Healthcare Quality and Improvement

A Primer

Part 2

• Review key concepts

• Move on to other QI methods

• Discuss project development

• Research vs. QI

• National patient safety goals

• Joint commission

Objectives

• Quality problems in health care• Define quality• Who, what, why and how of quality improvement

– Tools and methods• Key elements of a good QI project• Quality improvement vs.. research• QI project development• National Patient Safety Goals• Joint Commission

Defining Quality• Quality is…

– A systems-wide issue– An individual performance issue rarely

Quality is a team sport

Quality at CMHHow informed are you?

• Rate of compliance with hand washing?– 90%

• Central line infection rate?– 1.2/1000 cath days-PICU

• % of codes outside the PICU?– 50%

• % of inpatients with medication reconciliation performed?– 70%

Quality Improvement

• A process of innovation and adaptation designed to bring about immediate positive changes in the delivery of health care in particular settings– systematic – data-guided– multidisciplinary

Quality Improvementand Data

• Use data for learning, not judging– “Generate light, not heat”

• Use data to report system attributes

• Use aggregate not individual data

• Do not report data on individual performance

Improvement MethodsA brief overview

• Model for Improvement

• Lean

• Six Sigma

• Trigger tools

Model for Improvement

• Flexible improvement framework

• IHI• PDSA methodology• Emphasizes

– Aims and measures– Initial small tests of change– Widespread testing– Implementation and spread

Improvement Methods

• What is LEAN?

• What is Six Sigma?

• Identify a trigger tool

Lean

• Management philosophy based on 2 key themes– Continuous elimination of waste– Respect for people and society

• Key principles– Value is in the eyes of the customer– Make value flow without interuptions

• Improve work flow• Standardize work processes

– Pursue perfection

Lean

• Culture– Stop and fix the problem as soon as it is

identified– Toyota manufacturing culture

• Process– Measure– Change– Measure– Change…..

Lean Project“Improve ED Patient Flow”

• Project aim-reduce ED LOS by 50%• Process improvements(reduce waste)

– Work standards and evidence-based clinical practice guidelines for all ED staff defined

– Batching of orders eliminated– Right supplies and equipment in the right place;

eliminated unnecessary S&E– Admission process streamlined

• Results– Reduced ED LOS for discharges by 23%– Reduced ED LOS for admissions by 20%

Lean What is waste in medicine?

• Surgical infection• Preventable adverse drug events• Ventilator assisted pneumonia• Equipment failure• Waiting and lack of flow• Inadequate training or orientation• Unnecessary or poorly designed processes• Not following evidence based practices

Six Sigma

• Focus is to eliminate defects– Nonconformity of a product or service to its

specifications

• Six sigma processes have variation that result in <3.4 parts/million defects

Why Zero Defects is the Only Acceptable Quality Standard

• At 99.9% quality levels in a 250 bed hospital

– 12 inpatients per year would die due to errors– 6 day surgery patients would die– 9,742 wrong medications would be delivered– 4,923 incorrect laboratory tests would be

reported– 502 incorrect radiographs would be completed

Six Sigma

• Systematic and scientific management approach to reduce sources of process variation and improve reliability– Customer and financially focused– Strategic– Uses project management concepts– Strong statistical focus– Focus on “mistake-proofing”

• Requires rigorous professional training

Six Sigma Project“Reducing Hospital-Acquired Pressure Ulcers”

• 5 structured project phases– Define– Measure– Analyze– Improve– Control

Trigger Tools

• Method for identifying adverse events (harm) and measuring the rate of adverse events over time

• Method options – Retrospective review of a random sample of patient

records using triggers (clues)– Prospective surveillance of electronic patient records

• Goal-to identify areas for improvement and prevent harm

Trigger Tools Your medical world

• Are there triggers that could be used in your specialty to identify areas of potential patient harm?

Root Cause Analysis

• Process to identify causal factors for variation in performance; “learning from consequences”

• Systems and processes focus• Individual performance not a focus• Identifies potential improvements to

reduce likelihood of future event• Used in M&M process, sentinel event

investigations

Patient FactorsCondition (complexity and seriousness)Language and communicationPersonality and social factors

Individual (staff) factorsKnowledge and skillsCompetencePhysical and mental health

Work Environmental FactorsStaffing levels and skills mixWorkload and shift patternsDesign, availability and maintenance of equipmentAdministrative and managerial supportEnvironmentPhysical

Task FactorsTask design and clarity of structureAvailability and use of protocolsAvailability and accuracy of test resultsDecision-making aids

Team FactorsVerbal communicationWritten communicationSupervision and seeking helpTeam structure (congruence, consistency, leadership, etc)

Organizational and Management FactorsFinancial resources and constraintsOrganizational structurePolicy, standards and goalsSafety culture and priorities

Care Delivery problems (CDPs)Care deviated beyond safe limits of practiceThe deviation had at least a potential direct or indirect effect for an adverse outcome for the patient, staff or general publicExamples: Failure to monitor, observe or actIncorrect (with hindsight) decisionNot seeking help when necessary

Fishbone Diagram

Failure modes and Effects Analysis (FMEA)

• Prospective technique

• Systematic assessment to– Prevent problems before they occur– Reduce the chance of unintended adverse

harm if they occur

• Used for high risk procedures or error prone processes

Now its your turn!

• Form groups of 4-5 team members• Pick one of the following aims

– !00% of all requests for physician consultation include a verbal discussion between the physician requesting the consult and the physician receiving the request

– Reduce errors during patient care handoffs: sign out, transfer to another service, etc (right info at the right time, distractions, templates, etc)

– Reduce variation in practice for management of __________ by implementing evidence based practice standards

– You decide_______________________________

• Be prepared to present your plan

Now its your turn!

