Transcript Quality Improvement - Children's Mercy Hospital

Healthcare Quality and
Improvement
A Primer
Our current medical world
• Issues about the quality of healthcare are daily
news items
• Medical profession is in a “fishbowl”
I
Healthcare Safety
Medicine vs.. Airline Industry
• Headline: “Can you be as safe in a
hospital as you are in a jet?”
• Medical mistakes in hospitalized patients
account for a minimum of 120 deaths annually
• This equates to a crash of a Boeing 747 every
week killing all on board.
Healthcare Costs
Errors
• Headline: “Medication errors in
2006 added $3.5 billion to the cost
of healthcare”
• Headline: “80,000 catheter-related
bloodstream infections occur in
intensive care units in the US each
year”
Healthcare Effectiveness
Acute URIvisits/10,000 with antibiotic prescription
Healthcare Backlash
Boston Globe
• Headline: “We pay for medical
errors”
• By Richard Lord and Dr. Marylou Buyse. 9/12/ 2007
• “WHAT IF your mechanic forgot to replace the
lug nuts after changing one of your tires and you
got into a serious accident when the wheel came
off? You wouldn't expect your mechanic to send
you a bill for the repairs, would you?”
• “Unfortunately, that's what happens in
healthcare; we pay a high price for mistakes.”
Boston Globe
• “Healthcare entities should not be
rewarded financially when such
preventable errors occur. Hospitalacquired infections offer one example.”
• “No other industry generates revenue from
mistakes. Preventable errors should not
be part of the usual cost of healthcare.”
Can we fix this?
• The train is out of the station and it’s heading
towards YOU
• Hop on…….or prepare to be trampled
National Healthcare Quality Organizations
Agency for Healthcare Research and Quality (AHRQ)
www.ahrq.gov
Health Care Quality
www.consumer.gov/qualityhealth/index.html
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) www.jcaho.org.
National Committee for Quality Assurance
www.ncqa.org.
Quality Interagency Coordination (QuIC) Task Force
www.quic.gov.
URAC (also known as the American Accreditation Healthcare Commission) www.urac.org
U.S. Consumer Gateway: Health
www.consumer.gov/health.htm
U.S. News Online
www.usnews.com/usnews/nycu/health/hehome.htm
Quality Improvement
Basic ingredients
• Clinical knowledge
and experience
+
• QI basic concepts
+
• Systems approach
Objectives
•
•
•
•
•
•
•
Quality problems in health care
Define quality
Who, what, why and how of quality improvement
Key elements of a good QI project
Quality improvement vs.. research
Joint Commission
National Patient Safety Goals
Our current medical world
Contributing factors
• Knowledge and technology explosion
• Barriers to translation of scientific
knowledge into clinical practice
• Increasing complexity of healthcare needs
• Outdated processes and systems for
complex multidisciplinary healthcare
delivery
Our medical world
Past and future
• Cottage industry
– Individual patient focus
– “I know it when I see
it”
• Integrated healthcare
system
– System focus
– Evidence based
Our current medical world
Accelerating factors
• Multiple studies and reports
– widespread and frequent incidence of medical errors
– lack of consistency in the care received in different facilities
and from different providers
• Explosion of healthcare quality interest and
organizations
• Institute of Medicine Reports
– To Err is Human: Building a Safer Health System(1999)
– Crossing the Quality Chasm(2001)
Quality Chasm/Gap
• Defined by the IOM
• The difference between what is
scientifically sound and possible and the
actual practice and delivery of health
services
• Illustrates the need for healthcare quality
improvement efforts
Quality problems
Healthcare services
•
•
•
•
•
Underuse
Overuse
Misuse
Variation
Fragmentation
Institute of Medicine
Quality Aims
• Name the 6 quality
aims identified by the
IOM
Institute of Medicine
Quality Aims
•
•
•
•
•
•
Safe
Effective
Patient centered
Timely
Efficient
Effective
Institute of Medicine
Quality Aims
• Safe
– Avoid injury to patients from the care that is
intended to help them
• Examples
– Prescription of medication that patient is allergic
to
– Failure to address an abnormal lab or Xray result
– Failure to perform the correct procedure
Institute of Medicine
Quality Aims
• Effective
– Avoid overuse of ineffective care and
underuse of effective care
• Examples
– Obtaining lab or Xray tests that don’t alter
treatment plan
Healthcare Effectiveness
Acute URIvisits/10,000 with antibiotic prescription
Institute of Medicine
Quality Aims
• Patient centered
– Provide care that is respectful of and
responsive to individual patient preferences,
needs and values
• Examples
– Shared decision making for treatment options
Institute of Medicine
Quality Aims
• Timely
– Reduce waits and harmful delays for both
those who receive care and those who give
care
• Examples
Institute of Medicine
Quality Aims
• Efficient
– Avoid waste including waste of supplies,
equipment, ideas and energy
• Example
– Necessary supplies, personnel, and
medications in room for patient procedure
Institute of Medicine
Quality Aims
• Equitable
– Provide care that does not vary in quality due
to gender, ethnicity, geographic location or
socioeconomic status
• Example
Our current medical world
• Issues about the quality of healthcare are daily
news items
• Medical profession is in a “fishbowl”
I
Defining Quality
• “Quality is a way of thinking about work;
quality is about achieving excellencenothing less”
• IOM definition of quality
– The degree to which health services for
individuals and populations increase the
likelihood of desired health outcomes and are
consistent with current professional
knowledge
Defining Quality
• Quality is…
– A system-wide issue
– An individual performance issue rarely
Quality is a major team sport
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
Key elements
•
•
•
•
•
•
•
Systematic
Data-guided and knowledge informed
Experiential
Innovative
Employs formal explicit methodology
Continuous
Core responsibility of healthcare
professionals
QI vs. Informal Improvement
• Systematic
• Data-guided and
knowledge informed
• Experiential
• Innovative
• Employs formal explicit
methodology
• Continuous
• Core responsibility of all
healthcare professionals
• Systems change
• Individual or group
• May be knowledge
informed; rarely data
• Experiential, anecdotal
• Innovative
• Informal process
• Episodic
• No explicit responsibility.
