 There are a few, there are some changes that I wanted to make in the, in the, in the course you promote for residents, but this topic still applies, so they can, they can present, they can talk at the end of this. Do you want the lights on or lights off? For us it's good for you. As long as nobody falls asleep on me quite yet, I am good. It is okay to me, for me. I am Luca, I can't remember if I met any of you last time, I was here about a year ago. I am a value engineer that reports through hospital and clinics, so I had, but also I work with the School of Medicine and various other colleges, both with the graduate medical education program as well as the undergraduate, undergraduate education. So I've had the pleasure and the opportunity to work with learners of various experience, primarily in teaching aspects of quality improvement, value as well as cultural transformation, etc. My background is that I have been assisting, learning with other people for the last 10 years in healthcare. I spent five years at Intermountain Healthcare where we developed what they now call the continuous improvement framework. And then I came here to work with the academic and research enterprise. I actually, and I didn't mention, but I also work with the CCTS and the tri-innovation network in assisting researchers and removing barriers to participate in research as well. I was thinking about it, usually my approach is for this one-hour sessions, which I don't mind, but like I said, there's a lot of information and I end up talking a lot because I feel like I have to convey this information, but ultimately because then I have this naive belief that if people have questions, they can always reach me later and I can answer them, etc. Sometimes people don't have time either, though. Still, there is some information that is going to be conveyed to you, some of it is going to be familiar, some others is going to be new to you. I would like to challenge you to at least have one big idea. And what I mean for big idea is there's a lot, at least capture one thing, one concept, one principle, one tool, one idea of how you can use, you can take all this all in and help you in your practice. And I could even make it broader, I could say, I don't want to be like, how can this information help you in your life because as you're going to see, you're already doing these things, this is nothing new. It's how I'm packaging it that is going to be sounding like, hopefully it's going to be like, that's pretty cool. But one big idea, one concept that you're going to take out, take away with you, that can help you with your current job. Quality improvement. You can read this slide, but I'm going to ask you anyways. You've heard it, what does quality improvement means to you? I like it. Yeah, doing something, something better. Anything else? Sometimes to get better outcomes. Are we going to simply get better outcomes? Right. Is the focus of quality improvement always... It's not a trick question, I swear. Is the focus of quality improvement always to improve an outcome? Because ultimately it is. But sometimes you can't quite get to the outcome right away. You have to focus on other things. I briefly mentioned them here. There are outcome metrics and there are process metrics. The focus of your quality improvement project, let's use that term for once, it may actually be to just focus on those process metrics. Because the outcome is just too big. You can't focus on that quite right away. Quality improvement. This slide also mentions something else, the word systematic. Can you do quality improvement without actually thinking things through? It won't be very good. It will work. I don't want to say you can get lucky. But it does happen. You can just implement a change without a system, without a method, and you just may get lucky. And that's probably solved. There is this... Another challenge that I have is that the term quality improvement to me is somewhat diminishing. I use the term process improvement for a broader reason. Because quality is one aspect of what we're trying to achieve. Improving quality is one aspect of what we're trying to achieve. I want to show you the value of the question in a moment. But ultimately what creates quality, what creates cost, what creates service is driven by processes. What you do every day, coming to work, scrubbing in, operating on the patient, checking on the patient, running on the patient, those are all processes. And improving them is really what we're talking about in here. And I like that. But what quality improvement should be? Well, quality improvement should be your use to making the system safer, more timely, provide effective and efficient outcomes. And then equitable should be cost-effective. And then patient-centered. This is my... I used to have 10 slides over what quality improvement was and what lean was... Well, what is lean? What is Six Sigma was? It is what I'm going to give you now. Because I find that this is... It's pretty comprehensive for the purpose of what you're trying to do. And what you're trying to do is make sense of this. Have you seen this before? What do we mean by value equal quality plus service under cost? What it... Is this pretty unique to the University of Utah? It's not. There are different variations of this equation captured from different organizations. We add... Actually, the main... The only difference is that we add the service component other organizations leave it out. To us, it's important because we made a big deal out of it. And it is a big deal. And we're very good at it. So we feel that including the service as part of what our value outcome is makes sense. So we define value being equal quality plus service under cost. How do you define value? Yes, I'm going to try to make you talk for the next hour. Because this is helpful. It's about conversation. Is value different for you than this framework, this equation? Right. What's your name? Brad. Brad. Now, this is applying healthcare too. Yeah, I think so. Your patients come in they should be able to see you and be treated by all your staff and with high quality care and with good manners, bad side manners treat nicely, and then pay as little as possible. What does quality mean though? What's a good quality outcome? And who defines what that is? Do you, the patient, the