• Develop a plan to achieve the aim– Who’s on the team?– Responsibilities and roles– Improvement methods– Timelines

• Identify outcome and balancing measures• Identify data needed to assess improvement

and sources of data

Now its your turn!

• Share the projects you have done or are developing

Improvement project ideas

• Care process changes– Hand offs– Scheduling– Medication reconciliation

• Implementation of new clinical or administrative practices

• Practice standardization

Central Line InfectionsDefining the problem

• 15 million central venous catheter-days per year in ICUs

• Attributable mortality for these infections 4- 20%

• Bloodstream infections prolong hospitalization by a mean of 7 days 

Central Line InfectionsStating the project aim

• Reduce central line infection rate to 0 in the ICU in 12 months

Central Line InfectionsPractice Standardization

• Hand Hygiene • Maximal Barrier Precautions upon insertion • Chlorhexidine skin antisepsis • Optimal catheter site selection, with Subclavian

Vein as the preferred site for non-tunneled catheters

• Daily review of line necessity with prompt removal of unnecessary lines

Central Line InfectionsPractice Standardization

Quality ImprovementKey elements

• Systematic• Data-guided and knowledge informed• Experiential• Innovative• Employs formal explicit methodology• Continuous • Core responsibility of healthcare

professionals

Quality Improvement Work

• Focused on systems

• Team oriented

• Requires team skills– Collaboration– Meeting skills– Value all perspectives

• Develop local new useful knowledge to inform health care processes

Quality Improvement vs. ResearchIt’s Complicated….

• QI– Systematic data-guided

activities designed to bring about immediate positive changes in healthcare delivery in local practice settings

– An integral part of the ongoing healthcare delivery system

– A form of clinical and managerial innovation and adaptation

– Combines discipline specific knowledge with experiential learning and discovery

• Research– A systematic investigation

designed to develop or contribute to generalizable new knowledge

– Implementation of research is a separate process and occurs later, if at all

– A knowledge seeking enterprise that is independent of routine medical care

Hastings Report

Quality methods and terms_5_Sentinel event 1. a tool which uses clue to identify a possible adverse event

_8_Never event 2. an improvement method driven by statistical analysis of data to identify unwanted defects and variation

_9_PDSA 3. a tool used to systematically identify all factors that may have contributed to an adverse situation

_6_LEAN 4. unintended injury from medical care that requires additional treatment or monitoring or results in death

_2_Six sigma 5. an unexpected occurrence involving death, serious injury or the potential for serious injury

_11_Root Cause An. 6..an improvement method focused on eliminating waste through analysis of workflow

_3_Fishbone diagram 7. a prospective process which uses a systematic assessment to identify and prevent potential problems

_7_FMEA 8. an event that is reasonably preventable; e.g. pressure ulcer, hemostat left in patient during surgery

_4_Harm 9. a process used in the Model for Improvement to test changes

_1_Trigger tool 10. an error

_12_Action plan 11.a retrospective assessment of an adverse situation that has occurred

_10_Adverse event 12. a plan developed to address deficiencies identified during a root cause analysis

Questions?

Joint Commission

• Accrediting organization for healthcare institutions

• Sets administrative and practice standards and evaluates compliance

• Performs unannounced on-site surveys of accredited hospitals to assess compliance every 18-39 months

Joint CommissionMission

• To continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations

National Patient Safety Goals

• Key national safety goals for hospitals

• Set by Joint Commission

• Updated yearly

• Goal is to promote specific improvements in patient safety

2008 NPSG

• Goal 1 Improve the accuracy of patient identification. – 1A Use at least two patient identifiers when

providing care, treatment or services.

2008 NPSG

• Goal 2 Improve the effectiveness of communication among caregivers.– 2A For verbal or telephone orders or for

telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result.

– 2B Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.

2008 NPSG

• Goal 2 Improve the effectiveness of communication among caregivers.– 2C Measure and assess, and if appropriate,

take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.

– 2E Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.

2008 NPSG

• Goal 3 Improve the safety of using medications.– 3C Identify and, at a minimum, annually review a

list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs.

– 3D Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.

– 3E Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.

2008 NPSG

• Goal 7 Reduce the risk of health care-associated infections.7AComply with current World Health Organization (WHO) Hand Hygiene Guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.– 7B Manage as sentinel events all identified cases

of unanticipated death or major permanent loss of function associated with a health care-associated infection

2008 NPSG

• Goal 8 Accurately and completely reconcile medications across the continuum of care.– 8A There is a process for comparing the patient’s

current medications with those ordered for the patient while under the care of the organization.

– 8B A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility.

2008 NPSG

• Goal 9 Reduce the risk of patient harm resulting from falls.– 9B Implement a fall reduction program

including an evaluation of the effectiveness of the program.

2008 NPSG

– Goal 13 Encourage patients’ active involvement in their own care as a patient safety strategy.

• 13A Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.

2008 NPSG

• Goal 15 The organization identifies safety risks inherent in its patient population.– 15A The organization identifies patients at risk

for suicide.

2008 NPSG

• Goal 16 Improve recognition and response to changes in a patient’s condition.– 16A The organization selects a suitable

method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening.

Quality ImprovementKey elements

• Systematic• Data-guided and knowledge informed• Experiential• Innovative• Employs formal explicit methodology• Continuous • Core responsibility of healthcare

professionals

Healthcare Quality Improvement2007

• Move from cottage industry mode of care delivery to data driven system model of healthcare delivery

• Systems approach

• Individual blame not the norm

• Individual IS accountable