Quality Matters
Introduction to Quality Improvement Part One: Defining the Problem, Making a Plan Peter J. Chung, MD,* Rebecca A. Baum, MD,† Neelkamal S. Soares, MD,‡ Eugenia Chan, MD, MPH§
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lthough the term “quality” has different meanings for different stakeholders (providers, patients, payers, employers), all can agree on the goal of delivering the highest quality care possible to patients and families. How to achieve this goal, however, is often a daunting task, especially for clinicians who face many competing challenges in today’s health care environment. Quality improvement (QI) is a systematic, iterative process that calls for introducing a change in practice, measuring its effects, learning from the data, and continuing to make adjustments until results reach a target goal. Although every QI project is different, the process of creating effective and sustainable change follows the same general principles and presents similar themes and challenges. This 2-part series, while not intended to be a comprehensive overview, will introduce the reader to the field of QI, using a case scenario to illustrate how the methods and tools of QI can be used in developmentalbehavioral pediatrics. Part 1 will focus on defining the problem and developing a plan for change, and Part 2 will focus on the change process itself. More information regarding the tools used in the case can be found in the resources listed in Table 1.
Case Harry has recently graduated from a developmental-behavioral pediatric training program and is now struggling to adjust to the demands of a busy clinical practice. One issue he encounters repeatedly is missed appointments, or “no-shows,” particularly among his patients with attention-deficit hyperactivity disorder (ADHD). During 1 week, he calculated that he had a 15% no-show rate! He is worried about the effect of no-shows on his pro-
(J Dev Behav Pediatr 35:460–466, 2014) From the *Mattel Children’s Hospital, Department of Pediatrics, University of California Los Angeles, Los Angeles, CA; †Nationwide Children’s Hospital, Department of Pediatrics, The Ohio State University, Columbus, OH; ‡Geisinger Health System, Danville, PA; and §Division of Developmental Medicine, Boston Children’s Hospital, Boston, MA. Disclosure: The authors declare no conflict of interest. Address for reprints: Rebecca A. Baum, MD, Nationwide Children’s Hospital, Department of Pediatrics, The Ohio State University, 700 Children’s Drive, Columbus, OH 43205; e-mail: [email protected]. Copyright 2014 Lippincott Williams & Wilkins
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ductivity and wonders whether his new colleagues face the same issues and if so, what can be done about it. The other clinicians include Eric, the founding partner of the clinic, and Julie, a physician who completed fellowship a few years before. When Harry meets with Eric, the senior doctor assures him that this isn’t a widespread issue. “You’re still new here and parents haven’t had a chance to bond with you yet,” he says. “You know, ADHD is genetic so the parents might have some ‘challenges’ of their own.” Over coffee, Julie shares that she has had some similar concerns but seems indifferent. “I get a lot of no-shows too, but I just overbook patients and hope it averages out in the end.” During lunch in the break room, Harry casually brings up the topic with the office staff. The front desk staff is the first to agree that there is a problem. “You all are too nice,” says Lilia, the clinic coordinator. “We should kick out anyone who misses more than two appointments.” Marcus, one of the schedulers, disagrees, saying, “No, it’s because your appointments are booked out for months. By the time, their appointment finally comes around, they have forgotten about it.” Jennifer, a nurse who has been there for many years, acknowledges that there is a problem but says, “That’s just how it is and how it’s always been. I don’t think there’s much you can do about it.”
Improvers Assemble Effective quality improvement (QI) requires a team approach. Involving all individuals who are part of the process—clinicians, managers, front desk and administrative staff, and patients and families—is key to understanding how a system is working (or not working) from beginning to end. Team members offer multiple perspectives that can help spur creative thinking, resolve conflicts, and achieve more rapid results. Since people and systems tend to resist change, gaining buy-in and ownership from the key stakeholders through teamwork helps to create a shared understanding and vision. Motivating and leading others through change can be challenging, as the loftier goal of improving patient care often gives way to the demands of daily practice for both clinicians and office staff. For physicians, incentive to participate in QI projects stems from requirements to obtain American Board of Pediatrics Maintenance of Certification Part 4 Performance in Practice credit (more information available at www.abp.org/moc or at Journal of Developmental & Behavioral Pediatrics
Table 1. Additional QI Resources Online Institute for Healthcare Improvement—www.ihi.org National Initiative for Children’s Healthcare Quality—www.nichq.org Health Resources and Services Administration Toolkit—http://www.hrsa.gov/quality/toolbox/index/html Duke Center for Instructional Technology—http://patientsafetyed.duhs.duke.edu/module_a/module_overview.html Healthcare Improvement Skills Center—http://www.improvementskills.org/ The Team Handbook—www.teamhandbook.com/ In print Langley GJ, Moen RN, Nolan KM, et al. The Improvement Guide. 2nd ed. Jossey-Bass; 2009. Tague N. The Quality Toolbox. 2nd ed. ASQ Quality Press; 2005. Nelson EC, Batalden PB, Godfrey MM. Quality by Design: A Clinical Microsystems Approach. Jossey-Bass; 2009. Balestracci D. Data Sanity. Medical Group Management Association; 2009. Brassard M, Ritter D. The Memory Jogger 2: Tools for Continuous Improvement and Effective Planning. 2nd ed. Goal/QPC; 2010. Scholtes PR, Joiner BL, Streibel BJ. The Team Handbook. 3rd ed. Oriel; 2010.
