Healthcare Quality and Improvement

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Healthcare Quality and Improvement

• A Primer

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Part 2

• Review key concepts
• Move on to other QI methods
• Discuss project development
• Research vs. QI
• National patient safety goals
• Joint commission

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Objectives

• Quality problems in health care
• Define quality
• Who, what, why and how of quality improvement
• Tools and methods
• Key elements of a good QI project
• Quality improvement vs.. research
• QI project development
• National Patient Safety Goals
• Joint Commission

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Defining Quality

• Quality is
• A systems-wide issue
• An individual performance issue rarely
• Quality is a team sport

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Quality at CMHHow informed are you?

• Rate of compliance with hand washing?
• 90
• Central line infection rate?
• 1.2/1000 cath days-PICU
• of codes outside the PICU?
• 50
• of inpatients with medication reconciliation
  performed?
• 70

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Quality Improvement

• A process of innovation and adaptation designed
  to bring about immediate positive changes in the
  delivery of health care in particular settings
• systematic
• data-guided
• multidisciplinary

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Quality Improvementand Data

• Use data for learning, not judging
• Generate light, not heat
• Use data to report system attributes
• Use aggregate not individual data
• Do not report data on individual performance

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Improvement MethodsA brief overview

• Model for Improvement
• Lean
• Six Sigma
• Trigger tools

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Model for Improvement

• Flexible improvement framework
• IHI
• PDSA methodology
• Emphasizes
• Aims and measures
• Initial small tests of change
• Widespread testing
• Implementation and spread

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Improvement Methods

• What is LEAN?
• What is Six Sigma?
• Identify a trigger tool

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Lean

• Management philosophy based on 2 key themes
• Continuous elimination of waste
• Respect for people and society
• Key principles
• Value is in the eyes of the customer
• Make value flow without interuptions
• Improve work flow
• Standardize work processes
• Pursue perfection

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Lean

• Culture
• Stop and fix the problem as soon as it is
  identified
• Toyota manufacturing culture
• Process
• Measure
• Change
• Measure
• Change..

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Lean ProjectImprove ED Patient Flow

• Project aim-reduce ED LOS by 50
• Process improvements(reduce waste)
• Work standards and evidence-based clinical
  practice guidelines for all ED staff defined
• Batching of orders eliminated
• Right supplies and equipment in the right place
  eliminated unnecessary SE
• Admission process streamlined
• Results
• Reduced ED LOS for discharges by 23
• Reduced ED LOS for admissions by 20

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Lean What is waste in medicine?

• Surgical infection
• Preventable adverse drug events
• Ventilator assisted pneumonia
• Equipment failure
• Waiting and lack of flow
• Inadequate training or orientation
• Unnecessary or poorly designed processes
• Not following evidence based practices

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Six Sigma

• Focus is to eliminate defects
• Nonconformity of a product or service to its
  specifications
• Six sigma processes have variation that result in
  lt3.4 parts/million defects

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Why Zero Defects is the Only Acceptable Quality
Standard

• At 99.9 quality levels in a 250 bed hospital
• 12 inpatients per year would die due to errors
• 6 day surgery patients would die
• 9,742 wrong medications would be delivered
• 4,923 incorrect laboratory tests would be
  reported
• 502 incorrect radiographs would be completed

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Six Sigma

• Systematic and scientific management approach to
  reduce sources of process variation and improve
  reliability
• Customer and financially focused
• Strategic
• Uses project management concepts
• Strong statistical focus
• Focus on mistake-proofing
• Requires rigorous professional training

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Six Sigma ProjectReducing Hospital-Acquired
Pressure Ulcers

• 5 structured project phases
• Define
• Measure
• Analyze
• Improve
• Control

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Trigger Tools

• Method for identifying adverse events (harm) and
  measuring the rate of adverse events over time
• Method options
• Retrospective review of a random sample of
  patient records using triggers (clues)
• Prospective surveillance of electronic patient
  records
• Goal-to identify areas for improvement and
  prevent harm

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Trigger Tools Your medical world

• Are there triggers that could be used in your
  specialty to identify areas of potential patient
  harm?

