Rapid cycle PI Danielle Scheurer, MD, MSCR Chief Quality Officer Medical University of South Carolina

Objectives   Know how and why you need to have a disciplined approach to PI   Understand the importance of the reliability of interventions   Understand the importance of validating and evaluating interventions over time

Quality-Process Improvement Quality-Process Improvement worse better worse better Quality After Before Quality worse better Quality After Quality Quality Assurance Quality Improvement Bell Curve: Patient Population Tail  better Improvement and standardization in processes reduces variation (narrows the curve) and raises quality of care for all (shifts entire curve toward better care).

Quality-Process Improvement: Bridges the Implementation Gap Implementation Gap Scientific understanding Patient care Progress Time

The BEST quality is local “Bottom up” approach “Bottom up” approach Problems and remedies come from the “front line” Problems and remedies come from the “front line” Often come from frustration of seeing processes that are: Often come from frustration of seeing processes that are: – Highly variable, unpredictable, not reproducible – Potentially or actually harmful – Inefficient or redundant Different areas have different quality issues, although some are ubiquitous Different areas have different quality issues, although some are ubiquitous – Medication errors – Infection rates

Structure approach to PI  Ensure you are narrowing the scope of the problem to be addressed  Ensure you measure and analyze the problem, before you jump to a remedy  Ensure the remedy will “fix” the problem you are trying to solve  Force you to validate that the remedy was effective

Get a team  Champion: Overcome barriers  Process Owner: The driver  Facilitator: The navigator  Front line staff: Essential team members

Identify the problem  What is the problem?  Who identified it?  When was it identified?  When and where is it occurring?  Pick something that matters to you, and state WHY it matters  Who else cares about the problem (who are the stakeholders?) to assist with resources

Measure it  How can the data be collected (survey, administrative data, chart review)?  Is it valid/accurate?  Is it a manual process or automated?  Is there a clear definition of the outcome (or can it be interpreted different ways)?  Who is going to measure?  Can you sample?  Direct observation is the best way to determine what is actually happening  May want more than 1 type of measure:  Process, outcome, structural, balancing

Problem Analysis: What is causing the problem? Time of day, day of week Time of day, day of week Department specific / system wide Department specific / system wide Inefficient staffing (numbers or skill set) Inefficient staffing (numbers or skill set) Poor communication Poor communication Inadequate process or policy Inadequate process or policy Lack of controls to keep the problem from occurring Lack of controls to keep the problem from occurring Poor individual performance (usually not the only issue) Poor individual performance (usually not the only issue) Pick an appropriate process analysis tool to further analyze the problem/process Pick an appropriate process analysis tool to further analyze the problem/process

Remedy the critical issues  Pick a remedy based on the problem analysis.  What are the barriers?  What evidence is there that it will have an impact (has someone tried and succeeded or failed)?  How “reliable” is the intervention?  Do you need >1 intervention to make it nearly impossible to recur?

Remedies (in order of reliability)  Education  Reminders  Checklists  Order sets  Protocols  Pathways  Templates  “Hard stop” order entry

Operationalize  How are you going to make it work?  How will the barriers be removed?  What assistance is required from leadership?  What is the plan to roll out and implement solutions?

Changes that result in Improvement P DS A P DS A P DS A P DS A Time Big Idea Real time problem solving

Validate  How will we know we made a difference, what is your goal?  What are you measuring?  How often are you measuring it?  Is the measure meaningful?  Are you measuring “unintended consequences”?

Evaluate  How to sustain the improvement?  Who is responsible for monitoring and measuring over time?  What is the plan to react if the measures slip?  How will future staff be made aware of the new process?

Summary  Have a structured and disciplined approach to PI, with an executive summary  Always involve front line staff to determine what is actually happening, and what is feasible for change  Figure out the stakeholders and involve them early and often  Keep good records of what you have done and why

Example: Hand Hygiene  Recognized we had a problem  Formed a team  Determined how to measure (blended secret shopper and unit audits)  Analyzed the problem  Education  Rewards  Medication administration  Accountability

Hand Hygiene  Remedies  Education: Massive  Reward system: Incentives for all staff  Accountability system: Reports to leaders  Defined workflow for medication administration  Operationalized  Validate  Evaluate monthly