https://www.mocactivitymanager.org/public/abp/) or to meet payer “pay for performance” metrics. However, selecting a project that is highly relevant and has the potential for significant benefits to multiple stakeholders offers the best chance of success. Providing evidence (data) to demonstrate the impact of a problem is often the first and best step toward gaining support for change efforts. Evidence can be quantitative or qualitative, including information that can be elicited through interviews or focus groups of patients and parents. To see how many no-shows actually occur, Harry asks Lilia to start by keeping track of how many patients miss their appointments each week. Although he would like to know more details such as the reason for each no-show, Lilia says it will take too much time for her to keep track of those details. One of the college volunteers in the clinic agrees to go through the appointment records for the past 3 months to get an idea of the current no-show rate. Eric is surprised to see the resulting graph (Fig. 1). “This is a bigger problem than I thought,” he says, “This is costing us a lot of time and money!”
Figure 1. A run chart representing no-shows by week, with the dotted line representing the mean value. Vol. 35, No. 7, September 2014
A run chart is an important tool that can be used to assess baseline performance as well as to view the effects of process change. By graphing data points over time, a QI team can determine the degree of inherent (“random”) variation around a central tendency (typically a mean or median) in any given process at baseline. This information can be a powerful motivator to gain buy-in from team members and to develop a “goal line” to drive improvement efforts.
We Have Only Just Begun After reviewing the baseline no-show rates, the QI team is eager to jump in and start making changes, and everyone has a different idea of what changes should be made. Eric is particularly vocal about getting no-shows to zero by Friday. “It’s great to see such enthusiasm,” Harry interjects into the lively discussion, “but let’s not get ahead of ourselves. Let’s first agree on what the problem is before we decide what to do about it.” Harry then shows the Model for Improvement (Fig. 2).
The natural tendency to fix a problem as quickly as possible often propels QI teams to start introducing change before agreeing on what the problem actually is and what the goal(s) are. The Model for Improvement helps QI teams step back to define and plan the project more carefully. Answering these 3 questions can greatly improve the success of the project. 1. What are we trying to accomplish? This refers to the project AIM. A central aim statement sets a common vision and end-goal that guides the work of the improvement team. Aim statements focus on the “what,” not the “how.” In addition, the best aim statements are SMART: © 2014 Lippincott Williams & Wilkins
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Figure 2. Institute for Healthcare Improvement: Model for Improvement (adapted from Langley GL, et al.1).
Specific: One goal or intent Measurable: Progress can be monitored over time Actionable: Known barriers can be overcome Realistic: Given the resources available Timely: With a target date to achieve the goal. 2. How will we know that a change is an improvement? MEASURES and a measurement plan help improvement teams monitor the results of change and determine whether a change actually leads to improvement. Since QI is a data-driven process, measures should be pragmatic (rather than perfect), judiciously chosen, and require as little additional work in collecting data as possible. Often, it is desirable to have a measure set consisting of outcome, process, and balancing measures. • Outcome measures refer to impact on the patient, family, or system and may be clinical (e.g., morbidity and mortality), financial (e.g., cost or resource utilization), or service related (e.g., patient satisfaction). • Process measures focus on interactions between consumers and the health care system, such as diagnosis, treatment, and care coordination. Examples of measurable processes include documentation of weight and blood pressure for children prescribed stimulant medication, or using DSM criteria for diagnosis of ADHD. Process measures are particularly useful when clinical outcomes are rare or difficult to measure. • Balancing measures take into account the unintended consequences of a change. For example, if staff time and energy are focused on improving noshow rates among patients with ADHD by increasing the number of phone call reminders, how much time do they spend making telephone calls? How does this stress the staff? Are families waiting longer for calls to be answered? Planning for measurement includes considering what data are needed and how these data can be collected efficiently. Sampling (e.g., collecting data for 1 day per week, or for every Nth patient) and using or building on existing resources (e.g., electronic medical record or adding a checkbox to a paper form) are ways 462 Introduction to Quality Improvement
to minimize the impact of data collection on practice workflow. 3. What changes can we make that will result in improvement? IDEAS: Ideas are the proposed changes that the team hypothesizes will lead to improvement. They can range from simple workflow adjustments to more complex and creative endeavors. Understanding the existing system or process from the perspective of different stakeholders is often the first and most useful step in generating ideas for change. A variety of tools can be helpful in generating, organizing, and prioritizing ideas for change.
