Transcript Quality Improvement in Healthcare: Residency and Beyond

QUALITY IMPROVEMENT
IN HEALTHCARE:
RESIDENCY AND BEYOND
Lisa Knight, MD
Quality Improvement Lecture 3
February 27, 2014
LECTURE OUTLINE
• Refresher on the Basics of a QI project
• SQUIRE guidelines
• Refresher on upcoming QI deadlines
THE IOM HAS PROPOSED 6 SPECIFIC AIMS FOR IMPROVEMENT
• Healthcare should be:
• Safe
Avoiding injury from care that is meant to be helpful
• Effective
Avoiding underuse or overuse of services
• Patient-Centered
• Timely
• Efficient
• Equitable
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
HOW DO WE GO ABOUT CHANGING THE SYSTEM?
Model for
Improvement
5-Step Process for Improvement
Establish a
future plan
Plan
Act
Study the
results
1. Select the opportunity for
improvement
2. Study the current situation
3. Analyze the causes
4. Develop a theory for improvement
5. Select the team
Do
Study
Implement the
Improvement
Present
Situation
ACT
PLAN
STUDY
DO
ACT
PLAN
STUDY
DO
What are we trying to
accomplish?
AIM
MEASURES
How will we know that a change
is an improvement?
What change can we make that
will result in improvement?
CHANGES
ACT
PLAN
STUDY
DO
Ideal
Future
Lisa Knight
Whitney Brown
The Endocrine Clinic Secretary
Reduce the No-Show rate in the Pediatric Endocrine clinic from
35% to 20% by June1, 2014
No-Show rate (%) = Total number of patients who didn’t show
X 100
Total number of patients scheduled
Percentage of patients each day who received a phone call 24 hours before their appt
Secretary satisfaction with the appt reminder system
Secretary to make phone calls to patients 24 hours before their appt
HOW DO WE GO ABOUT CHANGING THE SYSTEM?
Model for
Improvement
5-Step Process for Improvement
Establish a
future plan
Plan
Act
Study the
results
1. Select the opportunity for
improvement
2. Study the current situation
3. Analyze the causes
4. Develop a theory for improvement
5. Select the team
Do
Study
Implement the
Improvement
Present
Situation
ACT
PLAN
STUDY
DO
ACT
PLAN
STUDY
DO
What are we trying to
accomplish?
AIM
MEASURES
How will we know that a change
is an improvement?
What change can we make that
will result in improvement?
CHANGES
ACT
PLAN
STUDY
DO
Ideal
Future
QI VS RESEARCH
Research
• Primary focus:
• Generating new, generalizable scientific
knowledge
Quality Improvement
• Primary focus:
• Making care better at unique local sites
REPORTING GUIDELINES
• Standardized guidelines have been developed for reporting the following:
• CONSORT – randomized controlled trials
• STARD – studies of diagnostic accuracy
• STROBE – epidemiological observational studies
• QUOROM – meta-analysis and systematic reviews of randomized controlled trials
• MOOSE – meta-analysis and systematic reviews of observational studies
• In 1999
• SQUIRE guidelines
• Standards for QUality Improvement Reporting Excellence
www.squire-statement.org
SQUIRE GUIDELINES: OVERVIEW
• Title
• Abstract
• Introduction
• Methods
• Results
• Discussion
• References
TITLE
• Needs to indicate that your project concerns the improvement of quality
• Needs to include the specific aim of the intervention
• Examples:
• A quality improvement project incorporating a procedural checklist in the sedation
unit to improve patient safety
• Outcomes of a quality improvement project to reduce the incidence of
hypoglycemia secondary to insulin administration in newly diagnosed diabetes
mellitus
• Decreasing Central Line Entries on the Children’s Cancer and Blood Disorders Unit:
a collaborative, hospital-based quality improvement project
INTRODUCTION
Why did you choose this problem and how are you going to address this problem?
• Background Knowledge
• Brief summary of current knowledge of the problem being addressed
• Characteristics of the organization in which the project is occurring
• Local Problem
• Details any previous work (if any) that has been done to target the problem
• Describes the nature and severity of the specific local problem being addressed and its significance
• Intended Improvement
• Describes the specific change that will be made to result in improved care
• Describes the specific AIM statement of the proposed intervention
• Answers the questions:
•
For whom
•
How big of a change
•
By when
INTRODUCTION: EXAMPLE
Background Knowledge: Brief summary of the current problem being addressed and
characteristics of the organization in which the project is occurring
Central line associated bloodstream infections (CLABSIs) are a costly and deadly problem in the
healthcare field. In the pediatric population there is an average of 0.7 to 7.4 CLABSIs per 1000 catheter
days……..
………At Palmetto Health Children’s Hospital, a 300 bed academic pediatric hospital, there is a 10-20%
attributable mortality per CLABSI as well as an estimated direct cost of $35,000 per CLABSI. Because
of these risks and the resulting increased financial burden, the reduction of CLABSIs is a large area in
need of continuing quality improvement…….
Local Problem: Previous work that has been done to target the problem and describe the nature
and severity of the specific local problem being addressed and why it is important
………Reducing CLABSIs has been a major initiative for PHCH for quite some time. PHCH PICU has
participated in the Children’s Hospital Association PICU Quality Transformation Network since January
2011 and focus has been on reduction of unnecessary central line entries.