Usually hierarchical
• Individual change
Quality Improvement Work
• Team oriented
• Requires team skills
– Collaboration
– Meeting skills
– Value all perspectives
• Develop local new useful knowledge to
inform health care processes
QI vs. Informal Improvement
• Systematic
• Data-guided and
knowledge informed
• Experiential
• Innovative
• Employs formal explicit
methodology
• Continuous
• Core responsibility of all
healthcare professionals
• Systems change
• Individual or group
• May be knowledge
informed; rarely data
• Experiential, anecdotal
• Innovative
• Informal process
• Episodic
• No explicit responsibility.
Usually hierarchical
• Individual change
Quality Improvement
Methods and Terms
• What is Root
Cause Analysis?
• What does PDSA
stand for?
• What are Sentinel
Events?
Quality Improvement
Methods and Terms
• Terms
• Methods
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Sentinel events
Never events
Practice standardization
Adverse events
Harm
Incident reports
Balanced scorecard
PDSA
LEAN
Six sigma
Root Cause analysis
Fishbone diagram
FMEA
Tracers
Trigger tools
Action plans
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
Model for Improvement
Setting Aims
• Improvement requires
setting aims. The aim
should be timespecific, measurable
and define the
specific population of
patients that will be
affected.
SIP Collaborative
Project Aim
SSI Rate
50% reduction
ED Wait Collaborative
Project Aim
– 25% reduction in ED length of stay by 6/30/07
Model for Improvement
Setting Aims
• What are you trying to accomplish?
Model for Improvement
Establishing Measures
• Teams use
quantitative measures
to determine if a
specific change
actually leads to an
improvement.
SIP Collaborative
Establishing Measures
Measurement
Collaborative Goal
SSI Rate
50% reduction
Antibiotic use rate
Skin anti-sepsis rate
Model for Improvement
Selecting Changes
• All improvement
requires changes, but
not all changes result
in improvement.
• Identify the changes
that are most likely to
result in improvement.
SIP Collaborative
Establishing Measures
Measurement
Antibiotic use rate
Timing
Re-dosing
Skin anti-sepsis rate
Chlorhexidine
Hair removal
Collaborative Goal
Our “Dizzying Complexity”
Communication to Admit One ED Patient
ED Wait Collaborative
Changes Selected
• Aim: 25% reduction in ED LOS
• Measures
– ED total LOS
– Time from provider to decision re: disposition
– Time from decision to discharge/admit
• Asthma/wheezing patients
– Initiation of Albuterol by RT/RN if emergent
• Practice change
– Asthma CPG revision
• Evidence based practice and process standardization
– Floor admission-selected patients receiving continuous Albuterol
• Practice and process change
Model for Improvement
Testing Change
• The Plan-Do-Study-Act
(PDSA) cycle is
shorthand for testing a
change in the real work
setting — by planning it,
trying it, observing the
results, and acting on
what is learned. This is
the scientific method
used for action-oriented
learning.
O4. Decision to Discharge Time
Average total minutes from clinical decision to child leaving the ED
Model for Improvement
Implementing Changes
• After testing a change
on a small scale,
learning from each
test, and refining the
change through
several PDSA cycles,
the team can
implement the change
on a broader scale
Model for Improvement
Spreading Change
• After successful
implementation of a
change or package of
changes for a pilot
population or an
entire unit, the team
can spread the
changes.
QI Projects?
• Are you doing any?
• How is it going?
• Lessons learned?
QI project development
Essential steps
• Identify a project aim
• Develop a plan to achieve the aim
– Responsibilities and roles
– Improvement methods
– Data sources
– Timelines
• Identify outcome and balancing measures
• Use data to identify improvement
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
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 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
Team Factors
Verbal communication
Written communication
Supervision and seeking help
Team structure (congruence,
consistency, leadership, etc)
Organizational and Management Factors
Financial resources and constraints
Organizational structure
Policy, standards and goals
Safety culture and priorities
CDP
DDDDPP
P
Patient Factors
Condition (complexity
and seriousness)
Language and
communication
Personality and social
factors
Individual (staff) factors
Knowledge and skills
Competence
Physical and mental health
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
QI projects
• Ideas/Aims
• Methods
• Data
• Challenges
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 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%
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
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
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
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