The QI team takes Eric’s initial declaration “zero no shows by Friday” and adapts it to fulfill SMART criteria. After much deliberation, the QI team agrees on their final aim statement: “Starting June 1, 2014, we will decrease patient no-show rates in our clinic to 2% per week or less by May 31, 2015.” The team agrees on one outcome measure (weekly no-show rate, calculated based on the number of missed appointments vs number of total scheduled appointments for that week). However, they cannot agree on what changes they could make that could lead to improvement. After much discussion, Jeffrey, the office manager, finally says, “I think our problem is that we don’t really know why our patients no-show so often. If we did, then we can focus on that reason so we don’t waste time and energy spinning our wheels.” Julie volunteers to look into the process of making appointments. “I’ve been here 5 years, and all I know is that the front desk makes it happen, somehow,” she says sheepishly. She decides to gather information by talking to Lilia and Marcus about the steps that go into the process. Since she wants to know how the process works—not just how it is supposed to work—she also asks nurse Jennifer to physically follow a few patients as they leave the examination room to see what really happens in real time. By pooling their findings, they come up with the following process map (Fig. 3).
Process maps are graphical representations of a workflow or system and can be used to detail an existing process or map out an improved (“ideal”) one. Process maps can help a team understand the steps in how things are done and identify areas of unnecessary complexity that could be targets for improvement (e.g., by eliminating redundant steps). A “swim lane” process map incorporates the roles of different people involved in the process and can be very useful in identifying “hand-offs” where the care of the patient is transferred from one role to another, as these transitions can be are particularly vulnerable to breakdown. Journal of Developmental & Behavioral Pediatrics
Harry realizes that the team has not actually included families in their QI process, so Jeffrey, the office manager, offers to interview some patients and families about why they might miss an appointment. This yields additional information that the clinicians and office staff had not previously considered. To organize and summarize all of the information thus far, Harry and Jeffrey develop the following diagram (Fig. 4).
Figure 3.
The fishbone diagram (or “Ishikawa diagram”) provides a way to brainstorm and organize factors that may contribute to a problem. In the manufacturing world, the common categories include the “6 Ms”: methods, materials, machines, manpower, measurement, and mother nature. However, the categories can also be modified to be most relevant to the project at hand and can serve to stimulate the identification of additional contributing factors.
“Swim lane” process map for scheduling appointments.
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A week later, the team reconvenes to review the process map and fishbone diagram and to discuss the next steps. They decide that while they have a better understanding of the appointment process and many reasons why patients no-show, they need to focus their change efforts on the most common reasons for no-shows. Harry asks Marcus to start a simple checktally system over the next month (Fig. 5), asking why the family missed the appointment when calling patients to reschedule appointments. Since part of his job has been to reschedule no-shows, this represents a minimal disruption to his workflow. At the end of a month, Harry collects the responses and assembles the graph below (Fig. 6). The Pareto Diagram is based on the concept that 80% of the problem is due to 20% of the factors. That is, although an issue may be due to a wide variety of reasons, only a few reasons are primary contributors and, if malleable, should be targeted for intervention. This helps the team to prioritize their improvement efforts for maximum effect.
Ch-Ch-Changes The QI team meets again the following week to make decisions based on the Pareto and fishbone diagrams. Harry reviews their SMART aim statement: “Starting June 1, 2014, we will decrease patient noshow rates in our clinic to 2% per week or less by May 31, 2015.” He then asks, “Knowing what we now know, how should we do this in our practice?”
Figure 4.
While the team approach is useful for gathering differing opinions and ideas, coming to consensus can be unwieldy if not managed effectively. The nominal group technique (NGT) is one method that can guide a group toward consensus. The 4 steps of the nominal group are as follows: 1. Generating, where individuals silently and independently write ideas in response to the question posed by the moderator; 2. Recording, where individuals share their ideas without any debate; 3. Discussing, in which the moderator leads the group in discussion of each suggestion; and 4. Voting, in which individuals privately vote on how to prioritize the ideas. At the conclusion of the session, the group should have a tally of which ideas should be pursued. Thus, NGT is a technique in which a group can rapidly come to a consensus without having a single individual dominate the discussion or decision.
A lively debate follows, but the group is able to come to consensus and decide on a priority list of changes that are most likely to decrease the practice’s no-show rates. To summarize the team’s roadmap, Harry develops the following key driver diagram (Fig. 7).
A key driver diagram summarizes the aim statement, leverage points (or “drivers”) and the intervention(s)
Fishbone diagram detailing reasons behind no-show rates.
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dress the underlying issues, and specify measures of improvement. Our team’s QI story illustrates some general principles for improvement projects, including:
Figure 5.
