Implementing Continuous Quality Improvement (CQI) Programs to Improve Clinical Care

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Implementing Continuous Quality Improvement (CQI)
Programs to Improve Clinical Care

• Thomas Minior, MD/MPH
• Chief of Party,
• FXB-Guyana

5th CCAS Caribbean International HIV Workshop
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Outline

• Background
• What is CQI
• How to Perform CQI
• Audits
• Tools
• Results (The Guyana CQI Roll-Out)
• Summary
• Simple Steps to set up a Clinical CQI Program
• Demonstration of Efficacy

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Background

• HAART works
• Where we are in Guyana
• Between 2002-2006 there was a significant
  emphasis on rapid scale-up of antiretroviral care
  and treatment programmes
• Now that there is (reasonably) easy access to
  ART, the focus has shifted to ensuring the
  quality of services delivered
• Life expectancy for PLHIV is significantly
  improved with current therapies.
• Requires high-quality wholistic care to realize
  these life expectancies

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Introduction HIV Has become a treatable disease
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HIV and life-expectancy

• Large cohort studies demonstrate that 41 of HIV
  positive individuals died of illnesses not
  attributable to HIV.
• Based on these studies, predictive models were
  developed to derive life-expectancy tables and
  estimate the percent of patients who would die
  from comorbid diseases
• Cohort studies from US Europe
• Based on presence of medications from pre-2004
• Model validated using a separate cohort
• Survival was long
• For 30 year old patients with CD4gt500, median
  survival ranges from 26.8-31.3 years
• For 50 year old patients with CD4gt500, median
  survival ranges from 21.1-22.3 years
• This may improve with improving therapies

Estimates of Median Survival for a 30 Year Old Patient Diagnosed with HIV Estimates of Median Survival for a 30 Year Old Patient Diagnosed with HIV Estimates of Median Survival for a 30 Year Old Patient Diagnosed with HIV
CD4 Viral Load Survival (years)
800 10,000 31.3
100,000 23.7
1,000,000 17.2
500 10,000 26.8
100,000 21.2
1,000,000 14.6
200 10,000 21.9
100,000 18.1
1,000,000 12.2
Braithwaite, R, Justice, A, et al. Estimating
the proportion of patients with HIV who will die
of comorbid diseases. American Journal of
Medicine (2005) 118, 890-898.
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What Does all this Mean?

• HAART Works We can increase the life
  expectancies of patients substantially
• People with HIV are beginning to die from other
  diseases (cardiovascular disease, diabetes, liver
  disease, cancer, etc.)
• Some of these comorbidities can be caused by
  HAART, or by the HIV disease itself
• Therefore, we now need to monitor rigorously for
  clinical failure, ARV side effects and
  comorbidities and intervene to prevent them
• How can we ensure that we are doing this well?

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CQI Purpose and Rationale

• What is CQI?
• Why do it?

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Purpose and Rationale

• Nothing (or nobody) is ever perfect despite our
  best intentions, we all can make errors.
• Errors in hospitals/clinics can occur in
  different ways
• Doctors and Nurses sometimes forget or dont have
  enough time to do the things they plan
• Patients sometimes dont follow up as they should
• Unintended glitches occur in obtaining diagnostic
  and monitoring tests
• Clinics dont always function at their best which
  places stress on both doctors and patients

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Purpose and Rationale (2)

• CQI Processes are designed to get regular
  feedback to health care professionals about how
  well their actual practice is meeting the stated
  goals.
• With the feedback, those same health care
  professionals can change their practice habits or
  the way the clinic works to do better.

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What CQI is

• A process to set goals and receive feedback on
  how close we are to achieving those goals
• Team-oriented
• Concept of CQI originated in the business industry

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What CQI is not

• CQI is not meant to be an ME (monitoring and
  evaluation) system for outcomes.
• e.g. not to track how many people with Tb or HIV
• Only selects a sample of charts
• That said, it is meant to be an ME system for
  processes
• CQI should not be used as a punitive measure
• More important than how well or poorly we are
  achieving is how much we get better

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The CQI Process How CQI Works?
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CQI Steps Plan-Do-Study-Act

• Plan
• Plan what you are going to do, after you have
  gathered some evidence of the nature and size of
  the problem.
• E.g. Plan to treat patients using the national
  guidelines.
• Do
• Do it, preferably on a small scale first.
• Doctors and Nurses are treating patients with the
  guidelines in mind.
• Study
• Study the results. Did the plan work?
• CQI Audit
• Act
• Act on the results. If the plan was successful,
  standardise on this new way of working. If it
  wasn't, try something else

