Quality Improvement in Healthcare: Residency and Beyond

1. Quality Improvement in Healthcare: Residency and Beyond Lisa Knight, MD Quality Improvement Lecture 3 February 5, 2015

2. Lecture Outline • Refresher on the Basics of a QI project • Project Implementation and Data Analysis • SQUIRE guidelines • Reminder on upcoming QI deadlines

3. QI vs Research Research Quality Improvement Primary focus: Making care better at unique local sites • Primary focus: • Generating new, generalizable scientific knowledge

4. How do we go about changing the system? 5-Step Process for Improvement Select the opportunity for improvement Study the current situation Analyze the causes Develop a theory for improvement Select the team Model for Improvement Plan What are we trying to accomplish? Establish a future plan How will we know that a change is an improvement? Act Do What change can we make that will result in improvement? Ideal Future Study Implement the Improvement Study the results Present Situation

5. QI Project Example 1: from start to finish 5-Step Process for Improvement Select the opportunity for improvement Study the current situation Analyze the causes Develop a theory for improvement Select the team • Night Team checkout • Large amount of time updating the resident/patient assignment list • Resident/Nurse communication • Unnecessary “transfer phone calls” to unit secretaries • Night team hand writes a new list everyday • A lot of redundancy • Unit secretaries update the nurse/patient assignment list everyday • Residents do not have access to it

6. QI Project Example 1: from start to finish Get Buy in from those affected • IT department • Development of a shared drive • Access for residents/attendings • Unit secretaries on 3rd and 4th floors • Nursing staff on 3rd and 4th floors • Residents on wards/NF during PDSA cycle periods

7. QI Project Example 1: from start to finish Model for Improvement Baseline Data Collection What are we trying to accomplish? How will we know that a change is an improvement? • Create a General Pediatric Shared Drive • Unified List • Outcome Measure • Number of minutes for residents to update list (min/day) • Number of transfer calls to unit secretaries each day (#calls/day) • Process Measure—Percent of days in the PDSA cycle that the list was appropriately updated • Balancing Measure—Amount of time (in min/day) that the unit secretaries spend making the new lists vs the old lists What change can we make that will result in improvement? • 2 weeks of night float this year • Unit secretaries track: • How many phone calls they receive from residents each day asking to be transferred to a nurse • Time themselves when they update the list • Night float residents time themselves when they update the list

8. Baseline Data: Results

9. Lindsey Stoltz Dr. Katie Stephenson 3rd and 4th Floor Unit Secretaries Night Team Pediatric Residents • Improve communication amongst residents and between residents and nurses by: • Reducing the amount of time (in minutes/day) that the night float team spends updating the floor lists from 19.3 minutes to 5 minutes by March 31, 2016 • Reducing the number of “transfer request” phone calls (in #calls/day) to the unit secretaries from 8.9 to 0 by March 31, 2016 1. Primary: Amount of time (in minutes/day) that the night float team spends updating the floor lists 2. Secondary: Number of transfer request phone calls from the residents (in #calls/day) to the unit secretaries Number of days in the PDSA cycle where the list was appropriately updated Number of days in the PDSA cycle X 100 Amount of time (in minutes/day) that the unit secretaries spend making the new lists versus the old lists Combine the resident and nurse assignments into one list, include an area with their corresponding pagers and IP numbers, respectively to allow for minimal daily adjustments, and save the lists on a shared computer drive for easy access for everyone

10. PDSA Cycle 1 Week 1 or 2 of Ward Month • Make all parties aware of project and goals • Night Float Team • Day Ward Residents (including weekend) • Unit Secretaries (4th floor) Remember to track all measures • Outcome Measures • Time for Night Float Residents to Update List (min/day) • Number of transfer request phone calls to unit secretaries (#Calls/day) • Process Measure • Percent of nights in PDSA cycle that the list was updated appropriately • By Night Float residents • By unit secretaries • Balancing Measure • Time for unit secretary to update new lists (min/day)

11. PDSA Cycle 1 Results

15. QI Methods: Next Steps • Discuss the new shared drive and list with all residents/attendings • Housestaff Meeting • CHOC QI Meeting • Separate Lecture • Ensure staff (secretaries and nurses) on affected floors are aware of new list/shared drive

16. QI Project Example 2: from start to finish 5-Step Process for Improvement Select the opportunity for improvement Study the current situation Analyze the causes Develop a theory for improvement Select the team • Large population of caregivers at CHOC who use tobacco • If caregiver is interested in tobacco cessation • Given a handout with contact info for SC DHEC tobacco cessation resource quitline • Caregiver then has to initiate contact on their own by calling the number on the handout • Many do not follow-up

17. QI Project Example 2: from start to finish Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? • Use e-referral to SC DHEC Tobacco Program • Instead of handout • Outcome Measure • Percent of e-referral caregivers who have continued follow-up with the SC DHEC smoking cessation program one month after the referral was made • Process Measure—Percent of caregivers for whom an e-referral to the SC DHEC smoking cessation program was made who can be successfully contacted at the one-month follow-up • Balancing Measure—Amount of time (in minutes/referral) that the residents spend making an e-referral What change can we make that will result in improvement?

