Six Decision Making Options - ChristianaCare
Association for Hospital
Medical Education (AHME)
April 13, 2011
Christiana Care Health System
Newark Delaware
Resources Developed by
Christiana Care Health System
Lee Ann Riesenberg, PhD, RN
Loretta Consiglio-Ward, RN, MSN
Carol K. Moore, MS, RN, NP
Thea Eckman, RN, BSN, CCRN
Teri Foy, MEd, RT
Theresa Fields
Donna Mahoney, BS, CPHQ
Omar Khan, MD, MHS
Contact Information
Lee Ann Riesenberg, PhD, RN
Director Medical Education Research & Outcomes, Christiana Care Health System, Newark DE
Research Assistant Professor, Jefferson School of Population Health, Thomas Jefferson University, Philadelphia PA
Lriesenberg@
Brian W. Little, MD, PhD
Chief Academic Officer, Christiana Care Health System, Newark DE
BWL@
Table of Contents
Improvement Project Work Book 1
Achieving Competency Today (ACT): Issues in Health Care Quality, Cost, Systems, and Safety Course 10
Course Syllabus 11
Course Meeting Details 12
Course Overall Goals 12
Course Overall Objectives 12
Course Summary at a Glance 13
ACT Background Information 16
Course Facilitator Training Program 18
Facilitator Textbooks 18
Decision Tools for Performance Improvement 19
Six Decision Making Options 20
Risk Reduction Strategies: recommended hierarchy of actions 21
Effort/Benefit Matrix 23
Diagnostic Tools 24
What Is A Fishbone Diagram? 25
Sample Fishbone Diagram 28
Flow Chart Instructions 29
Sample Flow Charts 32
Estimate the Cost of Implementing your Plan 34
Measurement Resources 35
Data Presentation 36
Control Charts 38
Performance Improvement Checklist / Action Steps 40
Check Sheet 42
Pareto Chart 43
Scientific Writing and Publication Resources 45
Squire Guidelines 46
Quality Scoring System 49
Acronyms and Other Relevant Resources 51
Quality Improvement & Patient Safety Acronyms, Definitions, and Web Sites 52
Quality Journals 64
Improvement Project Work Book
|PLAN |PLAN THE IMPROVEMENT |
|Clearly define the process | |
|opportunity (opportunity |Define the opportunity statement. |
|statement). |Example statement: Reduce the incidence of pressure ulcers in the critical care unit by 50 percent by June|
| |of 2012. |
|What are you trying to | |
|accomplish? |___________________________________________________________________________________________________________|
|Specific population that will be|_________ |
|affected? |__________________________________________________________ |
|Is it measurable? |__________________________________________________________ |
| |Examples of Measurable Words to Use for Opportunity Statement |
|Opportunity statement is a | |
|single sentence that is |Reduce |
|specific, measurable, and |Improve |
|addresses these points: | |
|How good? |Decrease |
|By when? |Increase |
|For whom (or for what system)? | |
| |Transfer every patient |
| |Achieve >95% compliance |
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| |Eliminate |
| |Grow |
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|PLAN |Insert your institution’s Mission/Quality Focus below and describe how your project links to that focus. |
| |[Insert institution Focus] (describe your project linkage): |
|[Insert your institutions’ logo |__________________________________________________________ |
|or quality symbol here.] |[Insert institution Focus] (describe your project linkage): |
| |__________________________________________________________ |
| |[Insert institution Focus] (describe your project linkage): |
| |__________________________________________________________ |
| |[Insert institution Focus] (describe your project linkage): |
| |__________________________________________________________ |
|PLAN |Identify potential resource individuals (anyone who might be able to help you obtain needed information). |
|Identify key stakeholders and|Resource Individual |
|bring them into the process |Team Member Who Will Contact |
|(i.e., interdisciplinary, key| |
|stakeholders and content | |
|experts). | |
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| |Identify individuals involved in the current process (individuals or groups currently affected by the |
| |process). |
| |Individuals or Groups |
| |Currently Affected |
| |Team Member Who Will Contact to Gather More Insight |
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| |Identify all departments/units that your project might affect. This goes beyond those currently affected, as |
| |your project may bring other departments/units into the process. |
| |Departments/Units |
| |that Might be Affected |
| |How Might They be Affected? |
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| |Is there a team or individual at your institution who is already working on this issue? If yes, how will you |
| |work with them? |
| |__________________________________________________________ |
| |__________________________________________________________ |
|PLAN |Schedule meetings with key stakeholders |
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| |Stakeholder: ______________________________________________ |
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| |Team member(s) assigned:__________________________________ |
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| |Meeting date: _____________________________________________ |
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| |Members attending: _______________________________________ |
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| |Stakeholder: ______________________________________________ |
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| |Team member(s) assigned:__________________________________ |
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| |Meeting date: _____________________________________________ |
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| |Members attending: _______________________________________ |
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| |Stakeholder: ______________________________________________ |
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| |Team member(s) assigned:__________________________________ |
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| |Meeting date: _____________________________________________ |
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| |Members attending: _______________________________________ |
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| |Stakeholder: ______________________________________________ |
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| |Team member(s) assigned:__________________________________ |
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| |Meeting date: _____________________________________________ |
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| |Members attending: _______________________________________ |
|PLAN |Clarify current knowledge of the process or practice. |
|Gather background data about |Review best practices/ conduct a literature review (Potential databases: Medline/PubMed, ERIC, CINAHL, |
|the current process |PsychInfo). |
|Conduct a literature review |Provide data/information from your own institution |
|How did you identify the |__________________________________________________________ |
|opportunity? |__________________________________________________________ |
|A strategic goal for the |__________________________________________________________ |
|year? |__________________________________________________________ |
|Practice change |__________________________________________________________ |
|recommendation? |__________________________________________________________ |
|System/ departmental data? |__________________________________________________________ |
|Satisfaction results? |__________________________________________________________ |
|An event that happened? | |
|Personal experience? | |
|PLAN |What information is already known about the current practice or process? |
|Identify potential causes of |Fishbone diagram (cause and effect diagram) |
|the problem or identify gaps |(pages 25-28) |
|in the process. | |
| |Flow chart current state of the process and/or practice if appropriate (pages 29-33). |
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| |Use appropriate Performance Improvement tool(s) to identify gaps or potential causes of the problem; i.e., |
| |brainstorming, Fishbone diagram, flow chart, etc. [list or attach PI tool(s)]. |
|PLAN |Collect baseline data about causes of the problem or gaps in the process. Select potential baseline measures|
|Analyze baseline data related|to use and describe how you will obtain the data. |
|to the process, if available.|Measures |
| |How will you obtain the data? |
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|DO |DO THE IMPROVEMENT |
|Generate potential action | |
|plans /strategies. |Develop a list of potential solutions/action plans for your project. |
| |For every solution listed, identify the data needed to determine if the change led to an improvement. |
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| |Potential Solutions “What” |
| |Measure/Data Source |
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|DO |Consider the feasibility of the potential solutions above. Things to consider include cost, time to implement, |
|Plan the action |steps to achieve, and barriers. List potential barriers and feasibility considerations below. |
|plans/strategies. |Feasibility Notes: _____________________________________________ |
| |_____________________________________________________________ |
| |_____________________________________________________________ |
| |_____________________________________________________________ |
| |_____________________________________________________________ |
| |_____________________________________________________________ |
| |_____________________________________________________________ |
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|DO |Use the “Estimate the Cost of Implementing your Plan” (page 34) to guide your discussion of the following: |
|Identify |1. Identify start-up costs: _____________________________________________ |
|potential costs.|____________________________________________________________________ |
| |____________________________________________________________________ |
| |2. Identify operating costs: ___________________________________________ |
| |____________________________________________________________________ |
| |____________________________________________________________________ |
| |3. List possible savings: ______________________________________________ |
| |____________________________________________________________________ |
| |____________________________________________________________________ |
| |4. Would your plan create any billable services? _________________________ |
| |____________________________________________________________________ |
| |____________________________________________________________________ |
| |5. Would your plan create non-financial benefits? ________________________ |
| |____________________________________________________________________ |
| |____________________________________________________________________ |
| |6. Categorize your Plan |
| |An ongoing financial expense (but worth it in terms of gaining desired outcomes)? |
| |Cost neutral? |
| |( A moneymaker for the hospital or group (increased performance may streamline processes, make them more efficient and |
| |effective, and still deliver improved care for your selected patient)? |
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| |What does your team need to do to get better answers to the cost questions above? Assign team members to find the answers. |
| |Team Member Name Assignment From Above |
| |________________________ ________________________________ |
| |________________________ ________________________________ |
| |________________________ ________________________________ |
| |________________________ ________________________________ |
| |________________________ ________________________________ |
|DO |Develop and implement recommended action plans/strategies (i.e., rapid cycle PDSA). |
|Plan the action | |
|plans/strategies. |Action Plans/Strategies |
|Implement the selected |(What) |
|action plans/strategies, |Responsible Person(s) (Who) |
|asking who, what, when, |Location (Where) |
|where, & how. |Target Date |
|Develop Education plan, if |(When) |
|appropriate. | |
|Do Rapid Cycle Improvements|1. |
|(small test of change) – | |
|one resident, one nurse, | |
|one unit, one patient. | |
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| |Meet with key stakeholders prior to testing. |
| |Date(s) scheduled:____________________________________________ |
| |____________________________________________________________ |
| |____________________________________________________________ |
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| |GO LIVE! |
| |Rapid Cycle Test Implementation Date(s): ________________________ |
| |____________________________________________________________ |
| |____________________________________________________________ |
|CHECK |CHECK THE RESULTS |
|Gather data to |Display outcome measures/data demonstrating baseline and post measurement, if appropriate. Provide new flow chart of|
|evaluate process and |processes, if appropriate. Put notes on results in this section. |
|effectiveness of | |
|action plans |Action Plan/ Strategy Number |
|/strategies. |Measure |
|Analyze the data to |Data Source |
|determine if the |Responsible person(s) |
|process has improved. | |
|If no improvement, | |
|identify the | |
|opportunity or process| |
|to be improved. | |
|Identify and evaluate | |
|results of measures to| |
|determine if the | |
|process improved | |
|(include cost savings | |
|/ avoidance). | |
|Identify if there are | |
|other unmet customer | |
|needs that need to be | |
|revisited. | |
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| |NOTES (about your results): |
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|ACT |ACT |
|Adopt the action |Describe the path forward to implement plan, for next rapid cycle PDCA, or to sustain improvement: |
|plans/ strategies. | |
|Identify areas where |_____________________________________________________________________________ |
|processes can be | |
|standardized or reduce|_____________________________________________________________________________ |
|variation. | |
|Identify any lessons |_____________________________________________________________________________ |
|learned. | |
|Identify systemic |_____________________________________________________________________________ |
|implications, barriers| |
|or changes that may be|_____________________________________________________________________________ |
|beyond the scope of | |
|the team. |List lessons learned |
|Identify ongoing | |
|measures/data of the |_____________________________________________________________________________ |
|process to sustain | |
|improvement. |_____________________________________________________________________________ |
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Communicate Results and CELEBRATE SUCCESS / STORYTELLING!
