Implementing Quality Improvement

Introduction to PDSA cycles

Objectives

After this session participants will:• Understand how to do a gap analysis• Understand the main steps in

implementing a change to improve quality

• Understand the concepts of PDSA

You’ve done the measurement.

What should you do with all that data?

Your data shows: Only 70% of eligible patients are routinely screened for TB.

How can you improve this?

How do we improve a problem?Some general principles

• Need to ensure there is an atmosphere of improvement

• The discussion is not accusatory or seeking to blame

• The problem is in the process not the individual– Clinic procedures, information, materials/supplies,

equipment

6

QI methods

• Many approaches, some overlaps, but all with the same goal: Improve a gap

• Some basic questions that the team must ask– Why does the gap exist?– How can we close the gap?– Did we succeed?

Introduction to PDSAA process that helps us to organize how we

will improve a gap

• Plan• Do• Study• Act

Remember the link between measurement and QI

Measure quality

Work to address the gap: QI

Identify a gap

Understand why gap exists

PDSA cycles focuses on the highlighted areas

Measure quality

Work to address the gap: QI

Identify a gap

Understand why gap exists

Adapted from JSI

PDSA cycles focuses on the highlighted areas

Measure quality

Work to address the gap: QI

Identify a gap

Understand why gap exists

Act Plan*

Study Do

Act

Does the intervention need to be modified?

ORIs the change ready to expand and integrate?

Plan*Understand why gap

existsMake a plan to fix the gapDecide how to implement

plan (who, what, where, when)

StudyDid the measurement

show the expected difference?

Were other changes seen?

Share with team

DoCarry out the plan on small scaleDocument problemsBegin analysis

The PDSA cycle

*Plan as response to identified gap

Adapted from IHI, HIVQUALJSI and others

Expand and integrateIdentify a gap

So how do you plan what your change (QI project) will be?

Step 1: Planning to improve a quality gap

1. Understand where in the system things are not working:1. Make a Flow chart2. Brainstorm - Where do we think problems are?3. Cause and Effect (Fishbone)

2. Develop the solution3. Make a plan to fix the gap4. Decide how the plan will be implemented

(discussed in next talk)

Make a flow chart• A map of what should happen• Work with the QI team and others as needed• Draw out each of the detailed steps required

to have the desired outcome– An eligible patient is started on ART

• Start with patient registering to clinic, end with patient started on ART.

– Patient receives Cotrimoxazole prophylaxis• Start with patient comes into clinic and end with

patient leaving clinic with CTX pills

Flow chart 1: TB screening , diagnosis and referral for treatment at the OPC

Patient

Document in the registration book & patients chart:- Check pt’s ID card- Stamp TB screening (if used)

- Physical examination- TB screening: check questions

Lab: smear or culture

Get result

Three sputum:- 1: on-site- 2: morning after- 3: on-site

BK positive

Giving to the registration nurse for documentation

Refer to TB unit for treatment

Any suspected symptom

2 days

1-5 days

Doctor

Registration nurse

Lab: taking specimens

Brainstorming• Refer to the flow chart as a guide• List all potential causes of the quality gap• Work as a team and continue until you have

exhausted all ideas• Categorize into potential groups

– Human resources– Patient factors– System/protocols– Guidelines– Infrastructure– Resources– Other factors

Flow chart 2: List all the possible gaps

Patient

Document in the registration book & patients chart:- Check pt’s ID card- Weight, temperature, BP- Stamp TB screening (if used)

- Physical examination- TB screening: check questions- Baseline tests: CBC, CD4, LFT, HBV, HCV, VDRL

Lab: smear or culture

Get result

Three sputum:- 1: on-site- 2: morning after- 3: on-site

BK positive

Giving to the registration nurse for documentation

Refer to TB unit for treatment

Any suspected symptom

2 days

1-5 days

1Stamp not available Forget to stamp chart

2Forget to ask about symptomsForget to document

Doctor

Registration nurse

Lab: taking specimens3

Do not take sputum

4 Lost or poor specimens

5 No resultResult not documented

Cause and effect/Fishbone

• Developed by Ishikawa• Helps to categorize the potential causes of the

gap – Ex. those developed by brainstorming

• Guides where you might try to improve

Systems and guidelines Resources

Other factors

Physical InfrastructureStaff

Gap

Patients

Guidelines and systemsScreening guidelines not clearCharts not well organized

ResourcesStamp lost Other factors

Physical Infrastructure: Inadequate space, Too crowded

StaffToo fewNot trainedMDs get called away

Patient not screened for TB

PatientsCome late to appointment

Step 1 Plan - Some tips• Work as a team. Every voice counts.• Start with a flow chart, then brainstorm

possible gaps in each step of the process.– The “change” or first QI project may be found

after this step.• Categorizing into systems will help to further

organize and guide where the change can be focused.

