Quality Improvement Primer Series: Launching a Quality Improvement Initiative

Quality Improvement Primer Series: Launching a Quality Improvement Initiative

Accepted Manuscript Quality Improvement Primer Series: Launching a Quality Improvement Initiative A.V. Weizman, J. Mosko, N. Bollegala, M. Bernstein, ...

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Accepted Manuscript Quality Improvement Primer Series: Launching a Quality Improvement Initiative A.V. Weizman, J. Mosko, N. Bollegala, M. Bernstein, M. Brahmania, L. Liu, A.H. Steinhart, S.S. Silver, C.M. Bell, G.C. Nguyen

PII: DOI: Reference:

S1542-3565(16)30207-5 10.1016/j.cgh.2016.04.041 YJCGH 54763

To appear in: Clinical Gastroenterology and Hepatology Accepted Date: 16 April 2016 Please cite this article as: Weizman A, Mosko J, Bollegala N, Bernstein M, Brahmania M, Liu L, Steinhart A, Silver S, Bell C, Nguyen G, Quality Improvement Primer Series: Launching a Quality Improvement Initiative, Clinical Gastroenterology and Hepatology (2016), doi: 10.1016/ j.cgh.2016.04.041. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. All studies published in Clinical Gastroenterology and Hepatology are embargoed until 3PM ET of the day they are published as corrected proofs on-line. Studies cannot be publicized as accepted manuscripts or uncorrected proofs.

ACCEPTED MANUSCRIPT Weizman AV, Mosko J et al.

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Quality Improvement Primer Series: Launching a Quality Improvement Initiative

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Weizman AV1,8*, Mosko J2*, Bollegala N3, Bernstein M4, Brahmania M5, Liu L5, Steinhart AH1,8, Silver SS6, Bell CM7,8, Nguyen GC1,8 1. Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine,

University of Toronto, Ontario, Canada

2. Division of Gastroenterology, St. Michael’s Hospital, Department of Medicine, University of

5. 6. 7. 8.

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Toronto, Ontario, Canada Division of Gastroenterology, Women’s College Hospital, Department of Medicine, University of Toronto, Ontario, Canada Division of Gastroenterology, Sunnybrook Health Sciences Centre, Department of Medicine, University of Toronto, Ontario, Canada Division of Gastroenterology, University Health Network, Department of Medicine, University of Toronto, Ontario, Canada Division of Nephrology, St. Michael’s Hospital, University of Toronto, Toronto, Canada Division of Internal Medicine, Mount Sinai Hospital, Department of Medicine, University of Toronto, Ontario, Canada Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada

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*co-principal author

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Corresponding Author:

Adam V. Weizman Mount Sinai Hospital 437-600 University Ave Toronto, Ontario M5G 1X5 T: 4160586-4800 x 1953 F: 416-586-8689 [email protected]

The authors have no conflicts of interest to declare

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Local Quality of Care Problem

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There has been increasing focus on measuring quality indicators in gastroenterology over the last few years. Adenoma detection rate (ADR) has emerged as one of the most important quality indicators as it is supported by robust clinical evidence [1-3]. With every 1% increase in

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ADR, a 3% reduction in interval colorectal cancer (CRC) has been noted [3]. As such, an ADR of 25% has been designated as an important quality target for all endoscopists who perform CRC

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screening [1].

You work at a community hospital in a large, metropolitan area. Your colleagues in a number of other departments across your hospital have been increasingly interested in quality

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improvement (QI) and have launched QI interventions, although none in your department. Moreover, there have been reforms in how hospital endoscopy units are funded in your jurisdiction, with a move towards volume-based funding with a quality overlay. In an effort to

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improve efficiency and better characterize performance, the hospital has been auditing the performance of all endoscopists at your institution over the last year. Among the eight

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endoscopists who work at your hospital, the overall ADR has been found to be 19%, falling below the generally accepted benchmark [1].

In response to the results of the audit in your unit, you decide that you would like to

develop an initiative to improve your group’s ADR.

Forming a Quality Improvement Team 2

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The first step in any quality improvement (QI) project is to establish an improvement team. This working group consists of individuals with specific roles who perform

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interdependent tasks and share a common goal [4]. Usually, front-line healthcare workers who are most impacted by the quality of care problem form the foundation of the team. A team lead is identified who will oversee the project. Content experts are also helpful members of the team

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who may have particular expertise in the clinical domain that will be the focus of the project. In addition, an improvement advisor, an individual with some expertise in quality improvement, is

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needed on the team. This may be from within your department or from outside. While they may not possess expertise in the clinical problem you are trying to tackle, they should have skills in QI methodology and process to aid the team. An executive sponsor also needs to be identified. This should be an influential and well-respected individual who holds a senior administrative

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position at your institution who can help the team overcome barriers and secure resources. Physician engagement is a critical, often overlooked step in any improvement effort. Regardless of the initiative, physicians continue to have tremendous influence over hospital-based outcomes

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[5]. Identifying a physician champion, a prominent and respected physician at your organization to help spread the importance of your efforts and create a burning platform for change is helpful.

