Quality Improvement in Healthcare: Residency and Beyond - PowerPoint Presentation

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