C1 Clair Mackelson - Developing an Integrated Quality Management System

Developing an Integrated

Quality Management System

Quality Forum

Feb 28, 2013

Claire Mackelson M.Sc

Coordinator, Implementation & Evaluation

[email protected]

Disclosure

Critical Success Factors (CSF)

1. Stakeholders

2. Knowledge

3. Information Systems

4. Tools & Templates

5. Quality Indicators

6. Reporting

7. Quality Improvement Activities

8. Structure

3

4

CSF #1: Stakeholders

Quality, Research &

Safety

BC Ambulance

QI & Crews

Emergency

Department s

Cardiac Units /

Labs

Quality Committee

Chairs

Intensive Care

Units

Clinical Information

Support

Patients &

Families

IMIT

Infection Prevention &

Control Practitioners

OR & PARR

Acute

Interventional

Services Anesthesia

Pharmacy

Performance

Monitoring

Heart IS team

Continuing

Professional

Development

Risk

Management

Medical

Records

5

CSF #2: Knowledge

Canadian Cardiovascular Society http://www.css.ca

Accreditation Canada (ROPs, Standards)

BC Patient Care Quality Review Board Act

BC Patient Safety & Quality Council http://www.bcpsqc.ca

Canadian Patient Safety Institute www.patientsafetyinstitute.ca

Institute of Healthcare Improvement http://www.ihi.org

VIHA Quality, Research & Safety Strategic Plan (2012)

VIHA Incident Report Policy

Section 51 BC Evidence Act (1996)

BC Freedom of Information & Protection of Privacy Act

Critical Incident Analysis Framework (CPSI, 2012)

Cycle of Improvement (Shewhart, 1939 & Deming, 1950’s)

CSF #3: Information Systems

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• BC Cardiac Registry, HEART IS

• VIHA Data Abstract Database & IDEAS

• Heart Health Safer Healthcare Now Access Database,

HFC/CR Access database

• AIS Section 51 Shared Drive, HH Quality Management

SharePoint, VIHA CQC Case Review Registry

• BC Patient Safety Learning System

• Cerner , NSQIP

• Cardiac Patient System (AFC/ICD/EP), MacLab /

CardioLab (GE Medical), Paceart, Xcelera

• MUSE, Holter systems (GE Medical, Philips, North east

monitoring - depending on site)

CSF #4: Tools & Templates

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• 20+ Data Report Templates e.g. readmissions within 30

days, complications, infections, mortality…

• ‘How-to-Guides’ on establishing / running /participating

in a local quality committee meeting

• Terms of Reference for local quality committees &

program quality councils aligning with organizational ToR

• Electronic Quality Review Form – based on CPSI

Canadian Incident Analysis Framework. Established

review criteria drives in-depth quality reviews.

• Electronic Quality Review Tracking Log – Collates

and tracks data from quality reviews including

recommendations, status of implementation

8

CSF #4: Tools (cont)

Program Quality Council

Prioritization of which indicators

should be monitored continuously,

periodically or on a random basis

9

CSF #5: Quality Indicators

Patient Satisfaction

AMI Readmissions

within 30-days

Ablation (for AF)

Readmissions within

30-days

CABG

Readmissions within

30-days

AMI Mortality

within 30-days

Heart Failure (all

cause) Readmissions

within 30-days

Surgical Site

Infection

Rates - CABG Surgical Site

Infection

Rates - valves

EMS to

Reperfusion

Post-procedural

complications - HCL

Post-procedural

complications - EP

ED Triage to

Initial ECG

PCI cases with

CABG within 2-days

PSLS incidents

& 50+ more…

Know your audience…

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CSF #6 : Reporting

CSF #6: Reporting

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CSF #6: Reporting (cont)

12

13

0% 20% 40% 60% 80% 100%

Num

ber

of P

atie

nts

(%)

Mode of Patient Transport to Hospital Affects Timeliness of Treatment

Ambulatory

PCP

ACP

ED Triage to TNK = 37 minutes

ED Triage to TNK = 30 minutes

ED Triage to TNK = 15 minutes

CSF #6: Reporting (cont)

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CSF #6: Reporting (cont)

2008 2009 2010Apr -Jun

2011

Jul -Sept2011

Oct -Dec

2011

Jan -Mar2012

Apr -Jun

2012

Jul -Sept2012

Oct -Dec

2012

911 to Reperfusion 116 120 113 98.5 87.5 106 96

EMS to Reperfusion 109 110 105 82 76.5 97.5 85

ED Triage to Reperfusion 104 116 84 79 82 66 72 91 68 72

0

20

40

60

80

100

120

140Ti

me

(M

inu

tes)

EMS -2-Reperfusion

Goal for Primary PCI

centre: 90 minutes

15

CSF #7: Quality Improvement Activities

16

CSF #8: Structure

Site-selective

interactions of MeOH

with η-alumina

McInroy, Lundie, Winfield, Dudman, Jones, Lennon, 2005

17

Thank You

Questions?

[email protected]