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Root Cause Analysis

• Process to identify causal factors for variation
  in performance learning from consequences
• Systems and processes focus
• Individual performance not a focus
• Identifies potential improvements to reduce
  likelihood of future event
• Used in MM process, sentinel event investigations

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Fishbone Diagram
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Failure modes and Effects Analysis (FMEA)

• Prospective technique
• Systematic assessment to
• Prevent problems before they occur
• Reduce the chance of unintended adverse harm if
  they occur
• Used for high risk procedures or error prone
  processes

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Now its your turn!

• Form groups of 4-5 team members
• Pick one of the following aims
• !00 of all requests for physician consultation
  include a verbal discussion between the physician
  requesting the consult and the physician
  receiving the request
• Reduce errors during patient care handoffs sign
  out, transfer to another service, etc (right info
  at the right time, distractions, templates, etc)
• Reduce variation in practice for management of
  __________ by implementing evidence based
  practice standards
• You decide_______________________________
• Be prepared to present your plan

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Now its your turn!

• Develop a plan to achieve the aim
• Whos on the team?
• Responsibilities and roles
• Improvement methods
• Timelines
• Identify outcome and balancing measures
• Identify data needed to assess improvement
• and sources of data

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Now its your turn!

• Share the projects you have done or are developing

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Improvement project ideas

• Care process changes
• Hand offs
• Scheduling
• Medication reconciliation
• Implementation of new clinical or administrative
  practices
• Practice standardization

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Central Line InfectionsDefining the problem

• 15 million central venous catheter-days per year
  in ICUs
• Attributable mortality for these infections 4-
  20
• Bloodstream infections prolong hospitalization by
  a mean of 7 days 

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Central Line InfectionsStating the project aim

• Reduce central line infection rate to 0 in the
  ICU in 12 months

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Central Line InfectionsPractice Standardization

• Hand Hygiene
• Maximal Barrier Precautions upon insertion
• Chlorhexidine skin antisepsis
• Optimal catheter site selection, with Subclavian
  Vein as the preferred site for non-tunneled
  catheters
• Daily review of line necessity with prompt
  removal of unnecessary lines

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Central Line InfectionsPractice Standardization
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Quality ImprovementKey elements

• Systematic
• Data-guided and knowledge informed
• Experiential
• Innovative
• Employs formal explicit methodology
• Continuous
• Core responsibility of healthcare professionals

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Quality Improvement Work

• Focused on systems
• Team oriented
• Requires team skills
• Collaboration
• Meeting skills
• Value all perspectives
• Develop local new useful knowledge to inform
  health care processes

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Quality Improvement vs. ResearchIts
Complicated.

• QI
• Systematic data-guided activities designed to
  bring about immediate positive changes in
  healthcare delivery in local practice settings
• An integral part of the ongoing healthcare
  delivery system
• A form of clinical and managerial innovation and
  adaptation
• Combines discipline specific knowledge with
  experiential learning and discovery

• Research
• A systematic investigation designed to develop or
  contribute to generalizable new knowledge
• Implementation of research is a separate process
  and occurs later, if at all
• A knowledge seeking enterprise that is
  independent of routine medical care

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Hastings Report
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Quality methods and terms

• _5_Sentinel event 1. a tool which uses clue to
  identify a possible adverse event
• _8_Never event 2. an improvement method driven by
  statistical analysis of data to identify unwanted
  defects and variation
• _9_PDSA 3. a tool used to systematically
  identify all factors that may have contributed to
  an adverse situation
• _6_LEAN 4. unintended injury from medical care
  that requires additional treatment or
  monitoring or results in death
• _2_Six sigma 5. an unexpected occurrence
  involving death, serious injury or the potential
  for serious injury
• _11_Root Cause An. 6..an improvement method
  focused on eliminating waste through analysis of
  workflow
• _3_Fishbone diagram 7. a prospective process
  which uses a systematic assessment to identify
  and prevent potential problems
• _7_FMEA 8. an event that is reasonably
  preventable e.g. pressure ulcer, hemostat left
  in patient during surgery
• _4_Harm 9. a process used in the Model for
  Improvement to test changes
• _1_Trigger tool 10. an error
• _12_Action plan 11.a retrospective assessment of
  an adverse situation that has occurred
• _10_Adverse event 12. a plan developed to address
  deficiencies identified during a root cause
  analysis

