Quality Improvement in the Hospital Jason Stein, MD Emory Reynolds Faculty Scholar Emory Hospital...

Quality ImprovementQuality Improvement in the Hospital in the Hospital

Jason Stein, MDJason Stein, MDEmory Reynolds Faculty ScholarEmory Reynolds Faculty ScholarEmory Hospital Medicine ServiceEmory Hospital Medicine Service

Highest Quality Care for the Hospitalized ElderlyHighest Quality Care for the Hospitalized Elderly

Quality Improvement in the Hospital:Quality Improvement in the Hospital:Goals for this PrimerGoals for this Primer

Understand fundamental concepts in Understand fundamental concepts in quality improvement quality improvement

Identify the environment and key steps for Identify the environment and key steps for a successful quality improvement project a successful quality improvement project

Become familiar with several quality Become familiar with several quality improvement tools and their use improvement tools and their use

Emory Reynolds Program

Emory Hospital Medicine Service

Highest Quality Hospital CareHighest Quality Hospital Care

ProcessesProcesses OutcomesOutcomes

What do you care more about?

Optimal ProcessOptimal Process::

identifyidentify correctable correctable problem problem

identify identify preventable preventable problem problem

Optimal OutcomeOptimal Outcome::

correct correctable correct correctable problemproblem

prevent preventable prevent preventable problemproblem

Highest Quality Hospital CareHighest Quality Hospital CareHighest Quality Hospital CareHighest Quality Hospital Care


ProcessesProcesses PhysiciansPhysicians

Is one more effective?

vs



Is one more reliable?

vs



If your hospital lacks a specific process to drive a specific outcome, do

individual physicians fill the gap?

vs

Quality Improvement: Quality Improvement: Bridging the Implementation GapBridging the Implementation Gap

Patient care

Pro

gres

s

Time

How good is American healthcare?


Patient care

Pro

gres

s

Time

We get it right 54% of the time.-Brent James, MD, MStat Executive Director, Intermountain Health Care


Implementation Gap

Scientific understanding

Patient care

Pro

gres

s

Time

Hospitalists and Quality ImprovementHospitalists and Quality Improvement

Complex process problems need multidisciplinary Complex process problems need multidisciplinary solutionssolutions

We are at the frontlines seeing system failures, process We are at the frontlines seeing system failures, process errors, and performance gaps with our own eyes -- which errors, and performance gaps with our own eyes -- which is our competitive advantageis our competitive advantage

Improved quality delivers:Improved quality delivers:– better patient care…better patient care…– at lower costs…at lower costs…– with potentially higher reimbursements (pay-for-performance)…with potentially higher reimbursements (pay-for-performance)…And it can make our jobs more interesting, fun, and rewarding.And it can make our jobs more interesting, fun, and rewarding.

Section I:Section I:

Quality Improvement and ChangeQuality Improvement and Change

in the Hospital Atmospherein the Hospital Atmosphere

Definition of Definition of QualityQuality

Meeting the needs and exceeding the Meeting the needs and exceeding the expectations of those we serveexpectations of those we serve

Delivering all and only the care that the patient Delivering all and only the care that the patient and family needsand family needs

““Definition” of Definition” of ImprovementImprovement

It is NOT…It is NOT… yelling at people to work harder, faster, or saferyelling at people to work harder, faster, or safer creating order sets or protocols and then failing to creating order sets or protocols and then failing to

monitor their use or effectmonitor their use or effect traditional Quality Assurancetraditional Quality Assurance research (but they can co-exist nicely)research (but they can co-exist nicely)

Principle #1:Principle #1: Improvement Requires ChangeImprovement Requires Change

Every system is perfectly designed to achieve Every system is perfectly designed to achieve exactly the results it getsexactly the results it gets

To improve the system, change the system…To improve the system, change the system…

Principle #2:Principle #2:

Less is MoreLess is More

You cannot destroy productivityYou cannot destroy productivity

When changing the system, keep it simpleWhen changing the system, keep it simple

Illustrating Principle #2: Less Is MoreIllustrating Principle #2: Less Is MoreProbability of Performing PerfectlyProbability of Performing Perfectly

No.No.

