UCLA FIELDING SCHOOL OF PUBLIC HEALTH DEPARTMENT OF HEALTH POLICY AND MANAGEMENT

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1 UCLA FIELDING SCHOOL OF PUBLIC HEALTH DEPARTMENT OF HEALTH POLICY AND MANAGEMENT HPM 215A Quality Improvement and Performance Excellence in Healthcare Organizations Spring 2016 Instructor: Moira Inkelas, PhD, MPH Office: CHS B Phone: (310) Mail: Class Time: day and day 1:00 2:50 PM Classroom: CHS Office Hours: By appointment; please INTRODUCTION Quality improvement (QI) methods have been adapted to health care after successful use in other industries. These methods alter structures and processes of health care to improve productivity and health care outcomes. The demand for quality improvement is increasing with pressures of cost containment and competition. Preparation for population health policy and management professions includes understanding basic quality improvement methods; having the capability to undertake quality improvement in health care delivery organizations; and understanding the value of and essential components of effective improvements are. An appreciation of how to improve the quality of health care systems is essential for health and public health professionals in policy, administration, and practice. The course focuses on developing skills to encourage and manage improvement in the delivery of health care, to increase the effectiveness, efficiency, performance, and quality of health care. The course will also offer population and public health applications of quality and process improvement. TEXTBOOK AND READINGS: The required textbook is: Langley G, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP, The Improvement Guide: A Practical Guide to Enhancing Organizational Performance. Second edition. San Francisco, CA: Jossey-Bass, The course will include supplemental readings and web materials that will be posted on CCLE. COURSE METHODOLOGY The quality improvement fundamentals, conceptual frameworks, organizational context, case studies and applications will be presented through lectures, discussion, group projects, visiting speakers, and readings. Theory and content will be covered in lectures, readings, class discussions, on-line tutorials, individual and group projects, case analyses, and presentations. This course is modeled from the improvement principle of learning by doing. Most sessions will include cases and interactive activities to help students master the methods by using them. 1

2 GRADING Grades will be based on class participation and performance on the following assignments: Activity Points Team or individual Date due Participation and Attendance 10 Individual Paper: QI External Reporting Organizations 10 Team day, April 28 IHI Open School Modules points each) 20 Individual Per syllabus Case Competition 20 Team Per sign-up Report: UCLA CICARE Experience 15 Individual day, May 24 Paper: Quality Project 25 Team Monday, June 6 TOTAL 100 The four Institute for Healthcare Improvement (IHI) Open School modules should be completed by the dates listed in the syllabus. Completion is on the honor system; there is no need to submit a certificate of completion. The modules are free for students and can be found at: Late assignments will be graded down 5% each day that the assignment is late. This encourages timely submission of assignments so that feedback can be provided in a timely way to everyone in the class. GENERAL REQUIREMENTS OF WRITTEN ASSIGNMENTS The written assignments are an opportunity for you to demonstrate your familiar with, and apply what you are learning from the readings, theory, concepts and tools covered in the course. In problem-solving assignments, you are encouraged to offer creative but realistic solutions. You should use frameworks and content from the lectures and readings. Written assignments should refer to empirical evidence and material from class and readings. You are encouraged to include and integrate concepts from other classes and personally researched readings on evidence and studies, as well. It is important to use excellent written English, including grammar, syntax, and spelling. The grading will take quality and clarity of the written communication into account. All written, narrative assignments should use the following formatting: Double spaced; 12 pt font; 1 margins. Please number the pages, and use a standard format for references, which can be footnotes or endnotes. Any consistent, complete referencing format is acceptable. We will use TurnItIn on My UCLA for submitting assignments. Please post the assignment electronically to TurnItIn on the due date. For group projects, only one team member needs to submit the electronic document. Turnitin will help identify issues with citation, paraphrasing, and crediting others appropriately. ACADEMIC INTEGRITY University guidelines and policy for academic integrity will be enforced. Please see the policy found at the following link for the policy provisions: ATTENDANCE and CLASS PARTICIPATION POLICY Class attendance is an important and necessary element of the class participation grade. Please notify the instructor if you will be absent. In recognition of the value of participation, more than two absences will result in a reduction of your class participation grade by 20%. 2

