Healthcare Quality and Improvement

Healthcare Quality and Improvement
A Primer This morning we are going to be focusing on health care quality improvement. This is the 1st part of a 2 part presentation and I welcome your questions and feedback. So why are fellows sitting in a classroom and listening to a discussion about quality improvement? Well, I’d like to set the stage for you a bit

Our current medical world
Issues about the quality of healthcare are daily news items Medical profession is in a “fishbowl” I Our current medical world looks very different from the medical world I entered over 30 years ago. You are young and therefore much of the shift in culture may not be as obvious to you. Issues about the quality of healthcare are daily national and international news items. Medicine is in a fishbowl more than ever. And there are many issues being openly and passionately debated about what and how you practice. Here are a few headlines to demonstrate the breadth of concerns

Healthcare Safety Medicine vs.. Airline Industry
Headline: “Can you be as safe in a hospital as you are in a jet?” Medical mistakes in hospitalized patients account for a minimum of 120 deaths annually This equates to a crash of a Boeing 747 every week killing all on board. Here is a particularly provocative headline about the status of health care safety. It puts this issue into a context that is easily understood both by healthcare providers and the general public

Healthcare Costs Errors
Headline: “Medication errors in 2006 added $3.5 billion to the cost of healthcare” Headline: “80,000 catheter-related bloodstream infections occur in intensive care units in the US each year” Other headlines focus on outcomes other than death; on the link between errors and health care cost. These headlines are also very effective at capturing the public’s attention

Healthcare Effectiveness Acute URIvisits/10,000 with antibiotic prescription
And what about the effectiveness of the diagnostic tests and treatments we provide? These are also receiving close scrutiny as demonstrated by this graph found in a national lay publication. These are just a few examples; there is no lack of headlines about the state of medical care and, in general, we are not faring too well. What is likely to add to your immediate concern is captured in the next headline because in 2008 you will not be reimbursed for care ($3.5 billion in 2006 at a minimum) for errors that are preventable and it will impact your salary

Healthcare Backlash Boston Globe
Headline: “We pay for medical errors” By Richard Lord and Dr. Marylou Buyse. 9/12/ 2007 “WHAT IF your mechanic forgot to replace the lug nuts after changing one of your tires and you got into a serious accident when the wheel came off? You wouldn't expect your mechanic to send you a bill for the repairs, would you?” “Unfortunately, that's what happens in healthcare; we pay a high price for mistakes.” This is a recent article that is particularly pointed. It goes on to say…

Boston Globe “Healthcare entities should not be rewarded financially when such preventable errors occur. Hospital-acquired infections offer one example.” “No other industry generates revenue from mistakes. Preventable errors should not be part of the usual cost of healthcare.” So, beginning in 2008 Medicaid Medicare will no longer pay for the consequences of medical error. Hospitals will have to absorb the cost of flawed processes and delivery systems

Can we fix this? The train is out of the station and it’s heading towards YOU Hop on…….or prepare to be trampled It is clear the public is demanding change and you have to agree that our healthcare systems need major improvement. Physicians are being challenged to participate in and lead many of these efforts. In fact physicians and nurses who are providing the bedside care are the people most likely and most needed to figure out how to make the healthcare system work better. So, to answer the question about why fellows are sitting in a classroom listening to a presentation on QI, you are here to gain new knowledge and insight about how you can change our healthcare system. You are the future of healthcare. And, oh by the way, if you don’t want to do this, there are plenty of others willing to do the work.

National Healthcare Quality Organizations
Agency for Healthcare Research and Quality (AHRQ) Health Care Quality Joint Commission on Accreditation of Healthcare Organizations (JCAHO) National Committee for Quality Assurance Quality Interagency Coordination (QuIC) Task Force URAC (also known as the American Accreditation Healthcare Commission) U.S. Consumer Gateway: Health U.S. News Online This is a small sample of the hundreds of health care improvement organizations that have emerged in the last decade or so. You may be familiar with some of these. The bottom line is, if you choose to delegate healthcare improvement exclusively to these organizations they will be happy to take that on. However you need to realize that you won’t have much to say about what they decide or how you will practice in the future. Given the dedication you as physicians have to your patients I’m guessing that you don’t want to delegate this. So what is the answer?