Achieving Competency Today (ACT): Issues in Health Care Quality, Cost, Systems, and Safety Course
Course Syllabus
Course Director Lee Ann Riesenberg, PhD, RN
Director Medical Education Research and Outcomes
(302) 623-4488
Team Facilitators Loretta Consiglio-Ward, RN, MSN
Carol Kerrigan Moore, MS, RN, NP
Christine Chastain-Warheit, MLS, AHIP
Thea Eckman, MSN, RN-BC, CCRN
Teri Foy, MEd, RT
Carmen Pal, RN, BSN, PCCN
Leslie Konizer, MS, CPHQ
Dean A. Bennett, RPh
Susan Coffey Zern, MD
LaRay Fox, CNMT, MEd
Course Faculty
|Brian Aboff, MD, FACP |Linda Laskowski-Jones, RN, MS, ACNS-BC, CCRN, CEN |
|Sharon Anderson, RN, BSN, MS, FACHE |Brian W. Little, MD, PhD |
|Michele Campbell, RN, MSM, CPHQ |Donna Mahoney, BS, CPHQ |
|Jerry Castellano, PharmD, CIP |Carol Kerrigan Moore, RN,MS APN |
|Loretta Consiglio-Ward, RN, MSN |Terri Lynn Palmer, MPA |
|William Conway |Patty Resnik, RRT, MBA, CPUR |
|Neil Jasani, MD |Lee Ann Riesenberg, PhD, RN |
|Omar Khan, MD, MHS |Glen Stryjewski, MD, MPH |
|Robert Laskowski, MD, MBA |Maureen Seckel, RN, MSN, APRN-BC |
Course Administrative Support
Theresa Fields
Course Meeting Details
Course Attendance:
Learners must arrive promptly at 4 PM and attend at least 10 of the 12 sessions to receive credit (no exceptions). Successful completion of the ACT program and ability to engage in the required teamwork requires consistent attendance. Recognizing that there are occasions that might require your presence elsewhere, we have elected to accept a maximum of two class session absences. Anticipated absences need to be communicated to course facilitators and team members prior to the class session. In the event of up to two absences, it is expected that you will collaborate with members of your team to ensure that you have received all materials distributed in class, and that your contribution to the teamwork component is disseminated to your team. Any additional absences compromise both learner objectives and teamwork in designing a performance improvement project plan. Therefore, a third absence will require immediate withdrawal from the course. Absences and withdrawals from the ACT course class sessions will be communicated to program directors for residents; to immediate supervisors, managers, or directors for nurses and allied health participants; to the chief academic officer for medical students. This is to ensure a shared knowledge and understanding of any barriers to full participation in the course. Admission into the course will not be granted if it is determined that you are not able to attend the first and last session of the course.
Course Overall Goals
• Increase learner’s competence in systems and practice improvement while stimulating inter-professional learning and collaboration.
• Increase learner’s awareness of how national and local systems, rules, and regulations contribute to systems-based issues in the practice environment.
• Promote learner’s role as advocates for quality and safety in patient care.
Course Overall Objectives
By the completion of this course, learners will be able to:
• Identify system problems that compromise the quality and safety of care.
• Analyze system problems and the effect they have on patient care.
• Synthesize findings from the research literature as it applies to the problem being investigated.
• Utilize systematic methodology for practice-based improvement activities.
• Develop an evidence-based, performance improvement project plan with preceptor support as part of an inter-professional team.
Course Summary at a Glance
|Week |Date/Location |Topic(s) |Pre-session Assignments: Readings, IHI Modules, & Other Assignments (to be completed prior to session) |
|1 |(Insert Date) |Quality, Safety, and |Readings |
| |Ammon Med. Educ. Building,|Performance |Berwick DM. Escape fire: Lessons for the future of health care. The Commonwealth Fund. 2002. |
| |Back of Auditorium |Improvement Overview |Annual Operating Plan |
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| | | |IHI Lessons (Instructions to access the IHI Lessons are on pages 9-11) |
| | | |Patient Safety 101: Lesson 1—To Err is Human |
| | | |Quality Improvement 101: Lesson 3—The Institute of Medicine’s Aims for Improvement |
|Between Session Work |Using what was learned during this session, identify 1-2 possible improvement ideas and write the ideas on the “ACT Course Work Sheet # 1” |
|2 |(Insert Date) |PDCA, RCA, High |Readings |
| |CCHS Main Hospital |Reliability |McKeon LM, Oswaks JD, Cunningham PD. Safeguarding patients: Complexity science, reliability organizations, and implications for team training in |
| |Conference Room 1100 | |healthcare. Clinical Nurse Specialist 2006;20(6):298-304. |
| | | |Shortell SM, Singer SJ. Improving patient safety by taking systems seriously. JAMA 2008;299(4):445-447. |
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| | | |IHI Lessons |
| | | |Quality Improvement 101: Lesson 1— Errors can happen anywhere and to anyone |
| | | |Quality Improvement 102: Lesson 1— An overview of the model for improvement |
| | | |Quality Improvement 102: Lesson 2—Setting an aim |
|Between Session Work |Complete “ACT Course PDCA Worksheet # 2” for each of the team’s top 2-4 project ideas. |
|3 |(Insert Date) |Teams and Opportunity |IHI Lessons |
| |Ammon Med. Educ. Building,|Statement |Patient Safety 103: Lesson 1—Why are teamwork and communication important |
| |Back of Auditorium | |Leadership 101: Lesson 1—Taking the leadership stance |
| | | |Leadership 101: Lesson 2—The leadership stance is not a pose |
|Between Session Work |Complete “ACT Course PDCA Worksheet # 3” to middle of page 3 |
|4 |(Insert Date) |Measurement and |IHI Lessons |
| |CCHS Main Hospital |Outcomes |Quality Improvement 101: Lesson 4—How to get from here to there: Changing Systems |
| |Conference Room 1100 | |Quality Improvement 102: Lesson 3—Measuring |
| | |Health Care Economics:|Quality Improvement 103: Lesson 1—Measurement fundamentals |
| | |Part 1 | |
|Between Session Work |Finalize fishbone, start flowchart (if appropriate), continue with background research |
|5 |(Insert Date) |Previous ACT Team |Readings |
| |Ammon Med. Educ. Building,|Presentation |Gawande A. The checklist: If something so simple can transform intensive care, what else can it do? The New Yorker December 10, 2007. Available at:|
| |Back of Auditorium | |. Accessed June 4, 2008. |
| | | | |
| | |AND |Newhouse RP, Pettit JC, Poe S, Rocco L. The slippery slope: Differentiating between quality improvement and research. JONA 2006;36(4):211-219 |
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| | |IRB |IHI Lessons |
| | | |Patient Safety 103: Lesson 4—Developing and executing effective plans |
|Between Session Work |Complete “ACT Course PDCA Worksheet # 3” pages 4 & 5 |
|6 |(Insert Date) |Change Theory |Readings |
| |Ammon Med. Educ. Building,| |VanHoy SN, Laskowski-Jones L. Early intervention for the pneumonia patient: An emergency department triage protocol. Journal of Emergency Medicine |
| |Back of Auditorium | |2006;32(2): 154-158. Additional readings may be assigned. |
| | | |Weed J. Factory efficiency comes to the hospital. The New York Times July 11, 2010. |
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| | | |IHI Lessons |
| | | |Quality Improvement 102: Lesson 4—Developing change |
| | | |Quality Improvement 102: Lesson 5—Testing change |
| | | |Leadership 101: Lesson 3—Influence, persuasion, and leadership |
|Between Session Work |Plan meeting with key stakeholders |
|7 |(Insert Date) |Workforce Issues | Workforce Readings |
| |Ammon Med. Educ. Building,| |The Adequacy of Pharmacist Supply: 2004 to 2030, Executive Summary |
| |Back of Auditorium | |Cooper RA. New directions for nurse practitioners and physician assistants in the era of physician shortages. Acad Med 2007;82:827-828. |
| | |AND |Kirch DG. Vernon DJ. Confronting the complexity of the physician workforce equation. JAMA 2008;299(22):2680-2682. |
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| | |Variations in Care |Variations in Care |
| | | |Gawande A. The cost conundrum. The New Yorker June 1, 2009. |
| | | |Davis K, Schoen C, Stremikis K. Mirror, mirror on the wall: How the performance of the U.S. health care system compares internationally. |
| | | |Commonwealth Fund; June 2010. |
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| | | |IHI Open School Module: |
| | | |Quality Improvement 101: Lesson 2—Health care today |
|Between Session Work |Complete “ACT Course PDCA Worksheet # 3” pages 6 & 7 |
|8 |(Insert Date) |The Evolution of the | |
| |Ammon Med. Educ. Building,|US Health Care System | |
| |Back of Auditorium |(History) | |
|Between Session Work |Continue work on Performance Improvement Project |
| |Complete self and team member evaluations |
|9 | |Health Care Economics:|Readings |
| |(Insert Date) |Part 2 |Review the previously assigned article: Gawande A. The cost conundrum. The New Yorker June 1, 2009. |
| |Ammon Med. Educ. Building,| | |
| |Back of Auditorium | |IHI Open School Module: |
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| | | |Quality Improvement 105: Lesson 1—Overcoming resistance to change |
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| | | |Assignment: Each participant needs to bring their print-out from IHI Web Site of the Completed IHI modules. |
|Between Session Work |Complete “ACT Course PDCA Worksheet # 3” pages 8 & 9 |
|10 |(Insert Date) |Teamwork Time | |
| |Ammon Med. Educ. Building,| | |
| |Back of Auditorium | | |
|Between Session Work |Focus on finalizing implementation and post-data collection; Finish first draft of presentation for practice. |
|11 |(Insert Date) |Practice Presentations| |
| |Ammon Med. Educ. Building,| | |
| |Back of Auditorium |Complete confidence | |
| | |survey during this | |
| | |session | |
|12 | |No class, unless needed for weather make-up |
| | |Deadline for submitting final PowerPoint to your Facilitator |
|13 |(Insert Date) |Formal Performance | |
| |Ammon Med. Educ. Building,|Improvement Project | |
| |Auditorium |Plan Presentations and| |
| | |Reception | |
Note: All course requirements must be met prior to receiving Certificates of Completion.
ACT Background Information
ACT is a graduate level interdisciplinary curriculum for systems-based practice and practice-based learning and improvement. The original ACT curriculum was developed by Harvard’s Partnerships for Quality Education (PQE) (), a national initiative of the Robert Wood Johnson Foundation. It has been piloted over the past five years. Christiana Care Health System is one of “six of the top performing ACT sites” and as a result we received an extension grant from Robert Wood Johnson Foundation, which will be used to continue our work on: curriculum development, evaluation and improvement, and outcomes research. This two-year extension grant started in January 2007 and concluded December 2008.
The course brings learners together with faculty and health system leaders to learn about systems and practice improvement. Learners work together in teams to identify a health care system-based performance improvement opportunity, review best practices and relevant literature, and design and present an evidence-based performance improvement project plan.
Past participants have had opportunities to present at the ACT national conference, and at least one team has published their results. ACT learners include nursing staff, graduate nursing students, advanced practice nurses, resident physicians, pharmacy residents, allied health professionals, and others. All sessions will include team work time to develop the final project plan.
The original course content was designed as a four-week intensive curriculum with online as well as traditional face-to-face lectures/discussions. The current curriculum has been modified to be completed in 12 weeks, allowing participants to increase retention; practice and improve interdisciplinary team skills; and enhance opportunities to synthesize and apply the course content.
The ACT model, which is preparing health care professionals to address the performance challenges of the future, has three essential elements:
1. An intensive, action-based learning curriculum that teaches learners about systems and practice improvement.
2. Interdisciplinary learning through collaboration on a performance improvement project.
3. Connecting the learners with the organization’s senior quality leadership.
Institute for Healthcare Improvement (IHI) Open School Modules
What is the IHI Open School?
The IHI Open School for Health Professions was developed to advance quality improvement and patient safety competencies in the next generation of health professionals worldwide. It is an important goal, one not currently fulfilled by the curriculum at most health professions schools. The IHI Open School aims to fill this gap.
Online Courses
There are three free online modules: Quality Improvement, Patient Safety, and Leadership. Each module contains courses (e.g., 101, 102, & 103). Each course has 3-5 lessons (about 15 minutes each). You may stop at any time and you may start back at that point. The software tracks your progress. There are pre-tests and post-tests for each lesson. You must achieve a 75% on the post-test to successfully complete the lesson.
