Ariane Marie-Mitchell, Preceptor and 3-4 students, meet weekly Patient Safety/ Quality Improvement Project Overview Ariane Marie-Mitchell, MD, PhD, MPH

Health Care Problem State reason for action Provide supporting data if available

Example: Health Care Problem There is a much longer delay for 1st dose delivery of antibiotics ordered between 11pm and 7am compared to day time averages This results in wasted time from the nurses and pharmacists, wasted medications, and poor quality of patient care

Historical Data – The Problem They even had baseline data that shows the problem

Stakeholder Analysis Who is involved? Who is affected? Try Mind Mapping Start interviewing- qualitative baseline data

Stakeholder Analysis Charge nurse Providers Nurses Patients Couriers families Illustrates a mind mapping technique to identify stakeholders. More detail could be added regarding the needs, wants and expectations of each stakeholder. Admin./PSR Pharmacists

Define the Aim What are you trying to accomplish? Specify numeric goals (how good?) time frame (by when?) patient population/system (for whom?) K. Shannon, 2012

Aim for Quality Health Care Safe — Avoid injuries to patients from the care that is intended to help them. Safety must be at the forefront of patient care. Timely — Reduce waiting for both patients and those who give care. Prompt attention benefits both the patient and the caregiver. Effective — Match care to science; avoid overuse of ineffective care and underuse of effective care. Efficient — Reduce waste. The health care system should constantly seek to reduce the waste and the cost of supplies, equipment, space, capital, ideas, time and opportunities. Equitable — Close racial and ethnic gaps in health status. Race, ethnicity, gender and income should not prevent anyone from receiving high-quality care. Patient-Centered — Honor the individual and respect choice. Each patient’s culture, social context and specific needs deserve respect, and the patient should play an active role in making decisions about her own care. The good news is that we know what we want… IOM, 2001

Example. Specific Aim “Decrease delivery delay in 1st dose antibiotic by 50% between 2300 and 0700 on units 6100-6300 by February 20, 2012”

Identify Measures of Change Outcome Measures e.g. Duration of delay in administration of 1st dose antibiotics Process Measures e.g. % of antibiotic following forms filled e.g. % of fax orders with telephone follow-up Balancing Measures e.g. Staff satisfaction

Cause-Effect Analysis Fishbone Diagrams Flowcharts Type of tool needed depends upon nature of problem

Constructing a Fishbone Cause and Effect Diagram Get the right people in the room State and clarify the “effect” Brainstorm list for 4 Ms/P involved in the process or effect interested in Brainstorm causes for each of these For each cause ask “why” 5 times to get to underlying causes K. Shannon, 2012

K. Shannon, 2012

Example: Fishbone Diagram Process Communication Unaware of effect on Poor MD RN communication Different levels of knowledge Repeat orders via fax Poor process understanding ABX Delay Old fax machines Understaffed 2300-0700 Unreliable tube system No EMR = extra steps # of pharmacy units open Machines System Failures 14

Constructing a Flowchart Start/End Input/ Output Process/ Task Delay Decision Document Sequence

Prescription Renewal The process begins when the patient requests renewal. The Product of Value is that the prescription is delivered. Example: Flowchart Call patient (need more info) Phone call (enough info provided) Name, DOB, Medication, Dose, Frequency, Pharmacy Review chart: medication sheet, last visit, next visit, other parent or pharmacy info (consistent) (not consistent) Discuss with clinician (PA not needed) (PA needed) Call for Medicaid Prior Approval Page 2

Select Change Focus on a change concept eliminate waste, improve work flow, optimize inventory, change work environment, improve patient interface, manage time, reduce variation, improve error proofing, improve service Perform effort vs yield analysis High effort Low yield High effort High yield Low effort Low yield Low effort High yield

Evidence Review Identify relevant literature or best practice models Who else has thought about this problem and tried to fix? Critically appraise and describe how relates to your project aim