Check sheet for tallying responses from parents.
needed to achieve the aim successfully. An effective key driver diagram should serve as a roadmap for the entire QI initiative and focus the efforts on improvement. In our example, the guided discussion and data gathered so far have established the foundation for a successful QI initiative. The improvement team is now able to understand the problem at hand, elicit support and interest from the various stakeholders, generate strategies to ad-
• Involving multiple stakeholders from the ground level • Taking time to understand the existing process using a variety of tools and perspectives • Developing a Specific, Measurable, Actionable, Realistic, and Timely (SMART) aim statement to guide the project • Defining measures that the team will monitor for the results of change • Using a key driver diagram to summarize the project’s planned interventions and how each relates to the SMART aim.
Figure 6.
Pareto diagram.
Figure 7.
Key driver diagram showing the relationship between key drivers and interventions and the aim statement.
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However, the process is far from over, and Part 2 of this series will follow the team through the challenges that lie ahead. We encourage the readers to consider how you might apply QI methods to a specific problem that you or your practice is facing. Explore the problem using some of the tools described in this article as well as others found in the resources listed below. In planning your project, ask your clinical team, administrative staff, and patients/families
for their input, considering the following questions: What is the most important? What is the most actionable? Then assemble a team to begin the process of change. REFERENCE 1. Langley GL, Moen RN, Nolan KM, et al. The Improvement Guide. 2nd ed. San Francisco, CA: Jossey-Bass; 2009.
Book Review Redesigning Health Care for Children With Disabilities by Heidi M. Feldman, Baltimore, MD, Brookes Publishing Company, 2013, 263 pp, $49.95 Soft Cover This comprehensive publication proposes a holistic and family-centered framework for providing health care for children with disabilities and challenges clinicians to redirect their focus toward maximizing children’s ability to function in and contribute to the community. Written by Dr. Heidi Feldman, Professor of Developmental-Behavioral Pediatrics at Stanford University School of Medicine, this book reflects her more than 30 years of expertise in working with children with chronic developmental and/or physical disabilities. Her previous training as a developmental psychologist also informs her recommendations for redesigning health care, as she emphasizes addressing the emotional and social needs of her patients and families as well as their physical care needs. Dr. Feldman recommends a comprehensive biopsychosocial approach to addressing the health care needs of children with disabilities. The 3 pillars of the proposed model are (1) inclusion—of children with disabilities into all aspects of community life; (2) contribution—full and active participation of children with disabilities, to the maximum extent possible; and (3) health—defined broadly as a state of physical, mental, and social well-being. This approach to health care requires a paradigm shift from a focus on symptom reduction and remediation of deficits to an emphasis on functionality and outcomes of interventions. The text explores the turbulent health care environment and the system’s challenges—fragmented health care and social services, unsustainable costs despite the proliferation of costfocused business models, legislative and policy mandates, and the ever-expanding
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numbers of children with disabilities without a comparable boom in the number of clinicians dedicated to their care. With the shift from emphasis on diagnosis to a focus on management after diagnosis with the goal of maximizing functional outcomes, these changes are likely to lead to positive outcomes not only for the children involved but for the larger systems as well. The first section of the book paints a picture of children with disabilities (Dr. Feldman prefers this term to the common usage of “children with special needs,” as this phrase may contribute to the perception of these children as separate and different). The text discusses the scope of disabilities addressed, as well as prevalence data, demographics, health care costs, complexity of care needs, and challenges inherent in caring for these children. Section 2 explores the goals of health care for children with disabilities in the context of the 3 pillars described above. As a step toward the paradigm shift of viewing disability and health care in the context of functioning, Dr. Feldman recommends implementing the World Health Organization’s 2002 model for classifying health conditions and functional status—the International Classification of Functioning, Disability and Health (ICF). Using the ICF in lieu of traditional diagnostic and disease classification taxonomies such as the DSM and ICD would help to refocus the goals of health care provision on improved functioning and quality of life. The third section offers health care providers strategies and tools that they can use to support this redesigned approach to care delivery. The book provides concrete examples and guidelines for
implementing processes that are often only discussed in the abstract, such as comprehensive integrated care plans, family-centered care, and effective care coordination. Finally, Section 4 is a call to action that encourages health care and social service providers to advance this new model of health care through education, research, and advocacy to effect policy change. Interspersed within the text are vignettes of real patients and families, overviews of supplemental services for children with disabilities, discussions of concepts such as inclusion and the fiscal implications of health care issues, and helpful resources for providers. Each chapter ends with questions and exercises designed to challenge and develop the reader’s perspective. As a social worker whose practice has focused on children with chronic conditions, I am heartened by the recognition that a biopsychosocial approach is the most effective way to provide care to this population. I hope that health care providers accept the charge to broaden the way they provide care as well as to advocate for higher-level system changes. Although the challenges of our current health care system may inhibit the adoption of some of the best practices delineated in this book, it is essential to move the system forward for the benefit of our patients, families, and the system as a whole. Disclosure: The author declares no conflict of interest. Dinah L. Godwin, MSW, LCSW Meyer Center for Developmental Pediatrics, Baylor College of Medicine Houston, TX
Journal of Developmental & Behavioral Pediatrics
Introduction to Quality Improvement Part One: Defining the Problem, Making a Plan Peter J. Chung, MD,* Rebecca A. Baum, MD,† Neelkamal S. Soares, MD,‡ Eugenia Chan, MD, MPH§
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lthough the term “quality” has different meanings for different stakeholders (providers, patients, payers, employers), all can agree on the goal of delivering the highest quality care possible to patients and families. How to achieve this goal, however, is often a daunting task, especially for clinicians who face many competing challenges in today’s health care environment. Quality improvement (QI) is a systematic, iterative process that calls for introducing a change in practice, measuring its effects, learning from the data, and continuing to make adjustments until results reach a target goal. Although every QI project is different, the process of creating effective and sustainable change follows the same general principles and presents similar themes and challenges. This 2-part series, while not intended to be a comprehensive overview, will introduce the reader to the field of QI, using a case scenario to illustrate how the methods and tools of QI can be used in developmentalbehavioral pediatrics. Part 1 will focus on defining the problem and developing a plan for change, and Part 2 will focus on the change process itself. More information regarding the tools used in the case can be found in the resources listed in Table 1.