Basic Certification
Basic certification is designed to provide a solid foundation in quality improvement, patient safety, and patient-centered care. Completion of all modules is required to obtain IHI certification. IHI will track completion and provide credit for all modules completed.
IHI Lessons for ACT Course
During the ACT course you will be completing 18 of the lessons. (Reminder: Completion of these 18 lessons will not complete the IHI certification requirements).
Step-by-Step Instructions for IHI Logon and Getting Started
You will be required to register with IHI (free) and register to take the courses. We suggest that you use the same login information for the IHI lessons as your membership login so that it is easier to remember.) Access web page () to become a member.
How to Start Taking Courses
Welcome to the IHI Open School for Health Professions online courses! This is a tutorial to help you get started. The whole setup process should take just a couple of minutes.
Course Facilitator Training Program
In 2008/09, we developed an intensive experiential facilitator training program that has led to each team having a trained, skilled facilitator. The training involves facilitator, team, and quality content instruction; co-facilitation with an experienced facilitator for one course; post session debriefs; reading two textbooks (one on QI content1 and the other on facilitator skills2); and every other week 90-minute meetings to discuss readings and application to course teams. In addition, these efforts resulted in the development of a Facilitator Guide, with resources and helpful tools for the facilitators.
Facilitator Textbooks
1. Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. (2nd Ed.). San Francisco: Jossey-Bass, 2009.
2. Schwarz R, Davidson A, Carlson P, McKinney S, and Contributors. The Skilled Facilitator Fieldbook: Tips, Tools, and Tested Methods for Consultants, Facilitators, Managers, Trainers, and Coaches. San Francisco: Jossey-Bass, 2005.
Decision Tools for Performance Improvement
Six Decision Making Options
|Option |Description |Pros |Cons |Uses |
|Spontaneous Agreement |Solution is favored by everyone, agreement |Fast |Too fast |When full discussion isn’t critical|
| |seems to happen automatically |Easy |Lacks discussion |Trivial issues |
| |Happens occasionally, often with simple issues |Unites group | | |
|One Person Decides |Decision that the group decides to refer to |Fast |Lack of group input |When one person is the expert |
| |one person to make on behalf of the group |Clear accountability |Can divide group |Individual willing to take sole |
| | | |Low buy-in |responsibility |
| | | |No synergy | |
|Compromise |Process of negotiation-when there are several |Generates discussion |Negotiating process |When two opposing solutions are |
| |distinct options and members are strongly |Creates a solution |tends to be adversarial-|proposed and consensus is |
| |polarized, a middle position is then created | |win/lose |improbable |
| |that incorporates ideas from both sides | |Divides the group | |
|Multi-voting |Priority setting tool when group has long set |Systematic |Limited discussion |To sort or prioritize a long list |
| |of options, rank ordering based on set criteria|Objective |Influenced choices if |of options |
| | |Democratic |voting is done openly | |
| | |Participative |Real priorities may not | |
| | | |surface | |
|Majority Voting |Choosing the option that is favored by show of |Fast |May be too fast |When decision needs to be made |
| |hand or ballot |High quality with dialogue|Low in quality if people|quickly |
| | |Clear outcome |vote based on their |When there are clear options |
| | | |feelings |When consensus attempted but |
| | | |Show of hands may |couldn’t be reached |
| | | |pressure people to |If division of group is okay |
| | | |conform | |
|Consensus Building |Involves everyone clearly understanding the |Collaborative |Takes time |Important issues |
| |problem to be decided, analyzing facts, and |Unites group |Requires data and member|When total buy-in matters |
| |jointly developing solutions |High involvement |skills | |
| |Characterized by listening, healthy debate, |Systematic | | |
| |testing of options |Fact driven | | |
Source: Bens I. Facilitation at a Glance! The Association of Quality and Participation (ACP)/Goal/QPC; 1999.
Risk Reduction Strategies: recommended hierarchy of actions
Risk reduction strategies are interventions that will treat (fix) the identified vulnerability in the system and prevent a recurrence and/or protect the patient from harm. Strong and well-crafted actions have a clear link to the vulnerabilities and are readily understood. The table below presents some categories and types of actions that might be considered. Stronger actions are viewed as those that are more likely to be successful in accomplishing the desired changes, rendering greater utility for the effort expended. Note: you may need multiple actions (stronger, intermediate or weaker) to address a single root cause/contributing factor.
|Recommended hierarchy of actions: |
|Stronger actions |Intermediate actions |Weaker actions |
|Physical plant changes (room, work area layout, people flow, |Increase in staffing/decrease in workload |Double checks |
|tools) |Software enhancements or modifications |Warnings and labels |
|New device with usability testing before purchasing |Eliminate/reduce distractions |New procedure, memorandum or policy |
|Engineering control or interlock (forcing functions) |Checklist/cognitive aid |Training |
|Simplify the process and remove unnecessary steps |Eliminate look and sound alikes |Additional study/analysis |
|Standardize on equipment or process or care maps |Read back | |
|Tangible involvement and action by leadership in support of |Enhanced documentation and communication | |
|patient safety |Redundancy | |
Adapted from: United States Department of Veterans Affairs: NCPS Root Cause Analysis Tools, Actions and Outcomes. Available at: . Accessed December 3, 2010.
|Field |Dictionary |
| |An action designed to reduce the likelihood of an adverse event. The action has a clear link to the root cause/contributing factor. |
|Risk Reduction Strategy |Actions can be thought of as stronger or weaker based upon their likelihood of reducing vulnerability. |
|Stronger Actions | A Stronger Action is more likely to eliminate or greatly reduce the likelihood of an event; uses physical plant or systemic fixes; |
| |applies human factors principles. |
|Physical plant changes/redesign |Redesign of room, work area layout, people flow, tool location |
|New device with usability testing |Having end-users test new device to identify hidden vulnerabilities associated with device before they occur. |
|Engineering control or interlock |Forcing functions |
|Simplify/standardize |Simplification of the process/ removal of unnecessary steps. Standardization of protocol/process/equipment |
|Tangible involvement and action by leadership |Action by leadership in support of patient safety |
|Intermediate Actions |An Intermediate Action is likely to control the root cause or vulnerability; applies human factors principles, but also relies upon |
| |individual action, e.g. checklist or cognitive aid. |
|Increase in staffing/decrease in workload |Adding more staff/ decreasing or realigning workload |
|Software enhancements or modifications |Automatic calculations, reminders, decision making assistance, safety mechanisms |
|Eliminate/reduce distractions |Elimination or reduction of the things that draw the mind away from the task at hand. |
|Checklist/cognitive aid |Reminders. Provide access to knowledge in the world instead of requiring memorization. |
|Eliminate look and sound alikes |Removing or separating items with similarities, i.e., similar labels, packaging, names, colors, caps. |
|Read back |Verbal verification and confirmation of communicated information by writing down and reading back order |
|Enhanced documentation and communication |Example: “Do not use unacceptable abbreviations,” Structured communication tools |
|Redundancy |Use of redundancy to heighten awareness of safe practice/behavior |
|Weaker Actions |Weaker Actions provide staff with additional information or new procedures to follow, but not a “hard fix” that can eliminate the |
| |vulnerability. The action relies on policies, procedures, and additional training. |
|Double checks |Independent check of accuracy by a second staff member, redundancy, inspections |
|Warnings and labels |Verbal and/or visual information/reminders about safety |
|New procedure, memorandum or policy |Writing new policy, procedure and/or memo |
|Training |Orientation/Education |
|Additional study/analysis |Further investigation |
Adapted from: United States Department of Veterans Affairs: NCPS Root Cause Analysis Tools, Actions and Outcomes. Available at: . Accessed December 3, 2010.
Effort/Benefit Matrix
|High | |Further Consideration Needed |
| |High Priority Solution | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
|Low | | |
| | |Low Priority/Rejected Solution |
| |Further Consideration Needed | |
| | |
| |High |
| | |
Adapted from
Diagnostic Tools
What Is A Fishbone Diagram?
Dr. Kaoru Ishikawa, a Japanese quality control statistician, invented the Fishbone diagram. Therefore, it may be referred to as the Ishikawa diagram. The Fishbone diagram is an analysis tool that provides a systematic way of looking at effects and the causes that create or contribute to those effects. Because of the function of the Fishbone diagram, it may be referred to as a cause-and-effect diagram. The design of the diagram looks much like the skeleton of a fish. Therefore, it is often referred to as the Fishbone diagram.
Whatever name you choose, remember that the value of the Fishbone diagram is to assist teams in categorizing the many potential causes of problems or issues in an orderly way and in identifying root causes.
When should a Fishbone diagram be used?
Does the team . . .
• Need to study a problem/issue to determine the root cause?
• Want to study all the possible reasons why a process is beginning to have difficulties, problems, or breakdowns?
• Need to identify areas for data collection?
• Want to study why a process is not performing properly or producing the desired results?
How is a Fishbone diagram constructed?
Basic Steps:
1. Draw the fishbone diagram....
2. List the problem/issue to be studied in the “head of the fish.”
3. Label each “bone” of the “fish.” The major categories typically utilized are:
• The 4 M’s:
o Methods, Machines, Materials, Manpower
• The 4 P’s:
o Place, Procedure, People, Policies
• The 4 S’s:
o Surroundings, Suppliers, Systems, Skills
Note: You may use one of the four categories suggested, combine them in any fashion or make up your own. The categories are to help you organize your ideas.
4. Use an idea-generating technique (e.g., brainstorming) to identify the factors within each category that may be affecting the problem/issue and/or effect being studied. The team should ask... “What are the machine issues affecting/causing...”
5. Repeat this procedure with each factor under the category to produce sub-factors. Continue asking, “Why is this happening?” and put additional segments each factor and subsequently under each sub-factor.
6. Continue until you no longer get useful information as you ask, “Why is that happening?”
7. Analyze the results of the Fishbone after team members agree that an adequate amount of detail has been provided under each major category. Do this by looking for those items that appear in more than one category. These become the most likely causes.
8. For those items identified as the most likely causes, the team should reach consensus on listing those items in priority order with the first item being the most probable cause.
Sample Fishbone Diagram
Opportunity: Increase near-miss reporting
(Note: to make this a complete opportunity statement you need to add “by how much,” “by when,” and “where—in what unit or area will this change occur?”)
[pic]
Flow Chart Instructions
Flowchart
Also called: process flowchart, process flow diagram
Description
A flowchart is a picture of the separate steps of a process in sequential order.
Elements that may be included are: sequence of actions, materials or services entering or leaving the process (inputs and outputs), decisions that must be made, people who become involved, time involved at each step and/or process measurements.
The process described can be anything: a health care process, an administrative or service process, a project plan. This is a generic tool that can be adapted for a wide variety of purposes.
When to Use a Flowchart?
• To develop understanding of how a process is done
• To study a process for improvement
• To communicate to others how a process is done
• To improve communication between people involved with the same process
• To document a process
• To plan a project
• The team needs to develop an understanding of how a process works in order to improve it. Why?
o All work is part of a process
o Most problems are related to processes rather than people
Flowchart Basic Procedure
• Materials needed: sticky notes or cards, a large piece of flipchart paper, and marking pens.
• Define the process to be diagrammed: Write its title at the top of the work surface.
• Identify beginning and ending: Discuss and decide on the boundaries of your process. At the outset, you must decided where or when the process starts and where or when it ends. Discuss and decide on the level of detail to be included in the diagram.
• Brainstorm the activities that take place: Write each on a sticky note. Sequence is not important at this point, although thinking in sequence may help people remember all the steps.
