Transcript Introduction to Quality Improvement:

Introduction to Quality
Improvement:
SELECTING AND DESIGNING A QUALITY
IMPROVEMENT PROJECT
Karen Greer, MD, MPH
Director, Ambulatory Pediatrics
St. Barnabas Hospital
Quality Is…
 “The degree to which health care services for
individuals and populations increase the
likelihood of desired health outcomes and are
consistent with current professional knowledge.”
• - INSTITUTE OF MEDICINE, MEDICARE, A STRATEGY FOR
QUALITY ASSURANCE, ED.,
Review: Definition Of Quality
 Quality: Meeting the needs and exceeding the
expectations of those we serve. Deliver all and only
the care that the patient and family needs.
√
Doing the right thing
(evidence based)
=
For every patient (equal care)
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Every time
(consistent care)
Review: What Is Healthcare Quality
Improvement?
 Healthcare Quality Improvement: The body of
knowledge, attitudes, and skills necessary to
efficiently influence and continuously improve the
multiple elements of care delivery within a
medical practice.
Review: The Six Aims of Healthcare Quality
Improvement
 Safe: Patients should not be harmed by the care that is
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intended to help them.
Effective: Provide services based on scientific knowledge to
all who could benefit and refrain from providing services to
those not likely to benefit (Avoid underuse and overuse).
Patient-Centered: Care should be respective of and
responsive to individual preferences, needs, and values.
Timely: Reduce unnecessary waits and harmful delays for
both those who receive and those who give care.
Efficient: Avoid wasting of equipment, supplies, ideas and
energy.
Equitable: Provide care that does not vary in quality because
of personal characteristics such as gender, ethnicity,
geographic location, and socio-economic status.
- Institute of Medicine
Choosing a Project
 QI projects can focus on:
 1. structure: how the system of care is configured and/or its
components
 2. process: how care is delivered
 3. outcomes: mortality, functional status, satisfaction,
quality of life
Choosing a Project
 So…where do you begin?
 Ideas for projects can come from a variety of
sources:
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Everyday experiences while performing clinical duties
Hospital quality improvement goals and standards
Clinical Guidelines
Local, State and Federal/National Guidelines or
Requirements
Current or Ongoing Projects
Choosing a Project: Everyday Experiences
 “Strange…this patient’s vaccination status is up to date
according to the clinic chart, but it’s not up to date in the
immunization registry.”
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Has this occurred with other patients?
What are the possible reasons for the discrepancy?
 “This patient didn’t show up for his follow-up weight
check/asthma check/ vaccination visit…again.”
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How often has this occurred for this patient? For other patients?
What processes are in place to notify patients about their appointments?
 This patient was just discharged from the inpatient service and
is here for a follow-up visit, but I have no idea what happened
during the admission.”
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Is this a standard occurrence?
How can this be avoided in the future?
What communication occurs between providers?
Choosing a Project: Everyday Experiences
 “Oops—her throat culture was positive last week, but I’m not sure if she
received antibiotics. Dr. Brown usually documents his treatment on the
lab report, but Dr. Green writes a new note. And Dr. White, well…”
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Is there a standardized system for lab follow-up?
 Three different shifts, three different attendings, three different
antibiotics chosen to treat an abscess…”
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Is there a standard protocol or guideline for treatment?
Is there scientific evidence to support the use of a particular antibiotic?
 “This is the third time I have made this referral/appointment. They
keep repeating the same tests.”
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How are referrals and follow-up appointments tracked?
What communication occurs between providers?
 “I tried to recall this patient for chlamydia treatment, but her number
is disconnected.” What do I do now?”
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How often are patients asked for demographic updates during registration? During the
visit?
Is there a better way to communicate with patients?
Choosing a Project: Everyday Experiences
 “This patient did not take his Concerta while he was admitted
last week. I guess that explains his behavior…”
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Does the intake process include a medication reconciliation component?
Is that process consistent?
If the medication was stopped for a reason, was it documented?
Are all patient medications reviewed upon discharge?
 “Each note has a different list of asthma medications. I can’t tell
which ones he’s actually using.”
 “This patient’s mom just complained that she waited over two
hours to be see this doctor, but saw another patient arrive and
leave before she did.
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What was her appointment time? Is there some way to quantify how long she
actually waited?
Are there identifiable delays in the registration process? In the triage
processs? In other sections of the visit?
What communication occurs between patient and staff?
Choosing a Project: Everyday Experiences
 In other words, look at the things that:
 Slow your day down
 Make your job more difficult
 Force you to do extra work in order to provide the best care
 Frustrate your patients
 Frustrate you
Choosing a Project:
Hospital Quality Goals and Standards
 Current St. Barnabas Hospital Goals:
 Reduction of Infection Rates
Hand Hygiene
 Isolation Procedures
 Equipment Maintenance
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Patient Satisfaction
Patient surveys
 Patient complaints
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Prevention of Falls
Choosing a Project:
Hospital Quality Goals and Standards
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Medication Reconciliation and Reduction of Medical Errors
Reduction of wrong-sided surgery/procedures
Time Outs
 Two patient identifiers
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Enhancing Communication between Providers
ER/Inpatient dischargesAmbulatory Clinic
 Referrals Tracking/Communication with Consultants
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Ensuring Adequate Chart Documentation
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Implementation of electronic medical records
Choosing a Project: Clinical Guidelines
 Are we compliant with established clinical
guidelines?
