(14) QI Step by Step Guide - 11.17.11

1 This document was adapted from information from the Institute for Healthcare Improvement, NC Center for Public Health Quality, NC Charlotte Area Health Education Center, and NC State University Industrial Extension Service. GETTING STARTED Select a QI Project Assemble a QI Team What changes can we make that will result in an improvement? IDEAS THE MODEL FOR IMPROVEMENT (The QI Roadmap) What are we trying to accomplish? AIM How will we know that our changes are an improvement? MEASURES TEST ideas with P lan- D o- S tudy- A ct cycles for learning & improvement SPREAD and SUSTAIN change ideas that are successful

STEP BY STEP GUIDE TO IMPLEMENT QUALITY IMPROVEMENT SELECT A QI PROJECT Choosing the right project is important. If the project is the first for your agency it is important to choose one that will be successful and produce results that gain buy-in from others in the organization. (It does not have to be a large project; sometimes smaller projects that produce results have a great impact.) Given the current budget constraints, one recommendation is to choose a project that focuses on improving efficiency within your agency. When choosing a project, consider the following:  Where are the gaps between what you desire and your actual performance? (Conduct a Gemba Walk to gather ideas, review your community health assessment, accreditation results, financial performance, and client/staff satisfaction surveys for ideas.)  Does the project have a strategic connection for your agency?  What areas do front line staff and clients think needs improving?  Can the project be done on a small scale and show results within 3 months?  Consider implementing projects that will produce “early wins”. How confident are you the project can completed successfully? (Consider the leadership support from top to bottom for the project as well as fiscal resources)  Consider the “Wow! Factor”. Is it an area that desperately needs improvement? , Will showing improvements in this area gain buy-in from staff to do future QI projects?  What is the resistance level from staff/managers/leaders? (Choose an initial project that has low resistance.) ASSEMBLE A QI TEAM Selecting the right team is important for successful implementation of your QI project. It is much easier to embrace change when you are involved in helping fix the problem rather than being told how to fix it. Choose your team members based on their knowledge of, and involvement in, the processes that will be affected by your selected improvement project. We recommend a core team of 4-8 individuals, though you may need additional "ad-hoc" team members to contribute at times. Team selection should be linked to your QI project. Try to create a diverse (age, gender, race etc.) and multi-discipline team. As you assemble your team, consider including members who can serve in the following capacities (Note: A team member sometimes may play more than one role):  A QI Team Leader is an individual with enough clout to help implement new changes and the authority to allocate the time and resources necessary to achieve the team’s aim. It is important that this person have influence over areas that are affected by the change. Examples of a QI Team Leader may include: Director of Nursing, Nursing Manager, Middle Manager, or WIC Director.  The QI Expert may have familiarity with QI methods and understands the processes and procedures that are the focus of improvement efforts. This individual has a good working relationship with colleagues, can “get things done,” and knows who to consult with when additional support or clinical/technical information is needed to guide the improvement efforts. Examples of QI Experts may include: Quality Improvement/Quality Assurance Coordinator or Nurse Manager for Quality.  Local Experts are “front-line” staff whose daily work occurs in the area that is the focus of the improvement. They have a thorough understanding of the processes and procedures and ideas about how to change them. They will benefit directly from changes and are able to understand the effects of proposed changes and have the desire and ability to drive the 2 This document was adapted from information from the Institute for Healthcare Improvement, NC Center for Public Health Quality, NC Charlotte Area Health Education Center, and NC State University Industrial Extension Service.