• Arrange the activities in proper sequence: When all activities are included and everyone agrees that the sequence is correct, draw arrows to show the flow of the process.
• Review the flowchart: Review the flowchart with others involved in the process (workers, supervisors, suppliers, customers) to see if they agree that the process is drawn accurately.
Flowchart Considerations
• Don’t worry too much about drawing the flowchart the “right way.” The right way is the way that helps those involved understand the process.
• Identify and involve in the flowcharting process all key people involved with the process. This includes those who do the work in the process: physicians, resident physicians, nurses, pharmacists, other health care staff, patients, customers, suppliers, and supervisors. Involve them in the actual flowcharting sessions by interviewing them before the sessions and/or by showing them the developing flowchart between work sessions and obtain their feedback.
• Do not assign a “technical expert” to draw the flowchart. People who actually perform the process should create the flowchart.
Adapted from Tague NR. The Quality Toolbox, (2nd ed), ASQ Quality Press; 2004, 255-257.
Analyze the flowchart looking for:
• What is it that is flowing along – information? documents? people?
• Unnecessary complexity
• Difficulty in handoffs
• Delays
• Redundancy
• Unnecessary or non-value added tasks
• Opportunities for error
Commonly Used Symbols in Detailed Flowcharts
|[pic] |One step in the process; the step is written inside the box. Usually, only one arrow goes out |
| |of the box. |
|[pic] |Direction of flow from one step or decision to another. |
|[pic] |Decision based on a question. The question is written in the diamond. More than one arrow goes|
| |out of the diamond, each one showing the direction the process takes for a given answer to the|
| |question. (Often the answers are “ yes” and “ no.”) |
| | |
|[pic] |Delay or wait |
| | |
|[pic] |Unclear or unknown steps |
|[pic] |Link to another page or another flowchart. The same symbol on the other page indicates that |
| |the flow continues there. |
| | |
|[pic] |Input or output |
| | |
|[pic] |Document |
| | |
|[pic] |Alternate symbols for start and end points |
Flowchart Template:
Sample Flow Charts
Simple Example
More Complex Example
[pic]
Estimate the Cost of Implementing your Plan
The Cost Estimate: In order to make an effective proposal for any system improvement, you must have a good sense of implementation costs. In this exercise, your task will be to identify the categories of costs and savings that your plan would generate (e.g., increased data analysis costs, cost of educating staff, savings in number of staff needed, savings from reducing use).
The basic architecture of a financial analysis is relatively straightforward. In any project, there are essentially two types of costs: (1) start-up (development and implementation) costs and (2) operating costs (ongoing costs). In a typical project, the start-up costs are “borrowed” and paid back from the savings generated by the project over time. Every project must, in some way, pay back start-up costs and initial operating losses. Even if a specific project is justified by improvements in quality or in service, its costs must be covered by a surplus from somewhere in the delivery system. You will need to develop accurate, detailed estimates of start-up and operating costs, any savings or new income that would be generated, and the net effect on the bottom line.
Step One is to identify the start-up costs that would be associated with your plan. Would it require purchasing new equipment? Would it require staff time to do the planning needed for implementation? Would staff training be needed?
Step Two is to identify the types of operating costs that would be associated with your proposed change. Think about any resources that would be needed and make a list. Don’t worry about their actual cost. Common expenses are personnel, space, equipment, and purchased services.
Step Three is to list the types of savings you think would result from implementing your idea. These commonly include efficiencies in staff work and savings in staff time, reductions in purchased supplies or services, and better use of space and equipment.
Step Four is to think about whether your intervention would create any billable services that might generate additional income for the hospital. For example, would it generate, or decrease visits, testing, referrals, or hospitalizations? These might be additional revenues if your hospital receives payment for such services; conversely income might decrease if you reduce revenue-producing services.
In Step Five, think about the nonfinancial benefits of your proposed plan (e.g., improvements in quality, patient service or satisfaction, or enhancements in staff satisfaction). Remember, although each of these benefits may have a long-term yield in financial performance, they do not usually create short-term savings. That said, it may still be worth spending money on them. It will be your job to make the case.
At this point, take a stab at categorizing your project. Do you think the project will be:
• An ongoing financial expense (but worth it in terms of gaining desired outcomes)?
• Cost neutral? or
• A moneymaker for the hospital or group (increased performance may streamline processes, make them more efficient and effective, and still deliver improved care for your selected patient)?
Adapted from Module 3, Activity 4, “Estimate the cost of implementing your QIP and get initial local administrative feedback.” From the original ACT curriculum developed by Harvard’s Partnerships for Quality Education (PQE) ().
Measurement Resources
Data Presentation
Appropriate data presentation can help in analyzing changes in measures, monitoring progress toward goals and sharing information with others. Graphic displays may provide insight into trends, comparisons, progress and controls that are not evident with numbers displayed in a table.
It is important to select the correct type of graph for the measure you are monitoring, and to know your audience. Often, many team members will want to see the numbers that make up a graph in a table format along with the graph.
|Table |Displays values for measures for each category and/or | |
| |time period. Useful for showing the actual value, but|[pic] |
| |may be difficult for monitoring trends or comparing | |
| |across categories. | |
| | | |
| |Often used as the data source for creating graphs in | |
| |Excel. | |
|Pie Chart |Pie Charts are circle graphs that display 100% of the |[pic] |
| |data. They are useful in showing the relationship of | |
| |various parts to a whole. They show the percentage of| |
| |contribution of each group to the whole. A convenient| |
| |way of representing percentages or relative | |
| |frequencies. | |
|Bar Graphs |Bar Graphs are columns of data that compare the |[pic] |
| |frequency of different groups of data. They compare | |
| |quantity of data between and among categories and | |
| |against a measurable scale (y axis). Bar Graphs are | |
| |useful when displaying many categories and multiple | |
| |figures. | |
|Histo-gram |A Histogram is a bar graph that is used to show the |[pic] |
| |distribution of data points related to some measurable| |
| |characteristics such as time, weight, size, or | |
| |temperature. | |
| | | |
| |The shape shows the nature of the distribution of the | |
| |data. The central tendency (average) and the | |
| |variability are easily seen | |
|Pareto |A Pareto Diagram helps you quickly see the order or | |
| |ranking among many different factors. The bars are | |
| |arranged in descending order of height from left to |[pic] |
| |right. This means the factors (causes) represented by| |
| |the tall bars on the left are higher contributors to | |
| |the problem, thus prioritizing opportunities. | |
| | | |
| |The name of the diagram derives from the Pareto | |
| |Principle: 80% of the problems are due to 20% of the | |
| |factors (vital few). | |
|Run Charts |Run Charts display a sequence of data points over a |[pic] |
| |specified time period. They identify meaningful | |
| |trends or shifts in the average, and provide a visual | |
| |perspective of a process over time. | |
|Control Chart |Control Charts are a specialized form of run charts on|[pic] |
| |which statistically determined upper and lower control| |
| |limit lines are added. The purpose of a control chart | |
| |is to help you better focus resources on identifying | |
| |and eliminating special (assignable) causes (see | |
| |attached definitions). | |
|Scatter Diagram |Scatter Diagrams require a large number of data |[pic] |
| |points. Scatter Diagrams often indicate what type of | |
| |relationship may be occurring between two variables. | |
| |They indicate possible cause & effect relationships. | |
Control Charts
Control charts provide a dynamic display that can assist in depicting variation over time. Run charts allow users to monitor trends, but may be misleading in that they do not support identification of “common-cause” versus “special cause” variation:
Common Cause (Random)
Common cause variation is inherent in every process. It is random and due to natural, irregular, or ordinary causes. This type of variation produces processes that are “in control” or stable, and allows team members to make predictions about a process.
• A process that is in control will not change unless the process is changed
• Actions should not be taken to address changes or “blips” in the data that are part of the natural rhythm of process
Special Cause (Assignable)
Special cause variation is due to irregular or unnatural causes that are not inherent in the process, such as implementation of an improvement. If special causes are present, the process will be “out of control” and unpredictable.
• Special causes indicate that something has occurred to change the process
• Action should be taken to address the issue:
o If the special cause is desirable, verify its cause (Did an action plan lead to this result?) and identify ways to maintain the change
o If the special cause is undesirable, ascertain its cause (What was different?) and identify ways to keep the cause from recurring.
Control Chart Elements
[pic]
The center line of a control chart is the Mean (average). The Upper Control Limit (UCL) and Lower Control Limit (LCL) are used to monitor process variation and identify common or special causes. The UCL & LCL are generally set at 3 standard deviations (3 sigmas) above and below the mean. Thus, assuming a normal distribution, we can expect 99.73% of the data to fall within the limits. Tighter limits indicate less variation in a process.
Control charts are divided into zones (A, B, C above), with each zone equal to 1 sigma or standard deviation. The following rules may be applied to identify special cause variation:
1. Each side of the center line (Mean):
A. 1 point outside the 3-sigma limit
B. 2 of 3 successive points in Zone A or beyond
C. 4 of 5 successive points in Zone B or beyond
D. 8 successive points in Zone C or beyond (on the same side of the center line)
2. Based on the chart as a whole:
A. 7 successive points steadily increasing or decreasing (if you have 21 or more data points); 6 points if there are less than 21 data points.
B. 14 successive points alternating up & down in a sawtooth pattern
C. 15 consecutive points in Zone C.
In the example above, special cause variation is identified by the green circle (per rule 1D). At this point, control limits may be re-set. In our example, the tighter control limits indicate less variation in the process, and it is now in control at the lower mean.
[pic]
Handout created by Donna Mahoney, BS, CPHQ, Director, Data Acquisition & Measurement
Christiana Care Health System
May 2008
Performance Improvement Checklist / Action Steps
Questions to Answer for Project Goals
1. What is the goal or end result of your project or planned improvement?
▪ Describe a clear goal. It should not be too detailed, but should be a broad overview.
2. Did you quantify the goal?
▪ Assign actual numbers to your goal (i.e., educate 50 nurses, save $10,000, vaccinate 100 people). Specifically quantifying a goal, or element of a goal, improves clarity and leads to increased precision.
3. Did you translate comparative terms into actual goals?
▪ Comparative terms – increase, decrease, more, fewer – have no meaning on their own (e.g., decrease length of stay, improve patient satisfaction). Instead, describe & quantify the specific result you want (e.g. decrease length of stay by 0.5 days to create additional capacity of 20 beds).
4. Are you creating results or solving problems?
▪ Problem-solving is taking action to make something go away, and is difficult to sustain. Creating results is taking action to fully meet your goals.
▪ Describe what you want to create or build instead of what you want to eliminate “Implement mechanism to assure vaccination” rather than “Eliminate missed vaccinations through nurse education.”
5. Do your goals describe an actual result or a process for achieving that result?
▪ Process describes the “how”; end results describe the “what.” “What will the project accomplish?” versus “How will it be accomplished?”
▪ Whenever possible, the goal (end result) should describe outcomes rather than process, such as “Reduce unplanned readmissions by 10% through vaccination.”
6. Are your goals specific or vague?
▪ Specific goals allow for improved organization around the goals. If goals cannot be quantified, they should be stated as specifically as possible.
Checklist for Baseline
( Did you use your goals as a reference point for describing the baseline (i.e., Length of stay is currently 5.0 days.)?
( Have you described the relevant picture?
( Have you included the whole picture?
( Avoid assumptions, exaggerations & editorials – be objective
▪ Example: “30% of flu vaccines were given on day of discharge” rather than “Vaccinations are always missed on day of discharge”
( Did you state what reality is, or how it got to be that way?
( Have you included all the facts you need?
▪ Consider patient demographics, satisfaction, and other relevant information.
Checklist for Action Steps
( Do you have action steps for each goal?
( If you took these steps, will your goal be reached?
▪ If your answer is No, identify additional action steps until you can answer “Yes.”