Quality Improvement Basic ingredients
Clinical knowledge and experience + QI basic concepts Systems approach Well, it’s pretty basic. You need to take your clinical knowledge and experience and combine it with some basic QI knowledge. Then adjust your perspective to a systems perspective. Then you will be ready to be part of the movement to produce positive systems changes in healthcare. Sound easy? Well, it’s simple. You need to have a little QI knowledge and use your experience and clinical knowledge to help produce positive change. And my hope is that, after this and the December presentation that you will have greater knowledge and skill to do so.

Objectives Quality problems in health care Define quality
Who, what, why and how of quality improvement Key elements of a good QI project Quality improvement vs.. research Joint Commission National Patient Safety Goals So the objectives of today’s presentation are to characterize the quality problems in healthcare in a very broad sense, to define healthcare quality and to focus on the who… of QI. I will briefly describe the key elements of a good QI project because you will have some work to do between today’s presentation and the next one in December to outline a QI project

Our current medical world Contributing factors
Knowledge and technology explosion Barriers to translation of scientific knowledge into clinical practice Increasing complexity of healthcare needs Outdated processes and systems for complex multidisciplinary healthcare delivery Let’s talk a little about what got us to our current medical world. As fellows you are well aware of the amount of knowledge you have been expected to acquire. It’s overwhelming! And technology applications in healthcare are also accelerating rapidly. For many reasons the scientific knowledge that is available is not always translated to the bedside. This is a complex problem with solutions being studied. I’m confident that you in his group could probably identify some of the many reasons why knowledge does not translate in to timely practice changes. Our patients are far more complex today than they were 20 years ago. Combine that with the fact that very little attention has been given to HOW we deliver this complex health care and we are behind the “8 ball”. It's time to change

Our medical world Past and future
Cottage industry Individual patient focus “I know it when I see it” Integrated healthcare system System focus Evidence based Small change has been occurring but we need to accelerate the pace. We have been dinosaurs in the way we provide healthcare and we are gradually moving from the cottage industry model to integrated health systems of healthcare

Our current medical world Accelerating factors
Multiple studies and reports widespread and frequent incidence of medical errors lack of consistency in the care received in different facilities and from different providers Explosion of healthcare quality interest and organizations Institute of Medicine Reports To Err is Human: Building a Safer Health System(1999) Crossing the Quality Chasm(2001) Our current medical world with the focus on healthcare deficiencies and the need to improve healthcare quality has been accelerated by 3 major factors. In the last decade multiple studies and reports have pointed out the…..These are not new facts; this has been known for a while. However the problem was not acknowledged until multiple studies and reports began to examine the issues about healthcare delivery and chronicle the misadventures and errors. This fueled the explosion of organizations and interest in HC quality. The biggest accelerant has been the IOM reports; in 1999 the IOM published the sentinel report on errors followed by the report crossing the quality chasm. (There is a 3rd report which will not be discussed today)

I’d like to focus on the 2nd report, Crossing…chasm, for a few minutes

Quality Chasm/Gap Defined by the IOM
The difference between what is scientifically sound and possible and the actual practice and delivery of health services Illustrates the need for healthcare quality improvement efforts In this report the IOM identified what they called a quality chasm or gap. They defined this as…They used this concept to illustrate…

Quality problems Healthcare services
Underuse Overuse Misuse Variation Fragmentation Some of the problems with healthcare quality that were identified by the report included….In your particular specialty area can you think of examples of these? (write on white board) Take some suggestions. You might consider thinking about these for potential QI projects you could work on.

Institute of Medicine Quality Aims
Name the 6 quality aims identified by the IOM The IOM also identified 6 quality aims or essential characteristics of quality. Quiz question #1 (write on white board)

Safe Effective Patient centered Timely Efficient I am sure that all of you have heard of these six quality characteristics/aims described the IOM report. . I’m going to briefly describe what they meant by each of these

Safe Avoid injury to patients from the care that is intended to help them Examples Prescription of medication that patient is allergic to Failure to address an abnormal lab or Xray result Failure to perform the correct procedure Does anyone have an example of a safe or unsafe practice they have observed?

Effective Avoid overuse of ineffective care and underuse of effective care Examples Obtaining lab or Xray tests that don’t alter treatment plan How about a situation in which you have observed care that is not effective?

Healthcare Effectiveness Acute URIvisits/10,000 with antibiotic prescription
This is the example I showed earlier as a headline. It aptly demonstrates the overuse of an ineffective treatment.

Patient centered Provide care that is respectful of and responsive to individual patient preferences, needs and values Examples Shared decision making for treatment options Patient centered is an area that I think pediatricians and pediatric specialists are really good at.

