Quality Improvement Strategies

Introduction Incidence of Adverse Events and Negligence in Hospitalized Patients — Results of the Harvard Medical Practice Study I by Troyen A. et al. N Engl J Med 1991; 324:370-376 Review of 30,121 randomly selected records from 51 randomly selected acute care, non psychiatric hospitals in New York in 1984 Adverse events occurred in 3.7 % of the hospitalizations (95 % CI, 3.2 to 4.2), and 27.6 % of the adverse events were due to negligence (95 % CI, 22.5 to 32.6). 70.5 % of the adverse events gave rise to disability lasting less than six months, 2.6 % caused permanently disabling injuries and 13.6 % led to death. 

Introduction The Nature of Adverse Events in Hospitalized Patients — Results of the Harvard Medical Practice Study II by Lucian L. et al. N Engl J Med 1991; 324:377-384 February 7, 1991 30,195 randomly selected hospital records, 1133 patients (3.7 %) with disabling injuries caused by medical treatment. Half the adverse events (48 % ) were associated with an operation The proportion of adverse events due to negligence was highest for diagnostic mishaps (75%) Errors in management were identified for 58 % of the adverse events, 

Places them at a greater risk for potentially preventable conditions

Instigators for better quality health care 2000 2001

Quality improvement tools Donabedian model Plan-Do-Study-Act (PDSA) Six Sigma Root Cause Analysis Failure Mode Effects Analysis (FMEA)

Donabedian model Structure Process Outcome

Donabedian model: Structure ICU structure Presence of positive and negative pressure rooms Adequate and accessible wash basins Separate clean and dirty utility rooms BPWs Equipment and supplies Staffing model Nursing House keeping Doctors Level of training for ICU staff and physicians

Donabedian model: Process Effective communication amongst staff Use of SBAR tool Use of SOPs, Protocols and guidelines Patient Identification Wrist bands Patients first name, last name, DOB and MR number Time out procedure Use of barcode technology Improves operational efficiency Ensures correct medications are administered Blood transfusion practice made safe

Donabedian model: Process Continuity of care Failure to hand over is major preventable cause of patient harm Deficiencies in handover can delay diagnosis or treatment Handover process In the ICU during shift change over During transfer from ICU to ward From one ICU to other ICU Written with verbal A standardized proforma

Donabedian model: Process Checklists Predetermined, evidence based set of steps Designed to remind the professionals of critical steps Should be completed during clinical encounter or medical procedure FASTHUG check list CRBSI bindle check list CAUTI bundle check list VAP bundle checklist WHO surgical safety check list

Donabedian model: Process Medication management Computarised physician order entry Universal drug card/chart Both reduces transcription errors Two nurses involved in administering the medication Central line insertion check list Hand hygiene process and compliance

Donabedian model: Outcome Clinical outcome is defined health state of a patient resulting from health care Crude mortality rate Risk adjusted mortality rate SMR Patients satisfaction Survey ALOS Readmission rates in 48 hours Reintubation rate

Donabedian model: Outcome Clinical outcome is defined as a health state of a patient resulting from health care VAP rate CAUTI rate CRBSI rate Hand hygiene compliance Accidental removal of ET tube Accidental removal of Central line Accidental removal of Urinary catheter Morbidity criteria

Data collection and Validation Manual data collection (Paper charting) Resource intensive Studies have shown that nurses spend 30% of their time in documentation and 7% of time assessing the patients Error rate is nearly 17% Electronic health record Real time capture Reduction in documentation time of nurses Reduction in error rate to 6% or less Validation of data by quality personnel by sampling the data

Other strategies Plan-Do-Study-Act (PDSA) Six Sigma Root Cause Analysis Failure Mode Effects Analysis (FMEA)

PDSA Cycle Best for specific problems which can be clearly defined Determine the nature and scope of the problem What changes can and should be made? Plan for specific change Observe the results Action is takien by implementing the change Begin the process again to close the loop

Six Sigma It comes from industry Adopting a goal of six sigma means setting tolerance limits for defective products at such a higher level that fewer than 3.4 defects occur per million units It inspects process outcome and counts the defects, calculates a defect rate per million, and uses a statistical table to convert defect rate per million to a σ (sigma) metric

Six Sigma Six sigma and PDSA are interrelated It uses 5 phased process Define Measure Analyse Improve Control

Toyota / Lean Production System Methodology overlaps with 6 sigma It differs in that “Lean” is driven by identification of customer needs and removing activities that are non value added Maximisation of value added activities It does the root cause of analysis of errors and Takes steps to prevent similar errors

Root Cause Analysis Root cause analysis is an approach for identifying the underlying causes of an incident so that the most effective solutions can be identified and implemented. What is the problem? Why did it happen? What will be done to prevent it from happening again?

Cause mapping method

Fish bone approach to RCA  It was created by Kaoru Ishikawa (1915-1989) in Japan

Failure Mode Effects Analysis (FMEA) It is a step-by-step approach for identifying and removing all possible failures in a health care process Was developed by US military and used by NASA FMEA focuses on the system of care and uses a multidisciplinary team to evaluate a process from a quality improvement perspective.

When to Use FMEA? When a process, product or service is being designed When improvement goals are planned for an existing process When analyzing failures of an existing process or service Periodically throughout the life of the process or service

FEMA Procedure Team formation Identify a process Identify the function of this process What is the purpose of this process? Identify the steps and failure related effects For each failure mode take measures to prevent it Identify all the actions for that process

Conclusion Quality improvement is a dynamic process More than one quality improvement tool may be required It requires substantial commitment from the management Adequate finance, equipment and personnel A strong leadership is required for quality improvement initiative to be successful.

Thanks.