**Transcript of Cyberseminar**

**QUERI Improvement Methods**

**Introduction to Quality Improvement Methods to Improve Research Impact**

**Presenter: David Belson, PhD**

**June 27, 2013**

**Introduction to Quality Improvement Methods to Improve Research Impact**

**June 27, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact: David Belson [belson@usc.edu].*

Lisa Rubenstein:Alright, I just wanted to introduce Dr. David Belson who we have been working with for some time as part of the CIPRS Center for Implementation, Science, Research, and Practice. He has been working as a consultant. He is a PhD engineer. 

He has been working in consulting for 25 years. He has consulted for a variety of industries including healthcare, hospitals, and outpatient practices, and so on. We are particularly thrilled to have him talk to us as someone who can represent the world of [inaud.], and six sigma, and all of those kind of industrial things; and also, connect it to our research world. 

Moderator:Thank you very much, Dr. Rubenstein. Dr. Belson, are you prepared to share your screens?

David Belson:Yes, I am. 

Moderator:Great, there you go.

David Belson:Okay. The audio is fine?

Moderator:Yes, you are coming through fine, thank you.

David Belson:Okay, so I will go ahead. I welcome everybody to this webinar, this cyber seminar. It is my pleasure to present materials as Lisa mentioned, on how to improve the impact of your research. As she mentioned, I have been doing work in industry particularly in healthcare for quite a few years. Using a variety of methods to make sure that the projects that we do are effective and have an impact... 

This past year, we have been looking at the QUERI research proposals and the results of research projects at the VA. Realize that there are a lot of methods out there in industry that are useful and have an impact; and have been used for many years. Not all researchers really make full use of these things. It appeared from the proposals sometimes researchers mentioned certain tools or techniques that are going to make sure they have an impact. But do not really seem to have a full grasp on just what those methods are or how they can really be accomplished. 

As a result of that we prepared a paper, which I believe you have all received a copy of or access to. That discusses some of these methods. How you can use them. When you should use them; which are appropriate for which point and time. A little bit about how challenging it is to use them or how to go about it. 

A little more on my background; as I mentioned, I am on the EOC research faculty. I have used all of these methods more than once in hospitals and in healthcare. There is a lot more of productivity and project improvement tools that are listed in the paper. But we thought we would list the ones that are particularly relevant. 

This seminar is going to discuss primarily what is in the paper; which is itself a summary of these various methods. This is sort of a summary of a summary. There has been a long period over a hundred years of developing various methods by industrial engineers and others to make sure projects are effective and have an impact that is commensurate with the amount of money that is spent on doing the research. 

Hopefully, this paper, which you have access to will serve as a guide, as a starting point for well, how do I go about making sure my research has an effect that is sustained?  That it is not just a temporary exercise and goes away. But remains and has an impact; and to the extent it is implemented in a hospital or a clinic. It spreads to the entire hospital or clinic or healthcare system. It is not just narrowly a result.

What I am going to talk about in the seminar is – well, I have been talking a little bit about what the purpose of it is. What is the benefit?  How are the impacts going to occur, then describing these various methods. There are about 40 different tools that are described in the paper, to give you a little idea of what they are and describing them. How they should go about using them as well as how you can get more information on each of these methods. 

As I mentioned, this is sort of a summary of a summary. The paper itself is a summary, not all of the detail you might possibly have. Also, as Lisa mentioned, money for research is a limited kind of thing. We want to get the most bang for the buck. The question I am trying to address here is how do you get the most bang for the buck of the research dollar and have an impact. The impact can be – certainly the idea here is to get the maximum impact, clinical impact from the intervention. How we make sure that, that clinical impact really occurs as I mentioned is sustained and spread throughout the institution where it is occurring. 

Other aspects of these tools are providing the information on how do we know we are really addressing the proper problem?   A lot of research dollars are wasted by focusing on not quite the real problem. How do we go about understanding?  Is the point  we are addressing really the one we should be and it is the important one. Also, certainly, the VA QUERI is going to smile on projects and proposals that do use these methods to make sure the results of the work are effective and have an impact. 

These are some of the reasons and kind of the purpose, the background of doing this paper and the seminar. One way to look at all of this is this little bit complicated diagram. I do not know if you can read it in the slide form. But it is in more detail in the paper. One way to look at research is maybe not the way researchers do. But this is the way an industrial engineer would look at research is saying well, there are different kind of types of research, different phases of it. 

Because some of it is a focus or at least starts on well, what is the problem we are trying to address?  What hypotheses are we going to try and test?  There are tools, the boxes down below. What are some tools that engineers would use to make sure we have analyzed the problem properly?  That we have grabbed onto all of the important aspects of it. 

Then after that, or in some projects, how do we evaluate what is going on?  How do we look at the different alternatives possible?  How do we generate what the alternatives are possible?  How do we determine what are the important factors dealing with the, or implementing the problem that we are addressing?  Then, how do we go about making improvements?  There is a theory of how to go about making improvements of testing improvements of testing interventions; and making sure the intervention is properly designed. 

Then finally, there are a number of methods listed I the box below of implementing the change. Well, we have figured out a better way to do something. Whether it is a clinical change; whether it is a procedural change of some sort; an administrative change, a physical change, an equipment change? Whatever it is, how do we make sure that, that implementation occurs properly?  Has the impact that we want?  Measure the results as well and do it in a timely manner. 

