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Quality Assurance Methodology Refinement
Series IMPROVING QUALITY OF
CARE IN EIGHT POLISH
HOSPITALS Jordan Gynecological -Obstetrical Hospital, Lodz-Baluty Mother's Memorial Hospital, Lodz
Opthalmological Hospital, Krakow
John Paul II Specialist Hospital, Krakow
Solidarity Foundation Center for Oncological Diagnostics, Legnica St. Luke's Hospital, Konskie
Provincial Hospital, Sieradz
Policemen's Hospital, Krakow With Technical Assistance By: The National Center for Quality Assessment,
Krakow and
The Quality Assurance Project
Center for Human Services
Bethesda, Maryland, U.S.A. 1 CONTENTS List of Figures and Tables ............................................................................................... 3 Executive Summary... ..................................................................................................... 5 Introduction .............. ..................................................................................................... 9 Case One: Jordan Gynecological-Obstetrical Hospital, Lodz-Baluty .............................. 13 Case Two: Mother’s Memorial Hospital, Lodz .............................................................. 17 Case Three: Ophthalmological Hospital, Krakow........................................................... 23 Case Four: John Paul II Specialist Hospital, Krakow ..................................................... 27 Case Five: Policeman’s Hospital, Krakow...................................................................... 31 Case Six: Solidarity Center for Oncological Diagnostics, Legnica .................................. 35 Case Seven: St. Luke’s Hospital, Konskie ..................................................................... 41 Case Eight: Provincial Hospital, Sieradz ........................................................................ 47 2 LIST OF FIGURES AND TABLES Figure 1.1 Process of Admission to Surgery................................................................. 13 Figure 1.2 Possible Causes of Delayed Surgery After Admission.................................. 14 Figure 1.3 Actual Causes of Delayed Surgery .............................................................. 14 Figure 1.4 Half-month Average Waiting Time in Hospital for Surgery ......................... 15 Figure 2.1 Timetable for Carrying out the Quality Improvement Activity ..................... 17 Figure 2.2 Lab Work Flowchart................................................................................... 18 Figure 2.3 Cause and Effect Diagram........................................................................... 19 Figure 3.1 Causes of Delay of Ambulatory Ophthalmologic Surgery ............................ 24 Figure 3.2 Waiting Days for Ambulatory Surgery Before/After Modified Process ....................................................................................................... 26 Figure 4.1 Causes of Delay of Ambulatory Ophthalmologic Surgery ............................ 28 Figure 5.1 Ultrasound Referral Process........................................................................ 31 Figure 5.2 Causes of Delayed Ultrasound for Outpatients ............................................ 32 Figure 5.3 Causes of Wasted Ultrasound Examination Time Slots................................ 32 Figure 6.1 Flowchart of Detailed Process..................................................................... 36 Figure 6.2 Timed Flowchart......................................................................................... 36 Figure 6.3 Potential Causes of Prolonged Waiting for Consultation.............................. 37 Figure 7.1 Patient Flow Through Admissions Unit ....................................................... 41 Figure 7.2 Causes of Delay in Admissions Unit ............................................................ 45 Figure 8.1 Echocardiogram Examination Process......................................................... 47 Figure 8.2 Possible Causes of Inefficient Use of Ultrasound Equipment ....................... 48 Figure 8.3 Average Number of Echocardiograms Performed Daily Before and After Intervention ....................................................................................…50 3 Table 2.1 Frequency by Error, by Type, Pre-/Post-Intervention .................................. 20 Table 5.1 Wasted Ultrasound Time-Slots Before and After Intervention by the Table 6.2 Pre-/Post-Intervention Delay Between Mammography Table 7.1 Delays (in Minutes) Incurred at Five Points Between Patient Arrival and Table 7.2 Relative Impact of Each Factor on Overall Duration of Period Prior to Table 8.1 Multiple Criteria Analysis: Selecting Strategies to Increase Number of Table 4.1 Staff Vaccination Status Before/After Intervention...................................... 29 Quality Improvement Team......................................................................... 33 Table 6.1 Waiting Times Prior to Intervention (113)................................................... 37 and Consultation with Physician.................................................................. 39 Completion of Services ............................................................................... 43 Decision ................................................................................................... 44 Echocardiogram.......................................................................................... 49 4 EXECUTIVE SUMMARY The Polish health care system is being transformed from its formerly centralized structure,
financed and largely directed by the Ministry of Health, to a more decentralized structure which
places emphasis on local direction, control, and financing. As a result, local governments and
providers have a heightened interest both in the technical quality of the care they provide and in
improving patient satisfaction. In October 1995, with funding from USAID/Warsaw, the National Center for Quality Assessment
(NCQA) and the Quality Assurance Project (QAP) entered into an agreement for QAP to provide
technical assistance to the Center. The collaboration had two goals. One was to demonstrate to a
larger audience in Poland the effectiveness of these methods and tools in improving service
quality; the other was to help strengthen the capacity of the NCQA staff in training and coaching
quality improvement activities by service providers in hospitals and clinics. USAID’s mandate
was to divide the collaboration into two phases. The first was to be a brief (six months)
demonstration phase. This would be an intense exercise in which a number of hospital staffs
would receive just the amount of training and coaching they needed to be able to apply basic QM
methods and tools to resolve a real quality problem in their hospital. Also in this phase, QAP
would provide targeted training to the NCQA staff in the use of key methods and tools of QM
and in techniques of training and coaching quality improvement teams. The short demonstration phase was recognized by USAID, NCQA, and QAP as not providing
sufficient time or effort to institutionalize quality management in the participating hospitals.
Assuming a successful demonstration, a second, longer phase would enable QAP to provide
training to NCQA in more advanced skills and tools, while providing funds for NCQA to work
with various hospitals to develop institutionalized QM cores rather than temporary quality
improvement teams that accomplish their purpose and then dissolve. It was anticipated that as
more of the country’s hospitals institutionalize QM, this would lead in time to real integration of
modern quality assurance philosophies and methods into the evolving healthcare system. (This
trend is expected to be supported by the promotive efforts of such organizations as the Polish
Association for Quality in Healthcare.) During November and December, the NCQA staff recruited seven hospitals and one clinic to
participate in this demonstration. In January, Dr. Stewart Blumenfeld and Ms. Jolee Reinke, both
senior trainers on the QAP staff, provided a workshop on quality management principles,
methods, and tools for half of the members of each of the eight participating teams. In February,
NCQA staff replicated the workshop for the other members of each team. Each team selected a
problem and, using the methods and tools in which they had been trained, identified the major
causes of the problem, developed and implemented a solution, and measured for improvement.
As they worked, each team was coached by an NCQA staff member. On April 26, 1996, the
teams convened in Krakow to present their results to one another and to observers from the
Ministry of Health and from several voivodships. 5 These reports describe the results of the first phase, demonstrating the effectiveness of the
methods and tools of quality management in improving quality by solving one problem at a time.
These activities did not focus on the longer term goals of institutionalized quality management,
assuring quality by preventive management and by continuous quality improvement. This would
be taken up in the second phase of the collaboration. The presentations were given in Polish.
These reports are based on notes taken by Dr. Blumenfeld, who attended the conference on behalf
of QAP, translations of the team’s visual aid materials, and additional consultations with the
NCQA coaches. The translations were done by Mrs. Barbara Kutryba, M.A., of the NCQA staff. The results of each team’s work are summarized below. Jordan Hospital, Lodz-Baluty, Reducing In-Hospital Waiting Time for Elective Surgery:
Waiting time for surgery once a patient was admitted was averaging 5.8 days, resulting in wasted
resources, increased costs, increased risk to the patient from nosocomial infection, and complaints
from the patients. The team tracked 80 cases over a four-week period to discover where most
time was lost. More than half of the delay was attributable to waiting for a specialist to see the
patient. Waiting for the results of EKGs and lab tests also contributed significantly to the
problem. Based on their analysis of causes for these delays, the team reorganized the admitting
process by having the specialist who will do the surgery see the patient by appointment prior to
admission. The specialist also specifies the tests that he or she wants done before surgery. In the
six weeks following the changed procedure, the period between admission and surgery fell
steadily to an average of 1.1 days and appeared to be leveling off at a point. Mother’s Memorial Hospital, Lodz, Reducing Repeated Laboratory Tests Resulting From
Procedural Errors: Many blood tests and urinalyses were being done over due to procedural
errors, causing delays in services to patients and additional costs. Analysis of the process from
the time a test is requested to the moment when the results are given to the physician revealed at
least 15 plausible sources of error. Measurement of nearly 1800 cases, however, revealed that
87% of the errors arose from just four causes: analytical apparatus deficiencies, mistakes made in
the collection of samples, mistakes made in transporting and storing samples, and unclear requests
from the physician. Analyzing the causes of apparatus deficiencies, the team determined that most
were related to the age of much of the equipment and the unavailability of spare parts due to
shortage of funds. Deciding there was little they could do to rectify the latter problem in the short
run, they decided to work on the other three causes, which collectively amounted to about 48% of
the problem. They developed some procedural standards which had not existed before, produced
job aids, and provided staff training on both the magnitude and consequences of procedural
mistakes. The result was a 35% reduction in errors in these three areas and an 18% reduction in
total errors. The team calculated that the savings in this three-week period from unrepeated tests
amounted to approximately $2,200. On an annual basis, this would come to about $36,000 in just
two clinics of the hospital. Ophthalmological Hospital, Krakow, Reducing Waiting Time for Ambulatory Surgery:
Ambulatory surgery is one of the newer services provided by the hospital and is much in demand.
