Basics of Quality Improvement (QI)

QUALITY IMPROVEMENT QUALITY IMPROVEMENT IN HEALTHCARE: IN HEALTHCARE:

RESIDENCY AND BEYONDRESIDENCY AND BEYONDLisa Knight, MDLisa Knight, MD

Quality Improvement Lecture 2Quality Improvement Lecture 2

September 18, 2014September 18, 2014

LECTURE OUTLINELECTURE OUTLINE

• The importance of QI efforts in healthcareThe importance of QI efforts in healthcare

• Basics of a QI projectBasics of a QI project

• PDSA cyclePDSA cycle

• AIM statementAIM statement

• Project Planning DocumentProject Planning Document

• Writing Your Introduction Section of your QI paperWriting Your Introduction Section of your QI paper

• Refresher on Residency QI Upcoming DeadlinesRefresher on Residency QI Upcoming Deadlines

PATIENT PROTECTION AND AFFORDABLE CARE PATIENT PROTECTION AND AFFORDABLE CARE ACTACT

• Pay for performancePay for performance

• Value-based purchasingValue-based purchasing

• Bundled paymentsBundled payments

• One lump sumOne lump sum

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=c6HF7T3g8vZ4WM&tbnid=dIu6igTM334UsM:&ved=0CAUQjRw&url=http://fellowshipofminds.wordpress.com/2010/07/19/25491-americans-sue-obamacare/&ei=9oBhUZTJKrDl4APSpoHgCA&bvm=bv.44770516,d.dmg&psig=AFQjCNHosqpxqMBiWs21QkUXpNJTRyOn3w&ust=1365430723328542

WHY QUALITY IMPROVEMENT?WHY QUALITY IMPROVEMENT?• A gap exists between the quality of care that is possible and the actual quality of care delivered to 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.persons living in the U.S.

• Due to the seriousness of these shortcomings there is increasing importance that physicians and Due to the seriousness of these shortcomings there is increasing importance that physicians and residents learn and use modern QI methods and toolsresidents learn and use modern QI methods and tools

Infant mortality in the US per 1000 live births is DOUBLE that of other leading nations

““EVERY SYSTEM IS PERFECTLY DESIGNED TO GET THE RESULTS IT EVERY SYSTEM IS PERFECTLY DESIGNED TO GET THE RESULTS IT GETS”GETS”

• This means that the US healthcare system is perfectly designed to:This means that the US healthcare system is perfectly designed to:

• Achieve 44,000 to 98,000 inpatient deaths per year due to medical errorsAchieve 44,000 to 98,000 inpatient deaths per year due to medical errors

• Have twice the infant mortality rate of other nationsHave twice the infant mortality rate of other nations

• Do all that for twice the cost per person of other industrialized countriesDo all that for twice the cost per person of other industrialized countries

• You can respond in 1 of 3 waysYou can respond in 1 of 3 ways

• Ignore itIgnore it

• Blame someone else (insurance, malpractice, Obama….)Blame someone else (insurance, malpractice, Obama….)

• Do something about itDo something about it

The only way to get different results is toCHANGE THE SYSTEM

INSTITUTE OF MEDICINE REPORTSINSTITUTE OF MEDICINE REPORTS

• (1999) (1999) To Err is Human: Building a Safer Health SystemTo Err is Human: Building a Safer Health SystemPut the spotlight on how tens of thousands of Americans die Put the spotlight on how tens of thousands of Americans die

each year from medical errorseach year from medical errors

Effectively put the issue of patient safety and quality on the Effectively put the issue of patient safety and quality on the

radar screen of public and private policymakersradar screen of public and private policymakers

• (2001) (2001) Crossing the Quality Chasm: A New Health Crossing the Quality Chasm: A New Health

System for the 21System for the 21stst Century CenturyDescribed broader quality issuesDescribed broader quality issues

Defined six aims for care delivery and redesignDefined six aims for care delivery and redesign

THE IOM HAS PROPOSED THE IOM HAS PROPOSED 6 SPECIFIC AIMS 6 SPECIFIC AIMS FOR IMPROVEMENTFOR IMPROVEMENT

• Healthcare should be:Healthcare should be:

• SafeSafe

• EffectiveEffective

• Patient-CenteredPatient-Centered

• TimelyTimely

• EfficientEfficient

• EquitableEquitable

Avoiding injury from care that is meant to be helpful

Avoiding underuse or overuse of services

Providing respectful, responsive, individualized care

Reducing waits and harmful delays in care

Avoiding waste of equipment, supplies, ideas, and energyProviding equal care regardless of personal characteristics

HOW DO WE GO ABOUT CHANGING THE SYSTEM?HOW DO WE GO ABOUT CHANGING THE SYSTEM?