There are a  lot of tools here. As I have said, I have discussed 0 in the paper. There are more than that, that are possible. This diagram is a little bit of an attempt to figure out which methods apply to which kind of research, or which phase of your research. Not that they strictly have to fit with a certain time or type of research. 

This table does not reproduce too well in the – on the slide basis. But the tools, the methods can be used at more one of these stages. Not just the diamond shaped phases. But they can be used in multiple ways at multiple phases. They are available for that kind of – kind of use. There is certainly an overlap of these tools. 

What is in the paper?  Well, for each of the method or tools, the paper described provides  a brief description of the – of the methods itself. What basically is it?  You got a basic idea of more than just the name of the tool. But what is it?  I have tried to list some good example resources, literature sources. There is a lot more. I probably have at most a half dozen different literature resources for each method. But I could have easily limit – listed hundreds, literally hundreds for each of these methods. 

Then I tried to give example of how it is applied in the healthcare setting or research setting, one example. Then some summary, kind of steps. How do you and what are the one, two, three, four, five things you do to implement that tool?  Some of the tools are big or can be complex in  a big effort. Some are very simple that in a matter of a few hours you can make the full use of them. There is kind of a range of you might say size of these different methods. Also, I want to give a little caveat here that this paper is not intended as full training in each of these 40 odd different methods. 

The idea here is just to provide some awareness that yes, this helpful tool exists. This is available. Maybe where you go to get some more information on it. But it is intentionally brief. That is kind of how – the format of the paper. These four different things are listed on each of the methods. Okay, the first method; so, we want to test what the – some kind of hypothesis or what, analyze the problem. A good tool for going about this is a pretty simple one and many of these are. Where we sit down as a group, a lot of – a lot of effective change occurs by group efforts of involving nurses, doctors, staff, or whoever. Sitting around and discussing the problem. 

But more than that, to kind of document it and organize the information that comes out from the discussion. This is an example from an actual project I did. Where we – as we discussed the particular problem, it may have been...  I did one recently. We were looking at a radiology department and things are not right. We need to make it better. It could be for kind of a research change. We want to try something. What are the issues involved in making that intervention. As we do it on a brainstorming kind of basis, people come up with ideas. 

Write a little sticky note. Post them on the wall or a flip chart, or what have you. But it is fine to have a discussion. It is great to have brainstorming. But you have got to capture it and make use of it. What you do in this kind of exercise is group. Your sticky notes can be moved. They can be moved about and grouped together with some color coating. Maybe as some color indicates that yellow  is a problem that we want to address. Blue is maybe an answer or a solution. Another color, headings of groups or what have you. This kind of gives us kind of a grouping of the things that are going on in the area we are trying to change. 

It is a starting point. Also a way to question the research; are we addressing these?  It is a  very important groups of issues or problems, or what has you. Another way to organize issues is a so-called pareto chart. Again, and some of the summary idea here is list all of the different problems that are occurring, or issues, or events that are occurring. Sort them into order of frequency like is done here and with the more frequent ones on the left. It quickly pops out. You can see how these are the three things that are important. 

Maybe we have 20 different kinds of errors. Here is the frequency of them sorted. Usually two, three, four different ones pop out as the important ones. Again, okay, these are the – in this case it is errors. Is our research addressing these high priority errors?  We do not need to address maybe everything. There may be 20, 30, or 40 more different kinds of errors in this example. What we really want to make sure as we address the important ones. The ones that have popped out as a high priority. 

This is another tool very commonly used. It works. It does not require a whole lot of analysis. It is kind of self-evident what it is. It does require a data. It does require numbers, quantities of what is happening. Of course, that is always a challenge to get such data. But it may be available from all different kinds of sources, from surveys, from the electronic medical records, from administrative data, or what have you. You can produce the chart such as this. Then by showing it to folks, it is evident what is going on. 

A lot of change or from research or what have you involves – to be successful involves getting the support and involvement of everybody involved. These kind of diagrams kind of help point out what is important. It reduces the amount of confusion, or misdirection, or what have you. Another good tool, a little more complex is a diagram that ends up looking like a fish and called a fishbone diagram. Where we have a particular problem. We have something we want to change. 

Maybe a pharmaceutical design that we want to make sure our medication is addressing a particular problem through discussion, brainstorming, meetings, communications, whatever. We list the different factors that are going into the – into the problem of the head of the fish, if you will. Organize it in such a way that the branches or categories or factors that are impacting this particular issue that we want to address. By organizing it in this way, we can see different paths. I have used this a number of times where we are having a discussion of different people involved. 

This is a good way to say okay, here are the different kinds of forces that are affecting our problem– are affecting the change that we want to take place. Or delaying things or what have you. The diagram goes and then shows what is related to what. You can add to this. You can make these more sophisticated. Color codes could be added to prioritize things. Or, allocate things to different – issues to different people. Some are different way to redesign these. 

These kind of tools are simple ones. They probably can be done in a few hours. They do not require a lot of time necessarily. But they are a  good way to kind of get started on things. These are some of the methods that are kind of early phase or problem definition. They would certainly be useful in a research project. 

We wanted to get a little more feedback from you all with the poll. I think Molly is going to conduct that.

Molly:Yes, thank you very much. As you can see attendees, up on your screen now. You do have a poll page. The question is what is your primary role in VA?  Please click the circle next to the best answer for you. Are you a student, trainee, or fellow?  Are you a clinician, a researcher, a manager or a policymaker or other?  We do appreciate your feedback. It does help Dr. Belson gear his talk a little more towards the audience. It looks like we have already 78 percent vote. We will give people just a few more seconds as the answers are still streaming in. Then we will be sure to share those results with everybody.

