QI, in a nutshell

1. QI, in a nutshell Georgia McIntosh, MD And Quality and Safety Educator’s Academy, Society of Hospital Medicine

2. 6 Steps to QI 1. Understand the problem 2. Identify areas for change/improvement 3. Explicitly state your goals 4. How will you measure progress 5. Create effective, reliable improvements 6. Build upon success and sustain the process

3. 6 Steps to QI 1. Understand the problem 2. Identify areas for change/improvement 3. Explicitly state your goals 4. How will you measure progress 5. Create effective, reliable improvements 6. Build upon success and sustain the process

4. Process Modeling Tools • Cause and Effect Diagram or Fishbone diagram • Standard Flow diagram • Deployment Flowchart or Swim-lane Diagram • Mind Map

5. Process Modeling Tools • Cause and effect diagram ( “fishbone or ishikawa”) • Process Map

6. Process Modeling ToolsMind Map

7. Process Modeling ToolsDeployment Flowchart or Swim-lane Diagram

8. Error Reduction Strategies

9. 6 Steps to QI 1. Understand the problem 2. Identify areas for change/improvement 3. Explicitly state your goals 4. How will you measure progress 5. Create effective, reliable improvements 6. Build upon success and sustain the process

10. Donabedian’s Topology of Quality Measures Structure How was care delivered to the patient Process What was done to the patient Outcome What happened to the patient Balancing Unintended, undesirable consequences

11. Structure, Process or Outcome? • 30 day mortality after CABG • Bone densitometry ordered in women over 65 • Computerized order entry • ACE or ARB for CHF pts with low EF • Last BP of < 140/90 in pts with HTN • Physician boarded in critical care medicine responding to codes at all times

12. 6 Steps to QI 1. Understand the problem 2. Identify areas for change/improvement 3. Explicitly state your goals 4. How will you measure progress 5. Create effective, reliable improvements 6. Build upon success and sustain the process

13. Aim Statement “VCUHS will be the safest hospital in the United States.”

14. Aim Statement VCUHS’ mission is “to become America’s safest health system with the goal of zero events of preventable harm to patients, team members and visitors.”

15. Aim Statement VCUHS’ mission is “to become America’s safest health system with the goal of zero events of preventable harm to patients, team members and visitors.” • For whom? • How good? • By when?

16. 6 Steps to QI 1. Understand the problem 2. Identify areas for change/improvement 3. Explicitly state your goals 4. How will you measure progress 5. Create effective, reliable improvements 6. Build upon success and sustain the process

17. MeasurementPayers Demanding Increased Accountability Voluntary reporting to payer Pay for reporting to payer Public reporting Pay for performance

24. 6 Steps to QI 1. Understand the problem 2. Identify areas for change/improvement 3. Explicitly state your goals 4. How will you measure progress 5. Create effective, reliable improvements 6. Build upon success and sustain the process

31. 6 Steps to QI 1. Understand the problem 2. Identify areas for change/improvement 3. Explicitly state your goals 4. How will you measure progress 5. Create effective, reliable improvements 6. Build upon success and sustain the process

32. Quality and Safety Concept Map • Quality • Safety • Measures • Adverse events • Near Misses • K Swiss Cheese Model • Root Cause Analysis • QI project Work • S • A • Change • Error Reporting • Safety Culture

33. Recently, several complaints have been filed by patients in your clinic about excessive wait times in the lobby. As a member of the quality team at your clinic, you are charged to study and fix this problem. Which of the following improvement methodologies would be most successful at reducing wait times for patients in the clinic lobby? • LEAN • Six Sigma • Cause-and-effect diagramming • Swim lane diagramming • Failure mode and effects analysis

34. Recently, several complaints have been filed by patients in your clinic about excessive wait times in the lobby. As a member of the quality team at your clinic, you are charged to study and fix this problem. Which of the following improvement methodologies would be most successful at reducing wait times for patients in the clinic lobby? • LEAN • Six Sigma • Cause-and-effect diagramming • Swim lane diagramming • Failure mode and effects analysis

35. LEAN • Developed by Toyota • Aim to eliminate waste in the system • Most common waste is patient wait time

36. Six Sigma • Invented by Motorola • Designed to remove defects and variations from a system • Six sigma means 6 standard deveiations from the mean which represents 3.4 defects per 1 million opportunities • Utilizes DMAIC methodology • Design, Measure, Analyze, Improve, Control

37. Cause and effect diagramming • AKA Fishbone diagram • Uncovers the factors that influence an outcome • Hypothesis-generating tool

38. Deployment Flowchart or Swim-lane Diagram

39. Failure mode and effects analysis • Tool for classifying errors by severity and likelihood of recurrence for use in prioritizing quality initiatives

40. Failure Mode and Effects Analysis • systematic, proactive method for evaluating a process to identify where and how it might fail, and to assess the relative impact of different failures in order to identify the parts of the process that are most in need of change.

41. 2. You serve on the sentinel event review committee. An event occurred in which a patient received an overdose of heparin. Your committee completes a root cause analysis and finds that the error resulted from a gap in physician knowledge about heparin dosing, the lack of an institutional consensus on heparin dosing, and a cumbersome order entry system. From the root cause analysis, which of the following interventions is most likely to have a sustained effect? • Online education module on heparin dosing • Distribution of a heparin dosing pocket card • A heparin order set • A new institutional policy on heparin dosing • A physician education conference on heparin dosing

42. 2. You serve on the sentinel event review committee. An event occurred in which a patient received an overdose of heparin. Your committee completes a root cause analysis and finds that the error resulted from a gap in physician knowledge about heparin dosing, the lack of an institutional consensus on heparin dosing, and a cumbersome order entry system. From the root cause analysis, which of the following interventions is most likely to have a sustained effect? • Online education module on heparin dosing • Distribution of a heparin dosing pocket card • A heparin order set • A new institutional policy on heparin dosing • A physician education conference on heparin dosing

43. Error Reduction Strategies

44. How do you prevent customers from leaving behind their ATM cards?