[music] Welcome to module one, an overview of health care quality improvement. Today, we're going to talk about three different components. First is the definition of quality. Second, the history of quality improvement and third a little example and summary of what we'll be covering over this course. So, what is quality? The Institute of Medicine lists six components of quality. The first is that care should be safe. Care in health care facilities should be as safe as care in your home. Second the care should be effective. Care should be science based, and evidence based. Third, care should be efficient, that the care we deliver, and services we provide should be cost effective. Fourth: timely, that there should be no waits, or delays, during our delivery of care. Fifth the care should be patient centered. Systems of care should revolve around our patients. And Sixth, that care should be equitable. The disparities in care should be eradicated. So to help us with understanding and remembering what quality is this rubric helps us, that care is safe, timely, efficient, effective, equitable, and patient centered. the definition of quality improvement then is the combined unceasing efforts of everyone, healthcare professionals, patients and their families, researchers, payers, planners, and educators to make the changes that will lead to better patient outcomes such as health, better systems performance, the care we deliver, and better professional development, all the learning and education that we go through. There are also levels of quality improvement. You can do quality improvement at the personal level. For example, if you wanted to improve the time you went to work or improve the care you were delivering to your individual patients. You can use these simple processes and improvement at this personal level. Second, you can use the principles you'll learn in this course at the micro system or your unit level, where you'll be able to take the components that you learn. And apply them to improve and make changes on your unit. And lastly quality improvement can be seen at the system level. And this is where major national initiatives take place, such as the Institute for Health Care Improvement and the triple aim, where agencies at organizations are working to improve population health, experiences of care and also the per capita of cost of care. Really quality improvement is, is a piece that learning is the core. It's where we understand what we do, and testing ways to do it better. This quality improvement perspective really leads to us avoiding blaming individuals. We focus now on methods and systems of care, rather than blaming individuals for problems of care. This also stimulates experimentation and creativity. Where if we see there is a gap in care, we are able to really try different things, new, innovative ways to improve the care that we deliver. Quality improvement also provides us to be reflective practitioners, where we pause and think about how we could do better in the future. So, who historically, is responsible for much of our quality improvement now? That is Florence Nightingale. And a reason why she was seen as a founder of quality improvement is because she collected data. So, when she was in the Crimean War, she collected these polar area diagrams to indicate where there were gaps in care, and then she provided improvement strategies to improve care. Similarly in medicine, Codman was our founder of quality improvement. And he had a wonderful system, where he was a surgeon, and he would keep little index cards in his pockets. And when he finished his surgery, he documented how the surgery went, what techniques he used, and then he looked at the out comes of the surgical procedure. And look to see the mortality, and recovery of the patient. And he kept these little cards, so he could study his performance and learn from his performance and then make improvement. An interesting story is that he shared his cards with his colleagues, and many of his colleagues said Put that card away, this is not something that we want to share our mistakes or the ways that we can improve, but Codman knew different and he used his little cards to make improvements in his practice. Why is this topic important? And really why is this whole module and this whole course in place? And that's because there are so many errors in healthcare today. This picture describes how many people die from medical mistakes in U. S. hospitals. And the statistics varied between different references. But one reference states that about one out of every three patients has experienced in the hospital a medical error. There are many reports also out that really highlight for us as healthcare professionals of the need to learn quality improvement methods. The first is the Institute of Medicine, way back in 2000, where they stated in “To Err is Human,” that about 44,000 to 98,000 people die per year due to medical error, costing our health care system billions of dollars. In 2001, the Agency for Health Care Research and Quality also said that making health care safety in 70 health care practices and they endorsed 12 practices for us to learn from in order to improve care. But it's been taking us many, many years to integrate these recommendations. In 2010 the Affordable Care Act came out with many different pieces that really state that we need to improve care and reduce the costs of care. And then in 2012 there was an article that came out that said one out of every 370 people die from medical error. And most recently, the Agency for Healthcare Research and Quality came out with another report. And they found that really our progress is very slow in the improvement of healthcare. And that's why we all need to get involved as the frontline healthcare professional. So that we can create a culture of healthcare improvement and we can make a real effort and a real impact on the care that we're delivering in healthcare. So health care professionals really have the potential to effect a wide-reaching changes in health care. Nurses, physicians, pharmacists, social workers, if we all learn the practices of quality improvement then we can have an effect on change and improve the health care that we deliver. Again a little piece of history is that health care quality improvement actually started in manufacturing back in the 1980s. Fathers of the manufacturing movement were Deming, Shewhart, and Donabedian. The whole quality improvement movement started probably in about 1993 where there was a total quality management impact. In health care, where we were learning for manufacturing and trying to apply these methods into our health care systems. The emphasis at this time were links between improvement, and change, and learning. So, we were really trying to determine from manufacturing how these improvements were being made, and then apply them in our health care practices. Our first projects were breast cancer and asthma. We were trying to increase the use of mammograms and also to reduce the incidents of ER visits for asthma care. What is this quality improvement? And the definition, just to repeat, is: The combined effort of everyone -- patients, families, healthcare professionals, researches, educators, payers and planners -- to make the changes that are going help us to lead to better patient outcomes, better health for all, better system performance, the care that we deliver, and also better professional development, and that is our educational systems. Quality improvement is really doing your work, and also improving your work. It's not a separate entity. It's just a part of what you do. And the quality