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Asthma Guidelines
Lead Screening
Obesity/BMI Screening and Management
Developmental Screening
Screening and Treatment of Sexually Transmitted Diseases
Treatment and Management of UTI
Management of Febrile Seizures
Example: NYC DOH Lead Screening Guideline
Choosing a Project:
Local, State, and Federal/National Criteria
 HEDIS: Health Effectiveness Data and Information
Set:
A widely used set of performance measures in the managed care
industry, developed and maintained by the National Committee
for Quality Assurance (NCQA).
 HEDIS measures are divided into eight categories:
 Effectiveness of Care
 Access/Availability of Care
 Satisfaction With the Experience of Care
 Health Plan Stability
 Use of Services
 Cost of Care
 Informed Choices
 Health Plan Descriptive Information.
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Choosing a Project:
Local, State, and Federal/National Criteria
 HEDIS: Health Effectiveness Data and
Information Set:
 Measures
are added, deleted, and revised annually.
 Data submission is required by CMS (Centers for Medicare
and Medicaid Services)
 HEDIS is one component of NCQA's accreditation process.
 HEDIS results are used to track year-to-year performance.
Choosing a Project:
Local, State, and Federal/National Criteria
 QARR: Quality Assurance Reporting
Requirements:
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Consists of measures from HEDIS plus New York Statespecific measures:
In 2012, the measures included:
 Well Child Visits in the First 15 Month of Life
 Adolescent Preventive Care and Immunizations
 Use of Appropriate Asthma Medications
 Follow-Up Care for Children Prescribed ADHD medication
 Annual Dental Visit
 Lead Screening in Children
 Like HEDIS, measures can be added or deleted over time.
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Choosing a Project:
Local, State, and Federal/National Criteria
 National Patient Safety Goals:
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Established in 2002 to help accredited organizations address
specific areas of concern in regards to patient safety
Goals:
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Improve the accuracy of patient identification
Improve the effectiveness of communication among caregivers
Improve the safety of using medications
Reduce the risk of health care-associated infections
Accurately and completely reconcile medications across the continuum
of care
Reduce the risk of patient harm resulting from falls
Prevent health care-associated pressure ulcers (decubitus ulcers)
Choosing a Project:
Local, State, and Federal/National Criteria
 New York City Immunization Registry:
 Established in 1998
 Required reporting of all vaccines given to patients <18
years of age (also NYS law)
 Quarterly reports provide Up-to-Date status of all patients
in a given practice
 Also used to track distribution and administration of
Vaccines For Children (VFC) vaccines
 Multiple provider-friendly functions, including prepopulated school forms, vaccine ordering, and recall
systems/queries
Choosing a Project:
Local, State, and Federal/National Criteria
 Newly Implemented Guidelines/Laws
 Example: New York State HIV Testing Law
 Must offer HIV testing to all patients aged 13-64 years at
least once per year.
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Must occur in all clinical settings:
 Inpatient
 Emergency Room
 Ambulatory Clinics
 Potential Projects:
 How do you demonstrate compliance?
 How close to compliance were we prior to the enacted law?
 Should other testing be done simultaneously?
Choosing a Project:
Current or Ongoing Projects
 Build on (steal from) the work of others:
 Prior QI projects that need a follow-up evaluation
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Examples: a former resident’s project that is unfinished or
needs a new phase
Prior QI projects that didn’t work and need reassessment
Why didn’t it work?
 What might you do differently?
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Prior QI projects, but with a different angle:
Examine a different component of the process
 Implement a new change to the process
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Next Steps
 OK, so I’ve picked a topic. Now what?
Next Steps: Model for Improvement
Model For
Improvement:
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The model has two
parts:
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1.
2.
Three fundamental
questions, which can
be addressed in any
order.
The Plan-Do-StudyAct (PDSA) cycle to
test and implement
changes in real work
settings.
Model for Improvement Question #1:
What are you trying to accomplish?
 Setting Aims:
 The aim should be:
Time-specific
 Measurable
 Should define the specific population of patients that will be
affected.
 Write a clear aim statement with specific numerical goals
 Make targets achievable
 Make targets for improvement clear
 Be flexible and prepared to refocus
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Model for Improvement Question #1:
What are you trying to accomplish?
 Examples: Adolescent Vaccination Status:
 Aim: Improve UTD vaccination status for adolescent
patients within 12 months.
Time-specific:
 Goal for target completion is outlined
 operational definition of being up-to-date according to CDC
and NYSDOH guidelines
 Measurable outcome: can review and quantify the number of
vaccines administered, determine the percentage of patients
that are considered UTD.
