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
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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)