improvement opportunities that we have are identifying the gaps. What do we know we should be doing, and then, what are we actually doing. And these are the gaps I'd like for you to think about this week during this module, as to, when you are working in your own situation, what really are the gaps that you see? What things could be improved? What really frustrates you about your job, that you feel you could have an impact on? The textbook that we're using is the Foundations of Health Care Improvement, and in Chapter 1 it talks about this gap between what do we know and what are we actually doing. The chapter talks and gives an example about beta blocker use, and how we learned many, many years ago of the effectiveness of giving patients after a myocardial infarction a beta blocker. But it took many, many years for this to be implemented into practice. I think the book actually talks about 17 years it took from that research to end up impacting healthcare practice at the bedside. How can we reduce this gap, how can we reduce the time it takes from our research to getting this implemented into practice? And the key is really this quality improvement. And that is that we can learn that how to diagnose and treat the systems of care, and not just treating the patient. And the book really describes many examples of how we need to move as healthcare professionals from simply diagnosing our individual patients to really learning about how to diagnose the systems of care. This table was a wonderful example of how we need to move and change our thinking as healthcare professionals from individual delivery of care to more systems of care. The table as you can reflect back in your reading were first of all the initial workup. When we initially work up a patient we look at laboratory values and we look at the patient's history. But when we really look at the system of care, we need to use other tools. And these are the tools you're going to learn in this course. These tools include fishbone diagrams, process diagrams and other ways to really look at the system, and diagnose what's happening in the context of the care we're delivering. The second row in this table talks about further work up and these are things that can also be used in diagnosing an individual patient, and also things that we need to look at for the system that can be referenced in the table. And then lastly is the therapy. When we deliver care we asses the patient, we create a diagnosis, and then we do some kind of intervention. Similarly in health care improvement, we diagnose the system, we figure out what we can do to improve, and then we use PDSAs or plan-do-study-act cycles in order to intervene, and make the system better. This evidence-based improvement equation was also listed in the book, and I think it's a really important equation. It lists that we do a lot of generalizable scientific evidence that we create in academia where we identify, what are the real important interventions that we need to provide. But as I mentioned a little while earlier, it takes 17 years for that research to impact the clinical practice at the front line. But if we use this equation, we can accelerate that. Because if we look at the particular context of healthcare, and we then take that intervention and apply it in this context when we understand the system, in this context, we can have a better success rate of improving. This is the equation that is really key to quality improvement. Now I'd like to just pause and have you kind of think about the pieces that we just discussed, and that is, what is quality improvement, remembering the steep rubric, and then also the history of quality improvement and how these prior founders of quality improvement were so dedicated to improving the care that they were delivering. And I'd like for you to kind of think about that excitement, and that enthusiasm, and kind of take that in as a motivator for you during this course. And now I want to just give a little overview of what the components of quality improvements are, so that you can see what you're going to be learning in this course and looking ahead. So, the components of quality improvement have been identified by Batalden and Stoltz back in 1993, so this have been out for quite awhile, and again taking some time for them to be implemented into practice. The first component of quality improvement is knowledge of the system. We use in quality improvement this tool, which is the fishbone diagram to help us to understand this knowledge of the system. This another great example looking at errors, and how this tool is used in improvement, and you're going to be learning about this next week. The second component of quality improvement is knowledge of variation. Really a key in improvement, is to understand and collect data. And, look at how this data varies over time. And the tool we use in quality improvements are run charts and control charts. You'll be learning about this in the third week. Here's an example of a nice run chart. And you can see that as we collect the data and as we narrate it with the interventions that we're attempting to improve the care, it gives us a wonderful visual of how the care is being improved. These data charts also serve as great motivators for the frontline staff to see that what they're doing is making a difference. And that is really a key. That's a key specifically for knowledge of psychology. How do we motivate healthcare professionals to make change? Because we all know change is very difficult, and we all know that most people don't really like to make change. In this course, we will be learning about knowledge of psychology: how to get professionals to change. One example of knowledge of psychology is the Rogers Adoption model, which shows that there is sort of a normal distribution of people in how they are prompted to change. We have innovators, so there's a percent of the population who are really innovators, who really are excited to make change. This curve then moves to early adopters, then adopters. And at the end, on the tail of this normal distribution, you can see there's laggards, and so the theory demonstrates that there's just people in our population who just really won't want to change, and any effort to try to change them probably will be futile and therefore we recommend an improvement then as part of this theory of psychology to just kind of ignore the laggards and move on with the people who are really motivated to make the change. So, the last component of quality improvement is the theory of knowledge, and in this course we use the model for improvement by Langley and Nolan. In this model for improvement, we look at: what are we trying to change? And how do we know this change is going to be an improvement? And what can we do to improve the care? And then we go through the plan-do-study-act. We'll be learning more about this model then in the last weeks of the course. You make the difference in quality and safety, and through this course you will be learning the tools and strategies of quality improvement so that you can apply these into your practice and have better patient outcomes. Now I'd like for you to explore the other components of module one. One is the case study, where you'll be going over an example of a physician who was, well, frustrated with the care that he was delivering in the emergency room department. Secondly, I'd like for you to look over the application video where you're going to learn specifically how you can take these tools, and move them into practice. Thanks for your attention during module one, and we look forward to our work ahead. [MUSIC]