Patients complained about the long wait and staff worried that in some cases the patient’s
condition worsened during the waiting period. An analysis of records to quantify the problem 6 found that in the previous three months, patients had averaged 71 days of waiting. Analysis of
probable causes of delay led the team to increase the number of surgical time-slots available by
reorganizing existing hospital staff, motivating surgeons to perform more surgeries per day (the
fact that the Hospital Director was a member of the Quality Improvement team was helpful), and
reducing the number of wasted slots due to no-show patients by introducing a better appointment
scheme and developing a list of patients who would come in for surgery on short notice. In the
three months following the intervention, the average wait for surgery declined to 10 days. John Paul II Specialist Hospital, Krakow, Improving Hepatitis B Vaccination Rate in
Hospital Staff: Although hospital policy is that all staff should be vaccinated against Hepatitis B,
of the 82 staff (doctors, nurses, support staff) in two pulmonary units in the study 24% had never
been vaccinated and 6% were only partially vaccinated. The team studied the reasons for this and
developed an educational program for all staff emphasizing the incorrectness of the reasoning
used by staff to avoid being vaccinated. They also set up a monitoring scheme to track the
vaccination status of the staff. Of the 25 people who were unvaccinated or not current, all 5 of
those who were due for boosters had gotten it. Of the 20 who had never been vaccinated, 14 had
started their series. The remaining 6, 4 physicians (out of 17 on staff) and 2 nurses (out of 39 on
staff) had not complied. In their follow-up, the team discovered that the 4 physicians simply did
not view HBV as a threat, while the 2 nurses held the misconception that the vaccine itself could
give them hepatitis. (Interestingly, there is no discernible penalty for not complying with this
policy.) Policemen’s Hospital, Krakow, Reducing Outpatient Waiting Time for Ultrasound
Examination: Inpatients, who have priority, were being served in a timely manner, but
outpatients were forced to wait about two weeks for their examination. Cause-effect analysis led
the team to believe that inefficient use of the equipment was the cause of this problem. As they
probed deeper into the details of the inefficiency, they discovered that a startling 48% of all
booked time-slots went unused. Half of these slots were due to rejection of the patient as an
inappropriate candidate for ultrasound when the Unit doctor examined the patient on the
proposed day of the procedure. These were categorized as incorrect diagnosis by the referring
physician. In another 18% of unused slots, the patient simply did not come for the scheduled
appointment. Also in 18% of unused time-slot cases the Unit physicians were able to ascertain
that the patient essentially had “forced/pressured” the referral against the better judgment of his or
her doctor. As its response, the team developed and promulgated very specific standards as to the
conditions under which it would accept patients. Over the course of the six weeks following this
intervention, referrals to the Unit declined by 41% and unused slots dropped from 48% to 19%.
Most of the rejections still were due to incorrect diagnosis by the referring physicians, but overall,
incorrect diagnosis as a category declined by 42%. A sample of 100 records after the intervention
showed that the average wait for outpatient service had dropped from 14 days to 7 days. Solidarity Center for Oncological Diagnostics, Legnica, Reducing Waiting Time and
Increasing Comfort for Mammography Patients: Patients were complaining that they wait for a
long time from the time a mammogram was taken to the time that they were examined and
counseled by a physician. Tracking 113 patients, the team found that 36% of patients waited
more than two hours and 18% patients waited more than three hours. Examining the process in 7 the clinic, the team found several reasons for the delay, including some shortage of equipment and
doctors. They thought, however, that some problems were due to the way the staff was
organized and to the propensity of Polish patients to come very early for appointments for fear
they might not get served. They therefore reorganized the work-hours of the two mammography
technicians and strengthened the appointment system by giving the patient an appointment for
both the mammogram and the doctor’s consultation. With these changes, the number of patients
waiting more than three hours declined to 7%--although now 43% of patients were waiting more
than two hours. The team decided to accept this trade-off. St. Luke’s Hospital, Konskie, Reducing the Period of Stay in the Admissions Room Pending
Admission or Discharge: Patients complained that they had to wait too long in the admissions
area before they were either treated on an outpatient basis or admitted as an inpatient. The staff
agreed that the process took too long. Using a very elaborate process analysis, the team focused
on five points in the process where major delays were incurred. They tracked 90 patients and
measured the waiting period at each of these points. They found that a wait for test or x-ray
results occurred in 70% of all cases and that in these cases 75% of the time this wait was the
longest single wait in the entire process of that case. In addition, 48% of all patient-minutes (the
total number of minutes spent in the admissions area by all 90 patients) were used waiting for
these results. The only factor that occupied a larger amount of total patient-time was the
observation hold-period following administration of some medical procedure. This occurred in
23% of all cases; nearly always, when it did, it was the longest factor in the patient’s stay.
However, the team felt that this is a delay that should not be shortened. The team reached the
point of proposing some modifications in the system, but had not had a chance to implement them
before the conference. Provincial Hospital, Sieradz, Increasing the Number of Daily Echocardiograms Performed
by the Cardiology Diagnostic Unit: The average daily number of echocardiograms performed by
the Unit over the past six months was 10.1, although it had inched up to about 12 in the previous
three months. However, the international benchmark for similarly equipped and staffed units is
about 14 per day. Process analysis and cause-effect analysis helped identify six impediments to
efficient use of the Unit’s resources. The team developed a set of five strategies that could
increase the Unit’s output and four different weighted criteria through which to filter the utility of
each strategy; the analysis was done in the form of a multiple criteria assessment matrix. As a
result, they began to book more patients per day, maintain a list of patients who could come for
the procedure on short notice when another patient cancels or doesn’t show, developed common
standards for the two subunits that constitute the overall unit and thereby make it easier to move
patients from one to another, and make the doctors more responsible for finding a staff
replacement if they could not come on schedule. After these changes were made, the Unit’s daily
average began to exceed the international standard slightly. 8 INTRODUCTION The Polish health care system is being transformed from its formerly centralized structure,
financed and largely directed by the Ministry of Health, to a more decentralized structure which
places emphasis on local direction, control, and financing. As a result, local governments and
providers have a heightened interest both in the technical quality of the care they provide and in
improving patient satisfaction. At the same time as this basic restructuring is occurring, Poland is participating in a world-wide
movement toward applying quality management principles to quality assurance in healthcare. In
1992, Poland began participating in a European Union project aimed at improving quality of care
in several hospitals. The following year a Polish Association for Promotion of Quality in
Healthcare was formed, and in 1994 a National Center for Quality Assessment (NCQA) was
established under the auspices of the Ministry of Health and directed by a senior member of the
faculty of the Jagiellonian University School of Public Health, Rafal Nizankowski, MD, PhD. The
National Center’s purposes are to promote awareness of modern quality assurance technologies
and to provide technical assistance to provider units that wish to improve quality by applying
these methods. The Center was assisted in its development by USAID and by a Flemish (Belgian)
cooperation project, both of which provided resources for training Center staff in the use of the
methods and tools of modern quality assurance. In October 1995, NCQA, with financial
assistance from USAID, held a two-day conference in Krakow at which nearly two-dozen
managers and providers presented the results of recent quality improvement activities they had
carried out. In September 1995, USAID/Warsaw asked the Quality Assurance Project 1 (QAP) to assist in advancing the application of modern quality assurance methods in Poland’s changing healthcare
system. In October, a team comprising Dr. James Heiby, Global Bureau Project Manager for
QAP, QAP Director, Dr. Stewart Blumenfeld, and a consultant, Dr. Robert Younes, visited
Poland to review the status of quality assurance in the country, assess overall interest in
expanding the use of more effective quality assurance approaches, and identify potential partners
in the expansion of awareness and capacity for using these technologies. The assessment team
found that interest in modern Quality Assurance is high, that national capacity is not yet very
great, and that the National Center for Quality Assessment, having already started on a course of
improving its own capacity to function as a national resource in quality management (QM), would
be a natural partner. With funding from USAID/Warsaw, NCQA and QAP entered into an agreement for QAP to
provide technical assistance to the Center. The collaboration had two goals. One was to
demonstrate to a larger audience in Poland the effectiveness of these methods and tools in
improving service quality; the other was to help strengthen the capacity of the NCQA staff in 1 The Quality Assurance Project is implemented by the Center for Human Services under Cooperative Agreement No. DPE- 5922-A-00-0050-00 with the Office of Health and Nutrition, Global Bureau, United States Agency for International
Development. 9 training and coaching quality improvement activities by service providers in hospitals and clinics.