Case Harry has recently graduated from a developmental-behavioral pediatric training program and is now struggling to adjust to the demands of a busy clinical practice. One issue he encounters repeatedly is missed appointments, or “no-shows,” particularly among his patients with attention-deficit hyperactivity disorder (ADHD). During 1 week, he calculated that he had a 15% no-show rate! He is worried about the effect of no-shows on his pro-
(J Dev Behav Pediatr 35:460–466, 2014) From the *Mattel Children’s Hospital, Department of Pediatrics, University of California Los Angeles, Los Angeles, CA; †Nationwide Children’s Hospital, Department of Pediatrics, The Ohio State University, Columbus, OH; ‡Geisinger Health System, Danville, PA; and §Division of Developmental Medicine, Boston Children’s Hospital, Boston, MA. Disclosure: The authors declare no conflict of interest. Address for reprints: Rebecca A. Baum, MD, Nationwide Children’s Hospital, Department of Pediatrics, The Ohio State University, 700 Children’s Drive, Columbus, OH 43205; e-mail: [email protected]. Copyright 2014 Lippincott Williams & Wilkins
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ductivity and wonders whether his new colleagues face the same issues and if so, what can be done about it. The other clinicians include Eric, the founding partner of the clinic, and Julie, a physician who completed fellowship a few years before. When Harry meets with Eric, the senior doctor assures him that this isn’t a widespread issue. “You’re still new here and parents haven’t had a chance to bond with you yet,” he says. “You know, ADHD is genetic so the parents might have some ‘challenges’ of their own.” Over coffee, Julie shares that she has had some similar concerns but seems indifferent. “I get a lot of no-shows too, but I just overbook patients and hope it averages out in the end.” During lunch in the break room, Harry casually brings up the topic with the office staff. The front desk staff is the first to agree that there is a problem. “You all are too nice,” says Lilia, the clinic coordinator. “We should kick out anyone who misses more than two appointments.” Marcus, one of the schedulers, disagrees, saying, “No, it’s because your appointments are booked out for months. By the time, their appointment finally comes around, they have forgotten about it.” Jennifer, a nurse who has been there for many years, acknowledges that there is a problem but says, “That’s just how it is and how it’s always been. I don’t think there’s much you can do about it.”
Improvers Assemble Effective quality improvement (QI) requires a team approach. Involving all individuals who are part of the process—clinicians, managers, front desk and administrative staff, and patients and families—is key to understanding how a system is working (or not working) from beginning to end. Team members offer multiple perspectives that can help spur creative thinking, resolve conflicts, and achieve more rapid results. Since people and systems tend to resist change, gaining buy-in and ownership from the key stakeholders through teamwork helps to create a shared understanding and vision. Motivating and leading others through change can be challenging, as the loftier goal of improving patient care often gives way to the demands of daily practice for both clinicians and office staff. For physicians, incentive to participate in QI projects stems from requirements to obtain American Board of Pediatrics Maintenance of Certification Part 4 Performance in Practice credit (more information available at www.abp.org/moc or at Journal of Developmental & Behavioral Pediatrics
Table 1. Additional QI Resources Online Institute for Healthcare Improvement—www.ihi.org National Initiative for Children’s Healthcare Quality—www.nichq.org Health Resources and Services Administration Toolkit—http://www.hrsa.gov/quality/toolbox/index/html Duke Center for Instructional Technology—http://patientsafetyed.duhs.duke.edu/module_a/module_overview.html Healthcare Improvement Skills Center—http://www.improvementskills.org/ The Team Handbook—www.teamhandbook.com/ In print Langley GJ, Moen RN, Nolan KM, et al. The Improvement Guide. 2nd ed. Jossey-Bass; 2009. Tague N. The Quality Toolbox. 2nd ed. ASQ Quality Press; 2005. Nelson EC, Batalden PB, Godfrey MM. Quality by Design: A Clinical Microsystems Approach. Jossey-Bass; 2009. Balestracci D. Data Sanity. Medical Group Management Association; 2009. Brassard M, Ritter D. The Memory Jogger 2: Tools for Continuous Improvement and Effective Planning. 2nd ed. Goal/QPC; 2010. Scholtes PR, Joiner BL, Streibel BJ. The Team Handbook. 3rd ed. Oriel; 2010.