……. Given that immunocompromised children are at high risk for healthcare-associated infections,
and many of these children have central lines that require frequent accessing for blood draws,
medication administration, etc, we began a similar project on the Cancer and Blood Disorders
unit…….
INTRODUCTION: EXAMPLE (CONT.)
Intended Improvement: Describe the specific change the will be made to result in improved care
……A data collection form will be created and distributed to the nursing team on the
CBD unit. Each time a nurse accesses a patient’s line on the CBD unit (for med
administration, blood draws, etc) an entry will be recorded on the data collection form.
This form will be reviewed by the nurses, physicians, and pharmacists on rounds each
morning in an attempt to reduce the number of times central lines are accessed
unnecessarily…..
Intended Improvement: Describe the specific AIM statement of the proposed intervention
…….The aim of this project was to evaluate the average number of central line entries
performed on children on the CBD unit and to decrease this number by 50% over a 4
month period
METHODS
What did you do?
• Planning the intervention
• Describe the intervention in sufficient detail that others could reproduce it
• Indicate main factors that contributed to choice of the specific intervention
• Analysis of causes of dysfunction
• Matching relevant improvement experience of others with the local situation
• Outline initial plans for how the intervention was to be implemented
• What is to be done (initial steps for implementation of the proposed change)
• By whom (intended roles)
• Planning the study of the intervention (Methods of evaluation and analysis)
• Provides details of qualitative and/or quantitative methods used to draw inferences from
data
METHODS: EXAMPLE
Planning the intervention: Describe the intervention in sufficient detail that others could reproduce it
A data collection form for recording each time a patient’s central line was accessed on the CBD
unit was created and was reviewed with and distributed to the nursing staff of that unit.
Anytime a central line was accessed on a patient, it was recorded on the data collection form.
For each entry, the nurse had to answer the question “Did they think that specific accessing of
the line was avoidable?” If the answer was “yes” then they were instructed to discuss with the
primary team (physicians and pharmacists) the following morning during rounds……
Planning the intervention: Indicate main factors the contributed to choice of the specific intervention
……A data collection form for recording details about central line accessing has previously
been utilized in the PICU of Palmetto Health Children’s Hospital with good success on a QI
project to reduce the incidence of CLABSIs in that unit. For this project, this PICU data
collection form was adapted and modified to more specifically fit the needs of the CBD
unit……
CENTRAL LINE ENTRY DATA COLLECTION FORM
METHODS: EXAMPLE (CONT)
Planning the intervention: Outline initial plans for how the intervention was to be implemented
A meeting between the charge nurse, pharmacist, and attending physicians on the CBD unit
was held to discuss the project with the goal of decreasing central line entries. The data
collection form mentioned previously was created and then was reviewed with and
distributed to the nursing staff on the CBD unit. The forms were utilized by the nursing staff
each day each time they accessed a patient’s central line for recording when and for what
reason they were doing so. The completed forms were reviewed by the physician and
pharmacist the following morning on daily rounds. During this review, the team assessed
whether any of the line entries could have been combined with others or eliminated
altogether…….
Planning the study of the intervention: quantitative methods used to draw inferences from data
……To determine the effectiveness of the intervention, the average number of central line
entries per day in the pre- and post-intervention period served as the primary outcome
measure. As a secondary outcome measure, the total number of line entries per day
classified by purpose of the line entry was utilized…….
RESULTS
What did you find?
• Discuss changes in processes of care and patient outcomes associated with the
intervention
• Written description
• Graphic representation
RESULTS: EXAMPLE
Discuss changes in processes of care associated with the intervention: written description
There was a decrease in the total number of line entries in patients with central lines
per day (see Figure). Following PDSA cycle #1, the average number of line entries per
day was 3.6. After PDSA cycle #3, the number of line entries had decreased to 0.8
entry per day. The data was also broken down by the type of line entries for each PDSA
cycle (see Figure). The three most common reasons for line entry were medications,
lab draws, and flushes. The total number of entries for these 3 reasons was also
decreased after 3 PDSA cycles with total medication entries for a one week period
decreasing from 90 to 8, total lab entries decreasing from 24 to 4, and total flush entries
decreasing from 35 to 9.
RESULTS: EXAMPLE
Discuss changes in processes of care associated with the intervention: graphic representation
RESULTS: EXAMPLE (CONT)
Discuss changes in processes of care associated with the intervention: graphic representation
DISCUSSION
What do the finding mean?
• Summary
• Summarize the most important successes and difficulties in implementing intervention
components, and main changes observed in care delivery and clinical outcomes
• Limitations (if any)
• Consider possible sources of confounding, bias, or imprecision in design, measurement, and
analysis that might have affected study outcomes
• Explore factors that could affect the generalizability of the results
• Describe plans for monitoring and maintaining improvement
• Conclusions
• Consider overall practical usefulness of the intervention
• Suggest implications of your report for further studies of improvement interventions
QUESTIONS?
UPCOMING QI DEADLINES
First Years
Second Years
• Feb 2014
• Feb 2014
• Second QI Lecture
• Second QI Lecture
• March 1, 2014
• March 31, 2014
• Choose QI topic
• Complete QI Project and collection of post-intervention data
• April 1, 2014
• April 25, 2014 (12:15p to 1:15p)
• Choose QI Faculty Mentor
• Poster Presentation Lecture
• May 1, 2014
• May 21, 2014
• Turn in completed Project Planning Document to me
• Turn in QI project write-up to me
Pediatric Residency QI Website
http://pediatrics.med.sc.edu/residency.asp