The original mandate divided this collaboration into two phases. The first was to be a brief (six
months) demonstration phase. This would be an intense exercise in which a number of hospital
staffs would receive just the amount of training and coaching they needed to be able to apply basic
QM methods and tools to resolve a real quality problem in their hospital. Also in this phase, QAP
would provide targeted training to the NCQA staff in the use of key methods and tools of QM
and in techniques of training and coaching quality improvement teams. Assuming a successful demonstration, a second, longer phase would enable QAP to provide
training to NCQA in more advanced skills and tools, while providing funds for NCQA to work
with various hospitals to institutionalize QM cores rather than rely on temporary quality
improvement teams that accomplish their purpose and then dissolve. It was anticipated that as
more of the country’s hospitals institutionalize QM, this would lead in time to real integration of
modern quality assurance philosophies and methods into the evolving healthcare system. (This
trend is expected to be supported by the promotive efforts of such organizations as the Polish
Association for Quality in Healthcare.) This report describes the results of the first phase, demonstrating the effectiveness of the methods
and tools of quality management in improving quality by solving one problem at a time. The short
demonstration phase was recognized by USAID, NCQA, and QAP as not providing sufficient
time or effort to institutionalize quality management in the participating hospitals. The activities
described here do not focus on the longer term goals of institutionalized quality management,
assuring quality by preventive management and by continuous quality improvement. This would
have been taken up in the second phase of the collaboration which will no longer be executed,
leaving the six-month phase as the main activity. During November and December 1995, the NCQA staff recruited teams (each comprising 4-6
members) from eight hospitals to participate in the quality improvement exercise. The activity
was to consist of two one-week workshops in January and February 1996, with half of each
quality improvement team attending the first workshop, the other half, the second. Team
members would learn some of the background philosophies that underlie modern quality
assurance approaches, be trained to use basic tools for identifying problems, their causes, and
their solutions, select a problem to work on from their own facility, and thereafter receive regular
coaching visits from Center staff to assure that they continued to apply properly the skills they had
learned in the workshop as they moved toward solving their quality problem. Dr. Blumenfeld
spent a week in December working with the Center staff to prepare overheads and written
training materials that used case examples that were relevant to the Polish health care system.
Since cardiovascular accidents are among the leading causes of morbidity and mortality in Poland,
a number of cases dealt with CVA. The first (January) workshop presented an interesting problem. It had been agreed that it should
be given by QAP staff (Dr. Blumenfeld and Ms. Jolee Reinke) so that NCQA staff would have an
opportunity to observe the training techniques employed by veteran trainers in the QA field.
Since QAP has no staff who can speak Polish, this meant that the workshop would be done in
English, and although the initial batch of workshop participants were to be selected in part 10 because it was hoped they could cope with the level of English required, it was not anticipated
that most would be strong in English. To assure that all the participants could learn the material
they needed to despite didactic presentations in English, all overheads and supplemental written
materials were translated into Polish by NCQA staff. While this was a difficult undertaking for
the staff, the task had the benefit of ensuring thorough familiarity with the materials and the
concepts they covered. Since the second (February) workshop was given entirely by NCQA staff,
this exhaustive familiarity almost certainly improved the quality of the second workshop. In the
week prior to the workshop, Ms. Reinke provided training in techniques of successful teamwork
for the NCQA staff. The first workshop was given by Dr. Blumenfeld and Ms. Reinke in Krakow January 15-19, 1996.
There were 23 participants representing eight different institutions. NCQA staff provided
occasional Polish-language elaboration as they deemed necessary. NCQA staff gave the
workshop for the second batch of team members February 5-9. At each workshop, the first two-and-a-half days were devoted to a discussion of the transition
from traditional approaches to quality assurance to the modern approach based in quality
management, the problem-solving process, and demonstrations of, and practice with, the basic
methods and tools used in this approach. One particularly successful innovation in this workshop
was hands-on use of affinity diagramming to produce a group-generated cause-effect diagram.
Two participative exercises highlighted techniques and benefits of working in teams. The last two
days of the workshop were designed to help launch the teams into a definition and analysis of the
quality problems they had selected and to give the NCQA staff who would act as facilitators for
these teams practice in serving in this capacity. As part of this process, each team developed a
detailed flowchart of the activity that incorporated the problem they had chosen. A few of the
teams generated a system model as a precursor to doing its flowchart. Each of the teams was
given an opportunity to present its flowchart to the entire group for critiquing. Dr. Blumenfeld
and Ms. Reinke observed and participated in this activity and were able to provide helpful hints
for the coaches concerning how to interact with the team, how to diagnose problems should the
team stall in its efforts, and what to suggest as a remedy in this case. Prior to the first workshop, it had been expected that each quality improvement team would
identify several problems of importance to the whole team and would delegate authority to the
group coming to the first workshop to select a problem for the entire team to work on. This
seems to have worked in some cases, but not in all. The teams that did not select a problem at the
first workshop did so at the second. A date was set in April 1996 for the teams to convene in Krakow under the auspices of NCQA to
report on their activity and results. The conference date established a definite endpoint for the
work and probably worked to enforce an unusually rapid pace of activity 2 . Each team was visited 2 In actuality, these teams progressed more quickly than almost any other group with which the Quality Assurance Project has collaborated. This is a tribute to the sincerity of their desire to learn about this new technology and to the efforts of their
NCQA coaches, Sabina Lyson, M.Soc., Anetta Pawlus, M.D., and Kinga Stanach, M.S.W. 11 by its NCQA coach every few weeks to check on progress and help clarify conceptual issues,
correct use of tools, or teamwork issues. The coaches spoke to the team leaders by telephone
between visits. The conference was held on April 26, 1996. Most members of each team and representatives of
the Ministry of Health and several voivodship health ministries participated. Each team presented
a verbal report and in addition set up a storyboard 3 . The presentations were given in Polish. These reports are based on notes taken by Dr. Blumenfeld, who attended the conference on behalf
of QAP, translations of the team’s visual aid materials, and additional consultations by Dr.
