Transcript Quality Improvement - Children's Mercy Hospital

Healthcare Quality and
Improvement
A Primer
Part 2
•
•
•
•
•
•
Review key concepts
Move on to other QI methods
Discuss project development
Research vs. QI
National patient safety goals
Joint commission
Objectives
• Quality problems in health care
• Define quality
• Who, what, why and how of quality improvement
– Tools and methods
•
•
•
•
•
Key elements of a good QI project
Quality improvement vs.. research
QI project development
National Patient Safety Goals
Joint Commission
Defining Quality
• Quality is…
– A systems-wide issue
– An individual performance issue rarely
Quality is a team sport
Quality at CMH
How informed are you?
• Rate of compliance with hand washing?
– 90%
• Central line infection rate?
– 1.2/1000 cath days-PICU
• % of codes outside the PICU?
– 50%
• % of inpatients with medication reconciliation
performed?
– 70%
Quality Improvement
• A process of innovation and adaptation
designed to bring about immediate
positive changes in the delivery of health
care in particular settings
– systematic
– data-guided
– multidisciplinary
Quality Improvement
and Data
• Use data for learning, not judging
– “Generate light, not heat”
• Use data to report system attributes
• Use aggregate not individual data
• Do not report data on individual
performance
Improvement Methods
A brief overview
•
•
•
•
Model for Improvement
Lean
Six Sigma
Trigger tools
Model for Improvement
• Flexible improvement
framework
• IHI
• PDSA methodology
• Emphasizes
–
–
–
–
Aims and measures
Initial small tests of change
Widespread testing
Implementation and spread
Improvement Methods
• What is LEAN?
• What is Six Sigma?
• Identify a trigger tool
Lean
• Management philosophy based on 2 key themes
– Continuous elimination of waste
– Respect for people and society
• Key principles
– Value is in the eyes of the customer
– Make value flow without interuptions
• Improve work flow
• Standardize work processes
– Pursue perfection
Lean
• Culture
– Stop and fix the problem as soon as it is
identified
– Toyota manufacturing culture
• Process
– Measure
– Change
– Measure
– Change…..
Lean Project
“Improve ED Patient Flow”
• Project aim-reduce ED LOS by 50%
• Process improvements(reduce waste)
– Work standards and evidence-based clinical practice
guidelines for all ED staff defined
– Batching of orders eliminated
– Right supplies and equipment in the right place;
eliminated unnecessary S&E
– Admission process streamlined
• Results
– Reduced ED LOS for discharges by 23%
– Reduced ED LOS for admissions by 20%
Lean
What is waste in medicine?
•
•
•
•
•
•
•
•
Surgical infection
Preventable adverse drug events
Ventilator assisted pneumonia
Equipment failure
Waiting and lack of flow
Inadequate training or orientation
Unnecessary or poorly designed processes
Not following evidence based practices
Six Sigma
• Focus is to eliminate defects
– Nonconformity of a product or service to its
specifications
• Six sigma processes have variation that
result in <3.4 parts/million defects
Why Zero Defects is the Only
Acceptable Quality Standard
• At 99.9% quality levels in a 250 bed hospital
–
–
–
–
12 inpatients per year would die due to errors
6 day surgery patients would die
9,742 wrong medications would be delivered
4,923 incorrect laboratory tests would be
reported
– 502 incorrect radiographs would be completed
Six Sigma
• Systematic and scientific management approach
to reduce sources of process variation and
improve reliability
–
–
–
–
–
Customer and financially focused
Strategic
Uses project management concepts
Strong statistical focus
Focus on “mistake-proofing”
• Requires rigorous professional training
Six Sigma Project
“Reducing Hospital-Acquired Pressure Ulcers”
• 5 structured project phases
– Define
– Measure
– Analyze
– Improve
– Control
Trigger Tools
• Method for identifying adverse events (harm)
and measuring the rate of adverse events over
time
• Method options
– Retrospective review of a random sample of patient
records using triggers (clues)
– Prospective surveillance of electronic patient records
• Goal-to identify areas for improvement and
prevent harm
Trigger Tools
Your medical world
• Are there triggers that
could be used in your
specialty to identify
areas of potential
patient harm?