ElementElementss

Probability of Success, Each ElementProbability of Success, Each Element

0.950.95 0.990.99 0.9990.999 0.999990.9999999

11

2525

5050

100100

0.950.95

0.280.28

0.080.08

0.0060.006

0.990.99

0.780.78

0.610.61

0.370.37

0.9990.999

0.980.98

0.950.95

0.900.90

0.999990.9999999

0.9980.998

0.9950.995

0.990.99

Understanding Change in the Hospital Understanding Change in the Hospital AtmosphereAtmosphere

ChangeChange = not just = not just doing doing something different, but something different, but engineeringengineering something different something different

at least one step in at least one processat least one step in at least one process

Hospital AtmosphereHospital Atmosphere = hospitals tend to be viscous, = hospitals tend to be viscous, complex systems with default levels of performancecomplex systems with default levels of performance

change engineered to improve performance can be a foreign concept - change engineered to improve performance can be a foreign concept - or even overtly resisted or even overtly resisted

Understanding Change in the Hospital Understanding Change in the Hospital

AtmosphereAtmosphere

A Common Strategy Which Commonly Fails:A Common Strategy Which Commonly Fails: Experts design a comprehensive protocol using Experts design a comprehensive protocol using

EBM over several monthsEBM over several months Protocol is presented as a finished, stand alone Protocol is presented as a finished, stand alone

productproduct Customization of protocol is discouragedCustomization of protocol is discouraged Compliance depends on vigilance and hard workCompliance depends on vigilance and hard work Monitoring for success or failure is the exception Monitoring for success or failure is the exception

to the rule (with failures coming to light after to the rule (with failures coming to light after patients are harmed)patients are harmed)

Flawed implementation leads to repetitive efforts Flawed implementation leads to repetitive efforts down the roaddown the road

Understanding Change in the Hospital Understanding Change in the Hospital

AtmosphereAtmosphere

High-Reliability Strategies Commonly Succeed:High-Reliability Strategies Commonly Succeed: Build a “decision aide” or reminder into the systemBuild a “decision aide” or reminder into the system Make the desired action the default action (not doing the Make the desired action the default action (not doing the

desired action requires opting out)desired action requires opting out) Build redundancy into responsibilities (e.g. if one person Build redundancy into responsibilities (e.g. if one person

in the chain overlooks it, someone else will catch it)in the chain overlooks it, someone else will catch it) Schedule steps to occur at known intervals or events Schedule steps to occur at known intervals or events Standardize a process so that deviation feels weirdStandardize a process so that deviation feels weird Take advantage of work habits or reliable patterns of Take advantage of work habits or reliable patterns of

behaviorbehavior

Build at least one - if not more - of these high-reliability Build at least one - if not more - of these high-reliability strategies into any changed process.strategies into any changed process.

Understanding Change in the Hospital Understanding Change in the Hospital AtmosphereAtmosphere

ChangeChange engineered to drive improvement depends on engineered to drive improvement depends on…… Workplace CultureWorkplace Culture: personnel must be receptive to change: personnel must be receptive to change AwarenessAwareness: administrative and medical staffs must care : administrative and medical staffs must care

about performance and support its improvement through about performance and support its improvement through changechange

EvidenceEvidence: local experts must identify which research to : local experts must identify which research to translate into practice translate into practice

ExperienceExperience: a skilled team must choose, implement, and : a skilled team must choose, implement, and follow up changes to ensure:follow up changes to ensure:

1) improvement efforts are ongoing and yielding better 1) improvement efforts are ongoing and yielding better performanceperformance