( Are the action steps accurate, brief, and concise?
( Does every action step have a due date?
▪ Setting reasonable due dates for each action step establishes a project time frame and an increased sense of reality.
( Is there one person assigned to each action step?
▪ One person should be responsible for (and held accountable for) each action step. This will help to ensure that the action is completed, and divides the labor among the team members.
Adapted from Fritz R. The Path of Least Resistance for Managers: Designing Organizations to Succeed. San Francisco, CA: Berrett-Koehler Publishers; 1999.
Handout created by Donna Mahoney, BS, CPHQ, Director, Data Acquisition & Measurement
Christiana Care Health System
September 2007
Check Sheet
Also called: defect concentration diagram
Description
A check sheet is a structured, prepared form for collecting and analyzing data. This is a generic tool that can be adapted for a wide variety of purposes.
When to Use a Check Sheet
• When data can be observed and collected repeatedly by the same person or at the same location.
• When collecting data on the frequency or patterns of events, problems, defects, defect location, defect causes, etc.
• When collecting data from a production process.
Check Sheet Procedure
1. Decide what event or problem will be observed. Develop operational definitions.
2. Decide when data will be collected and for how long.
3. Design the form. Set it up so that data can be recorded simply by making check marks or Xs or similar symbols and so that data do not have to be recopied for analysis.
4. Label all spaces on the form.
5. Test the check sheet for a short trial period to be sure it collects the appropriate data and is easy to use.
6. Each time the targeted event or problem occurs, record data on the check sheet.
Check Sheet Example
The figure below shows a check sheet used to collect data on telephone interruptions. The tick marks were added as data was collected over several weeks.
[pic]
Excerpted from Tague NR. The Quality Toolbox, (2nd ed). ASQ Quality Press; 2004, pages 141-142.
Important Note: When gathering performance improvement data, do not include patient identifiers in your database.
Create a Check Sheet
This tool also creates a histogram, bar chart, and Pareto chart using the check-sheet data.
Start using the check sheet tool (Excel-Windows, 85 KB).
Pareto Chart
Also called: Pareto diagram, Pareto analysis
Variations: weighted Pareto chart, comparative Pareto charts
Description
A Pareto chart is a bar graph. The lengths of the bars represent frequency or cost (time or money), and are arranged with longest bars on the left and the shortest to the right. In this way the chart visually depicts which situations are more significant.
When to Use a Pareto Chart
When analyzing data about the frequency of problems or causes in a process.
• When there are many problems or causes and you want to focus on the most significant.
• When analyzing broad causes by looking at their specific components.
• When communicating with others about your data.
Pareto Chart Procedure
1. Decide what categories you will use to group items.
2. Decide what measurement is appropriate. Common measurements are frequency, quantity, cost and time.
3. Decide what period of time the Pareto chart will cover: One work cycle? One full day? A week?
4. Collect the data, recording the category each time. (Or assemble data that already exist.)
5. Subtotal the measurements for each category.
6. Determine the appropriate scale for the measurements you have collected. The maximum value will be the largest subtotal from step 5. (If you will do optional steps 8 and 9 below, the maximum value will be the sum of all subtotals from step 5.) Mark the scale on the left side of the chart.
7. Construct and label bars for each category. Place the tallest at the far left, then the next tallest to its right and so on. If there are many categories with small measurements, they can be grouped as “other.”
Steps 8 and 9 are optional but are useful for analysis and communication.
8. Calculate the percentage for each category: the subtotal for that category divided by the total for all categories. Draw a right vertical axis and label it with percentages. Be sure the two scales match: For example, the left measurement that corresponds to one-half should be exactly opposite 50% on the right scale.
9. Calculate and draw cumulative sums: Add the subtotals for the first and second categories, and place a dot above the second bar indicating that sum. To that sum add the subtotal for the third category, and place a dot above the third bar for that new sum. Continue the process for all the bars. Connect the dots, starting at the top of the first bar. The last dot should reach 100 percent on the right scale.
Pareto Chart Examples
Example #1 shows how many customer complaints were received in each of five categories.
Example #2 takes the largest category, “documents,” from Example #1, breaks it down into six categories of document-related complaints, and shows cumulative values.
If all complaints cause equal distress to the customer, working on eliminating document-related complaints would have the most impact, and of those, working on quality certificates should be most fruitful.
Example #1
[pic]
Example #2
[pic]
Excerpted from Tague NR. The Quality Toolbox, (2nd ed). ASQ Quality Press; 2004, pages 376-378.
Create a Pareto Chart
Analyze the occurrences of up to 10 defects. Start by entering the defects on the check sheet. This tool creates a Pareto chart using the data you enter. Start using the Pareto chart tool
(Excel-Windows, 85 KB).
Scientific Writing and Publication Resources
Squire Guidelines
The SQUIRE guidelines provide a checklist designed to guide authors of health care improvement studies in writing more useful and consistent reports of their studies.
SQUIRE Guidelines
(Standards for QUality Improvement Reporting Excellence)
Final revision – 4-29-08
• These guidelines provide a framework for reporting formal, planned studies designed to assess the nature and effectiveness of interventions to improve the quality and safety of care.
• It may not be possible to include information about every numbered guideline item in reports of original formal studies, but authors should at least consider every item in writing their reports.
• Although each major section (i.e., Introduction, Methods, Results, and Discussion) of a published original study generally contains some information about the numbered items within that section, information about items from one section (for example, the Introduction) is often also needed in other sections (for example, the Discussion).
|Text section; Item |Section or Item description |
|number and name | |
|Title and Abstract |Did you provide clear and accurate information for finding, indexing, and scanning your paper? |
|1. Title |a. Indicates the article concerns the improvement of quality (broadly defined to include the safety, |
| |effectiveness, patient-centeredness, timeliness, efficiency, and equity of care) |
| |b. States the specific aim of the intervention |
| |c. Specifies the study method used (for example, “A qualitative study,” or “A randomized cluster trial”) |
|2. Abstract |Summarizes precisely all key information from various sections of the text using the abstract format of the |
| |intended publication |
|Introduction |Why did you start? |
|3. Background Knowledge |Provides a brief, non-selective summary of current knowledge of the care problem being addressed, and |
| |characteristics of organizations in which it occurs |
|4. Local problem |Describes the nature and severity of the specific local problem or system dysfunction that was addressed |
|5. Intended Improvement |Describes the specific aim (changes/improvements in care processes and patient outcomes) of the proposed |
| |intervention |
| |Specifies who (champions, supporters) and what (events, observations) triggered the decision to make |
| |changes, and why now (timing) |
|6. Study question |States precisely the primary improvement-related question and any |
| |secondary questions that the study of the intervention was designed to |
| |answer |
|Methods |What did you do? |
|7. Ethical issues |Describes ethical aspects of implementing and studying the improvement, such as privacy concerns, protection|
| |of participants’ physical well-being, and potential author conflicts of interest, and how ethical concerns |
| |were addressed |
|8. Setting |Specifies how elements of the local care environment considered most likely to influence change/improvement |
| |in the involved site or sites were identified and characterized |
|9. Planning the intervention |a. Describes the intervention and its component parts in sufficient detail that others could reproduce it |
| |b. Indicates main factors that contributed to choice of the specific intervention (for example, analysis of |
| |causes of dysfunction; matching relevant improvement experience of others with the local situation) |
| |c. Outlines initial plans for how the intervention was to be implemented: e.g., what was to be done (initial|
| |steps; functions to be accomplished by those steps; how tests of change would be used to modify |
| |intervention), and by whom (intended roles, qualifications, and training of staff) |
|10. Planning the study of the |a. Outlines plans for assessing how well the intervention was implemented (dose or intensity of exposure) |
|intervention |b. Describes mechanisms by which intervention components were expected to cause changes, and plans for |
| |testing whether those mechanisms were effective |
| |c. Identifies the study design (for example, observational, quasi-experimental, experimental) chosen for |
| |measuring impact of the intervention on primary and secondary outcomes, if applicable |
| |d. Explains plans for implementing essential aspects of the chosen study design, as described in publication|
| |guidelines for specific designs, if applicable (see, for example, equator-) |
| |e. Describes aspects of the study design that specifically concerned internal validity (integrity of the |
| |data) and external validity (generalizability) |
|11. Methods of evaluation |a. Describes instruments and procedures (qualitative, quantitative, or mixed) used to assess a) the |
| |effectiveness of implementation, b) the contributions of intervention components and context factors to |
| |effectiveness of the intervention, and c) primary and secondary outcomes |
| |b. Reports efforts to validate and test reliability of assessment instruments |
| |c. Explains methods used to assure data quality and adequacy (for example, blinding; repeating measurements |
| |and data extraction; training in data collection; collection of sufficient baseline measurements) |
|12. Analysis |a. Provides details of qualitative and quantitative (statistical) methods used to draw inferences from the |
| |data |
| |b. Aligns unit of analysis with level at which the intervention was implemented, if applicable |
| |c. Specifies degree of variability expected in implementation, change expected in primary outcome (effect |
| |size), and ability of study design (including size) to detect such effects |
| |d. Describes analytic methods used to demonstrate effects of time as a variable (for example, statistical |
| |process control) |
|Results |What did you find? |
|13. Outcomes |a) Nature of setting and improvement intervention |
| |i. Characterizes relevant elements of setting or settings (for example, geography, physical resources, |
| |organizational culture, history of change efforts), and structures and patterns of care (for example, |
| |staffing, leadership) that provided context for the intervention |
| |ii. Explains the actual course of the intervention (for example, sequence of steps, events or phases; type |
| |and number of participants at key points), preferably using a time-line diagram or flow chart |
| |iii. Documents degree of success in implementing intervention components |
| |iv. Describes how and why the initial plan evolved, and the most important lessons learned from that |
| |evolution, particularly the effects of internal feedback from tests of change (reflexiveness) |
| |b) Changes in processes of care and patient outcomes associated with the intervention |
| |i. Presents data on changes observed in the care delivery process |
| |ii. Presents data on changes observed in measures of patient outcome (for example, morbidity, mortality, |
| |function, patient/staff satisfaction, service utilization, cost, care disparities) |
| |iii. Considers benefits, harms, unexpected results, problems, failures |
| |iv. Presents evidence regarding the strength of association between observed changes/improvements and |
| |intervention components/context factors |
| |v. Includes summary of missing data for intervention and outcomes |
|Discussion |What do the findings mean? |
|14. Summary |a. Summarizes the most important successes and difficulties in implementing intervention components, and |
| |main changes observed in care delivery and clinical outcomes |
| |b. Highlights the study’s particular strengths |
|15. Relation to other evidence |Compares and contrasts study results with relevant findings of others, drawing on broad review of the |
| |literature; use of a summary table may be helpful in building on existing evidence |
|16. Limitations |a. Considers possible sources of confounding, bias, or imprecision in design, measurement, and analysis that|
| |might have affected study outcomes (internal validity) |
| |b. Explores factors that could affect generalizability (external validity), for example: representativeness |
| |of participants; effectiveness of implementation; dose-response effects; features of local care setting |
| |c. Addresses likelihood that observed gains may weaken over time, and describes plans, if any, for |
| |monitoring and maintaining improvement; explicitly states if such planning was not done |
| |d. Reviews efforts made to minimize and adjust for study limitations |
| |e. Assesses the effect of study limitations on interpretation and application of results |
|17. Interpretation |a. Explores possible reasons for differences between observed and expected outcomes |
| |b. Draws inferences consistent with the strength of the data about causal mechanisms and size of observed |
| |changes, paying particular attention to components of the intervention and context factors that helped |
| |determine the intervention’s effectiveness (or lack thereof), and types of settings in which this |
| |intervention is most likely to be effective |
| |c. Suggests steps that might be modified to improve future performance |
| |d. Reviews issues of opportunity cost and actual financial cost of the intervention |
|18. Conclusions |a. Considers overall practical usefulness of the intervention |
| |b. Suggests implications of this report for further studies of improvement interventions |
|Other information |Were other factors relevant to conduct and interpretation of the study? |
|19. Funding |Describes funding sources, if any, and role of funding organization in design, implementation, |
| |interpretation, and publication of study |
SQUIRE Guidelines. Available at: . Accessed September 20, 2009.