Root Cause Analysis
• Process to identify causal factors for
variation in performance; “learning from
consequences”
• Systems and processes focus
• Individual performance not a focus
• Identifies potential improvements to
reduce likelihood of future event
• Used in M&M process, sentinel event
investigations
Fishbone Diagram
Task Factors
Task design and
clarity of structure
Availability and use
of protocols
Availability and
accuracy of test
results
Decision-making
aids
Patient Factors
Condition (complexity
and seriousness)
Language and
communication
Personality and social
factors
Team Factors
Verbal communication
Written communication
Supervision and seeking help
Team structure (congruence,
consistency, leadership, etc)
Individual (staff) factors
Knowledge and skills
Competence
Physical and mental health
Organizational and Management Factors
Financial resources and constraints
Organizational structure
Policy, standards and goals
Safety culture and priorities
Work Environmental Factors
Staffing levels and skills mix
Workload and shift patterns
Design, availability and maintenance
of equipment
Administrative and managerial
support
Environment
Physical
Care Delivery problems (CDPs)
Care deviated beyond safe limits of
practice
The deviation had at least a
potential direct or indirect effect for
an adverse outcome for the
patient, staff or general public
Examples: Failure to monitor,
observe or act
Incorrect (with hindsight) decision
Not seeking help when necessary
Failure modes and Effects
Analysis (FMEA)
• Prospective technique
• Systematic assessment to
– Prevent problems before they occur
– Reduce the chance of unintended adverse
harm if they occur
• Used for high risk procedures or error
prone processes
Now its your turn!
• Form groups of 4-5 team members
• Pick one of the following aims
– !00% of all requests for physician consultation include a
verbal discussion between the physician requesting the
consult and the physician receiving the request
– Reduce errors during patient care handoffs: sign out,
transfer to another service, etc (right info at the right time,
distractions, templates, etc)
– Reduce variation in practice for management of
__________ by implementing evidence based practice
standards
– You decide_______________________________
• Be prepared to present your plan
Now its your turn!
• Develop a plan to achieve the aim
– Who’s on the team?
– Responsibilities and roles
– Improvement methods
– Timelines
• Identify outcome and balancing measures
• Identify data needed to assess improvement
and sources of data
Now its your turn!
• Share the projects
you have done or are
developing
Improvement project ideas
• Care process changes
– Hand offs
– Scheduling
– Medication reconciliation
• Implementation of new clinical or
administrative practices
• Practice standardization
Central Line Infections
Defining the problem
• 15 million central venous catheter-days
per year in ICUs
• Attributable mortality for these infections 420%
• Bloodstream infections prolong
hospitalization by a mean of 7 days
Central Line Infections
Stating the project aim
• Reduce central line infection rate to 0 in
the ICU in 12 months
Central Line Infections
Practice Standardization
•
•
•
•
Hand Hygiene
Maximal Barrier Precautions upon insertion
Chlorhexidine skin antisepsis
Optimal catheter site selection, with Subclavian
Vein as the preferred site for non-tunneled
catheters
• Daily review of line necessity with prompt
removal of unnecessary lines
Central Line Infections
Practice Standardization
Quality Improvement
Key elements
•
•
•
•
•
•
•
Systematic
Data-guided and knowledge informed
Experiential
Innovative
Employs formal explicit methodology
Continuous
Core responsibility of healthcare
professionals
Quality Improvement Work
• Focused on systems
• Team oriented
• Requires team skills
– Collaboration
– Meeting skills
– Value all perspectives
• Develop local new useful knowledge to
inform health care processes
Quality Improvement vs. Research
It’s Complicated….
• QI
– Systematic data-guided
activities designed to bring
about immediate positive
changes in healthcare delivery
in local practice settings
– An integral part of the ongoing
healthcare delivery system
– A form of clinical and
managerial innovation and
adaptation
– Combines discipline specific
knowledge with experiential
learning and discovery
• Research
– A systematic investigation
designed to develop or
contribute to generalizable
new knowledge
– Implementation of research
is a separate process and
occurs later, if at all
– A knowledge seeking
enterprise that is
independent of routine
medical care
Hastings Report
Quality methods and terms
_5_Sentinel event
_8_Never event
1. a tool which uses clue to identify a possible adverse event
2. an improvement method driven by statistical analysis of data to identify unwanted
defects and variation
_9_PDSA
3. a tool used to systematically identify all factors that may have contributed to
an adverse situation
_6_LEAN
4. unintended injury from medical care that requires additional treatment or
monitoring or results in death
_2_Six sigma
5. an unexpected occurrence involving death, serious injury or the potential for
serious injury
_11_Root Cause An. 6..an improvement method focused on eliminating waste through analysis of workflow
_3_Fishbone diagram 7. a prospective process which uses a systematic assessment to identify and prevent
potential problems
_7_FMEA
8. an event that is reasonably preventable; e.g. pressure ulcer, hemostat left in
patient during surgery
_4_Harm
9. a process used in the Model for Improvement to test changes
_1_Trigger tool
10. an error
_12_Action plan
11.a retrospective assessment of an adverse situation that has occurred
_10_Adverse event
12. a plan developed to address deficiencies identified during a root cause analysis
Questions?
