Quality Improvement in Dementia Care

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Quality Improvement in Dementia Care

• Eleanor S. McConnell, PhD, RN
• modified from a presentation by Duke Geriatric
  Education Center faculty Chip Bailey, PhD,
  RN Emily Egerton, PhD Bob Konrad, PhD Mitchell
  Heflin, MD Deirdre Thornlow, PhD, RN, CPHQ
  Heidi White, MD

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What is Quality?

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Quality Definition

• Institute of Medicine (IOM)
• the degree to which healthcare services for
  individuals and populations increase the
  probability of desired health outcomes and is
  consistent with current professional knowledge of
  best practice.

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IOM Six Aims of Quality

• Patient-centered
• Efficient
• Effective
• Equitable
• Timely
• Safe
• Institute of Medicine (2001). Crossing the
  quality chasm A new health system for the
  twenty-first century, Washington DC National
  Academy Press

                              
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The Business Case for Quality
Despite spending 2 trillion annually on health
care services, American adults receive just half
of recommended care for the leading causes of
death and disability Similarly older adults,
receive only one-third of recommended care
delivered for geriatric conditions such as
dementia, falls, and urinary incontinence
Failure to follow best practices for AMI and
Stroke comprises more than 1.5 billion in
preventable hospitalizations per year
McGlynn EA, Asch SM, Adams J, et al. The quality
of health care delivered to adults in the United
States. N Engl J Med 2003 34826352645) (Ganz
DA, Wenger NS, Roth CP, et al. The effect of a
quality improvement initiative on the quality of
other aspects of health care the law of
unintended consequences? Med Care. 2007
45818). National Committee for Quality
Assurance, The State of Health Care Quality)
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Improvement Gap

• A substantial gap exists between what we know
  works and what is being done for patients.
• Real benefits accrue to patients, payers, and
  providers when inappropriate practice variations
  decline (Brent James)
• Standardization is the first step in ensuring
  quality improvement (Elizabeth McGlynn)

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Quality Improvement Steps

1. Identify Opportunity for Improvement
2. Select Team
3. Choose Improvement Model
4. Apply Quality Improvement Tools
5. Implement Solutions
6. Sustain Gains

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QI Model FOCUS PDSA

• Find an opportunity to improve
• Organize a team that knows the process
• Clarify current knowledge of the process
• Understand causes of process variation
• Select the process improvement strategy
• Plan the improvement
• Do it!
• Study PI data / results
• Act to hold gain /continue to improve

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Step 1 Find an Opportunity to Improve

• Issue should be
• Data-driven (where do the data tell you to
  focus?)
• Clinically relevant
• Prevalent (large numbers of patients affected)
• Fixable (feasible)
• Measurable
• Amenable to an interdisciplinary approach
• Often driven by consumers, payors, regulators
• CMS Quality Indicators http//www.hospitalcompare.
  hhs.gov
• Joint Commission National Patient Safety Goals
• www.jointcommission.org
• Challenge in dementia what quality indicators
  exist?

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Challenge in Dementia Care What Quality
Indicators Exist?

• March 2013 -- National Quality Forum endorsed
• 2091 Persistent indicators of dementia without a
  diagnosislong stay (American Medical Directors
  Association)
• 2092 Persistent indicators of dementia without a
  diagnosisshort stay (American Medical Directors
  Association)
• 2111 Antipsychotic use in persons with dementia
  (Pharmacy Quality Alliance)
• http//www.qualityforum.org/News_And_Resources/Pre
  ss_Releases/2013/NQF_Endorses_Additional_Neurology
  _Measures.aspx

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Challenge in Dementia Care What Quality
Indicators Exist?

• Healthy People 2020 Indicators
• DIA-1     (Developmental) Increase the proportion
  of persons with diagnosed Alzheimers disease and
  other dementias, or their caregiver, who are
  aware of the diagnosis
• DIA-2     (Developmental) Reduce the proportion
  of preventable hospitalizations in persons with
  diagnosed Alzheimers disease and other
  dementias
• Source http//www.healthypeople.gov/2020/topicsob
  jectives2020/objectiveslist.aspx?topicId7

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Percent of Long-stay Nursing Home Residents who
Received an Antipsychotic Medication (lower is
better)
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The big picture

• Antipsychotic Use is Being Targeted for Reduction
  by CMS
• Indicator of quality
• Increased risk of death, morbidity
• A target for improvement
• A way to reduce costs????

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Decision

• Based on its national significance, available
  data, patient interviews, and recent studies
  highlighting its importance, your team decides to
  focus on reduction of antipsychotic use in
  persons with dementia.

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Clinical Scenario

• Your team wants to set up a meeting to plan
  their next steps.

