Integrating Health Information Technology into your Quality Improvement Program
Integrating quality improvement and medical education
description
Transcript of Integrating quality improvement and medical education
Stephanie Parks Taylor MDDepartment of Internal Medicine
Division of Hospital Medicine
INTEGRATING QUALITY IMPROVEMENT AND MEDICAL EDUCATION
OBJECTIVES• Overview of Quality Improvement
• Importance of QI in residency training
• QI Principles and tools we need to be teaching
WHAT IS QUALITYInstitute of Medicine definition
• Quality consists of the “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (evidence)”
Blumenthal, NEJM
• Errors account for between 44,000 and 98,000 deaths per year in the US
• More people die from medical errors than breast cancer, AIDS, or MVAs
• Errors occur because of system failures, not individual failures
DOES QUALITY NEED IMPROVING?
To Err is Human: Building a safer healthcare system
IOM RECOMMENDATIONSSix major goals for health care• Safe• Effective• Patient-centered • Timely • Efficient • Equitable
IOM RECOMMENDATIONSTen “rules” for healthcare1. Care should be based on continuous healing
relationships2. Customization based on patient needs and values3. The patient as the source of control4. Shared knowledge and free flow of information5. Evidenced-based decision making
IOM RECOMMENDATIONSTen “rules” for healthcare6. Safety as a system property7. The need for transparency8. Anticipation of needs9. Continuous decrease in waste10. Cooperation among clinicians
REFLECTIVE PRACTICE• Definition Reflective practice simply refers to a systematic
approach to review one’s clinical practice, including errors, seek answers to problems, and make changes in practice habits, styles, and approaches based on self-reflection and review.
• Value• Accountability• Self-assessment
QUALITY OF CARE: EXAMPLE• 47 year-old unemployed Spanish-speaking only male with HTN,
HLD, and DM is admitted to the hospital for uncontrolled blood glucose. He has been admitted 6 times in the past year
• Current meds are
• HCTZ 25 mg daily
• Bystolic (nebivolol) 10 mg daily
• Byetta (exenatide) 10 mcg SC BID
• Metformin 1000 mg BID
QUALITY OF CARE: EXAMPLE• Admission data: BP 170/95, glucose 350, Creatinine 1.8
• Record review shows he has been treated by a different ward team each of his last 6 visits
• Glucose and BP were improved during last hospitalizations but no medication changes were made
• Patient has never made any follow up appointments at 30 th street clinic
QUALITY OF CARE: EXAMPLE• How well does this patient’s care meet the 6 IOM criteria?
• Safe• Effective• Patient-centered• Timely• Efficient• Equitable
QI IN RESIDENCY PROGRAMSWhy is it important to involve residents in quality improvement?
WHY INVOLVE RESIDENTS IN QI?• Residents are “invisible” in the quality improvement process,
because the attending physician is the physician of record and ultimately responsible
Carol M. Ashton, MD, MPH 1993 article in Academic Medicine
• “On the national level, residents are invisible on the patient safety journey”
Jim Conway, Sr Vice President Institute for Healthcare Improvement
WHY INVOLVE RESIDENTS IN QI?• Residents are front‐line workers
• They see all the issues and know what works and does not work in the hospital
• In most teaching hospitals, residents provide the bulk of inpatient care, write most orders, and drive day to day care of inpatients
• Many important metrics and JCAHO national patient safety goals involve work that is done chiefly by residents
• Residents often have great ideas and want to improve the process, but have traditionally felt powerless or ignored
• Residents are the future clinical leaders
WHY INVOLVE RESIDENTS IN QI?• Because we HAVE to!• ACGME core competencies
• Medical knowledge
• Patient care
• Professionalism
• Interpersonal and communication skills
• Practice-based learning and improvement • Systems-based practice
WHY INVOLVE RESIDENTS IN QI?• Residency programs integrate QI as one way to
incorporate the Practice-based learning and improvement and Systems-based learning into curricula
• PBLI and SBP require residents to reflect on the outcomes of their practice and to understand principles of improving the process of care
PRACTICE-BASED LEARNING AND IMPROVEMENT
• Residents are expected to use scientific evidence and methods to investigate, evaluate, and improve patient care practices
Internal medicine working group
PRACTICE-BASED LEARNING AND IMPROVEMENT
• Develop and maintain a willingness to learn from errors and use errors to improve the system or processes of care
• Use information technology to access and manage information, support patient care decisions and enhance both patient and physician education
PRACTICE-BASED LEARNING AND IMPROVEMENT
• Identify areas for improvement and implement strategies to enhance knowledge, skills, and attitudes and processes of care
• Analyze and evaluate practice experiences and implement strategies to continually improve the quality of patient practice
PRACTICE-BASED LEARNING AND IMPROVEMENT
• Two major themes
• Effective application of EBM to patient care• Diagnostics, therapeutics
• Clinical skills, too!
