1. Quality Improvement Strategies

2. 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:
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. 

3. 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: 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, 

4. Places them at a greater risk for potentially preventable conditions

5. Instigators for better quality health care
2000
2001

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

7. Donabedian model
Structure
Process
Outcome

8. 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

9. 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

10. 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

11. 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

13. 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

14. 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

15. 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

16. 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

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

18. 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

19. 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

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

21. 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

22. 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?

23. Cause mapping method

24. Fish bone approach to RCA
 It was created by Kaoru Ishikawa ( ) in Japan

25. 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.

26. 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

27. 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

28. 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.

29. Thanks.