18. PrOject Implementation Get Buy in from those affected Baseline Data Collection CHOC Clinic month (1st year) Decide who will be collecting data How will residents notify the data collector when they have given a handout to a caregiver Who will be making the follow-up phone calls at the one month mark Collect names/contact info of caregivers given a handout with the SC DHEC smoking cessation hotline number Contact each caregiver one month later to determine what percent of caregivers have continued follow-up • Residents in CHOC during the baseline data collection month

20. Michael Mitchell Dr. Katie Stephenson CHOC Residents/Faculty Increase the one-month follow-up with smoking cessation services for caregivers of the patients of the Children’s Hospital Outpatient Center by 25% by March 31, 2016 The percent of e-referral caregivers who have continued follow-up with the SC DHEC smoking cessation program one month after the referral was made Percent of caregivers for whom an e-referral to the SC DHEC smoking cessation program was made who can be successfully contacted at the one-month follow-up Amount of time (in minutes/referral) that the residents spend making an e-referral Instead of giving caregivers a handout in clinic that has the SC DHEC smoking quitline number information and asking them to contact the number on their own, resident physicians in CHOC will utilize the SC DHEC electronic referral process for caregivers interested in smoking cessation

21. PDSA Cycle 1 CHOC month of 1st or 2nd Year • Make all parties aware of project and goals • Residents/Attendings in CHOC that month Remember to track all measures • Outcome Measures • Percent of patients who have continued f/u with the SC DHEC smoking cessation program at the one month time mark • Process Measure • Percent of caregivers who could be successfully contacted at the one month time mark • Balancing Measure • Amount of time (minutes/referral) it takes for a resident to complete an e-referral

22. Baseline PDSA 2 PDSA 3

25. Reporting Guidelines • Standardized guidelines have been developed for reporting the following: • CONSORT – randomized controlled trials • STARD – studies of diagnostic accuracy • STROBE – epidemiological observational studies • QUOROM – meta-analysis and systematic reviews of randomized controlled trials • MOOSE – meta-analysis and systematic reviews of observational studies • In 1999 • SQUIRE guidelines • Standards for QUalityImprovement Reporting Excellence www.squire-statement.org

26. SQUIRE Guidelines: Overview • Title • Abstract • Introduction • Methods • Results • Discussion • References

27. Title • Needs to indicate that your project concerns the improvement of quality • Needs to include the specific aim of the intervention • Examples: • A quality improvement project incorporating a procedural checklist in the sedation unit to improve patient safety • Outcomes of a quality improvement project to reduce the incidence of hypoglycemia secondary to insulin administration in newly diagnosed diabetes mellitus • Decreasing Central Line Entries on the Children’s Cancer and Blood Disorders Unit: a collaborative, hospital-based quality improvement project

28. Introduction Why did you choose this problem and how are you going to address this problem? • Background Knowledge • Brief summary of current knowledge of the problem being addressed • Characteristics of the organization in which the project is occurring • Local Problem • Details any previous work (if any) that has been done to target the problem • Describes the nature and severity of the specific local problem being addressed and its significance • Intended Improvement • Describes the specific change that will be made to result in improved care • Describes the specific AIM statement of the proposed intervention • Answers the questions: • For whom • How big of a change • By when

29. Methods What did you do? • Planning the intervention • Describe the intervention in sufficient detail that others could reproduce it • Indicate main factors that contributed to choice of the specific intervention • Analysis of causes of dysfunction • Matching relevant improvement experience of others with the local situation • Outline initial plans for how the intervention was to be implemented • What is to be done (initial steps for implementation of the proposed change) • By whom (intended roles) • Planning the study of the intervention (Methods of evaluation and analysis) • Provides details of qualitative and/or quantitative methods used to draw inferences from data

30. Results What did you find? • Discuss changes in processes of care and patient outcomes associated with the intervention • Written description • Graphic representation

31. discussion What do the findings mean? • Summary • Summarize the most important successes and difficulties in implementing intervention components, and main changes observed in care delivery and clinical outcomes • Limitations (if any) • Consider possible sources of confounding, bias, or imprecision in design, measurement, and analysis that might have affected study outcomes • Explore factors that could affect the generalizability of the results • Describe plans for monitoring and maintaining improvement • Conclusions • Consider overall practical usefulness of the intervention • Suggest implications of your report for further studies of improvement interventions

32. Questions?

33. Upcoming QI Deadlines First Years Second Years March 31, 2015 Complete collection of post-”Change” data April 2015 (Date TBA) Poster Presentation Lecture Friday, May 8, 2015 Turn in QI project write-up to me by midnight Friday, June 19, 2015 (730a – 9a) 3rd Annual Resident QI Presentation Day July 2015 SCAAP Poster Presentations • Develop a timeline for implementation of the “Change” you will be making for your QI project • Finalize Baseline data collection on your outcome measure • Process and Balancing measures, if applicable • Develop a timeline for data collection following implementation of the “Change” Pediatric Residency QI Website http://pediatrics.med.sc.edu/residency.asp