Basic Concepts and Principles of QI

Learning objectives
After completing this module, learners will be able to:

• Describe the principles of quality improvement (QI)
• Understand the concept of system performance variation
• Understand the concept of robust process improvement
• Distinguish among quality assurance, quality improvement, and
quality management
• Identify key components that lead to sustainability of quality
management programs
Quality Improvement: A Refresher 1

QUESTION: What is your previous experience in QI?
A. I have never participated in a QI team in my healthcare
organization.
B. I have been a member of a QI team in my healthcare
organization focusing on HIV care
C. I have been a member of a QI team in my health focusing
on something other than HIV care
D. Both B and C
E. I have never heard of QI

What is the problem?
“Health care interventions that are known to work and save lives are
not being implemented for every patient every time. We must address
this gap between knowing and doing.”
The know-do gap – how what we

know differs from what we do
What we know What we do

Closing the “know-do” gap
Source: Project Fives Alive! 4

HEALTHQUAL model

Quality assurance vs. quality improvement

Quality assurance vs. quality improvement
Quality assurance Quality improvement
Motivation Measuring compliance with Continuously improving processes

standards to meet standards
Means Inspection (external) Measurement by participants
Attitude Required, defensive Chosen, proactive
Focus Outliers: “bad apples” Processes

Individuals Systems
Scope Medical provider Organization (facility)
Responsibility Few All

QUESTION: In which discipline did QI start?
A. Laboratory science
B. Automobile manufacturing
C. Health care
D. Statistics
E. Communication Walter Shewhart

Quality improvement in simple terms
• Understanding variation
• Systems thinking

QUESTION: Which of the following is NOT a
fundamental principle of improvement science?
A. Working in teams
B. Focusing on the customer
C. External audit
D. Systems-based thinking
E. Testing changes
W. Edwards Deming

Quality improvement principles
Fundamental concept of improvement:
“Every system is perfectly designed to achieve exactly the results it
achieves.”
Principles of improvement:
1. Understanding work in terms of processes and systems
2. Developing solutions by teams of providers and patients
3. Focusing on patient needs
4. Testing and measuring effects of change
5. Peer learning

achieves.”
5. Peer learning

Closing the “know-do” gap
Source: Project Fives Alive! 13

What is a system?
“A system is a set of interdependent elements working to

achieve a common aim.”
–Institute of Medicine
Systems thinking
Resources Activities Results

(Inputs) (Processes) (Outcomes
• People • What is done • Health services delivered
• Infrastructure • How it is done • Changes in health
behavior
• Materials
• Changes in health status
• Information • Patient satisfaction
• Technology
Source: Donabedian, A. Explorations in Quality Assessment and Monitoring Vol. 1. The Definition of Quality and Approaches to Its Assessment. Ann Arbor, MI: Health
15
Administration Press, 1980.
Systems thinking
Resources Activities Results

(Inputs) (Processes) (Outcomes
• People • What is done • Health services delivered
• Infrastructure • How it is done • Changes in health
behavior
• Materials
• Changes in health status
• Information • Patient satisfaction
• Technology

Viral Load Suppression Rate
100
90
80
70
Performance Rate (%)
60
50
40
p<0.001
30
20
10
0
Jan-09 May Sep Dec Jan-10 May Sep Dec Jan-11 May Sep Dec

QUESTION: Should we call our efforts successful?
A. Yes
B. No

100
90
80
70
60
50
40
30
20
10
0

100
90
80
70
60
50
40
Also p<0.001
30
20
10
0

100
90
80
70
60
50
40
30
20
10
0

100 Viral Load Suppression Rate
90
80
70
60
50
40
30
20
10
0
Jan-09 May Sep Dec Jan-10 May Sep Dec Jan-11 May Sep Dec Jan-12 May Sep Dec Jan-13

New Viral Load Suppression Rate
100
90
80
70
60
50
40
30
20
10

Understanding systems: root cause analysis
Definition:
“Approaches, tools, or techniques used to uncover the causes of
identified problems"
Examples:
• Brainstorming
• Fishbone (cause and effect diagram)
• Flow chart (process map)
• Five whys
• Pareto analysis

achieves.”
5. Peer learning

Why teamwork?

What is a team?
“A team is a small number of people with complementary skills
who are committed to a common purposes, common
performance goals and a common approach, and for which they
hold themselves mutually accountable.”
–Katzenbach and Smith, The Wisdom of Teams (1993)

Teams outperform individuals when…
• The task is complex
• Creativity is needed
• More efficient use of resources is required
• Fast learning is necessary
• High commitment is desirable
Source: Scholtes P, Joiner B, Streibel B. The Team Handbook. Madison, WI: Oriel Incorporated, 2003. 28
achieves.”
5. Peer learning

Dimensions of quality
Technical Quality Experiential Quality

Provider perception of Consumer perception
quality of HIV care of quality of HIV care

How to involve consumers?
• Consumer advisory board
• Focus groups
• Exit interviews
• Participation on quality teams
• Reviewing data
• Setting priorities for improvement
• Patients serving on QM Committee

achieves.”
5. Peer learning

Linking PDSAs to performance measures
Changes that
Theories/Ideas/
lead to
Best practices
improvement
Very small- Follow-up Test new Large-scale
scale test test conditions test

The Model for Improvement (PDSA)

What are we trying

to accomplish?
How will we know

that a change is an
improvement?
What change can we
make that will result in
improvement?

