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Basics of Quality Improvement (QI)

Basics of Quality Improvement (QI). Lisa Knight, MD 04-10-2013. It’s not rocket science. Lecture Objectives. Understand the role of QI in healthcare and residency Know the 3 components of the Model for Improvement Know the 4 stages of a PDSA cycle

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Basics of Quality Improvement (QI)

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  1. Basics of Quality Improvement (QI) Lisa Knight, MD 04-10-2013 It’s not rocket science

  2. Lecture Objectives • Understand the role of QI in healthcare and residency • Know the 3 components of the Model for Improvement • Know the 4 stages of a PDSA cycle • Be familiar with the IOM’s six specific aims for improvement Planning, starting and completing your residency QI project

  3. Why Quality Improvement? • A gap exists between the quality of care that is possible and the actual quality of care delivered to persons living in the U.S. • Due to the seriousness of these shortcomings there is increasing importance that physicians and residents learn and use modern QI methods and tools Infant mortality in the US per 1000 live births is DOUBLE that of other leading nations

  4. “Every system is perfectly designed to get the results it gets” • This means that the US healthcare system is perfectly designed to: • Achieve 44,000 to 98,000 inpatient deaths per year due to medical errors • Have twice the infant mortality rate of other nations • Do all that for twice the cost per person of other industrialized countries • You can respond in 1 of 3 ways • Ignore it • Blame someone else (insurance, malpractice, Obama….) • Do something about it The only way to get different results is to CHANGE THE SYSTEM

  5. Patient Protection and Affordable Care Act • Pay for performance • Quality-based reimbursement • Bundled payments • One lump sum American College of Physicians: “adoption of appropriate quality improvement strategies, if done right, will result in higher quality patient care leading to increased physician and patient satisfaction. But the College is also concerned that these changes could lead to more paperwork, more expense, and less revenue; detract from the time that internists spend with patients, and have unintended adverse consequences for sicker and non-compliant patients American Academy of Neurology(AAN): "An unintended consequence is that current relative payments are distorted and represent a misaligned incentive system, encouraging diagnostic tests over thoughtful and skilled patient care. The AAN recommends addressing these underlying inequities before a P4P program is adopted.[

  6. Pediatric Residency Review Committee • The Pediatric Residency Review Committee (RRC) requires that all residents: • Learn QI methods • Participate in a QI project "residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-assessment and life-long learning. Residents are expected to develop skills and habits to be able to systematically analyze their practice using QI methods, and implement changes with the goal of practice improvement; residents are expected to participate in a QI project." • The ABP requires all board certified pediatricians to participate in QI activities as part of their MOC

  7. QI Projects Ongoing at USC/PH • Central Line Associated Blood Stream Infection (CLABSI) • 10-20% attributable mortality per CLABSI • $35,000 attributable direct cost per CLABSI • Reviewed technique with staff for accessing the CL • Emphasis on device utilization • Conversion to PO • Spring-cleaning of the MAR

  8. 6. Implement the improvement AIM 7. Study the results MEASURES CHANGES 8. Establish a future plan Ideal Future • Select the opportunity for improvement • Select the team • Study the current situation • Analyze the causes • Develop a theory for improvement Present Situation

  9. The Model for Improvement (MFI) AIM MEASURES CHANGES PDSA Cycle

  10. You Conduct PDSA Cycles Everyday: “I made my lunch for work before going to bed last night. That worked out pretty well for me.” OR “I drove a different way to work this morning than I normally do. That did not work out so well for me.”

  11. An everyday PDSA cycle: Planning Stage • Identify problem: • I fall asleep at work every morning • Overall Goal: • Improve my level of wakefulness in the morning • AIM • Stay awake in the morning at work 100% of the time by May 1, 2013 • Measures • Quantitative: • Awake at 10am? Check yes or no • Qualitative: • Scale of 1 to 10—how awake do I feel? • Changes

  12. An everyday PDSA cycle: Planning Stage MFI: AIM Statement • Should provide an answer to the question • “What are we trying to accomplish” • A good aim is: • Specific • Measurable • Addresses these points: • For whom (or for what system)? • How good? • By when? “I will stay awake in the morning 100% of the time by May 1, 2013”

  13. AIM Statements: Strong or Weak? WEAK • We aim to reduce harm and improve patient safety for all of our internal and external customers • By June of 2008, we will reduce the incidence of pressure ulcers in the critical care unit by 50% • We will reduce all types of hospital-acquired infections • Our most recent data reveal that, on average, we reconcile the medications of only 35% of our discharged patients. We intend to increase this average system-wide to 50% by April 1, 2008 and to 75% by August 31, 2008 STRONG WEAK STRONG

  14. An everyday PDSA cycle: Planning Stage MFI: Measures • Should provide an answer to the question • “How will we know that a change is an improvement?” • Qualitative data: subjective • Quantitative: objective • 3 main types of measures: • Outcome • Tell you if you are reaching your ultimate result • How many mornings am I awake at 10am per week • Process • Are the parts/steps in the system performing as planned • How many mornings do I actually drink coffee • Balancing • Tell you if changes designed to improve one part of the system are causing new problems in other parts of the sysem • Starbucks is $4/coffee which is hurting my wallet

  15. Potential set of measures for improving my AM wakefulness AIM Outcome Measures Process Measures Balancing Measures I will stay awake in the morning 100% of the time within one week • Awake or not awake at 10am • How awake I feel in AM on scale of 1-10 How many days per week I actually drink coffee in the morning How much money I spend on coffee per week at Starbucks