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It is also valuable to have a patient on the improvement team to provide unique perspectives that only the end user of healthcare can convey and to ensure that the project is patient centered, as all improvement efforts should be [6].

Improvement Framework

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Prior to starting any improvement effort, there are several important considerations that need to be addressed when choosing a quality improvement target [7]. It is important to have a good understanding of the burden and severity of the problem. This often requires audit and

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measuring. For example, while we may think there is a problem with ADR in our endoscopy unit based on a general impression, it is critical to have data to support this suspicion. This is part of a current state analysis (discussed later). It is also important to select a quality of care

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problem that is under you or your group’s direct control. For example, it would be difficult to initiate a quality improvement project aimed at changing practice of radiology reporting as a

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gastroenterologist. It is important to pick a problem that is focused and within a narrow scope that is feasible to address and then improve. Consideration of the unintended consequences of an improvement initiative is often overlooked, but needs to be considered as not all that comes out of quality improvement efforts is good. Lastly, the likelihood of success of a quality initiative is

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significantly increased if it can generate momentum and lead to other interventions both within your department and beyond.

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There are several specific improvement frameworks that can be used by a team to address a quality of care problem and carry out a quality improvement project. The framework chosen

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depends on the type of problem that is being targeted and the training of the individuals on the improvement team. Three of the most commonly used improvement frameworks include: 1. Six Sigma; 2. Lean and; 3. Model for Improvement.

Sig Sigma

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Six Sigma is focused on improvement by reducing variability [8]. It is a highly analytical framework relying on statistical analysis and mathematical modeling. It is best suited for projects whereby the root cause and contributors to the target problem remains unclear and the

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aim of the intervention is to reduce variation.

Lean

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Lean emphasizes improvement through elimination of waste and classifies all parts of any process as value added and non-value added [9]. It is estimated that 95% of activities in any

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health care process are non-value added and the objective of Lean is to identify opportunities to simplify and create efficiencies. It is best suited for target problems that can be directly observed and mapped out, for example process of care, flow, and efficiency of an endoscopy unit.

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Model for Improvement

The Model for Improvement has been popularized by the Institute for Healthcare Improvement [10,11]. It is well suited for healthcare teams, and its advantages are its

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adaptability to many improvement targets and lack of extensive training, consultant support, or statistical training as required by the previous frameworks mentioned above. As a result, it is the

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most commonly used improvement framework.

Using the Model for Improvement

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The Model for Improvement is organized around 3 main questions: (1) What are we trying to accomplish?; (2) How will we know that a change is an improvement?; and (3) What

Question 1: What are we trying to accomplish?

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changes can result in improvement?

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The first stage using the Model for Improvement is developing a clear project aim. A good aim statement should be specific in defining what measures one is hoping to improve and

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setting a concrete deadline by which to achieve it [10,11]. It should answer the questions of what the team is trying to improve, by how much, and by what date. It is more effective for the target to be an ambitious, stretch goal to ensure the effort is worth the resources and time that will be invested by the team. Not only does a good aim statement serve as the foundation for the

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project, but it can re-direct the team if the improvement effort is getting off track. In the above example of improving ADR, an aim statement could be “to increase the ADR of all endoscopists

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who perform colonoscopy at your hospital to 25% over a 12-month period”.

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Question 2: How will we know that a change is an improvement?

This step involves defining measures that will allow you to understand if changes

implemented are impacting the system within which your target problem resides and if this represents an improvement. This usually involves continuous, real time measurement. Outcome measures are clinically relevant outcomes and are the ultimate goal of what the project team is trying to accomplish. In the example of ADR, this could be the proportion of endoscopists at

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your institution with an ADR > 25%. Process Measures are relevant to the system within which you are working and your target problem resides. Typically, the intervention that you implement will have impact that is measureable much earlier by process outcomes than outcomes measures,

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which are usually a downstream effect. As such, an improvement project may still be a success if it demonstrates improvements in process measures only. For example, the proportion of

endoscopists measuring withdrawal time would be a process measure in an intervention aimed at

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improving ADR. In time, improvement in process measures may translate to improvements in the outcome measure. Balancing measures are indicators of unintended consequences of the

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project. Not all that comes from an improvement effort is necessarily positive. If improvements in certain process measures come at the cost of harms demonstrated by the balancing measures, such as deterioration in staff satisfaction or increase in time per procedure, the improvement

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project may not be worth continuing.

Importance of understanding the target problem: current-state analysis In contrast to classic enumerative research where the clinical environment can be well

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controlled, quality improvement work focuses on sampling and intervening upon a less controlled and dynamic process or system with the intent of improving it [10]. Just as treatment

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strategies in clinical medicine are based on diagnostic testing, so too in quality improvement work, the strategy of ‘diagnosing’ the current state allows for linking the root cause of quality problems with solutions that can induce positive change.

Several common diagnostic tools are used to identify root causes of quality and safety issues. These include: (1) Process mapping; (2) Cause and effect diagrams; (3) Pareto charts

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Process mapping Process maps are tools used to understand the system that is being studied. It is a

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graphical depiction of the flow through a process, which creates a collaborative awareness of the current state and identify opportunities for improvement. It is important that multiple individuals who have knowledge of the process in question are involved in its creation. Process maps are

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created by first establishing the start and end of the process. Second, the high level steps are

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included. Third, a more detailed set of steps can be included within each of the high level steps.