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Example

• PLAN
• The Ministry of Health sets standards and goals
  for patient care e.g. every PLWHA in care
  should be screened for Tuberculosis.
• DO
• These goals are then carried out at the clinic
  level e.g. Dr. Tom sees patients at Clinic X
  and writes prescriptions for PPD/Mantoux testing
  for new patients.
• Many things can happen along the way
• Dr. Minior can forget to give the prescription to
  some patients.
• Other patients may lose the prescription
• Still others may get the test, but be unable (or
  forget) to have it read.
• Some may have it read, but lose the result
• There may be stock outages, etc.

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Example

• STUDY
• Cant check every chart would take too long
• Check a random sample of 20 charts 8/20 (40)
  charts documented evidence of PPD testing.
• ACT
• Meet with clinic staff to discuss reasons why it
  didnt happen all the time.
• In 5 cases (25), Dr. Tom did not document
  requesting the test.
• In 7 other cases (35), the patient never
  followed up
• Clinic staff can then ask themselves how can we
  improve these numbers?
• Implement plans as needed (e.g. standing orders,
  stocking PPD, training outreach workers to read
  PPDs)

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Audits (Study)

• Take a sample of charts (or other document you
  are auditing e.g. lab forms)
• Two types of audits
• Random (gives the best overall picture)
• Sentinel events (based on a bad occurrence
  death, hospitalization, etc. gives a worst case
  scenario)
• Check these charts for the indicators you are
  looking for (e.g. blood pressure recorded)
• Provided we have sampled enough charts, this
  should gives a representative picture of how well
  (or not so well) we are doing

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Good Audits

• Random Samples are used in most all cases
• Sample enough charts
• The percent of charts needed is larger for small
  sites
• The percent of charts needed is smaller for
  larger sites
• Use standardized tool for all charts to collect
  data collect the same way for each chart

Rough Guide to Sampling Rough Guide to Sampling
Total Eligible Cases Total Minimum Size
50 or fewer 60 (30)
51-75 50 (36)
76-125 35 (38)
126-159 25 (40)
160-249 20 (41)
250-399 15 (50)
400-449 13 (58)
500-749 10 (63)
1000-4999 5 (70)
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Data Collection Tools

• Any standardized tool will do
• Many programs start with paper questionnaires
• Advantages
• Dont require computers
• Disadvantages
• Require photocopying
• Requires a second step of data entry before
  tabulating results
• Can also consider computerized methods
• Advantages
• Quick, easy analysis
• Instant results to review with staff while still
  fresh
• Disadvantages
• Usually requires computer software (e.g. Excel,
  Access)
• Typing errors can lead to mistakes must have
  secondary review

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Interpreting Results

• For the first time always emphasize that the
  first results dont necessarily reflect that one
  doctor or clinic is better than another
• Some clinics have sicker patients
• Some doctors have patients who have to travel
  further it may be harder for them to follow-up
• There is always some statistical variation, etc.
• The data can help us broadly identify issues that
  we can act on
• The most important thing is that the clinic
  improves in areas that did not reach the goal.

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Just Doing CQI can Leadto Better Results

• Guyana CQI Roll-Out
• A Look at Results and the Kind of Information a
  CQI Program can Generate

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Guyana CQI Roll-out
PARTICIPATING MOH CARE TREATMENT SITES
GUM Clinic
Campbellville Health Center
Dorothy Bailey Health Center
New Amsterdam (NAFHC)
West Demerara Regional Hospital
Linden-Wismar
Skeldon Hospital
Suddie Hospital

• Random selection of charts
• Standardized audit tool (list of questions)
  entered directly into Xcel database
• Reviews retrospectively assess care given in the
  last twelve months
• Four audit cycles
• 01 May 2006 30 April 2007
• 01 August 2006 31 July 2007
• 01 January 2007 31 Dec 2007
• 01 April 2007 31 March 2008

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CQI Indicators Examples

• Demographic Indicators
• Age
• Gender
• Patient visit history
• Has the patient been seen in the clinic in the
  last 3 months?
• Has the patient been seen in the clinic in the
  last 6 months?
• How many defaulted for over 6 months?
• Was the patients newly enrolled in the last 12
  mos?
• Is the patient taking HAART?

