1. QUALITY IMPROVEMENT IN HEALTHCARE: RESIDENCY AND BEYOND Lisa Knight, MD Quality Improvement Lecture 3 February 5, 2015

2. LECTURE OUTLINE Refresher on the Basics of a QI project Refresher on the Basics of a QI project Project Implementation and Data Analysis Project Implementation and Data Analysis SQUIRE guidelines SQUIRE guidelines Reminder on upcoming QI deadlines Reminder on upcoming QI deadlines

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

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? 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. QI PROJECT EXAMPLE 1: FROM START TO FINISH Night Team checkout Night Team checkout Large amount of time updating the resident/patient assignment list Large amount of time updating the resident/patient assignment list Resident/Nurse communication Resident/Nurse communication Unnecessary “transfer phone calls” to unit secretaries Unnecessary “transfer phone calls” to unit secretaries Night team hand writes a new list everyday A lot of redundancy Unit secretaries update the nurse/patient assignment list everyday Residents do not have access to it 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

6. Get Buy in from those affected IT department Development of a shared drive Access for residents/attendings Unit secretaries on 3 rd and 4 th floors Nursing staff on 3 rd and 4 th floors Residents on wards/NF during PDSA cycle periods QI PROJECT EXAMPLE 1: FROM START TO FINISH

7. What are we trying to accomplish? How will we know that a change is an improvement? Create a General Pediatric Shared Drive Create a General Pediatric Shared Drive Unified List Unified List Outcome Measure Outcome Measure Number of minutes for residents to update list (min/day) Number of minutes for residents to update list (min/day) Number of transfer calls to unit secretaries each day (#calls/day) Number of transfer calls to unit secretaries each day (#calls/day) Process Measure—Percent of days in the PDSA cycle that the list was appropriately updated Process Measure—Percent of days in the PDSA cycle that the list was appropriately updated Balancing Measure—Amount of time (in min/day) that the unit secretaries spend making the new lists vs the old lists Balancing Measure—Amount of time (in min/day) that the unit secretaries spend making the new lists vs the old lists Model for Improvement What change can we make that will result in improvement? QI PROJECT EXAMPLE 1: FROM START TO FINISH Baseline Data Collection 2 weeks of night float this year 2 weeks of night float this year Unit secretaries track: Unit secretaries track: How many phone calls they receive from residents each day asking to be transferred to a nurse How many phone calls they receive from residents each day asking to be transferred to a nurse Time themselves when they update the list Time themselves when they update the list Night float residents time themselves when they update the list Night float residents time themselves when they update the list

8. BASELINE DATA: RESULTS Baseline Data Collection Day Time for NF Residents to Update ListPhone Calls to Unit SecretariesTime for Unit Secretaries to Update List Min/Day#Calls/DayMin/Day 122715 2 1110 31799 423612 5141011 619814 720813 818712 9191315 10201017 11168 1221913 2289 14241014 Average19.38.912.9

9. Lindsey Stoltz Dr. Katie Stephenson Night Team Pediatric Residents Improve communication amongst residents and between residents and nurses by: 1.Reducing the amount of time (in minutes/day) that the night float team spends updating the floor lists from 19.3 minutes to 5 minutes by March 31, 2016 2.Reducing the number of “transfer request” phone calls (in #calls/day) to the unit secretaries from 8.9 to 0 by March 31, 2016 1. Primary: Amount of time (in minutes/day) that the night float team spends updating the floor lists 2. Secondary: Number of transfer request phone calls from the residents (in #calls/day) to the unit secretaries Number of days in the PDSA cycle where the list was appropriately updated Number of days in the PDSA cycle Amount of time (in minutes/day) that the unit secretaries spend making the new lists versus the old lists Combine the resident and nurse assignments into one list, include an area with their corresponding pagers and IP numbers, respectively to allow for minimal daily adjustments, and save the lists on a shared computer drive for easy access for everyone 3 rd and 4 th Floor Unit Secretaries X 100

10. PDSA CYCLE 1 Week 1 or 2 of Ward Month Make all parties aware of project and goals Make all parties aware of project and goals Night Float Team Night Float Team Day Ward Residents (including weekend) Day Ward Residents (including weekend) Unit Secretaries (4 th floor) Unit Secretaries (4 th floor) PLAN DO STUDY ACT PLAN DO STUDY ACT Remember to track all measures Outcome Measures Outcome Measures Time for Night Float Residents to Update List (min/day) Time for Night Float Residents to Update List (min/day) Number of transfer request phone calls to unit secretaries (#Calls/day) Number of transfer request phone calls to unit secretaries (#Calls/day) Process Measure Process Measure Percent of nights in PDSA cycle that the list was updated appropriately Percent of nights in PDSA cycle that the list was updated appropriately By Night Float residents By Night Float residents By unit secretaries By unit secretaries Balancing Measure Balancing Measure Time for unit secretary to update new lists (min/day) Time for unit secretary to update new lists (min/day)

11. PDSA CYCLE 1 RESULTS PDSA Cycle 1 Data Collection Primary Outcome MeasureSecondary Outcome MeasureProcess MeasureBalancing Measure Day Time for NF Residents to Update List Phone Calls to Unit SecretariesPercent of Days New List Updated Time for Unit Secretaries to Update List Min/Day#Calls/Day% Days (0=no, 1=yes)Min/Day 151114 24019 33018 442110 561111 62700 750112 Average4.11.686%9.1 Baseline19.38.9-12.9 PDSA 241100%14 PDSA 350100%13