What are we trying to

accomplish?
How will we know

that a change is an
improvement?
What change can we
improvement?

What are we trying to

accomplish?
How will we know

that a change is an
improvement?
What change can we
improvement?

Pareto charts: the “vital few,” “80:20 rule”
Barriers to viral suppression
16 100%
Cumulative percentage
14
Frequency (#)
80%
12
10 60%
8
6 40%
4
20%
2
0 0%
Fear of initiation Mental health Lost to follow Side effects Declined ART Treatment Substance Transportation
up failure abuse
Vital few
PROBLEM: What is the problem or gap we’ve identified in our system? PDSA
ACT PLAN
• Do we adopt, adapt, or • What change are we testing?
abandon the change? • Who are we testing the change on?
• What needs to be modified • When are we testing?
before the next PDSA cycle? • Where are we testing?
• What should the next PDSA • What data do we need to collect?
AIM: cycle test? • Who will collect the data? MEASUREMENT:
What process or • When will the data be collected? How will we know
outcome are we • Where will the data be collected? that a change will
trying to improve? result in
STUDY DO
improvement?
• Analyze all data, and summarize lessons • What was done to implement the change?
learned. • Was the change implemented as planned?
• Did the change result in measurable • What where the barriers to implementation?
improvement? • Was the change acceptable to staff and
patients?

PROBLEM: Incorrect contact information in patient care booklet, leading to difficulties physically or telephonically
tracing loss-to-follow-up clients. PDSA 1
ACT PLAN
• The change was adapted. What: Update contact information in 70
• The next PDSA will enlist 2 patient care booklets
additional CHWs to assist in Who: 1 community health worker will
updating client contact update client contact information MEASUREMENT:
AIM: information, and outcomes Where: Clinic registration area • Number of
We aim to improve will be re-measured When: One week, March 1-7, 2017 patient care
loss-to-follow-up booklets with
rates by updating updated contact
contact information information
STUDY DO
and tracing LTFU • Proportion of
clients • Between March 1-7, 2017, only 3 (4%) of • 1 CHW from Project HOPE was assigned to active caseload
the expected 70 patient care booklets update contact information
that is LTFU
were updated • Barriers to implementation included low
• Rates of loss to follow-up pending in April rapport between CHW and some clients; poor
documentation of updated information;
existing workload of CHW

PDSA 1
120%
Target: 70
57%
updated PCBs
4%
1 CHW to Follow-up Test new Large-scale

update conditions
test test
contact
details

ACT PLAN
• The change was adapted. What: Update contact information in 70
• The next PDSA will enlist the patient care booklets
entire clinic team to assist in Who: 3 community health workers will
updating client contact update client contact information MEASUREMENT:
AIM: information, and outcomes Where: Clinic registration area • Number of
We aim to improve will be re-measured When: One week, March 8-14, 2017 patient care
STUDY DO
clients • Between March 8-14, 2017, only 40 (57%) • 3 CHWs from Project HOPE and TCE were active caseload
of the expected 70 patient care booklets assigned to update contact information
that is LTFU
were updated • Barriers to implementation included low
• Rates of loss to follow-up pending in April rapport between CHWs and some clients; poor
documentation of updated
information; some clients providing
false information

PDSA 2
120%
Target: 70
57% updated PCBs
4%
1 CHW to 3 CHWs to Test new Large-scale

update update conditions test
contact contact
details details

ACT PLAN
• The change was adopted What: Update contact information in 70
• The change was patient care booklets
implemented and an SOP Who: Entire clinic team will update client
was drafted for updating of contact information MEASUREMENT:
AIM: patient contact information Where: Clinic registration area • Number of
We aim to improve When: One week, March 15-21, 2017 patient care
STUDY DO
clients • Between March 15-21, 2017, 90 (129%) of • Entire clinic team was assigned to update active caseload
the expected 70 patient care booklets contact information
that is LTFU
were updated
• Rates of loss to follow-up pending in April

PDSA 3
120%
Target achieved!
Target: 70
57% updated PCBs
4%
1 CHW to 3 CHWs to Entire clinic team SOP drafted, change

Large-scale
adopted into routine
update update to update contact test
practice
contact contact details
details details

Change adopted Continue monitoring to ensure
sustained improvement
120%
Target: 70
57% updated PCBs
4%
1 CHW to 3 CHWs to Entire clinic team SOP drafted, change

Large-scale
adopted into routine
update update to update contact test
practice
contact contact details
details details

achieves.”
5. Peer learning

Peer learning
• Accelerates spread of ideas and
proven implementation
strategies, leading to great
impact
• Cultivates and strengthens
communities of practice for
ongoing peer learning

QI project components
• Aim Statement – what do we aim to improve?
• QI Team—who is responsible for QI activities?
• Measurement description—what are we measuring?
• Baseline data—how well does our current system perform?
• Process evaluation—what is the current design of our system?
• Root cause analysis—what are the gaps in our system?
• Action plan—what changes can we make to improve these gaps?
• Evaluation—were the changes associated with improvement?

