Quality Improvement

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Quality Improvement

• Nicole Paradise Black
• Lindsay Thompson
• Erik Black

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Why is QI Important?

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Improvements in quality translate to.

• Improved patient experience (more referrals)
• Expedited accounts receivable (more )
• Improved patient health (kinda important)
• Reduction in expenses (more )

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The goals of the QI process for you

• We are providing you with the tools and
  opportunity to learn how to conduct quality
  improvement projects
• You will utilize this skill for the rest of your
  career (whether informally or formally through
  MOC, aka maintenance of certification for the
  ABP).

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The Improvement Model
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PDSA- Plan? Do? Study? Act

• Plan
• Always includes a prediction
• Do--test the change
• Study
• Did my prediction hold?
• What assumptions need revision?
• Act
• Adapt
• Adopt
• Abandon

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PDSA
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PDSA cycles for testing

• Increase your belief that the change will result
  in improvement
• Opportunity for failures without impacting
  performance
• Document how much improvement can be expected
  from the change
• Learn how to adapt the change to conditions in
  the local environment
• Evaluate costs and side-effects of the change
• Minimize resistance upon implementation

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Aim Statements

• Answers the first question
• What are you trying to accomplish?

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Aim statements which one is the best?

• I will give a talk about how to do quality
• I will explain how to use the model for
  improvement
• By 2pm on 5/6/10, 75 of QI 101 participants will
  have completed SMART Aim statements.

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Aim statements which one is the best?

• I will give a talk about how to do quality
• I will explain how to use the model for
  improvement
• By 2pm on 7/26/09, 75 of QI 101 participants
  will have completed SMART Aim statements.

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SMART Aim statement

• A written statement of the accomplishments
  expected from teams improvement effort
• SPECIFIC
• MEASURABLE
• ACTION-ORIENTED
• REALISTIC and RELEVANT
• TIMELY

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Another example

• We will decrease the rates of bloodstream
  infection.
• We will implement the insertion and maintenance
  bundles as recommended by the CDC.
• We will decrease the rates of catheter-acquired
  blood stream infections for all PICU patients to
  less than 2/1000 device days by July, 2010.

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Learning structure

• A diagram that organizes the theory of
  improvement for a specific project.
• Connects the outcome (Aim), key drivers with
  measures design changes.

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• Learning Structure

Design changes, interventions
Key drivers
Aim
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Key drivers- critical issues

• Ideal evidence or data-based
• Important to revisit as you understand the
  project more
• By convention they should be stated in the
  affirmative

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Identifying key drivers

• If no evidenced or data-based drivers are known,
  ask
• What is necessary to achieve this aim?
• Consider the following
• Performance of a component of a system (e.g., MD
  fills out a form)
• An operating rule or value (e.g., RT owns asthma
  education)
• An element of system structure (e.g., real time
  data for discharge time failure)

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• Learning Structure

Design changes, interventions
Key drivers

• Hemostasis in holding room
• Extubate in holding room
• Rectal chloral hydrate if
• necessary

Finish Previous Case 1. Hemostasis bandage 2.
Extubation 3. Transfer pt to recovery

• Next patient ready
• Present
• Consents obtained
• Sedation given
• Transfer to cath lab

Call CCU early to transfer pt
Aim To decrease mean (and SD) time between
cardiac caths by 50 by Jan 1, 2010
Cath Lab Preparation 1. Clean lab 2. Clean
anesthesia equip 3. Table preparation 4. Computer
check list
Call Housekeeping early Call Anesthesia Tech early
Staff Readiness 1. Cath nurses 2. Radiology
tech 3. Cardiologists 4. Anesthesiologist
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Selecting an improvement idea to test- how to
gather data

• Process watch
• Flow chart
• Evidence/best practices
• Voice of the customer
• Brainstorming
• Change concept

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Change concepts vs. specific changes
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Measurement forQuality Improvement

• You cant improve what you cant (or dont)
  measure.
• Measures tell a team if the changes they make are
  making a difference.
• The team needs just enough data to tell if the
  change is making an improvement. Should speed
  improvement, not slow it down.
• Measurement is not the goal.

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Our take on QI

• Keep it simple, dont try to save the world
• Talk to the experts (fellow residents,
  attendings, nurses, other staff)
• Remember the scientific method

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That Scientific Method Thing

• Define the question
• Gather information and resources
• Form hypothesis
• Perform experiment and collect data
• Analyze data
• Interpret data and draw conclusions that serve as
  a starting point for new hypotheses
• Publish results

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An Example Back to sleep in the NICU

• Problem Based on limited analysis, a significant
  number of NICU patients are not being placed to
  sleep on their backs.
• Define Question
• Gather Information and Resources
• Form Hypothesis
• Perform Experiment/Collect Data
• Analyze Data
• Interpret Data
• Publish Results

