QUALITY IMPROVEMENT
IN HEALTHCARE:
RESIDENCY AND BEYOND
Lisa Knight, MD
Quality Improvement Lecture 2
September 18, 2014
LECTURE OUTLINE
• The importance of QI efforts in healthcare
• Basics of a QI project
• PDSA cycle
• AIM statement
• Project Planning Document
• Writing Your Introduction Section of your QI paper
• Refresher on Residency QI Upcoming Deadlines
PATIENT PROTECTION AND AFFORDABLE CARE ACT
• Pay for performance
• Value-based purchasing
• Bundled payments
• One lump sum
WHY QUALITY IMPROVEMENT?
• A gap exists between the quality of care that is possible and the actual quality of care delivered to persons living in
the U.S.
Infant mortality in the US per 1000 live births is DOUBLE that of other leading nations
• Due to the seriousness of these shortcomings there is increasing importance that physicians and residents learn
and use modern QI methods and tools
“EVERY SYSTEM IS PERFECTLY DESIGNED TO GET THE RESULTS IT
GETS”
• This means that the US healthcare system is perfectly designed to:
• Achieve 44,000 to 98,000 inpatient deaths per year due to medical errors
• Have twice the infant mortality rate of other nations
• Do all that for twice the cost per person of other industrialized countries
• You can respond in 1 of 3 ways
• Ignore it
• Blame someone else (insurance, malpractice, Obama….)
• Do something about it
The only way to get different results is to
CHANGE THE SYSTEM
INSTITUTE OF MEDICINE REPORTS
• (1999) To Err is Human: Building a Safer Health System
 Put the spotlight on how tens of thousands of Americans die each
year from medical errors
 Effectively put the issue of patient safety and quality on the radar
screen of public and private policymakers
• (2001) Crossing the Quality Chasm: A New Health System for
the 21st Century
 Described broader quality issues
 Defined six aims for care delivery and redesign
THE IOM HAS PROPOSED 6 SPECIFIC AIMS FOR IMPROVEMENT
• Healthcare should be:
• Safe
Avoiding injury from care that is meant to be helpful
• Effective
Avoiding underuse or overuse of services
• Patient-Centered
Providing respectful, responsive, individualized care
• Timely
Reducing waits and harmful delays in care
• Efficient
Avoiding waste of equipment, supplies, ideas, and energy
• Equitable
Providing equal care regardless of personal characteristics
HOW DO WE GO ABOUT CHANGING THE SYSTEM?
Model for
Improvement
5-Step Process for Improvement
Establish a
future plan
Plan
Act
Study the
results
1. Select the opportunity for
improvement
2. Study the current situation
3. Analyze the causes
4. Develop a theory for improvement
5. Select the team
Do
Study
Implement the
Improvement
Present
Situation
ACT
PLAN
STUDY
DO
ACT
PLAN
STUDY
DO
AIM
What are we trying to
accomplish?
CHANGES
What change can we make that
will result in improvement?
How will we know that a change
is an improvement?
MEASURES
ACT
PLAN
STUDY
DO
Ideal
Future
When selecting a QI topic…
• Go for low-hanging fruit
• Ensure Organizational support and participation will be provided for this improvement
process
LOW-HANGING FRUIT IN THE ENDOCRINE DIVISION
• No Show rate
• Endocrine patients
• Healthy Lifestyles patients
• Medication compliance in adolescents with diabetes
• Diabetes school forms
• Motivation to make lifestyle changes in Healthy Lifestyles patients
1.
2.
3.
4.
5.
6.
Safe
Effective
Patient-Centered
Timely
Efficient
Equitable
A HEALTHCARE –RELATED PDSA CYCLE: PLANNING STAGE
1. Select the Opportunity for Improvement
• No-Show rate in the Pediatric Endocrine clinic
2. Study the current situation
• Define why improvement in this area is necessary
 Health risk of the patient who doesn’t show
 Health risk of the patient seeking an appt, but unable to book
 Poor staff utilization
 Loss of multiple streams of revenue
• Collect and/or review baseline data in your problem area
 Track the following for one month
5-Step Process for Improvement
1.
2.
3.
4.
5.
Select the opportunity for improvement
Study the current situation
Analyze the causes
Develop a theory for improvement
Select your team
Model for
Improvement
AIM: What are we trying to
accomplish
MEASURES: How will we know
that a change is an
improvement
CHANGES: What change can
we make that will result in
improvement
• Total number of patient appointments scheduled
• Total number of patients seen
No Show Rate = 35%
ACT
PLAN
STUDY
DO
A HEALTHCARE RELATED PDSA CYCLE: PLANNING STAGE
3. Analyze the causes
• Determine factors contributing to no-shows in your population
5-Step Process for Improvement
1.