Also visit the Squire home page at . There you will find many resources, including a link to an article that provides more detail and examples for each item in the SQUIRE checklist: .
Quality Scoring System*
|Study quality indicator |Points |
|Study type |
|Single group cross-sectional, or single group post-test only, or qualitative study |1 |
|Single group pre- and post-test, or cohort |1.5 |
|Non-randomized trial (includes control or comparison group) |2 |
|Randomized controlled trial |3 |
|Total sample size | |
|Unclear |0.0 |
|≤ 10 |0.5 |
|11-50 |1.0 |
|51-100 |1.5 |
|101-150 |2.0 |
|151-200 |2.5 |
|201 or more |3.0 |
|Reporting |Yes |No |
| Is the hypothesis/aim/objective/purpose of the study clearly described? |1 |0 |
| Are the participants clearly described? Number, rotation or clerkship name (e.g., pediatrics, medicine), and stage of | | |
|training, if medical students; Number, residency type (e.g., internal medicine, surgery), and stage of training, if residents; |1 |0 |
|number and discipline (e.g., internists, hospitalists, surgeons) if attending physicians. | | |
| Are the main outcomes to be measured clearly described in the Introduction or Methods section? (If the main outcomes were|1 |0 |
|first mentioned in the Results section, this question was answered no. If the article does not have clearly marked sections for| | |
|Introduction, Methods, Results, this question was answered no.) | | |
| Are the methods described with enough details to replicate the study (e.g., intervention, interview process, quality |1 |0 |
|improvement process, measurement process and instrument) – given you had the resources, training, etc needed? | | |
| Are the main outcomes of the study clearly described in the Results? (Simple outcome data—including denominators and |1 |0 |
|numerators—should be reported for all major findings so that the reader can check the major analyses and conclusions.) | | |
|Internal validity |
| Did they use a previously validated or published instrument, questionnaire, interview script? |1 |0 |
| Did they conduct any validity assessment (e.g., analyze reliability, validity, inter-rater reliability)? |1 |0 |
| Did they use any method designed to enhance the quality of measurement (e.g., multiple observations; training of | | |
|observers/interviewers; iterative process used to develop a tool, assessment instrument, or to conduct analysis for qualitative |1 |0 |
|analysis or quality improvement process; pilot study; focus group; or Delphi process used to develop measurement tool)? | | |
| Did they report obtaining Institutional Review Board (IRB) approval? |1 |0 |
| Did the reported conclusions follow from the reported results? |1 |0 |
*The quality scoring system in this chart was designed to assess both experimental and observational studies and was adapted from the Downs and Black1 quality scoring system. This quality scoring system was developed by Lee Ann Riesenberg, PhD, RN; Jessica Leitzsch; Jaime L. Massucci, MD; Joseph Jaeger, MPH; and Jamie S. Padmore. It was used in the following manuscripts:
Riesenberg L, Leitzsch J, Cunningham JM. Nursing handoffs: A systematic review of the literature. American Journal of Nursing 2010;110(4):24-34.
Riesenberg L, Leitzsch J, Massucci JL, Jaeger J, Rosenfeld JC, Patow C, Padmore JS, Karpovich KP. Residents’ and attending physicians’ handoffs: A systematic review of the literature. Acad Med 2009;84(12):1775-1787.
Padmore JS, Jaeger J, Riesenberg L, Karpovich KP, Rosenfeld JC, Patow CA. “Renters” or “Owners”? residents’ perceptions and behaviors regarding error reduction in teaching hospitals: A literature review. Acad Med 2009;84(12):1765-1774.
Reference
1. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52:377-384.
Acronyms and Other Relevant Resources
Quality Improvement & Patient Safety Acronyms, Definitions, and Web Sites
Listed below are brief explanations of common health care acronyms, definitions, and organizations in the areas of quality improvement and patient safety, as well as relevant Web sites and Journals.
Active Error: An error that occurs at the level of the practitioner and that has almost immediate effects.
Adverse Drug Reaction (ADR): An adverse effect produced by the use of a medication in the recommended manner. These effects range from “nuisance effects” (e.g., dry mouth with anticholinergic medications) to severe reactions, such as anaphylaxis to penicillin. An ADR is an adverse drug event.
Adverse Event (AE): Any injury caused by medical care. Identifying something as an adverse event does not imply error, negligence, or poor quality care. It simply indicates that an undesirable clinical outcome resulted from some aspect of diagnosis or therapy, not an underlying disease process. Examples: pneumothorax from central venous catheter placement; anaphylaxis from penicillin allergy; postoperative wound infection; hospital-acquired delirium (or “sun downing”) in elderly patients.
Affinity Diagram: A method to summarize qualitative data into groups with a common theme.
Agency for Healthcare Research and Quality (AHRQ):
The Agency for Healthcare Research and Quality (AHRQ) is a public Health Service agency in the Department of Health and Human Services (HHS). Reporting to the HHS Secretary, AHRQ sponsors and conducts research that provides evidence-based information on health care outcomes; quality; and cost, use, and access. The information helps health care decision makers—patients and clinicians, health system leaders, purchasers, and policy makers—make more informed decisions and improve the quality of health care services. The mission of AHRQ is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. Information from AHRQ’s research helps people make more informed decisions and improve the quality of health care services. AHRQ was formerly known as the Agency for Health Care Policy and Research.
AHRQ–Health Care Innovations Exchange () that includes innovations and tools to improve quality and reduce disparities. AHRQ–Web M&M (Morbidity & Mortality Rounds on the Web) () includes patient safety resources and journals that showcases patient safety lessons drawn from actual cases of medical errors.
Aim: A written, measurable, and time-sensitive statement of the expected results of an improvement project.
American College of Medical Quality (ACMQ):
The American College of Medical Quality (ACMQ) is a physician membership specialty society that welcomes all health care professionals. They also offer membership to institutions, organizations and corporations. The mission of the American College of Medical Quality is to provide leadership and education in health care quality management.
American Congress of Obstetricians and Gynecologists (ACOG) Patient Safety and Quality Improvement: departments/dept_web.cfm?recno=28
The American Congress of Obstetricians and Gynecologists (ACOG) Patient Safety and Quality department makes recommendations on methods to improve patient safety, from the surgical environment through medication.
American Hospital Association (AHA) Quality Center:
The American Hospital Association (AHA) Quality Center is a resource of the AHA to help hospitals accelerate their quality and performance improvement processes. It features tools, articles and other resources to support hospitals to achieve better patient outcomes, enhanced safety, increased satisfaction and improved operational and financial performance.
American Society for Quality:
The American Society for Quality is a membership organization devoted to health care quality.
Annotated Time Series: A line chart showing results of improvement efforts plotted over time. The changes made are also noted on the line chart at the time they occur. This allows the viewer to connect changes made with specific results.
Barrier Analysis: Study of the safeguards that can prevent or mitigate an unwanted event.
Benchmarking: The process of measuring products, services, and practices against the best performers or those companies recognized as industry leaders.
Best Practice: A service, function, or process that produces superior outcomes. A “best practice” entails whatever a health care team does to give patients what they need when they need it, and creates the best odds of achieving a desired clinical outcome. In this context, best practices for patient safety are those system elements and processes that reduce medical errors.
Briefing: A conversation and two-way dialogue of concise and relevant information shared prior to a procedure or activity. Surgical “time-out” may be a briefing. Elements include: Get the person’s attention; make eye contact; introduce yourself; use names; use SBAR; supply explicitly asked for information; talk about next steps; encourage ongoing monitoring and cross‐monitoring.
Cause and Effect Diagram: A tool for organizing a group’s current knowledge regarding a problem or issue. Useful for recording ideas in a brainstorming session (also called a fishbone diagram or an Ishikawa diagram).
Center for Continuous Quality Improvement (CCQI):
Center for Continuous Quality Improvement provides the knowledge and expertise to effect organizational improvement, focuses on the structure and dynamics of the entire organization to equip it with the tools and skills to meet existing and emergent challenges, provides education workshops at CCQI’s headquarters and on site, and was founded in 1991 by Dr. Robert Gelina. Since then, CCQI has advised and assisted over 95 organizations.
Centers for Medicare and Medicaid Services (CMS):
The Centers for Medicare and Medicaid Services (CMS) was formerly known as the Health Care Financing Administration (HCFA). The agency of the US Department of Health and Humans Services that administers Medicare, Medicaid, and the State Children’s Health Insurance Program (SCHIP). The current mission of CMS is “to ensure effective, up-to-date health care coverage and to promote quality care for beneficiaries.”
Certified Professional in Healthcare Quality (CPHQ)
Professionals working in quality improvement can become a Certified Professional in Health Care Quality (CPHQ). Certifying body is the Healthcare Quality Certification Board, at
Change Concept: A general idea for changing a process. Change concepts are usually at a high level of abstraction, but evoke multiple ideas for specific processes. “Standardize,” “simplify,” “reduce handoffs,” and “consider all parties as part of the same system” are all examples of change concepts.
Christiana Care Health Care System, Issues in Health Care Quality, Cost, Systems, and Safety Course Materials:
Clinical Governance: The process of training and engaging accountable leadership.
Close Call: A close call is an event or situation that could have resulted in an accident, injury, or illness, but did not, either by chance or through timely intervention. Such events have also been referred to as “near miss” incidents. An example of Close Calls would be: Surgical or other procedure almost performed on the wrong patient due to lapses in verification of patient identification but caught at the last minute by chance. Close calls are opportunities for learning and afford the chance to develop preventive strategies and actions. Close calls will receive the same level of scrutiny as adverse events that result in actual injury.
Close-loop Communication: When a request is made of team members, someone specifically affirms aloud that they will complete the task and states aloud when the task has been completed.
Common Cause Variation: Variation due to factors inherent in a process itself; can be reduced only through system redesign.
Complex, Adaptive Systems: Macrosystems (e.g., a community health care network) involved in intrinsically hazardous activities and consisting of numerous, specialized Microsystems (e.g., individual physicians’ offices, hospitals, retail pharmacies) that are highly interdependent and respond to stimuli in different, dynamic, and fundamentally unpredictable ways.
Computerized Physician Order Entry (CPOE): A computer‐based system for physicians and other prescribers to enter orders for medications and diagnostic tests. These orders are communicated over a computer network to the members of the health care staff (nurses, therapists, pharmacists, or other physicians) or to the departments (pharmacy, laboratory, or radiology) responsible for fulfilling the order.
Continuous Quality Improvement (CQI): Continuous Quality Improvement (CQI) is an approach to quality improvement in which past trials of change are used as the basis of future trials and something is always being tested for its effects on improvement.
Control Chart: A method used to distinguish between variation in a process due to common causes and variation due to special causes. It is constructed by obtaining measurements of some characteristic of a process, summarizing with an appropriate statistic, and grouping the data by time period, location, or other process variables. There are many different types of control charts, depending on the statistic analyzed on the chart.
Crew Resource Management (CRM): Safety team training borrowing principles from the aviation industry now applied to health care. Vanderbilt and Johns Hopkins were early adopters.
Critical Language: Use of key phrases understood by all team members to mean “stop and listen, we have a potential problem.” Specific phrases may differ from one institution or work unit to another.
