Family Medicine Rural Clerkship

Continuous Quality Improvement

Definition:

An approach to quality management that builds upon traditional quality assurance methods by emphasizing the organization and systems: focuses on “process” rather than the individual; recognizes both internal and external “customers”; promotes the need for objective data to analyze and improve processes.  Source:  Graham, N.O. Quality in Health Care (1995).

  • CQI is a management philosophy which contends that most things can be improved.  This philosophy does not subscribe to the theory that “if it ain’t broke, don’t fix it.”
  • It is a set of concepts, principles and methods developed from quality principles proposed by early quality gurus, W. Edwards Deming, Joseph Juran, Philip Crosby, Brian Joiner, and others.
  • These CQI principles, tools, and techniques have been found to work effectively in manufacturing industries.  They have recently been found to also effectively work in human service industries, including healthcare.
  • At the core of CQI is serial experimentation (the scientific method) applied to everyday work to meet the needs of those we serve and improve the services we offer.

Core Concepts of CQI

  • Quality is defined as meeting and/or exceeding the expectations of our customers.
  • Success is achieved through meeting the needs of those we serve.
  • Most problems are found in processes, not in people.  CQI does not seek to blame, but rather to improve processes.
  • Unintended variation in processes can lead to unwanted variation in outcomes, and therefore we seek to reduce or eliminate unwanted variation.
  • It is possible to achieve continual improvement through small, incremental changes using the scientific method.
  • Continuous improvement is most effective when it becomes a natural part of the way everyday work is done.

Core Steps in Continuous Improvement

  • Form a team that has knowledge of the system needing improvement.
  • Define a clear aim.
  • Understand the needs of the people who are served by the system.
  • Identify and define measures of success.
  • Brainstorm potential change strategies for producing improvement.
  • Plan, collect, and use data for facilitating effective decision making.
  • Apply the scientific method to test and refine changes.

Model for Improvement
(Students - refer to assigned reading:  Langley, G. J., Nolan, K. M.,  Nolan, T. W.  "The Foundation of Improvement."  Quality Progress, June 1994, pp. 81-86.)

  • A model to develop, test, and implement change that results in improvement
  • Improvement is based on building knowledge (of what works and does not work) and applying it appropriately.
  • The model offers a “trial and learning” approach that helps reveal the outcomes of change.
  • Three basic questions (see Figure 2 of article):
       1. What are we trying to accomplish?
       2. How will we know that a change is an improvement?
       3. What changes can we make that may result in an improvement?
  • Test a change on a small scale using PDSA.
    * * P = Plan; D= Do; S = Study; A= Act * *   Plan the change strategy including who will be involved, what data will be collected, how and when the data will be collected, and when the data will be considered adequate to study.  Do the intervention.  Study the results.  Act on the knowledge you gain from the data (maintain the plan, modify the plan, add to the plan).  Continue with a second PDSA Cycle, and so forth. The process continually builds learning to foster improvement efforts.
  • If the “change” was successful, solidify it by:
       -Expanding it to the rest of the system.
       -Establishing systems to support it.
       -Identifying ways in which further improvements can be made.

Additional Thoughts About Improvement Efforts

  • Before you try to solve a problem, define it.
  • Before you try to control a process, understand it.
  • Before trying to control everything, find out what is important, and work on the most important or on that process having the biggest impact.
  • Recognize that we can learn from failures, so respect  “meaningful failures”


Commonly Used CQI Tools and Methods
(Source: Brassard, M. and Ritter, D.  The Memory Jogger, 1994)

  • Brainstorming -- Creating bigger and better ideas
    To generate a high volume of ideas on any topic by creating a process that is free of criticism and judgment.
    *Nominal Group Technique (NGT)Ranking for consensus
    To allow a team to quickly come to consensus on the importance of issues, problems, or solutions
    *MultivotingRating for concensus
    To allow a team to quickly come to consensus on the importance of issues, problems, or solutions
  • Cause & Effect/Fishbone Diagram - Find and cure causes, NOT symptoms
    To identify, explore, and graphically display, in increasing detail, all of the possible causes related to a problem or condition to discover its cause(s).
  • Control Charts - Recognizing sources of variation
    To monitor, control, and improve process performance over time by studying variation and its source.
  • Flowchart - Picturing the process
    To identify the actual flow or sequence of events in a process that any product or service follows.
  • Histogram - Process centering, spread, and shape
    To summarize data from a process that has been collected over a period of time, and graphically present its frequency distribution in bar form.
  • Pareto Chart - Focus on key problems
    To focus efforts on the problems that offer the greatest potential for improvement by showing their relative frequency or size in a descending bar graph.Pareto principle: 20% of the sources cause 80% of any problem.
  • Run (Trend) Chart - Tracking trends
    To study observed data (a performance measure of a process) for trends and patterns over a specified period of time.
  • Scatter Diagram - Measuring relationships between variables
    To study and identify the possible relationship between the changes observed in two different sets of variables.
  • Storyboard
    A communication vehicle to display improvement efforts to alert others of changes being tested or carried out.
  • Conducting Effective Meetings: 7-step meeting process
 
 
 

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