3 Please limit use of laptops and tablet devices for taking notes during the lecture. Every effort will be made to have the lecture slides posted prior to the lecture session. Please arrive to class on time so that you do not disturb the speaker or your classmates. There will be a number of interactive activities and group exercises in class, since this is the best way to learn many of the tools that will be covered in the class, so it is important to start together on time. All students are expected to complete the reading before coming to class, ask relevant questions, and contribute to the group discussions. Much learning comes from the class discussions and group discussions. Participation involves cogent, thoughtful and considered comments that contribute to furthering understanding and knowledge of the subject matter. This is not a matter of counting how much you say, but the quality of your contribution as well. Session Objectives Required Readings Assignments Due 1 3/29 Introductions. Syllabus review. Review of class activities. Introduction to quality improvement. Berwick, The Moral Test 2 3/31 3 4/5 4 4/7 5 4/12 6 4/14 7 4/19 8 4/21 Model for Improvement I: Developing an aim, SMART aim, PDSA cycles Tools for Improvement I: Flow Diagrams and Process Mapping Tools for Improvement II: Key driver diagram, developing changes Tools for Improvement IV: Root Cause Analysis Improvement Guide, Chapters 1, 2, 3, 4, 5 Case: Medication error Improvement Guide: Chapter 6, Appendix A Case: Carla s story Reliability IHI Innovation Series Improving the reliability of health care Spear, Fixing healthcare from the inside, today Human centered design Brown & Martin, Design for action, Harvard Business Review, Sept 2015 Mindset clips (7) at Tools for Improvement V: Improvement Guide: Chapter 7 Systems, variation, measures, Pareto charts, run charts Sign-ups for CICARE Rounds Sign-ups for Case Competition Date DUE: IHI Open School Module PS 103: Teamwork and Communication DUE: IHI Open School Web Module PS 104: Root Cause and Systems Analysis DUE: IHI Open School Module QI 106: Mastering PDSA Cycles and Run Charts 3

4 Session Objectives Required Readings Assignments Due 9 4/ / /3 12 5/5 13 5/ / / / / / / /2 Patient Safety and Medical Errors Guest: Clint Coil, MD, MPH, Chief Quality Officer, LA County Harbor-UCLA Med Center Managing Quality Improvement Teams and Processes in Organizations Guest: Jennifer Kozakowski, MN, MPH Improvement in UCLA Health Guest: Robert Martin, Performance Excellence, UCLA Health System Using Data to Drive Performance Guest: Bob Blair, Medical Group Administrator, SCPMG South Bay Organizing Improvement Projects (A3), and Implementation Case Competition 1 Malcolm Baldrige National Quality Award Case Competition 2 Human element of change Case Competition 3 Learning culture Case Competition 4 Quality improvement in community systems Health information systems: Applications in performance management Guest: Jean Balgrosky, RHIA, PhD Scale-up and spread of quality and process Improvement A3 examples CICARE Wrap-Up Amalberti et al, Five System Barriers to Achieving Ultrasafe Health Care IOM To Err is Human, Executive Summary IOM Crossing the Quality Chasm, Executive Summary Case 1 (for 5/12) posted on CCLE Improvement Guide, Appendix B IHI Going Lean Case 2 (for 5/17) posted on CCLE Case 3 (for 5/19) posted on CCLE Improvement Guide, Chapter 8 Case 4 (for 5/24) posted on CCLE Improvement Guide, Chapter 13 Baldrige application excerpt: Southcentral Foundation (2011) Baldrige press release (2011) Improvement Guide, Chapter 14 Berwick, Escape Fire Miller et al (2010) Tallia et al (2006) Improvement Guide, Chapter 11 Improvement Guide, Chapter 9 Atul Gawande, Slow Ideas DUE: IHI Open School Web-Module PS 102: Human Factors and Safety Due: Quality Reporting Organizations paper Due: CICARE Report 4