https://www.mocactivitymanager.org/public/abp/) or to meet payer “pay for performance” metrics. However, selecting a project that is highly relevant and has the potential for significant benefits to multiple stakeholders offers the best chance of success. Providing evidence (data) to demonstrate the impact of a problem is often the first and best step toward gaining support for change efforts. Evidence can be quantitative or qualitative, including information that can be elicited through interviews or focus groups of patients and parents. To see how many no-shows actually occur, Harry asks Lilia to start by keeping track of how many patients miss their appointments each week. Although he would like to know more details such as the reason for each no-show, Lilia says it will take too much time for her to keep track of those details. One of the college volunteers in the clinic agrees to go through the appointment records for the past 3 months to get an idea of the current no-show rate. Eric is surprised to see the resulting graph (Fig. 1). “This is a bigger problem than I thought,” he says, “This is costing us a lot of time and money!”
Figure 1. A run chart representing no-shows by week, with the dotted line representing the mean value. Vol. 35, No. 7, September 2014
A run chart is an important tool that can be used to assess baseline performance as well as to view the effects of process change. By graphing data points over time, a QI team can determine the degree of inherent (“random”) variation around a central tendency (typically a mean or median) in any given process at baseline. This information can be a powerful motivator to gain buy-in from team members and to develop a “goal line” to drive improvement efforts.
We Have Only Just Begun After reviewing the baseline no-show rates, the QI team is eager to jump in and start making changes, and everyone has a different idea of what changes should be made. Eric is particularly vocal about getting no-shows to zero by Friday. “It’s great to see such enthusiasm,” Harry interjects into the lively discussion, “but let’s not get ahead of ourselves. Let’s first agree on what the problem is before we decide what to do about it.” Harry then shows the Model for Improvement (Fig. 2).
The natural tendency to fix a problem as quickly as possible often propels QI teams to start introducing change before agreeing on what the problem actually is and what the goal(s) are. The Model for Improvement helps QI teams step back to define and plan the project more carefully. Answering these 3 questions can greatly improve the success of the project. 1. What are we trying to accomplish? This refers to the project AIM. A central aim statement sets a common vision and end-goal that guides the work of the improvement team. Aim statements focus on the “what,” not the “how.” In addition, the best aim statements are SMART: © 2014 Lippincott Williams & Wilkins
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Figure 2. Institute for Healthcare Improvement: Model for Improvement (adapted from Langley GL, et al.1).
Specific: One goal or intent Measurable: Progress can be monitored over time Actionable: Known barriers can be overcome Realistic: Given the resources available Timely: With a target date to achieve the goal. 2. How will we know that a change is an improvement? MEASURES and a measurement plan help improvement teams monitor the results of change and determine whether a change actually leads to improvement. Since QI is a data-driven process, measures should be pragmatic (rather than perfect), judiciously chosen, and require as little additional work in collecting data as possible. Often, it is desirable to have a measure set consisting of outcome, process, and balancing measures. • Outcome measures refer to impact on the patient, family, or system and may be clinical (e.g., morbidity and mortality), financial (e.g., cost or resource utilization), or service related (e.g., patient satisfaction). • Process measures focus on interactions between consumers and the health care system, such as diagnosis, treatment, and care coordination. Examples of measurable processes include documentation of weight and blood pressure for children prescribed stimulant medication, or using DSM criteria for diagnosis of ADHD. Process measures are particularly useful when clinical outcomes are rare or difficult to measure. • Balancing measures take into account the unintended consequences of a change. For example, if staff time and energy are focused on improving noshow rates among patients with ADHD by increasing the number of phone call reminders, how much time do they spend making telephone calls? How does this stress the staff? Are families waiting longer for calls to be answered? Planning for measurement includes considering what data are needed and how these data can be collected efficiently. Sampling (e.g., collecting data for 1 day per week, or for every Nth patient) and using or building on existing resources (e.g., electronic medical record or adding a checkbox to a paper form) are ways 462 Introduction to Quality Improvement
to minimize the impact of data collection on practice workflow. 3. What changes can we make that will result in improvement? IDEAS: Ideas are the proposed changes that the team hypothesizes will lead to improvement. They can range from simple workflow adjustments to more complex and creative endeavors. Understanding the existing system or process from the perspective of different stakeholders is often the first and most useful step in generating ideas for change. A variety of tools can be helpful in generating, organizing, and prioritizing ideas for change.