Okay, it looks like we are at about 80 percent. I am going to go ahead and close the poll now. I am going to share the results. Dr. Ganz, you should be able to see those, if you want to talk through them real quick. Sorry, David – and Dr. Belson.

David Belson:Yeah, sorry, see most of the people who are our researchers, which is the intent of all of this. A mixture of others, whatever the others might be. But this is exactly the audience we wanted to address. I will continue on. Is that okay?

Molly:Perfect. I am going to turn it back over to  you right now.

David Belson:Okay. What are some of these methods?  I am not going over all of them in this presentation just some of them, some key ones. This is a method. Maybe you are already familiar with this. That I use in essentially every research project, every project really. If I am dealing with a kind of a complex systems that often occur in healthcare, I need to understand the sequence of events, the flow of things. Maybe the flow patients, maybe the flow information;  and maybe the flow of most anything that has a beginning and an end. 

A map is a good way to do that. I always love maps. One nice thing about maps is that you draw them. It is kind of self-evident again what it is. The idea of a process map. Sometimes they go under different names. I should mention, the modes I have listed in the paper. I have tried to use the most common name for these things, particularly the most commonly used name in healthcare. But people have other names for the same, essentially the same thing. Some may call it a process map. They may call it a work flow diagram. It may go under a number of different labels. Different organizations tend to – and the cultures, it tends to pick up on one name or another. 

The idea here is to make  a diagram from the start of some process to the end of it with symbols, meaning, and certain things. The arrows meaning kind of the movement of time or movement of people. Standardized symbols are often like a square for a process. Or like a patient registers or checked in. The diamond shaped is a question or a decision where things could go down different paths. Then this, the sequence of events. It can be a very informal hand drawn kind of thing on a sheet of paper. There are all various degrees of sophistication, which is true to most of these things. They can become pretty sophisticated or not. 

There is software available to draw such diagrams, specifically flow charting software. Common product software such as PowerPoint is set up to do process maps. Then there are different forms of doing a process map. I have described some of it in the paper. This is just, the one on the screen here is just a basic timeline. But you can organize them so that they are segregated into different lanes for different parts of the organization. so called swim lane flowchart, a variety of different kinds of formats can be used. 

But I think one of the most important things for the researcher is say, okay, let us make sure we really understand the process that we are dealing with here. Or the organization that we are dealing with. Or the department we are dealing with. Or the clinical process that we are dealing with. I found these particularly useful for discussion. Say, okay, this is how I understand things work. Go back to the practitioners. Go back to the providers. Say, is this what really happens?  Often, I do not have the right understanding. We change it. 

We may do it two, or three, or four times. I recently did a pharmacy research project. We mapped the whole thing out in great detail. Went over it with the people in the pharmacy. No, that is not how things work. We work differently. That was really very valuable to understand in an accurate way just how things work. It is more a matter of getting it down on paper. Showing it to people. Making sure that we have a common understanding. These things can be like I say terribly complicated. 

We have done some that have literally gone hundreds of pages to some that are just very simple, as simple as the one you see on the screen; and kind of confirming that with others. This also I think is a good first step when you the early stages. It is not necessarily useful in the latter stages. It is more a matter of making sure we understand how things work and confirming  it. In many cases and in some project  earlier this year where we saw in by mapping the process out. This was – let us see, this was...  I think this was also a pharmacy related project where we saw this is obvious. Everything has to go through one person. We have a bottleneck. 

We have a problem. Just sometimes just mapping processes out helps you see where a problem occurs. This is very useful tool. You cannot understate its usefulness. Here is another simple kind of tool, so called spaghetti diagram. Because that is off of from what is kind of looking like. The idea here is you are going to diagram. It can be just the fairly brief exercise of what is going on physically in an area such as a nurse’s station, or a lab, or a work area, and what sort – whatever sort. I have done this in the number of VA locations. 

You sit it on – you sit in the area that you are going to study or observe with a pencil and a paper. Hopefully on the paper you have got a rough sketch of the layout of the area. Then using the pencil without picking it up from the paper, trace the steps that the person you are observing or person you are observing go through – go through. Where do they walk from one point to the next to the next. 

This kind of spaghetti looking diagram is the steps that people went through or maybe a person went through over a short period of time to get an idea of the flow of work. I did this recently in a radiology department in a VA clinic. We discovered geez, there is a lot of wasted walk. We can rearrange things. We can use this to better organize the work – the work that is done. Usually it is kind of a brief exercise. This is another tool for kind of understanding what is going on. Here is another quite different one. That is creating a matrix of who is doing what. The rows, the column – the left-hand vertical are people working in an area. 

There were – the columns, the labels across the top are things that people are doing, the responsibilities, what have you. You can see who is doing what. It is a way to identify duplication. A way to identify opportunities for improvement. If we are developing a new procedure or a new assignment, a new responsibility, this kind of diagram helps you decide perhaps where the assignment desk would go. Or if we do assign it, are we going to trade some duplication and where we want to reorganize things?  Change where responsibilities occur?  

I did this recently in a surgery area in pre-op where we discovered a lot of duplicate and interviewing duplicate questions of what have you. We wanted to make some changes, some additional work for people to do in pre-op. This kind of diagram was a good starting off point. Another thing I wanted to mention in this kind of a thing is it is very importantly that you create these kind of descriptions, if you will by actually observing what is going on. That it is not just by talking to one person. You got to really talk to the people involved. 