Plan

Do

Study

Act

5-Step Process for Improvement

1.Select the opportunity for improvement2.Study the current situation3.Analyze the causes4.Develop a theory for improvement5.Select the team

Model for Improvement

What are we trying to accomplish?

What change can we make that will result in improvement?

How will we know that a change is an improvement?

AIM

MEASURES

CHANGES

Implement theImprovementStudy the

results

Establish a future plan

Present Situation

IdealFuture

• Go for low-hanging fruitGo for low-hanging fruit

• Ensure Organizational support and participation will be provided for this Ensure Organizational support and participation will be provided for this

improvement processimprovement process

When selecting a QI topic…

LOW-HANGING FRUIT IN THE ENDOCRINE DIVISIONLOW-HANGING FRUIT IN THE ENDOCRINE DIVISION

• No Show rateNo Show rate

• Endocrine patientsEndocrine patients

• Healthy Lifestyles patientsHealthy Lifestyles patients

• Medication compliance in adolescents with diabetesMedication compliance in adolescents with diabetes

• Diabetes school formsDiabetes school forms

• Motivation to make lifestyle changes in Healthy Lifestyles Motivation to make lifestyle changes in Healthy Lifestyles

patientspatients

1. Safe2. Effective3. Patient-Centered4. Timely5. Efficient6. Equitable


1.Select the opportunity for improvement2.Study the current situation3.Analyze the causes4.Develop a theory for improvement5.Select your team


AIM: What are we trying to accomplish

MEASURES: How will we know that a change is an

improvementCHANGES: What change can we make that will result in improvement

A HEALTHCARE –RELATED PDSA CYCLE: PLANNING STAGEA HEALTHCARE –RELATED PDSA CYCLE: PLANNING STAGE

1.1. Select the Opportunity for ImprovementSelect the Opportunity for Improvement

• No-Show rate in the Pediatric Endocrine clinicNo-Show rate in the Pediatric Endocrine clinic

2.2. Study the current situationStudy the current situation

• Define why improvement in this area is necessaryDefine why improvement in this area is necessary Health risk of the patient who doesn’t showHealth risk of the patient who doesn’t show

Health risk of the patient seeking an appt, but unable to bookHealth risk of the patient seeking an appt, but unable to book

Poor staff utilizationPoor staff utilization

Loss of multiple streams of revenueLoss of multiple streams of revenue

• Collect and/or review baseline data in your problem areaCollect and/or review baseline data in your problem area Track the following for one monthTrack the following for one month

• Total number of patient appointments scheduledTotal number of patient appointments scheduled

• Total number of patients seenTotal number of patients seen

No Show Rate = 35%

A HEALTHCARE RELATED PDSA CYCLE: PLANNING STAGEA HEALTHCARE RELATED PDSA CYCLE: PLANNING STAGE

3.3. Analyze the causesAnalyze the causes

• Determine factors contributing to no-shows in your populationDetermine factors contributing to no-shows in your population

• Describe the current process for patient appt remindersDescribe the current process for patient appt reminders Automated phone call to primary phone in EMR 48-72 hours before apptAutomated phone call to primary phone in EMR 48-72 hours before appt

4.4. Develop a theory for improvementDevelop a theory for improvement

5.5. Select your teamSelect your team







DEVELOP A THEORY FOR IMPROVEMENT: DEVELOP A THEORY FOR IMPROVEMENT: AIM STATEMENTAIM STATEMENT

• A good aim is:A good aim is:

• SpecificSpecific

• MeasurableMeasurable

• Addresses these points:Addresses these points:

• For whom (or for what system)?For whom (or for what system)?

• How good?How good?

• By when?By when?





We will reduce the patient appt no-show rate in the Pediatric Endocrine clinic from 35% to 20% by March 31, 2015

DEVELOP A THEORY FOR IMPROVEMENT:DEVELOP A THEORY FOR IMPROVEMENT:CHANGESCHANGES

• Processes for formulating ideas for change:Processes for formulating ideas for change:

• Critical thinking about the current systemCritical thinking about the current system• Flowchart on the current processFlowchart on the current process

• Analyze data on the current systemAnalyze data on the current system

• BenchmarkingBenchmarking• Comparing your own process to “best practice”Comparing your own process to “best practice”

• Take the patient’s perspectiveTake the patient’s perspective• Ask the patient/caregiver for ideasAsk the patient/caregiver for ideas

• Using technologyUsing technology• Text messagingText messaging

• Social mediaSocial media





Office secretary to make phone call to patient’s caregivers 24 hours before appt

DEVELOP A THEORY FOR IMPROVEMENT:DEVELOP A THEORY FOR IMPROVEMENT:MEASURESMEASURES

• Qualitative data: SubjectiveQualitative data: Subjective

• Quantitative: ObjectiveQuantitative: Objective

• 3 main types of measures: 3 main types of measures: Outcome MeasureOutcome Measure::

• Are you reaching your ultimate result?Are you reaching your ultimate result?

