Six Aims for Improvement in healthcare

system:
(http://www.ahrmm.org/ahrmm/news_and_issues/issues_and_initiatives/IOM6/)

Safe
Safety is the fundamental cornerstone of the healthcare system. If care is not provided in a safe manner
in a safe environment, the chances of a positive outcome are lessened significantly. As noted in the
Institute of Medicine’s publication, crossing the Quality Chasm “Patients should not be harmed by the
care that is intended to help them, nor should harm come to those who work in healthcare.”
While the goal is to provide safe healthcare at all times, it is clearly recognized that humans provide care
and that errors can and do occur. Thus, the goal must be to prevent harm from reaching patients and
those involved in providing care to those patients. To do so, requires everyone to be involved in
identifying opportunities where patient care can be made safer. It also requires that everyone be
continuously involved in learning from medical errors and “near misses.”
Timely
Delays have become a frequently accepted norm within healthcare today. Delays may be attributed to long waits for
appointments, long delays in waiting rooms, or in transporting patients. Delays can also mean problems in readily accessing
patient test results or inability to provide treatments in a timely manner. Regardless, all of those involved in healthcare
should be focusing on ensuring that patient care processes flow smoothly

Effective
Crossing the Quality Chasm defines effectiveness as “care that is based on the use of systematically acquired evidence to
determine whether an intervention, produces better outcomes than alternatives – including the alternative of doing nothing”.
This premise is the foundation upon which “evidence-based medicine” rests.
As noted in the IOM report, evidence-based medicine is “the integration of best research evidence with clinical expertise and
patient values”. This definition represents the melding of three critical factors: (1) best research evidence: a broad base of
evidence that is derived from laboratory experiments, clinical trials, epidemiological and outcomes research; (2) clinical
expertise – refers to the ability of the clinician to utilize clinical skills and experience to rapidly evaluate each patient’s unique
health state to make a diagnosis and to recommend interventions based upon knowledge of the respective risks and
benefits; and (3) patient values that refers to each patient’s unique preferences, concerns, and expectations that are part of
each clinical encounter.
One of the most significant improvement needs concerning effectiveness of care is in the areas of palliative and end-of-life
care. Nowhere do the AHA quality goals converge more poignantly to confirm the need for providers and patients to work
together to make care better and to help people manage their own health and healthcare; asking "what care is right”?

Efficient
Fragmented healthcare delivery promotes wasted time, efforts, materials, medications, money, and trust. The Efficiency Aim
describes the divide between good healthcare and the healthcare that people may actually receive. The term “efficiency” is
often mistaken for cutting corners. This is not the focus of the IOM report. The report notes that there are two primary
methods to increase the efficiency of the healthcare system: (1) reduce waste at all levels, and (2) reduce administrative or
production costs.
Reducing waste may require a basic redesign to match the work to the worker; i.e.; developing competency requirements for
each position. Reduction in administrative costs can also occur through the elimination of duplicative paper work, redundant
testing, and multiple re-entries of various types of practitioner orders

1
Equitable
Simply stated by the IOM, the “purpose of the health system is to continually reduce the burden of illness, injury, and
disability, and to improve the health and functioning of the people of the United States.” The focus of this Aim is that these
benefits of the healthcare system should be available to all.
Equity occurs at two levels: (1) population – where disparities in the provision of healthcare services are to be reduced and
eliminated for all subgroups, whether it be on the basis of race, ethnicity, or gender, and (2) individual – where each
individual is treated on the basis of their needs in regard to availability of care and quality of services rather than on the
basis of personal characteristics that are unrelated to their illness.

Patient-Centered
This specific Aim focuses “on the patient’s experience of illness and healthcare and on the systems that work or fail to work
to meet individual patients’ needs.”
In work done by the Picker Institute and utilized in the 1996 AHA Eye on Patients report, several characteristics of patient-
centered care have been identified: (1) respect for patients’ values, preference, and expressed needs; (2) coordination and
integration of care; (3) information, communication, and education; (4) physical comfort; (5) emotional support; (6)
involvement of family and friends; and (7) access.
While patients vary in their desire to be involved in their healthcare, all too often, patients feel excluded from discussions and
decisions that affect them and the healthcare that they receive. As a consequence, patients may find their healthcare to be
not only impersonal, but they are often left confused and unsure as to what they need to do in regard to participation in their
care.