nurses? Sometimes it depends. Sometimes we have projects that are, that also deal more, I guess, satisfaction of the residents for their learning experience. And then one thing that I would add to cost is that value should also be timely. But time is money, so I guess it's like time is cash. But I feel like a lot of the processes that we try to address in quality improvement is timeliness. If something's not efficient or the workflow has a problem, then we try to increase the efficiency or effectiveness in a timely fashion. I like what you said and you actually used another word. You talk to us about timeliness and importance of the processes from the point of view of the residents. Value according to who? There is another piece of this equation that I've not mentioned yet, which but use this. Who defines what the value is? Which defines what is it we're working on? Is it a resident? Is it a provider? Is it a patient? Is it Luca? I wish you could decide what we work on, but I think they're never mine. I think sometimes I would lead the right way. Sometimes they're probably somewhat selfish, which is actually very important too. This is what we're talking about, sponsors and people that help you with your project. Remember, people are people and they have their own priorities. For the purpose of these conversations, we always talk about the patient defining what value is. They are the ones that ultimately we're trying to cater with their definition of value. And value is an activity that transforms or add to the product or service being created. The didactic's a luxury statement, but ultimately I stand by it. You are doing something, you're operating on your patient, you are talking with him or her, or you're walking to the patient, or you're changing to treat the patient. The changing, the walking is not value added. A patient doesn't care about that. A patient just want to be treated. They want to be told what is wrong with them and so on. But also many of the processes don't directly tie to the patient. So like residence, log, charting and logging, or tracking of information, that is not really direct tying to the patient. Those are processes too. The customer just different changes. All throughout the patient care journey from a registration all the way to inpatient, all the way to billing and so on, there is view. There is a downstream, there is an upstream. There are value added activities and non-value added activities that take place. Ultimately for the purpose of simplicity, an activity in healthcare is value added when it builds on patient's information or it is part of direct care provision. So when we are talking about patient treatment, patient care, that the previous statement I gave is still valid, but for patient treatment, we say that an activity is value added when it builds on patient information or it helps with care provision. That is you. This slide is important to me because hopefully it gives you visual that there are people helping, working in the process before you and after you. We call them stakeholders in this process. And when we say we cannot improve the processes, improve quality by ourselves, we mean that there are other people involved in the process. And sometimes there are problems. Not everything goes well. Patient doesn't show up on time or any instrument is missing in the surgical tray or there was an incorrect error in the chart. There was an incorrect statement in the chart, et cetera. The patient bill was never sent. There are errors in the problem. There are errors in the system. There are problems. For the purpose of Lucas presentations, a problem is a gap in performance. Problems are not bad. Problems are expected. Most of the time, the reasons why we're doing quality improvement projects is because we're addressing an identified and known problem. We just don't know what's causing it. Question for you, which also this builds on your potential quality improvement projects. What are examples of non-value added activities? The value added activity is something that builds to direct care provision or adds to the patient's information. And for the non-patient related processes, a value added activity is something that builds and adds towards the completion of an outcome. What are examples of non-value added activities? Quality improvement project that involves just resident education alone. Fun one. Is this this resident education value added? It could be. Technically. Technically. Let's take an example. When you're moving the patient from the waiting room to the OR or from the surgery, I'm not familiar with how many steps there are in ophthalmologist surgery. I'm a little bit more familiar with different surgery. But from the little room to the OR table is that process of moving the patient's value added. It's not, it's not, it's not. You have transportations, you have motion of the patient. All this going between rooms is not value added. It's waste. It's wasteful. It is making and having to fix the chart or having to fix the building or having to fix the scheduling because an error was making and doing it. Is that value added? No. Errors are not value added. They delay the process of care. What else? Overdoing more exams. This is one is easy. It's always in the news. Doing more exams like whether there are X-rays or CTs than the patient requires. Is it value added? It's not. We call them over-processing or over-producing. Any other examples? Think about this. Because most of the quality improvement projects something like implementing a protocol for patients checking or implementing a hand-offs process or something like that. They are aiming to eliminate some sort of waste. Non-value other activities that are also called waste. Usually it's something like addressing communications, waiting for something to take place. Waiting is a big one. That's right. I forgot about it. How can I forget about waiting? The OR, that patient is not there yet. Usually I have the patient waiting. Let's make him a surgeon waiting. I had an orthopedic surgeon. He was waiting for 10 minutes. Eventually he looked at me. We had a good relationship. He was like, where's my patient? I'm here waiting. And the patient is in the area. This stuff happens. You know this more than me. The patient had to go to the bathroom at the last moment. The provider was waiting. It's