Timely Reduce waits and harmful delays for both those who receive care and those who give care Examples I’m sure you could think of multiple examples of this aim. Perhaps some of you have tried to tackle this problem on your own. If so you’ve likely not met with huge success. This is definitely a system problem that requires a system solution-and is a perfect opportunity for a QI project

Efficient Avoid waste including waste of supplies, equipment, ideas and energy Example Necessary supplies, personnel, and medications in room for patient procedure Here’s one of my pet peeves and I’ll bet this affects you on a daily basis as well

Equitable Provide care that does not vary in quality due to gender, ethnicity, geographic location or socioeconomic status Example I think this one is pretty straightforward. So, you are now familiar with the IOM report and the 6 aims for quality in healthcare and we know why we’re in this mess(and why you have to sit through this presentation)

Our current medical world
Issues about the quality of healthcare are daily news items Medical profession is in a “fishbowl” I Our current medical world revisited. But I haven’t yet defined quality. I ‘m pretty sure we all believe we provide quality medical care but how do you define quality?

Defining Quality “Quality is a way of thinking about work; quality is about achieving excellence-nothing less” IOM definition of quality The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge Defining quality is not easy to do. There are many definitions of quality and not everyone agrees. What I think we would all agree with is that the provision of quality work is a basic value for physicians. I think most of us would agree with the 1st definition of quality. The IOM definition looks beyond individual healthcare provider quality to a systems perspective and defines quality as……the quality of your care is impacted by the care provided by other members of your team and the systems and processes in place. Healthcare quality is more than just the quality of care you provide as a physician.

Defining Quality Quality is… Quality is a major team sport
A system-wide issue An individual performance issue rarely Quality is a major team sport Here is a more basic view of quality. Simply stated quality is an attribute of a system. It requires team work among healthcare providers to achieve. I’d like to state that again; quality is a system issue that requires a team effort and commitment. It is rarely an individual performance issue. However we will see that individual accountability IS a key component of a well functioning system. So, we’ve talked about how to define quality. Now let’s move on to what quality improvement involves

Quality Improvement A process of innovation and adaptation designed to bring about immediate positive changes in the delivery of health care in particular settings systematic data-guided multidisciplinary Just like quality, quality improvement has numerous definitions but the best definition I have found is healthcare quality improvement is……. Key attributes of the QI process are that it is systematic…. (nor me, not you, not the nurses or the unit clerks or whoever else is a part of your team-it’s about the team. There are many reasons for the choice of words here especially immediate HC delivery, particular. Requires collaboration

Quality Improvement Key elements
Systematic Data-guided and knowledge informed Experiential Innovative Employs formal explicit methodology Continuous Core responsibility of healthcare professionals These are key elements. To expound a bit on some of them. Again systems and a systematic and deliberate approach is a critical concept-the focus is on improving systems. These activities generally are guided by data and prevailing knowledge. Experience of the caregivers is important in identifying opportunities for improvement and suggesting innovations. Innovation is key-try new things. Formal explicit methodology requires team skills effort and commitment. And it is a core responsibility of all healthcare providers. HCP must be accountable for disregarding identified safe practices or engaging in unjustified hazardous conduct. So, I’m sure many of you are thinking, what’s so new about that? We do that!

QI vs. Informal Improvement
Systematic Data-guided and knowledge informed Experiential Innovative Employs formal explicit methodology Continuous Core responsibility of all healthcare professionals Systems change Individual or group May be knowledge informed; rarely data Experiential, anecdotal Innovative Informal process Episodic No explicit responsibility. Usually hierarchical Individual change Yes, some of this work has been done in the past. Generally it was informal, came from the top, often anecdotal and rarely evaluated. A good example is the physician who changes their practice after seeing the report on antibiotics prescribed for URIs that I showed earlier. This physician decides to stop prescribing the Abx. Now his patients, who are use to getting the antibiotics are not getting them And they realize that, hey, maybe the other docs in the practice are still giving antibiotics. So, instead of scheduling an appointment for their sick child with this doctor they wait until 8PM and call the on call doctor who prescribes amoxicillin for the cold. In a QI mode the entire practice would read the report, have a discussion about practice change, all implement the practice and improve the care for the entire practice, not just one individual. And…the on call doctor would not have to take that 8PM phone call. Key differences between QI and informal improvement are systematic, data guided, formal, continuous and an expectation of all from the front line to the boardroom