Blumenfeld with the NCQA coaches. The translations were done by Mrs. Barbara Kutryba,
M.A., of the NCQA staff. 3 For those not familiar with the storyboard tool used in quality management, a storyboard is a visual communications tool using pictures, graphics, and terse text to describe the nature of the problem, the members of the team and their roles, the
analysis of the problem, the development and selection of solutions, and the results of implemented solutions. 12 CASE ONE: JORDAN GYNECOLOGICAL-OBSTETRICAL HOSPITAL LODZ-BALUTY REDUCING IN-HOSPITAL WAITING TIME FOR ELECTIVE SURGERY THE QUALITY IMPROVEMENT TEAM: Coach/Facilitator: Sabina Lyson, M.Soc. Barbara Jablonska-Krasomska, MD, PhD, National Center for Quality Assessment Chief Physician; Maria Olesiejuk, MD, PhD, Edited by Stewart Blumenfeld, Dr.P.H., CPHQ Deputy Chief, Neonatal Ward; Mgr. Quality Assurance Project Aleksandra Kociemska, Chief of Nursing; Center for Human Services Agnieszka Kaniera, MD, Assistant Chief,
Rehabilitation; Mgr. Magda Kedziera-
Osuchowska,Health Educator; Ewa Kuziel,
MD, Health Educator. Problem Statement : Both patients and staff agreed that the period between admission to the hospital and surgery was
too long, on average 5.8 days. From the hospital’s viewpoint, this resulted in wasted resources,
increased costs, and additional risk to the patient. For their part, the patients complained that
their time was wasted, that there was great inconvenience to the family, and that, moreover, the
protracted anticipation of surgery was distressing. The team set a goal of having at least 90% of
patients undergo their surgery
within 24 hours of admission. Problem Analysis: To identify possible nodes in the
system where significant delay may
be incurred, the quality
improvement team developed a
flow chart of the process by which
patients are admitted to the hospital
and then proceed to surgery. Using
the flowchart (Figure 1.1) to
identify possible places in the
process where time may be lost, the
team developed a cause-effect
diagram to speculate on how and
why time might be lost at these
points in the process. Discussing the cause-effect diagram
(Figure 1.2), the team decided to Patient arrives at
waiting room Initial examination Admit? Patient examined at unit Additional tests ordered Consultation with specialist Patient qualifies
for surgery? Consultation with
anaesthesiologist Okay for
surgery? Surgery Specify date of
admission N Y Other treatment N Y Correct deficiencies N Y FIGURE 1.1 PROCESS: ADMISSION TO SURGERY 13 measure delays occurring at three different points in the process which they thought were likely to
give rise to significant delays: • waiting for lab tests to be done
and reported • waiting for EKG and ultrasound
tests and results • waiting for consultation by a
specialist This team noted that this
problem had been on
their minds for some
time, and that
participation in this
quality improvement
activity had given them
the impetus and
additional skills and tools Increased waiting
time for surgery METHOD Wait for specialist
consultation in ward Admitted without results of additional testsAdmitted without results of recent tests Admitted with incomplete set of tests Lack of early specialist consultation Many tests done after admission Additional tests
ordered in ward Limited consultation days Poor information flow between gyn
O/P clinic and hospital Separation of clinic and hospital duties Separation of cases Separation of staff PATIENT Unsatisfactory physical condition Insufficient information given Lack of discipline re instructionsSudden infection Stress Unsatisfactory psychological condition Lack of information regarding surgery and consequences Unfamiliar surgeon Discontinuity in care between
clinic and hospital Separation from family FIGURE 1.2 POSSIBLE CAUSES OF DELAYED SURGERY AFTER ADMISSION to study the problem in a systematic way. They had progressed well into the analytical phase at
the training workshops, developing their flowchart, cause-effect analysis, and data-collection
approach and tools in near-final form before they finished, so that they were ready to start
collecting data very early in the
project. Data were collected by
modifying the medical record to
show delays in surgery and the
reasons for the delay as noted by
the attending staff. Using the modified medical
record, the team collected data
on 20 cases a week for four
weeks and obtained results,
shown in Figure 1.3. As
indicated by the Pareto chart,
the wait for consultation with a
specialist (gynecologist)
accounted for more than half the
delays, but there also were
substantial delays waiting for lab 0.52 0.99 0.99 3.3 0.00 1.45 2.90 4.35 5.80 100% 80% 60% 40% 20% 0% Wait for
Specialist EKG Lab tests Other ? ? ? ? FIGURE 1.3 ACTUAL CAUSES OF DELAYED SURGERY Ave. Days of
Delay By
Primary Cause 57% 74% 91% work to be reported and for the EKG unit to become available. 14 Solutions and Results The cause-effect diagram had already provided the team with a number of potential solutions to
the problem of long delay between admission and surgery. Once their suspicions were confirmed
through use of the new information on the patient record, they reorganized their procedure fairly
drastically. The major change was to establish a polyclinic within the hospital itself. Before,
referrals for surgery came directly from the regional clinics. Now, referrals come from the
regional clinic to the hospital polyclinic. There, the same doctors who will do the surgery see the
patient order the tests that they demand prior to operating. Moreover, these surgeons set the
operating room schedule for their own patients in conjunction with an integrated schedule for use
of these theaters. Thus, they know when they are going to operate and therefore when they need
to see their patient beforehand and what lab results they need to have in hand before the scheduled
surgery. This enables then to take steps, such as reminders to the labs, to assure that they have
these results on time. In many ways, the new procedure gives the surgeon more control over the
flow of the process and seems to heighten a sense of obligation to assure that the patient moves
smoothly through the process leading up to the surgery. The result of these changes, as shown
in Figure 1.4, is that, in the eight 8 weeks following, the average number 7 of days waiting in hospital for surgery 6 dropped to about 1.5 days and
appeared to be leveling off under the 5 Days new system at about 1.1 days. This is 4 compared to the average 5.8 days in 3 the eight weeks preceding the 2 changes. The team was quite gratified 1 by this outcome, feeling that by 0 7.4 5.6 7.1 5.6 4.1 2.1 1.4 1.1 15- 31- 15- 31- 15- 29- 15- 31- 15- Dec Dec Jan Jan Feb Feb Mar Mar Apr reducing the time patients must spend
in hospital before surgery to such a Process modified large degree, they obviously are saving
hospital “hotel” costs, are reducing the FIGURE 1.4 HALF-MONTH AVERAGE WAITING TIME IN HOSPITAL FOR SURGERY patient’s exposure to nosocomial
infection, are reducing patient stress,
and generally are producing a more satisfactory experience for the patient and the family. 15 1.1 16 CASE TWO: MOTHERS’ MEMORIAL HOSPITAL, LODZ, POLAND REDUCING REPEATED LABORATORY TESTS RESULTING FROM PROCEDURAL THE QUALITY IMPROVEMENT TEAM: mgr. farm. Malgorzata Majer, Chief,
Economics Section; mgr. pielgn. Anna
Wisniewska, Nurse; lek. med. Michal
Krekora, Physician; mgr. farm. Miroslaw
Szeligowski, Chief, ClinicalPharmacology
Laboratory. ERRORS Coach/Facilitator: Sabina Lyson, M.Soc.
National Center for Quality Assessment Edited by Stewart Blumenfeld, Dr.P.H., CPHQ
Quality Assurance Project
Center for Human Services Problem Statement : Many blood tests and urinalyses requested by physicians in the pediatric and obstetrics-
gynecology wards must be repeated due to procedural errors. The result is delay in getting final
results to the physician and unnecessary costs due to rework. The team worked from the following timetable: WEEK 1 WORK
PHASE 2 3 4 5 6 7 8 9 10 11 12 1 2 Problem
analysis Design instruments, collect data 3 4 5 6 Analysis,
solutions Analyze data,
design solutions Implementation and data
collection Data analysis (after
solutions
implemented) Evaluation of
results FIGURE 2.1 TIMETABLE FOR CARRYING OUT THE QUALITY IMPROVEMENT ACTIVITY 17 Problem Analysis : The first part of the analysis comprised a flowchart
to examine the current process, beginning with the
ordering of a test by a physician all the way
through to the reporting of the results to the
doctor. The flowchart developed by the team is
shown in Figure 2.2. This detailed analysis of the
process by the team led to a much greater
appreciation of the complexity of what is often
regarded as a simple (“routine”) process and the
numerous places it can deviate from the assumed
“standard procedure”. Once the process had been flowcharted, the team
developed a cause-effect diagram to speculate on
possible reasons for errors. This informed
guessing then was used to guide a data-collection
effort to measure the frequency of actual errors by
type. The team focused on potential errors related
to staff actions, equipment problems, and systemic
procedural impediments to minimizing errors
(Figure 2.3). The diagram allowed the team to
reduce the number of variables to be measured to
a manageable level. Based on the cause-effect diagram, the team
decided for its first quality improvement effort to
focus on fifteen types of problems. These were: • Unclear description of the test desired • Poor quality of test tubes and capillary tubes • Wrong timing of collection (e.g., non- fasting) • Collection during IV infusion • Insufficient blood taken • Air in capillary tube • Sample not mixed adequately • Incorrect ratio of blood to anticoagulant • Lipemia Physician orders lab work Nurse accepts order and fills form Order clear? N Prepare disposable
collection outfit Appropriate
syringe & needle? Y N Prepare set of tubes Correct
type clear? Correct tubes
available? N Y Y N Collect material, note time Transport to lab Material received
at lab, note time Y Material collected
as ordered? Is the sample
acceptable? Y N N A Y B A Initial work-up
of material Results in
believable range? Sample sent to lab
analytical room Sample acceptable
to lab? Sample analyzed Quality control: Analysis
performed correctly? Standard result? Result
recorded Reported to
physician Is result nevertheless
believable? Any material
left? Any material
left? Y Y Y Y N Y N N Y Y N B N N N FIGURE 2.2 LAB WORK FLOWCHART 18 Unnecessary
