Benchmarking in health care is defined as the continual and collaborative discipline of measuring and comparing the results of key work processes with those of the best performers 26 in evaluating organizational performance. There are two types of benchmarking that can be used to evaluate patient safety and quality performance. Internal benchmarking is used to identify best practices within an organization, to compare best practices within the organization, and to compare current practice over time.
The information and data can be plotted on a control chart with statistically derived upper and lower control limits. However, using only internal benchmarking does not necessarily represent the best practices elsewhere.
Competitive or external benchmarking involves using comparative data between organizations to judge performance and identify improvements that have proven to be successful in other organizations.
More than 40 years ago, Donabedian 27 proposed measuring the quality of health care by observing its structure, processes, and outcomes. Structure measures assess the accessibility, availability, and quality of resources, such as health insurance, bed capacity of a hospital, and number of nurses with advanced training. Process measures assess the delivery of health care services by clinicians and providers, such as using guidelines for care of diabetic patients.
Outcome measures indicate the final result of health care and can be influenced by environmental and behavioral factors.
Examples include mortality, patient satisfaction, and improved health status. Twenty years later, health care leaders borrowed techniques from the work of Deming 28 in rebuilding the manufacturing businesses of post-World War II Japan. The TQM model is an organizational approach involving organizational management, teamwork, defined processes, systems thinking, and change to create an environment for improvement.
This approach incorporated the view that the entire organization must be committed to quality and improvement to achieve the best results. CQI has been used as a means to develop clinical practice 30 and is based on the principle that there is an opportunity for improvement in every process and on every occasion.
CPI, an approach lead by clinicians that attempts a comprehensive understanding of the complexity of health care delivery, uses a team, determines a purpose, collects data, assesses findings, and then translates those findings into practice changes.
From these models, management and clinician commitment and involvement have been found to be essential for the successful implementation of change.
Shojania and colleagues 38 developed a taxonomy of quality improvement strategies see Table 1 , which infers that the choice of the quality improvement strategy and methodology is dependent upon the nature of the quality improvement project. Quality improvement projects and strategies differ from research: while research attempts to assess and address problems that will produce generalizable results, quality improvement projects can include small samples, frequent changes in interventions, and adoption of new strategies that appear to be effective.
The lack of scientific health services literature has inhibited the acceptance of quality improvement methods in health care, 43 , 44 but new rigorous studies are emerging. It has been asserted that a quality improvement project can be considered more like research when it involves a change in practice, affects patients and assesses their outcomes, employs randomization or blinding, and exposes patients to additional risks or burdens—all in an effort towards generalizability. Quality improvement projects and studies aimed at making positive changes in health care processes to effecting favorable outcomes can use the Plan-Do-Study-Act PDSA model.
This is a method that has been widely used by the Institute for Healthcare Improvement for rapid cycle improvement. The purpose of PDSA quality improvement efforts is to establish a functional or causal relationship between changes in processes specifically behaviors and capabilities and outcomes.
Langley and colleagues 51 proposed three questions before using the PDSA cycles: 1 What is the goal of the project? The PDSA cycle starts with determining the nature and scope of the problem, what changes can and should be made, a plan for a specific change, who should be involved, what should be measured to understand the impact of change, and where the strategy will be targeted. Change is then implemented and data and information are collected.
Results from the implementation study are assessed and interpreted by reviewing several key measurements that indicate success or failure. Lastly, action is taken on the results by implementing the change or beginning the process again. Six Sigma, originally designed as a business strategy, involves improving, designing, and monitoring process to minimize or eliminate waste while optimizing satisfaction and increasing financial stability. This method is applicable to preanalytic and postanalytic processes a.
This method is suitable for analytic processes in which the precision and accuracy can be determined by experimental procedures. One component of Six Sigma uses a five-phased process that is structured, disciplined, and rigorous, known as the define, measure, analyze, improve, and control DMAIC approach.
Next, continuous total quality performance standards are selected, performance objectives are defined, and sources of variability are defined. As the new project is implemented, data are collected to assess how well changes improved the process.
To support this analysis, validated measures are developed to determine the capability of the new process. Application of the Toyota Production System—used in the manufacturing process of Toyota cars 57 —resulted in what has become known as the Lean Production System or Lean methodology. This methodology overlaps with the Six Sigma methodology, but differs in that Lean is driven by the identification of customer needs and aims to improve processes by removing activities that are non-value-added a.
Steps in the Lean methodology involve maximizing value-added activities in the best possible sequence to enable continuous operations. Physicians, nurses, technicians, and managers are increasing the effectiveness of patient care and decreasing costs in pathology laboratories, pharmacies, 59—61 and blood banks 61 by applying the same principles used in the Toyota Production System.
