them to identify and make positive changes to several processes and workflows. Many of the improvements perceived by the staff are interrelated. The standardization of a complex, time-consuming process, for example, may have had ripple effect leading to improved patient flow, communication, and collaboration; the provision of safer and better quality care; and enhanced patient access to care. Read the full report.

Virginia Mason Medical Center used Lean concepts to redesign their entire organization. In ambulatory care, these principles have improved preventive screenings, communication with patients, coordination of care, and care management of patients with chronic conditions. Read about Mistake-Proofing Primary Care.

4.C.3. Six Sigma

The essential goal of Six Sigma is to eliminate defects and waste, thereby improving quality and efficiency, by streamlining and improving all business processes. A sigma rating indicates the percentage of defect-free products created by a process. A six sigma process is one in which 99.99966% of all production opportunities are expected to be free of defects. While it was first designed for use in manufacturing and became central to General Electric’s business strategy in 1995, the health care industry uses Six Sigma to increasing the reliability of the process of delivering health care services.

Six Sigma seeks to improve the quality of process outputs by identifying and removing the causes of defects (errors) and minimizing variability in processes. It uses a set of quality management methods and creates a special infrastructure of people within the organization who are experts in these methods (“Champions,” “Black Belts,” “Green Belts,” “Yellow Belts,” etc.).

A key focus of Six Sigma is the use of statistical tools and analysis to identify and correct the root causes of variation. As a roadmap for problem solving and process improvement, Six Sigma uses the DMAIC Methodology: Define, Measure, Analyze, Improve, Control. Additional information about DMAIC can be found at  http://www.dmaictools.com.13

Learn About Lean and Six Sigma in Health Care Settings

• Aherne, Joe and John Whelton. Applying Lean in Healthcare: A Collection of International Case Studies, 2009.
• Arthur, J. Lean Six Sigma for Hospitals: Simple Steps to Fast, Affordable, and Flawless Healthcare, 2011.
• Butler G, Caldwell C, Poston N. Lean-six sigma for healthcare: A senior leader guide to improving cost and throughput. Milwaukee: American Society for Quality; 2009.
• Fillingham D. Lean Healthcare: Improving the Patient’s Experience (Healthcare Improvement), 2008.
• Jones, D., Ian Taylor, Marc Baker, Alan Mitchell Making Hospitals Work: How to improve patient care while saving everyone’s time and hospitals’ resources, 2011.
• Kenney C. Transforming Health Care. Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience. Productivity Press; 2010.
• Lighter DE. Basics of health care performance improvement: A lean six sigma approach. Burlington: Jones & Bartlett Learning; 2013.
• Scoville R, Little K. Comparing Lean and Quality Improvement. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2014. This IHI white paper provides detailed descriptions of Lean and the IHI approach to quality improvement, including the basic concepts and principles of each approach, how they are similar and different (in history and approach), and for what purposes each approach is the most appropriate.
• Stamatis DH. Essentials for the improvement of healthcare using lean & six sigma. Boca Raton: Taylor & Francis Group, LLC; 2011
• Zidel, Thomas. A Lean Guide to Transforming Healthcare: How to Implement Lean Principles in Hospitals, Medical Offices, Clinics, and Other Healthcare Organizations, 2006.

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4.D. Tools To Enhance Quality Improvement Initiatives

This section summarizes two strategies that can support health care organizations in implementing a model of quality improvement.

4.D.1. The Team Strategies and Tools To Enhance Performance and Patient Safety (TeamSTEPPS®)

For many health care organizations, one of the biggest challenges to improvement is getting a team of highly trained and busy professionals to work together effectively. TeamSTEPPS is an evidence-based training program designed to improve quality and safety by enhancing communication and teamwork skills among health care professionals. The program was developed jointly by the Department of Defense (DoD) and the Agency for Healthcare Research and Quality (AHRQ).

TeamSTEPPS teaches techniques to improve team structure, communication, leadership, understanding of what is happening (“situation monitoring”), and mutual support among team members. Together, these factors have a strong influence on quality improvement and quality of care. Organizations can also use TeamSTEPPS to “coach coaches” or “train the trainer.”

While TeamSTEPPS was originally designed for the hospital setting, AHRQ also offers a primary care version of TeamSTEPPS training in which the core concepts of the program were adapted to reflect the environment of primary care office-based teams.

4.D.2. Practice Facilitators

Another common challenge for physician practices is not having the expertise, time, or capacity to focus on designing and implementing a quality improvement program. To help overcome that problem, organizations can seek help from practice facilitators (PFs), sometimes referred to as quality improvement coaches or practice enhancement assistants.

PFs are full or part-time personnel hired or contracted to help medical practices evaluate and build organizational capacity for continuous quality improvement. The functions of a PF can include:

• Analyzing and evaluating performance, customer/patient feedback, or patient experience surveys.
• Recommending changes and supporting internal teams with implementation.
• Training clinicians and staff in quality improvement methods.
• Team building.
• Disseminating best practices and innovative ideas.
• Providing specific materials and resources (flow charts, computer training, etc.).

PFs can also assist with enhancing communication and technology, promoting adherence to best practices, and creating the capacity to participate in and benefit from research.

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References

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10. Agency for Healthcare Research and Quality. How Two Provider Groups Are Using the CAHPS® Clinician & Group Survey for Quality Improvement. CAHPS Issue Brief. Available at: https://ahrq.gov/cahps/quality-improvement/reports-and-case-studies/cgcahps-webcast-brief-2014.pdf. Accessed on July 29, 2015.
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13. American Society for Quality. The Define Measure Analyze Improve Control (DMAIC) Process. Accessed at http://asq.org/learn-about-quality/six-sigma/overview/dmaic.html on May 20, 2015.

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