waiting value added. Now, waiting is not quite added to the current process and then the one coming later as well. So, there are documents that are hand-outs I've prepared and I'm going to make available to you which actually goes through examples of seven types of these non-value other activities or waste. Take a look at them. This may help you to get ideas of what to work on. This is not a trick question. What is problem solving? Perfect. Thank you. Identifying a problem using some sort of method to fix and make a change. How often do we do problem solving? How complex is problem solving? It depends on the problem. Bingo. This does not tend to over complicate things. There is a time and a place for complex problem solving and there is time and a place for just doing something simple. The easiest way I came up to help you see the difference is if you're driving on the freeway or you're driving anywhere and your fuel gauge which by the way is called visual management is a visual indicator of something which is how much fuel I have in my car is going with the little light, orange light that lights up. What do you do when you see the little orange light lights up in your fuel gauge indicator? You could ignore it. That helps. You can put a bandaid on it. What do you do? You think about getting gas but you could hopefully get put gas in it. Do you take the car to the mechanic? Oh my gosh. There is an orange light in there. It's light up. Next. Now this is one of the examples where it's simple problem solving. You can't wait until forever. You can be like Cramer in Seinfeld and see how far you can go with an empty tank of gas or you can go to the nearest gas station and put gas in it. Now you're driving on the freeway or any other road and your car starts rattling and your engine shuts off. What do you do? You pull over. Now you go to the mechanic. Now it's complex problem solving. Now you need some help from other from other people. It's different. There are examples. This is important to me because then I get into argument and debates for hours with people explaining trying to get me to say Luca, just do it. Those ideas that don't require a team that just help you fix a simple process that you know what's causing the problem and you just want to make a quick change. Is that quality improvement? Yes it is. It's a complex problem solving where you use a framework of some sort like we were saying earlier where you collect data you analyze it then you finally make a change. Is that quality improvement? Yes. It's research where really you're trying to test an idea, you're trying to get new information. Is that quality improvement? Yes it is. So why are you telling me that I really should be doing complex problem solving? Because I'm trying to create this process where you're actually learning to use certain tools and then just making a change. But Luca, what about I have a gut feeling about this problem and I really don't my QI project is going to be surveying people to collect data. Is that quality improvement process? I don't like it but yes it is because if you're trying to make a change and you have no data and you know that there is a problem the act of collecting the data is part of your future quality improvement project. I call them phase 0 or the beginning of a project but then you go there and you present in front of the audience I thought we had this problem we surveyed people this is our result and that's the end of it. Okay, that is great. So these are all type of complex problems of quality improvement processes but it just depends what varies in complexity is your resources it's a much time you're going to take a project and so on. Notice I have tried not to use a word project yet because if someone comes to me and say do I need a project to do a just do it kind of implementation do I need a project to see to get permission to get more cables to fit the right computers because one is always running away so I have a great idea let's just have a backup cord now you don't need to assemble a team you just do it that's what I call them just do it this is where you have a project this is where you have a project this is where you have your teams working with you also right for the next 30 minutes or so my goal my focus is to help you get some understanding of tools in complex problem solving by the way how many of you are familiar with the IHI modules in quality improvement have you gone through the videos right through them ok they're valid they're good there's a lot of information out there we're making our own I think I like it and I think we're doing a good job the IHI modules promotes what is the PDSA cycle plan do study act to me plan do study act is here and that's what I finally settled in when you're doing a small those are the plan do study act works well with a small test of change otherwise you've got to when you have right back and forth and I apologize for that in here most of the time you know what the cause of the problem is or if you don't it's usually very simple to figure it out complex problem solving you don't know what the problem is what's causing the problem and that's what you need to figure out the difference between the two approaches is really root cause analysis which is what now we're going to talk about it there are many variations of methods and system in ways of approaching quality improvement sorry I didn't even remember I got your name Rachel when you were talking to us about problem solving you kind of mentioned framework for solving problems how are you familiar with stuff have you taken these kind of classes before no I think it's just a bit more it's like this where we talk about so if I said things like Six Sigma or Demake or PDSA that's good one out of four so far or A3 or 20 I'm making stuff up now I have counted about 15 different frameworks for doing complex problem solving at the University of Utah it's entertaining to me because in the end call them what you want I don't care ultimately when you're doing complex problem solving and this happens in daily life as well this is not about healthcare quality improvement you're trying to figure out if you have a problem you're trying to figure out why is it a problem what is causing it and how are you going to solve it and how do you know if it worked is how we call our steps which