• Indicators on New Patient Care (patients who have
  newly enrolled in the last 12 months)
• Documentation of baseline physical examination,
  weight, height (for children), and blood pressure
• Baseline TB screening (Mantoux/PPD)
• Baseline WHO Clinical Stage
• Baseline Laboratory Testing
• HIV Antibody test or referral
• CBC
• LFTs Creatinine
• CD4 Cell count (or for children)
• Baseline CD4 value

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CQI Indicators Examples

• Indicators to Assess Everyday Care (these
  indicators are recorded for all patients the
  most recent visit is selected to provide a
  snapshot of ongoing care)
• Documentation of clinical care performed at the
  visit (physical exams, blood pressure, weight,
  height, etc.)
• Appropriate completion of chart documentation
• Documentation and recording of CD4 screening at
  least every six months
• Documentation of appropriate PCP (cotrimoxazole)
  prophylaxis
• TB screening (PPD/Mantoux)

• Indicators for Patients taking HAART
• Documentation of laboratory monitoring in
  accordance with the national guidelines
• CBC within the last three months
• LFTs within the last three months
• Creatinine within the last six months
• Documentation of an Adherence Assessment at the
  most recent visit
• For patients on second line HAART Documentation
  for a reason of switching (toxicity, failure,
  other, etc.)
• Improvement of the CD4 count since HAART
  initiation

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Sample Demographics Allow you to know if your
sample is representative
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Results for New Patients
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Snapshots of Everyday Care
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Results for Patients on HAART
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Summary

• Next Steps you can use

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Summary 1 General Thoughts

• A CQI Program can be an effective tool to both
  measure and improve the quality of clinical
  services
• A CQI Program need not be complex
• The PDSA (Plan-Do-Study-Act) Process is the
  underlying goal, but the CQI process itself
  just providing feedback to the multidisciplinary
  clinical team can lead to improved outcomes
• Data can be analyzed from two perspectives the
  clinic perspective and a national perspective
• The ultimate level is the clinic level
• Data from several clinics can be aggregated to
  create a national picture
• Regardless of which perspective, it is important
  not to focus on the actual value, but how we can
  make it even better

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Summary 2 Setting up a CQI Program

• Step 1 Make a list of indicators you would like
  to capture
• Having a set of policies or guideline to work
  from is helpful
• Keep the list simple to start you can always
  make it more complex as you get used to the
  process
• Step 2 Create the audit tool
• The audit tool is just a form on which to collect
  the data
• This can be done on paper or straight into the
  computer
• Phrasing indicators into Yes/No answers makes
  analysis simpler though isnt always necessary
• What happens if the CQI audit tool is not perfect
  when you start implementation?
• Dont worry about it! Just fix it next time
  through. Thats the point.

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Summary 2 Setting up a CQI Program (2)

• Step 3 Set up a sampling strategy
• Determine where you will audit and how many
  charts you will need. Use the guide
• Determine how often you will perform audits
• In general, every six months is adequate changes
  sometimes take 3-6 months before they can be seen
• When beginning, consider every 3 months this
  will help you and the clinic staff to get used to
  the process and work through any unforseen issues
• Determine who will implement the program Many
  times the person(s) creating the indicators/tool
  should be involved at the beginning

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Summary 2 Setting up a CQI Program (3)

• Step 4 Just Do it! Perform the audit using the
  audit tool
• Sometimes a small pilot with 5-10 charts can be
  helpful to see where simple unforeseen problems
  may arise
• These can then be corrected prior to full-scale
  implementation
• Step 5 Sit down with the clinical team to
  discuss
• Make the discussion non-judgemental
• Be sure to focus on strengths as well as
  weaknesses the first time
• Step 6 Repeat! (in __ Months)

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Summary 3 Expected Challenges and Next Steps

• Getting buy-in from multidisciplinary teams
• Transitioning the program entirely to the
  clinical staff
• Naturally this is additional work
• However, most staff appreciate receiving the
  regular feedback
• The amount of time clinical staff can be involved
  in the auditing process depends on how heavy the
  clinic workload is
• Incorporate indicators for all members of the
  clinical team
• Incorporate Patient Satisfaction (usually via a
  questionnaire or structured interviews)

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Demonstration ofClinical Efficacy
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Questions and Comments

• Please offer any thoughts or questions you may
  have. Thank you!