1. QUALITY IMPROVEMENT IN HEALTHCARE: RESIDENCY AND BEYOND Lisa Knight, MD Quality Improvement Lecture 3 February 27, 2014

2. LECTURE OUTLINE Refresher on the Basics of a QI project Refresher on the Basics of a QI project SQUIRE guidelines SQUIRE guidelines Refresher on upcoming QI deadlines Refresher on upcoming QI deadlines

3. THE IOM HAS PROPOSED 6 SPECIFIC AIMS FOR IMPROVEMENT Healthcare should be: Healthcare should be: Safe Safe Effective Effective Patient-Centered Patient-Centered Timely Timely Efficient Efficient Equitable Equitable Avoiding injury from care that is meant to be helpful Avoiding underuse or overuse of services Providing respectful, responsive, individualized care Reducing waits and harmful delays in care Avoiding waste of equipment, supplies, ideas, and energy Providing equal care regardless of personal characteristics

4. HOW DO WE GO ABOUT CHANGING THE SYSTEM? Plan Do Study Act 5-Step Process for Improvement 1.Select the opportunity for improvement 2.Study the current situation 3.Analyze the causes 4.Develop a theory for improvement 5.Select the team Model for Improvement What are we trying to accomplish? What change can we make that will result in improvement? How will we know that a change is an improvement? AIM MEASURES CHANGES Implement the Improvement Study the results Establish a future plan PLAN DO STUDY ACT PLAN DO STUDY ACT PLAN DO STUDY ACT Present Situation Ideal Future

5. Lisa Knight Whitney Brown The Endocrine Clinic Secretary Reduce the No-Show rate in the Pediatric Endocrine clinic from 35% to 20% by June1, 2014 No-Show rate (%) = Total number of patients who didn’t show Total number of patients scheduled X 100 Percentage of patients each day who received a phone call 24 hours before their appt Secretary satisfaction with the appt reminder system Secretary to make phone calls to patients 24 hours before their appt

6. HOW DO WE GO ABOUT CHANGING THE SYSTEM? Plan Do Study Act 5-Step Process for Improvement 1.Select the opportunity for improvement 2.Study the current situation 3.Analyze the causes 4.Develop a theory for improvement 5.Select the team Model for Improvement What are we trying to accomplish? What change can we make that will result in improvement? How will we know that a change is an improvement? AIM MEASURES CHANGES Implement the Improvement Study the results Establish a future plan PLAN DO STUDY ACT PLAN DO STUDY ACT PLAN DO STUDY ACT Present Situation Ideal Future

7. QI VS RESEARCH Research Primary focus: Generating new, generalizable scientific knowledge Quality Improvement Primary focus: Making care better at unique local sites

8. REPORTING GUIDELINES Standardized guidelines have been developed for reporting the following: Standardized guidelines have been developed for reporting the following: CONSORT – randomized controlled trials CONSORT – randomized controlled trials STARD – studies of diagnostic accuracy STARD – studies of diagnostic accuracy STROBE – epidemiological observational studies STROBE – epidemiological observational studies QUOROM – meta-analysis and systematic reviews of randomized controlled trials QUOROM – meta-analysis and systematic reviews of randomized controlled trials MOOSE – meta-analysis and systematic reviews of observational studies MOOSE – meta-analysis and systematic reviews of observational studies In 1999 In 1999 SQUIRE guidelines SQUIRE guidelines Standards for QUality Improvement Reporting Excellence Standards for QUality Improvement Reporting Excellence www.squire-statement.org

9. SQUIRE GUIDELINES: OVERVIEW Title Title Abstract Abstract Introduction Introduction Methods Methods Results Results Discussion Discussion References References

10. TITLE Needs to indicate that your project concerns the improvement of quality Needs to indicate that your project concerns the improvement of quality Needs to include the specific aim of the intervention Needs to include the specific aim of the intervention Examples: Examples: A quality improvement project incorporating a procedural checklist in the sedation unit to improve patient safety A quality improvement project incorporating a procedural checklist in the sedation unit to improve patient safety Outcomes of a quality improvement project to reduce the incidence of hypoglycemia secondary to insulin administration in newly diagnosed diabetes mellitus Outcomes of a quality improvement project to reduce the incidence of hypoglycemia secondary to insulin administration in newly diagnosed diabetes mellitus Decreasing Central Line Entries on the Children’s Cancer and Blood Disorders Unit: a collaborative, hospital-based quality improvement project Decreasing Central Line Entries on the Children’s Cancer and Blood Disorders Unit: a collaborative, hospital-based quality improvement project

