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ISQua Fellowship Forum

Using Quality Improvement (QI) Tools 

Phil Hassen, President of the Canadian Network for International Surgery; ISQua Fellowship Forum Moderator.


April 2017

Providing excellence in patient care and improving quality and safety involves using systematic methods and quality improvement tools to gain knowledge, get at the root cause of problems and to implement a plan for change.  It is the purpose of this Forum to describe at a relatively high level quality improvement tools and methods within the context of a well-established framework for improving quality and safety. The importance of understanding the needs and expectations of patients and families, and engaging teams when using tools and methods is essential and must be considered when utilizing tools and methods. 

Framework for Improvement
Perhaps one of the most effective and best understood frameworks for quality improvement is the Plan, Do, Study and Act cycle (PDSA). This framework can be applied in many different situations and has been used widely by many health care organizations in many countries to improve quality and safety processes and outcomes. 

One starts the PDSA improvement cycle by answering three questions:

1. What are you trying to accomplish? - Be specific. 

2. How will you know change is an improvement? - Identify measures. 

3. What changes can you make that may result in an improvement? Identify ideas and then use the PDSA cycle. 

Quality Improvement Tools and Methods

A number of different tools and methods are available to collect, analyze and organize data. It can be helpful to group quality improvement tools according those that involve numbers, data collection and their analyses, and those that describe processes or are helpful in generating ideas and creating a plan. Some of the most common and useful tools are outlined below. 

Using Tools with Quality Improvement Teams: Tips for Success
• Engage people working in the process and who have knowledge to make improvement.
• Understand that most processes involve more than one work unit/area/department and problems often arise at the hand-off points between units.
• Emphasize that improvement initiatives focus on processes and not on people.
• Keep team membership flexible, especially if the improvement goal is not well defined at first.
• Use a small scale improvement as an initial learning and development experience so that as you look to solve and improve more complex care, safety and service issues, you better understand the PDSA cycle.
• Start the improvement by getting a “bird’s eye” view of the processes by using a high level flow diagram especially when the team is forming.  You will likely notice that there are different views/perspectives on how the process currently works.

In closing, this overview is intended to assist you with gaining some knowledge about an ongoing cycle for improvement (PDSA) and tools and methods. When this framework is used systematically your efforts with improving care, safety, services and processes will be accelerated. 
Key references highlighted in this Forum are available on-line and should be studied as a supplement to this introduction. With practice you will increase your ability for improving care and safety for patients. You will see marked improvements as you and your teams become skilled in the use of these quality improvement tools.

• Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009. 
• The Plan-Do-Study-Act (PDSA) cycle was originally developed by Walter A. Shewhart.. W. Edwards Deming modified Shewhart's cycle. See Deming WE. The New Economics for Industry, Government, and Education. Cambridge, MA: The MIT Press; 2000.

Questions for Discussion
1. What tools and methods have you used to better understand a quality/safety issue?
2. Based on your experience what are some of the challenges facing you with the use of quality improvement tools and methods?
3. If you have formed a quality improvement team what departments or services were involved in or affected by this quality issue? (List)
4. What are your next steps to better utilize quality improvement tools and methods?
5. Given your hospital/health care service, list two or three areas needing improvement. For one improvement, briefly explain what you are trying to accomplish and how you can apply the PDSA cycle?



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