15. QI METHODS: NEXT STEPS Discuss the new shared drive and list with all residents/attendings Discuss the new shared drive and list with all residents/attendings Housestaff Meeting Housestaff Meeting CHOC QI Meeting CHOC QI Meeting Separate Lecture Separate Lecture Ensure staff (secretaries and nurses) on affected floors are aware of new list/shared drive Ensure staff (secretaries and nurses) on affected floors are aware of new list/shared drive

16. QI PROJECT EXAMPLE 2: FROM START TO FINISH Large population of caregivers at CHOC who use tobacco Large population of caregivers at CHOC who use tobacco If caregiver is interested in tobacco cessation Given a handout with contact info for SC DHEC tobacco cessation resource quitline Caregiver then has to initiate contact on their own by calling the number on the handout Many do not follow-up 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

17. What are we trying to accomplish? How will we know that a change is an improvement? Use e-referral to SC DHEC Tobacco Program Use e-referral to SC DHEC Tobacco Program Instead of handout Instead of handout Outcome Measure Outcome Measure Percent of e-referral caregivers who have continued follow-up with the SC DHEC smoking cessation program one month after the referral was made Percent of e-referral caregivers who have continued follow-up with the SC DHEC smoking cessation program one month after the referral was made Process Measure—Percent of caregivers for whom an e-referral to the SC DHEC smoking cessation program was made who can be successfully contacted at the one-month follow-up Process Measure—Percent of caregivers for whom an e-referral to the SC DHEC smoking cessation program was made who can be successfully contacted at the one-month follow-up Balancing Measure—Amount of time (in minutes/referral) that the residents spend making an e-referral Balancing Measure—Amount of time (in minutes/referral) that the residents spend making an e-referral Model for Improvement What change can we make that will result in improvement? QI PROJECT EXAMPLE 2: FROM START TO FINISH

18. PROJECT IMPLEMENTATION Get Buy in from those affected Residents in CHOC during the baseline data collection month Baseline Data Collection CHOC Clinic month (1 st year) Decide who will be collecting data How will residents notify the data collector when they have given a handout to a caregiver Who will be making the follow-up phone calls at the one month mark Collect names/contact info of caregivers given a handout with the SC DHEC smoking cessation hotline number Contact each caregiver one month later to determine what percent of caregivers have continued follow-up

19. Baseline Data Collection Primary Outcome MeasureProcess Measure Caregiver Caregivers Still Enrolled at 1 mo F/UAble to be Contacted at 1 mo F/U 1=Yes, 0=No 101 201 3 0 401 511 611 701 811 901 1001 11 0 1211 1301 1401 1501 Percent31%87%

20. Michael Mitchell Dr. Katie Stephenson CHOC Residents/Faculty Increase the one-month follow-up with smoking cessation services for caregivers of the patients of the Children’s Hospital Outpatient Center by 25% by March 31, 2016 The percent of e-referral caregivers who have continued follow-up with the SC DHEC smoking cessation program one month after the referral was made Percent of caregivers for whom an e-referral to the SC DHEC smoking cessation program was made who can be successfully contacted at the one-month follow-up Amount of time (in minutes/referral) that the residents spend making an e-referral Instead of giving caregivers a handout in clinic that has the SC DHEC smoking quitline number information and asking them to contact the number on their own, resident physicians in CHOC will utilize the SC DHEC electronic referral process for caregivers interested in smoking cessation

21. PDSA CYCLE 1 CHOC month of 1 st or 2 nd Year Make all parties aware of project and goals Make all parties aware of project and goals Residents/Attendings in CHOC that month Residents/Attendings in CHOC that month PLAN DO STUDY ACT PLAN DO STUDY ACT Remember to track all measures Outcome Measures Outcome Measures Percent of patients who have continued f/u with the SC DHEC smoking cessation program at the one month time mark Percent of patients who have continued f/u with the SC DHEC smoking cessation program at the one month time mark Process Measure Process Measure Percent of caregivers who could be successfully contacted at the one month time mark Percent of caregivers who could be successfully contacted at the one month time mark Balancing Measure Balancing Measure Amount of time (minutes/referral) it takes for a resident to complete an e-referral Amount of time (minutes/referral) it takes for a resident to complete an e-referral

22. PDSA Cycle 1 Primary Outcome MeasureProcess MeasureBalancing Measure Day Caregivers Still Enrolled at 1 mo F/UAble to be Contacted at 1 mo F/UTime to Make an E-referral 1=Yes, 2=No Min/Referral 1110.8 2111 3110.7 4011.2 5111.3 6 00.9 711 8111 9011.1 10110.9 11110.8 12110.9 13111 14010.6 15010.7 73%93%0.9 31%87%N/A 59%90%N/A 67%92%N/A PDSA 2 PDSA 3 Baseline

25. 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

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

27. 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

28. 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?

29. 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?

30. 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?

31. 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 findings mean?

32. QUESTIONS?

33. UPCOMING QI DEADLINES First Years Develop a timeline for implementation of the “Change” you will be making for your QI project Finalize Baseline data collection on your outcome measure Process and Balancing measures, if applicable Develop a timeline for data collection following implementation of the “Change” Second Years March 31, 2015 Complete collection of post-”Change” data April 2015 (Date TBA) Poster Presentation Lecture Friday, May 8, 2015 Turn in QI project write-up to me by midnight Friday, June 19, 2015 (730a – 9a) 3 rd Annual Resident QI Presentation Day July 2015 SCAAP Poster Presentations Pediatric Residency QI Website http://pediatrics.med.sc.edu/residency.asp