2) productivity is preserved2) productivity is preserved

An Atmosphere for ChangeAn Atmosphere for Change

AAWARENESSWARENESS

OOFF THETHE L LOCAL OCAL PPERFORMANCEERFORMANCE G GAPAP PatientPatient

Medical StaffMedical Staff

Administrative SupportAdministrative Support

EEXPERIENCEXPERIENCE

WWITHITH SSIMILAR IMILAR IIMPROVEMENTMPROVEMENT EEFFORTSFFORTS

Hospitalist Quality OfficerHospitalist Quality Officer

Multidisciplinary Team MembersMultidisciplinary Team Members

Success Stories From Other Success Stories From Other InstitutionsInstitutions

EEVIDENCEVIDENCE

TTOO T TRANSLATERANSLATE I INTONTO P PRACTICERACTICE

““Bedside” TeachingBedside” Teaching

Didactic Teaching SessionsDidactic Teaching Sessions

Local Expertise in Disease Local Expertise in Disease LiteratureLiterature

WWORKPLACE ORKPLACE CCULTUREULTURE

RREADYEADY T TOO A ACCEPTCCEPT C CHANGEHANGE

Task LoadTask Load

Culture of ImprovementCulture of Improvement

Culture of Negative ExpectationsCulture of Negative Expectations


AAWARENESSWARENESS

OOFF THETHE L LOCAL OCAL PPERFORMANCEERFORMANCE G GAPAP PatientPatient

Medical StaffMedical Staff

Hospital AdministrationHospital Administration

PatientPatientAt mercy and increasingly aware of At mercy and increasingly aware of

underperforming underperforming status quostatus quo

Now can access a new resource Now can access a new resource promoting transparency in hospital promoting transparency in hospital performance: performance: www.hospitalcompare.hhs.govwww.hospitalcompare.hhs.gov

Hospital AdministrationHospital AdministrationUnderstands sUnderstands status quotatus quo is unacceptable is unacceptable

(IOM, Leapfrog, NQF, JCAHO) (IOM, Leapfrog, NQF, JCAHO)

Sees fiscal health tied to performance Sees fiscal health tied to performance against national benchmarks, ability to against national benchmarks, ability to reduce costs & LOS, improve margins, reduce costs & LOS, improve margins, and competitive reputation in the and competitive reputation in the communitycommunity

Medical StaffMedical StaffHas professional responsibility to improveHas professional responsibility to improve

Knows all too well where system failsKnows all too well where system fails

Recognizes that professional livelihood Recognizes that professional livelihood will depend on paying attention to will depend on paying attention to outcomes: outcomes:

Pay-for-Performance Pay-for-Performance

http://www.hospitalcompare.hhs.gov/


EEXPERIENCEXPERIENCE

WWITHITH SSIMILAR IMILAR IIMPROVEMENTMPROVEMENT EEFFORTSFFORTS

Hospitalist Team FacilitatorHospitalist Team Facilitator


Successful Strategies of OthersSuccessful Strategies of Others

Hospitalist Team FacilitatorHospitalist Team Facilitator

Technical expert on Quality Technical expert on Quality Improvement theory and tools Improvement theory and tools

Owns the team process, enforces Owns the team process, enforces ground rules, helps judge feasibility ground rules, helps judge feasibility

Teaches the team while doingTeaches the team while doing


Chosen for hands-on, fundamental Chosen for hands-on, fundamental knowledge of key processesknowledge of key processes

Inclusive, open, & consensus seekingInclusive, open, & consensus seeking

Impact not only the change(s) but the Impact not only the change(s) but the implementationimplementation

Successful Strategies of OthersSuccessful Strategies of Others

Learn from mistakes of others Learn from mistakes of others

Adapt successes of others (tools and Adapt successes of others (tools and methods): steal shamelesslymethods): steal shamelessly

Get specific advice in ’Ask the Expert’ Get specific advice in ’Ask the Expert’ forums or other consortiums that forums or other consortiums that collect and share experience collect and share experience


