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Contents

Page 1 of 2
4.A. Focusing on Microsystems
4.B. Understanding and Implementing the Improvement Cycle

Page 2 of 2
4.C. An Overview of Improvement Models
4.D. Tools To Enhance Quality Improvement Initiatives
References

4.C. An Overview of Improvement Models

To succeed in improving patients' experiences, it is important to use a systematic, structured approach that gives feedback on your progress. If your organization has already adopted an established quality improvement model, you will be able to apply its system and methods to improve patient experience and your organization's CAHPS survey scores. If not, you can learn about and adapt one of the models described below to pursue improvements:

• The Institute for Healthcare Improvement's Model for Improvement
• Lean
• Six Sigma

Established QI models share several common features, including:

• Emphasis on leadership to hold people accountable, communicate the vision and strategy, and eliminate cultural and other barriers to improvement.
• Clear goals.
• Use of measurement and analysis to identify issues and guide decisions.
• Emphasis on stakeholders as participants and audiences for the improvement processes.
• Use of structured, iterative processes to implement improvement interventions.
• Use of many of the same tools to support analysis and implementation.
• Monitoring of front-line clinical activity through observations and the collection and reporting of process data as feedback on the effect of changes or to track the progress of the implementation process.
• Transparent metrics.

As you work with any QI method, the key is to carefully choose strategies that have the best chance to improve how your organization interacts with patients.

4.C.1. The Model for Improvement

The is a simple, yet powerful model that focuses on setting aims and selecting or developing measures to indicate if a change resulted in improvement. At the heart of the Model for Improvement is the Plan-Do-Study-Act (PDSA) cycle (see Figure 4-1).

The first part of the Model for Improvement is based on a "trial and learning" approach using rapid cycle improvement (RCI; see box below). During this first part, a QI team guides development of its strategy and action plan by answering the following questions:

• What are we trying to accomplish?
• How will we know that a change is an improvement?
• What changes can we make that will result in improvement?

In the second part of the model, the QI team uses RCI and the PDSA cycle to implement its action plan with small-scale interventions introduced rapidly to test the changes, learns from these tests, and then modifies the intervention for implementation in another cycle.

4.C.2. Lean

Lean, which is sometimes referred to as the Toyota Production System, is a tool used by businesses to streamline manufacturing and production processes. The main emphasis of Lean is on cutting out unnecessary and wasteful steps in the creation of a product or the delivery of a service so that only steps that directly add value are taken. One core principle of Lean is the need to provide what the internal or external customer wants, i.e., to provide "value" to the customer, with minimal wasted time, effort, and cost. Another is that any part of a process that does not add value is simply removed from the equation, leaving a highly streamlined and profitable process that will flow smoothly and efficiently, creating additional capacity and hence enhanced performance. In health care, Lean "thinking" involves a clear understanding of the process under review, including every step involved, eliminating unnecessary steps, and basing the redesigned process on the "pull" needs of the patient.¹²

Lean uses a technique called Value Stream Mapping (VSM). In VSM, a QI team creates a visual map of each step in the flow of the current process. To do that, the team will have to discuss and agree on the current process's sequential steps from beginning to end. VSM is extremely useful for mapping the steps that a patient will take when visiting a clinician's office. Another example would be mapping the flow of a medication prescription, fill, and dispense. Using this technique, QI teams can find steps in the process that result in waste, poor flow, low value, and/or errors.

The next step in Lean is to do 5S organization. During 5S workplace organization, team members systematically review each environment to:

1. Sort,
2. Simplify (set in order),
3. Standardize,
4. Sweep/shine, and
5. Initiate self-controls that will sustain the order of standardization.

The purpose of 5S is to improve space organization and to eliminate the time or "motion waste" of "searching" for things or getting prepared to work. VSM coupled with 5S are proven tools to create processes that are "leaner," offer more value to those involved in the process, and increase the success rate of sustained process improvement.

In a Lean culture, the focus is on interdisciplinary teams, where leaders are coaches and enablers. There is a strong patient focus and decisions are data and process driven. Rewards accrue to the team or group; however, the focus remains on the customer's needs and expectations. For example, from the patient perspective, a process with value would include no unnecessary delays in access to care, error-free process, no long wait times, and a satisfactory outcome. From the provider perspective, a process with value would result in readily available charts, equipment, labs and essential patient data.

4.C.3. Six Sigma

The essential goal of Six Sigma is to eliminate defects and waste, thereby improving quality and efficiency, by streamlining and improving all business processes. A sigma rating indicates the percentage of defect-free products created by a process. A six sigma process is one in which 99.99966% of all production opportunities are expected to be free of defects. While it was first designed for use in manufacturing and became central to General Electric's business strategy in 1995, the health care industry uses Six Sigma to increasing the reliability of the process of delivering health care services.

