Lisa Knight MD Quality Improvement Lecture 3 February 27 2014 Lecture Outline Refresher on the Basics of a QI project SQUIRE guidelines Refresher on upcoming QI deadlines The IOM has proposed ID: 674528
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Slide1
Quality Improvement in Healthcare: Residency and Beyond
Lisa Knight, MDQuality Improvement Lecture 3February 27, 2014Slide2
Lecture Outline
Refresher on the Basics of a QI projectSQUIRE guidelinesRefresher on upcoming QI deadlinesSlide3
The IOM has proposed
6 specific aims for improvementHealthcare should be:
Safe
Effective
Patient-Centered
Timely
EfficientEquitable
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 characteristicsSlide4
How do we go about changing the system?
Plan
Do
Study
Act
5
-Step Process for Improvement
Select the opportunity for improvement
Study the current situation
Analyze the causes
Develop a theory for improvement
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
Present Situation
Ideal
FutureSlide5
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
apptSlide6
How do we go about changing the system?
Plan
Do
Study
Act
5
-Step Process for Improvement
Select the opportunity for improvement
Study the current situation
Analyze the causes
Develop a theory for improvement
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
Present Situation
Ideal
FutureSlide7
QI vs
ResearchResearch
Primary focus:
Generating new,
generalizable
scientific knowledge
Quality ImprovementPrimary focus:
Making care better at unique local sitesSlide8
Reporting Guidelines
Standardized guidelines have been developed for reporting the following:CONSORT – randomized controlled trialsSTARD – studies of diagnostic accuracy
STROBE – epidemiological observational studies
QUOROM – meta-analysis and systematic reviews of randomized controlled trials
MOOSE – meta-analysis and systematic reviews of observational studies
In 1999
SQUIRE guidelinesStandards for QUality I
mprovement Reporting Excellence
www.squire-statement.orgSlide9
SQUIRE Guidelines: Overview
TitleAbstractIntroductionMethodsResults
Discussion
ReferencesSlide10
Title
Needs to indicate that your project concerns the improvement of qualityNeeds to include the specific aim of the interventionExamples:
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
Decreasing Central Line Entries on the Children’s Cancer and Blood Disorders Unit: a collaborative, hospital-based quality improvement projectSlide11
Introduction
Background KnowledgeBrief summary of current knowledge of the problem being addressed
Characteristics of the organization in which the project is occurring
Local 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 significanceIntended ImprovementDescribes the specific change that will be made to result in improved careDescribes the specific AIM statement of the proposed intervention
Answers the questions:For whomHow big of a changeBy when
Why did you choose this problem and how are you going to address this problem?Slide12
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 importantSlide13
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 interventionSlide14
Methods
Planning the interventionDescribe the intervention in sufficient detail that others could reproduce it
Indicate main factors that contributed to choice of the specific intervention
Analysis of causes of dysfunction
Matching relevant improvement experience of others with the local situation
Outline initial plans for how the intervention was to be implemented
What is to be done (initial steps for implementation of the proposed change)By whom (intended roles)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
What did you do?Slide15
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 interventionSlide16
Central Line entry Data Collection form Slide17
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 dataSlide18
Results
Discuss changes in processes of care and patient outcomes associated with the interventionWritten descriptionGraphic representation
What did you find?Slide19
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 descriptionSlide20
Results: Example
Discuss changes in processes of care associated with the intervention: graphic representationSlide21
Results: Example (cont)
Discuss changes in processes of care associated with the intervention: graphic representationSlide22
discussion
SummarySummarize the most important successes and difficulties in implementing intervention components, and main changes observed in care delivery and clinical outcomesLimitations (if any)
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
Describe plans for monitoring and maintaining improvement
Conclusions
Consider overall practical usefulness of the interventionSuggest implications of your report for further studies of improvement interventions
What do the finding mean?Slide23
Questions?Slide24
Upcoming QI Deadlines
First Years
Feb 2014
Second QI Lecture
March 1, 2014
Choose QI topic
April 1, 2014Choose QI Faculty MentorMay 1, 2014Turn in completed Project Planning Document to me
Second Years
Feb 2014Second QI LectureMarch 31, 2014
Complete QI Project and collection of post-intervention dataApril 25, 2014 (12:15p to 1:15p)Poster Presentation LectureMay 21, 2014
Turn in QI project write-up to me
Pediatric Residency QI Website
http://pediatrics.med.sc.edu/residency.asp