Quality Improvement Work
Team oriented Requires team skills Collaboration Meeting skills Value all perspectives Develop local new useful knowledge to inform health care processes I really want to re-emphasize that qi work is team oriented and requires team skills. The product of QI work is to develop local….It is proactive not reactive; the focus is in improving systems not blaming individuals

QI vs. Informal Improvement
Systematic Data-guided and knowledge informed Experiential Innovative Employs formal explicit methodology Continuous Core responsibility of all healthcare professionals Systems change Individual or group May be knowledge informed; rarely data Experiential, anecdotal Innovative Informal process Episodic No explicit responsibility. Usually hierarchical Individual change We are now going to focus on the explicit methodology associated with QI. Many of these methods have been borrowed from other disciplines. These methods are used to structure cooperation of participants, change the process or system, monitor what happens and evaluate changes.

Quality Improvement Methods and Terms
What is Root Cause Analysis? What does PDSA stand for? What are Sentinel Events? So here’s quiz questions # 2, 3,4. And, if you know the answers to all 3 you can probably leave now. We will discuss all of these further (sentinel events-serious events associated with significant injury or death-wrong site surgery, post op paralysis, death from drug patient is known to be allergic to)

Quality Improvement Methods and Terms
Sentinel events Never events Practice standardization Adverse events Harm Incident reports Balanced scorecard Methods PDSA LEAN Six sigma Root Cause analysis Fishbone diagram FMEA Tracers Trigger tools Action plans Well there are many QI terms and methods and many more to emerge. Again, most of these have been borrowed from industry and other disciplines. I am not going to discuss all of these unless I hear that you would like more info and then I can cover that in part 2. however I did want to emphasize that QI has a language of it’s own and does have some proven methods to inform QI work

Improvement Methods A brief overview
Model for Improvement Lean Six Sigma Trigger tools I would like to address several of the methods used in this formal process to improve the system of care delivery and will begin today with the model for improvement. I do want to state that in some projects more than 1 method may be and often is used. Has anyone heard of the model for improvement?

Model for Improvement Flexible improvement framework IHI
PDSA methodology Emphasizes Aims and measures Initial small tests of change Widespread testing Implementation and spread You have probably heard of PDSA.

Model for Improvement Setting Aims
Improvement requires setting aims. The aim should be time-specific, measurable and define the specific population of patients that will be affected. Setting an aim is the first step in any QI project, regardless of the methodology to be used. It is important to clearly define your goal

SIP Collaborative Project Aim
SSI Rate 50% reduction This is an example of the SIP collaborative done here at CMH (Surgical infection prevention; surgical site infection)

ED Wait Collaborative Project Aim
25% reduction in ED length of stay by 6/30/07 And the ED Wait collaborative also done here

Model for Improvement Setting Aims
What are you trying to accomplish? I’d like to you to think about something in your scope of practice in need of improvement. Think along the 6 quality aims of the IOM. Now take this paper and write out a project aim. Would anyone like to share their aim? I’d like you to keep this paper and use it to outline

Model for Improvement Establishing Measures
Teams use quantitative measures to determine if a specific change actually leads to an improvement. Once you identify the goal of your project the next step is to identify measures that will be used to inform your process. Remember QI work is data guided and you need to collect some data to help you identify if changes you are making have made a difference.

SIP Collaborative Establishing Measures
Measurement Collaborative Goal SSI Rate 50% reduction Antibiotic use rate Skin anti-sepsis rate This is an example of the SIP collaborative done here at CMH. The goal was. The measurements chosen were SSI,

Model for Improvement Selecting Changes
All improvement requires changes, but not all changes result in improvement. Identify the changes that are most likely to result in improvement. Now you have your goal, and measures identified to assess if you are improving. Now you have to decide what changes to make that are most likely to result in an improvement

SIP Collaborative Establishing Measures
Measurement Collaborative Goal Antibiotic use rate Timing Re-dosing Skin anti-sepsis rate Chlorhexidine Hair removal In the SIP collaborative changes made included for antibiotic use rate implementing practice recommendations for timing of dose and need for re-dose. For skin antisepsis rate changes included recommendations about skin cleansing solutions and hair removal

Our “Dizzying Complexity”
Communication to Admit One ED Patient You could pick changes anywhere along this crazy cascade for one component of the ED process

ED Wait Collaborative Changes Selected
Aim: 25% reduction in ED LOS Measures ED total LOS Time from provider to decision re: disposition Time from decision to discharge/admit Asthma/wheezing patients Initiation of Albuterol by RT/RN if emergent Practice change Asthma CPG revision Evidence based practice and process standardization Floor admission-selected patients receiving continuous Albuterol Practice and process change