The QI team takes Eric’s initial declaration “zero no shows by Friday” and adapts it to fulfill SMART criteria. After much deliberation, the QI team agrees on their final aim statement: “Starting June 1, 2014, we will decrease patient no-show rates in our clinic to 2% per week or less by May 31, 2015.” The team agrees on one outcome measure (weekly no-show rate, calculated based on the number of missed appointments vs number of total scheduled appointments for that week). However, they cannot agree on what changes they could make that could lead to improvement. After much discussion, Jeffrey, the office manager, finally says, “I think our problem is that we don’t really know why our patients no-show so often. If we did, then we can focus on that reason so we don’t waste time and energy spinning our wheels.” Julie volunteers to look into the process of making appointments. “I’ve been here 5 years, and all I know is that the front desk makes it happen, somehow,” she says sheepishly. She decides to gather information by talking to Lilia and Marcus about the steps that go into the process. Since she wants to know how the process works—not just how it is supposed to work—she also asks nurse Jennifer to physically follow a few patients as they leave the examination room to see what really happens in real time. By pooling their findings, they come up with the following process map (Fig. 3).
Process maps are graphical representations of a workflow or system and can be used to detail an existing process or map out an improved (“ideal”) one. Process maps can help a team understand the steps in how things are done and identify areas of unnecessary complexity that could be targets for improvement (e.g., by eliminating redundant steps). A “swim lane” process map incorporates the roles of different people involved in the process and can be very useful in identifying “hand-offs” where the care of the patient is transferred from one role to another, as these transitions can be are particularly vulnerable to breakdown. Journal of Developmental & Behavioral Pediatrics
Harry realizes that the team has not actually included families in their QI process, so Jeffrey, the office manager, offers to interview some patients and families about why they might miss an appointment. This yields additional information that the clinicians and office staff had not previously considered. To organize and summarize all of the information thus far, Harry and Jeffrey develop the following diagram (Fig. 4).
Figure 3.
The fishbone diagram (or “Ishikawa diagram”) provides a way to brainstorm and organize factors that may contribute to a problem. In the manufacturing world, the common categories include the “6 Ms”: methods, materials, machines, manpower, measurement, and mother nature. However, the categories can also be modified to be most relevant to the project at hand and can serve to stimulate the identification of additional contributing factors.
“Swim lane” process map for scheduling appointments.
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A week later, the team reconvenes to review the process map and fishbone diagram and to discuss the next steps. They decide that while they have a better understanding of the appointment process and many reasons why patients no-show, they need to focus their change efforts on the most common reasons for no-shows. Harry asks Marcus to start a simple checktally system over the next month (Fig. 5), asking why the family missed the appointment when calling patients to reschedule appointments. Since part of his job has been to reschedule no-shows, this represents a minimal disruption to his workflow. At the end of a month, Harry collects the responses and assembles the graph below (Fig. 6). The Pareto Diagram is based on the concept that 80% of the problem is due to 20% of the factors. That is, although an issue may be due to a wide variety of reasons, only a few reasons are primary contributors and, if malleable, should be targeted for intervention. This helps the team to prioritize their improvement efforts for maximum effect.
Ch-Ch-Changes The QI team meets again the following week to make decisions based on the Pareto and fishbone diagrams. Harry reviews their SMART aim statement: “Starting June 1, 2014, we will decrease patient noshow rates in our clinic to 2% per week or less by May 31, 2015.” He then asks, “Knowing what we now know, how should we do this in our practice?”
Figure 4.
While the team approach is useful for gathering differing opinions and ideas, coming to consensus can be unwieldy if not managed effectively. The nominal group technique (NGT) is one method that can guide a group toward consensus. The 4 steps of the nominal group are as follows: 1. Generating, where individuals silently and independently write ideas in response to the question posed by the moderator; 2. Recording, where individuals share their ideas without any debate; 3. Discussing, in which the moderator leads the group in discussion of each suggestion; and 4. Voting, in which individuals privately vote on how to prioritize the ideas. At the conclusion of the session, the group should have a tally of which ideas should be pursued. Thus, NGT is a technique in which a group can rapidly come to a consensus without having a single individual dominate the discussion or decision.
A lively debate follows, but the group is able to come to consensus and decide on a priority list of changes that are most likely to decrease the practice’s no-show rates. To summarize the team’s roadmap, Harry develops the following key driver diagram (Fig. 7).
A key driver diagram summarizes the aim statement, leverage points (or “drivers”) and the intervention(s)
Fishbone diagram detailing reasons behind no-show rates.
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dress the underlying issues, and specify measures of improvement. Our team’s QI story illustrates some general principles for improvement projects, including:
Figure 5.