Cross-monitoring: A method for acknowledging the concerns of others—watch team members, have awareness of their actions, verbally state concerns, share work load, verbally update others in a manner less formal than briefing, respond to the concerns of team members.
Debriefing: A conversation and two‐way dialogue of concise and relevant information shared after the procedure or activity is completed. Debriefing identifies what went well, what could have been done differently, and what was learned.
Define, Measure, Analyze, Improve, Control (DMAIC): DMAIC is a rapid cycle quality improvement toll used by six sigma.
Dot Plot: A tool to display data that presents basic information about the location, shape, and spread of a set of data (also called a histogram or frequency chart).
Early Adopter: In the improvement process, the opinion leader within the organization who brings in new ideas from the outside, tests them, and uses positive results to persuade others in the organization to adopt the successful changes. Source: Diffusion of Innovation (Everett Rogers, 1995).
Early Majority/Late Majority: The individuals in the organization who will adopt a change only after it is tested by an early adopter (early majority) or after the majority of the organization are already using the change (late majority). Source: Diffusion of Innovation (Everett Rogers, 1995).
Emergency Care Research Institute (ECRI) Patient Safety Organization (PSO):
The Emergency Care Research Institute (ECRI) PSO has been officially listed (effective 11/5/08) by the U.S. Department of Health and Human Services as a federal Patient Safety Organization under the Patient Safety and Quality Improvement Act of 2005. ECRI Institute Patient Safety Organization will serve nationwide as a PSO directly for providers, hospitals, and health systems as well as provide support services to state and ECRI Institute is an independent nonprofit organization whose mission is to benefit patient care by promoting the highest standards of safety, quality, and cost-effectiveness in health care. We accomplish this through our research, publishing, education, and consultation.
Error: Failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim.
Evidence-Based Medicine (EBM): The deliberate and well-informed use of specific, reliable, and measurable evidence in making decisions about the care of individual patients.
Evidence-Based Hospital Referral (EHR):
Evidence-based Hospital Referral (EHR) under the advisement of national experts in quality improvement, the Leapfrog Group has adopted EHR as one of its initial Safety Standards. Conditions and volume criteria were selected after review of published research in the field and consultation with leading experts in surgery and neonatal intensive care.
Failure Mode: Operation of a system element in an unintended or undesirable manner.
Failure Mode and Effects Analysis (FMEA): FMEA is a procedure for analysis of potential failure modes within a system for classification by severity or determination of the effect of failures on the system. Failure modes are any errors or defects in a process, design, or item, especially those that affect the customer, and can be potential or actual. Effects analysis refers to studying the consequences of those failures.
Failure to Rescue: “Failure to rescue” is shorthand for failure to respond to (i.e., prevent a clinically important deterioration, such as death or permanent disability) for a complication of an underlying illness (e.g., cardiac arrest in a patient with acute myocardial infarction) or a complication of medical care (e.g., major hemorrhage after thrombolysis for acute myocardial infarction). The failure may reflect the quality of monitoring, the effectiveness of actions taken once early complications are recognized, or both. For a more detailed definition, please go to .
Fishbone Diagram: A tool for organizing a group’s current knowledge regarding a problem or issue. Useful for recording ideas in a brainstorming session (also called a cause and effect diagram or an Ishikawa diagram).
First-look Analysis Tool for Hospital Outlier Monitoring (FATHOM): First-look Analysis Tool for Hospital Outlier Monitoring (FATHOM) helps Quality Improvement Organizations (QIOs) compare short inpatient hospital stays and areas at risk for payment error using Medicare discharge data at .
Food and Drug Administration (FDA) Patient Safety News:
The Food and Drug Administration (FDA) Patient Safety News is a televised series for health care personnel, carried on satellite broadcast networks aimed at hospitals and other medical facilities across the country. It features information on new drugs, biologics and medical devices, on FDA safety notifications and product recalls, and on ways to protect patients when using medical products.
Forcing Function: An aspect of a design that prevents a target action from being performed or allows its performance only if another specific action is performed first. For example, automobiles are now designed so that the driver cannot shift into reverse without first putting a foot on the brake pedal. An example of a forcing function in health care is the design of enteral tubing to prevent connections with IV ports.
Frequency Chart: A tool to display data that presents basic information about the location, shape, and spread of a set of data (also called histogram or dot plot).
Health Care Financing Administration (HCFA) is now known as Centers for Medicare and Medicaid Services (CMS):
The Medicare and Medicaid programs were signed into law on July 30, 1965. Since 1965, a number of changes have been made to CMS programs. The current mission of CMS is “to ensure effective, up-to-date health care coverage and to promote quality care for beneficiaries.”
Health and Human Services (HHS):
The Department of Health and Human Services (HHS) is the United States government’s principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves. The work of HHS is conducted by the Office of the Secretary and 11 agencies. The agencies perform a wide variety of tasks and services, including research, public health, food and drug safety, grants and other funding, health insurance, and many others.
Health Insurance Portability and Accountability Act (HIPAA):
HIPAA, which stands for the American Health Insurance Portability and Accountability Act of 1996, is a set of rules to be followed by doctors, hospitals and other health care providers. HIPAA took effect on April 14, 2003. The HIPAA Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes. The Security Rule specifies a series of administrative, physical, and technical safeguards for covered entities to use to assure the confidentiality, integrity, and availability of electronic protected health information. HIPAA helps ensure that all medical records, medical billing, and patient accounts meet certain consistent standards with regard to documentation, handling, and privacy. In addition, HIPAA requires that all patients be able access their own medical records, correct errors or omissions, and be informed how personal information is shared used. Other provisions involve notification of privacy procedures to the patient. In sum, HIPAA is a body of national standards for electronic medical records and transactions for health care providers, health plans, and employers. It also addresses the security and privacy of electronic health records.
Health Literacy: Individuals’ ability to find, process, and comprehend the basic health information necessary to act on medical instructions and make decisions about their health.
Health Plan Employer Data and Information Set (HEDIS):
A set of standardized measures of health plan performance. HEDIS permits comparisons between plans on quality, access and patient satisfaction, membership and utilization, financial information, and health plan management.
Health Resources and Services Administration (HRSA):
HRSA is an agency of the US Department of Health and Human Services, which is the Nation’s Access Agency. HRSA focuses on uninsured, underserved, and special needs populations in its goals and program activities. HRSA provides national leadership, program resources and services needed to improve access to culturally competent, quality health care.
High Reliability Organizations (HROs): High reliability organizations refer to organizations or systems that operate in hazardous conditions but have fewer than their fair share of adverse events. Commonly discussed examples include air traffic control systems, nuclear power plants, and naval aircraft carriers. Weick and Sutcliffe identified the following characteristics in high reliability organizations.
• Preoccupation with failure—the acknowledgment of the high-risk, error-prone nature of an organization’s activities and the determination to achieve consistently safe operations.
• Commitment to resilience—the development of capacities to detect unexpected threats and contain them before they cause harm, or to recover from them when they do occur.
• Sensitivity to operations—an attentiveness to the issues facing workers at the front line. This feature comes into play when conducting analyses of specific events (e.g., front‐line workers play a crucial role in root cause analyses by identifying unrecognized latent threats in current operating procedures), and also in connection with organizational decision making that is somewhat decentralized. Management units at the front line are given some autonomy in identifying and responding to threats, rather than adopting a rigid top‐down approach.
• A culture of safety, in which individuals feel comfortable drawing attention to potential hazards or actual failures without fear of censure from management.
Hindsight Bias: This expression captures the tendency for people to regard past events as expected or obvious, even when, in real time, the events perplexed those involved. More formally, one might say that after learning the outcome of a series of events—whether the outcome of the World Series or the steps leading to a war—people tend to exaggerate the extent to which they had foreseen the likelihood of its occurrence. For a more detailed definition, please go to .
Histogram: A tool to display data that presents basic information about the location, shape, and spread of a set of data (also called a frequency chart or dot plot).
Hospital Compare:
Hospital Compare is a Web site created through the efforts of the Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services, and other members of the Hospital Quality Alliance: Improving Care Through Information (HQA). The information on the Web site comes from hospitals that have agreed to submit quality information for Hospital Compare to make public. Using this tool, you can find information on how well hospitals care for patients with certain medical conditions and surgical procedures, as well as results from a survey of patients about the quality of care they received during a recent hospital stay.
Hospital Payment Monitoring Program (HPMP): Hospital Payment Monitoring Program – performed by Quality Improvement Organizations (QIOs) and acts along with a HINN.
Hospital Standardized Mortality Ratio (HSMR): Hospital death rates, a key quality indicator and baseline measure for hospitals engaged in improvement work. A new statistical methodology to standardize hospital mortality rates in order to fairly compare them, developed by Institute for Healthcare Improvement partner, Sir Brian Jarman.
Human Factors: Refers to the study of human behavior, abilities, limitations, and other characteristics as they affect the design and smooth operation of equipment, systems, and jobs. And work environments
Iatrogenic: An adverse effect of medical care, rather than of the underlying disease (literally “brought forth by healer,” from the Greek iatros, for healer, and gennan, to bring forth).
Implementation: Making a change to a process a permanent part of the system. A change may be tested first and then implemented throughout the organization. Implementation involves engaging the infrastructure of the organization such as staff training, documentation, compensation, supply or equipment requirements, hiring, policy, procedures, measurement, etc. Implementation takes longer than testing and typically involves more resistance to change. Developing strategies to mitigate resistance to change is part of implementation.
Informed Consent: Refers to the process whereby a physician informs a patient about the risks and benefits of a proposed therapy or test. Informed consent aims to provide sufficient information about the proposed treatment and any reasonable alternatives so that the patient can exercise autonomy in deciding how to proceed. For a more detailed definition, please go to .
Institute for Healthcare Improvement (IHI):
The Institute for Healthcare Improvement (IHI) is a not-for-profit organization driving the improvement of health by advancing the quality and value of health care. Founded in 1991 and based in Cambridge, Massachusetts, IHI offers comprehensive products and services. IHI is a reliable source of energy, knowledge, and support for a never-ending campaign to improve health care worldwide. The Institute helps accelerate change in health care by cultivating promising concepts for improving patient care and turning those ideas into action.
Institute for Healthcare Improvement (IHI) Open School:
The IHI Open School for Health Professions is an inter-professional educational community that gives students the skills to become change agents in health care improvement. The IHI Open School — including all of our online tools and resources, and our online courses — is open and free for students of all health care professions.
Institute of Medicine (IOM):
The Institute of Medicine (IOM) is an independent, nonprofit organization that works outside of government to provide unbiased and authoritative advice to decision makers and the public. Established in 1970, the IOM is the health arm of the National Academy of Sciences, which was chartered under President Abraham Lincoln in 1863. Nearly 150 years later, the National Academy of Sciences has expanded into what is collectively known as the National Academies, which comprises the National Academy of Sciences, the National Academy of Engineering, the National Research Council, and the IOM. The Institute of Medicine serves as adviser to the nation to improve health.
Institute of Medicine (IOM) “Aims for Improvement”—STEEEP:
In 1999, the Institute of Medicine (IOM) in Washington, DC, USA, released To Err Is Human: Building a Safer Health System, an alarming report that brought tremendous public attention to the crisis of patient safety in the United States. In 2001, IOM followed up with Crossing the Quality Chasm: A New Health System for the 21st Century, a more detailed examination of the immense divide between what we know to be good health care and the health care that people actually receive. This second report called for six “aims for improvement”: safe, effective, efficient, equitable, patient centered, and timely. The acronym STEEEP may be used to help remember these aims
Institute for Safe Medication Practices (ISMP):
Institute for safe medication practices is a non-profit health care agency comprised of pharmacists, nurses, and physicians. Founded in 1994, the organization is dedicated to learning about medication errors, understanding their system-based causes, and disseminating practical use.