11. INTRODUCTION Background Knowledge Background Knowledge Brief summary of current knowledge of the problem being addressed Brief summary of current knowledge of the problem being addressed Characteristics of the organization in which the project is occurring Characteristics of the organization in which the project is occurring Local Problem Local Problem Details any previous work (if any) that has been done to target the problem Details any previous work (if any) that has been done to target the problem Describes the nature and severity of the specific local problem being addressed and its significance Describes the nature and severity of the specific local problem being addressed and its significance Intended Improvement Intended Improvement Describes the specific change that will be made to result in improved care Describes the specific change that will be made to result in improved care Describes the specific AIM statement of the proposed intervention Describes the specific AIM statement of the proposed intervention Answers the questions: Answers the questions: For whom For whom How big of a change How big of a change By when By when Why did you choose this problem and how are you going to address this problem?

12. INTRODUCTION: EXAMPLE Central line associated bloodstream infections (CLABSIs) are a costly and deadly problem in the healthcare field. In the pediatric population there is an average of 0.7 to 7.4 CLABSIs per 1000 catheter days…….. ………At Palmetto Health Children’s Hospital, a 300 bed academic pediatric hospital, there is a 10-20% attributable mortality per CLABSI as well as an estimated direct cost of $35,000 per CLABSI. Because of these risks and the resulting increased financial burden, the reduction of CLABSIs is a large area in need of continuing quality improvement……. ………Reducing CLABSIs has been a major initiative for PHCH for quite some time. PHCH PICU has participated in the Children’s Hospital Association PICU Quality Transformation Network since January 2011 and focus has been on reduction of unnecessary central line entries. ……. Given that immunocompromised children are at high risk for healthcare-associated infections, and many of these children have central lines that require frequent accessing for blood draws, medication administration, etc, we began a similar project on the Cancer and Blood Disorders unit……. Background Knowledge: Brief summary of the current problem being addressed and characteristics of the organization in which the project is occurring Local Problem: Previous work that has been done to target the problem and describe the nature and severity of the specific local problem being addressed and why it is important

13. INTRODUCTION: EXAMPLE (CONT.) ……A data collection form will be created and distributed to the nursing team on the CBD unit. Each time a nurse accesses a patient’s line on the CBD unit (for med administration, blood draws, etc) an entry will be recorded on the data collection form. This form will be reviewed by the nurses, physicians, and pharmacists on rounds each morning in an attempt to reduce the number of times central lines are accessed unnecessarily….. …….The aim of this project was to evaluate the average number of central line entries performed on children on the CBD unit and to decrease this number by 50% over a 4 month period Intended Improvement: Describe the specific change the will be made to result in improved care Intended Improvement: Describe the specific AIM statement of the proposed intervention

14. METHODS Planning the intervention Planning the intervention Describe the intervention in sufficient detail that others could reproduce it Describe the intervention in sufficient detail that others could reproduce it Indicate main factors that contributed to choice of the specific intervention Indicate main factors that contributed to choice of the specific intervention Analysis of causes of dysfunction Analysis of causes of dysfunction Matching relevant improvement experience of others with the local situation Matching relevant improvement experience of others with the local situation Outline initial plans for how the intervention was to be implemented Outline initial plans for how the intervention was to be implemented What is to be done (initial steps for implementation of the proposed change) What is to be done (initial steps for implementation of the proposed change) By whom (intended roles) By whom (intended roles) Planning the study of the intervention (Methods of evaluation and analysis) Planning the study of the intervention (Methods of evaluation and analysis) Provides details of qualitative and/or quantitative methods used to draw inferences from data Provides details of qualitative and/or quantitative methods used to draw inferences from data What did you do?

