1. Resident Longitudinal QI Projects ”Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self- evaluation and life-long learning.“ ACGME Common Program Requirements

2. Specifically, ACGME would like us to  Identify strengths, deficiencies and limits in one’s knowledge and expertise  Set learning and improvement goals  Systematically analyze one’s practice using quality improvement methods (PDSA), and implement changes with the goal of practice improvement  Incorporate formative evaluation feedback into daily practice  Locate, appraise and assimilate evidence from scientific studies related to patients’ health problems

3. Its not just ACGME… ABIM’s Maintenance of Certification

4. Maintenance of Certification

5. PIM- Professional Improvement Module

6. More PIM

7. Objectives 1) Understand how to develop an Aim Statement Measurement Plan Improvement Plan 2) Understand rapid cycle improvement

8. State the aim clearly Include numerical goal and time frame that require fundamental system change Set stretch goals Avoid aim drift Be prepared to refocus the aim Step #1 - Setting the AIM – What are we trying to accomplish?

9. Step #2 - Establishing measures – How will we know that a change is an improvement? Plot data over time Seek usefulness, not perfection Use sampling Integrate measurement into the daily routine Use qualitative and quantitative data

10. Baseline Data (HgA1C) HgA1C after 6 months Step #2 - Establishing measures – How will we know that a change is an improvement? HgA1C is the outcome, but the most important data is to determination the intervention’s effectiveness. Evaluate your current management and Nationally recognized guidelines. How do they differ? Data to collect 1. How many patients met with the pharmacist 2. When? Early enough to detect change in HgA1C? Plan, Do- Each patient will meet with pharmacist to evaluate medications

11. Step #3 – Overall Plan for Improvement Avoid “the same” responses Implement recommended practices guidelines Think processes and systems of work –Simplify processes –Reduce waste or unnecessary redundancies Creative thinking Appropriate use of new or existing technology

12. “Every system is perfectly designed to get the results it gets.” Paul Batalden, M.D.

13. The Model for Improvement PDSA The Improvement Guide (Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. San Francisco, California, USA: Jossey-Bass Publishers, Inc.; 1996 What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement?

14. The Cycle- Plan, Do, Study, Act Also known as:  PDCA (Check instead of Study)  The Deming Cycle/Wheel  The Shewart Cycle  The Learning and Improvement Cycle

15. Plan Sequence: 1)Gather background data on the current system. 2)Describe your tactic (intervention) 3)Predict outcome 4)List tasks needed 5)Plan for collection of data

16. DO – Carry it Out Implement (preferably on a small scale) Document problems and unexpected observations See plan through to completion Motivations to carry it out

17. Study or Check – What did we learn? Review the Data / take survey Compare the data to your predictions What worked or went well? What did not? Summarize and Reflect on what was learned -- Draw Conclusions

18. ACT Adopt it Abandon it More study needed Modify overall aim, measure, or plan Create new plan

19. Rapid Cycle - Multiple Cycles Overall AIM Increase documented eye exams for our diabetes population by 45% in the next 12 months Time Expect Challenges and Barriers Cycle #1 – Contact Eye Doctors Cycle #2 – Patient Fax Back Form Cycle #3 – Front Office track down eye results Cycle #4 – Computer Network with eye doctors Cycle #5 – Reminder letter from PCPs Implement Final Changes

20. Discouraged…  So, your patient’s are no more healthy than when you started…  The system in which you function isn’t working- now you have data to support that.  Re-analyze the system, identify areas you can change, areas that are ineffective, areas that are chaotic.  Start a new PDSA cycle to tease out what parts of these areas can be changed  Design an intervention, implement it, gather data and analyze it…  Shampoo, rinse, repeat.

21. How to manage your panel in Powerchart (sort of) Any Diabetic Patient click

23. Say “ok”

25. Not very helpful! Modify display under Components tab

27. Double Click

28. Name and MRN‘To Row,’ everything else to ‘Page’ Name and MRN‘To Row,’ everything else to ‘Page’

29. Upcoming Longitudinal QI Projects  Interns- Start with HgA1C (UNM Clinics) and Hypertension (VA).  Except NE Heights- you’re special  Upper levels  Options!!! If you are interested in switching projects, consider HgA1C (at VA), Hypertension (at UNM), Lipid Guidelines

30. QI Projects Plug (aka how to improve your CV and future employability)  Inpatient Influenza Vaccination Project  Increase the frequency of inpatient influenza vaccine screening,  Increase the number of patients who receive flu vaccine by the time of discharge  Improve documentation of reasons for not administering flu vaccine among inpatients.  Improving influenza vaccination among residents, fellows, and faculty.  Influenza vaccination status was not known for 60% among UNM physicians last year.  Lower the barriers for receiving the influenza vaccine (i.e., working with different groups to find convenient times/locations for influenza vaccination)  Improve collection of documentation

31.  Hand washing on 4-west  4 West is among the worst floors for hospital acquired c-diff  RN’s are working on a hand washing initiative  People are watching! You may be placed in a raffle to win coffee and/or candy  Improved Discharge of Behaviorally Challenged Patients from 4west  MHC order sets  Improved medication compliance after transfer  Improved coordination of security  CIWA Project- more about that later  RN driven improvement in CIWA protocol  Less GTT’s, less MICU transfers, less sitter use, less oversedation QI Projects Plug (aka how to improve your CV and future employability)

32.  Dr. Langsjoen- early probiotics in patient’s receiving antibiotics  Dr. Crowell- Sepsis bundle- lots of opportunity for lactates between 2 and 4  Pulm/Crit care people.  Stand out on your application  PSN Project, improved documentation, reporting  7-Day Readmits-  Still in development  Hospitals will not be reimbursed for 30 day readmits- starting with low-lying fruit by evaluating 7-day readmits  MICU transfers  Outpatient pain management  Also still in development-  Increasing Advanced Directives completed in clinic setting  Sign prompting patients to ask about advanced directives QI Projects Plug (aka how to improve your CV and future employability)