EEVIDENCEVIDENCE

TTOO T TRANSLATERANSLATE I INTONTO P PRACTICERACTICE



Local Expertise in Disease LiteratureLocal Expertise in Disease Literature


To an audience of residents or students To an audience of residents or students

To build cadre of “experts” (and to help To build cadre of “experts” (and to help meet ACGME requirements)meet ACGME requirements)

Download teaching pearls from SHM Download teaching pearls from SHM resource roomsresource rooms

Local Expertise in Disease LiteratureLocal Expertise in Disease Literature

Decide what changes to make based on Decide what changes to make based on the level of evidencethe level of evidence

Establishes team’s credibilityEstablishes team’s credibility

Extends team’s authority when local sub-Extends team’s authority when local sub-specialists or experts participate in specialists or experts participate in selecting and implementing changeselecting and implementing change


To an audience of peers, administrators, To an audience of peers, administrators, nurses, or support staff nurses, or support staff

To boost awareness, knowledge, enthusiasm, To boost awareness, knowledge, enthusiasm, and support and support

Download slide sets from SHM resource Download slide sets from SHM resource rooms rooms


WWORKPLACE ORKPLACE CCULTUREULTURE

RREADYEADY T TOO A ACCEPTCCEPT C CHANGEHANGE

Task LoadTask Load

Culture of Improvement vs.Culture of Improvement vs.


Task LoadTask Load

Be sensitive about piling new tasks onto Be sensitive about piling new tasks onto over-tasked personnelover-tasked personnel

Use the input of personnel who will be Use the input of personnel who will be responsibile for implementingresponsibile for implementing

Make it easy and desirable to do the right Make it easy and desirable to do the right thingthing


Overcome it, one person and one project at a time Overcome it, one person and one project at a time

Attach pride to balance between performance Attach pride to balance between performance successes and failuressuccesses and failures

Consider using a ‘cultural survey’ to identify Consider using a ‘cultural survey’ to identify problems and address them through proper problems and address them through proper channelschannels

Culture of ImprovementCulture of Improvement

Extend it, one person and one project at a timeExtend it, one person and one project at a time

Advertise successesAdvertise successes

Use or adapt this online ‘cultural survey:’ Use or adapt this online ‘cultural survey:’ http://www.patientsafetygroup.org/program/step1c.cfmhttp://www.patientsafetygroup.org/program/step1c.cfm

https://webmail.service.emory.edu/horde/util/go.php?url=http%3A%2F%2Fwww.patientsafetygroup.org%2Fprogram%2Fstep1c.cfm&Horde=a717d352d24325c4a4ebb1ad681622a0

Section II:Section II:

The Multidisciplinary TeamThe Multidisciplinary Team

Defining an Approach to ChangeDefining an Approach to Change

The Driving Force for ChangeThe Driving Force for Change

TTHEHE MMULTIDISCIPLINARYULTIDISCIPLINARY TTEAMEAM

Leverages frontline expertise and experience. Leverages frontline expertise and experience. Impacts not only the change/interventions, Impacts not only the change/interventions,

but also the implementationbut also the implementation

The Driving Force for Change:The Driving Force for Change: The Multidisciplinary Team The Multidisciplinary Team

A team is not the same as a committee…A team is not the same as a committee…CommitteeCommittee individuals bring individuals bring representationrepresentation productive capacity = single most able memberproductive capacity = single most able member

TeamTeam individuals bring individuals bring fundamental knowledgefundamental knowledge productive capacity = synergistic (more than the productive capacity = synergistic (more than the

sum of all individual team members together)sum of all individual team members together)


Features of a good team…Features of a good team… Safe (no Safe (no ad hominemad hominem attacks) attacks) Inclusive (values all potential contributors including Inclusive (values all potential contributors including

diverse views; not a clique)diverse views; not a clique) Open (considers Open (considers allall ideas fairly) ideas fairly) Consensus seekingConsensus seeking