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Questions?
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Joint Commission

• Accrediting organization for healthcare
  institutions
• Sets administrative and practice standards and
  evaluates compliance
• Performs unannounced on-site surveys of
  accredited hospitals to assess compliance every
  18-39 months

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Joint CommissionMission

• To continuously improve the safety and quality of
  care provided to the public through the provision
  of health care accreditation and related services
  that support performance improvement in health
  care organizations

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National Patient Safety Goals

• Key national safety goals for hospitals
• Set by Joint Commission
• Updated yearly
• Goal is to promote specific improvements in
  patient safety

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2008 NPSG

• Goal 1 Improve the accuracy of patient
  identification.
• 1A Use at least two patient identifiers when
  providing care, treatment or services.

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2008 NPSG

• Goal 2 Improve the effectiveness of communication
  among caregivers.
• 2A For verbal or telephone orders or for
  telephonic reporting of critical test results,
  verify the complete order or test result by
  having the person receiving the information
  record and "read-back" the complete order or test
  result.
• 2B Standardize a list of abbreviations, acronyms,
  symbols, and dose designations that are not to be
  used throughout the organization.

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2008 NPSG

• Goal 2 Improve the effectiveness of communication
  among caregivers.
• 2C Measure and assess, and if appropriate, take
  action to improve the timeliness of reporting,
  and the timeliness of receipt by the responsible
  licensed caregiver, of critical test results and
  values.
• 2E Implement a standardized approach to hand
  off communications, including an opportunity to
  ask and respond to questions.

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2008 NPSG

• Goal 3 Improve the safety of using medications.
• 3C Identify and, at a minimum, annually review a
  list of look-alike/sound-alike drugs used by the
  organization, and take action to prevent errors
  involving the interchange of these drugs.
• 3D Label all medications, medication containers
  (for example, syringes, medicine cups, basins),
  or other solutions on and off the sterile field.
• 3E Reduce the likelihood of patient harm
  associated with the use of anticoagulation
  therapy.

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2008 NPSG

• Goal 7 Reduce the risk of health care-associated
  infections.7AComply with current World Health
  Organization (WHO) Hand Hygiene Guidelines or
  Centers for Disease Control and Prevention (CDC)
  hand hygiene guidelines.
• 7B Manage as sentinel events all identified cases
  of unanticipated death or major permanent loss of
  function associated with a health care-associated
  infection

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2008 NPSG

• Goal 8 Accurately and completely reconcile
  medications across the continuum of care.
• 8A There is a process for comparing the patients
  current medications with those ordered for the
  patient while under the care of the organization.
• 8B A complete list of the patients medications
  is communicated to the next provider of service
  when a patient is referred or transferred to
  another setting, service, practitioner or level
  of care within or outside the organization. The
  complete list of medications is also provided to
  the patient on discharge from the facility.

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2008 NPSG

• Goal 9 Reduce the risk of patient harm resulting
  from falls.
• 9B Implement a fall reduction program including
  an evaluation of the effectiveness of the program.

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2008 NPSG

• Goal 13 Encourage patients active involvement in
  their own care as a patient safety strategy.
• 13A Define and communicate the means for patients
  and their families to report concerns about
  safety and encourage them to do so.

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2008 NPSG

• Goal 15 The organization identifies safety risks
  inherent in its patient population.
• 15A The organization identifies patients at risk
  for suicide.

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2008 NPSG

• Goal 16 Improve recognition and response to
  changes in a patients condition.
• 16A The organization selects a suitable method
  that enables health care staff members to
  directly request additional assistance from a
  specially trained individual(s) when the
  patients condition appears to be worsening.

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Quality ImprovementKey elements

• Systematic
• Data-guided and knowledge informed
• Experiential
• Innovative
• Employs formal explicit methodology
• Continuous
• Core responsibility of healthcare professionals

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Healthcare Quality Improvement2007

• Move from cottage industry mode of care delivery
  to data driven system model of healthcare
  delivery
• Systems approach
• Individual blame not the norm
• Individual IS accountable