Perhaps all of these people on the left-hand side. Observe what they do. It cannot – this is not... These are not theoretical exercise, but have to be done in person, in the place. Sitting there observing what people do. Make sure it is really an accurate description. It is not a, one person’s description. It is often a good idea once you do this to go back and verify it. Okay so, these that are some of these tools to kind of identify current practices. To understand how  things work before we implement change or create some kind of intervention. Then you have a chance to talk about everything. 

These are some of the others that are discussed in the paper. Period of constraints is the idea of looking for bottlenecks. That is really where we ought to address our changes is where the bottlenecks occur. Scatter diagrams are kind of a non-statistical plotting of data. You can see trends quickly. Another – a side pocket is the idea of let us look at how things work in terms of the...   A lot of these tools have to do with kind of categorizing what is going on. SIPOC stands for Suppliers, Inputs, Processes, Outputs and Customers; and kind of organizing information in that way. Failure Mode and Effect Analysis FMEA, comes from the defense industry. 

A number of these tools come from the defense industry. What could go wrong?  What can we do about it?  How do we know what is going wrong?  Do we have ways of sensing things?  Kind of organizing the information. It can be quite quantitative. It can be a computerized way of looking at how errors, and failures, and problems occur. How they pass through the organization. Impact the system in a broader way. Maturity model is a field of study looking at the organization itself. How ready is it for change?  How do we know whether the organization is ready for change?  We are trying to intervention the research change. It does matter where that change is occurring. What the organization, structure, and responsibilities look like where we want the change to occur. 

Maturity Model, sometimes a survey is done to kind of figure out where the organization stands on its ability to make changes. These are some other tools to evaluate current processes. Moving on to the more kind of analytical kind of thing is another tool. This tends to be a little bigger deal in order to utilize it. But this is the discrete event simulation model, which is to create a computerized. It does not have to be computerized but generally is – to describe the functioning of a function that we want to study. 

We may want to change. Maybe you want to – want to create an intervention of one sort or another. There is quite a bit of computer software available to do this sort of thing. Where we create a computerized model that simulates over time how a particular function, or a department, or area works. Then we can use that to do sort of a paper test or a computer test before we actually make the change itself in the real system. Sometimes making changes are expensive or maybe even dangerous. Or have concerns about quality; or we are not sure what the impact is going to be. By creating a simulation model, we can test out changes before – and in the computer. 

If you consider various alternatives before we have to make the change itself. I have done this in a number of areas. I just did a paper on a simulation model like a GI colonoscopy department and their simulation. Well, I should mention. There are a number of simulation software tools for healthcare. Some of these tools are designed for simulating emergency departments, surgery, or the different clinical areas. They are very useful to test alternatives like I say. It is also useful to understand what is going on in an area. The patient flows. The information flows,  what have you to occur in a department, in a hospital are complicated. A lot of interrelated effects going on. 

If we have a good simulation model, that is a – can be very cost effective tool to test out and optimize our change before actually implementing it in the hospital or clinic or wherever the change is likely to take place. Simulation tools are very useful. Another use of them is to explain what is going on. Most of the software allows an animated output. That is you can create a simulation of patients moving through a department or information flows or equipment movement and what have you. 

Then, run the simulation on a screen for people to see as a way to explain what is going on. Why are waiting lines occurring?  Why are equipment – why is equipment being used in a certain way?  An animated version of these becomes a, kind of fun really description that you can see and try out changes with. Simulation models are a useful tool. It can be expensive depending on the extent of the model. How much you want a model. But usually there is a  – there is a good payback for it when you do it. 

Another tool, or really kind of a family of tools that has become very popular in the healthcare industry; and many healthcare systems have adopted is the so-called Lean method, which is a combination of tools that were – much of it was originally developed by the Toyota Motor Company in the 1950s or so as a way to improve their productivity. But it is very useful. It has turned out to be surprisingly...   Well, it came from manufacturing industry. 

It has turned out to be a surprisingly popular in the healthcare industry. I had an opportunity to do a project, research projects surveying hospital systems around the country a few years ago. What methods they are using to improve the performance of their hospitals and clinics. The so-called Lean approach is certainly the most popular one. It is not the only approach. But it is the most popular one used in healthcare these days. It has a number of methods as part of it, which I have listed in the paper. 

It is certainly useful in implementing change successfully. It has some kind of basic ideas. I am going into too much here, but some basic ideas that it uses an approach. You kind of see where it came from a manufacturing industry. But very applicable in healthcare. Some of the ideas, this idea of waste. The lot of things that are done in all sorts of organizations are not necessary. It could be eliminated. Lean provides methods for identifying waste. Identifying things that we do not need to do. 

In a research sense, it could also be used to identify what changes do we need to make. What changes are not necessary?  How can we make sure that intervention is effective as possible?  Another idea I think I mentioned a little bit about this earlier. Some of the – some of the tools of Lean have Japanese names to them, like Gemba, which is basically you can walk around, observe. Be there when you are studying what is going on. Some healthcare organizations use the Japanese labels for these things and some do not. 

There is always an English equivalent. Gemba is the idea that Toyota found earlier on when we were looking at how things work and how to make them better. You got to be there. You got to stand there. In some cases, you got to stand there and observe what is going on for days in order to really understand things. You cannot – you cannot do it from remotely. It is – you got to be there. Kaizen is the idea of being organized and making a change. Involve the people, involve the staff. Have a clear goal. It is – there is a considerable amount of lead research. 

