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An Introduction to Quality Improvement

An Introduction to Quality Improvement. Kevin D. O’Brien, MD Fellow’s Research Conference July 23, 2014. Outline. Cost  Outcomes IHI, AHA and APM  Cost and  Outcomes: 2 examples: SE Alaska, Denver Health The IHI Model for Improvement A UWMC Example:  Cost and  Outcomes

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An Introduction to Quality Improvement

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  1. An Introduction to Quality Improvement Kevin D. O’Brien, MD Fellow’s Research Conference July 23, 2014

  2. Outline • Cost  Outcomes • IHI, AHA and APM •  Cost and  Outcomes: • 2 examples: SE Alaska, Denver Health • The IHI Model for Improvement • A UWMC Example: •  Cost and  Outcomes • Overcoming Barriers • Potential Training and Resources

  3. US Healthcare is Expensive-1…

  4. US Healthcare is Expensive-2… http://www.forbes.com/sites/danmunro/2012/12/30/2012-the-year-in-healthcare-charts/

  5. …but Outcomes are Poor http://www.forbes.com/sites/danmunro/2012/12/30/2012-the-year-in-healthcare-charts/

  6. The IHI Model for Improvement, AIM-PDSA:AIM: Aim, Improvement, Measures • Aim: What are we trying to accomplish? A good aim: • Issue important to those involved • Is specific, measurable, and addresses these points: How good? By when? For whom (or what system)? • Struggling?Remember STEEP (Safe, Timely, Effective, Efficient, Equitable, and Patient-centered) 2. Measures: How will we know a change is an improvement? • Outcome Measures = Where are we ultimately trying to go? • Process Measures = Are we doing the right things to get there? • Balancing Measures = Are the changes we are making to one part of the system causing problems in other parts of the system? 3. Changes: What changes can we make that will result in improvement? • 5 ways to develop changes: Critical thinking, benchmarking, using technology, creative thinking, and change concepts. • Change concepts: Eliminate waste, improve work flow, optimize inventory, change the work environment, producer/customer interface, manage time, focus on variation, focus on error proofing, focus on the product or service.

  7. The IHI Model for Improvement, AIM-PDSA:PDSA: Plan-Do-Study-Act • Plan: Plan the test or observation, including a plan for collecting data. • Do: Try out the test on a small scale. • Study: Set aside time to analyze the data and study the results. • Act: Refine the change, based on what was learned from the test.

  8. Care Coordination and Length of Stay Initiative on the Advanced Heart Failure Service: Results and Key Success Factors to date September 26, 2013 Robb Maclellan, MD Kevin O’Brien, MD Vandna Chaudhari

  9. Organizational Alignment • Inpatient Capacity: • Reduce LOS and Optimize Care via Standardization • Cardiology, Cardiac Surgery, Otolaryngology/HNS • Remove Waste and Optimize the Patient’s Value Stream • Standardize Clinical Pathway Milestones and Decisions • Reduce Readmits • Improve D\C Times

  10. Table 1. Scope of the Problem: Pre-PI (July 2012 to February 2013) Measures for the UW Advanced Heart Failure Service

  11. Table 2. Key Measures: Data Sources, Methods of Calculation and Measure Types. *HPM = Horizon Performance Management system maintained by UWMC Finance and Center for Clinical Excellence (CCE) for quality measures.

  12. Key Protocols • “Idealized HF” Pathway Protocol: • Based on UCLA model • Accelerates Tx/LVAD and anticipates Early Discharge: • Tx/LVAD W/U Starts on Day of Admission • Simultaneous Medical HF Optimization • Discharge Planning Completed by Hospital Day 2 • Complete Tx/LVAD Evaluation by Hospital Day 3 • New Protocols (UW-generated) to address other LOS barriers: • IV Diuretic Protocol: • Standardized approach to aggressive diuresis • Logical target (Weight Loss, not Net I/O) • Minimize use of high-cost, low benefit meds (e.g., Nesiritide) • Evidence-based Anticoagulation: • Stopped routine anticoagulation of HF patients • Risk-based Table to assess need for heparin “bridging”

  13. Card B Length of Stay “Run” Chart -4 Days p=0.023

  14. Card B CORES Census 9/1/2010 – 12/31/2013 Daily Census and 30 Day Moving Average LOS PI Project Start Improved Access: Jul-Dec 2013 Daily Census  by 3.1 patients (93 bed days/mo)

  15. ADV HF QUALITY IMPACT

  16. Cardiology B: Advanced HF PI & service level financial IMPACT • PI savings FY 2014 YTD • 1 (Heart Transplant Therapies) + • 2 (Medical Therapies cardiac DRGs only) • $6,338,740 • Pharmacy savings ($542,000) • $5,796,740 Service-wide savings FY 2014 YTD (Heart Transplant Therapies) + (Medical Therapies, all DRGs) $7,604,474

  17. Part 1: Develop Care Pathway Part 2: Navigate the Implementation “Minefield” Pathway Development No Data/ Data as a “Hammer” Bad Team Dynamics Resistance to Change (esp. MDs) Lack of Support http://politicaldisconnect.blogspot.com/2008/07/obama-entering-dangerous-mine-field.html http://thetyee.ca/News/2013/07/11/Clark-Marathon/

  18. EXPRESSIVE AMIABLE ANALYTIC DRIVER Personality Styles and Cardiology B Extroverted Introverted Feeling • Trained to focus on identifying problems (“Barriers”) • Perfectionist Thinking Merrill and Reid

  19. Overcoming Barriers to Progress • Regularly-scheduled Card B LOS Meeting: • Agenda distributed in advance (don’t meet just to meet) • Attendance by Division Head • Developing Protocols: • Modify existing protocols from respected peer institutions • Modify 10% rather than create 100% • Many generated internally • Implement with Plan-Do-Study-Act (PDSA) cycles (http://www.youtube.com/watch?v=xzAp6ZV5ml4): • PDSA a “shop floor” version of the experimental method: • Easier to get out of Committee • Whole team involved • Team-based measure of success (Cardiology B LOS)

  20. Donald Berwick, MD, MPP, Founder, Institute for Healthcare Improvement (IHI) https://www.youtube.com/watch?v=5vOxunpnIsQ Don Goldmann, President, IHI - 7 Rules for Engaging Clinicians in Quality Improvement https://www.youtube.com/watch?v=831mdPYGouo&feature=player_detailpage

  21. Challenges for QI Projects • Training in basic QI methods, IHI Open School: • “Basic Quality Certificate” • Online modules, about 20+ hours • Six modules (QI 101-106) required for MHA students prior to QI project • Potential Resource: Brenda Zierler, PhD, FAAN • Mentorship: • Relative paucity of faculty mentors within Division • IHI Open School Practicum • Pair with MHA students? • Training in QI research methodology: • Potential Resources: • Tom Staiger, MD • Doug Zatzick, MD • Potential data sources: • DCDR (De-identified Clinical Data Repository) through ITHS • Potential Resource: Bob Harrington, MD (ID Division)

  22. Potential Training (IHI Open School) and Data (DCDR) Resources IHI Open School DCDR https://www.iths.org/dcdr • http://app.ihi.org/lms/mycatalogs.aspx

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