Model for Improvement Testing Change
The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change in the real work setting — by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method used for action-oriented learning. Now you implement these changes by using short PDSA cycles. Make the change, measure based on the measures you have identified and act on what you have learned

O4. Decision to Discharge Time Average total minutes from clinical decision to child leaving the ED
Here is an example of a graph of a measure used during the ED Wait collaborative-time-to assess the impact of various changes

Model for Improvement Implementing Changes
After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the team can implement the change on a broader scale Once the process is refined you can implement the change

Model for Improvement Spreading Change
After successful implementation of a change or package of changes for a pilot population or an entire unit, the team can spread the changes. And, if appropriate spread the change to other areas

QI Projects? Are you doing any? How is it going? Lessons learned?
So, I'm sure some of you have led or participated in QI projects. Can you tell us what you have done?

QI project development Essential steps
Identify a project aim Develop a plan to achieve the aim Responsibilities and roles Improvement methods Data sources Timelines Identify outcome and balancing measures Use data to identify improvement The next step is to begin to think about a quality improvement project that you can do. Essential steps in launching a project include….You have already identified a project aim. You may use that one or decide on a different project before the next presentation and complete your plan for aims, improvement methods and tools and assessment. If you are currently doing a project you may list what your project involves

Part 2 Review key concepts Move on to other QI methods
Discuss project development Research vs. QI National patient safety goals Joint commission

Objectives Quality problems in health care Define quality
Who, what, why and how of quality improvement Tools and methods Key elements of a good QI project Quality improvement vs.. research National Patient Safety Goals Joint Commission In the 1st session we discussed quality problems, defined quality and began to discuss improvement methods and terms. We also touched briefly on developing a project and you wrote out a project aim. You were to return today with some further definition of your aim, QI tools and methods you might use and an assessment plan. We will talk more about these. I wanted to briefly review several key points

Defining Quality Quality is a team sport Quality is…
A systems-wide issue An individual performance issue rarely Quality is a team sport Just a reminder that quality is a system issue and requires a team effort to produce. Again quality work focuses on system improvement however individuals are held accountable to engage in safe practices

Quality Improvement A process of innovation and adaptation designed to bring about immediate positive changes in the delivery of health care in particular settings systematic data-guided multidisciplinary QI is a deliberate process that is systematic, data informed and multidisciplinary It requires a great deal of collaboration and cannot be done successfully in isolation

Quality Improvement and Data
Use data for learning, not judging “Generate light, not heat” Use data to report system attributes Use aggregate not individual data Do not report data on individual performance I’d like to make a few comments on the use of data in QI efforts. Regardless of the improvement method used in a project there are some very important messages about the use of data that I’d like to present. Data for individual performance is generally not used until aggregate reporting has achieved a 90-95% rate of success in achieving the desired outcome. At that point you might consider the use of blinded provider data to identify differences among providers

Improvement Methods A brief overview
Model for Improvement Lean Six Sigma Trigger tools Back to our improvement methods. We discussed the model for improvement last time and you were asked to outline a QI project aim and identify tools and methods you would use to implement the project. As I briefly discuss improvement methods I’d suggest you refer back to your outline and update it if needed.

Model for Improvement Flexible improvement framework IHI
PDSA methodology Emphasizes Aims and measures Initial small tests of change Widespread testing Implementation and spread As you recall we discussed the model for improvement in November. It is a flexible framework for improvement that uses PDSA methodology. It emphasizes points about the model include

Improvement Methods What is LEAN? What is Six Sigma?
Identify a trigger tool Now we will move on to some other methods. Does anyone want to describe Lean, six sigma, trigger tool?

Lean Management philosophy based on 2 key themes Key principles
Continuous elimination of waste Respect for people and society Key principles Value is in the eyes of the customer Make value flow without interuptions Improve work flow Standardize work processes Pursue perfection Lean is a very specific methodology focused on eliminating defects by continuously focusing on eliminating waste. The focus is on the customer, who are our patients, needs and lean methods seek to standardize and improve work flow and processes with the ultimate goal of pursuing perfection. Many organizations use lean methods to inform their QI processes

Lean Culture Stop and fix the problem as soon as it is identified Toyota manufacturing culture Process Measure Change Change….. Lean culture originated in the Toyota manufacturing plants and focuses on stopping. The cycle is measure, change, measure….