Joint Commission
• Accrediting organization for healthcare
institutions
• Sets administrative and practice standards
and evaluates compliance
• Performs unannounced on-site surveys of
accredited hospitals to assess compliance
every 18-39 months
Joint Commission
Mission
• To continuously improve the safety and
quality of care provided to the public
through the provision of health care
accreditation and related services that
support performance improvement in
health care organizations
National Patient Safety Goals
•
•
•
•
Key national safety goals for hospitals
Set by Joint Commission
Updated yearly
Goal is to promote specific improvements
in patient safety
2008 NPSG
• Goal 1 Improve the accuracy of patient
identification.
– 1A Use at least two patient identifiers when
providing care, treatment or services.
2008 NPSG
• Goal 2 Improve the effectiveness of
communication among caregivers.
– 2A For verbal or telephone orders or for
telephonic reporting of critical test results, verify
the complete order or test result by having the
person receiving the information record and
"read-back" the complete order or test result.
– 2B Standardize a list of abbreviations, acronyms,
symbols, and dose designations that are not to be
used throughout the organization.
2008 NPSG
• Goal 2 Improve the effectiveness of
communication among caregivers.
– 2C Measure and assess, and if appropriate,
take action to improve the timeliness of
reporting, and the timeliness of receipt by the
responsible licensed caregiver, of critical test
results and values.
– 2E Implement a standardized approach to
“hand off” communications, including an
opportunity to ask and respond to questions.
2008 NPSG
• Goal 3 Improve the safety of using medications.
– 3C Identify and, at a minimum, annually review a
list of look-alike/sound-alike drugs used by the
organization, and take action to prevent errors
involving the interchange of these drugs.
– 3D Label all medications, medication containers
(for example, syringes, medicine cups, basins), or
other solutions on and off the sterile field.
– 3E Reduce the likelihood of patient harm
associated with the use of anticoagulation
therapy.
2008 NPSG
• Goal 7 Reduce the risk of health care-associated
infections.7AComply with current World Health
Organization (WHO) Hand Hygiene
Guidelines or Centers for Disease Control and
Prevention (CDC) hand hygiene guidelines.
– 7B Manage as sentinel events all identified cases
of unanticipated death or major permanent loss of
function associated with a health care-associated
infection
2008 NPSG
• Goal 8 Accurately and completely reconcile
medications across the continuum of care.
– 8A There is a process for comparing the patient’s
current medications with those ordered for the
patient while under the care of the organization.
– 8B A complete list of the patient’s medications is
communicated to the next provider of service
when a patient is referred or transferred to
another setting, service, practitioner or level of
care within or outside the organization. The
complete list of medications is also provided to
the patient on discharge from the facility.
2008 NPSG
• Goal 9 Reduce the risk of patient harm
resulting from falls.
– 9B Implement a fall reduction program
including an evaluation of the effectiveness of
the program.
2008 NPSG
– Goal 13 Encourage patients’ active
involvement in their own care as a patient
safety strategy.
• 13A Define and communicate the means for
patients and their families to report concerns
about safety and encourage them to do so.
2008 NPSG
• Goal 15 The organization identifies safety
risks inherent in its patient population.
– 15A The organization identifies patients at risk
for suicide.
2008 NPSG
• Goal 16 Improve recognition and
response to changes in a patient’s
condition.
– 16A The organization selects a suitable
method that enables health care staff
members to directly request additional
assistance from a specially trained
individual(s) when the patient’s condition
appears to be worsening.
Quality Improvement
Key elements
•
•
•
•
•
•
•
Systematic
Data-guided and knowledge informed
Experiential
Innovative
Employs formal explicit methodology
Continuous
Core responsibility of healthcare
professionals
Healthcare Quality Improvement
2007
• Move from cottage industry mode of care
delivery to data driven system model of
healthcare delivery
• Systems approach
• Individual blame not the norm
• Individual IS accountable