The Health Care Data Guide

Learning from Data for Improvement

Lloyd P. Provost, Sandra K. Murray

• Publisher: Jossey-Bass
• Year: 2011
• ISBN:
  9781118085882
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

The Health Care Data Guide is designed to help students and professionals build a skill set specific to using data for improvement of health care processes and systems. Even experienced data users will find valuable resources among the tools and cases that enrich The Health Care Data Guide. Practical and step-by-step, this book spotlights statistical process control (SPC) and develops a philosophy, a strategy, and a set of methods for ongoing improvement to yield better outcomes.

Provost and Murray reveal how to put SPC into practice for a wide range of applications including evaluating current process performance, searching for ideas for and determining evidence of improvement, and tracking and documenting sustainability of improvement. A comprehensive overview of graphical methods in SPC includes Shewhart charts, run charts, frequency plots, Pareto analysis, and scatter diagrams. Other topics include stratification and rational sub-grouping of data and methods to help predict performance of processes.

Illustrative examples and case studies encourage users to evaluate their knowledge and skills interactively and provide opportunity to develop additional skills and confidence in displaying and interpreting data.

Companion Web site: www.josseybass.com/go/provost

PART I

USING DATA FOR IMPROVEMENT

CHAPTER 1

IMPROVEMENT METHODOLOGY

This book is about using data to improve health care1 and this chapter, a summary of The Improvement Guide,2 describes approaches and methods used to make improvements. It provides a backdrop, setting the stage for understanding and contextualizing the rest of the book. This chapter will:

• Describe the Model for Improvement
• Illustrate use of the Plan, Do, Study, Act Cycle for testing and implementing changes
• Introduce graphical methods to learn from data
• Describe a typical health care improvement project
• Enumerate the methods and tools used to support improvement

How do you make improvements? Historically people have used a trial-and-error approach to improving all aspects of their lives. Typically an idea for an improvement (a change) comes to someone. These ideas are often reactions to problems or difficulties that we all face in life and in our work. So we make the change and then see whether the situation improves. Sometimes we also check to see if anyone complains or if something else stops working because of the change that we made. Because of its sporadic track record on real, sustainable improvement, this natural trial-and-error approach has often been criticized as “jumping to solutions” without sufficient study.

As a response to this criticism, some improvement specialists have turned to extensive study of the problem before a change or trial is attempted. Sometimes this approach leads to a better track record on making sustained improvements, but more often it can lead to never actually making changes. The person with the problem gets bogged down in the study, “paralysis by analysis” sets in, or other problems begin to take priority. Many health care professionals are trained in research methods with strict protocols, rigid data requirements, and large sample sizes. When they begin work on improvement projects, they naturally bring this training to the project. How do we obtain a balance between the trial-and-error approach and extensive study that may never lead to action? How do we find the balance between the goals of formal clinical research and the natural learning and improvement from daily work in health care?

This chapter presents a Model for Improvement3 that attempts to provide that balance. The model provides a framework for developing, testing, and implementing changes that lead to improvement. The model can be applied to improving aspects of one’s personal endeavors, as well as the improvement of processes, products, and services in health care organizations. The model attempts to balance the desire and rewards from taking action with the wisdom of careful study before taking action. The use of data in this book will frequently be connected to an individual or an improvement team that is using the Model for Improvement to guide their learning and execution.

FUNDAMENTAL QUESTIONS FOR IMPROVEMENT

The Model for Improvement is based on three fundamental 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?

The model is also based on a “cycle” for learning and improvement. Variants of this improvement cycle have been called the Shewhart Cycle, Deming Cycle, and PDSA Cycle. The cycle promotes a trial-and-learning approach to improvement efforts. The cycle is used for learning, to develop changes, to test changes, and to implement changes. Figure 1.1 contains a diagram of the basic form of the model.

FIGURE 1.1 The Model for Improvement

Why are we promoting the use of this particular approach to improvement? Our experience with the Model for Improvement since its development in the 1980s shows that it:

• Is useful for both process and product improvement
• Is applicable to all types of organizations
• Is applicable to all groups and levels in an organization
• Facilitates the use of teamwork to make improvements
• Provides a framework for the application of statistical tools and methods
• Encourages planning to be based on theory
• Emphasizes and encourages the iterative learning process
• Provides a way to empower people in the organization to take action

This framework is compared to other frameworks used in quality improvement (such as Six Sigma’s DMAIC) in Appendix C of The Improvement Guide.4 The use of the Model for Improvement begins with trying to answer the three basic questions.

What Are We Trying to Accomplish?

Before starting to develop any activities, or test or implement changes, participants and other stakeholders in the improvement effort need to agree on what is to be accomplished. The use of a well-written aim statement can be an effective tool for answering the first question in the Model for Improvement. If there is not a common understanding between people who are depending on the aim statement for guidance, then individuals will naturally try to fill the void of understanding with their personal view of what is to be accomplished. These well-intentioned efforts usually lead to misunderstandings—during team meetings and other activities—that will not achieve the intended accomplishments, ultimately resulting in wasted time, resources, and frustration for everyone involved. The written aim can be a formal document (sometimes called a charter) from a hospital’s strategic planning process or it can be a statement written on the whiteboard by a group of nurses and physicians brainstorming more effective care of their patients.

Why take the time to develop an aim statement for an improvement effort? A statement of the aim:

• Provides leaders a mechanism to think through all aspects of the proposed effort
• Aids in selection of the team to make the improvements
• Reduces variation in activities from the original purpose
• Helps in the selection of particular processes or products for study
• Empowers individuals to make cha...