Lois L. Bready, M.D. Associate Dean for GME and DIO UTHSCSA Quality Improvement 101 Lois L. Bready, M.D. Associate Dean for GME and DIO UTHSCSA Quality Improvement is an important part of medical practice. Most of our programs include some component of QI in our regular conferences – usually in the form of Morbidity and Mortality conferences.

Quality Improvement What is ‘quality improvement’? Why is it important to the resident? To the practicing physician? How does QI relate to Patient Safety? The goals of this presentation are to help learners and faculty alike to understand basic elements of QI, including how it relates to patient safety.

Competency Questions in your PIF Quality Improvement List the activities in which residents actively participate to learn and apply the principles of quality improvement, and identify those who oversee these activities. Give an example of a quality improvement activity/project that residents have been involved with during the past year or are currently. Describe its development, goal, implementation, evaluation of success. How does the program ensure that residents provide and document continuity of care? The ACGME RRCs are including new questions that address the GENERAL COMPETENCIES – some of those new questions are listed on this slide.

Quality Improvement – What is it? Incorporated in the ACGME General Competence “Practice Based Learning & Improvement” “Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices.”

Quality Improvement Components: Self-reflection Quality or Practice Improvement Lectures/Seminars/Conferences Quality Improvement Project Evidence Based Medicine Teaching Skills

“Systems Based Practice” Content Health Care System Different types of medical practice and delivery systems System resources System issues and the reduction of errors Conducting a root cause analysis Setting Clinical teaching Patient Safety projects Systems based approach - M & M Lectures/Seminars/Conferences Interdisciplinary Teams Important elements of SYSTEMS BASED PRACTICE, one of the 6 GENERAL COMPETENCIES, are listed here.

Model Quality Improvement The classic QI model is ‘PDSA’ – plan, do, study, act.

Quality Improvement W. Edwards Deming American statistician, professor, author, lecturer, and consultant Improved production in the U.S. during World War II and in Japan after the war Pioneer – use of statistical analysis to achieve better industrial quality control – ‘quality movement’ W. Edwards Deming was the Father of QI. His work with the restoration of industry in post-WWII Japan resulted in the tremendous improvement in quality of production techniques and output – for example, in the automotive industry.

Quality Improvement Quality improvement - a method for ensuring that all the activities necessary to design, develop and implement a product or service are effective and efficient with respect to the system and its performance. It’s been said that a system is perfectly designed to result in the outcome that it gets. That is, to change an outcome, one must change the system.

Another depiction of the PDSA cycle.

Quality Improvement Health care “Quality improvement” “Quality & risk management” “Quality and performance improvement” “Compliance and quality improvement” “TQM = total quality management” Variations on those themes . . . There are a variety of names for QI, particularly in the healthcare environment.

Quality Improvement General uses: “How can we make ___ process more efficient?” EC patient through-put MICU bed turnover OR utilization “Why did this patient receive tube feedings into the brochus?” “What are Dr. X’s patient care outcomes?” “How can we ensure that all residents pass their board exams on the first attempt?” There are lots of processes that we might want to measure and improve. Some are patient-care related, others are individual practitioner outcomes, and of course in GME there are a great many measures we are interested in improving.

Quality Improvement Quality improvement project: Identify an issue Build a team to address it Define the problem Choose a target Test the change Reconsider or extend the improvement efforts Steps in a process.

Quality Improvement Quality improvement project: Identify an issue A process that is causing concern or a possible opportunity for a positive change.   

Quality Improvement Quality improvement project: Build a team to address it Representation from groups involved – this step is critical.

Quality Improvement Quality improvement project: Define the problem Identify and carefully describe what it is you really want to improve; the source of the problem you are confronting, etc.

Quality Improvement Quality improvement project: Choose a target   Introduce and evaluate interventions, using quality improvement tools and skills

Quality Improvement Quality improvement project: Test the change Data measures to determine when a process change over time is likely to be due to chance and when it is not

Quality Improvement Quality improvement project: Reconsider or extend the improvement efforts Reconsider, sustain, and/or extend process improvements

Patient Safety Issues ‘First do no harm’ Build systems with safety barriers So, why do adverse outcomes continue to happen??

Quality Improvement Sentinel Event A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.  Serious injury specifically includes loss of limb or function.  The phrase, "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.  Such events are called "sentinel" because they signal the need for immediate investigation and response. www.jointcommission.org/SentinelEvents/

No single barrier is foolproof! The Swiss cheese model of how defenses, barriers, and safeguards may be penetrated by an accident trajectory Reason, J. BMJ 2000;320:768-770 No single barrier is foolproof! Copyright ©2000 BMJ Publishing Group Ltd.

