ACGME Common Duty Hour Requirements II.A.4.j).(2): “The program director must monitor resident duty hours, according to sponsoring institutional policies, with a frequency sufficient to ensure compliance with ACGME requirements.”
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ACGME Common Duty Hour Requirements
II.A.4.j).(2): “The program director must monitor
resident duty hours, according to sponsoring institutional policies, with
a frequency sufficient to ensure compliance with ACGME
requirements.”
Duty Hours Dashboard AY 2012-2013
Components of a QI Project
The Nuts & Bolts
Objectives
• Define QI • Review models & tools • Practical Exercise
What is Quality Improvement?
QI is a systematic, formal approach to the analysis of:
• practice performance
• efforts to improve performance
Basics of QI
• Culture • Determine & prioritize potential areas for
improvement • Collect & analyze data • Communicate results • Commit to ongoing evaluation
Basics of QI
Culture
Areas of Improveme
nt
Collect & Analyze
Data Communicate Results
Commit to ongoing
evaluation
QI Models
• IHI’s Model for Improvement – TQM + Rapid Cycle Improvement (PCI) =
PDSA
• Lean Sigma – Lean + Six Sigma – Assess value of potential projects
QI Tools
• Run Charts • Process Maps • Fishbone Diagrams
MODEL FOR IMPROVEMENT (PDSA)
Institute for Healthcare Improvement (IHI)
Plan Act
Do Study
What are we trying to accomplish?
How will we know if a change is an improvement?
What changes can we make that will result in an improvement?
What do you want to know?
Duty Hours Report August, 2012
• 24+4: 1 report -> stayed after for 1 hr of admin û • Short Break: 3 reports < 8 hrs
– PGY-2 -> 4.5 hrs / 5.5 hrs -> Continuity delivery ü / û
– PGY-2 -> 4.5 hrs -> Continuity Delivery ü • Short Break: 21 reports < 10 hrs but > 8 hrs
– All on Inpatient Medicine – Team Short 1 member
80 Hrs
16 Hrs
24+4 Hrs Call Short
Break Day Off
Night Float
0 0 1 0 24(3) 0 0
What are we trying
to accomplish?
How will we know if a change is an improvement?
What changes can we make
that will result in an improvement?
Model for Improvement
• Setting Aims – Time-specific – Measureable – Specific population or
system
AIM: Reduce (eliminate?) short-break duty hour violations on the inpatient service within 30 days.
What are we trying
to accomplish?
How will we know if a change is an improvement?
What changes can we make
that will result in an improvement?
Model for Improvement
• Establishing Measures – Quantitative
MEASURES: Short-break duty hour violations.
What are we trying
to accomplish?
How will we know if a change is an improvement?
What changes can we make
that will result in an improvement?
Model for Improvement
• Selecting Changes
CHANGES: How do we know what changes to make?
Cue the tools…
Fishbone Diagrams
Process Maps
Run Charts
Run Charts
• Graph that displays data in a time sequence.
• Usually represents output or performance
DutyHoursReportAugust,2012
05101520
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31
InpatientCensus
0
1
2
3
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31
ShortBreakViolations
Flow (Process) Maps
Flow (Process) Maps Start / End
Action
Decision
Flow
Report Pre-round Morning Report Rounds
Admits (ER/Clinic) Procedure Inpt
Consult PM
Clinic
Tasking?
Procedure
Turnover
Go Home
Fishbone Diagrams (Cause & Effect)
Fishbone Diagrams (Cause & Effect)
Short Team Late day admits
New Interns High census
Duty Hr Violations
Inefficient
Late turnover time
One inpt team
Attrition
GMESB Awareness
Plan Act
Study Do
Plan Act
Do Study
Plan Act
Do Study Plan It
• Education – Resident/attending lecture
• Change turnover time – 1730 -> 1700 – NF 62.5 hrs -> 65 hrs (11 hrs out of hosp)
• Avoid short-manned teams early in AY
Plan Act
Do Study Try It
• Implemented for October 2012 • Monitored monthly
Plan Act
Do Study Observe It
Inpatient: Oct – 0; Nov – 2; Dec – 1
Plan Act
Do Study Act on it
• Any modifications to be made? • Mirrored approach for post-
continuity delivery duty hour violations
What now?
• Make small tweaks as needed – Continue PDSA cycle
• Small scale -> large scale • Spread change
Summary
• Good QI/PI requires a culture of support
• Structured approach
Website Recommendations • AAFP Basics of Quality
Improvement • IHI Science of Improvement • Making Every Minute Count: Tools
to Improve Office Efficiency (FPM, April 2005)
Thank you!
What are we trying
to accomplish?
How will we know if a change is an improvement?
What changes can we make
that will result in an improvement?
Model for Improvement
• Selecting Changes
What are we trying
to accomplish?
How will we know if a change is an improvement?
What changes can we make
that will result in an improvement?
Model for Improvement
Plan Act
Do Study
Plan Act
Do Study
Plan Act
Do Study
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