Example: Evidence Review Background  Pneumonia = 600, 000 Medicare hospitalizations/yr Previous Medicare Guidelines recommend antibiotic treatment within 8 hrs of hospital arrival. Methods  Retrospective cohort study design 18, 209 Medicare patients (>65 yrs) hospitalized with community-acquired pneumonia (July 1998-March 1999) Outcomes: severity-adjusted mortality (in hospital and 30 day) readmission within 30 days of discharge length of stay (LOS) Conclusions  Antibiotic administration <4 hours of arrival was associated with decreased mortality and LOS among a random sample of older inpatients with community-acquired pneumonia who had not received antibiotics as outpatients. Houck, P, et al. Timing of Antibiotic Administration and Outcomes for Medicare Patients Hospitalized With Community-Acquired Pneumonia. Arch Intern Med. 2004;164:637-644.

Test a Change Repeat, Tweak, Stop Who,What, When, Where Analyze Act Plan Study Do Who,What, When, Where QI and Research seem similar, particular when talking about testing an intervention Analyze Results Collect Data A P S D

Plan Specify a hypothesis Use SMART Objectives Specific - have a single purpose Measurable - tied to a result statement Attainable/realistic - know your barriers and resources Responsibilities clear – tie names to each objective Time connected - clear completion dates (consider creating a timeline)

Example: SMART Objectives Interview charge nurse, nurses, couriers and pharmacists during a full overnight shift (11p-7a) by day 7- Jose Conduct a literature review of best practices by day 7- Paymonh Meet as a team to do cause-effect analysis by day 9- team Collect quantitative data on initial state using Form 1a by day 10- Brent and Craig Meet as a team to discuss potential interventions by day 12- team Discuss intervention plan with pharmacists, couriers and nurses and implement by day 16- Jose and Paymohn Collect quantitative data on follow-up state using Forms 1b and 2a by day 20 and analyze- Brent and Craig Gets built over course of project depending upon results of prior objective

Do Two types of data How did you collect the data? Qualitative e.g. interviews, focus groups, suggestion boxes show quotations, summarize themes Quantitative e.g. anything that can be counted show run charts, bar charts, pie charts… How did you collect the data? What sample did you use and what was your reasoning?

Study Qualitative Data Quantitative Data What did you learn? Where does this lead you?

Example: Qualitative Data Parents observed speech problems by age 4 and as young as 11 months “Around 10 months I noticed she was not starting to talk like my other children did” A minority of children received Early Intervention “I asked the doctor about it but they were just like oh, he’ll grow out of it” “We were supposed to have a lady come to the house and stuff but it was impossible because I was working full-time and he was at daycare”

Automated BMI% calculation Incorporated BMI% into nursing data collection Added BMI% to vitals

Act How does your data inform your understanding of the health care problem? How does your data influence your interpretation of how to improve the system? What will you do next?

Sustainability What barriers do you perceive to sustaining the change? What resources are available to sustain the change? What is the cost-benefit of the old process versus the new process?

References References for literature cited Names of faculty/staff interviewed Location of sites where processes observed, or any other relevant info

≠ Quality Research Improvement Aim(s) Next steps Hypotheses Methods Act Plan Study Do QI and Research seem similar, particular when talking about testing an intervention Methods Measures Results A P S D

Research Quality Improvement Intervention is demonstrated, known, or widely accepted Project limited to implementing a practice to improve quality of care Performance data collected for clinical, practical or administrative purposes only Systematic investigation designed to contribute to generalizable knowledge Project involves introducing an untested intervention and data is being collected to establish scientific evidence of its efficacy IRB approval required *** IRB approval not required but ask if uncertain or if considering publication

IHI Open School QI Practicum Optional Receive additional guidance and a Certificate Sign agreement with faculty mentor Submit aim/plan and receive feedback Submit cause-effect diagram, PDSA cycles, run chart, and summary