is somewhat borrowed by the Six Sigma framework what is that don't worry about it for now to me it's just important that when you have a project when you have something to work on you can when you have a problem that you want to address you know that and you come to me look I would like some help you owe me a problem statement and then I'm going to help you do a baseline analysis which is collecting the data then we're going to figure out what's causing the problem before you are actually solving anything usually people come to me with look I want to create a protocol is creating a protocol a problem let me rephrase that question is not having a protocol a problem not necessarily it could be we don't know yet so why do we why do we jump start this process by saying we need to implement a protocol we need to create a standard we need to buy a machine those poor wonderful robots we need to have them in the OR they just buy a bunch of them because they make us happy and it cost millions of dollars there is a problem we have millions of dollars to spend let's spend them let's quickly go through this this is where we're going to be spending time if we meet together specifically on a project by the way I guess I should have been clarified what is a quality improvement project at this point for you question I swear to identify the problem you're going to address it and you will dedicate a specific amount of time and personal resources that's your project right let's all agree to that I'm making arbitrary decision that's what a quality improvement project is it really is so when we have a quality improvement a problem statement is where things start people this is important because if you don't have a well formulated problem statement you're going to get lost in the problem it becomes there is such a worded scope you do problem statements all the time when you meet with patients you ask questions you ask them do you hurt where does it hurt where can you see what is going on what about this, what about that you are trying to clarify what the problem is before you actually address it I have found and I'm happy to actually have seen that if I give you these questions you actually come up with a pretty good problem statement from those people that used to come to me and say look my problem is that I need to implement a standard work document a protocol in my department because people are late so I need to improve the charting if they start thinking okay what is the problem why is it a problem how does the problem impact the customer when and where does it happen that's just when is the frequency like in the morning in the afternoon when the patient arrives etc and where is the unit I'm just trying to be specific if you answer these questions that's how an example of a problem statement that was written I don't know if you can read from over there women presenting for screening mammography at enhancement cancer institute have to wait an average of 6 days to receive final normal results for 97%, 98% of women who can be given normal results after routine exam this is a necessary delay and a major source of anxiety time to result service is a surrogate target for reducing arms now what's the problem why is it a problem because of anxiety where does it happen husband how often that is 98% of the patients it's a simple enough formula when you get to your how many of you have you guys identified a problem already you're going to be working on have you built your problem statement in some sort of fashion what problem are you working on what's the problem there so many is that we have an inter-manual that's five years out of date there are so many processes that you mess up for the patient or waste an undue anxiety for the intern and the patient I have to ask these questions because people are like, just give me a break I just make a change no, you can't if you can't think through why an old manual isn't bad then you're just through it guys, the fact is that time, money, resources are limited if we had unlimited resources there is a concept around lean lean is built around the principles and management system of the Toyota production system the guys that build cars there is a principle in there unlike in Six Sigma from a different methodology from Motorola in lean we say that we're going to work on all the problems eventually we're going to get there so you work on the smallest thing possible but you still have to understand what you're working on so the first part is what is the problem, you build a problem statement the second part, why is it a problem is the baseline analysis baseline analysis is collecting the data how did you know that the manuals were five years old the handwriting of residents how did I go back five years so how did you know that did you go look what about the lack of the not having training formalized training or what you were saying earlier there just isn't a curriculum the fact that it's not a curriculum how did you know that again, you want to look for it so this is not, again I'm over simplifying things but ultimately what you did is called going and seeing the only Japanese word you may or may not choose to remember is gamba if you like to use it, do it if you don't like me, say go and see it's doing observations basically you're going to before you can make a change before you understand what the problem is you gotta talk to people you gotta open a binary to actually check the dates you go and see but this is important because when you're going and saying when you're doing observations you're asking questions you're there to learn you're not there to give advice refrain from making judgments refrain from giving advice or trying to solve problems on the spot that's not what you're doing there some other times you may need to do a process map usually when you're looking at something like timing components or delays or waiting or trying to figure out where the issues are in the process it is not very well known you do a process map these are just examples of them and if you would like some help with your specific projects let me know and I will help you more details of creating a process map for your project process mapping which is visualizing the process usually it takes place in a room like this you are on a white board you're drawing steps and you're talking