5 Public Reporting by External Quality Organizations 1. Select an organization from those below (1 reporting organization per team). Each team should have 4 people. 2. Present findings in a written report. 3. The paper should address the following questions. a. Investigate the organization s effort to improve quality. b. Who are the sponsors, and the audience? c. Identify the origin, mission and goals of the reporting organization. d. What quality improvement concepts are used by the organization? If they are not used, how might they be? e. What measures are used? f. What data sources are used? g. What are the sources of/reasons for resistance, and/or acceptance, to the work of the reporting organization? What stakeholder groups are behind the resistance and/or acceptance that you found? h. What burden does the work of the reporting organizations place on entities whose information is reported? i. Assess the effectiveness, impact and potential impact of the reporting organization s work. Reporting Organization: Select one from the following organizations: Agency for Healthcare Research and Quality ( CalQualityCare ( Hospital Compare (CMS) ( Hospital Mortality reports on Medicare ( The Joint Commission ( Leapfrog Group ( National Quality Forum (NQF) ( National Committee for Quality Assurance (NCQA) ( WHO ranking of health systems US News & World Report ( Why Not the Best ( One of your choosing (please check with the instructor before choosing an alternative reporting organization). 4. Written Report a. 5 double-spaced pages b. Please answer the questions in narrative form. 5

6 CICARE/PCAT Report Students will attend Peer CICARE Assessment Tool (PCAT) rounds at Ronald Reagan UCLA (RRUCLA) Medical Center or Santa Monica UCLA Medical Center. The schedule and details about the PCAT rounds are posted at cicare.uclahealth.org. After attending the CICARE rounds, please prepare a two page written review of the rounds to include: A description of the activity A brief analysis of the rounds relative to the readings, i.e. how did the rounds relate to the concepts from the class readings and learning. You may reference any relevant literature from class readings. This is an experiential narrative so the emphasis should be on what you experienced and learned, rather than on citing literature. Where to go: Location at RRUCLA Medical Center: Tamkin Auditorium B-130 Location Santa Monica UCLA Medical Center: Auditorium of the hospital, 1 st floor Guidelines: You will receive information for the PCAT rounds contact. Bring your UCLA identification card or badge. Please wear appropriate business attire. You will be visiting patient rooms, and touring with hospital management. Please check in with the information desk before going to the staging area so you can receive a visitor name tag. Please arrive 10 minutes early to receive your assignment. 6

7 Case Competition Assignment The case completion gives students the opportunity to apply quality improvement knowledge and skills to a specific case. Students will work in teams to analyze a case study: what went wrong, why it went wrong, and how the system might be changed to prevent similar problem from occurring in the future. Student teams (4 persons per team) will create a presentation explaining their findings. Several different cases will be used for this assignment. Each team will present on one case. Several teams will be assigned to each case, and will present in the same class session. Student teams will sign up for a presentation date. The case will be posted on CCLE two (2) weeks prior to the presentation date. All students in the course should read the case before the presentation date. The student teams will: Analyze the case using concepts and skills related to quality improvement, patient safety, and other disciplines relevant to system-level improvement including root cause analysis and process mapping to describe the problem; Develop a specific plan to improve the gap in the system of care, including defining key measures and proposing changes, with an emphasis on process changes (not new programs, new purchases, etc.) Identify likely challenges to planned improvements, and how these can be mitigated. The product of this assignment is an in-class presentation. The grading rubric for the presentation (see below) shows what is expected. Presentations should be slides (no more than 15) including the title slide. Please bring one printed copy of the Powerpoint presentation to class. Presentations will be 8-10 minutes in length (maximum of 10 minutes), allowing about 5 minutes for Q&A. Each team member should participate in the oral presentation. Grading rubric: Clear application of QI and performance improvement concepts Statement of the problem Flow diagram (describing what happened) Root cause analysis (fishbone diagram) Ideal process flow (describing the ideal process) Quality of the proposed improvement plan, proposed changes, analysis and logic behind the plan Clearly stated challenges to the proposed improvements Appropriate metrics to show if the proposed changes are leading to the desired improvement (including numerators, denominators, periodicity) At least one specific PDSA cycle/planned test(s) of change Overall content of the powerpoint: graphics demonstrate knowledge and detailed analytical work, quality of PowerPoint slides (not too busy, yet adequate; slide leads to discussion; not too much detail) Organization of presentation including evidence of consistency and integration across slides and topics Quality of public speaking All team members contribute to the oral presentation 7