Lean Project “Improve ED Patient Flow”
Project aim-reduce ED LOS by 50% Process improvements(reduce waste) Work standards and evidence-based clinical practice guidelines for all ED staff defined Batching of orders eliminated Right supplies and equipment in the right place; eliminated unnecessary S&E Admission process streamlined Results Reduced ED LOS for discharges by 23% Reduced ED LOS for admissions by 20% A healthcare example e of a lean project is the following project done in an adult hospital. The project aim was to …and they used lean principles to eliminate waste and improve and standardize work flow processes. This resulted in……In essence they eliminated waste(waiting in the ED) by standardizing processes and improving their work flow

Lean What is waste in medicine?
Surgical infection Preventable adverse drug events Ventilator assisted pneumonia Equipment failure Waiting and lack of flow Inadequate training or orientation Unnecessary or poorly designed processes Not following evidence based practices Here are some additional examples of waste in medicine. I’m sure all of you could easily identify examples of waste in your area-anyone want to share? At this point you may want to review your project aim and decide of lean methods would assist you in your QI project

Six Sigma Focus is to eliminate defects
Nonconformity of a product or service to its specifications Six sigma processes have variation that result in <3.4 parts/million defects Now we’ll move on to 6 sigma. How many of you have heard about 6 sigma? Have any of you been involved I 6 sigma projects? The 6 sigma method focuses on eliminating defects which are defined as Six sigma is also a method focused on eliminating defects. Black belts-16 day course; green belts 8 day course. To put this into context….99.9% accuracy has 1 defect for each so, if you are doing liver biopsies you will have 1 death for every 1000 you perform.

Why Zero Defects is the Only Acceptable Quality Standard
At 99.9% quality levels in a 250 bed hospital 12 inpatients per year would die due to errors 6 day surgery patients would die 9,742 wrong medications would be delivered 4,923 incorrect laboratory tests would be reported 502 incorrect radiographs would be completed

Six Sigma Systematic and scientific management approach to reduce sources of process variation and improve reliability Customer and financially focused Strategic Uses project management concepts Strong statistical focus Focus on “mistake-proofing” Requires rigorous professional training Black belts-16 day course; green belts 8 day course

Six Sigma Project “Reducing Hospital-Acquired Pressure Ulcers”
5 structured project phases Define Measure Analyze Improve Control Here is a healthcare example of a six sigma project. This project focused on…..It was a customer/patient focused project attempting to eliminate pressure ulcers. In keeping with the project management concepts used in 6 sigma there were 5 structured phases this method emphasizes to conduct the project. Define the problem. Measure the current situation and interventions. Analyze the process and intervention data. Improve the process based on this analysis. Control or sustain the results ((Identfiy what control means))

I included this chart just to demonstrate the rigor of the project management concepts including the risk assessment and abatement plan. For example, if pressure ulcers are not managed, how to proceed

And here are their results
And here are their results. In general 6 sigma requires a considerable statistical expertise, a core group of green and black belts, and a major commitment form the organization to implement and sustain the projects. on this chart you can see the impact on measurement

Trigger tools Method for identifying adverse events (harm) and measuring the rate of adverse events over time Method options Retrospective review of a random sample of patient records using triggers (clues) Prospective surveillance of electronic patient records Goal-to identify areas for improvement and prevent harm Another improvement method that you may have heard about or used is the trigger tool. Trigger tools are a method of identifying..and measuring the rate of these adverse events. Hospitals have traditionally relied on event reporting of adverse events to identify these areas, and event reports have been found to identify less than 10% of actual errors. Trigger tools allow a more proactive and systematic method of identifying adverse events and have a greater yield. To use trigger tools requires either a…of 20 charts/month or prospective surveillance. The goal of trigger tools is to….and prevent harm/patient injury

This is an example of a neonatal trigger tool that was developed
This is an example of a neonatal trigger tool that was developed. This chart gives you some idea of how these work. You can see that this process requires some chart review to uncover the trigger and then decide if an adverse event has occurred. Antibiotic use is the trigger or clue. The adverse event you are trying to identify is nosocomial infection. Using this info you can generate a rate for nosocomial infection in the NICU (data guided), analyze or trend this, create an aim to have 0 nosocomial infections and then identify changes to improve

Trigger Tools Your medical world
Are there triggers that could be used in your specialty to identify areas of potential patient harm? Narcan for opiate OD, Benadryl for a drug allergy, readmission to the hospital for uncovering late surgical site infections, return to surgery….. Would this method be useful in the QI project you are developing?