When the safety barriers work

When failures occur Failures can occur because of active or latent conditions. AHRQ definitions (see http://www.psnet.ahrq.gov/) Active Error (or Active Failure): The terms "active" and "latent" as applied to errors were coined by James Reason.(1,2) Active errors occur at the point of contact between a human and some aspect of a larger system (eg, a human-machine interface). They are generally readily apparent (eg, pushing an incorrect button, ignoring a warning light) and almost always involve someone at the frontline. Latent errors (or latent conditions), in contrast, refer to less apparent failures of organization or design that contributed to the occurrence of errors or allowed them to cause harm to patients. Active failures are sometimes referred to as errors at the "sharp end," figuratively referring to a scalpel. In other words, errors at the sharp end are noticed first because they are committed by the person closest to the patient. This person may literally be holding a scalpel (eg, an orthopedist who operates on the wrong leg) or figuratively be administering any kind of therapy (eg, a nurse programming an intravenous pump) or performing any aspect of care. To complete the metaphor, latent errors are those at the other end of the scalpel—the "blunt end"—referring to the many layers of the health care system that affect the person "holding" the scalpel. Latent Error (or Latent Condition): The terms "active" and "latent" as applied to errors were coined by James Reason.(1,2) Latent errors (or latent conditions) refer to less apparent failures of organization or design that contributed to the occurrence of errors or allowed them to cause harm to patients. For instance, whereas the active failure in a particular adverse event may have been a mistake in programming an intravenous pump, a latent error might be that the institution uses multiple different types of infusion pumps, making programming errors more likely. Thus, latent errors are quite literally "accidents waiting to happen." Latent errors are sometimes referred to as errors at the "blunt end," referring to the many layers of the health care system that affect the person "holding" the scalpel. Active failures, in contrast, are sometimes referred to as errors at the “sharp end,” or the personnel and parts of the health care system in direct contact with patients.

Preconditions for Unsafe Acts Often there are multiple layers of preconditions that can lay the groudwork for an unsafe act. The Human Factors Analysis and Classification System–HFACS – U.S. DOT (FAA)

Types of Unsafe Acts The Human Factors Analysis and Classification System–HFACS – U.S. DOT (FAA)

Categories of Unsafe Supervision The Human Factors Analysis and Classification System–HFACS – U.S. DOT (FAA)

Quality Improvement Tools

Quality Improvement Root cause analysis (RCA) is a class of problem solving methods aimed at identifying the root causes of problems or events. Systems need designed-in redundancy so that desired outcomes don’t depend on “the ____ being more careful . . .” In the practice of QI, there are a variety of tools employed to analyze problems. RCA is one of the most commonly used means of determining where the issue lie.

Root Cause Analysis The practice of RCA is predicated on the belief that problems are best solved by attempting to correct or eliminate root causes, as opposed to merely addressing the immediately obvious symptoms. By directing corrective measures at root causes, it is hoped that the likelihood of problem recurrence will be minimized. However, it is recognized that complete prevention of recurrence by a single intervention is not always possible. Thus, RCA is often considered to be an iterative process, and is frequently viewed as a tool of continuous improvement.

Quality Improvement Safety-based RCA descends from the fields of accident investigation and occupational safety and health. Root causes tend to be viewed as failed or missing safety barriers, unrecognized risks or hazards, or inadequate safety engineering.

Quality Improvement General principles of root cause analysis Aiming corrective measures at root causes is more effective than merely treating the symptoms of a problem. To be effective, RCA must be performed systematically, and conclusions must be backed up by evidence. There is usually more than one root cause for any given problem.

Quality Improvement General process for performing RCA Define the problem. Gather data/evidence. Identify problems that contributed to problem (Causal Factors). Find root causes for each Causal Factor. Develop solution recommendations. Implement the solutions.

Ishikawa (Fishbone) Diagram

Ishikawa (Fishbone) Diagram The 4 M’s: Methods, Machines, Materials, Manpower The 4 P’s: Place, Procedure, People, Policies The 4 S’s: Surroundings, Suppliers, Systems, Skills

How is a fishbone diagram constructed? Draw the fishbone diagram. 2. List the problem/issue to be studied in the "head of the fish".

3. Label each ""bone" of the "fish" 3. Label each ""bone" of the "fish". The major categories typically utilized are: The 4 M’s: Methods, Machines, Materials, Manpower The 4 P’s: Place, Procedure, People, Policies The 4 S’s: Surroundings, Suppliers, Systems, Skills Note: You may use one of the four categories suggested, combine them in any fashion or make up your own. The categories are to help you organize your ideas.

4. Use an idea-generating technique (e. g 4. Use an idea-generating technique (e.g., brainstorming) to identify the factors within each category that may be affecting the problem/issue and/or effect being studied. The team should ask... "What are the machine issues affecting/causing...“ 5. Repeat this procedure with each factor under the category to produce sub-factors. Continue asking, "Why is this happening?" and put additional segments each factor and subsequently under each sub-factor. Continue until you no longer get useful information as you ask, "Why is that happening?"

6. Analyze the results of the fishbone after team members agree that an adequate amount of detail has been provided under each major category. Do this by looking for those items that appear in more than one category. These become the 'most likely causes". 7. For those items identified as the "most likely causes", the team should reach consensus on listing those items in priority order with the first item being the most probable" cause.

Quality Improvement Processes

Flowcharting is a very useful tool – who knew that it took 57 separate steps to get an IV antibiotic administered to a patient in the hospital?

Process Flowcharting Process Start/stop Alternate process Data Redefined process Decision point Process flowcharting can help teams understand where bottlenecks exist in a particular process, improve discussion by focusing the entire team on key steps in the process, and encourage a scientific, impartial approach to problem solving. Merge Preparation

Quality Improvement Control chart Control charting is useful for ongoing monitoring of some processes – e.g., slip & fall in the hospital, use of unapproved abbreviations, etc.

Where are we now? List the activities in which residents actively participate to learn and apply the principles of quality improvement, and identify those who oversee these activities. Where is our program today? What steps can we take to move towards better understanding and education in QI, and in helping our learners become comfortable with its concepts and tools?

Where are we now? Give an example of a quality improvement activity/project that residents have been involved with during the past year or are currently. Describe its development, goal, implementation, evaluation of success. Remember, this will be a question on your PIF.

Where are we now? How does the program ensure that residents provide and document continuity of care? This, too.