 Target goal = 90% of patients with UTD status
 Population-specific: target population = all adolescent
outpatients aged 14 years old, seen during the past 12 months
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Developing an Aim Statement
MFI Question #2: How will you know that
a change is an improvement?
 What processes are you examining?
 Example: Adolescent Vaccination Project
processes:
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Timely well child care and follow-up vaccination visits
Accurate and regular reporting to the CIR
MFI Question # 2: How will you know that a
change is an improvement?
 Establishing Measures:
 Use quantitative measures to determine if a specific change
actually leads to an improvement.
Establishing Measures
 Types of Measures:
 Outcome Measures: How is the system performing? What is
the result?
Number of days to appointment/Time to third next available
appointment
 Average wait times
 Average hemoglobin A1c level for population of patients with
diabetes
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Establishing Measures
 Types of Measures:
 Process Measures: Are the parts/steps in the system
performing as planned?
Percentage of patients receiving developmental screening at
age 18 months
 Percentage of patients with lead screening performed at age 1
and 2 years.
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Establishing Measures
 Types of Measures:
 Balancing Measures: are changes designed to improve one
part of the system causing new problems in other parts of
the system?
If the goal was to reduce patients’ length of stay in the hospital,
are the readmission rates increasing as a result?
 Does creating an open access schedule for appointments
decrease availability for well child appointments?
 Does allowing patients to walk-in for sick visits increase wait
times for patients with scheduled appointments?
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Establishing Measures
 Types of Measures:
 Benchmarks: the “best in class”
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Actual vs. expected performance:
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“Should reflect the best current assessment of optimal care and
efficiency”
Is the outcome of a patient above, below, or equal to the
outcome that would be expected for a group of patients with
similar underlying conditions and health status?
Percent Compliance:
Denominator = the number of times that a provider had the
opportunity to provide an element of recommended care to a
patient who was a candidate for that care
 Numerator = the number of times that care was provided
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Operational Definition Worksheet
Operational Definition Worksheet
MFI Question #2: How will you know that a
change is an improvement?
 For your first QI project, you must first establish a
baseline:
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Assess current status: how close is it to the target goal?
Evaluation of a retrospective period or an immediately
current period
 Example: Adolescent project:
 Obtain a report from the CIR indicating UTD rate for all 14
year-old adolescents seen in the outpatient clinics during
the past 12 months.
 Review the actual clinic charts for the same population of
patients to determine UTD rate based on chart information.
 Compare chart review results to CIR results.
MFI Question #3: What Changes Can be Made
that Will Result in Improvement?
 Selecting Changes:
 “All improvement will require change, but not all change
will result in improvement.” Therefore, we must identify
the changes that are most likely to result in improvement.
 Example: Adolescent Vaccination Project
 Should we revise our reminder/recall system for
appointments? How?
Developing Change Concepts
PDSA: Plan-Do-Study-Act
 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.
PDSA Worksheet
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 — for example, for an
entire pilot population or on an entire unit.
Implementing Changes
Implementing Change
Performance Improvement Reporting
Acronym Decoder
 AHRQ: Agency for Healthcare Research and Quality: www.ahrq.gov
 CAHPS: Consumer Assessment Health Plan Survey
 HCAPHS: Hospital Consumer Assessment Plan Survey
 CIR: City Immunization Registry: www.nyc.gov/health/cir
 CMS: Center for Medicare/Medicaid Services: www.cms.gov
 COE: Center of Excellence
 HEDIS: Health Effectiveness Data and Information Set
 IHI: Institute for Healthcare Improvement: www.ihi.org
 IOM: Institute of Medicine: www.iom.edu
 JCAHO/TJC: Joint Commission for Accreditation of Hospitals (now known as
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The Joint Commission: www.jointcommission.org
NCQA: National Committee on Quality Assurance www.ncqa.org
NQF: National Quality Forum www.qualityforum.org
NYCDOHMH: New York City Department of Health and Mental Hygiene
www.nyc.gov/health
QARR: Quality Assurance Reporting Requirements
RHIO: Regional Health Information Organization
References
 Crossing the Quality Chasm: A New Health System for the 21st
Century. Committee on Quality Health Care in America,
Institute of Medicine. National Academy Press, Washington,
D.C. 2001.
 The Improvement Guide: A Practical Approach to Enhancing
Organizational Performance. G. Langley, K. Nolan, T. Nolan, C.
Norman, L. Provost. Jossey-Bass Publishers, San Francisco,
1996.
 An Introduction to the Model for Improvement. (Lecture) Robert
Lloyd, PhD.
 Road Map for Quality Improvement: A Guide for Doctors. Manoj
Jain, MD MPH
www.mjain.net/medicine/roadmap_for_qualityimprovement.pdf
 How to Improve. Institute for Healthcare Improvement.
www.ihi.org/IHI/Topics/ImprovementMethods/HowToImprove
Questions?