Check sheet for tallying responses from parents.
needed to achieve the aim successfully. An effective key driver diagram should serve as a roadmap for the entire QI initiative and focus the efforts on improvement. In our example, the guided discussion and data gathered so far have established the foundation for a successful QI initiative. The improvement team is now able to understand the problem at hand, elicit support and interest from the various stakeholders, generate strategies to ad-
• Involving multiple stakeholders from the ground level • Taking time to understand the existing process using a variety of tools and perspectives • Developing a Specific, Measurable, Actionable, Realistic, and Timely (SMART) aim statement to guide the project • Defining measures that the team will monitor for the results of change • Using a key driver diagram to summarize the project’s planned interventions and how each relates to the SMART aim.
Figure 6.
Pareto diagram.
Figure 7.
Key driver diagram showing the relationship between key drivers and interventions and the aim statement.
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However, the process is far from over, and Part 2 of this series will follow the team through the challenges that lie ahead. We encourage the readers to consider how you might apply QI methods to a specific problem that you or your practice is facing. Explore the problem using some of the tools described in this article as well as others found in the resources listed below. In planning your project, ask your clinical team, administrative staff, and patients/families
for their input, considering the following questions: What is the most important? What is the most actionable? Then assemble a team to begin the process of change. REFERENCE 1. Langley GL, Moen RN, Nolan KM, et al. The Improvement Guide. 2nd ed. San Francisco, CA: Jossey-Bass; 2009.
Book Review Redesigning Health Care for Children With Disabilities by Heidi M. Feldman, Baltimore, MD, Brookes Publishing Company, 2013, 263 pp, $49.95 Soft Cover This comprehensive publication proposes a holistic and family-centered framework for providing health care for children with disabilities and challenges clinicians to redirect their focus toward maximizing children’s ability to function in and contribute to the community. Written by Dr. Heidi Feldman, Professor of Developmental-Behavioral Pediatrics at Stanford University School of Medicine, this book reflects her more than 30 years of expertise in working with children with chronic developmental and/or physical disabilities. Her previous training as a developmental psychologist also informs her recommendations for redesigning health care, as she emphasizes addressing the emotional and social needs of her patients and families as well as their physical care needs. Dr. Feldman recommends a comprehensive biopsychosocial approach to addressing the health care needs of children with disabilities. The 3 pillars of the proposed model are (1) inclusion—of children with disabilities into all aspects of community life; (2) contribution—full and active participation of children with disabilities, to the maximum extent possible; and (3) health—defined broadly as a state of physical, mental, and social well-being. This approach to health care requires a paradigm shift from a focus on symptom reduction and remediation of deficits to an emphasis on functionality and outcomes of interventions. The text explores the turbulent health care environment and the system’s challenges—fragmented health care and social services, unsustainable costs despite the proliferation of costfocused business models, legislative and policy mandates, and the ever-expanding
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numbers of children with disabilities without a comparable boom in the number of clinicians dedicated to their care. With the shift from emphasis on diagnosis to a focus on management after diagnosis with the goal of maximizing functional outcomes, these changes are likely to lead to positive outcomes not only for the children involved but for the larger systems as well. The first section of the book paints a picture of children with disabilities (Dr. Feldman prefers this term to the common usage of “children with special needs,” as this phrase may contribute to the perception of these children as separate and different). The text discusses the scope of disabilities addressed, as well as prevalence data, demographics, health care costs, complexity of care needs, and challenges inherent in caring for these children. Section 2 explores the goals of health care for children with disabilities in the context of the 3 pillars described above. As a step toward the paradigm shift of viewing disability and health care in the context of functioning, Dr. Feldman recommends implementing the World Health Organization’s 2002 model for classifying health conditions and functional status—the International Classification of Functioning, Disability and Health (ICF). Using the ICF in lieu of traditional diagnostic and disease classification taxonomies such as the DSM and ICD would help to refocus the goals of health care provision on improved functioning and quality of life. The third section offers health care providers strategies and tools that they can use to support this redesigned approach to care delivery. The book provides concrete examples and guidelines for
implementing processes that are often only discussed in the abstract, such as comprehensive integrated care plans, family-centered care, and effective care coordination. Finally, Section 4 is a call to action that encourages health care and social service providers to advance this new model of health care through education, research, and advocacy to effect policy change. Interspersed within the text are vignettes of real patients and families, overviews of supplemental services for children with disabilities, discussions of concepts such as inclusion and the fiscal implications of health care issues, and helpful resources for providers. Each chapter ends with questions and exercises designed to challenge and develop the reader’s perspective. As a social worker whose practice has focused on children with chronic conditions, I am heartened by the recognition that a biopsychosocial approach is the most effective way to provide care to this population. I hope that health care providers accept the charge to broaden the way they provide care as well as to advocate for higher-level system changes. Although the challenges of our current health care system may inhibit the adoption of some of the best practices delineated in this book, it is essential to move the system forward for the benefit of our patients, families, and the system as a whole. Disclosure: The author declares no conflict of interest. Dinah L. Godwin, MSW, LCSW Meyer Center for Developmental Pediatrics, Baylor College of Medicine Houston, TX
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