Quality Improvement
Nicole Paradise Black
Lindsay Thompson
Erik Black
Why is QI Important?
$$$
Improvements in quality translate to….

Improved patient experience (more referrals)

Expedited accounts receivable (more $$$)

Improved patient health (kinda important)

Reduction in expenses (more $$$)
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).

The Improvement Model
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?
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
PDSA
• Act
• Plan
What changes
are to be
made?
Next cycle?
• Study
Complete analysis
of the data
• Compare data to
predictions
• Summarize
what was learned
Objectives
• Questions and
predictions (why)
• Plan to carry out
the cycle (who,
what, where, when)
Carry out the plan
• Document problems
& unexpected
observations
• Begin analysis
of the data
• Do
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

Aim Statements
Answers the first question:
What are you trying to accomplish?
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.

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.

SMART Aim statement

A written statement of the
accomplishments expected from
team’s improvement effort
◦
◦
◦
◦
◦
SPECIFIC
MEASURABLE
ACTION-ORIENTED
REALISTIC and RELEVANT
TIMELY
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.

Learning structure
A diagram that organizes the “theory of
improvement” for a specific project.
 Connects the outcome (Aim), key drivers
with measures & design changes.

Learning Structure
Key drivers
Aim
Design changes,
interventions
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

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)
Learning Structure
Key drivers
Finish Previous Case
1. Hemostasis & bandage
2. Extubation
3. Transfer pt to recovery
Aim
To decrease mean (and
SD) time between
cardiac caths by 50% by
Jan 1, 2010
Next patient ready
1. Present
2. Consents obtained
3. Sedation given
4. Transfer to cath lab
Cath Lab Preparation
1. Clean lab
2. Clean anesthesia equip
3. Table preparation
4. Computer & check list
Staff Readiness
1. Cath nurses
2. Radiology tech
3. Cardiologists
4. Anesthesiologist
Design changes,
interventions
•Hemostasis in holding room
•Extubate in holding room
•Rectal chloral hydrate if
necessary
Call CCU early to transfer
pt
Call Housekeeping early
Call Anesthesia Tech early
Selecting an improvement idea to
test- how to gather data
Process watch
 Flow chart
 Evidence/best practices
 Voice of the customer
 Brainstorming
 Change concept

Change concepts vs. specific
changes
Vague, strategic,
creative
Improve process to
reduce anxiety
Provide families with freedom to
leave waiting room
Use beepers for family and
friends waiting
Specific actionable results
Make beepers available
to sample of families
next week
Measurement for
Quality Improvement
You can’t improve what you can’t (or
don’t) 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.

Our take on QI

Keep it simple, don’t try to save the world

Talk to the experts (fellow residents,
attendings, nurses, other staff)

Remember the scientific method
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
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.
1.
2.
3.
4.
5.
6.
7.
Define Question
Gather Information and Resources
Form Hypothesis
Perform Experiment/Collect Data
Analyze Data
Interpret Data
Publish Results
Low-touch Intervention
Data Collection
PROJECT TIMELINE NICU EVALUATION - PRE
Task
10/1
10/3
10/5
10/7
10/10
10/12
10/14
10/16
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
INTERVENTION
PROJECT TIMELINE NICU EVALUATION - POST
Task
11/1
11/3
11/5
11/7
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
Task
EVAL 1 – DAY – Random
EVAL 2 – NIGHT – Random
EVAL 3 – DAY – Random
EVAL 4 - NIGHT - Random
12/1
12/2
1/1
1/2
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.

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
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
Run chart example: CVL infections
•Staff care education
•CHG Scrub for care line
and insertions
•Maximal sterile barriers
Max Cap
introduced
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):
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):
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.
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 you’re stuck
come and talk to us!