• No-Show rate in the Pediatric Endocrine clinic (%)No-Show rate in the Pediatric Endocrine clinic (%) Process MeasureProcess Measure::

• Are the parts/steps in the system performing as planned?Are the parts/steps in the system performing as planned?

• What percent of patients receive a reminder phone call from What percent of patients receive a reminder phone call from the secretary the secretary

Balancing MeasureBalancing Measure::

• Are changes designed to improve one part of the system Are changes designed to improve one part of the system causing new problems causing new problems in other parts of the system?in other parts of the system?

• Are the secretaries unable to get their other work done Are the secretaries unable to get their other work done because of time spent calling patients?because of time spent calling patients?





FORMING AN EFFECTIVE TEAMFORMING AN EFFECTIVE TEAM

• Identify a QI mentorIdentify a QI mentor

• Be sure to include members familiar with all the different parts of the process Be sure to include members familiar with all the different parts of the process

you are trying to improveyou are trying to improve

• Endocrine Team:Endocrine Team:

• Myself: Project LeaderMyself: Project Leader

• Dr. Whitney Brown: Division DirectorDr. Whitney Brown: Division Director

• Endocrine Clinic secretaryEndocrine 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 SMALLALWAYS START SMALL

• First PDSA cycle:First PDSA cycle:• Only my patientsOnly my patients

• Not the other 3 endocrine providersNot the other 3 endocrine providers

• Morning clinic of September 15, 2015 Morning clinic of September 15, 2015 • 10 patients10 patients

• Increase inIncrease in• ScaleScale

• ScopeScopePresent

Situation

IdealFutur

e

QI VS RESEARCHQI VS RESEARCH

ResearchResearch Quality ImprovementQuality Improvement

• Form hypothesisForm hypothesis

• Stick with it until bitter endStick with it until bitter end

• One large testOne large test

• T-tests, chi square, p-valueT-tests, chi square, p-value

• Form a hypothesisForm a hypothesis

• Adjust through multiple PDSA cycles Adjust through multiple PDSA cycles

to work out kinksto work out kinks

• Sequential testsSequential tests

• Run charts or Shewhart chartsRun charts or Shewhart charts

In QI, the goal is to improve the conditions that exist….not merely to describe what they areAnd 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

Steal Shamelessly








1.1. Select the Opportunity for ImprovementSelect the Opportunity for Improvement

• Hyperglycemia in diabetics after transition from insulin gttHyperglycemia in diabetics after transition from insulin gtt

to SC injectionsto SC injections

2.2. Study the current situationStudy the current situation

• Define why improvement in this area is necessaryDefine why improvement in this area is necessary Continued hyperglycemia may result in:Continued hyperglycemia may result in:

• Prolonged hospital stayProlonged hospital stay

• More frequent BG checksMore frequent BG checks

• More frequent corrective insulin injectionsMore frequent corrective insulin injections

• Added stress/anxiety for child/caregiverAdded stress/anxiety for child/caregiver








2. Study the current situation (cont.)2. Study the current situation (cont.)

a.a. Current transition protocolCurrent transition protocol

• ½ dose Lantus given at breakfast½ dose Lantus given at breakfast

• Insulin gtt d/cInsulin gtt d/c

• ½ dose Lantus given at bed½ dose Lantus given at bed

• Full Lantus dose given the following night at bedtimeFull Lantus dose given the following night at bedtime

Collect and/or review baseline data in your problem areaCollect and/or review baseline data in your problem area

a. Track the following for six monthsa. Track the following for six months

• Average BG level for each patientAverage BG level for each patient

• In the 4-6 hours before insulin gtt d/c AND in the 12 hours In the 4-6 hours before insulin gtt d/c AND in the 12 hours

after full Lantus dose given after full Lantus dose given

• During the 36 hour transition periodDuring the 36 hour transition period

• Reoccurrence of urinary ketones after insulin gtt d/cReoccurrence of urinary ketones after insulin gtt d/c

• Number of correction insulin doses givenNumber of correction insulin doses given

Average BG 152 mg/dL

Average BG 276 mg/dL

A HEALTHCARE RELATED PDSA CYCLE: PLANNING STAGEA HEALTHCARE RELATED PDSA CYCLE: PLANNING STAGE3.3. Analyze the causesAnalyze the causes

a.a. Determine factors contributing to hyperglycemiaDetermine factors contributing to hyperglycemia• Was the insulin gtt turned off too early?Was the insulin gtt turned off too early?