Two reviews of projects using Toyota Production System methods reported that health care organizations improved patient safety and the quality of health care by systematically defining the problem; using root-cause analysis; then setting goals, removing ambiguity and workarounds, and clarifying responsibilities.
When it came to processes, team members in these projects developed action plans that improved, simplified, and redesigned work processes. Root cause analysis RCA , used extensively in engineering 62 and similar to critical incident technique, 63 is a formalized investigation and problem-solving approach focused on identifying and understanding the underlying causes of an event as well as potential events that were intercepted.
The Joint Commission requires RCA to be performed in response to all sentinel events and expects, based on the results of the RCA, the organization to develop and implement an action plan consisting of improvements designed to reduce future risk of events and to monitor the effectiveness of those improvements.
RCA is a technique used to identify trends and assess risk that can be used whenever human error is suspected 65 with the understanding that system, rather than individual factors, are likely the root cause of most problems.
An RCA is a reactive assessment that begins after an event, retrospectively outlining the sequence of events leading to that identified event, charting causal factors, and identifying root causes to completely examine the event. Using a qualitative process, the aim of RCA is to uncover the underlying cause s of an error by looking at enabling factors e.
Those involved in the investigation ask a series of key questions, including what happened, why it happened, what were the most proximate factors causing it to happen, why those factors occurred, and what systems and processes underlie those proximate factors.
Answers to these questions help identify ineffective safety barriers and causes of problems so similar problems can be prevented in the future.
Often, it is important to also consider events that occurred immediately prior to the event in question because other remote factors may have contributed. The final step of a traditional RCA is developing recommendations for system and process improvement s , based on the findings of the investigation.
Due the breadth of types of adverse events and the large number of root causes of errors, consideration should be given to how to differentiate system from process factors, without focusing on individual blame.
The notion has been put forth that it is a truly rare event for errors to be associated with irresponsibility, personal neglect, or intention, 71 a notion supported by the IOM. Even the majority of individual factors can be addressed through education, training, and installing forcing functions that make errors difficult to commit.
Errors will inevitably occur, and the times when errors occur cannot be predicted. In health care, FMEA focuses on the system of care and uses a multidisciplinary team to evaluate a process from a quality improvement perspective. This method can be used to evaluate alternative processes or procedures as well as to monitor change over time.
To monitor change over time, well-defined measures are needed that can provide objective information of the effectiveness of a process. In , the Joint Commission mandated that accredited health care providers conduct proactive risk management activities that identify and predict system weaknesses and adopt changes to minimize patient harm on one or two high-priority topics a year. There are five steps in HFMEA: 1 define the topic; 2 assemble the team; 3 develop a process map for the topic, and consecutively number each step and substep of that process; 4 conduct a hazard analysis e.
In conducting a hazard analysis, it is important to list all possible and potential failure modes for each of the processes, to determine whether the failure modes warrant further action, and to list all causes for each failure mode when the decision is to proceed further.
After the hazard analysis, it is important to consider the actions needed to be taken and outcome measures to assess, including describing what will be eliminated or controlled and who will have responsibility for each new action.
Fifty studies and quality improvement projects were included in this analysis. Several common themes emerged: 1 what was needed to implement quality improvement strategies, 2 what was learned from evaluating the impact of change interventions, and 3 what is known about using quality improvement tools in health care. Substantial and strong leadership support, 80—83 involvement, 81 , 84 consistent commitment to continuous quality improvement, 85 , 86 and visibility, 87 both in writing and physically, 86 were important in making significant changes.
Substantial commitment from hospital boards was also found to be necessary. Even with strong and committed leadership, some people within the organization may be hesitant to participate in quality improvement efforts because previous attempts to create change were hindered by various system factors, 93 a lack of organization-wide commitment, 94 poor organizational relationships, and ineffective communication.
Yet adopting a nonpunitive culture of change took time, 61 , 90 even to the extent that the legal department in one hospital was engaged in the process to turn the focus to systems, not individual-specific issues. The improvement process needed to engage 97 and involve all stakeholders and gain their understanding that the investment of resources in quality improvement could be recouped with efficiency gains and fewer adverse events. The successful work of these strategies was dependent upon having motivated 80 and empowered teams.
There were many advantages to basing the work of the quality improvement strategies on the teamwork of multidisciplinary teams that would review data and lead change. Team leaders and the composition of the team were also important. Team leaders that emphasized efforts offline to help build and improve relationships were found to be necessary for team success. The multidisciplinary structure of teams allowed members to identify each step from their own professional practice perspective, anticipate and overcome potential barriers, allowed the generation of diverse ideas, and allowed for good discussion and deliberations, which together ultimately promoted team building.
Teams needed to be prepared and enabled to meet the demands of the quality initiatives with ongoing education, weekly debriefings, review of problems solved and principles applied, 84 and ongoing monitoring and feedback opportunities. The influence of teamwork processes enabled those within the team to improve relationships across departments.