2.
3.
4.
5.
Select the opportunity for improvement
Study the current situation
Analyze the causes
Develop a theory for improvement
Select your team
Model for
Improvement
AIM: What are we trying to
accomplish
• Describe the current process for patient appt reminders
 Automated phone call to primary phone in EMR 48-72 hours before appt
4. Develop a theory for improvement
MEASURES: How will we know
that a change is an
improvement
CHANGES: What change can
we make that will result in
improvement
5. Select your team
ACT
PLAN
STUDY
DO
DEVELOP A THEORY FOR IMPROVEMENT:
AIM STATEMENT
• A good aim is:
• Specific
• Measurable
• Addresses these points:
• For whom (or for what system)?
• How good?
• By when?
We will reduce the patient appt no-show rate in the
Pediatric Endocrine clinic from 35% to 20% by March
31, 2015
Model for
Improvement
AIM: What are we trying to
accomplish
MEASURES: How will we know
that a change is an
improvement
CHANGES: What change can
we make that will result in
improvement
ACT
PLAN
STUDY
DO
DEVELOP A THEORY FOR IMPROVEMENT:
CHANGES
• Processes for formulating ideas for change:
Model for
Improvement
• Critical thinking about the current system
AIM: What are we trying to
accomplish
• Flowchart on the current process
• Analyze data on the current system
• Benchmarking
• Comparing your own process to “best practice”
• Take the patient’s perspective
MEASURES: How will we know
that a change is an
improvement
CHANGES: What change can
we make that will result in
improvement
• Ask the patient/caregiver for ideas
• Using technology
ACT
PLAN
STUDY
DO
• Text messaging
• Social media
Office secretary to make phone call to patient’s
caregivers 24 hours before appt
DEVELOP A THEORY FOR IMPROVEMENT:
MEASURES
• Qualitative data: Subjective
Model for
Improvement
• Quantitative: Objective
• 3 main types of measures:
AIM: What are we trying to
accomplish
 Outcome Measure:
• Are you reaching your ultimate result?
• No-Show rate in the Pediatric Endocrine clinic (%)
 Process Measure:
• Are the parts/steps in the system performing as planned?
MEASURES: How will we know
that a change is an
improvement
CHANGES: What change can
we make that will result in
improvement
• What percent of patients receive a reminder phone call from the
secretary
 Balancing Measure:
• Are changes designed to improve one part of the system causing
new problems in other parts of the system?
• Are the secretaries unable to get their other work done because of
time spent calling patients?
ACT
PLAN
STUDY
DO
FORMING AN EFFECTIVE TEAM
• Identify a QI mentor
• Be sure to include members familiar with all the different parts of the process you are
trying to improve
• Endocrine Team:
• Myself: Project Leader
• Dr. Whitney Brown: Division Director
• Endocrine Clinic secretary
Lisa Knight
Whitney Brown
The Endocrine Clinic Secretary
Reduce the No-Show rate in the Pediatric Endocrine clinic from
35% to 20% by March 31, 2015
No-Show rate (%) = Total number of patients who didn’t show
Total number of patients scheduled
X 100
Percentage of patients each day who received a phone call 24 hours before their appt
Secretary satisfaction with the appt reminder system
Secretary to make phone calls to patients 24 hours before their appt
ALWAYS START SMALL
Ideal
Future
• First PDSA cycle:
• Only my patients
• Not the other 3 endocrine providers
• Morning clinic of September 15, 2015
• 10 patients
• Increase in
• Scale
• Scope
Present
Situation
ACT
PLAN
STUDY
DO
ACT
PLAN
STUDY
DO
ACT
PLAN
STUDY
DO
QI VS RESEARCH
Steal Shamelessly
Research
Quality Improvement
• Form hypothesis
• Form a hypothesis
• Stick with it until bitter end
• Adjust through multiple PDSA cycles to
work out kinks
• One large test
• Sequential tests
• T-tests, chi square, p-value
• Run charts or Shewhart charts
In QI, the goal is to improve the conditions that exist….not merely to describe what they are
And to do that, you need to be able to modify your assumptions and retest your theories based
on what you learn in the course of your tests
A HEALTHCARE –RELATED PDSA CYCLE: PLANNING STAGE
1. Select the Opportunity for Improvement
• Hyperglycemia in diabetics after transition from insulin gtt
to SC injections
2. Study the current situation
• Define why improvement in this area is necessary
 Continued hyperglycemia may result in:
• Prolonged hospital stay
• More frequent BG checks
• More frequent corrective insulin injections
• Added stress/anxiety for child/caregiver
5-Step Process for Improvement
1.
2.
3.
4.
5.
