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Enhancing Quality Improvement for Patients ( Enhancing Quality Improvement for Patients (

Enhancing Quality Improvement for Patients ( - PowerPoint Presentation

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Enhancing Quality Improvement for Patients ( - PPT Presentation

EQuIP Equipping Louisiana with a Quality Future What is this and why do it Schoolwide initiative Engage residents and fellows in systemsbased quality improvement and patient safety QIPS ID: 593534

root analysis factors rca analysis root rca factors case mock projects improvement equip project performance principles review core patient process quality outcomes

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Slide1

Enhancing Quality Improvement for Patients (EQuIP)

Equipping Louisiana with a Quality Future.Slide2

What is this and why do it?

School-wide initiativeEngage residents and fellows in systems-based quality improvement and patient safety (QI/PS) projects.Neither fully top-down nor fully bottom-up.

Is this one of those ACGME things I have to do?Slide3

What you should do…

Check out hospital QI/PS committees to determine if you would like to join them.Examine your surroundings – how can we make the system better for patients?Work with your program to identify a project.

Each project should have tangible objectives and measurable outcomes.Slide4

EQuIP Projects – Core Principles

Residents and fellows are in a good position to know what needs improving.Improvement requires change.Watch out for unintended consequences.

Richard Tejedor, MD, “Performance Improvement Projects: Core Principles of Project Acceptability,” LSU QI Forum 2013.Slide5

EQuIP Projects – Core Principles

ImportanceHave you measured a performance gap?Will the project be high- or low-impact?Is an intervention likely to improve health outcomes or improve patient safety?

Richard Tejedor, MD, “Performance Improvement Projects: Core Principles of Project Acceptability,” LSU QI Forum 2013.

Scientific Acceptability

Does the evidence support the initiative?

Endorsed national initiatives are preferred.

Do you need IRB review?Slide6

EQuIP Projects – Core PrinciplesFeasibility (or, usability)

Is your plan actionable?Do you have measurable data elements?Should be routinely generated.Absolute performance

Unintended consequences

Is your intervention appropriate for all entities?

Race, sex, age, comorbid conditions, etc.

Concentrate on outcome measures rather than process measures.

Richard Tejedor, MD, “Performance Improvement Projects: Core Principles of Project Acceptability,” LSU QI Forum 2013.Slide7

Sample Projects

Comparison of pre- and post-operative med compliance after implementation of an instruction sheet for patients. Retrospective chart review to evaluate current guidelines for neutropenic fever.Gap analysis of current practice discovered no intervention was needed.

Autopsy Quality Assurance (

AQuA

): Correlating clinical diagnosis with autopsy results; improving physician awareness of autopsy procedures; decrease turn-around-time for autopsies at ILH.

Discovered significant gaps in provider knowledge regarding autopsies; implementing system changes to decrease turn-around-time (Ongoing).Slide8

Sample Projects

Less-ideal projects:e.g., Basic administrative functions with no impact on patient care or outcomes.Projects that do not track measurable patient outcomes.Enhancing medical knowledge – is it QI?

Patient education – when is it QI?Slide9

EQuIP Project Review Form

Completed for each EQuIP projectAvailable at: www.medschool.lsuhsc.edu/equipTurn in to EQuIP office (vharki@lsuhsc.edu)Document project goals – i.e. targeted patient outcomesAddresses IRB and hospital requirements

EQuIP facilitates communication.Slide10

Improvement MethodologiesSlide11

Improvement ToolsSlide12

Root Cause Analysis (RCA)

A review of the systems and process factors that contributed to a variance in performance (e.g. sentinel event).Does NOT focus on individual performance.Slide13

Root Cause Analysis (RCA)

Progress from special causes in clinical process to common causes in the organization.

Identify changes that could be made to reduce risk of event occurring again.

Repeatedly ask “Why?” to dig deeper and find out why things happened the way they did.Slide14

Root Cause Analysis (RCA)Thorough

Determine ALL factors most directly associated with event.Analyze underlying systems and processes through a series of “Why?” questions.

Identify risk points and determine what improvements could decrease likelihood of a repeat event.

Credible

Must include participation by organizational leadership and individuals most closely associated with the processes and systems under review.

Provide consistent explanations for all findings (including “no problem” or “not applicable”).