Teamwork can have many advantages, but only a few were discussed in the reports reviewed. Teams were seen as being able to increase the scope of knowledge, improve communication across disciplines, and facilitate learning about the problem. Group work was seen as difficult for some and time consuming, and problems arose when everyone wanted their way, 97 which delayed convergence toward a consensus on actions.
Team members needed to learn how to work with a group and deal with group dynamics, confronting peers, conflict resolution, and addressing behaviors that are detrimental. As suggested by Berwick, the leaders of the quality improvement initiatives in this review found that successful initiatives needed to simplify; 96 , standardize; stratify to determine effects; improve auditory communication patterns; support communication against the authority gradient; 96 use defaults properly; automate cautiously; 96 use affordance and natural mapping e.
Simplification and standardization were found to be effective as a forcing function by decreasing reliance on individualized decisionmaking. Several initiatives standardized medication ordering and administration protocols, 78 , 87 , , , — , , — realizing improvements in patient outcomes, nurse efficiency, and effectiveness. Related to simplification and standardization is the potential benefit of using information technology to implement checks, defaults, and automation to improve quality and reduce errors, in large part to embedding forcing functions to remove the possibility of errors.
Often workflow and procedures needed to be revised to keep pace with technology. Data and information were needed to understand the root causes of errors and near errors, 99 to understand the magnitude of adverse events, to track and monitor performance, 84 , and to assess the impact of the initiatives.
Using and analyzing data was viewed as critical, yet some team members and staff may have benefited from education on how to effectively analyze and display findings. The meaning of data can be better understood by using measures and benchmarks. Repeated measurements were found to be useful for monitoring progress, but only when there was a clear metric for measuring the degree of success.
When multiple measures were used, along with better documentation of care, it was easier to assess the impact of the initiative on patient outcomes. The cost of the initiative was an viewed as important factor in the potential for improvement, even when the adverse effects of current processes were considered as necessitating rapid change.
It was also purported that the costs associated with change will be recouped either in return on investment or in reduced patient risk and thus reduced liability costs. Ensuring that those implementing the initiative receive education is critical.
There were several examples of this. Two initiatives that targeted pain management found that educating staff on pain management guidelines and protocols for improving chronic pain assessment and management improved staff understanding, assessment and documentation, patient and family satisfaction, and pain management.
Despite the benefits afforded by the initiatives, there were many challenges that were identified in implementing the various initiatives:. Despite the aforementioned challenges, many investigators found that it was important to persevere and stay focused because introducing new processes can be difficult, 84 , but the reward of quality improvement is worth the effort.
Other considerations were given to the desired objective of sustaining the changes after the implementation phase of the initiative ended. Influential factors attributed to the success of the initiatives were effecting practice changes that could be easily used at the bedside; 82 using simple communication strategies; 88 maximizing project visibility, which could sustain the momentum for change; establishing a culture of safety; and strengthening the organizational and technological infrastructure.
Collaboratives could also be a vehicle for encouraging the use of and learning from evidence-based practice and rapid-cycle improvement as well as identifying and gaining consensus on potentially better practices. Quality tools used to define and assess problems with health care were seen as being helpful in prioritizing quality and safety problems 99 and focusing on systems, 98 not individuals. The various tools were used to address errors and growing costs 88 and to change provider practices.
These are discussed as follows:. Plan-Do-Study-Act PDSA was used by the majority of initiatives included in this analysis to implement initiatives gradually, while improving them as needed. The rapid-cycle aspect of PDSA began with piloting a single new process, followed by examining results and responding to what was learned by problem-solving and making adjustments, after which the next PDSA cycle would be initiated.
The majority of quality improvement efforts using PDSA found greater success using a series of small and rapid cycles to achieve the goals for the intervention, because implementing the initiative gradually allowed the team to make changes early in the process 80 and not get distracted or sidetracked by every detail and too many unknowns.
Failure modes and effects analysis FMEA was used to avoid events and improve or maintain the quality of care. Health failure modes and effects analysis HFMEA was used to provide a more detailed analysis of smaller processes, resulting in more specific recommendations, as well as larger processes.
HFEMA was viewed as a valid tool for proactive analysis in hospitals, facilitating a very thorough analysis of vulnerabilities i. From the improvement strategies and projects assessed in this review, several themes emerged from successful initiatives that nurses can use to guide quality improvement efforts. The strength of the following practice implications is associated with the methodological rigor and generalizability of these strategies and projects:.
Given the complexity of health care, assessing quality improvement is a dynamic and challenging area. The body of knowledge is slowly growing in this area, which could be due to the continued dilemma as to whether a quality improvement initiative is just that or whether it meets the definition of research and employs methodological rigor—even if it meets the requirements for publication. Because of the long standing importance of quality improvement, particularly driven by external sources e.