A considerable amount of literature on how to use the Kaizen idea in making change and making improvements. One thing that was important to Toyota and it turns out it is pretty important in healthcare  is so-called overproduction. Doing things that are not necessarily necessary. We certainly have it occurring in healthcare where too many tests are ordered. Duplicate questions, unnecessary paperwork, what have you. You do not want to it have to occur in your – in your research intervention as well. Value stream mapping is taking that process mapping idea I mentioned earlier. 

Adding some quantification to it in terms of values; in terms of what is the – what is the – a waste component. What is the really useful and value component of various processes in the workflow. Another idea, which sometimes is lumped under Lean and sometimes not is how do we go about making changes?  Okay, we may have an intervention we want to take place. How do we do it in such a way to make sure that change really is effective?  It does what we intended it to do and is spread and sustained?  The PDSA, sometimes other acronyms are used to describe it. A plan, do, check, act is looking at change as a cyclic process. 

It is not just a one-time thing. Often it is not just a one-time thing. But includes repetitive efforts to get the change fully implemented. A part of that is the idea that – a good idea is to make. Rather than try to make the entire change all at once, you do it on an incremental basis. Make a small step. Then continue on and expend it beyond that first step. PDSA is a way of creating change, of implementing change. Make sure change occurs. 

Again, I have described these in the paper. I have given you some literature sources. I have given you some examples. Another idea, it comes from Toyota. But it is the idea that we do want patients or other work to flow through the organization. It happens best by balancing the workload. But not giving too much work to one and too little to another. It creates waste. It creates waiting and what have you. 

If you are planning the intervention and multiple people are involved, you need to look at the pace that is required related to the volume of work to be done so that things are done in a balanced way. Like a river, if it flows at a continuous  smooth kind of pace, most gets through it. If there are starts, and stops, and delays, then less occurs. Less impact from the results of your research. This, I have seen this used in surgery and in other areas where we want to kind of balance out the workload. 

Another change tool comes from Toyota. It is A-3. A-3 is a paper format. A large, kind of legal or bigger than legal kind of format. The idea here is when we plan a change. When we plan an improvement, what have you. Let us put it all down on one sheet of paper. It is a simple idea, but it works. Let us put it all down on one sheet of paper. Share it throughout the organization. I have seen it. It was a hospital this year where they had done this A-3 form. They had it posted about – in every department. They had several things going on. 

You look at the A-3. You see where things are going and where things stand. Who is responsible for what?  What is the objective?  What are the things that we are doing?  For change to occur, and be a success, you got to get everybody involved. Healthcare is such a teamwork kind of basis. It is important to share information. It is important to make sure everybody knows what is going on and where we stand. The A-3 again include an example. There is literature on how to do these. At some or some hospitals I have seen use these as the kind of format for the project  itself. 

Another idea that is popular and that is important for our Lean  is standardizing work and making sure it is all written down. That the people know who is responsible for what. That work is done in a consistent way. I know that most clinical processes are documented, and procedures, and what have you; which is maybe is not that most interesting and fun thing to do. But it is important to have it there. If you are changing some practice, clearly it has got to be written down. 

Clearly, the change has to be written down. Like I said, it may not be the most popular thing to – fun thing to do. But it is necessary for training purposes, for sustaining quality, for that sort of thing. These are – these are kind of tools having to do with sustaining a change. Making sure that the change is effective and consistently done. 

Molly, we wanted to do another little survey here.

Molly:Excellent. I am going to go ahead and launch that right now. For our attendees, you do see the poll on your page. At this time, which best describes your research experience?  Has not done research?  Have collaborated on research?  Have conducted research myself?  Have applied for research funding?  Or have led a funded research grant?  It looks like we have had just over 55 percent of our audience vote we will give people some more time as the answers are streaming in. 

We do appreciate your feedback. That looks like we have a very experienced crowd just at these preliminary results. Alright, it looks like we have capped off at about 75 percent. I am going to go ahead and close the poll. Share the results. Dr. Belson, you should be to see those on your screen now. 

David Belson:I have done it. At least I have got a variety of the answers. Although the biggest chunk are people who have led research grants. If you are leading a research grant, I would hope – or you are applying for research. I hope you are going to find some usefulness from this paper of tools that you could use. Or at least how you go about finding those tools. That is just great. 

Okay, so I will continue on here. Again, this is a – this is a survey of a survey. I apologize for the briefness of all this. Things are also fairly brief in the – in the paper itself. But the idea here is to give you some idea of which tools are available; which tools work best in what kind of situation. How to get more information about it. Well, I mentioned the Lean approach, very popular in industry, very popular in healthcare these days. 

Another sort of, some people would say, parallel kind of approach to making improvements and maintaining improvements is six sigma, which is kind of the statistical term. But it includes a wide variety of tools and methods. Some overlaps with Lean depending on who you talk to. But it has been involved, widely evolved in hospitals. 

Some healthcare systems I know say well, we have Lean for certain kinds of things. We have six sigma for other kinds of things. Six sigma has a little bit different focus than Lean. Six sigma is a little more focused on quantification and analysis. Whereas Lean is a little more focused on making sure we have people to participate in change and have an a effective, an effective processes whereas six sigma is, a lot of it is focused on reducing variability, of making sure that things are under control. That things – that work is done in a consistent way. 

