Quality Improvement in Healthcare: Residency and Beyond

QUALITY IMPROVEMENT IN HEALTHCARE:

RESIDENCY AND BEYONDLisa Knight, MD

Quality Improvement Lecture 3February 27, 2014

LECTURE OUTLINE

• Refresher on the Basics of a QI project• SQUIRE guidelines• Refresher on upcoming QI deadlines

THE IOM HAS PROPOSED 6 SPECIFIC AIMS FOR IMPROVEMENT

• Healthcare should be:• Safe

• Effective

• Patient-Centered

• Timely

• Efficient

• Equitable

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 careAvoiding waste of equipment, supplies, ideas, and energyProviding equal care regardless of personal characteristics

HOW DO WE GO ABOUT CHANGING THE SYSTEM?

Plan

Do

Study

Act

5-Step Process for Improvement1. Select the opportunity for

improvement2. Study the current situation3. Analyze the causes4. Develop a theory for

improvement5. 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?

AIMMEASURESCHANGES

Implement theImprovementStudy the

results

Establish a future plan

PLANDOSTUDYACT

PLANDOSTUDYACT

PLANDOSTUDYACT

Present Situation

IdealFuture

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 appt

HOW DO WE GO ABOUT CHANGING THE SYSTEM?

Plan

Do

Study

Act

5-Step Process for Improvement1. Select the opportunity for

improvement2. Study the current situation3. Analyze the causes4. Develop a theory for

improvement5. 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?

AIMMEASURESCHANGES

Implement theImprovementStudy the

results

Establish a future plan

PLANDOSTUDYACT

PLANDOSTUDYACT

PLANDOSTUDYACT

Present Situation

IdealFuture

QI VS RESEARCH

Research• Primary focus:

• Generating new, generalizable scientific knowledge

Quality Improvement• Primary focus:

• Making care better at unique local sites

REPORTING GUIDELINES

• Standardized guidelines have been developed for reporting the following:• CONSORT – randomized controlled trials• STARD – 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 guidelines• Standards for QUality Improvement Reporting Excellence

www.squire-statement.org

SQUIRE GUIDELINES: OVERVIEW

• Title• Abstract• Introduction• Methods• Results• Discussion• References

TITLE

• Needs to indicate that your project concerns the improvement of quality• Needs to include the specific aim of the intervention• Examples:

• 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 project

INTRODUCTION

• Background Knowledge• Brief 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

significance• Intended Improvement

• Describes the specific change that will be made to result in improved care• Describes the specific AIM statement of the proposed intervention

• Answers the questions:• For whom• How big of a change• By when

Why did you choose this problem and how are you going to address this problem?

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 important

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 intervention

METHODS

• Planning the intervention• Describe 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?

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 intervention

CENTRAL LINE ENTRY DATA COLLECTION FORM

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 data

RESULTS

• Discuss changes in processes of care and patient outcomes associated with the intervention• Written description• Graphic representation

What did you find?

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 description

RESULTS: EXAMPLEDiscuss changes in processes of care associated with the intervention: graphic representation

RESULTS: EXAMPLE (CONT)Discuss changes in processes of care associated with the intervention: graphic representation

DISCUSSION

• Summary• Summarize the most important successes and difficulties in implementing intervention components,

and main changes observed in care delivery and clinical outcomes• Limitations (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 intervention• Suggest implications of your report for further studies of improvement interventions

What do the finding mean?

QUESTIONS?

UPCOMING QI DEADLINES

First Years• Feb 2014

• Second QI Lecture• March 1, 2014

• Choose QI topic• April 1, 2014

• Choose QI Faculty Mentor• May 1, 2014

• Turn in completed Project Planning Document to me

Second Years• Feb 2014

• Second QI Lecture• March 31, 2014

• Complete QI Project and collection of post-intervention data

• April 25, 2014 (12:15p to 1:15p)• Poster Presentation Lecture

• May 21, 2014• Turn in QI project write-up to me

Pediatric Residency QI Website

http://pediatrics.med.sc.edu/residency.asp