QI project reporting template
Program/Organization: Process Evaluation
Flow Charts (attach)
Project: Define high-level process steps for QI topic
Initial process completed? Yes___ No ____
Aim Statement: Revised process completed? Yes___ No ____
Root Cause Analysis

Problem Statement: Fishbone Diagram (attach)
Ask Why at least 5 times for each cause
Circle the root cause
QI Team Rank the causes by how often they happen and
Team Leader: whether you have the ability to impact the cause
Team Members
Gap identified:
Measurement Description (indicator definitions):
Follow-up data:
Baseline Data (indicator performance results): What is your plan?

Components of robust process improvement
1. Identifying root causes of a
problem
2. Measuring the importance of
each cause
3. Proving the effectiveness of
the solutions
4. Deploying programs to ensure
sustainability of the
improvements Source: NHS Foundation Trust
Source: Chassin M, Loeb J. “The ongoing quality improvement journey: next stop, high reliability.
52
Health Aff. 2011;30:4.
Pareto charts: the “vital few,” “80:20 rule”
Barriers to viral suppression
16 100%
Cumulative percentage
14
Frequency (#)
80%
12
10 60%
8
6 40%
4
20%
2
0 0%
Fear of initiation Mental health Lost to follow Side effects Declined ART Treatment Substance Transportation
up failure abuse
Vital few
Quality management
Definition:
“Quality management is the act of overseeing all activities and tasks needed to
maintain a desired level of excellence. This includes the determination of
a quality policy, creating and implementing quality planning and assurance, and
quality control and quality improvement.”
Sustainability:
Sustained improvement activities require attention to the organizational quality
management program in which structures, processes, and functions support
measurement and improvement activities.

Domains of quality management
• Organizational structures for improvement
• Planning
• Leadership
• Patient & community involvement
• Data systems that measure performance
• Linking process measures to outcomes
• Knowledge management/communication
• Staff capacity-building: training and coaching
• Peer learning
• Evaluation

Resources
HEALTHQUAL
(www.healthqual.ucsf.edu/)
The Healthcare Accreditation Institute

(https://www.ha.or.th/)
Healthcare Improvement Scotland

(http://www.healthcareimprovementscotland.org/)
Institute for Healthcare Improvement

(http://www.ihi.org/)
The Health Foundation

(https://www.health.org.uk/theme/quality-improvement)
Agency for Healthcare Research and Quality

(https://www.ahrq.gov/)
New York State Department of Health AIDS Institute HIV

Quality Quality AofRefresher
Improvement: Care Program 56
Questions?

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Learning objectives

After completing this module, learners will be able to:

Quality Improvement: A Refresher 1

Quality Improvement: A Refresher 2

The know-do gap – how what we

Quality Improvement: A Refresher 3

Source: Project Fives Alive! 4

Quality Improvement: A Refresher 5

Quality Improvement: A Refresher 6

Motivation Measuring compliance with Continuously improving processes

Attitude Required, defensive Chosen, proactive

Focus Outliers: “bad apples” Processes

Responsibility Few All

Quality Improvement: A Refresher 7

Quality Improvement: A Refresher 8

Quality Improvement: A Refresher 9

Quality Improvement: A Refresher 10

Quality Improvement: A Refresher 11

Quality Improvement: A Refresher 12

Source: Project Fives Alive! 13

“A system is a set of interdependent elements working to

Resources Activities Results

Resources Activities Results

Quality Improvement: A Refresher 16

Quality Improvement: A Refresher 17

Quality Improvement: A Refresher 18

Quality Improvement: A Refresher 19

Quality Improvement: A Refresher 20

Quality Improvement: A Refresher 21

Quality Improvement: A Refresher 22

Quality Improvement: A Refresher 23

Quality Improvement: A Refresher 24

Quality Improvement: A Refresher 25

Quality Improvement: A Refresher 26

Quality Improvement: A Refresher 27

Quality Improvement: A Refresher 30

Technical Quality Experiential Quality

Quality Improvement: A Refresher 31

Quality Improvement: A Refresher 32

Quality Improvement: A Refresher 33

Quality Improvement: A Refresher 34

Quality Improvement: A Refresher 35

What are we trying

How will we know

Quality Improvement: A Refresher 36

What are we trying to

How will we know

Quality Improvement: A Refresher 37

What are we trying to

How will we know

Quality Improvement: A Refresher 38

Quality Improvement: A Refresher 40

Quality Improvement: A Refresher 41

1 CHW to Follow-up Test new Large-scale

Quality Improvement: A Refresher 42

Quality Improvement: A Refresher 43

1 CHW to 3 CHWs to Test new Large-scale

Quality Improvement: A Refresher 44

Quality Improvement: A Refresher 45

1 CHW to 3 CHWs to Entire clinic team SOP drafted, change

Quality Improvement: A Refresher 46

1 CHW to 3 CHWs to Entire clinic team SOP drafted, change

Quality Improvement: A Refresher 47