It would be particularly useful and some of its ideas useful in an intervention or research where we made a change. We want to see that change is consistently applied and has the impact that we want. By tracking data, doing things such as a control chart like I showed in this diagram. Where we are tracking some quantity. We have set limits on what is – we expect some variability. There is always variability in everything that we do. But if it is beyond a certain expected variability and beyond the randomness that we would expect, then it indicates action. Red flags go up or what have you. One of the elements of six sigma is this kind of control chart idea. Tracking what is happening over time as well as other ideas to improve performance and manage change. 

Just a couple of other ideas that are both in Lean and in six sigma is neatness. Again, a real simple idea, but we want to have things work properly in healthcare. That it is just a simple idea like this diagram here, which was from an exercise we did in an Emergency Department where they had surplus forms. There was a chance of air or what have you by just organizing and neatening things up. It had a very  positive effect. We could save costs. 

Project management, I mentioned a little bit of it in the day period. People leading the research projects may be pretty familiar, but there is a very large body of knowledge on how to do – how to manage a project. How to manage three dimensions of a project that the time, the cost, the performance, or the results. How do we manage those three conflicting things, if we want to speed things up?  It often increases the costs or reduces the results. How do we manage those things?  Make sure that we get the results that we want?  

A very challenging thing to manage a project as I guess you know. The number of tools that are available. Diagramming, like this critical path diagram I mentioned here; bar charts, Gantt charts; again, a variety of tools to do project management properly. I am trying to give you a little starting point for where that information might exit. 

Some other things that I talk about in the paper having to do with implementing change and improving the impact of change are these. Some are quite statistical like design of experiments to minimize the amount of experiments that are necessary. To more simple kind of ideas of developing checklists. Or how do we manage change?  I mean, it is a field of study in itself. Certainly cost effectiveness is important. 

There are right and wrong ways of going about measuring and quantifying cost effectiveness. I am giving a quick survey of the things that are in the paper. Hopefully you will find them useful. Listed some books and periodicals that are available. There are a number of professional organizations that work on these things. The VA has several, the QUERI and VERC, as well as government AHRQ publishes a wealth of material on improving results in healthcare, incident for healthcare improvement; professional organizations like industrial engineers and so on. 

There are some, certainly a variety of consultants. Some specialized in certain of these tools, some do not. There are a lot of online resources. There is also programs, training programs available from the organizations that I mentioned as well as training programs available at your local college and universities. Often in the industrial engineering or MHA programs; as well as students who would be probably more than happy to help out. Provide support in terms of training that they might have on these various methods. 

That is kind of what I wanted to cover. I think I am basically on time here. I guess you received. If you are attending this, you have received access to the paper that I have been referring to. I also wanted to mention, this is a kind of a work in process. Please consider it a draft. We are likely to exchange, to change and expand on this in the future in terms of the paper. That is what I wanted to cover. If we have questions?  Molly, do you have that?

Molly:Great. Yeah, I do. We have got a lot of good questions that have come in. A number of them are saying I did not receive the paper. How do I get it?  Again, refer back to the reminder e-mail you received about three hours ago. If you scroll down, there is a hyperlink to the handouts. The paper is actually tacked onto the end of the presentation slides you just saw. In fact, you do have the paper. You just need to click on that hyperlink. 

We do have some questions that have come in. for any of those of you that joined us after the top of the hour, to submit a question please go to that gotowebinar dashboard that is on the right-hand side of your screen. You will see a box where it says ask the staff a question. Simply type your question or comment into that box. Press send. Let us see. Could the message table be shared with the audience?  

David Belson:Well, there are the tables in the – tables in the paper. I guess it is available. 

Molly:Great, thank you. The overview and introduction of QI principles and tools that industrial engineers use is very helpful. While this is beyond the main topic, could the organizer provide a summary paper slash overview of research designs that are most applicable for implementation research?  For instance, cluster designs, interrupted time series, other quality experimental designs; I acknowledge that this may be beyond the scope of this presentation.

David Belson:Yeah, it is beyond the scope of this presentation. We could do that. I think well as I mentioned, this paper is a draft. It is a probably a good thought to include in any kind of future versions. But yes, like the answer is yes. Can I do it right now?  No.

Molly:No problem. I do see that your contact information is up on the screen. Are you okay with him contacting you offline?

David Belson:Sure.

Molly:Great, thanks for making yourself available. Okay, onto the next question. Let us see. Sorry, just scrolling through these. Where...?  Okay, after the presentation, can you let us know which tools you are seeing used the most, top three to five perhaps?

David Belson:Well, let me just answer that off the top of my head. Which tools are the most popular?  Well, as I mentioned the whole Lean idea is quite popular. I do not have a good hard data at the moment of how many healthcare systems used – use Lean. But it is very popular. I know it is used – or many of the tools are used in the VA system. In general, Lean is very popular. 

In terms of more detailed tools, certainly the process mapping, I think is a very popular tool. It is used a great deal. That would have to be in the top two, or three. The other tools, they are – it kind of depend on where – though the particular problem. They are not all applicable to all different situations. While a tool like Takt Time that I mentioned or the A-3 idea, is very useful and used a lot. But it only applies in certain situations, which I have tried to indicate in the paper. 

Molly:Thanks so much. We do have somebody that just corrected your bio. Am I correct that if they Google you, they will find your bio on the school site?

David Belson:Yeah, that is true.

Molly:Okay, excellent.

David Belson:But ignore the picture. 

Molly:Do we not all wish we could ignore every picture of us online. Okay. Lots more questions coming in. this is great. Is there a resistance in the research community?