Consensus…Consensus… definitiondefinition: finding a solution acceptable enough that : finding a solution acceptable enough that

all members can support it; no member opposes itall members can support it; no member opposes it

It is not:It is not:– A unanimous vote (consensus may not represent A unanimous vote (consensus may not represent

everyone’s first priorities)everyone’s first priorities)– A majority vote (in a majority vote, only the majority gets A majority vote (in a majority vote, only the majority gets

something they are happy with; people in the minority something they are happy with; people in the minority may get something they don’t want at all, which is not may get something they don’t want at all, which is not what consensus is all about)what consensus is all about)

– Everyone totally satisfiedEveryone totally satisfied


Three types of team members…Three types of team members…1) Team Leader1) Team Leader

2) Team Facilitator2) Team Facilitator

3) Process Owners (members with operational, hands-on 3) Process Owners (members with operational, hands-on fundamental knowledge of the process)fundamental knowledge of the process)


Team Leader…Team Leader… schedules and chairs team meetingsschedules and chairs team meetings sets the agenda (printed at each meeting)sets the agenda (printed at each meeting) records team activities (working documents in records team activities (working documents in

binder)binder) reports to management (Steering Team)reports to management (Steering Team) often a member of Steering Teamoften a member of Steering Team


Team Facilitator…Team Facilitator… owns the team process (enforces ground rules)owns the team process (enforces ground rules) technical expert on QI theory and toolstechnical expert on QI theory and tools assists Team Leaderassists Team Leader teaches while doing, within teamteaches while doing, within team


Process Owners…Process Owners… chosen for fundamental knowledgechosen for fundamental knowledge will help implementwill help implement should become leaders (so choose wisely)should become leaders (so choose wisely)


Team Ground Rules…Team Ground Rules… All team members and opinions are equalAll team members and opinions are equal Team members will speak freely and in turnTeam members will speak freely and in turn

– We will listen attentively to othersWe will listen attentively to others– Each must be heardEach must be heard– No one may dominateNo one may dominate

ProblemsProblems will be discussed, analyzed, or attacked (not will be discussed, analyzed, or attacked (not peoplepeople)) All agreements are kept unless renegotiatedAll agreements are kept unless renegotiated Once we agree, we will speak with "One Voice" (especially after leaving the Once we agree, we will speak with "One Voice" (especially after leaving the

meeting)meeting) Honesty before cohesivenessHonesty before cohesiveness Consensus vs. democracy: each gets his say, not his wayConsensus vs. democracy: each gets his say, not his way Silence equals agreementSilence equals agreement Members will attend regularlyMembers will attend regularly Meetings will start and end on timeMeetings will start and end on time

A Brief Digression into Quality A Brief Digression into Quality Improvement TheoryImprovement Theory


worse better Quality

After

Before

Quality Assu

rance

Bell Curve:Inpatient Population

Tail

Will the team target ‘all’ patients in the inpatient bell curve, or just a sub-group considered ‘at-risk’ (depicted in the outlying tail)? Is the quality of inpatient care which is not in the tail somehow ‘acceptable?’


worse better Quality

After

Before

worse betterQualityQuality

Assurance


Tail

If the team can identify and define an inpatient sub-group ‘at-risk,’ then improvement efforts could conceivably focus just on these ‘at-risk’ patients - this is similar to traditional Quality Assurance. Note that even if tail events are eliminated, the quality of care for the rest of the inpatient population (depicted by the unchanged position and shape of the bell curve) does not improve at all. While the mean does move toward better care, this is due only to eliminating statistical outliers.


worse better

worse betterQuality

Quality

After

Before

worse betterQualityQuality

Assurance

Quality Improvement


Tail

betterbetter

If the team identifies a performance gap applicable to a wider patient population, the team may design changes in processes with the potential for dramatic effect: improvement and standardization in processes reduces variation (narrows the curve) and raises quality of care for all (shifts entire curve toward better care). This radical change is what defines Quality Improvement.