FOCUS PDCA Improvement

Methodology:
(http://smartchurchmanagement.com/what-is-focus-pdca-methodology/)

FOCUS PDCA is an improvement methodology that many organizations use to guide

their improvement efforts. It’s simply a formalized process for improvement.
So what does FOCUS PDCA mean? It is actually an acronym for an approach to
problem-solving and it stands for:

FOCUS
Find
Organize
Clarify
Understand
Select

2
Now let’s go through each one to understand its meaning:

Find a process or identify a problem that needs improvement. Problems are pretty
easy to identify. Just think about the chronic complaints you get or those things that
simply frustrate you at work. Those things that impact church customers (members,
volunteers, and employees) or internal processes that make it difficult to do things.
For example, if new volunteers are continually venting frustration about the length of
time it takes to go through the volunteer application, approval, and placement process,
it’s probably time to work toward streamlining the process.

Organize a team that understands or works with the process or problem. The team
consists of people who know the process well and can speak to what works and what
needs changing. For example, if you want to improve the volunteer application
process, you need a team that includes the people who administer the process as well
as people who experience the process – new volunteers.

Clarify the knowledge. Clarifying the knowledge of the process can help to ensure
there’s agreement on what the real issues are. Every person who walks through the
process or experiences the problem sees things from a little different perspective
making it important to clarify the knowledge from every perspective.

Understand the process variations. There are variations in every process. The trick is
to discover what causes the variations so you can minimize the peaks and valleys.

For example, think about how long it takes you to drive to work. There’s an average
commute time that’s calculated by using the actual times it takes every day.

Let’s say your commute is anywhere from 16 minutes to 24 minutes, depending on

traffic and weather conditions. Your average commute time would be 20 minutes and
any variation more than four minutes either side is an outlier. In this example, a snow
day might make the time vary significantly, but it’s still an outlier because it’s an
unusual (not daily) occurrence.

3
In the example of the volunteer application process, to understand process variations,
you need to collect some baseline (before) data so you can track the length of time it
takes to process a volunteer. This involves collecting data starting from the date you
receive the application to the date the volunteer has a position and a schedule to work.
Use this baseline data later as a measure to see whether the improvements resulted in
a positive change.

Select a solution to test. Have the team determine what solution you’d like to test and
create a goal for the improvement.

For instance, streamlining the volunteer application process time might result in a
team goal that reduces the volunteer application processing time from six weeks to
seven days. This gives the team a specific AIM and goal to work toward.

After there’s an understanding of the problem, and you selected a solution, it’s
time to:

PDCA
Plan
Do
Check
Act

Plan the improvement effort. You do this by creating an action-plan for team
members to implement. Creating an action plan requires identifying all the necessary
tactical steps, assigning accountability or responsibility for each step, and creating a
timeline for completion. This action plan document is what you use to monitor
progress and hold team members accountable for achieving objectives.

Do the plan. You do this by completing the steps in the action plan and holding people
accountable for assigned steps and timelines. This is the most critical step in the entire
improvement process. If people do not follow through with the Do, the plan is nothing
more than a piece of paper.

4
Check the results to see whether the improvement efforts truly made a difference. In
the volunteer application process example, it’s important to have the baseline data
showing the actual length of the process prior to the improvement efforts as a
measure to monitor progress. Collect the same data after the improvements are in
effect and compare the before and after process times to determine whether the efforts
resulted in the goal or AIM of the efforts.

And finally, you’re going to Act on those results. If the improvements worked, write
the policy, train the people who work with the process, and continue to monitor.

In the volunteer application process, update the policy for processing new volunteers,
train the volunteer department on the new process, and communicate the new
expectations for volunteer processing times. Once those who work with the process
receive training, you’ll monitor how the process is working and help to fine-tune the
process.