With this in mind, researchers, leaders and clinicians will need to define what should be considered generalizable and publishable in the peer-reviewed literature to move the knowledge of quality improvement methods and interventions forward.
While the impact of many of the quality improvement projects included in this analysis were mentioned in terms of clinical outcomes, functional outcomes, patient satisfaction, staff satisfaction, and readiness to change, cost and utilization outcomes and measurement is important in quality improvement efforts, especially when variation occurs. There are many unanswered questions. Some key areas are offered for consideration:. In planning quality improvement initiatives or research, researchers should use a conceptual model to guide their work, which the aforementioned quality tools can facilitate.
To generalize empirical findings from quality improvement initiatives, more consideration should be given to increasing sample size by collaborating with other organizations and providers. We need to have a better understanding of what tools work the best, either alone or in conjunction with other tools. It is likely that mixed methods, including nonresearch methods, will offer a better understanding of the complexity of quality improvement science.
We also know very little about how tailoring implementation interventions contributes to process and patient outcomes, or what the most effective steps are that cross intervention strategies. Lastly, we do not know what strategies or combination of strategies work for whom and in what context, why they work in some settings or cases and not others, and what the mechanism is by which these strategies or combination of strategies work.
Whatever the acronym of the method e. Quality improvement requires five essential elements for success: fostering and sustaining a culture of change and safety, developing and clarifying an understanding of the problem, involving key stakeholders, testing change strategies, and continuous monitoring of performance and reporting of findings to sustain the change. To identify quality improvement efforts for potential inclusion in this systematic review, PubMed and CINAL were searched from to present.
Findings from the projects and research included in the final analysis were grouped into common themes related to applied quality improvement. Turn recording back on. National Center for Biotechnology Information , U. Show details Hughes RG, editor. Search term. Author Information Authors Ronda G. Affiliations Ronda G. Hughes, Ph. E-mail: vog. Background The necessity for quality and safety improvement initiatives permeates health care.
Quality Improvement Strategies More than 40 years ago, Donabedian 27 proposed measuring the quality of health care by observing its structure, processes, and outcomes. Six Sigma Six Sigma, originally designed as a business strategy, involves improving, designing, and monitoring process to minimize or eliminate waste while optimizing satisfaction and increasing financial stability.
Root Cause Analysis Root cause analysis RCA , used extensively in engineering 62 and similar to critical incident technique, 63 is a formalized investigation and problem-solving approach focused on identifying and understanding the underlying causes of an event as well as potential events that were intercepted.
Failure Modes and Effects Analysis Errors will inevitably occur, and the times when errors occur cannot be predicted. Research Evidence Fifty studies and quality improvement projects were included in this analysis. Some physicians would notaccept the new protocol and thwarted implementation until they had confidence in the tool. Hospital leadership was not adequately engaged.
There was insufficient emphasis on importance and use of measures. The number and type of collaborative staffing was insufficient. The time required for nurses and other staff to implement the changes was underestimated. The extent to which differences in patient severity accounted for results could not be evaluated because severity of illness was not measured. Improvements associated with each individual PDSA cycle could not be evaluated.
The full impact on the costs of care, including fixed costs for overhead, could not be evaluated. Failure to consider the influence of factors such as fatigue, distraction, time pressures. The Hawthorne effect may have caused improvements more so than the initiative.
Many factors were interrelated and correlated. There was a lack of generalizability because of small sample size. Show More Show Less. Additional Tags math. Instructional Ideas Lead a discussion on how to determine the starting number to try. Classroom Considerations Expects that individuals know how to evaluate a cubic expression Scholars should understand what it means to find a solution to an equation.
Pros Answer key shows the expected work The worksheet includes application problems. Cons None. Common Core SL. Start Your Free Trial Save time and discover engaging curriculum for your classroom. Try It Free. Put on your thinking caps because middle school math has never been more interesting in this huge resource full of thought provoking questions. Written as a newsletter, the resource has 10 two-page newsletters with a variety of Dang, it's a word problem!
Pupils address a variety of word problems that involve knowledge of proportions and geometric topics. The General Certificate of Secondary Education review problems require determining costs based on area Perfect as a review guide, this worksheet provides a range of questions focusing on functions. Topics include composing functions, transformations, domains, and polynomials.
Also included are corresponding worksheets focusing on other How about the largest possible numbers? Main menu Search. Trial and Improvement at KS2. Simply 'having a go' is a great way to make a start on a mathematical problem. Whatever happens, you will have learnt more about the situation and can then tweak your approach. These activities all lend themselves to this 'trial and improvement' way of working.
Fractions in a Box Age 7 to 11 Challenge Level The discs for this game are kept in a flat square box with a square hole for each.
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