Six Sigma seeks to improve the quality of process outputs by identifying and removing the causes of defects (errors) and minimizing variability in processes. It uses a set of quality management methods and creates a special infrastructure of people within the organization who are experts in these methods ("Champions," "Black Belts," "Green Belts," "Yellow Belts," etc.).

A key focus of Six Sigma is the use of statistical tools and analysis to identify and correct the root causes of variation. As a roadmap for problem solving and process improvement, Six Sigma uses the : Define, Measure, Analyze, Improve, Control. Additional information about DMAIC can be found at  .¹³

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4.D. Tools To Enhance Quality Improvement Initiatives

This section summarizes two strategies that can support health care organizations in implementing a model of quality improvement.

4.D.1. The Team Strategies and Tools To Enhance Performance and Patient Safety (TeamSTEPPS^®)

For many health care organizations, one of the biggest challenges to improvement is getting a team of highly trained and busy professionals to work together effectively. TeamSTEPPS is an evidence-based training program designed to improve quality and safety by enhancing communication and teamwork skills among health care professionals. The program was developed jointly by the Department of Defense (DoD) and the ´óÏóÊÓƵ (AHRQ).

TeamSTEPPS teaches techniques to improve team structure, communication, leadership, understanding of what is happening ("situation monitoring"), and mutual support among team members. Together, these factors have a strong influence on quality improvement and quality of care. Organizations can also use TeamSTEPPS to "coach coaches" or "train the trainer."

While TeamSTEPPS was originally designed for the hospital setting, ´óÏóÊÓƵalso offers a primary care version of TeamSTEPPS training in which the core concepts of the program were adapted to reflect the environment of primary care office-based teams.

4.D.2. Practice Facilitators

Another common challenge for physician practices is not having the expertise, time, or capacity to focus on designing and implementing a quality improvement program. To help overcome that problem, organizations can seek help from practice facilitators (PFs), sometimes referred to as quality improvement coaches or practice enhancement assistants.

PFs are full or part-time personnel hired or contracted to help medical practices evaluate and build organizational capacity for continuous quality improvement. The functions of a PF can include:

• Analyzing and evaluating performance, customer/patient feedback, or patient experience surveys.
• Recommending changes and supporting internal teams with implementation.
• Training clinicians and staff in quality improvement methods.
• Team building.
• Disseminating best practices and innovative ideas.
• Providing specific materials and resources (flow charts, computer training, etc.).

PFs can also assist with enhancing communication and technology, promoting adherence to best practices, and creating the capacity to participate in and benefit from research.

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References

1. Quinn J, Baruch J, Zien K. Innovative Explosion: Using Intellect and Software to Revolutionize Growth Strategies. New York: Free Press; 1997.
2. Berwick DM. A user's manual for the IOM's 'Quality Chasm' report. Health Aff (Millwood) 2002;21(3): 80-90.
3. ´óÏóÊÓƵPatient Centered Medical Home Research Center. Accessible at .
4. Wasson J, Godfrey M, Nelson E, et al. Microsystems in health care: Part 4. Planning patient-centered care. Jt Comm J Qual Patient 2003 May; 29(5):227-37(11).
5. Pronovost P, Weast B, et al. Implementing and validating a comprehensive unit-based safety program. J Patient Saf 2005 Mar;1(1):33-40.
6. Batalden PB, Nelson EC, Edwards WH, et al. Microsystems in health care: Part 9. Developing small clinical units to attain peak performance. Jt Comm J Qual Patient 2003 Nov;29(11):575-85.
7. Berwick DM. Developing and testing changes in the delivery of care. Ann Intern Med 1998;128(8):651-6.
8. Iles V, Sutherland K. Organizational change: A review for health care managers, professionals and researchers. London: NCCSDO; 2001.
9. Greenhalgh T, Robert G, Bate P, et al. How to Spread Good Ideas: a systematic review of the literature on diffusion, dissemination and sustainability of innovations in health service delivery and organization. London: NCCSDO; 2004.
10. ´óÏóÊÓƵ. How Two Provider Groups Are Using the CAHPS^® Clinician & Group Survey for Quality Improvement. CAHPS Issue Brief. Available at: https://ahrq.gov/cahps/quality-improvement/reports-and-case-studies/cgcahps-webcast-brief-2014.pdf. Accessed on July 29, 2015.
11. Rogers E. Diffusion of innovation. New York: The Free Press; 1995.
12. ASHP Foundation. Clinical Microsystems. Transformational Framework for Lean Thinking. Accessible at: .
13. American Society for Quality. The Define Measure Analyze Improve Control (DMAIC) Process. Accessed at on May 20, 2015.

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