Improving Health Care Quality. Cecilia Fernanda Martinez

Improving Health Care Quality - Cecilia Fernanda Martinez


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Additional discussion on variability in the context of quality improvement can be found in Deming (1986) and Hoerl and Snee (2012).

      1.4.1 Define–Measure–Analyze–Improve–Control (DMAIC)

      The DMAIC framework is a systematic approach to quality improvement applied in Six Sigma programs. The American Society for Quality (ASQ 2019), defines Six Sigma as “a method that provides organizations tools to improve the capability of their business processes.” The DMAIC cycle begins with the Define phase where a team is assembled to develop a project charter that describes the process to be improved and the objectives of the initiative. During this phase, requirements and improvement opportunities are elicited from stakeholders. A clear problem statement is a central part of the project charter. In the Measure phase, a process or value stream map is created to provide stakeholders with a common understanding of how the process operates and serves as the basis for generating improvement ideas. Process performance indicators are also identified, such as delay times and errors. In the Analyze step, the process and associated data are examined to discover potential sources of variation or error. During the Improve phase, process changes that will reduce or eliminate sources of error or variation are developed. Once process changes have demonstrated their effectiveness, they are implemented. Finally, the Control phase puts in place monitoring systems, such as control charts, to ensure that the quality improvements are maintained over time.

      The TJR project, parts of which are described in Chapters 1214, employed the DMAIC framework. Statistical tools including process capability analysis, hypothesis tests, box plots, and dot plots were used in each of the various steps of the process. Insights gained from these tools were critical for the identification of the root cause of the unnecessary process delays. Taken together, in the Improve stage, process root cause countermeasures were brainstormed, solutions designed and evaluated, and pilot testing took place to measure the effectiveness of the solution before its full implementation. In the Control stage, the process elapsed time was monitored in order to maintain the improvements.

      1.4.2 Plan–Do–Check–Act (PDCA)

      As an example, nurses in a hospital wanted to reduce the severity of injuries associated with patient falls. They initiated a PDCA cycle to experiment with fall mats placed next to a patient's bed. They developed a plan to acquire and test the fall mats on a single unit. This change reduced the severity of injuries associated with falls and was adopted on a hospital‐wide basis. PDCA initiatives are often conducted sequentially devising, testing, and deploying a series of process changes.

      1.4.3 Choosing a Framework

Schematic illustration of the framework-type of problem matrix.

      There are other methodologies used when designing new products such as TRIZ, which is a Russian acronym from “Theory of Inventive Problem Solving,” which is based on universal principles of creativity and invention for the design of innovative solutions to design problems (Altshuller 1999). Last, the concept of robustness is also used when solving complex design problems where the objective is to reduce variability in the performance of a product by making improvements in the product design. While these latter approaches originated in the manufacturing sector, these can also be applied to healthcare by focusing on the process or products used necessary for providing patient care. These quality improvement approaches, however, are beyond the scope of this casebook.


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