A Stepwise Approach to Quality Improvement

1. A Stepwise Approach to Quality Improvement Michelle Mourad, MD Director of Quality and Safety, Division of Hospital Medicine UCSF Medical Center

2. Hand Hygiene 60% reliable VTE Bundles 80% reliable Central Line Bundles 70% reliable Why do we fail to do simple things that improve care?

3. What is QI ? Quality Gap Progress Best practice Actual practice Time

4. What is QI? QI is about producing reliable and sustainable change. Yay QI! Yay QI Yay Sepsis! I’m tired • Foley out • DVT ppx • Pain Control • Daily BM

5. Start with a story… • Mayoral election in Romania • NeculaiIvascu incumbent mayor … “ I know he died, but I don’t want change.” I’ll ask you a question…

6. Do you work in a great hospital? • Do you work in a great hospital? • What’s keeping it from being great? • Do the leadership and faculty want greatness? Do you? • If we all want to work at a great hospital…

7. You as a leader • Doctors not trained as leaders • Doctors make poor followers.

8. Objectives • Understand how the principles of QI can help you achieve PCQN vision • Guide you through a stepwise approach to improvement • Understand how PCQN data can be used for improvement

9. You log into the PCQN website after a recent Palliative Care faculty meeting… Turns out despite a lot of work, your institution is still below the group average

10. Stages of QI – Kübler Ross Style Denial – That can’t be my data Acceptance – We should probably try to improve Emotional Response Depression – No one else is doing any better Shock – Is that my data? Bargaining – Our patients are sicker Anger – The measurement strategy must be flawed Time

11. How do we improve care? • Set the vision for improvement • Understand the Problem • Identify Areas for Improvement • Devise a Measurement Strategy • Prioritize small tests of change • Measure Change • Message value & Sustain the change

12. Using a QI framework to improve care • Set the vision for improvement • Understand the Problem • Identify areas for Improvement • Devise a measurement strategy • Prioritize small tests of change • Measure change • Sustain the change 8:40

13. Vision • Align, Define & Inspire • Focus on why, not what or how.

14. As a leader of change, the GOAL is not to make every body do what you want, the goal is to inspire people to believe what you believe

15. The BI will eliminate all preventable harm by 2020.

16. Using a QI framework to improve care • Set the vision for improvement • Understand the problem • Identify areas for improvement • Devise a measurement strategy • Prioritize small tests of change • Measure change • Sustain the change 9:15

17. The problem = Persistently high pain scores

18. The problem = Pain management Equipment Process People - No timely orders - Lack of Nursing buy in - Unclear Physician buy in Materials Management Environment - Pain meds not stocked • Sicker patients - Staffing on the floors

19. Fishbone Diagram The Cause The effect Equipment Process People The Problem primary cause secondary cause Materials Management Environment

20. Table exercise – Create a Fishbone – 10 minutes Equipment Process People Materials Management Environment

21. What did you come up with? Equipment Process People • No timely orders • Teams wont let PC write orders • Rounding only once a day - PCAs take too long to order - Lack of Nursing buy in - Unclear Physician buy in - Need more chaplain / SW support Materials Management Environment - Pain meds not stocked • Sicker patients • Staffing on the floors • Not reliably measuring pain scores - Existential pain, not treated with opiates - More cancer patients

22. Fishbone = structured brainstorming about why you have the problem Use as a guide for data you may want to collect

23. Use data to ensure you are fixing the right problem

24. The problem = Timely pain management Equipment Process People - No timely orders - Lack of Nursing buy in - Unclear Physician buy in Is different than fixing time to pain med delivery Fixing Nurse & Physician buy in Materials Management Environment - Pain meds not stocked • Sicker patients - Staffing on the floors

25. Case example: Patient Satisfaction • Goal: Improve Patient Satisfaction with MD Communication • Intervention: Teach hospitalists best practices in patient communication • Outcome: No improvement WHY? • Data: Patient comments all report dissatisfaction with communication between hospitalist & specialists which was not improved.

26. We discover • Hour long delays between recs & orders • Nurses not giving doses promptly • Patients aren’t asking for PRN meds • No afternoon reassessment

27. Using a QI framework to improve care • Set the vision for improvement • Understand the problem • Identify areas for improvement • Devise a measurement strategy • Prioritize small tests of change • Measure change • Sustain the change 9:55

28. Identify areas for improvement • Go and see for yourself • Keep asking why until you get to the root of things

29. Identify Areas for Improvement(current state) 45 year old woman with malignant bowel obstruction due to colon cancer with nausea, vomiting and abd pain, progressive inability to take oral meds/hydration PCS Rounds (day 1) Informal ✔ in w/ primary teams FAMILY MTGS Write notes with “official recs” Write orders OR Page team with updated recs 1hr 3hrs 3 hrs 2 hrs PCS Rounds (day 2) Day 2 pain scores unchanged • Team (or you) wrote orders “just before they went home. • Patient unaware of “new” regimen. • Did not ask for additional PRNs • Nurse didn’t provide info on available meds

30. Removing Obstacles • Ask your team why don’t people do this already?