Intentional Unsafe Acts: Intentional unsafe acts, as they pertain to patients, are any events that result from: a criminal act; a purposefully unsafe act; an act related to alcohol or substance abuse, impaired provider/staff; or events involving alleged or suspected patient abuse of any kind.
International Center for Patient Safety (ICPS):
International Center for Patient Safety (ICPS) – The Center was established in 2005 by the Joint Commission and Joint Commission Resources (JCR). The Center’s missions is to continuously improve patient safety by providing solutions, processes and procedures that help eliminate preventable adverse events in all health care settings worldwide.
International Society of Six Sigma Professionals (ISSSP):
International Society of Six Sigma Professionals committed to promoting the adoption, advancement and integration of Six Sigma in business. Our community supports this mission through advocacy and awareness efforts; professional recognition and development; and by serving as an information and referral source.
Ishikawa Diagram: A tool for organizing a group’s current knowledge regarding a problem or issue. Useful for recording ideas in a brainstorming session (also called a cause and effect diagram or a fishbone diagram).
Joint Commission (used to be JACHO):
The Joint Commission evaluates the quality and safety of care for nearly 15,000 health care organizations and programs in the United States. An independent, not-for-profit organization, the Joint Commission is the nation’s predominant standards-setting and accrediting body in health care. Since 1951, the Joint Commission has developed state-of-the-art, professionally based standards and evaluated the compliance of health care organizations against these benchmarks. Its mission is to improve continuously the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations.
Measure: An indicator of change. Key measures should be focused, clarify your team’s aim, and be reportable. A measure is used to track the delivery of proven interventions to patients and to monitor progress over time.
Medical Error: An adverse event or near miss that is preventable with the current state of medical knowledge.
Medication Error: Any preventable event that may cause or lead to unintended and incorrect medication use or patient harm, while the medication is in the control of the health care professional or patient.
Medication Reconciliation: The process by which health care providers collect a list of the medications that a patient is taking, using that information to make treatment decisions, and ensuring that all other caregivers who need to know are informed of changes to those medications. Applies in all health care settings where medication regimens may be modified.
Microsystem: A small, organized patient care unit with a specific clinical purpose, set of patients, technologies, and practitioners who work directly with these patients.
Model for Improvement: An approach to process improvement, developed by Associates in Process Improvement, that helps teams accelerate the adoption of proven and effective changes.
National Association for Healthcare Quality (NAHQ):
The mission of the National Association for Healthcare Quality (NAHQ) is to empower health care quality professionals from every specialty by providing vital research, education, networking, certification and professional practice resources, and a strong voice for health care quality.
National Center for Patient Safety:
The National Center for Patient Safety (NCPS) was established in 1999 to develop and nurture a culture of safety throughout the Veterans Health Administration. Their goal is the nationwide reduction and prevention of inadvertent harm to patients as a result of their care. Patient safety managers at 153 VA hospitals and patient safety officers at 21 VA regional headquarters participate in the program.
National Institutes of Health (NIH):
The National Institutes of Health (NIH), is a part of the US Department of Health and Human Services. The NIH is the primary Federal agency for conducting and supporting medical research. National Institute for Nursing Research (NINR), founded in 1993, is part of NIH along with many other subspecialty research organizations.
National Patient Safety Foundation (NPSF):
National Patient Safety Foundation (NPSF) is an independent, non-profit research and education organization dedicated to the measurable improvement of patient safety in the delivery of health care.
National Quality Forum (NQF):
National Quality Forum (NQF) is a private, non-profit, open membership, public benefit corporation with participation from 170 organizations that represent all sectors of the health care industry. NQF was created to develop and implement a national strategy for health care quality measurement and reporting. The National Quality Forum (NQF) has a three-part mission: 1. Setting national priorities and goals for performance improvement; 2. Endorsing national consensus standards for measuring and publicly reporting on performance; and 3. Promoting the attainment of national goals through education and outreach programs.
Near Miss: An event or situation that could have resulted in an adverse event, but did not, either by chance or through timely intervention.
Operational Definition: A definition that gives communicable meaning to a concept by specifying how the concept is applied within a particular set of circumstances.
Outcome Measure: Outcome measures evaluate how a system is performing. For example, in a project to improve some aspect of clinical care, an outcome measure will evaluate the degree of change in the well‐being of a defined population. Improvement in the outcome measure will reflect results related directly to the patient and will have an effect on mortality and morbidity.
Pareto Chart: A tool for helping focus improvement efforts by identifying how frequently categories of events occur.
Performance Improvement (PI): Performance improvement is the concept of measuring the output of a particular process or procedure, then modifying the process or procedure to increase the output, increase efficiency, or increase the effectiveness of the process or procedure.
Physician Order Entry (POE): See Computerized Physician Order Entry (CPOE)
Plan, Do, Check, ACT (PDCA): The PDCA Cycle is one quality improvement methodology. The four letters “PDSA” stand for Plan, Do, Study, and Act. At Christiana Care Health System we use the Plan, Do, Check, Act (PDCA) cycle. Other institutions may use Plan, Do, Study, Act (PDSA).
Process: A series of actions or operations definitely conducting to an end.
Process Change: A specific change in a process in the organization. More focused and detailed than a change concept, a process change describes what specific changes should occur. “Institute a pain management protocol for patients with moderate to severe pain” is an example of a process change.
Proximal (proximate) Cause: An observable system failure that leads directly to an error.
Process Measure: Process measures evaluate whether the system is functioning as planned. For example, in a project to improve some aspect of clinical care, a process measure will evaluate care delivery to the patient, that is, what is done to, for, with, or by defined individuals or groups as part of the delivery of services.
Quality-Adjusted Life Years (QALYs): Quality-adjusted life years, or QALYs, are a measure of the benefit of a medical intervention. QALYs are based on the number of years of life that would be added by the intervention. Each year in perfect health is assigned the value of 1.0 down to a value of 0 for death. If the extra years would not be lived in full health, for example if the patient would lose a limb, or be blind or be confined to a wheelchair, then the extra life-years are given a value between 0 and 1 to account for this. The “weight” values between 0 and 1 are usually determined by methods such as:
• Time-trade-off (TTO)—In this method, respondents are asked to choose between remaining in a state of ill health for a period of time, or being restored to perfect health but having a shorter life expectancy.
• Standard gamble—In this method, respondents are asked to choose between remaining in a state of ill health for a period of time, or choosing a medical intervention which has a chance of either restoring them to perfect health, or killing them.
• Another way of determining the weight associated with a particular health state is to use standard descriptive systems such as the EuroQol EQ-5D questionnaire.
However, the weight assigned to a particular condition can vary greatly, depending on the population being surveyed. Those who do not suffer from the affliction in question will, on average, overestimate the detrimental effect on quality of life, while those who are afflicted have come to live with their condition. QALYs are controversial as the measurement is used to calculate the allocation of health care resources based upon a ratio of cost per QALY. As a result some people will not receive treatment as it is calculated that cost of the intervention is not warranted by the benefit to their quality of life.
Quality Assurance/Quality Improvement (QA/QI): Involves efforts to improve health care services and increase desired health care outcomes.
Quality Improvement Organization (QIO):
Quality Improvement Organization (QIO) contract with Centers for Medicare and Medicaid Services (CMS) to collaborate with providers, administrators, and others to improve quality health care.
Reliability: The extent of failure‐free operation over time (Source: David Garvin)
Return on Investment (ROI): Return on Investment is a performance measure used to help make capital investment decisions. ROI is calculated by considering the annual benefit divided by the investment amount. To calculate ROI, the benefit (return) of an investment is divided by the cost of the investment; the result is expressed as a percentage or a ratio.
Robert Wood Johnson Foundation (RWJF):
The Robert Wood Johnson Foundation (RWJF) is a funding source for health initiatives. The mission of the Robert Wood Johnson Foundation is to improve the health and health care of all Americans. Their goal is to help Americans lead healthier lives and get the care they need. They support training, education, research and projects that demonstrate effective ways to deliver health services, especially for the most vulnerable populations.
Root Cause Analysis (RCA): A structured process for identifying the causal or contributing factors underlying adverse events or other critical incidents. For a more detailed definition, please go to .
Run Chart: A graphical record of a quality characteristic measured over time. For a more detailed definition, please go to .
Sampling Methods: The selection of units for study. Different sampling methods include judgment sampling, simple random sampling, proportionate random sampling, systematic sampling, and stratified sampling.
Sampling Plan: A specific description of the data to be collected, the interval of data collection, and the subjects from whom the data will be collected. The plan emphasizes the importance of gathering samples of data and how to obtain “just enough” information.
Sentinel Event (SE):
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response. In support of its mission to improve the quality of health care provided to the public, The Joint Commission includes the review of organizations’ activities in response to sentinel events in its accreditation process, including all full accreditation surveys and random unannounced surveys.
Severity of illness (SOI): Severity of Illness (SOI) is a mechanism to determine the complexity of a patient’s illness. SOI systems are a clinical tool for measuring the physical effects of disease on the patient, planning treatment, and predicting outcomes. SOI allows for grouping of like patients for comparison purposes (e.g., expected length of stay.) In addition, SOI is especially useful at large tertiary care hospitals that tend to treat more severely ill patients, where the SOI can be used as a management tool to help explain and justify above average treatment costs.
Spread: The intentional and methodical expansion of the number and type of people, units, or organizations using the improvements. The theory and application comes from the literature on Diffusion of Innovation (Everett Rogers, 1995).
Statistical Methods: Use of more advanced statistical methods such as correlation analysis, regression analysis, confidence intervals, analysis of variance, statistical tests, and power analysis.
Systems Thinking/Analysis: A view of the organization as comprising interdependent processes and products, and as dynamic and adaptive to the needs of the customer.
Test: A small-scale trial of a new approach or a new process. A test is designed to learn if the change results in improvement and to fine-tune the change to fit the organization and patients. Tests are carried out using one or more PDCA/PDSA cycles.
Total Quality Improvement (TQI): Total Quality Improvement (TQI) is a collection of methods and practices used in an attempt to achieve total quality. TQI represents a theory for transformation that requires continuous quality improvement (CQI).
Total Quality Management (TQM): Total Quality Management is a comprehensive and structured approach to organizational management that seeks to improve the quality of products and services through ongoing refinements in response to continuous feedback.
Tree Diagram: A tool used to visualize the structure of a problem, plan, or any other opportunity of interest. It helps in thinking systematically about each aspect of the problem or plan. It also has been called a “systematic diagram.” The tree diagram presents a graphical view of different level of details about a problem or plan.
Utilization Review (UR): Utilization review is a review of services delivered by a health care provider to evaluate the appropriateness, necessity, and quality of the prescribed services. The review can be performed on a prospective, concurrent, or retrospective basis.
Quality Journals
American Journal of Medical Quality:
BMC Health Services Research:
Health and Quality of Life Outcomes:
Health Services Research:
International Journal for Quality in Health Care:
Medical Decision Making:
Patient Safety & Quality Healthcare:
Quality and Safety in Healthcare:
Quality of Life Research:
The Joint Commission Journal on Quality and Patient Safety:
Value in Health: [pic]
-----------------------
Care plan developed
No
Hospital A
Hospital B
System
FY 2003
5.6
5.6
5.6
FY 2004
5.3
5.5
5.4
FY 2005
5.2
5.2
5.2
FY 2006
4.9
5.0
5.0
FY 2007
5.0
4.9
5.0
Nurse puts AD on patient’s chart
Yes
Pastoral Care assists patient in completing AD
Does patient want an AD?
Patient asks about Advance Directive (AD) in the Emergency Department
Causes
Effect
Causes
Insert
Problem
(Insert brief description of area for improvement)
Effort
(Insert Opportunity Statement)
Benefit
................
................
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