Section III:Section III:

Tools for Engineering ChangeTools for Engineering Change

Engineering ChangeEngineering Change

Hospitals have two dynamic levels impacting Hospitals have two dynamic levels impacting performance:performance:1) Processes1) Processes

tasks performed in series or in parallel, impacting patient care tasks performed in series or in parallel, impacting patient care and potentially patient outcomesand potentially patient outcomes

2) Personnel 2) Personnel skilled people with hearts and minds, with variable levels of skilled people with hearts and minds, with variable levels of

attention, time, and expertiseattention, time, and expertise

Engineering Change:Engineering Change: What Variables Impact Quality Outcomes of Care?What Variables Impact Quality Outcomes of Care?

Structure Processes Outcomes of Care

Inputs Steps Outputs

•Patients•Equipment•Supplies•Training•Environment

•Inventory Methods•Coordination•Physician orders•Nursing Care•Ancillary staff•Housekeeping•Transport

•Physiologic parameters•Functional status•Satisfaction•Cost

Engineering Change:Engineering Change: What Variables Impact Quality Outcomes of Care?What Variables Impact Quality Outcomes of Care?

Processes

Steps

•Inventory Methods•Coordination•Physician orders•Nursing Care•Ancillary staff•Housekeeping•Transport

The two most dynamic levels impacting performance

Personnel


ProcessesProcesses– all those affecting relevant aspects of patient all those affecting relevant aspects of patient

care care clinical decision making, order writing, admission clinical decision making, order writing, admission

intake, medication delivery, direct patient care, intake, medication delivery, direct patient care, discharge planning, PCP communication, discharge discharge planning, PCP communication, discharge follow-up, etcfollow-up, etc


PersonnelPersonnel– anybody who touches the patient or a relevant anybody who touches the patient or a relevant

process in the systemprocess in the system departments, physicians, clerks, pharmacy, nursing, departments, physicians, clerks, pharmacy, nursing,

RT, PT/OT/ST, care technicians, phlebotomist, RT, PT/OT/ST, care technicians, phlebotomist, patient transport, administrationpatient transport, administration

Engineering Change: Engineering Change: The Multidisicplinary Team Asks “What?”The Multidisicplinary Team Asks “What?”

What?What?– is the right thing to do?is the right thing to do?– will make the system more effective?will make the system more effective?

Engineering Change: Engineering Change: The Multidisicplinary Team Asks “Where?”The Multidisicplinary Team Asks “Where?”

Where?Where?– are the processes to improve?are the processes to improve?

BrainstormingBrainstorming Multivoting & nominal group techniqueMultivoting & nominal group technique Affinity groupingAffinity grouping

– do we start? (dissect and understand the processes)do we start? (dissect and understand the processes) Cause and effect diagrams Cause and effect diagrams (Ishikawa or ‘fishbone’ diagrams) (Ishikawa or ‘fishbone’ diagrams) Tally sheetsTally sheets Pareto chartsPareto charts Flow Flow (conceptual flow, decision flow) (conceptual flow, decision flow) chartscharts Run chartsRun charts SPC chartsSPC charts Scatter chartsScatter charts

Tools for Engineering Change: Tools for Engineering Change: Cause-and-Effect DiagramCause-and-Effect Diagram

sometimes also called a ‘fishbone’ or sometimes also called a ‘fishbone’ or Ishikawa diagramIshikawa diagram graphically displays list of possible factors, focused on one graphically displays list of possible factors, focused on one

topic or objectivetopic or objective used to quickly organize and categorize ideas during a used to quickly organize and categorize ideas during a

brainstorming session, often as an interactive part of the brainstorming session, often as an interactive part of the session itself (the added organization can help produce session itself (the added organization can help produce balanced ideas during a brainstorming session)balanced ideas during a brainstorming session)