Review of any relevant literature.Slide15

Root Cause Analysis (RCA)

Action PlansProducts of RCAs – identify strategies that organization will implement to reduce the risk of similar events in the future.Names:Person(s) responsible for implementationTimeline for implementation

How effectiveness of intervention will be measured.Slide16

Root Cause Analysis (RCA) – Mock Case

49y.o. female.Mitral stenosis, pulmonary hypertension, atrial fibrillationPast history: asthma, hyperthyroidism, total hysterectomy 1992.

Meds:

Lisinopril

20mg daily; Coumadin 5mg daily; Lasix 20mg daily; Albuterol 2 puffs

prn

; Propranolol 80mg BID;

Propylthiouracil

50mg 3tabs 3x/day.

Admitted for mitral valve replacement and modified maze ablation for A-fib

Twenty-four

hours pre-op,

heparinized

Twelve

hours pre-op, ACT was greater than

1,000Slide17

Root Cause Analysis (RCA) – Mock Case

During procedure, pt had difficulty with ventilation (peak airway pressure >50)Endotracheal tube suctioned; aerosol nebs instilled directlyPt

started developing severe edema of the face, tongue and abdominal wall

Incision made in peritoneal cavity; large amount of ascites fluid evacuation

Benadryl, IV epinephrine and IV steroids administered.

Allergic reaction

suspectedSlide18

Root Cause Analysis (RCA) – Mock Case

Pulmonary: peak airway pressure evalCardiology: Transesophageal echo to inspect valves, which were found to be working well.

Pt

had evidence of left & right ventricular failure.

Intraaortic

balloon inserted into

rt

femoral artery; calcium and protamine administered and lungs

hyperinflated

.

Wound not closed primarily

Gortex

patch sewn circumferentially in wound using

Prolene

patch.Slide19

Root Cause Analysis (RCA) – Mock Case

Post-op: pt transferred to MICUHemodynamically compromisedConsultants: Pulmonary, Cardiology, Allergy, and Hematology.

No consensus of etiology

Treated with FFP, platelets, blood transfusions, epinephrine and steroids.

Condition continued to deteriorate.

Pt

pronounced at 6:11 p.m.Slide20

Root Cause Analysis (RCA) – Mock Case

What areas/services were impacted?

OR

MICU

Perfusion

Laboratory

Anesthesia

Pharmacy

Blood Bank

Nursing

Pulmonary

Cardiology

Allergy

Hematology

Quality Management

Risk ManagementSlide21

Proximate Factors

Common Cause Variation

Root Cause Analysis (RCA) – Mock Case

Special Cause VariationSlide22

Root Cause Analysis (RCA) – Mock CaseSlide23

Root Cause Analysis (RCA) – Mock Case

Why did it happen?(Proximate factors)

Process

What are the steps in the process?

What steps contributed?

Human factors

What human factors were relevant?

Equipment factors

How did equipment performance affect the outcome?

Controllable factors

What factors directly affected the outcome?

Uncontrollable external factors

Are these truly beyond the organization’s control?Slide24

Proximate Factors

Common Cause Variation

Root Cause Analysis (RCA) – Mock Case

Special Cause Variation

(

as appropriate

)Slide25

Root Cause Analysis (RCA) – Mock Case

Human Factors & Information Management – Continue to ask “why”Slide26

Root Cause Analysis (RCA) – Mock Case

Equipment Factors – Continue to

a

sk “why”

Cultural Factors – Continue to

a

sk “why”Slide27

Root Cause Analysis (RCA) – Mock Case

Uncontrollable Factors – Continue to

a

sk “why”

Wrap-Up:

What did we learn from this case?

What are the things we would do differently based on this case?

Action Plans for improvementSlide28

“Why?”Involvement by everyoneNo “shame and blame”Action plans developed

Root Cause Analysis (RCA) – Mock CaseSlide29

EQuIP - Why do it?It’s the right thing to do.

Our patients deserve this.Our residents and fellows need this.Improvement is its own reward.

Only through continued self-assessment will we improve.Slide30

Questions?

Director of EQuIPMurtuza (Zee) Ali, MD, FACC, FSCAI (email: mali@lsuhsc.edu)

EQuIP

Coordinator

Victoria Harkin, MA (Phone: 504.568.2593; email: vharki@lsuhsc.edu)