What is Quality?

1. Applying Quality Improvement Skills to Stroke Care11th Annual Stroke CollaborativeToronto, 20 October 2008Dr. Ben Chan, MD MPH MPACEO, Ontario Health Quality Council 1

2. What is Quality? “Quality health care means doing the right thing at the right time in the right way for the right person and having the best results possible.” 2

3. Attributes of Quality & High Performing Health System • Effective • Efficient • Equitable • Accessible • Safe • Patient-centred • Focused on population health • Integrated • Appropriately resourced 3

4. What is Optimal Stroke Care? • Population health • low physical activity, overweight • smoking, excess etOH, stress • diet (low fruits/veggies, hi fat/sodium) • lack of awareness of signs & sx 4

5. What is Optimal Stroke Care? • Stroke prevention in primary care • screening - for DM (q3yrs), cholesterol (q1-3 yrs), BP • diabetes - BS control (A1c<7, FBG 4-7, 2 hr postprandial 5-10) • BP control (140/90 or 130/80 if DM, kidney dis) • ASA (if past TIA, stroke, CAD, DM, etc.) • coumadin (if atrial fib) • lipid control / statin (w/ risk stratification) 5

6. What is Optimal Stroke Care? • Acute Stroke Management • tPA within 3 hrs onset • CT/MRI asap • dedicated stroke unit admission • dysphagia assessment • tight BS control 6

7. What is Optimal Stroke Care? • Post stroke treatment • access to dedicated stroke rehab unit (in-pt, cmty) • carotid imaging & endarterectomy/stent (if indicated) • LTC unit with stroke experience • post-stroke depression mgt (SSRI, etc.) 7

8. Which Areas Have Biggest Room for Improvement? • Population Health • Stroke prevention in Primary Care • Acute management of stroke • Post-stroke treatment 8

9. How Are We Doing With Quality? 9

10. Effectiveness – Chronic Disease Management 10

11. INSERT Bar Chart from report – page 91 11

12. 12

13. Avoidable Complications of DM, CAD 13

14. Avoidable Complications With Better Management of DM, CAD 14

15. 15

16. Preventable Risk Factors 16

17. Preventable Risk Factors 17

18. How Do We Move… • From Strategy… • To Action? 18

19. QI Tools & Approaches 19

20. Before Fixing the Problem… • Diagnose the underlying root causes • Consider differential diagnosis of causes • Prioritize which causes to address first • If not sure which causes to tackle first, collect some data 20

21. Process Mapping 21

22. A process map gives you… • An overview of the complete process • A visual aid to effectively plan • Ideas from all different types of staff What you need… • Blank wall • Yellow stickies • Facilitator – focus on main scenarios (what happens 80% of time) 22

23. Analyzing the Map • From the patient perspective: • How many steps are there for the patient? • How many times is the patient passed from one person to another? • What is the approximate task time? • What is the approximate wait time? • How many steps add no value for the patient? 23

24. For each step, ask if it can be: • eliminated? • Combined with other steps • Done in different order? • Done elsewhere? Reduce wasted travel? • Done by someone else more effectively / efficiently? • Done in parallel instead of sequentially? • Where are bottlenecks? Need to shift capacity to here? 24

25. Example: Routine Labs in Primary Care Labs needed? Abnormal? Pt Appointment Yes Give Pt Requisition Lab Done No No Yes Book earlier f/u, or call pt 25

26. Alternate Process Scheduled Apptmt, Review Recent Labwork Show up for Lab apptmt? Pre-book lab for before next apptmt in 3 mo Reminder to pt before lab apptmt No RN calls pt x 2, rebook Yes Lab Done 26

27. Ishikawa Diagrams 27

28. Ishikawa Diagrams • Put problem at right • Draw spine • Draw offshoot lines for categories of causes • Draw offshoots for causes of causes • Use “Five Why’s” technique to elicit root causes • Identify those causes which you can impact • Prioritize as a group the most NB causes 28

29. Why Aren’t Labs Done? 29

30. Reasons: Pt can’t understand instructions Language barrier Lab hours inconvenient MD forgot to order lab Pt lost the requisition Pt forgot Pt missed apptmt – weather, emergency Pt not seen for months (e.g. gets med refills by phone) Change ideas? Reasons Why Labs Not Done 30

31. Lots of Great Ideas… • What next? 31

32. 32

33. Aim Statements for QI Projects • What are we trying to accomplish? • “Improve diabetes care for our patients.” 33

34. Aim Statements for QI Projects • What are we trying to accomplish? • Improve diabetes care for our regular patients in the Bay St, May St. and Gray St. clinics. Increase the % of these patients hitting their targets for BP, cholesterol & AIC to 75%. Do this by March 2009. 34

35. Well Designed Aim Statements • Is it clear? • Is it measurable? • Is time specified? • Is the target population identifiable? • Can you hear the promise for better patient outcomes? 35

36. Measures:How Will We Know a Change is an Improvement? • outcome measures • e.g. A1C, BP, chol • Process measures • e.g. use of recommended drugs, % getting regular labs • e.g. improved team functioning • Consider balancing measures • Unintended consequences 36

37. Example: Pt Self-Mgt • Let’s implement patient self-management over the next few months. We’ll show a nifty bar chart of how our results for A1C & cholesterol improved before and after. Good or bad idea? 37

38. Quality Measurement • Measure frequently throughout course of project • Get early feedback on impact of changes • Correct course or accelerate 38

39. % of patients who have set >= 1 written pt mgt goal in past 6 months 50 47 46 50 34 40 31 23 24 30 21 New tool w Group sessions 23 Percent 20 10 Test new tool 10 new doctor 0 Nov Jan Oct Dec July May April Sept June August Time Period Annotated Run Charts 39

40. Where Do I Get the Data??? 40

41. Data Sources • Ideal: • Disease registries • Regular queries from electronic medical record • Stroke registry • Alternate: small periodic samples • Defect check sheets • Mini-surveys 41

42. Defect Cause Check Sheet Quality Improvement Project:_____________________________ Defect / Defect Cause of Interest: ________________________ Instructions to Recorders on When to Record a Defect:_____ Type of patients or services being observed for defects:____ Setting: _________________________________________________ Time Frame for Data Collection: __________________________ Data Recorders:_________________________________________ 42

43. Sampling Plans 43

44. What Changes Can We Make That Can Result in Improvement? 44

45. Source of Change Ideas • Best practices literature • other QI initiatives • Your own system analysis • Ideas from your peers • Your own brainstorming 45

46. What Changes Can We Make That Can Result in Improvement? • Avoid jumping immediately to the perceived panacea solution • Consider best practice examples for implementation from elsewhere • Conduct careful analysis of system, root causes, cause & effect, process maps before implementing changes 46

47. ImplementationExample: Pt Self-Mgt • We’re going to create a committee. In the next four months they’re going to research pt self mgt tools. We’re going to carefully select a package of materials. Then we’re going to have extensive in-service sessions to train all the staff on how to use the materials. 47

48. Implementation Example:Pt Self Management • Pt self management seems like a great idea. There are many different tools out there. We’re also not sure who’s the best person on our team to deliver different components of self management – the doctor, nurse, dietician, counsellor. Let’s systematically test different ways of implementing this and see what works best in our environment. 48

49. Alternative Approach from QI Science • Implementing Change: PDSA cycles • Plan, Do, Study, Act • Testing predictions • Learning from small tests of change • Rapid cycle improvement 49

50. Objective What do you want to learn/try? Plan Who, what, where, when? Measurement Predict outcome as a group Do Just do it! Study What worked? What didn’t? Predict correctly? Act Next steps What should a PDSA look like? Write It down! 50