Repeat Lab Tests PEOPLE EQUIPMENT METHODS Poor Professional Training Lack of motivational system Insufficient training No funds Weak supervision No funds QC principles
not observed Lack of motivation system No funds Lack of a QA system No funds Poor disposable equipment Poor quality No funds Not properly selected Personnel
not trained Lack of clear
procedure Damaged equipment Infrequent use No funds Poor maintenance No funds Unskilled personnel No funds Incorrect collection time No procedures Staff not well-trained No training/supervision Lack of motivation system No funds Poor storage and transport No procedures Staff not well-trained No training/supervision Lack of motivation system No funds Material incorrectly collected Material scanty Improper collection Faulty patient
objective Personnel not
well-trained Wrong blood-coagulant ratio No procedures Personnel not well-trained Incorrect order description No training/supervision Staff careless No procedures No supervision Lack of motivation system No funds FIGURE 2.3 CAUSE AND EFFECT DIAGRAM • Reagents out of date • Repeating tests because of lack of confidence in equipment • Apparatus out of calibration • Apparatus otherwise broken • Other causes A data collection sheet was designed and the frequency of each problem was tracked over a three-
week period. Once the data were in, the team decided that the problems could be condensed into
seven categories, which were then cast as a Pareto chart. As may be seen, the team discovered
that three classes of problems accounted for 80% of repeat tests. Because a fourth problem was
almost as frequent as the third, the team hoped to tackle it as well. Thus, four problems were
considered for improvement intervention activities: those related to malfunctioning analytical
apparatus, to sample collection, to transport and/or storage of samples, and to documentation or
writing of orders. Ultimately, they decided that in the short time available for the quality
improvement exercise it would not be feasible to deal with the issue of malfunctioning equipment
which, in good part, was attributable to old, somewhat worn out equipment that required
replacement (and therefore the attendant funds—which are not available). 19 Solutions and Results The interventions designed by the team consisted of development of very specific standards and
job aids for collecting blood samples and for transporting and storing the samples, followed by a
review and discussion of the standards with the nurses and technicians responsible for these
activities. In keeping with the quality management principles the team had learned, they tried as
much as possible to involve these workers in the discussions of why the standards were necessary,
as opposed to simply declaring something like “these are the standards and they must be followed After the training and indoctrination of the nurses and technicians, data were collected for the
next three weeks on the same set of problems that had been tracked before. The results are
shown in Table 2.1. TABLE 2.1: FREQUENCY OF ERROR, BY TYPE, PRE-/POST-INTERVENTION Cause Number Pre- intervention Number Post- intervention Percentage Reduction (Increase) Apparatus deficiencies 108 110 (2) Collection errors 524 302 42 Transport/storage errors 165 112 32 Order clarity 154 138 10 Analyzer/reagent 108 110 (2) Other causes 82 90 (10) Quality of disposable outfit 6 9 (50) Totals 1763 1437 Ave Change=18% The three shaded problem areas were the subject of intervention. As may be seen, significant
reductions in the numbers of re-works were accomplished in these areas, while the others were
relatively unchanged. From these results, the quality improvement team concluded that (1) their
targeted quality improvement efforts were effective, and (2) the QI process that they had learned
and applied works well in their context. The team went one step further. During the training sessions, the QAP advisory team had
expressed its conviction that “quality does not cost, quality pays”, i.e., that quality improvement
often translates directly to cost reduction. The team therefore estimated the cost of the amount of
potential re-work they had saved, using their pre-intervention frequency data as their baseline. On
that basis, they estimated that in the three-week post-intervention period the two departments
involved had saved approximately 5,714 zl, approximately US$2,200. Projecting this to a full 20 year yields an approximate saving of $36,000 in the first year alone. They did not estimate the
cost of the QI exercise itself to see what the payoff ratio might be, but even if the time the team
took for training, the cost of travel and subsistence for the team members in Krakow, and the cost
of the Polish trainers/facilitators is taken into consideration, their investment would not come to
half the saving in one year alone, to say nothing of succeeding years. Moreover, this team, while
it might still benefit from continued facilitation by the NCQA staff, will not require anything
comparable to the intensive--and relatively expensive--initial training it received. Thus, the payoff
ratio for a future stream of benefits would be even greater. 21 22 CASE THREE: OPHTHALMOLOGICAL HOSPITAL OF KRAKOW REDUCING WAITING TIME FOR AMBULATORY SURGERY THE QUALITY IMPROVEMENT TEAM: Coach/ Facilitator: Sabina Lyson, M.Soc. lek. med. Marta Kuczma, Ophthalmological National Center for Quality Assessment Surgeon lek. med. Pawel Papee, Hospital Edited by Stewart Blumenfeld, Dr.P.H., CPHQ Director lek. med. Teresa Wojowicz, Surgeon Quality Assurance Project Joanna Werszler, Sr. Medical Statistician- Center for Human Services Economist Marta Synal, Senior Nurse lek.
med. Maria Pociej-Zero, Data Analyst Teresa
Domagala, Sr. Surgical Nurse Assoc. Prof.
Jan Pociej, Consultant Problem Statement : The Ophthalmologic Hospital is a specialty hospital serving the populations of four voivodships,
including Krakow itself. It is heavily used and as a result the staff receive many complaints from
patients concerning the long wait for services. Ambulatory surgery is one of the newer services
provided by the hospital, but there often is a long wait for this service. The clinic staff believe that
it is possible to reduce this wait, both to increase the satisfaction of the patients and because
delayed surgery in some conditions (severe corneal abrasion or ulceration, for example) may lead
to complications and a worse situation for the patient. Problem Analysis : A review of records of all patients who received outpatient surgical services in three months
(October and November 1995, January 1996—December was omitted because the holidays
reduce the number of patients seeking service, as well as the number of surgeons available for
service) preceding the quality improvement intervention showed a consistent pattern of waiting
after the decision was made: 76, 69, and 67 days. The team went directly to cause-effect analysis to help them think through probable causes for
unnecessary delay. The cause-effect diagram is shown in Figure 3.1. Of the causes shown in the
diagram, the ones the team thought most likely to cause delay were organizational—mainly a
shortage of operating slots—and inefficiency—wasted slots due to problems with patients. Solutions and Results : The team chose four interventions: • Increase the number of ambulatory surgery days from one to two; • Increase the number of surgeons available to perform surgery; • Increase the number of surgeries performed each day; 23 • Reduce patient ­ related wastage
of available slots. The first two of these
interventions were
accomplished basically
by fiat, clearly
demonstrating the value
of having top-level
management closely
involved in the quality
improvement process.
In this case, the Director
of the hospital (Dr.
Papee) was a co-leader
of the team. He became
convinced of the
seriousness of the Long wait
for surgery Poor use of working time Poor training Poor attitude toward work Lack of
motivation Too few surgeries being done Inefficient use of equipment Only 1 surgery day per week Small number of patients serviced per day System deficiencies Too few surgeons available to ambulatory clinic No list of reserve patients Hasn't complied with pre-op instructions Disqualification prior to surgery Patient doesn't show Stress/anxiety Illness Lack of discipline STAFF ORGANIZATION PATIENTS FIGURE 3.1 CAUSES OF DELAY OF AMBULATORY OPHTHALMOLOGIC SURGERY up Patient arrives unprepared problem and simply authorized a reorientation of the hospital’s assets, in this case, it’s surgical
staff. This enabled the outpatient surgery clinic to add more surgeons to its roles and to add a
second day of surgery each week. Increasing the number of surgeries done per day was a different problem. This was more a matter
of motivation than increasing resources. It was pointed out to the head of the ambulatory surgery
department that the surgeons did not receive any extra incentive for seeing more patients. It is
not clear that this issue was resolved completely. Certainly, no extra compensation was provided.
The team members do feel, however, that, once again, the presence and awareness by the Hospital
Director of the problems caused by a relatively leisurely daily pace of surgery did have an impact.
In any event, the degree of improvement suggests that the clinic now is turning out more surgeries
than can be accounted for by simply doubling the potential number of surgery-hours available. To help with the problem of patients either showing up for their surgery in a condition which
makes surgery inappropriate or not coming for their appointment at all, standardized written
instructions were produced to be given to the patient at the time the appointment was set up.
These are reproduced on the following page. 24 INFORMATION FOR AMBULATORY SURGERY PATIENTS Esteemed Patients! Our hospital has begun ambulatory surgery for certain cases. A specialist determines the need for
surgery during your visit to the polyclinic and schedules the day. We would like to provide you
with the following information and remarks: 1. On the day of surgery, the patient should register at the clinic at 0930 and wait for surgery. 2. Surgery is performed under local anesthesia. 3. To qualify for surgery that day, the patient: A. If female, can not be menstruating; B. Must have a blood pressure in the normal range; C. Must bring standard pre-operatory laboratory results [N.B.: CBC and coagulation time— apparently a pre-op requirement in Poland widely known to medical personnel. –SNB].