If the improvement effort didn’t work, you go through the process again. Repeating
the cycle is how continuous improvement works!

5
Data display:
(http://en.wikibooks.org/wiki/Statistics/Displaying_Data/Scatter_Graphs)

Comparison of data:
1. Bar Chart:

The Bar Chart (or Bar Graph) is one of the most common ways of displaying
categorical/qualitative data. Bar Graphs consist of 2 variables, one response (sometimes
called "dependent") and one predictor (sometimes called "independent"), arranged on the
horizontal and vertical axis of a graph. The relationship of the predictor and response
variables is shown by a mark of some sort (usually a rectangular box) from one variable's
value to the others.

6
 2. Pie Charts:
A Pie-Chart/Diagram is a graphical device - a circular shape broken into sub-divisions.
The sub-divisions are called "sectors", whose areas are proportional to the various parts
into which the whole quantity is divided. The sectors may be colored differently to show
the relationship of parts to the whole. A pie diagram is an alternative of the sub-divided
bar diagram.

Relationship of data:
Scatter Plots:
Scatter Plot is used to show the relationship between 2 numeric variables. It is not useful when
comparing discrete variables versus numeric variables. A scatter plot matrix is a collection of
pairwise scatter plots of numeric variables

7
Graphs for prioritization:
Pareto charts:
Are used to graphically display the relative importance of groups or segments of data. This makes it
easier to identify which problems are most important. Typically, the data groups in a Pareto chart are
displayed as a histogram or vertical bar chart, in descending order of significance.

Graphs show trends:

1- Line Graph:

Used to display comparisons between 2 variables, line graphs involve an x-axis horizontally and a y-axis
vertically on a grid. Dot-connected and grid-plotted lines are what comprise a line graph. These lines
monitor and compare various data sets. Usually, the x-axis represents time measurements while the y-
axis is a representative of measure or percentage of quantity.

8
 2- Control chart:

A control chart is a statistical tool used to distinguish between variations in a process

Resulting from common causes and variation resulting from special causes. It
Presents a graphic display of process stability or instability over time

9
Lean in healthcare Improvement
Methodology:
(http://www.healthcare.philips.com/pwc_hc/main/shared/assets/documents/about/news/articles/deploying_lean.pdf)

What is Lean?

Lean is a customer-centric methodology focused on continuously identifying improvement opportunities

by eliminating “non-value added” (or wasteful) activities and creating value. In a Lean process, a
customer is any individual or entity that benefits from the Lean Program. For example,
consumer/patients and physicians benefit from improving the turnaround time of critical laboratory
tests. Value is defined as any activity within a process that is essential to delivering what a customer will
pay for. By focusing efforts on reducing wasteful activities, healthcare organizations can more efficiently
attain organizational objectives. As described below, waste in healthcare has many forms. Attention to
these seven high-level areas will better enable healthcare organizations to begin using Lean to more
effectively identify potential causes of waste:

1. Transportation.
2. Inventory.
3. Overproduction.
4. Waiting.
5. Rework (Defects)
6. Searching(Motion)
7. Confusing.

(http://leanmanufacturingtools.org/7-wastes/)

10
11
12
13
Confusion
• Confusion is a type of waste
in Lean where instructions /
information / Data are not
clear.

• Example:
o Ambiguous policy
o Undefined
objective/goal
o Unclear mission / task
o Unclear Audit Tool

.1

14
IHI Model Improvement
Methodology:
(IHI open school)

The Model for Improvement, developed by Associates in Process Improvement, is a simple yet
powerful tool for accelerating improvement. The model is not meant to replace change models
that organizations may already be using, but rather to accelerate improvement. This model has
been used very successfully by hundreds of healthcare organizations in many countries to
improve many different healthcare processes and outcomes.

The model has two parts:

• Three fundamental questions, which can be addressed in any order.
• The Plan-Do-Study-Act (PDSA) cycle to test changes in real work settings. The PDSA
cycle guides the test of a change to determine if the change is an improvement.

15
Forming the Team:

Including the right people on a process improvement team is critical to a successful improvement
effort. Teams vary in size and composition. Each organization builds teams to suit its own needs.

