- -

? (IOM, 1990)

,

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

Classification of Quality Problems

Overuse Underuse Misuse

From JAMA 1998;280:1000-1005

Some Examples from Medical Literatures- Overuse & Underuse -

Unnecessary surgery: 8 - 86%(Leape, 1992) No regular HbA1c & retinal exam. for many D.M.

patients(Weiner et al., 1995) Only14% of pt. with CV Ds. achieved recommended

lipid level(McBride et al., 1998). Failure to treat effectively AMI leads to 18,000

preventable deaths/yr(Chassin & Galvin, 1998).

Some Examples from Medical Literatures- Misuse -

In US 180,000 deaths/yr partly as a result ofiatrogenic injuries(Leape, 1994)

In US 106,000 deaths/yr by fatal ADR amonginpatietns(Lazarou et al., 1998)

Fatal medication errors in US doubled amongoutpatients btw. 1983 & 1993(Phillips et al, 1998).

Lower quality of care within hospitals for black &the uninsured(Kahn et al., 1994; Burstin et al, 1992)

QI Implicit case review Medical audit Problem-oriented studies Ongoing monitoring of departmental indicators Systems thinking Practice guidelines Outcomes management TQM/CQI Organization-wide continuous improvement in performance

Performance What How well

Results Health outcomes Costs Satisfaction

Judgment Quality Value

(JCAHO) What is done

(efficacy) (appropriateness)

How it is done (availability) (timeliness) (effectiveness) (continuity) (safety) (efficiency) (respect and caring)

(customer focus)

(understanding work as processes and systems)

(testing changes)

(emphasizing the use of data)

(teamwork)

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: (external customer)

(internal customer)

: 15%, : 85%

(root cause analysis) bad apple syndrome

: (medication error)

Inputs Processes Outputs/Outcomes

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PDCA Cycle: Plan-Do-Check-Act

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(Individual Problem Solving)

(Rapid Team Problem Solving)

(Systematic Team Problem Solving)

(Process Improvement)

Q1: ? : Process Improvement : Q2

Q2: ? : Individual Problem Solving : Q3

Q3: ? : Systematic Team Problem Solving : Rapid Team Problem Solving

When to use When you know the problem is dependent on only one person

Teams Unnecessary

Data Almost none

Time Little

When to use When the team needs quick results and has a lot of intuitive ideas

Teams Ad hoc

Data Can succeed with little data

Time Little

When to use When the problem is complex or recurring, requiring analysis

Teams Ad hoc

Data Need data to understand the causes of the problem

Time Limited to the time necessary

When to use When a key process or system requires ongoing monitoring or continual improvement

Teams Permanent

Data Data from continuous monitoring; may need to collect more

Time Continuous

QI 9: FOCUS-PDCA

FOCUS Find a process improvement opportunity Organize a team that knows a process Clarify the current knowledge of the process Understand causes of process variation Select the process improvement

PDCA Plan - Do - Check - Act

QI 9: FOCUS-PDCA

FOCUS Find, Organize, Clarify, Understand, Select

PDCA Plan the process improvement Do the improvement, data collection & analysis Check the results and lessons learned Act by adopting, adjusting, or abandoning the change

QI

Assessment : , , QI: FOCUS

Improvement : , QI: PDCA

1: - -

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Brainstorming Data Collection The 7 Management Tools

Affinity Diagrams Interrelationship Diagrams Tree Diagrams Matrix Diagrams Prioritization Matrices Process Decision Program Chart Activity Network Diagrams

2:

(Internal customers) (External customers)

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: Brainstorming

3:

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(Common cause variation) (Special cause variation)

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Brainstorming Cause and Effect Diagram Inverse Tree Diagram Multi-Voting Scatter Diagrams Run and Control Charts Histograms

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Q3: ? : Do Nothing, :

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Brainstorming Process Decision Program Charts

7:

8:

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Data Collection

Scatter Diagrams

Run and Control Charts

Histograms

Customer Surveys

9:

(Hold the gain)

(Adopt the change)

(Adjust the change)

(Abandon the change)

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Four Steps to Quality Improvement

Step 1: Identify

Determine what to improves

Step 2: Analyze

Understand what must be known or understood about the problem in order to make improvement

Step 3: Develop

Hypothesize about what changes will yield improvement

Step 4: Test & Implement

Test the hypothesized solution to see if it yields improvement; based on the results, decide whether to abandon, modify, or implement the solution

Identify Individual decision making for a small problem that is not interdependent on others

Analyze Relies on individual analysis, using existing data, observation, and intuition

Develop The change is usually minor and not interdependent on others

Test & Implement Trial and error approach to testing

Identify

An ad hoc team identifies an intuited or obvious problem based on intuition, observation, and existing data

Analyze

Generally requires minimal analysis using mainly existing data and group intuition

Develop

A series of small changes

Test & Implement

Many small to medium tests in similar systems

Identify An ad hoc team addresses a complex, recurring problem

Analyze The team examines the problem to try to identify its root causes; existing data and/or data collection is used

Develop Generally large change that addresses the root cause of the problem

Test & Implement Generally requires extensive testing before implementation.

Identify

A permanent team addresses a core process or issue in a large process or system

Analyze

Requires detailed process knowledge from on-going data collection and monitoring

Develop

A change in a key process

Test & Implement

Depends on the approach used and magnitude of the change; permanent teams continue to monitor and improve the process

:

Find ,

Organize

Clarify : 11.8( 9.1)

Understand (+)

Select

: Plan

(2nd) : 120 ml/day 3ml/Kg/day Do

4

Check : 9.1 6.1 : 0/19 0/18 : 11.8 10.1

Act

Make a new organizational culture Consider cost of poor quality Focus on System/Process Do the right thing right the first time Communicate success stories Use positive enforcements Encourage team approach & integration

- - ? (IOM, 1990)Classification of Quality ProblemsSome Examples from Medical Literatures- Overuse & Underuse -Some Examples from Medical Literatures- Misuse -QI (JCAHO) : QI 9: FOCUS-PDCAQI 9: FOCUS-PDCAQI 1: - - 1: - - 1: - - 1: - - 2: 3: 4: 4: - - 5: 6: 7: 8: 8: - - 9: 9: - - 9: Four Steps to Quality Improvement : :