Root Cause Analysis Process to identify causal factors for variation in performance; “learning from consequences” Systems and processes focus Individual performance not a focus Identifies potential improvements to reduce likelihood of future event Used in M&M process, sentinel event investigations On to root cause analysis. Many of you may be familiar with this process. It is a process that is a retrospective assessment of a situation that has already occurred. Like all good QI tools and activities it focuses on systems and processes and not on individual performance. I suspect most of you are familiar with this process and the fishbone diagram

Care Delivery problems (CDPs)
Fishbone Diagram Patient Factors Condition (complexity and seriousness) Language and communication Personality and social factors Individual (staff) factors Knowledge and skills Competence Physical and mental health Work Environmental Factors Staffing levels and skills mix Workload and shift patterns Design, availability and maintenance of equipment Administrative and managerial support Environment Physical Task Factors Task design and clarity of structure Availability and use of protocols Availability and accuracy of test results Decision-making aids Team Factors Verbal communication Written communication Supervision and seeking help Team structure (congruence, consistency, leadership, etc) Organizational and Management Factors Financial resources and constraints Organizational structure Policy, standards and goals Safety culture and priorities C D P DDDDPPP Care Delivery problems (CDPs) Care deviated beyond safe limits of practice The deviation had at least a potential direct or indirect effect for an adverse outcome for the patient, staff or general public Examples: Failure to monitor, observe or act Incorrect (with hindsight) decision Not seeking help when necessary The fishbone is often used in root cause analysis and provides a systematic frame work to work through all the potential factors that may have contributed to the situation. If you have been to the Dept of Pediatrics M&M you have seen this used

Failure modes and Effects Analysis (FMEA)
Prospective technique Systematic assessment to Prevent problems before they occur Reduce the chance of unintended adverse harm if they occur Used for high risk procedures or error prone processes In contrast to root cause analysis is another process is called FMEA. It is a prospective process that involves a systematic assessment of a process to prevent problems before they occur and/or to reduce the chance of a bad outcome if they do occur. This technique is generally used for….Can you think of a situation where this technique might be sueful?(Implementation of a high risk procedure or technique)

QI projects Ideas/Aims Methods Data Challenges
So, let’s discuss some of the ideas and plans for QI projects you have identified.

Improvement project ideas
Care process changes Hand offs Scheduling Medication reconciliation Implementation of new clinical or administrative practices Practice standardization There are many ideas and areas that improvement projects can focus on. These include….The next few slides describe a QI project with a focus on practice standardization

Central Line Infections Defining the problem
15 million central venous catheter-days per year in ICUs Attributable mortality for these infections % Bloodstream infections prolong hospitalization by a mean of 7 days Setting the stage

Central Line Infections Stating the project aim
Reduce central line infection rate to 0 in the ICU in 12 months

Central Line Infections Practice Standardization
Hand Hygiene Maximal Barrier Precautions upon insertion Chlorhexidine skin antisepsis Optimal catheter site selection, with Subclavian Vein as the preferred site for non-tunneled catheters Daily review of line necessity with prompt removal of unnecessary lines Approach to change involved standardization of practice. After several small tests of change each of these items were tested and implemented

Central Line Infections Practice Standardization
And these were the results. But there is a solution and probably more than one to the aim of reducing central line infections. In this case the group developed a bundle. A bundle is a group of precautionary steps with approximate time and space characteristics that, when executed collectively and reliably, have an enhanced affect on patient outcomes. The bundle provides a "forcing function" for teamwork, and this teamwork has led to outstanding results.

Quality at CMH How informed are you?
Rate of compliance with hand washing? 90% Central line infection rate? 1.2/1000 cath days-PICU % of codes outside the PICU? 50% % of inpatients with medication reconciliation performed? 70% So, how informed are you of QI activites going on here at Mercy? In the 1st quarter of 2007 the correct hand washing technique 90%

Healthcare Quality Improvement 2007
Move from cottage industry mode of care delivery to data driven system model of healthcare delivery Systems approach Individual blame not the norm Individual IS accountable Before I discuss qi vs. research let me just summarize my message about quality improvement. In 2007 we need to move…

Quality Improvement vs. Research It’s Complicated….
QI Systematic data-guided activities designed to bring about immediate positive changes in healthcare delivery in local practice settings An integral part of the ongoing healthcare delivery system A form of clinical and managerial innovation and adaptation Combines discipline specific knowledge with experiential learning and discovery Research A systematic investigation designed to develop or contribute to generalizable new knowledge Implementation of research is a separate process and occurs later, if at all A knowledge seeking enterprise that is independent of routine medical care You will hear a lot of discussion about what is QI and what is reasearch. And I’m sure sometime during these 2 QI presentations you have found yourself thinking that there is not a huge difference betweeen some QI projects and research. I know this is a hot issue for many IRBs and investigators and I don’t have a perfect answer. Here is my best comparison at this point.