Setting Aims :
Improvement requires setting aims. The aim should be time-specific and measurable; it should
also define the specific population of patients or other system that will be affected.

Establishing Measures:
Teams use quantitative measures to determine if a specific change actually leads to an
improvement.

Selecting Changes :

Ideas for change may come from the insights of those who work in the system, from change
concepts or other creative thinking techniques, or by borrowing from the experience of others
who have successfully improved.

Testing Changes:
The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change in the real work setting
— by planning it, trying it, observing the results, and acting on what is learned. This is the
scientific method adapted for action.

Implementing Changes:
After testing a change on a small scale, learning from each test, and refining the change through
several PDSA cycles, the team may implement the change on a broader scale — for example, for
an entire pilot population or on an entire unit.

Spreading Changes:
aAfter successful implementation of a change or package of changes for a pilot population or an

entire unit, the team can spread the changes to other parts of the organization or in other
organizations.

16
 The Knowledge Management Process:
(http://www.tutorialspoint.com/management_concepts/knowledge_management.htm)

The Knowledge Management process has six basic steps assisted by different tools and techniques. When
these steps are followed sequentially, the data transforms into knowledge.

Step 1: Collecting:

This is the most important step of the knowledge management process. If you collect the incorrect or irrelevant data,
the resulting knowledge may not be the most accurate. Therefore, the decisions made based on such knowledge could be
inaccurate as well.

Step 2: Organizing:

The data collected need to be organized. This organization usually happens based on certain rules. These rules are
defined by the organization.

17
Step 3: Summarizing:

In this step, the information is summarized in order to take the essence of it. The lengthy information is presented in
tabular or graphical format and stored appropriately.

For summarizing, there are many tools that can be used such as software packages, charts (Pareto, cause-and-effect),
and different techniques.

Step 4: Analyzing:

At this stage, the information is analyzed in order to find the relationships, redundancies and patterns.

Step 5: Synthesizing:

At this point, information becomes knowledge. The results of analysis (usually the reports) are combined together to
derive various concepts and artefacts

Step 6: Decision Making:

At this stage, the knowledge is used for decision making. As an example, when estimating a specific type of a project
or a task, the knowledge related to previous estimates can be used

18
Data validation:
Data Validation: is a process of verifying that data
Values are correct and accurate

Definitions:
• Data: Un-interpreted observations or facts usually collected to be translated to
information
• Information: Interpreted data, useful for decision making.
• Measure/Indicator: is quantitative tool expressed as, rate, ratio, or percentage
that evaluates actual performance, and compare it with a target or standard.
• Statistical valid sample: refers to that the sample collected represents the
studied population.
• Accuracy: The percentage of agreement between the two abstractors.
• Error: This is the acceptable margin of error around the reported percentage of
agreement.

19
Why Data Validation?
• Understanding the quality of the collected data.
• Establishing the level of confidence decision makers can have in the data.

When to Validate?
• New measure implemented.
• Data source changed or process supporting it has changed.
• Data Subject changed.
• Data will be made public.
• Change has been made to an existing measure.
• Unexplainable change in data results.
• Data collection tool change.
• Data abstraction process change.

Data Accuracy:
• When comparing recollected data to original data the accuracy must be at least 90%.
• Data accuracy=Total number of same data elements/Total number of data elements x 100
• If the accuracy is less than 90%, a corrective action must take place after a root-cause analysis
to understand the reason behind this discrepancy; reasons might be related to :

-System errors.

And / Or

- Human errors.

20
System errors
• Programming mistakes.
• Unclear definition of data elements.
• Abstraction Guidelines-not clear or misinterpreted.
• Incorrect patient matching when integrating various data sources.
• Hardware failure.

Human errors:
• Data entry mistakes.
• Missing data entry
• Data transcription problems/illegible handwriting.
• Inaccurate data collection.
• Poor training in collection and entering of data.
• Misrepresentation by patient or other.

For more information on Data Validation refer back to

Validation and publication of data APP on our info gate
(APP number 1432-06)

21