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Low-touch Intervention
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Data Collection
PROJECT TIMELINE NICU EVALUATION - PRE PROJECT TIMELINE NICU EVALUATION - PRE PROJECT TIMELINE NICU EVALUATION - PRE PROJECT TIMELINE NICU EVALUATION - PRE PROJECT TIMELINE NICU EVALUATION - PRE PROJECT TIMELINE NICU EVALUATION - PRE PROJECT TIMELINE NICU EVALUATION - PRE PROJECT TIMELINE NICU EVALUATION - PRE PROJECT TIMELINE NICU EVALUATION - PRE
Task 10/1 10/3 10/5 10/7 10/10 10/12 10/14 10/16
EVAL 1 DAY 11am
EVAL 2 DAY 2pm
EVAL 3 DAY 9am
EVAL 4 - DAY WEEKEND
EVAL 5 NIGHT 9pm
EVAL 6 NIGHT 1am
EVAL 7 NIGHT 5am
EVAL 8 NIGHT WEEKEND

INTERVENTION INTERVENTION INTERVENTION INTERVENTION INTERVENTION INTERVENTION INTERVENTION INTERVENTION INTERVENTION
PROJECT TIMELINE NICU EVALUATION - POST PROJECT TIMELINE NICU EVALUATION - POST PROJECT TIMELINE NICU EVALUATION - POST PROJECT TIMELINE NICU EVALUATION - POST PROJECT TIMELINE NICU EVALUATION - POST PROJECT TIMELINE NICU EVALUATION - POST PROJECT TIMELINE NICU EVALUATION - POST PROJECT TIMELINE NICU EVALUATION - POST PROJECT TIMELINE NICU EVALUATION - POST
Task 11/1 11/3 11/5 11/7 11/10 11/12 11/14 11/16
EVAL 1 DAY 11am
EVAL 2 DAY 2pm
EVAL 3 DAY 9am
EVAL 4 - DAY WEEKEND
EVAL 5 NIGHT 9pm
EVAL 6 NIGHT 1am
EVAL 7 NIGHT 5am
EVAL 8 NIGHT WEEKEND
PROJECT TIMELINE NICU EVALUATION - POST PROJECT TIMELINE NICU EVALUATION - POST PROJECT TIMELINE NICU EVALUATION - POST PROJECT TIMELINE NICU EVALUATION - POST PROJECT TIMELINE NICU EVALUATION - POST PROJECT TIMELINE NICU EVALUATION - POST PROJECT TIMELINE NICU EVALUATION - POST PROJECT TIMELINE NICU EVALUATION - POST PROJECT TIMELINE NICU EVALUATION - POST
Task 12/1 12/2 1/1 1/2
EVAL 1 DAY Random
EVAL 2 NIGHT Random
EVAL 3 DAY Random
EVAL 4 - NIGHT - Random
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Analysis and Interpretation

• For each count number on back and total
  population.
• Chart Progress.
• Perform t-tests and compared day vs night shift,
  ANOVA of longitudinal results comparing months.
• Interpretation of data.

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Other forms of evaluation

• Focus groups (pre-post intervention) consider
  bias
• Questionnaires consider reasonable numeric
  significance
• Chart reviews (pre-post intervention) consider
  reasonable numeric significance

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Example of data measurement using a run chart

• Gather data
• Need a minimum of 12 points to establish a
  baseline.
• Need 20 25 points to detect meaningful patterns
• Create a graph
• Vertical scale (Y-axis) Measurement of interest
• Horizontal Scale (X-axis) Time or sequence
• Plot the data
• Calculate the centerline (median or mean)
• Annotate improvement interventions

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Run chart example CVL infections

• Staff care education
• CHG Scrub for care line and insertions
• Maximal sterile barriers

Max Cap introduced
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The Project Description Worksheet

• Due by September 1, 2010
• Mentor
• Project description (brief paragraph providing
  general idea of project)
• Initial Aim Statement (can be less specific than
  SMART Aim statement)
• Timeline (pre-implementation data gathering,
  implementation, post-implementation data
  gathering)

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The Project Description Worksheet

• Due by December 15, 2010 
• Pre-implementation data findings
• SMART Aim statement (specific, measurable,
  action-oriented, realistic/relevant, timely)
• Key Drivers (should be stated in the affirmative
  and list all key drivers even if you are not
  going to target them for change)
• Design Change(s)/Intervention(s)
•  Measure(s)

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The Project Description Worksheet

• Due by June 1, 2011
• Project is complete.
• Preparing for platform presentation or poster
  presentation to occur during that month.
• Project Description Worksheet, presentation and
  evaluation of project will be placed in your
  electronic portfolio.

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Remember

• Handing in stuff before deadlines is ALWAYS
  welcomed!
• If you are having trouble meeting a deadline,
  just let us know (we are understanding folks!)
• We love to see your faces, if youre stuck come
  and talk to us!