These tests are available at the regional outpatient clinics or cooperatives. 4. If a need arises for additional histopathology tests arises, the patient must cover the additional cost of 6.60 Zl for the laboratory. 5. If, for personal reasons, you will be able to come as scheduled, please call us and arrange for time. 6. We have to apologize for lack of space and for all the inconvenience this brings. We hope for your indulgence and understanding. 7. We wish all our patients a speedy recovery and a good outcome. The team also began developing and using a list of patients who stated they could come in for
surgery on short notice. The chart in Figure 3.2 compares the average waiting time for ambulatory surgery before and
after the changes implemented by the quality improvement team. The three-month average before
the change was 71 days; for the three months afterward the average declined to ten days. 25 In summing up their
results, the team pointed
out that before this
exercise, many of the
senior hospital staff were
sure that no improvement
could be obtained without
some significant infusion of
funds. (To his credit, the
hospital director, reputedly
a dynamic leader, although
a little skeptical, was
willing to try.) Now,
according to the team’s
leader, there is a swelling
of enthusiasm for this QA
methodology which many,
including the Director,
would like to continue, seeing this first activity as a “prelude” to establishing a program of
continuous quality improvement. The team has asked NCQA for continued assistance in this
regard. 69 67 14 7 9 76 0 20 40 60 80 Oct-95 Nov-95 Jan-96 Feb-96 Mar-96 Apr-96 Waiting Time (Days) CHANGE FIGURE 3.2 WAITING DAYS FOR AMBULATORY SURGERY BEFORE/AFTER MODIFIED PROCESS 26 CASE FOUR: JOHN PAUL II SPECIALIST HOSPITAL, KRAKOW IMPROVING HEPATITIS B VACCINATION RATE IN HOSPITAL STAFF THE QUALITY IMPROVEMENT TEAM: Coach/Facilitator: lek. med. Anetta Pawlus lek. med. Barbara Baka-Cwierz, National Center for Quality Assessment Chief,Hepatitis Outpatient Clinic; lek. med. Edited by Stewart Blumenfeld, Dr.P.H., CPHQ Zbigniew Grochowski, Department Chief; lek. Quality Assurance Project med. Malgorzata Kalinowska, Neurologist; Center for Human Services mgr Grazyna Kwarciak, Chief, Bacteriology
Unit; lek. med. Ewa Marek, Pulmonologist. Problem Statement Hospital policy requires that all personnel shall have up-to-date vaccination against Hepatitis B
virus 4 . The policy has not been enforced and as a result it was suspected that a substantial number of staff either never have been vaccinated, have not completed their series, or are not current on
their booster. The subject staff work in the two pulmonary units of the hospital and comprise a
total of 82 persons. Problem Analysis: Although recent vaccination is on an individual’s medical record at the hospital’s polyclinic,
vaccinations are not a fixed part of personnel records in the hospital and it was therefore not
possible to reliably ascertain the vaccination status of staff members simply by a review of those
records. The team’s approach, therefore, was a combination of identifying those staff who did
have a record of vaccination in the polyclinic and interviewing all the others. The interviewees,
whether they claimed they had been vaccinated in the past year or not (some said they had been
vaccinated at some facility where they had worked before), underwent serotesting. Of the 82
staff, 57 either had had a recent vaccination or were shown by the lab to have a protective titer.
Thus, 25 staff, or 30%, were out of compliance with the regulation. Prior to selecting an intervention, the team did a cause-effect analysis to help understand why the
policy was not being followed. They did not do a flowchart of the process because they felt that
the process was so unsystematic as to be almost nonexistent. The cause effect diagram is shown
on the next page. 4 Poland uses a three-shot series at t 0, 1 month, and 6 months, with boosters thereafter at 5 year intervals. 27 Solution and Results: The team felt the susceptible status of such a large proportion of staff called for rapid action. The
solution chosen consisted of both an educational and a monitoring component. The entire was
staff was called together and the hospital’s policy requiring all staff to have been immunized was
restated. The threat of HBV to clinical and support staff was pointed out and discussed at the
same time. Thereafter, a plan was developed to individually contact the 25 staff who needed
immunization and press them to arrange an appointment at the polyclinic to start their series. In
addition, a scheme was set up to monitor the progress of these individuals through their series.
Table 4.1 shows the immunization status of the staff by professional category before and after the
intervention. As may be seen in ORGANIZATION STAFF Table 4.1, before
the increased
immunization
action began, the
physicians on the
staff were
proportionately the
most non­
compliant of the
staff categories,
with six out of the
seventeen doctors
either
unvaccinated or
overdue for a
booster. At the
end of the
exercise, they still
were. Among the
physicians, the
doctor who Long wait
for surgery Poor use of working time Poor training Poor attitude toward work Lack of
motivation Too few surgeries being done Inefficient use of equipment Only 1 surgery day per week Small number of patients serviced per day System deficiencies Too few surgeons available to ambulatory clinic No list of reserve patients Hasn't complied with pre-op instructions Disqualification prior to surgery Patient doesn't show Stress/anxiety Illness Lack of discipline PATIENTS FIGURE 4.1 CAUSES OF DELAY OF AMBULATORY OPHTHALMOLOGIC SURGERY up Patient arrives unprepared needed to get a booster had done so, and one of the doctors who needed to start the series from
the beginning also had done so. That, of course, left four of the five doctors who needed to start
the series having taken no action more than two months after being reminded of the hospital’s
policy on HBV immunization. Two nurses also had not begun their series. In their follow-up attempts to move non-complying staff to take action, some team members
discussed the situation with these staff. While they expected to hear excuses about not having
time, to their surprise, they discovered that several of the six people (four doctors and two nurses)
actually held considerable misconceptions about the threat and the vaccine itself. By and large,
the doctors just did not view the likelihood of their contracting the virus as significant and thus
not worth worrying about. Although the team did not present data on the frequency of HBV
infection among unvaccinated hospital personnel in Poland, hepatitis B is not a particularly rare 28 disease in the country. The team even mentioned that one of the outcomes of this present activity
might be to reduce lawsuits filed against the hospital by patients charging that they caught the
disease during the course of a stay in the hospital. While the feeling of very low risk by some medical staff is, if misguided, not very surprising, the
responses of the two nurses is. They expressed concern that the vaccine might, in fact, give them
hepatitis. It is not clear whether this fear is completely unfounded or if bad batches of vaccine
have been released in the country in the past. The team members did seem to feel that the risk not
being immunized is much greater than any threat from the vaccine. TABLE 4.1 STAFF VACCINATION STATUS BEFORE/AFTER INTERVENTION Ward Attendant Category MD Nurse Other Totals N= 17 39 19 7 82 Fully Vaccinated 11 31 11 4 57 (70%) Before Partially Vaccinated 1 2 1 1 5 (6%) Unvaccinated 5 6 7 2 20 (24%) Booster Obtained 1 2 1 1 5/5 After Started Series 1 4 7 2 14/20 Noncompliant 4 2 0 0 6/25 Concerning those staff who have refused to comply with the hospital’s policy, to date no effort
has been made to force compliance through administrative sanctions. Concluding their presentation, the team noted the need to continue the system that was set up to
check on and track the immunization status of all staff in their unit, as well as to intensify staff
education on the need for maintaining HBV immune status. They did not talk about installing
enforcement measures to deal with knowledgeable, but recalcitrant, staff. The team summed up what it saw as the benefits of their effort as follows: • Increased staff awareness of the danger of HBV infection in the hospital • Greater protection against HBV infection for the staff • Greater protection for patients and families vis-a-vis the staff • Reduced absence due to infection in staff 29 • Hospital costs saved by averting hospitalization of staff for HBV • Costs of averted lawsuits by patients charging they contracted hepatitis in hospital. They also stated that, while their quality improvement dealt only with the two pulmonology units,
the Chief of Hospital is watching their work and has expressed an interest in applying the
methodology to increasing compliance with hospital policy on all immunizations hospital-wide. 30 CASE FIVE: POLICEMEN’S HOSPITAL, KRAKOW REDUCING OUTPATIENT WAITING TIME FOR ULTRASOUND EXAMINATION THE QUALITY IMPROVEMENT TEAM: Coach/Facilitator: Kinga Stanach, M.S.W. Dr. Tadeusz Mazurkiewicz, Director of National Center for Quality Assessment Medicine; Dr. Marek Rosa, Assistant Chief, Edited by Stewart Blumenfeld, Dr.P.H., CPHQ Ultrasound Unit; Dr. Ewa Glinka, Sr. Assistant, Quality Assurance Project
Obstetrics and Gynecology; Henryka Center for Human Services Szymanska, Chief of Nursing; Jan Joskiewicz,
Chief of Diagnostic Laboratories; Dr.
