Quality Improvement

1. Quality Improvement Nicole Paradise Black Lindsay Thompson Erik Black

2. Why is QI Important? $$$

3. Improvements in quality translate to…. • Improved patient experience (more referrals) • Expedited accounts receivable (more $$$) • Improved patient health (kinda important) • Reduction in expenses (more $$$)

4. The goals of the QI process for you • We are providing you with the tools and opportunity to learn how to conduct quality improvement projects • You will utilize this skill for the rest of your career (whether informally or formally through MOC, aka maintenance of certification for the ABP).

5. The Improvement Model

6. PDSA- Plan Do Study Act • Plan • Always includes a prediction • Do--test the change • Study • Did my prediction hold? • What assumptions need revision? • Act • Adapt • Adopt • Abandon

7. PDSA

8. PDSA: cycles for testing • Increase your belief that the change will result in improvement • Opportunity for “failures” without impacting performance • Document how much improvement can be expected from the change • Learn how to adapt the change to conditions in the local environment • Evaluate costs and side-effects of the change • Minimize resistance upon implementation

9. Aim Statements Answers the first question: What are you trying to accomplish?

10. Aim statements: which one is the best? • I will give a talk about how to do quality • I will explain how to use the model for improvement • By 2pm on 5/6/10, 75% of QI 101 participants will have completed SMART Aim statements.

11. Aim statements: which one is the best? • I will give a talk about how to do quality • I will explain how to use the model for improvement • By 2pm on 7/26/09, 75% of QI 101 participants will have completed SMART Aim statements.

12. SMART Aim statement • A written statement of the accomplishments expected from team’s improvement effort • SPECIFIC • MEASURABLE • ACTION-ORIENTED • REALISTIC and RELEVANT • TIMELY

13. Another example • We will decrease the rates of bloodstream infection. • We will implement the insertion and maintenance bundles as recommended by the CDC. • We will decrease the rates of catheter-acquired blood stream infections for all PICU patients to less than 2/1000 device days by July, 2010.

14. Learning structure • A diagram that organizes the “theory of improvement” for a specific project. • Connects the outcome (Aim), key drivers with measures & design changes.

15. Design changes, interventions Key drivers Aim Learning Structure

16. Key drivers- critical issues • Ideal = evidence or data-based • Important to revisit as you understand the project more • By convention they should be stated in the affirmative

17. Identifying key drivers • If no evidenced or data-based drivers are known, ask: • What is necessary to achieve this aim? • Consider the following: • Performance of a component of a system (e.g., MD fills out a form) • An operating rule or value (e.g., RT owns asthma education) • An element of system structure (e.g., real time data for discharge time failure)

18. Design changes, interventions Key drivers • Hemostasis in holding room • Extubate in holding room • Rectal chloral hydrate if • necessary Finish Previous Case 1. Hemostasis & bandage 2. Extubation 3. Transfer pt to recovery Next patient ready Present Consents obtained Sedation given Transfer to cath lab Call CCU early to transfer pt Aim To decrease mean (and SD) time between cardiac caths by 50% by Jan 1, 2010 Cath Lab Preparation 1. Clean lab 2. Clean anesthesia equip 3. Table preparation 4. Computer & check list Call Housekeeping early Call Anesthesia Tech early Staff Readiness 1. Cath nurses 2. Radiology tech 3. Cardiologists 4. Anesthesiologist Learning Structure

19. Selecting an improvement idea to test- how to gather data • Process watch • Flow chart • Evidence/best practices • Voice of the customer • Brainstorming • Change concept

20. Change concepts vs. specific changes

21. Measurement forQuality Improvement • You can’t improve what you can’t (or don’t) measure. • Measures tell a team if the changes they make are making a difference. • The team needs just enough data to tell if the change is making an improvement. Should speed improvement, not slow it down. • Measurement is not the goal.

22. Ourtake on QI • Keep it simple, don’t try to save the world • Talk to the experts (fellow residents, attendings, nurses, other staff) • Remember the scientific method

23. That Scientific Method Thing… • Define the question • Gather information and resources • Form hypothesis • Perform experiment and collect data • Analyze data • Interpret data and draw conclusions that serve as a starting point for new hypotheses • Publish results

24. An Example: Back to sleep in the NICU • Problem: Based on limited analysis, a significant number of NICU patients are not being placed to sleep on their backs. • Define Question • Gather Information and Resources • Form Hypothesis • Perform Experiment/Collect Data • Analyze Data • Interpret Data • Publish Results

25. Low-touch Intervention

26. Data Collection

27. Analysis and Interpretation • For each count: number on back and total population. • Chart Progress. • Perform t-tests and compared day vs night shift, ANOVA of longitudinal results comparing months. • Interpretation of data.

28. Other forms of evaluation • Focus groups (pre-post intervention): consider bias • Questionnaires: consider reasonable numeric significance • Chart reviews (pre-post intervention): consider reasonable numeric significance

29. Example of data measurement using a run chart • Gather data • Need a minimum of 12 points to establish a baseline. • Need 20 – 25 points to detect meaningful patterns • Create a graph • Vertical scale (Y-axis): Measurement of interest • Horizontal Scale (X-axis): Time or sequence • Plot the data • Calculate the centerline (median or mean) • Annotate improvement interventions

30. Run chart example: CVL infections • Staff care education • CHG Scrub for care line and insertions • Maximal sterile barriers Max Cap introduced

31. The Project Description Worksheet Due by September 1, 2010 • Mentor: • Project description (brief paragraph providing general idea of project): • Initial Aim Statement (can be less specific than SMART Aim statement): • Timeline (pre-implementation data gathering, implementation, post-implementation data gathering):

32. The Project Description Worksheet Due by December 15, 2010 • Pre-implementation data findings: • SMART Aim statement (specific, measurable, action-oriented, realistic/relevant, timely): • Key Drivers (should be stated in the affirmative and list all key drivers even if you are not going to target them for change): • Design Change(s)/Intervention(s): •  Measure(s):

33. The Project Description Worksheet Due by June 1, 2011 • Project is complete. • Preparing for platform presentation or poster presentation to occur during that month. • Project Description Worksheet, presentation and evaluation of project will be placed in your electronic portfolio.

34. Remember • Handing in stuff before deadlines is ALWAYS welcomed! • If you are having trouble meeting a deadline, just let us know (we are understanding folks!) • We love to see your faces, if you’re stuck come and talk to us!