Tools for Engineering Change: Cause-and-Effect Diagram

PhysiologicFactors

PharmocologicFactors

Drug Administration

Errors

Ordering Errors

Transcribing

Spelling

Pharmacokinetics

Renal

Dilution

Time

Nurse

Route

Rate

ADE

NursePhysician

Pharmacist

PhysicianPharmacy

Nurse/Clerk

PharmacistPatient

PhysicianDietician

Patient

Wrong Drug

Dose

Scheduling

Dosage

Route

Past Allergic Reaction

Absorption

WeightAge

Gender

Electrolyte

Hepatic

RacePharmacodyamics

ExpectedDrug/Drug

Unforeseen

Drug/Food

Drug/Lab

Cognitive

Psychiatric

Compliance

Patient Errors

Order Missed

Place outcome here

Example: Adverse Drug Events (ADE)

This Cause-and-Effect Diagram (a.k.a. “Fishbone” or This Cause-and-Effect Diagram (a.k.a. “Fishbone” or IshikawaIshikawa DiagramDiagram) is very ) is very versatile: it’s also an effective tool for retrospective (versatile: it’s also an effective tool for retrospective (Root Cause AnalysisRoot Cause Analysis) or ) or prospective analyses of patient safety issues (prospective analyses of patient safety issues (Failure Modes Effect AnalysisFailure Modes Effect Analysis).).

Tools for Engineering Change: Pareto Chart

• graphical display of the relative weights or frequencies of competing events, choices, or options

• a bar chart, sorted from greatest to smallest, that summarizes the relative frequencies of events, choices, or options within a class

• often includes a cumulative total line

• used to focus within a broad category containing many choices, based on factual or opinion-based information

• can combine factors that contribute to each item's practical significance

0

10

20

30

40

50

60

70

80

90

100

Perc

en

t

CausesCauses

Tools for Engineering Change: Pareto Chart

Con

trib

uti

ng

Causes Contributing to Adverse Drug Events

Tools for Engineering Change: Tools for Engineering Change: Sketching Processes or FlowSketching Processes or Flow

Macro Process MapsMacro Process Maps Decision Flow DiagramsDecision Flow Diagrams

Tools for Engineering Change: Tools for Engineering Change: Macro Process MapMacro Process MapThe patient is

admitted to thehospital

The patient isclinically identified

as having heartfailure

The ejection fractionis evaluated

The ejection fractionis documented in the

chart

The ejection fraction< 40%

The ejection fraction> 39%

The patient isprescribed an ACEI

in hospital

The patient isprescribed an ACEI

at discharge

The patient is notprescribed an ACEI

in hospital

The contraindicationfor an ACEI is

documented in thechart

The patient isexcluded from thetarget population

Example: Heart Failure Core Measures 2-3

Deep Post-OpWound Infection

BacteremiaUTI Pneumonia Other

Prevention

Detection

Treatment

PatientPreparation

ProphylacticAntibiotics

Surgery

Post-OpWound Care

- Sterile Technique- Operative Findings

Prevention

PatientSelection

AntibioticSelection

Delivery

- Duration

Prophylaxis

- Timing

Tools for Engineering Change: Decision Flow Diagram

For iatrogenic infections, any given type of infection can be dissected into the hierarchy of

contributing layers.

Contributing layer dissected: Prevention

Contributing layer dissected: Prophylactic Antibiotics

Calling out the contributing layers helps the team think through the steps ripest for change.