and everybody thinks they know what is going on nobody by themselves really does because unless you own the process and you're the only person doing it but still going to the Gamba observing it's important to fill in the gaps often what actually takes place in the workplace and then of course collect some data the easiest again we can talk about more detail when we meet separately but the point we're making that some quite often just talking about averages it doesn't provide a complete picture so leveraging histograms bar charts or run charts gives you a better vision of what actually this is a problem this is where complex problem solving is different from just do it kind of implementation because in just do it you identify your problem you look at your base and analysis I want to know how to fix it you just fix it in complex problem solving you're like what the heck is like I'm doing a project for to simplify the clinical placement of students of learners Residents also but primarily undergrad students or people from different colleges are placed in clinics this process of getting view you've gone through this trying to find try to match your schedule to the provider schedule the clinic schedule so you can observe the process in there and learn it's a mess how to fix it is not simple that's what we used and by the way this funny to me because it's usually somebody's fault but it's not there is a process there is sorry there is the causes of the problem are usually deeper and what you think they are trying to decide what to address it's it revolves around specific tools like these fishbone diagrams 5 y's then ANOVA, Pareto analysis, FMEA risk analysis what are those things I don't even talk about them most of the time the type of problem solving we do here in healthcare at this level 5 fishbone diagram and 5 y's are more than sufficient I had some handouts on that to get you started finally we have collected all this data we have decided what cause we are going to address if I say what cause we are going to address what do I mean do I have to explain it differently what's the cause of the problem what's the cause of the problem system system can be part of it too but when I talk about cause of the problem the problem is the problem is still there you are just picking something that you are going to be addressing on don't jump to solution when do you know when it's time to fix it well because the group has decided to hopefully your project is going to include other people besides yourself there are specific tools to improve a process but unless your change eliminate waste eliminate errors improve performance please don't make a change is it going to be pointless if you are actually not improving anything it's pointless if if the curriculum you are building that you are making it clear because it's going to decrease variation in knowledge it's going to improve performance it doesn't actually get to there maybe you need to reconsider your intervention this is important because everybody does this one of my favorite learning experience was when me and this improvement group made a change we were so proud of it we found a way to streamline the intake process by having the patient charts being reviewed earlier and we saved 10 minutes of the intake process and then the surgery director told me that the top surgeon came to her and is like where is the patient chart or the nurse has it but I need to view it first but we did an improvement project and so this saves us 10 minutes but I can't see the chart so where is the chart don't worry I'll make it work I don't want the surgeon to tell me I don't want anyone to tell me how it works we missed the opportunity to include them in a discussion around improving the process in reality we didn't really make any difference I'm almost done how do you know it worked is a conversation around outcome measure, process measure, balance measures when you're trying to improve patient experience when you're trying to reduce mortality rates when you're trying to improve those are effectual rates vaccinations screenings those are outcomes it's different type of metrics that you set for those otherwise because sometimes if somebody comes to me and say look we're going to increase improve our discharge time okay how are you gonna do that because discharge times has a lot of factors into it there are many processes that go into making it happen and so decreasing discharge time it's a complex problem solving sure but it's also an outcome so how are you gonna do that well we're going to focus on residence order reviews okay, residence order reviews that's your process metric discharge time that's your outcome and you don't want to make anybody mad patient satisfaction or customer satisfaction is your balance measure without this you don't know if your project worked or not that's why many QI projects that go like we surveyed people by the way everybody does it so if your project is that I have no problem I'm just being clear if your QI project is collecting data and surveying people and in the end you've not made a change you don't know if something happened in reality that is not the full cycle QI project yours specific thank you for providing me some examples education you can work with something like that in reviewing last in reviewing the past five years of projects either you do a lot of rotations on the VA for the VA and I thought of a portfolio it is which I'm glad because they're visible you can see them every time I ask people you know what I'm not picking on them actually I'm very glad that residents or people that work at the VA they can find problems just like that because when I ask people here what problem can you solve I don't know but you don't know so VA for making easier to find problems whether you have more of them or not I don't know flow when you're trying to improve a response code or improving patient access that's a flow type of project quality or cost you can partner up with two peers to reduce costs as well this is a lot of information all at once this is why there are other resources when I send you some links for it you can review them this is our versions of IHI modules and then don't forget you're not alone there are many other people that you can leverage and you can ask questions and you can learn from I do this all the time