Transcript Resident Longitudinal QI Projects

Resident Longitudinal QI Projects
”Residents must demonstrate the ability to investigate
and evaluate their care of patients, to appraise and
assimilate scientific evidence, and to continuously
improve patient care based on constant selfevaluation and life-long learning.“
ACGME Common Program Requirements
Specifically, ACGME would like us to
 Identify strengths, deficiencies and limits in one’s knowledge
and expertise
 Set learning and improvement goals
 Systematically analyze one’s practice using quality
improvement methods (PDSA), and implement changes with
the goal of practice improvement
 Incorporate formative evaluation feedback into daily practice
 Locate, appraise and assimilate evidence from scientific studies
related to patients’ health problems
Its not just ACGME…
ABIM’s Maintenance of Certification
Maintenance of Certification
PIM- Professional Improvement Module
More PIM
Objectives
1) Understand how to develop an
Aim Statement
Measurement Plan
Improvement Plan
2) Understand rapid cycle improvement
Step #1 - Setting the AIM – What are we
trying to accomplish?
• State the aim clearly
• Include numerical goal and time frame that
require fundamental system change
• Set stretch goals
• Avoid aim drift
• Be prepared to refocus the aim
Step #2 - Establishing measures –
How will we know that a change is an improvement?
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Plot data over time
Seek usefulness, not perfection
Use sampling
Integrate measurement into the daily routine
Use qualitative and quantitative data
Step #2 - Establishing measures –
How will we know that a change is an improvement?
Data to collect
1. How many patients
met with the pharmacist
2. When? Early enough
to detect change in
HgA1C?
Evaluate your current
management and Nationally
recognized guidelines. How do
they differ?
Baseline
Data
(HgA1C)
Plan, DoEach patient will
meet with
pharmacist to
evaluate
medications
HgA1C
after 6
months
HgA1C is the outcome,
but the most important data is to
determination the intervention’s
effectiveness.
Step #3 – Overall Plan for Improvement
• Avoid “the same” responses
• Implement recommended practices
guidelines
• Think processes and systems of work
– Simplify processes
– Reduce waste or unnecessary redundancies
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Creative thinking
Appropriate use of new or existing
technology
“Every system is perfectly
designed to get the results it
gets.”
Paul Batalden, M.D.
The Model for Improvement
PDSA
What are we trying to
accomplish?
How will we know that a change is
an improvement?
What changes can we make that
will result in improvement?
The Improvement Guide (Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. San Francisco, California, USA: Jossey-Bass Publishers, Inc.; 1996
The Cycle- Plan, Do, Study, Act
Also known as:
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PDCA (Check instead of
Study)
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The Deming Cycle/Wheel
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The Shewart Cycle
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The Learning and
Improvement Cycle
Plan
Sequence:
1) Gather background data on the current
system.
2) Describe your tactic (intervention)
3) Predict outcome
4) List tasks needed
5) Plan for collection of data
DO – Carry it Out
• Implement (preferably on a small
scale)
• Document problems and unexpected
observations
• See plan through to completion
• Motivations to carry it out
Study or Check –
What did we learn?
• Review the Data / take survey
• Compare the data to your predictions
• What worked or went well? What did not?
• Summarize and Reflect on what was
learned -- Draw Conclusions
ACT
• Adopt it
• Abandon it
• More study needed
• Modify overall aim,
measure, or plan
• Create new plan
Rapid Cycle - Multiple Cycles
Overall AIM Increase documented eye
exams for our diabetes population by 45% in the next 12
months
Implement Final
Changes
Cycle #5 – Reminder letter from PCPs
Expect Challenges
and Barriers
Cycle #4 – Computer Network with eye doctors
Cycle #3 – Front Office track down eye results
Cycle #2 – Patient Fax Back Form
Cycle #1 – Contact Eye Doctors
Time
Discouraged…
 So, your patient’s are no more healthy than when you started…
 The system in which you function isn’t working- now you have
data to support that.
 Re-analyze the system, identify areas you can change, areas
that are ineffective, areas that are chaotic.
 Start a new PDSA cycle to tease out what parts of these areas
can be changed
 Design an intervention, implement it, gather data and analyze
it…
 Shampoo, rinse, repeat.
How to manage your panel in Powerchart
(sort of)
Any Diabetic Patient
click
click
Say “ok”
Modify display under Components tab
Not very helpful!
Double Click
Name and MRN‘To Row,’
everything else to ‘Page’
Upcoming Longitudinal QI Projects
 Interns- Start with HgA1C (UNM Clinics) and Hypertension (VA).
 Except NE Heights- you’re special
 Upper levels
 Options!!! If you are interested in switching projects, consider HgA1C (at VA),
Hypertension (at UNM), Lipid Guidelines
QI Projects Plug
(aka how to improve your CV and future employability)
 Inpatient Influenza Vaccination Project
 Increase the frequency of inpatient influenza vaccine screening,
 Increase the number of patients who receive flu vaccine by the time of
discharge
 Improve documentation of reasons for not administering flu vaccine among
inpatients.
 Improving influenza vaccination among residents, fellows, and
faculty.
 Influenza vaccination status was not known for 60% among UNM physicians last
year.
 Lower the barriers for receiving the influenza vaccine (i.e., working with
different groups to find convenient times/locations for influenza vaccination)
 Improve collection of documentation
QI Projects Plug
(aka how to improve your CV and future employability)
 Hand washing on 4-west
 4 West is among the worst floors for hospital acquired c-diff
 RN’s are working on a hand washing initiative
 People are watching! You may be placed in a raffle to win coffee and/or candy
 Improved Discharge of Behaviorally Challenged Patients from 4west
 MHC order sets
 Improved medication compliance after transfer
 Improved coordination of security
 CIWA Project- more about that later
 RN driven improvement in CIWA protocol
 Less GTT’s, less MICU transfers, less sitter use, less oversedation
QI Projects Plug
(aka how to improve your CV and future employability)
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Dr. Langsjoen- early probiotics in patient’s receiving antibiotics
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Dr. Crowell- Sepsis bundle- lots of opportunity for lactates between 2 and 4
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Pulm/Crit care people.
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Stand out on your application
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PSN Project, improved documentation, reporting
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7-Day Readmits
Still in development
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Hospitals will not be reimbursed for 30 day readmits- starting with low-lying fruit by evaluating 7-day
readmits
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MICU transfers
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Outpatient pain management
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Also still in development-
Increasing Advanced Directives completed in clinic setting
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Sign prompting patients to ask about advanced directives