  16. An everyday PDSA cycle: Planning Stage MFI: Changes • Should provide an answer to the question • “What change can we make that will result in improvement?” • Critical thinking about the current system • Flowchart on the current process • Analyze data on the current system • Benchmarking • Comparing your own process to “best practice” • Take the patient’s perspective • Ask the patient/caregiver for ideas • Using technology • Text messaging • Social media

  17. An everyday PDSA cycle: Planning Stage MFI: Changes

  18. An everyday PDSA cycle: DO – STUDY - ACT • Decide on: • Start date • April 11, 2013 • Timeframe • One week --Awake everyday at 10am --Score improved from 3 to 9 --Drank a cup of coffee from Starbucks everyday Spent $28 dollars on coffee AIM Outcome Measures Process Measures Balancing Measures I will stay awake in the morning 100% of the time within one week • Awake or not awake at 10am • How awake I feel in AM on scale of 1-10 How many days per week I actually drink coffee in the morning How much money I spend on coffee per week at Starbucks

  19. QI vs Research Steal Shamelessly Research Quality Improvement Form hypothesis Stick with it until bitter end One large test T-tests, chi square, p-value Form a hypothesis Adjust through multiple PDSA cycles to work out kinks Sequential tests Run charts or Shewhart charts In QI, the goal is to improve the conditions that exist… not merely to describe what they are And to do that, you need to be able to modify your assumptions and retest your theories based on what you learn in the course of your tests

  20. Institute of Medicine Reports • (1999) To Err is Human: Building a Safer Health System • Put the spotlight on how tens of thousands of Americans die each year from medical errors • Effectively put the issue of patient safety and quality on the radar screen of public and private policymakers • (2001) Crossing the Quality Chasm: A New Health System for the 21st Century • Described broader quality issues • Defined six aims for care delivery and redesign

  21. The IOM has proposed 6 specific aims for improvement • Healthcare should be: • Safe • Effective • Patient-Centered • Timely • Efficient • Equitable Avoiding injury from care that is meant to be helpful Avoiding underuse or overuse of services Providing respectful, responsive, individualized care Reducing waits and harmful delays in care Avoiding waste of equipment, supplies, ideas, and energy Providing equal care regardless of personal characteristics

  22. When selecting a QI topic… Go for low-hanging fruit • Consider these areas when choosing a topic: • Near misses, adverse events, complaints • Repeated mistakes • A process that adds excessive costs to the patient or facility • Process that adds excessive time to care • Variations in care • Process or equipment/supplies that can be changed • Organization support and participation will be provided for this improvement process

  23. QI in the outpatient Endocrine clinic • No Show rate • Endocrine patients • Healthy Lifestyles patients • Medication compliance in adolescents with diabetes • Call volume from school nurses • First appt availability for new onset diabetic patients • Motivation to make lifestyle changes in Healthy Lifestyles patients • Amount of work we do outside of clinic hours that we do not get reimbursed for • Poor on-call check-out from week to week • Safe • Effective • Patient-Centered • Timely • Efficient • Equitable

  24. Developing a QI Project: Clinical Example • Identify an issue that you feel needs improvement • No Show rate in the outpatient Pediatric Endocrine clinic • Define why improvement in this area is necessary • Health risk of the patient who doesn’t show • Health risk of the patient seeking an appt, but unable to book in that no-show spot • Poor staff utilization • Loss of multiple streams of revenue • Collect and/or review baseline data in your problem area • Track the following for one month • Total number of patient appts scheduled • Total number of patients seen NS rate = 40%

  25. Developing an AIM Statement: Clinical Example • What are you trying to accomplish? • Reduce appt no-show rate • For Whom • Pediatric Endocrine outpatient clinic • How good? • Reduce to 30% • By when • October 2013 AIM Statement = We will reduce the NS rate in the outpatient Pediatric Endocrine clinic from 40 to 30% by October 2013

  26. Developing Measures and Changes: Clinical Example • Outcome Measure • No-Show rate (%) Total Patients Scheduled – Total Patients Seen Total Patients Scheduled • How will you determine what to change? • Determine factors contributing to no-shows in your population • Describe the current process for patient appt reminders • Automated phone call to primary phone in EMR 48-72 hours before appt X 100

  27. Developing Measures and Changes: Clinical Example • Change to be implemented • Secretary to contact patients on • Cell phone (if available) • Home phone • 24 hours before appt AIM Outcome Measures Process Measures Balancing Measures Change Reduce the NS rate in the Pediatric Endo clinic from 40 to 30% by October 2013 NS rate (%) How many patients each day receive a phone call 24 hours before appt Secretary satisfaction with the appt reminder system Secretary to make phone call to patient 24 hrs before appt

  28. Forming an Effective Team • Identify a QI mentor • Be sure to include members familiar with all the different parts of the process you are trying to improve • Endocrine Team: • Myself: Project Leader • Dr. Jackson: Division Director • Jen Tobias: Unit secretary

  29. Always Start Small • First PDSA cycle: • Only my patients • Not the other 3 endocrine providers • Morning clinic of April 11, 2013 • 10 patients • Increase in • Scale • Scope Ideal Future Present Situation

  30. We know what good health care is, that’s not the problem • The challenge is to close the gap, the “chasm” between • What we know to be good care and • The care that people actually receive

  31. Any Questions? AIM Measures • Safe • Effective • Patient-Centered • Timely • Efficient • Equitable Change Ideal Future Present Situation

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