David Belson:Well, I am not sure I have data in terms of resistance. But as I think Lisa mentioned, and David Ganz may have mentioned in other times. We found in looking at research proposals to QUERI that it was pretty uneven in terms of use of the – these kind of tools. In some cases, there was no mention of these ideas of how to improve impact and so on. In some cases, there was a mention but not much discussion or, we should say proof that the researcher had a clear grasp of what they were going to do with the particular tool. I do not know if it is...  

From what we saw, I do not know if it is resistance. But it is certainly not very complete use of the opportunity that is out there in terms of these things. But they really do work. Certainly many researchers do use these tools. I know the bunch. But in terms of what we saw in research proposals, it was a pretty uneventhing. 

Molly:Great.

David Belson:Okay, and thanks.

[Crosstalk] 

Molly:Thank you for that reply. Okay so many good questions to get through. Let us see. It is not obvious. Okay, it is not obvious to me how the QI tools would be used by researchers applying for grants in contrast to healthcare managers slash staff who usually would rely on the activities you have described rather than research. Do you have any reply?

David Belson:Yeah, sure. I understand what you are saying. It is true that these methods are primarily used by management to improve performance. But much research is saying we want to improve performance as well. We want to have better clinical outcomes. We want to reduce costs. A number of the proposals I looked at were fairly operational oriented. We wanted to reduce costs. We want to create savings. What have you, a better way of doing things. 

These methods, while it is true, they are more often used for operational and management kind of things. Much of the research, particularly applied kind of research needs to use these tools as well if they expect their research to be – expect their research to be effective and implemented, and what have you. Also a number of these tools are very useful for identifying problems and identifying hypotheses that research – that researchers need to know. I hope that answers the question.

Molly:Thanks. They always have the opportunity to write in for further clarification. We do have a comment that came in. I just scanned through your paper, a great start. Thank you for that comment. Being in a clinical setting, projects may be on a fast track. Is there one method that is most conducive to a faster process?

David Belson:Well, sure. As I mentioned, project management tools are focused on balancing three things; time, cost, and results. If you want to speed things up, there is – and keeping focus on time. One of the basic ideas in project management, the idea of a critical path. What is the sequence of tasks that you need to do to constrain the overall end point of the project, research project or any kind of project?  The critical path idea, you should be familiar with that. Another tool the project managers use. Again, I think I provided reference to it. There is a book, a “...Body of Knowledge”. A book that is published by the – it is your project managers, Project Management Institute. That describes the whole, myriad of different project management tools. But one that is important to understand is the idea of crashing a project. You want to speed up a project. You want to reduce the overall time of a project. It usually involves having some impact besides just speeding things up. It often involves the need for more resources. Or maybe changes in the results. 

Project crash, project acceleration; kind of tools are there to analyze that, particularly on a larger type project. But overall, the whole idea of  a critical path of the thing that. What is the sequence of tasks that concern the overall life of the project is that it is certainly a key idea that you need to address. Okay?

Molly:Thank you for that reply. The next question we have. Why do you think Lean is so popular in healthcare as opposed to other tools?  What characteristics best explains its popularity.

David Belson:That is a great question. I wish I had a really great answer. Yeah, Lean has really caught on. I have been involved actually more than 25 years in productivity improvement and so on. I think it is maybe the packaging. Because a lot of the Lean ideas have been around longer than the label Lean has been around. It seems to just kind of snowball effect. Like I say many and maybe the majority of healthcare organizations are making use of the Lean idea. 

This is kind of a convenient reasonably understandable label for some of these tools, which can be a bit esoteric. But put them under the label of Lean. Lean, it implies efficiency and lack of waste, and a focus, and that sort of thing. I think it is largely packaging. Nothing against that. Nothing against that. But I would also be aware that the whole topic of Lean has some what should I say?  It depends on who you talk to about it. Different people have different ideas of what it includes. 

There is no official owner of the Lean idea. Project management, there is a Project Management Institute. Everybody agrees this is what the project management includes. Here is how you become certified in the project management. Not true for Lean. It is a broader kind of idea. Toyota maybe came up with it. But they do not own it. They do not make any claim to owning it. It is up to the – to the user or the consultant, the organization, or whatever. I think it I has just kind of struck a sweet spot, I guess in healthcare. It has certainly caught on.

Molly;Thank you for that reply. Alright, we do have a few more questions to get through. What recommendations do you have to apply for grants or funding for these types of research projects?

David Belson:I think that is not in my – not of my job description. David Ganz, are you on?  Do you want to respond to that , or Lisa?  

David Ganz:Molly, is my mic turned on?

Molly:Yes, we can hear you. Just speak up a little bit, please.

[Crosstalk] 

David Belson:Do you want?  Maybe you ought to repeat the question. I am sorry, I did that.

David Ganz:Well, the question I think was what type of funding opportunities are available?  Why?  I do not speak on behalf of QUERI. I work with Lisa Rubenstein on CIPRS. But, QUERI does have both rapid response projects and service directed projects. The links to those funding opportunity that are available on the QUERI website. I think as there has been a growing interest in partnered projects with operations, these kind of projects that do involve these techniques would be looked upon favorably. 

But obviously, there is needs to – they need to be merged with research concepts as well. This is just one part of the bigger picture. Again, I do not speak for the QUERI central office. But I think QUERI would be very motivated to consider proposals that use these techniques. 