• Quality improvement• Individual improvement: reflective practice
• Systems improvement: active participation
SYSTEMS-BASED PRACTICE• Residents are expected to demonstrate both an understanding
of the contexts and systems in which healthcare is provided, and the ability to apply this knowledge to improve and optimize healthcare
Internal medicine working gtoup
SYSTEMS-BASED PRACTICE• Understand, access, and utilize the resources,
providers, and systems necessary for optimal care
• Understand the limitations an opportunities inherent in various delivery systems, and develop strategies to optimize care for the individual patient
SYSTEMS-BASED PRACTICE• Apply evidence-based, cost-conscious strategies to
prevention, diagnosis and disease
• Collaborate with other members of the healthcare team to assist patients to deal effectively with complex systems and improve systematic processes of care
RESIDENT “COMPETENCY”: PBL&I• Customer knowledge: Able to identify needs specific to
resident’s patient population
• Making change: demonstrate how to use several cycles of change to improve care delivery
• Measurement: Use balanced measures to show changes have improved patient care
• Developing local knowledge: apply continuous quality improvement to discrete population or different subpopulations
Ogrinc Acad Med, 2003
RESIDENT “COMPETENCY”: SBP• Healthcare as system: Understand and describe the reactions of
a system perturbed by change initiated by the resident
• Collaboration: contribute to interdisciplinary effort
• Social context/accountability: demonstrate business case for QI and identify community resources
Ogrinc Acad Med, 2003
RESIDENTS AND QI SKILLS• Understand key definitions and IOM rules
• Defining aim and mission statement
• How to measure quality
• Understand micro-systems
• Process tools:
• PDSA
• Flowcharts
RESIDENTS AND QI SKILLS• Role of physician leadership
• What is a physician opinion leader/champion?
• Working in interdisciplinary teams• Move beyond the ward team concept
MISSION STATEMENTS• Key ingredients for the explicit expression of goals
• Measurables
• Deliverables
• Timeline
Dembitzer, Stanford Contemporary Practice, 2004
EFFECTIVE MISSION STATEMENTS• Clear and concise, unambiguous
• Define the “problem” to be fixed
• Measurable and specific • Context, target population, duration
• Outcome-based (explicit target positive rate or failure rate)
• Reasonable, worthwhile, relevant topic• Important issue that will bring broad buy-in
MISSION STATEMENT EXAMPLE• “Do better with vaccine compliance in the hospital”
VERSUS• “Within the next 12 months, 80% of our COPD patients
will receive influenza vaccination before hospital discharge, increased from current rate of 45%”
MEASURING QUALITY • What are we measuring?
• Donabedian model
• Structure
• Process
• Outcome
MEASURING QUALITY • Structure
• The way a healthcare system is set up and the conditions under which care is provided
STRUCTURE: MICROSYSTEM• Microsytem: small group of people, working together
regularly to provide care to a discrete population of patients
• Shares• Clinical and business aims
• Linked processes
• Information
• Produces performance outcomesNelson, 2003
STRUCTURE: MICROSYSTEM
Nelson, 2003
MEASURING QUALITY • Donabedian model
• Structure
• Process
• Outcome
MEASURING QUALITY: PROCESS• Process: the activities that constitute healthcare
• Diagnosis, treatment, prevention ,counseling, etc
MEASURING QUALITY: PROCESS• Importance of understanding a process
• Frontline test
• Processes tend to be hierarchical
• Step A Step B Step C
• Helps manage complexity without drowning in detail
• Allows focus within context
Rudd, Stanford Contemporary Practice, 2004
UNDERSTANDING PROCESS: FLOWCHARTS TIPS
• Flowchart a process, not a system
• Avoid too much detail
• Process should reflect mission statement
• Get all necessary information
• Show process as it actually occurs, not in ideal state
• Critical stage: take as much time as needed
• Show the flowchart to front line people for input
• Look for areas of delay, hassles, complaints
MD decides patient needs ICU transfer
MD places transfer orders
Bed control notified for ICU bed
Nurse to nurse communication
prior to transport
ICU nurse assigned to
accept patient
Patient transported by
appropriate staff
ICU staff notified of patient arrival
Patient arrives in ICU unit
MD to MD report
Patient is under care
of ICU team
MEASURING QUALITY • Donabedian model
• Structure
• Process
• Outcome
MEASURING QUALITY: OUTCOMES • Outcomes: changes (desired or undesired) occurring in
individuals that can be attributed to healthcare
• Changes in health status
• Changes in knowledge among patients
• Changes in patient behavior
• Patient satisfaction
SYSTEM BASED APPROACH TO OUTCOMES
Patient Needs
Process of Care
Practice Systems
Outcomes of Care
SYSTEM BASED APPROACH TO OUTCOMES
Patient Needs
Practice Systems
Outcomes of Care
Access Evaluation DX RX P. Activation
Demographics
Co-morbidity
Risk Factors
Barriers to Self-Care
Clinical
Functional
Satisfaction
Safety
Cost
Process of Care
MODEL FOR IMPROVEMENTWhat are we trying to
accomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Act Plan
Study Do
PDSA CYCLE• PLAN:
• Identify the problem/process that needs improvement (may require data!)
• Describe current processes around improvement opportunity
• Describe possible causes of the problem and agree on root causes
• Develop effective and workable action plan- select targets!
PDSA CYCLE• DO
• Implement the proposed solution on a small scale
• STUDY• Review and evaluate the result of the change
• Will almost always require some form of data collection (medical record review, patient satisfaction, etc)
PDSA CYCLE• ACT
• Reflect and act on what was learned
• “reflective practice for the team”
• Assess the results, recommend changes
• Continue improvement process where needed, standardize when possible
• Celebrate successes!
NOW WHAT?
How do we close the gap from “invisible” residents to meeting ACGME competencies and the expectations of
heath systems for newly hired physicians?
FUTURE NEEDS• Curriculum design to integrate QI
• Educate program directors and core faculty get them excited about PBLI and SBP competencies
• Residency curriculum must be adjusted to allow time for didactic and experiential QI learning
• Not an “add-on” or “squeeze-in”
• Provide residents with tools and authority to implement changes
FUTURE NEEDS• Consider residents as part of the healthcare team
• Train and learn QI in teams
• Use residents as a resource for improving systems
• Educate residents to become faculty and leaders in QI
FINAL THOUGHT:THE TRIPLE AIM
IHI Triple Aim:• Improve the health of the population
• Enhance the patient experience of care (including quality, access, and reliability)
• Reduce, or at least control, the per capita cost of care
QUESTIONS?
Thank you!