Cause and effect diagrams

Cause and effect diagrams, also known as Ishikawa or fishbone diagrams, are helpful brainstorming tools used to graphically display and explore potential causes of a target problem.

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They illustrate that there are often many contributing factors to one underlying problem and the relationship between contributing factors. Classic examples of categories include equipment, environment, materials, methods and process, people and measurement [10]. Figure 1 provides

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Pareto charts

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an example of these tools in an effort to improve ADR.

To identify the most important contributors to the target problem and thus where to focus

improvement efforts, a Pareto chart, a bar graph that places all defects/causes in order of the frequency that they occur, is constructed. The x-axis is a list of possible defects (Figure 1). The y-axis is the frequency with which any one defect is occurring and the third (x-2) axis is cumulative frequency. In theory, it is expected that there will be a “vital few” defects that

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account for 80% of all occurrences (refer to by some as the 80:20 rule) [10,11]. Populating this graph requires measurement which, as discussed above, is the key to understanding any problem.

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Question 3: What changes can result in improvement?

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Measurement can be accomplished through direct observation/audit, chart review and/or multi-

Once the improvement team has defined an aim and established its family of measures, it

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is time to develop and implement an intervention. Rather than investing time and resources into one intervention that may or may not be successful, it is preferable to carry out small change cycles where the intervention is conducted in a small scale, refined, and either repeated or changed. As a result, most quality improvement projects consist of an iterative process. The

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Model for Improvement defines four steps that allow the improvement team to do this: Plan, Do, Study, Act (PDSA) [4, 10,11]. The first two questions above allowed the improvement team to plan the intervention. The next step, ‘Do’ involves implementing your project on a small scale

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thereby testing your change while collecting continuous measurements. ‘Study’ involves interpreting your data using both conventional methods and several improvement specific

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methods (discussed later) that help answer the question; how will we know that a change is improvement. Finally, ‘Act’ involves making a conclusion about your first PDSA cycle helping to inform subsequent cycles. This results in a series of small, rapid cycle changes, one building on the next, that lead to implementation of change(s) that ultimately serve to address your improvement problem and your project aim.

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A change concept is an approach known to be useful in developing specific changes that result in improvement. Change concepts are used as a starting point to generate change ideas. A number of change concepts spanning 9 main categories have been defined by the

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Associates for Process Improvement [10], including eliminating waste, improving work flow, managing variation, and designing systems to prevent error. For the purpose of improving ADR, your team may choose a few change concepts and ideas based on the diagnostic work up. For

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example, the change concept of designing the system to prevent errors through standardizing withdrawal time for all physicians may lead to an improvement in ADR. This is then linked to

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the change idea of audible timers placed in endoscopy suites to ensure longer withdrawal times [12]. The impact of this change would be measured and the next cycle would build on these results.

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Summary and Next Steps

In this first article of the series, the QI team moved forward with their aim to increase

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ADR. A root cause analysis was undertaken using multiple diagnostic tools including a fishbone diagram and Pareto chart. Finally, change ideas were generated based on the above root causes

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and established change concepts. The next steps involve undertaking PDSA cycles to test change ideas and monitor for improvement.

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REFERENCES

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1. Rex DK, Schoenfeld PS, Cohen J et al. Quality indicators for colonoscopy. Gastrointest Endosc. 2015;81(1):31-53. 2. Rex DK, Bond JH, Winawer S, et al. Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2002;97:1296-308. 3. Corley D, Jensen CD, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 2014;370:1298-306. 4. Kotter JP: Leading change, Boston, Mass., Harvard Business Review Press, 2012 5. Taitz JM, Lee TH, Sequist TD: A framework for engaging physicians in quality and safety. BMJ quality & safety, 21: 722-728, 2012 6. Carman KL, Dardess P, Maurer M, et al. Patient and Family Engagement: A Framework for Understanding the Elements and Developing Interventions and Policies. Health Affairs 2013;33(2):223-31 7. Ranji SR, Shojania SG. Implementing Patient Safety Interventions in Your Hospital: What to Try and What to Avoid. Med Clin N Am 2008;92:275-93 8. Antony J. Six Sigma vs Lean: Some perspectives from leading academics and practitioners. International Journal of Productivity and Performance Management 2011; 60:185-190 9. Bercaw R: Taking improvement from the assembly line to healthcare : the application of lean within the healthcare industry, Boca Raton, Taylor & Francis, 2012 10. Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP: The improvement guide : a practical approach to enhancing organizational performance, San Francisco, Jossey-Bass, 2009 11. Berwick DM. A primer on leading the improvement of systems. BMJ 1996;312;619-22 12. Corley DA, Jensen, CD, Marks, AR. Can we improve adenoma detection rates? A systematic review of intervention studies. GIE 2011, 74(3), 656–665.

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Figure 1: Common diagnostic tools used for root cause analyses. (A) Fishbone diagram; (B) Pareto chart.

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