15. METHODS: EXAMPLE A data collection form for recording each time a patient’s central line was accessed on the CBD unit was created and was reviewed with and distributed to the nursing staff of that unit. Anytime a central line was accessed on a patient, it was recorded on the data collection form. For each entry, the nurse had to answer the question “Did they think that specific accessing of the line was avoidable?” If the answer was “yes” then they were instructed to discuss with the primary team (physicians and pharmacists) the following morning during rounds…… ……A data collection form for recording details about central line accessing has previously been utilized in the PICU of Palmetto Health Children’s Hospital with good success on a QI project to reduce the incidence of CLABSIs in that unit. For this project, this PICU data collection form was adapted and modified to more specifically fit the needs of the CBD unit…… Planning the intervention: Describe the intervention in sufficient detail that others could reproduce it Planning the intervention: Indicate main factors the contributed to choice of the specific intervention

16. CENTRAL LINE ENTRY DATA COLLECTION FORM

17. METHODS: EXAMPLE (CONT) A meeting between the charge nurse, pharmacist, and attending physicians on the CBD unit was held to discuss the project with the goal of decreasing central line entries. The data collection form mentioned previously was created and then was reviewed with and distributed to the nursing staff on the CBD unit. The forms were utilized by the nursing staff each day each time they accessed a patient’s central line for recording when and for what reason they were doing so. The completed forms were reviewed by the physician and pharmacist the following morning on daily rounds. During this review, the team assessed whether any of the line entries could have been combined with others or eliminated altogether……. ……To determine the effectiveness of the intervention, the average number of central line entries per day in the pre- and post-intervention period served as the primary outcome measure. As a secondary outcome measure, the total number of line entries per day classified by purpose of the line entry was utilized……. Planning the intervention: Outline initial plans for how the intervention was to be implemented Planning the study of the intervention: quantitative methods used to draw inferences from data

18. RESULTS Discuss changes in processes of care and patient outcomes associated with the intervention Discuss changes in processes of care and patient outcomes associated with the intervention Written description Written description Graphic representation Graphic representation What did you find?

19. RESULTS: EXAMPLE There was a decrease in the total number of line entries in patients with central lines per day (see Figure). Following PDSA cycle #1, the average number of line entries per day was 3.6. After PDSA cycle #3, the number of line entries had decreased to 0.8 entry per day. The data was also broken down by the type of line entries for each PDSA cycle (see Figure). The three most common reasons for line entry were medications, lab draws, and flushes. The total number of entries for these 3 reasons was also decreased after 3 PDSA cycles with total medication entries for a one week period decreasing from 90 to 8, total lab entries decreasing from 24 to 4, and total flush entries decreasing from 35 to 9. Discuss changes in processes of care associated with the intervention: written description

20. RESULTS: EXAMPLE Discuss changes in processes of care associated with the intervention: graphic representation

21. RESULTS: EXAMPLE (CONT) Discuss changes in processes of care associated with the intervention: graphic representation

22. DISCUSSION Summary Summary Summarize the most important successes and difficulties in implementing intervention components, and main changes observed in care delivery and clinical outcomes Summarize the most important successes and difficulties in implementing intervention components, and main changes observed in care delivery and clinical outcomes Limitations (if any) Limitations (if any) Consider possible sources of confounding, bias, or imprecision in design, measurement, and analysis that might have affected study outcomes Consider possible sources of confounding, bias, or imprecision in design, measurement, and analysis that might have affected study outcomes Explore factors that could affect the generalizability of the results Explore factors that could affect the generalizability of the results Describe plans for monitoring and maintaining improvement Describe plans for monitoring and maintaining improvement Conclusions Conclusions Consider overall practical usefulness of the intervention Consider overall practical usefulness of the intervention Suggest implications of your report for further studies of improvement interventions Suggest implications of your report for further studies of improvement interventions What do the finding mean?

23. QUESTIONS?

24. UPCOMING QI DEADLINES First Years Feb 2014 Second QI Lecture March 1, 2014 Choose QI topic April 1, 2014 Choose QI Faculty Mentor May 1, 2014 Turn in completed Project Planning Document to me Second Years Feb 2014 Second QI Lecture March 31, 2014 Complete QI Project and collection of post-intervention data April 25, 2014 (12:15p to 1:15p) Poster Presentation Lecture May 21, 2014 Turn in QI project write-up to me Pediatric Residency QI Website http://pediatrics.med.sc.edu/residency.asp