Hastings Report The Hastings report was issues in 2006 and addressed the ethics of using QI methods to improve quality and safety

Questions? Before we move on to regulatory issues and joint commission I’d like to take questions from you re: quality improvement, your projects, etc

Joint Commission Accrediting organization for healthcare institutions
Sets administrative and practice standards and evaluates compliance Performs unannounced on-site surveys of accredited hospitals to assess compliance every months And now we’ll move on to joint commission. I’m going to give you a few highlights about joint commission. They publish over 100 pages of standards that hospitals must comply with to be accredited. You are likely familiar with many of these standards although you may not be aware they originate from the joint commission. H&Ps, how medical staffs are organized and governed, etc

Joint Commission Mission
To continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations Why do they do this? Well, their mission is to…. So, their focus is definitely on performance improvement in the areas of healthcare quality and safety. They publish an annual list of patient safety goals

National Patient Safety Goals
Key national safety goals for hospitals Set by Joint Commission Updated yearly Goal is to promote specific improvements in patient safety Many of these goals are developed based on data about near miss or sentinel events reported to the joint commission data base. There are many other sources for consideration of key patient safety goals. I m going to briefly identify the goals for 20o8

2008 NPSG Goal 1 Improve the accuracy of patient identification.
1A Use at least two patient identifiers when providing care, treatment or services. This pertains to you as when you assess, treat or perform procedures you must have the correct patient and you do this by identifying patients by name, med record #, DOB

2008 NPSG Goal 2 Improve the effectiveness of communication among caregivers. 2A For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result. 2B Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. Goal 2 focuses on communication and there are many components to it. Key elements are verbal orders-write down, read back, abbreviations

2008 NPSG Goal 2 Improve the effectiveness of communication among caregivers. 2C Measure and assess, and if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. 2E Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions. Reporting of critical test results and handoffs.

2008 NPSG Goal 3 Improve the safety of using medications.
3C Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs. 3D Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field. 3E Reduce the likelihood of patient harm associated with the use of anticoagulation therapy. Goal 3 relates to medication safety and safe practices

2008 NPSG Goal 7 Reduce the risk of health care-associated infections.7AComply with current World Health Organization (WHO) Hand Hygiene Guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. 7B Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection Goal 7 focuses on reducing risk of infections acquired in the hospital. Thinking back one of the projects on reducing central line infections focused on this goal

2008 NPSG Goal 8 Accurately and completely reconcile medications across the continuum of care. 8A There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization. 8B A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility. I know you have heard a lot about this goal-which addresses medication reconciliation. I know there are lots of opinions and angst about this goal. Nationally the same concerns and struggles are occurring so we are not alone

2008 NPSG Goal 9 Reduce the risk of patient harm resulting from falls.
9B Implement a fall reduction program including an evaluation of the effectiveness of the program. 9 concerns falls and reducing their likelihood

2008 NPSG Goal 13 Encourage patients’ active involvement in their own care as a patient safety strategy. 13A Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so. Goal 13 is a patient centered goal and requires us to involve patients and families to an even greater extent than we have as a patient safety strategy. Patients are told to speak up about unsafe practices; a good example is hand washing and parents have become empowered to stop healthcare providers and ask them to wash their hands

2008 NPSG Goal 15 The organization identifies safety risks inherent in its patient population. 15A The organization identifies patients at risk for suicide. We now screen for suicide risk at admission

2008 NPSG Goal 16 Improve recognition and response to changes in a patient’s condition. 16A The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening. We have done well with this goal with the implementation of the RRT

Quality Improvement Key elements
Systematic Data-guided and knowledge informed Experiential Innovative Employs formal explicit methodology Continuous Core responsibility of healthcare professionals

Quality Improvement Work
Focused on systems Team oriented Requires team skills Collaboration Meeting skills Value all perspectives Develop local new useful knowledge to inform health care processes

Healthcare Quality and Improvement

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