Developing an Integrated
Quality Management System
Quality Forum
Feb 28, 2013
Claire Mackelson M.Sc
Coordinator, Implementation & Evaluation
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
6
• 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
7
• 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…
10
CSF #6 : Reporting
CSF #6: Reporting
11
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)
14
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