agreement on the project aim and can provide the needed resources to support the project. Once you have agreement, ask your health director to sign the aim statement. DEVELOP MEASURES (Answers the question: How will we know our changes are an improvement?) Have you ever changed something in your personal life (e.g., a new hairstyle)? How did you know that the change you made was an improvement? You probably had some kind of data (e.g., a tally of positive comments from observers or before and after picture of your new hairstyle) to assess the improvement. As with a personal change, when you are doing an improvement project, measurement is also important. It helps show results and achievements toward your desired goal and also helps replace personal subjectivity so that you do not rely on the notion of “I think or I feel that things are better”. Instead, you have data to actually show if the changes you make are improving your current process. As you think about collecting data for your project, you should include three types of measures, which are linked to your project aim and goals. These measures include:  Outcome -the ultimate results you are trying to achieve o Examples: Overall wait time for family planning visit; time to receive final septic tank permit  Process -what you do to achieve your outcome o Examples: Number of forms to complete; number of steps the patient takes during their visit  Balancing -what could we “mess up” while trying to improve the process o Examples : Satisfaction with the time spent with provider when increasing clinic efficiency; staff satisfcation when improving the process; accuracy or # of errors when improving septic tank permit delays While it is critical to have quantitative measures as above, qualitative data including stories from customers/front line staff and before and after pictures are important to add richer meaning to your results. In addition, these items will be critical to fully communicate the success of your project as well as help spread your improvements to other areas in your agency. Once measures are established, it is important to define the measures and develop a plan for collecting the data (e.g. how will it be collect, how often, who will collect it, etc.) Once your data are collected, use a run chart to visually display the data. IDENTIFY CHANGE IDEAS (Answers the question: What Changes Can We Make that will result in an improvement?) Before you can make an improvement it is important to understand how your current process works. A great way to accomplish this is to conduct a Gemba Walk. Go to where the work is done and observe the process (and flow) firsthand so that you can see how the process is actually performed. It is best to schedule a time when your entire QI team can conduct the Gemba walk together. As you observe the process you should:  Document each step of the process  Record the time it takes to complete each process step (cycle time)  Record the time it takes to complete the entire process from start to end (lead time)  Record any wait times between each process step or during the process step  Document any “waste” you see in the process—remember to view the process from you customer’s point of view. (Use the 8-Wastes Checklist to help identify the wastes--Defects, 4 This document was adapted from information from the Institute for Healthcare Improvement, NC Center for Public Health Quality, NC Charlotte Area Health Education Center, and NC State University Industrial Extension Service.

Overproduction, Waiting, Non Value-Added Processing, Transportation, Inventory, Motion, and Employee Underutilization) After the Gemba walk, the team should discuss the waste identified and create a list. Additionally, the team should use the data collected to create a value stream map . This visual depiction of your process greatly helps the team analyze the process, see where the flow is interrupted or stopped, and highlight opportunities to reduce waste and improve the process. Depending on your aim statement and goals, some additional tools may be used to enhance your team's understanding of the current process, including spaghetti diagrams, functional charts (swim lanes), and time bar charts. Once you have analyzed the process flow, it is time to identify opportunities for improvement. Review your current process through the eyes of your client and begin to categorize each activity within the process based upon Lean thinking:  What activities are value added ? (i.e. activities that the client deems necessary and are at the right time and cost)  What activities are non-value added but necessary ? (i.e. activities that have to be performed but are not considered of value to the client)  What activities are non-value added ? (i.e. activities that the client does not see as necessary and are unwilling to pay for (waiting to see a nurse) You want to focus your improvement efforts on eliminating non-value added activities and reducing non-value added but necessary activities. In addition, for projects aimed at improving health outcomes or improving the process' effectiveness, you want to identify changes that will increase the value added nature of the process (e.g., adding an evidence-based component to your current process, such as incorporating a referral to an evidence-based smoking cessation program in a project aimed at improving care for diabetic patients). A Pareto chart or fishbone diagram may be helpful in organizing data, identify the “vital few” areas to focus your improvements on, and will help you better understand the root cause of the problems you identified. To avoid putting a Band-Aid on the problems, make sure to drill down to the root cause of the problem using the 5 Whys . Identify and Prioritize Change Ideas Once your team has identified areas to focus your improvements and uncovered the root cause of the problem, it is time to identify potential change ideas for improvement. There are many tools and strategies to help your team generate change ideas. These include:  Use your list of Gemba Walk observations or the general change concepts list  Brainstorm and use affinity diagrams to organize ideas based upon prior observations and your current state value stream map  Identify evidence-based and promising practices (e.g., the open access scheduling change package from the Clinical Microsystems website, Bright Futures, 5As for smoking cessation, and ideas that other local health department and Division of Public Health teams have used)  Collect feedback from staff and clients on ideas for improvement --usually those who are part of the process can identify innovative ways to improve Many times you team will develop a long list of change ideas. Work with your team to prioritize the change ideas to identify the changes you will work on first. You want to begin testing changes which are easiest to implement and will have the largest benefits to the organization (i.e. “the biggest bang for your buck” and the "easy wins"!). You can use tools such as PACE charts, multi-voting, and a selection matrix to help prioritize your changes. TEST CHANGE IDEAS 5 This document was adapted from information from the Institute for Healthcare Improvement, NC Center for Public Health Quality, NC Charlotte Area Health Education Center, and NC State University Industrial Extension Service.