• Ask representative from leadership to join and develop the detailed plan

Step 1: Example of a plan to improve TB screening from 70% to 90% of patients

• After discussion of the possible causes, the clinic decides the biggest problem is that nurses and doctors forget to ask about symptoms and a reminder is needed.

• Solution: Place signs on the desk and use a stamp that had been provided, but not regularly used.

Step 2: Do

The PDSA Cycle

Do• Carry out the plan• Document

problems• Begin analysis

Do: Principles• Is there something easy that another clinic has

already done?• Start small and simple

– What can we change by next week?

• Test it out – don’t be afraid to just try something small to see if it works

• Document what happens, both good and bad.– Do a mini chart review– Note any affects on resources or other systems

The PDSA CycleRef. National Quality Center

Example simple solution

Step 3: Study

The PDSA Cycle

StudyDid the measurement

show the expected difference?

Were other changes seen?

Share with team

Did the stamp improve TB screening?

13% 70%

TB screening stamp with symptom put on doctor’s desk

• Quick review of 10 charts: 9 screened for TB• Minimal work for nurses

Step 3: Study

The PDSA Cycle

StudyDid the measurement

show the expected difference?

Were other changes seen?

Share with team

Yes! This plan worked

No effects on resources

Step 4: Act

The PDSA Cycle

ActDid the plan work?

Yes: How will you expand or sustain it?

No: What will you try next?

Act: What Will We Do (Based on What We Learned)?

In our example:1) we will continue to use the stamp2) make sure that it has a secure place to stay3) add signs to remind staff and patients about

TB screening4) continue to monitor.

The PDSA Cycle

Example: TB screening

13% 70% 90%

- Remind staff about TB screening in staff meeting- Make a paper reminder put on the desk in front of the doctor

TB screening stamp with symptom put on doctor’s desk

Goal: 90%

Another example

• Clinic ABC found that many patients were missing clinic visits.

• After writing out a flow chart and brainstorming potential causes they decided the core cause was many patients had barriers to keeping appointments

Plan: Tool to improve on time visits.

• Objective: screen HIV patients for issues that might affect their ability to come to clinic on time.

• Prediction: adding a screening tool will add time to the patient visit, but we can keep this to a minimum

• Steps: Nurse Thuy and Counselor Ngoc researched and identified possible tools that were reviewed by Ngoc and Dr. Phuong. They selected one tool for Dr. Phuong to use with at least three patients in the clinic on Thursday

• Necessary tasks: 1. Identify tool. 2. Copy tool and place in patients' charts. 3. Dr. Phuong reviews instructions for using tool. 4. Explain tool to patient. 5. Use tool

Adapted from the National Quality Center

Do: Implementing the adherence tool

• Dr. Phuong used the tool on one patient the next day

The PDSA Cycle

Study: What happened with the tool?

• The tool was 5 pages long• Added 35 minutes to the patient’s visit• The next patient waiting for the doctor was

late for work so had to leave his appointment

• We made things worse!

The PDSA Cycle

Act: What happened with the tool?

• The clinic team sat down again to come up with a new plan to screen patients for barriers.

Emphasis point

All improvements require change, however, all changes don’t lead to

improvement

Summary

• Goal of QI is to improve• Requires team approach• Many approaches exist – most use

incremental and continuous change• Start small• Measure before, during and after to make

sure there is improvement• Make sure the change is institutionalized so

the change is sustained.

Summary slides - Quality Improvement: first step

Guidelines and standards

Performance goal

Actual performance

Quality Indicators

Performance gap

Quality Improvement Intervention

Adapted from JSI and EGPAF

95%

80%

Actual performance

Performance gap

Performance goal

Second QI Intervention

Quality Indicators

Guidelines and standards

Quality Improvement: second intervention

Adapted from JSI and EGPAF

95%

85%

90%

Resources

• NationalQualityCenter.org• HIVQUAL• John Snow International• Institute for Healthcare Improvement• Partners in Health

Resources