• Are CHO being counted appropriately?Are CHO being counted appropriately?

• Are patients/caregivers sneaking food/drink into their room?Are patients/caregivers sneaking food/drink into their room?

• Are insulin doses being calculated correctly?Are insulin doses being calculated correctly?

• Does the current transition protocol give enough insulin?Does the current transition protocol give enough insulin?

4.4. Develop a theory for improvementDevelop a theory for improvement

a.a. ½ dose Lantus transition protocol provides too little basal insulin½ dose Lantus transition protocol provides too little basal insulin

b.b. Will give full dose Lantus at transitionWill give full dose Lantus at transition

5.5. Select your teamSelect your team

a.a. MyselfMyself

b.b. Dr. Whitney Brown (Endocrine Division Director)Dr. Whitney Brown (Endocrine Division Director)

c.c. Dr. Elizabeth Mack (PICU attending)Dr. Elizabeth Mack (PICU attending)







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

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 thenext day, dinner the day after that, and bedtime on the following day)

Change in Average BG level with Full Dose TransitionChange in Average BG level with Half Dose Transition

X 100

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: INTRODUCTIONQI WRITE-UP: INTRODUCTION

• Background Knowledge:Background Knowledge: Provides a brief, nonselective summary of current knowledge of the care problem being Provides a brief, nonselective summary of current knowledge of the care problem being

addressed, and the characteristics of organizations in which it occursaddressed, and the characteristics of organizations in which it occurs

• Local ProblemLocal Problem Describes the nature and severity of the local specific problem or system dysfunction that was Describes the nature and severity of the local specific problem or system dysfunction that was

addressedaddressed

• Intended ImprovementIntended Improvement Describes the specific aim of the proposed intervention (changes/improvements in care processes Describes the specific aim of the proposed intervention (changes/improvements in care processes

and patient outcomes)and patient outcomes) Specifies who (champions, supporters) and what (events, observations) triggered the decision to Specifies who (champions, supporters) and what (events, observations) triggered the decision to

make changesmake changes

• Study QuestionStudy Question Specifies specific AIM statement of the projectSpecifies specific AIM statement of the project

Details precisely the primary improvement-related question and any secondary questions that the Details precisely the primary improvement-related question and any secondary questions that the study of the intervention was designed to answerstudy of the intervention was designed to answer

We know what good health care is, that’s not the We know what good health care is, that’s not the

problemproblem

The challenge is to close the gap, the “chasm” betweenThe challenge is to close the gap, the “chasm” between

What we know to be good care andWhat we know to be good care and

The care that people actually receiveThe care that people actually receive

NEXT STEPSNEXT STEPS

First YearsFirst Years

• Friday, January 30, 2015Friday, January 30, 2015 The following are due by end of day:The following are due by end of day:

a.a. Project Planning DocumentProject Planning Document

b.b. Introduction/Background section of QI Introduction/Background section of QI

write-upwrite-up

Second YearsSecond Years• Feb 2015Feb 2015

Second QI Lecture (Date TBA)Second QI Lecture (Date TBA)

• March 31, 2015March 31, 2015 Complete collection of post-intervention dataComplete collection of post-intervention data

• April 2015April 2015 Poster Presentation Lecture (Date TBA)Poster Presentation Lecture (Date TBA)

• Friday, May 8, 2015Friday, May 8, 2015 Turn in QI project write-up to me by end of dayTurn in QI project write-up to me by end of day

• Friday, June 19, 2015Friday, June 19, 2015 33rdrd Annual Pediatric Residency QI Presentation Day Annual Pediatric Residency QI Presentation Day

• July 2015July 2015 SCAAP Annual Meeting Poster Presentations (Date TBA)SCAAP Annual Meeting Poster Presentations (Date TBA)

USC PEDIATRIC RESIDENCY QI WEBSITEUSC PEDIATRIC RESIDENCY QI WEBSITE

http://pediatrics.med.sc.edu/residency.asp

Basics of Quality Improvement (QI)

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