Katarzyna Kotula, AssistantinInternal
Medicine; Dr. Renata Saganowska, Assistant
in Pediatrics. Problem Statement : It is in accordance to hospital policy to give inpatient needs priority over outpatients in order to
minimize length of stay of the former. Although the ultrasound unit was able to accommodate
inpatient requirements in a timely manner, outpatients were forced to wait approximately two
weeks for their examination. Hospital management and the ultrasound clinic staff felt that even
though inpatients should still receive priority, it might be possible to reduce the delay for
ambulatory patients. Problem Analysis: The team started their analysis
of the problem by flowcharting
the process by which patients
referred for ultrasound
ultimately receive their
examination. The flowchart is
shown in Figure 5.1. The team
next examined potential causes
for delays in service by means of
a cause-effect analysis; their
fishbone diagram is shown in
Figure 5.2. When the fishbone
was completed, the consensus
of the team was that inefficient
use of the equipment was
probably the major cause for
delay. A review of the clinic’s
most recent 150 records did indeed show that a startling 48% of all booked outpatient ultrasound
time-slots went unused. Prior to this quality improvement undertaking, the team sensed that Initial
examination Requires
ultrasound? Referred to
US clinic Registered Given
appointment Wait Ultrasound
performed Results
interpreted Treatment/
discharge Y N FIGURE 5.1 ULTRASOUND REFERRAL PROCESS 31 unused time-slots might be a major contributor to the clinic’s delay in serving outpatients , but
they were unaware of the magnitude of the problem. Detailed examination of PATIENT STAFF the records showed that
an incorrect initial
diagnosis (“incorrect” in
the sense that an
ultrasound examination
could not contribute
significantly to a correct
diagnosis by the referring
physician--gastric ulcer,
duodenal ulcer, and
colitis were the most
common diagnoses)
accounted for 50% of
wasted referrals.
Although these referrals Ultrasound exam
delayed Not competent Wrong referral Doesn't come for
appointment Not properly
prepared for exam Patient has
forced referral Only one apparatus
available Inefficient organization of
apparatus working time Overutilization Other diagnostic method preferable Poor organization of
available physician time EQUIPMENT were booked into time- METHOD slots, they were rejected FIGURE 5.2 CAUSES OF DELAYED ULTRASOUND FOR OUTPATIENTS when the patient
registered at the clinic for
his her examination. In addition to unjustified referrals, team was able to identify several other high-frequency causes
of booked time-slots not being used. As may be seen in the Pareto chart in Figure 5.3, patients
who did not show up for their appointment accounted for another 18% of unused slots, and
“forced” referrals, that is, cases in which the physician succumbs to pressure from the patient even
though the provider is
aware that an ultrasound is 150 21 27 75 27 ? ? ? ? 50% 68% 86% 100 probably unnecessary, for
yet another 18%. The 120 80 latter was maintained as a 90 60 Number of separate category from the Cumulative larger “incorrect diagnosis” Rejected Referrals Percentage (N=150) 40 category because the team 60 felt that their solutions 30 20 should deal with that
problem separately from 0 pure lack of knowledge of Initial the applicability of Diagnosis 0 Pt. No- Pt. Forced Other Show Referral ultrasound as a diagnostic FIGURE 5.3 CAUSES OF WASTED ULTRASOUND EXAMINATION TIME SLOTS tool. 32 Solution and Results: The team decided to take an educative approach to solving a significant part of the problem. Up
to that time, the ultrasound unit had relied upon the original training and experience of the various
providers who referred to the clinic to use the service appropriately. Seeing that that approach
allowed for too much variation, they decided to develop and promulgate very specific standards
for referral to the ultrasound clinic. They did this and then held a series of meetings with the
referring physicians to show the results of the analysis of incorrect referrals, the result of so many
incorrect referrals (a protracted wait for service for outpatients), and thus the need for strict
adherence to the new guidelines. Their feeling was that this intervention might affect not only the
large number of incorrect diagnoses, but also the number of times the primary physician gives in
to the demand of a patient that he or she receive an ultrasound when it really is not indicated.
They then had six weeks to measure the result of their intervention before preparing their data for
presentation. Over the course of the six weeks, the number of total outpatient referrals for ultrasound
procedures decreased by 41% and, tellingly, the percentage of unused slots declined from 48% to
19%. Table 5.1 shows the change in unused slots and major reasons. Examination of 100 patient
records showed that the average wait declined from approximately 14 days to seven days. TABLE 5.1 WASTED ULTRASOUND TIME-SLOTS BEFORE AND AFTER INTERVENTION BY THE QUALITY IMPROVEMENT TEAM Percent of All Booked Slots Going Unused Percent of All Slots
Unused Due to
Incorrect Diagnosis Percent of All Slots Unused Due to No- Show Patients Percent of All Slots Unused Due to “Forced Referral” Percent of All Slots Unused
Due to Other Causes Before 48% 24% 9% 9% 7% After 19% 14% 2% 3% While the substantial drop in unjustified referrals and the subsequent reduction in waiting period
was gratifying to the team, a review of records showed that incorrect initial diagnosis now
accounted for 73% of incorrect referrals, or 14% of all referrals. Thus, the team feels that further
investigation of the reasons for continuation of these errors would be useful, with possible reasons
being lack of clarity of the guidelines, non-acceptance of these standards by some physicians, or
culture-related inability of some physicians to resist pressure from some patients. In a significant
move to continue reducing the problem of wasted time-slots, the ultrasound clinic is instituting a
permanent mechanism to monitor unjustified referrals with the intent of feeding back this
information periodically. 33 34 CASE SIX: SOLIDARITY FOUNDATION CENTER FOR ONCOLOGICAL DIAGNOSTICS, LEGNICA REDUCING WAITING TIME AND INCREASING COMFORT FOR MAMMOGRAPHY PATIENTS THE QUALITY IMPROVEMENT TEAM: Coach/Facilitator: Kinga Stanach, M.S.W. lek. med. Dorota Czudowska, Clinic Director National Center for Quality Assessment Czeslawa Kupec, Administrator; Edited by Stewart Blumenfeld, Dr.P.H., CPHQ Jozefa Staniszewska, Midwife and Staff Quality Assurance Project Coordinator; Regina Styczen, X-ray Center for Human Services Technician. Problem Statement: Many patients had to wait several hours after a mammogram was taken before they could be
examined and counseled to complete their visit. Moreover, the area where they had to wait was
not pleasant and did not facilitate the patient’s productive use of this time, such as by receiving
educational information regarding early recognition and self-diagnostic techniques. Patients often
registered their dissatisfaction with the situation informally, and the clinic staff had to agree with
them. Timetable: The quality improvement team worked from the following summarized timetable: Phase I: January 15 - February 2 • Team training in QI techniques, patient flow analysis, cause-effect analysis, identification of required information Phase II: February 2-23 • Develop patient survey instrument and survey plan Phase III: February 23 - March 13 • Administer survey Phase IV: March 13-23 • Analyze survey results, discuss with staff, propose and select interventions 35 Phase V: March 23-30 • Develop procedures for intervention Phase VI: March 31 - April 1 • Implement changes Phase VII: April 2-15 • Post-intervention survey of patients Phase VIII: April 15-22 • Analysis of data, discussion of results with staff Phase IX: April 22-25 • Preparation for 4/26 conference in Krakow (presentation and
storyboard) Problem Analysis: To begin the analytic process, the team did
two flowcharts. The first flowchart traced
the path of patients between their arrival
and when they are seen for consultation
following their mammogram. In order to
understand the minimum time a patient
might take in this process, a second
flowchart was done of the same process,
this time showing only its major steps, but
adding the minimum time each step would
take under ideal conditions, that is, as if no
other patients were being served and a
patient could travel through the system
without any delay between steps. These two flowcharts are shown
in Figures 6.1 and 6.2. Cursory examination of the two flowcharts
led the team to believe that the system could be improved
sufficiently so that most patients should not have to wait more than
two hours for a doctor to see them after their mammogram had been
taken. Before making any changes in the system, however, the team sought
to achieve a clearer understanding of the problems that might be
leading to delays through the use of a cause-effect diagram. The
cause-effect diagram is shown in Figure 6.3. In order to get quantitative data on the interval between
mammography and meeting with the physician, the team developed
a questionnaire which was administered to 200 patients coming to FIGURE 6.1 DETAILED PROCESS Refer out/
reschedule Examine patient Order ultrasound
exam? Confer with
patient Ultrasound exam Wait Y N III Roman numerals refer to
sections on time flowchart Register patient? Patient receives/
fills questionairre Mammogram done Physician interprets mammogram Patient arrives Physician available? N Y I II IV Y N I Registration 10 min II Mammography 8-12 min III Wait for consultation 15 min Consultation IV 5-15 min Max S S =52 min FIGURE 6.2 TIMED FLOWCHART 36 the clinic for mammography.