Who should you invite?
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Step 2 Organize QI Team

• Stakeholders
• Implementers
• Opinion Leaders
• The loud-mouthed nay-sayer

• Technical expert(s)
• Day to Day Champion
• Leadership

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Step 3 Clarify Current Practice

• Flowcharting
• identify the flow or sequence of events in a
  process
• Shows where simplification and standardization
  may be possible
• Helps to identify improvement opportunities
• Identifies areas for data collection and analysis
  (trending)

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FLOWCHART SYMBOLS

• OVAL denotes beginning and ending
  of process
• SQUARE describes specific
  function or activity
• DIAMOND yes/no decision point
• ARROW direction of steps in a process

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Source Gitlin, L et al., JAMA 2012
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• Review/project your flow diagram

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Step 3 Clarify Current Practice

• Measure Current Practice - Keep it simple!
• Select Measures
• Reliable, valid
• Balanced
• Structure, process and outcome
• Feasible / practical (already being collected)
• Standardized (benchmark)

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Reasons for antispsychotic use?

• Pareto Chart
• 80/20 rule
• 80 of the occurrences come from 20 of causes
• Used to separate the vital few
• Graphically illustrates the priority or frequency
  of data

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Benchmarking

• Benchmarks
• Key metrics
• Internal and external comparisons
• Best practices
• Issues
• Selection bias, Risk adjustment
• ABCs Achievable Benchmark of Care
• Examine top 10 of comparable organizations
• 10-25 of your effort Find peers by comparing
  outcomes
• 75- 90 of your effort Examine process

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Clinical Scenario

• You have chosen to focus on the reduction in
  antipsychotic use and wish to know your current
  performance..

How should you proceed?
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Step 4 Understand Causes of Variation

• Improvement is never an accident. Every process
  performs exactly how it was designed to perform.
• Understand Variation in Antipsychotic use in
  dementia
• Control chart trended run charts
• Random vs common cause variation
• Cause Effect / Fishbone diagram
• Identify root causes / contributing factors

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Sources of Variation People Education, OJT
Payment Equipment and Materials Malfunction,
new equipment Policies Process Procedures Envi
ronment Staffing, interruptions
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Fishbone Diagram
People
Policies
Interqual std
Knowledge Skills
HIPAA
Values
APS rules
Factors and/or categories of factors
DementiaWoes
Factor
Handoffs
Factor
Factor
Procedures
Payment
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Exercise
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Step 5 Select an Intervention

• What changes can we make that will result in an
  improvement?
• How can we make changes in the real world
  setting?
• Select feasible, practical, cost-effective,
  measurable improvements
• Anticipate barriers and facilitators to
  implementation
• Identify Best Practices
• Dont reinvent the wheel
• Select evidence-based interventions
• Use examples from other organizations and
  providers

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Priority Matrix Selecting the Intervention
  Fig. 1. Example Prioritization Matrix
http//syque.com/quality_tools/toolbook/Priority/e
xample.htm
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Priority Matrix Exercise
Suggested Improvement Volume/ Importance Feasibility Measurability Affordability Total Points



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Step 6 Plan, Do, Study, Act

• What are we trying to accomplish?
• How will we know that a change is an improvement?
  
• What changes can we make that will result in
  improvement?
• How can we make changes in the real world
  setting?

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Step 6 Plan, Do, Study, Act (Implement in Baby
Steps)

• Plan What small change can you make by next
  Tuesday?
• Eg. Try collecting data on antipsychotic use on
  2 patients this week.
• Do Just do it!
• Study How long did it take? Did everyone do
  their part? Problems?
• Any improvement?
• Act Revise and retest, or move on to next baby
  step. How can this process be improved further?

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Plan, Do, Study, Act (Implement in Baby Steps)
Now start developing form and process for
tracking behaviors
Provide more staff training, Revise form, reassess
What medication problems were missed?
Does staff understand how to use the form?
Try assessment form with 3 new patients
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Healthcare Quality Organizations

• American Society for Quality (ASQ)
• Healthcare division
• Institute for Healthcare Improvement (IHI)
• Joint Commission (JC)
• National Association for Healthcare Quality
  (NAHQ)
• National Committee for Quality Assurance (NCQA)
• National Quality Forum (NQF)
• Agency for Healthcare Research Quality (AHRQ)

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QI Resources

• IHI resources http//www.ihi.org/IHI/Topics/Improv
  ement/ImprovementMethods/HowToImprove/testingchang
  es.htm
• AHRQ Resources http//www.qualitymeasures.ahrq.
  gov/
• http//www.qualitytools.ahrq.gov/
• QIO Resources
• http//www.medqic.org http//www2.thecaroli
  nascenter.org/ncqic/public/home.aspx
• CDC Resources http//www.cdc.gov
• http//apps.nccd.cdc.gov/brfss/index.asp
• Care Transitions
• http//www.caretransitions.org/mdt_main.asp