Molly:Thank you for that reply, David Ganz. We do have somebody that just wrote in. let us see. This resource is applicable to the recent question. It is a citation; Proctor, Powell, Baumann, Hamilton, Santens, et al. writing about implementation, research grant proposals, ten key ingredients. That is found in Implementation Science from the year 2012, 7th volume, 96. Thank you for the person who wrote that in. I will save that if you want to e-mail cyberseminar at VA dot gov and pass that along. 

Okay, next question. Can you...?  One more – we do have a comment that came in. I just want to mention that in addition to QUERI and the VERC within the VA, there is also the national office of systems redesigned. The name may have changed. They support training tools and philosophies presented in this webinar. Mike Davies, M.D. is the director of that office. Thank you  to that attendee for providing further resources. The next question; my experience with industrial engineers is that sometimes it is hard to know when an IE is really useful. Can you give examples of greater or lesser value of involving IEs?

David Belson:A good question. I think it is helpful to have – if you are involving an IE. And healthcare research are not the only people who use these methods. There are certainly taught and used by people in the business school background, an MHA background, and MPH even. I get a lot of students from our global medicine program and others. But in terms of industrial engineers, I find that it is pretty helpful if the person has had prior healthcare experience. 

Probably all would agree, healthcare has kind of got a lot of unique elements to it. It is different than – and industrial engineer may have been involved in manufacturing. If they have had some experience in healthcare. Of course, there is always the chicken and egg problem there. But it is pretty helpful if they have been involved in healthcare or at least in the service industry. They would have somewhat similar. 

This may sound silly, but similar kind of issues like service industries like banking, or restaurants, or what have you. There is an – there is an overlap with healthcare. Industrial engineers at the student level; if you are talking about these and utilizing a student who is kind of a – not have any experience at all. Then probably as long as you make allowances for that particular student then probably any industrial engineer would be – would be helpful. As far as the more experienced ones, I think there is an important element of having some experience in healthcare in terms of the terminology, the culture, the economics, and that sort of thing. I hope that is a help. 

Molly:Thank you very much. I still see we do have some attendees raising their hand. Again, I cannot unmute you. Please type in your questions or comment. Thank you. We do have more questions. I do know that we are at the top of the hour. Dr. Belson, are you available to stay on and answer the few remaining questions?  We can capture the recording.

David Belson:Sure, I would be happy to. I love this. I love this kind of stuff. I got to tell you...

[Crosstalk] 

Molly: I think we really appreciate it.

David Belson:I got to tell you. I mean, I have been doing this work for quite a long while. It is really a pleasure to see there is so much interest. We have – at my school, we have a degree program now. We are graduating people with healthcare and industrial engineering background. The job market is really strong. It is really a pleasure to work in this kind of area. Go ahead.

Molly:Thank you. Well, we are getting a lot of positive feedback. Feel free to come back and present any time. Okay. Next one; can you reference any case studies, books, or articles that provide good examples, tools, and models for spreading research, slash, change in medical care settings?

David Belson:Sure. Maybe we will make a note of doing that. Maybe somebody will add it to a website or what have you. I am not sure I can do it right here. But there are a number of publications from industrial engineering organization, and from operations research replied mathematics, from consulting organizations. 

I am involved in an organization called the Society of Healthcare Improvement Professionals. We have a journal. I am the editor in published case studies. There are a lot of case studies out there that describe this. Probably one of the unfortunate things I have noticed in case studies though. They tend to focus on a few clinical areas like surgery and Emergency Department. Less so on other areas; but yeah, there are a lot of case studies. Maybe we should add that.  Go ahead.

[Crosstalk] 

Molly:Thank you. We can add additional resources to the archive file, if you would like to at any point and time. Okay, and the next question. Actually, we have a couple of comments. Bravo for the professional project management. Researchers can certainly benefit from additional education related to planning, schedule estimates, and budget management. Another one; thank you so much. This has been incredibly informative. Also some more input. 

The VERC also has resources to support research and to provide assistance. That acronym again is V as in Victor, E as in Edward, R as in Richard, C as in Charlie. You can also Google VERC. They have more resources. VA Healthcare Quality Improvement managers and staff are very familiar with the tools you presented today. That sounds like another resource somebody is mentioning. 

That is the final question. We do have a lot of people who just wrote in saying thanks. This was great. At this time, I would like to give you the opportunity to make any concluding comments you would like to.

David Belson:I guess one thing come to mind. That is when we looked at research proposal, the VA research QUERI, the research proposals, it seemed to me. Not just me, others that were kind of collaborating on this. That there was really a missed opportunity on a lot of research projects. But making use of these tools that effect, that create effective change. It would – there  certainly would be a big payoff if these tools were used more often and properly. I think that is the key message we wanted to do in this paper. Thanks.

Molly:Thank you. Thank you so much for presenting. Thank you for our very engaged audience. I do want to plug a couple of other sessions. First of all, if you go to our archive catalogue you can sort by series on the top right-hand corner. You can look for other QUERI sessions, which touch on a lot of research help. Furthermore, I want to plug our next QUERI session, which is Thursday, September 5, from 1:00 to 2:00 p.m. Eastern. That is QUERI Implementation Research – Pragmatic Trial Design. 

Again, if you go to the Cyber Seminar catalogue you can sign up for that. I want to thank Dr. Belson again. I want to thank Dr. Rubenstein for the introduction; and David Ganz, and Debbie Delevan for your support. When you exit the session, please do wait just a second. A feedback survey will populate on your screen. It is your feedback that guides where our program goes. Thank you so much to everyone. Have a wonderful day. 

[END OF TAPE] 

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