The questionnaire is shown on
page 38. As may be seen, the
team also felt that since some
waiting is almost inevitable this
time could be converted to a
productive use, providing
patients with educational
information concerning breast
cancer diagnosis, treatment,
and prevention. As noted in
the problem statement, the
team also was concerned with
the patients’ perception of the
comfort of the waiting area. One hundred thirteen
questionnaires were returned
to the Centre. Waiting times
are shown in the following table: Prolonged
waiting time FIGURE 6.3 POTENTIAL CAUSES OF PRONGED WAITING FOR CONSULTATION X-RAY TECHNICIAN 5-hr workday Workload REGISTRATION Too few office staff Insufficient information Workload PATIENT Too many patients Stress before
consultation Lack of funds Fear of not receiving
consultation PHYSICIAN Short time in clinic
(2 pm - 6 pm) Few physicians available Rare speciality Lack of funds EQUIPMENT Only 1 apparatus Lack of funds METHOD Consultation standards
not followed Heavy workload Incomplete information TABLE 6.1 WAITING TIMES PRIOR TO INTERVENTION (113) Wait Percentage Cumulative Percentage <1 hr 29 29 1-2 hrs 35 64 2-3 hrs 18 82 3-4 hrs 12 94 >4 hrs 6 100 Thus, the team discovered that 18% of patients had to wait at least three hours between their
mammogram and their consultation with the gynecologist. Ninety-four percent of respondents
said that they had been told that there would be a delay before the physician could examine them
and talk with them. Eighty-one percent said that they had remained in the waiting room for that
period, 9% said that they had waited at home, and another 5% said they had gone shopping. 37 Solutions and Results: The team decided that, for the time being, a wait for service by a gynecologist of up to three
hours was acceptable, but that few or none of their patients should have to wait longer than that.
Studying the results of the cause-effect analysis, the team felt that the prolonged waiting time
could reasonably be attributed to the following causes: 1. There is a single mammography machine to service a heavy demand for service; 2. There are relatively few gynecologists available to the clinic; 3. The mammography technicians tended to be available toward the morning hours, while the doctors were more available in the afternoon, so more mammograms were done in the
morning and more consultations were done in the afternoon; 4. Clinic patients in Poland have a mind-set that causes them to arrive quite early for their appointments (apparently under the misapprehension that they are more likely to be served
that day if they enter the queue early). Following some brainstorming, the quality improvement team decided to take the following steps: 1. Reorganize the flow of work in the x-ray room by staggering working hours of the two technicians to make only one available early and one late in the day, with the two of them
alternating rest and work during the middle part of the day (there being only one x-ray in the
clinic); 2. Strengthen the appointment system by giving the patient a slip showing the time of her appointment, both for the mammogram and with the doctor; 3. Train the registration office staff to inform patients that there might be some waiting time to see the doctor and encourage them to come for the mammogram right at the appointed time; 4. Improve waiting room conditions by providing newspapers, magazines, and educational materials; 5. In 1997, move to a more convenient location and begin providing in the waiting room a taped presentation on self-examination and other preventive measures. Except for item 5, these changes were effected in the first two weeks of April. During this period,
41 patients responded to the same survey as before. As may be seen in Table 6.2, below, the appointment system and the work schedule
reorganization were successful in helping to meet the target outcome: the percentage of patients
who had to wait more than three hours for their consultation with a physician did indeed drop
considerably, from 18% down to 7%. At the same, however, the percentage of patients waiting
two hours or less dropped from 64% to 57%, and the percentage who passed through the system in the near-ideal time of less than an hour dropped from 29% to 13%. 38 TABLE 6.2 PRE-/POST-INTERVENTION DELAY BETWEEN MAMMOGRAPHY AND CONSULTATION WITH PHYSICIAN Waiting Time Percentage Before Intervention N=113 Cumulative Percentage After Intervention N=41 Cumulative <1 hr 29 29 13 13 1-2 hrs 35 64 44 57 2-3 hrs 18 82 36 93 3-4 hrs 12 94 2 95 >4 hrs 6 100 5 100 The quality improvement team learned a couple of valuable lessons from this result. First, that
not all interventions produce unequivocal “improvements”; and second, that it is essential to
check on the outcome of an intervention and not to assume that the problem analysis yields such
perfect understanding of a problem that a correct solution is inescapable. Nevertheless, overall,
for a first pass at the problem, the team was reasonably satisfied to reduce the especially-long wait
time for many patients. Their confidence in their decision criterion (reduce the frequency of the 3-
hour-plus wait) was bolstered by a drastic reduction of complaints in the patient
complaint/suggestion box concerning waiting time following the change in the system. Still, the
team realizes it has some distance to go because, among respondents to the questionnaire, the
percentage of patients who said their wait for the physician was fairly short or about right
increased only a little after the changes, from 45% to 51%. Because the mammography takes
longer than the consultation, the team feels it is essential to have a reservoir of patients waiting for
the doctor when she comes. At present, since the doctors work only in the afternoon, patients
who come in the morning inevitably are going to have a wait reaching upwards of three hours. It
is possible that, with more experience in tracking waiting time by time of arrival, the team could
refine the appointment scheme further to reduce the percentage of patients who wait more than
two hours. Two-thirds of the patients liked the appointment scheme, or at least the idea of one. Concerning conditions in the waiting area, although the staff were not satisfied, the patients who
responded to the survey before any changes were made apparently did not have too many
complaints: none said that conditions were less than satisfactory, 25% said the conditions were
satisfactory and the balance, 75%, said they were good or very good. The addition of newspapers
and magazines and other materials moved those numbers up only to 21% and 79%, respectively. 39 __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________ PATIENT INFORMATION QUESTIONNAIRE This anonymous questionnaire is designed to evaluate comfort of waiting for interpretation of
mammogram with the intent of making improvements. Please tick your choices and in the open
question do not share hesitate to share with us your opinions and suggestions. 1. Since your mammogram was taken, how long did you wait for your physician examination
and consultation? ? Less than 1 hr ? 1-2 hrs ? 2-3 hrs ? 3-4 hrs ? Over 4 hrs 2. Did anyone inform you about the necessity of waiting for consultation after your
mammogram? ? Yes ? No 3. If yes, was information provided ? Orally ? In writing ? Both 4. Do you consider the time of waiting ? Very long ? Fairly long ? About right ? Short ? Very short 5. Where did you spend your waiting time? ? In the waiting area ? Home ? Shopping ? At work ? Other 6. If you decided to spend your waiting time at the Centre, was that due to ? Fear of losing your turn ? It’s a pleasant atmosphere ? Long distance from home ? Bad weather ? Other 7. How would you rate the waiting conditions at the Centre? ? Very good ? Good ? Satisfactory ? Poor ? Very poor 8. What changes do you suggest to make waiting more pleasant both for you and for other
patients? Personal Data Year of birth: 19____ Education: ? Elementary ? Technical ? Secondary ? University Residence: ? Legnica ? Less than 50 km from Legnica ? More than 50 km from Legnica How long did it take to come from your home to the Centre: ____hrs ____min THANK YOU FOR FILLING THIS QUESTIONAIRRE 40 CASE SEVEN: ST. LUKE’S HOSPITAL, KONSKIE REDUCING THE PERIOD OF STAY IN THE ADMISSIONS ROOM PENDING ADMISSION OR DISCHARGE THE QUALITY IMPROVEMENT TEAM: Coach/Facilitator: lek. med. Anetta Pawlus lek. med. Wojciech Przybylski, Hospital National Center for Quality Assessment Director dr. n. med. Jozef Gaweda, Chief of Edited by Stewart Blumenfeld, Dr.P.H., CPHQ Rheumatology; lek. med. Rached Hadj Ali, Quality Assurance Project Center for Human Radiology Department mgr. Maria Lukomska, Services Administrator; mgr. Sabina Misztal, Chief
Nurse, mgr. Roman Jaskolski, Director,
Diagnostics Laboratory, piel. Anna Los,
Nurse, Dialysis and Nephrology Unit; piel.
Ewa Niewegloska, Nurse-Coordinator,
Outpatient Clinics Problem Statement :