8 Quality Project Paper The Institute of Medicine (IoM) in To Err is Human described the impact of medical errors in the U.S. health system. This led to a range of initiatives to improve healthcare quality. The follow-up report, Crossing The Quality Chasm, offered a proposal with six specific aims for a 21 st Century health care system. This report offers ten rules with which to achieve those aims. Achieving those aims is a formidable challenge. Organizations are challenged to create a culture that incorporates these new rules into health care delivery. The goal of this assignment is to apply process improvement strategies to enhance organizational performance related to one of the 10 basic improvement rules identified in Crossing The Quality Chasm. This is a group project, with four (4) people in each team. Your team will identify an organization that will be the focus of your project. You may choose an organization you are familiar with, or the instructor can provide suggestions of organizations if needed. You will select one of the ten rules that is relevant to the goals of the organization that you choose. You will analyze what is underway in the organization and propose recommendations for strengthening this rule within the organization, using features of process improvement. The project includes the following: Identify the organization that is/will be striving to implement the rule; Describe the rule that your team is addressing and why it was selected (i.e., why is it of interest to the organization); Interview at least two or three individuals at that organization regarding the rule, to identify what is being done at that organization to incorporate the rule into management and practice. Please interview people who have different roles in the organization, including at least one person in a management role in the organization, and at least one person involved in direct patient care. Develop recommendations for the implementation of the selected rule, based on what you learned about the rule and the organization. Address such issues as the types of organizational change that would have to occur such as organizational culture, formation of a team, etc. Determine how the organization would evaluate the extent to which it has effectively implemented the rule, including what kinds of indicators will be used to determine if the organization is improving. This paper should be a maximum of 10 double-spaced pages. There should also be a one-page executive summary. You may include an additional page of citations. 8

9 LEARNING OBJECTIVES: What you will learn in this course Understand the principles and practice of quality measurement, quality improvement, and process redesign in healthcare Know and be familiar with skills needed to make specific quality improvement changes in organizations Identify and evaluate selected core processes and operations of health care organizations Apply a systems framework to the evaluation of health delivery organizations. Apply organizational problem solving tools, including root cause analysis, Lean, Pareto analysis, PDSA, and other methods to assess and improve health care organization operations Public Health Competencies (FSPH MPH) E.7 Apply quality & performance improvement concepts K1.12 Understand quality of care, patient safety, and other performance indicators in the context of the U.S. and international health systems. How you will be evaluated/assessed QI external reporting organizations paper IHI open school modules E.7 Apply quality & performance improvement concepts Quality project paper IHI open school modules E.7 Apply quality & performance improvement concepts K2.2 Organization Development and Change: Recognize the need to change; determine what and how to change; and manage and lead the change process to improve organizational effectiveness. K2.5 Information Management: Understand the use of electronic clinical and management information systems and decision support tools. E.8 Apply systems thinking to resolve organizational problems; K2.8 and L2.2 Systems Thinking: Recognizes system level properties that result from dynamic interactions K3.2 and L3.5 Identifies and analyzes problems, potential solutions and best practices to determine appropriate courses of action. E.1 Apply epidemiologic and statistical reasoning and methods to address, analyze, and solve problems in public health E.7 Apply quality & performance improvement concepts E.8 Apply systems thinking to resolve organizational problems K2.11 and L2.5 Quality and Performance Management: Understands and uses methodologies to assess, improve and monitor organizational quality K3.2 and L3.5 Identifies and analyzes problems, potential solutions and best practices to determine appropriate courses of action. K3.11 and L3.14 Utilizes creative and innovative thinking to arrive at solutions to critical issues, or to adopt previous solutions in new ways K3.12 and L3.15 Seeks to understand more deeply by searching for the root of issues, asking penetrating questions, uncovering complexity and going beyond routine questions. K3.16 Achieves familiarity with use of data to conduct needs analysis, market assessment, Quality project paper QI external reporting organizations paper CICARE IOM Quality Chasm paper CICARE report Quality project Participation in class discussions and activities CICARE report