Select the opportunity for improvement
Study the current situation
Analyze the causes
Develop a theory for improvement
Select your team
Model for
Improvement
AIM: What are we trying to
accomplish
MEASURES: How will we know
that a change is an
improvement
CHANGES: What change can
we make that will result in
improvement
ACT
PLAN
STUDY
DO
A HEALTHCARE –RELATED PDSA CYCLE: PLANNING STAGE
2.
Study the current situation (cont.)
a.
Current transition protocol
•
½ dose Lantus given at breakfast
•
Insulin gtt d/c
•
½ dose Lantus given at bed
•
Full Lantus dose given the following night at bedtime
Collect and/or review baseline data in your problem area
a.
Track the following for six months
• Average BG level for each patient
• In the 4-6 hours before insulin gtt d/c AND in the 12 hours
5-Step Process for Improvement
1.
2.
3.
4.
5.
Select the opportunity for improvement
Study the current situation
Analyze the causes
Develop a theory for improvement
Select your team
Model for
Improvement
AIM: What are we trying to
accomplish
MEASURES: How will we know
that a change is an
improvement
CHANGES: What change can
we make that will result in
improvement
after full Lantus dose given
• During the 36 hour transition period
• Reoccurrence of urinary ketones after insulin gtt d/c
ACT
PLAN
STUDY
DO
• Number of correction insulin doses given
Average BG 152 mg/dL
Average BG 276 mg/dL
A HEALTHCARE RELATED PDSA CYCLE: PLANNING STAGE
3.
Analyze the causes
a.
4.
5.
Determine factors contributing to hyperglycemia
•
Was the insulin gtt turned off too early?
•
Are CHO being counted appropriately?
•
Are patients/caregivers sneaking food/drink into their room?
•
Are insulin doses being calculated correctly?
•
Does the current transition protocol give enough insulin?
Develop a theory for improvement
a.
½ dose Lantus transition protocol provides too little basal insulin
b.
Will give full dose Lantus at transition
Select your team
a.
Myself
b.
Dr. Whitney Brown (Endocrine Division Director)
c.
Dr. Elizabeth Mack (PICU attending)
5-Step Process for Improvement
1.
2.
3.
4.
5.
Select the opportunity for improvement
Study the current situation
Analyze the causes
Develop a theory for improvement
Select your team
Model for
Improvement
AIM: What are we trying to
accomplish
MEASURES: How will we know
that a change is an
improvement
CHANGES: What change can
we make that will result in
improvement
ACT
PLAN
STUDY
DO
Lisa Knight
Whitney Brown
Dr. Elizabeth Mack
Reduce the Average BG level in patients with diabetes in the
PICU during the 36 hours following transition from an insulin gtt
to SC injections from by 25% by March 31, 2015
Change in Average BG level with Full Dose Transition X 100
Change in Average BG level with Half Dose Transition
Percentage of patients who received the full Lantus dose at the time of transition
Was there increased confusion about when to administer subsequent doses of Lantus
Full Lantus dose to be given at time of transition (then moved to lunch the
next day, dinner the day after that, and bedtime on the following day)
Average BG 166.3 mg/dL
Average BG 217.8 mg/dL
Change of 123.4 mg/dL
Change of 51.5 mg/dL
QI WRITE-UP: INTRODUCTION
• Background Knowledge:
 Provides a brief, nonselective summary of current knowledge of the care problem being addressed, and the
characteristics of organizations in which it occurs
• Local Problem
 Describes the nature and severity of the local specific problem or system dysfunction that was addressed
• Intended Improvement
 Describes the specific aim of the proposed intervention (changes/improvements in care processes and
patient outcomes)
 Specifies who (champions, supporters) and what (events, observations) triggered the decision to make
changes
• Study Question
 Specifies specific AIM statement of the project
 Details precisely the primary improvement-related question and any secondary questions that the study of the
intervention was designed to answer
We know what good health care is, that’s not the problem
The challenge is to close the gap, the “chasm” between
What we know to be good care and
The care that people actually receive
NEXT STEPS
First Years
• Friday, January 30, 2015
 The following are due by end of day:
a. Project Planning Document
b. Introduction/Background section of QI
write-up
Second Years
• Feb 2015
 Second QI Lecture (Date TBA)
• March 31, 2015
 Complete collection of post-intervention data
• April 2015
 Poster Presentation Lecture (Date TBA)
• Friday, May 8, 2015
 Turn in QI project write-up to me by end of day
• Friday, June 19, 2015
 3rd Annual Pediatric Residency QI Presentation Day
• July 2015
 SCAAP Annual Meeting Poster Presentations (Date TBA)
USC PEDIATRIC RESIDENCY QI WEBSITE
http://pediatrics.med.sc.edu/residency.asp