Our brains understand graphics better than tablesOur brains understand graphics better than tables Tabular information doesn’t convey trends over time very Tabular information doesn’t convey trends over time very

wellwell Keep it simpleKeep it simple In center of In center of horizontal axishorizontal axis place: baseline mean place: baseline mean

performanceperformance In center of In center of vertical axisvertical axis place: implementation point place: implementation point Can add upper and lower control limits, but usually not Can add upper and lower control limits, but usually not

neededneeded

Tools for Engineering Change: Run Charts

Percent Sliding Scale Insulin Only

0

10

20

30

40

50

60

70

80

Perc

ent 10/20/03

New Order Set

01/20/04

CPOE - TH


Percent with Frank Hypoglycemic Events

0

2

4

6

8

10

12

14

16

Perc

en

t

10/20/03New Order Set

CPOETH - 1/04HC - 8/04

March 2003Team Forms


Percent with Optimal/Acceptable Glucose Readings

0

10

20

30

40

50

60

70

80

90

100

Perc

ent

CPOETH - 1/04HC - 8/04

10/20/03New Order Set

March 2003Team Forms

Tools for Engineering Change:

Run Charts

Engineering Change: Engineering Change: The Multidisicplinary Team Asks “How?”The Multidisicplinary Team Asks “How?”

How?How?– can you make it easy to do the right thing?can you make it easy to do the right thing?

You cannot destroy productivityYou cannot destroy productivity– Changes must maintain, or enhance, workplace efficiency or balanceChanges must maintain, or enhance, workplace efficiency or balance

You must devote as much attention to fitting changes into clinical work You must devote as much attention to fitting changes into clinical work flow as you do to the evidence-based guideline flow as you do to the evidence-based guideline

– Changes must be blended into the flow of clinical careChanges must be blended into the flow of clinical care– Important variables to consider: staffing, training, supplies, physical layout, Important variables to consider: staffing, training, supplies, physical layout,

information flow, and educational materialsinformation flow, and educational materials


Improve incrementally. Learn through action.Improve incrementally. Learn through action.

PPlan lan DDo o SStudy tudy AActct

PDSA PDSA PDSA PDSA PDSA PDSA PDSA PDSA PDSA PDSA PDSA PDSA

Test your changes. Assess their effect.Test your changes. Assess their effect. Then re-work the changes and do it again…and Then re-work the changes and do it again…and

again…again…

Engineering Change: Engineering Change: PDSA PDSA

(the Benefits of Repeated Cycles)(the Benefits of Repeated Cycles)

Increases belief that change will result in Increases belief that change will result in improvementimprovement

Allows opportunities for “failures” without Allows opportunities for “failures” without impacting performanceimpacting performance

Provides documentation of improvementProvides documentation of improvement Adapts to meet changing environmentAdapts to meet changing environment Evaluates costs and side-effects of the changeEvaluates costs and side-effects of the change Minimizes resistance upon implementationMinimizes resistance upon implementation

Engineering ChangeEngineering Change: : PDSAPDSA

Overview:Overview:– scientific method for action-oriented learning: scientific method for action-oriented learning:

shorthand for testing a change in the real world shorthand for testing a change in the real world settingsetting

– test a change by: planning it, trying it, test a change by: planning it, trying it, measuring its results… and then trying to do it measuring its results… and then trying to do it better the next time better the next time

– multiple rounds of changes – some failures and multiple rounds of changes – some failures and some successes - should lead to improved some successes - should lead to improved aggregate outcome aggregate outcome

Engineering ChangeEngineering Change: : PDSAPDSA

Principles for Success:Principles for Success:– start new changes on the smallest possible start new changes on the smallest possible

scale, e.g. one patient, one nurse, one doctorscale, e.g. one patient, one nurse, one doctor– run just as many PDSA cycles as necessary to run just as many PDSA cycles as necessary to

gain confidence in your change – then expand gain confidence in your change – then expand – expand incrementally to more patientsexpand incrementally to more patients– expand to involve more nurses, more doctors, expand to involve more nurses, more doctors,

more departmentsmore departments– balance changes within system to ensure other balance changes within system to ensure other

processes not adversely stressedprocesses not adversely stressed

What do we want to achieve?

How will we measure our progress?

What changes will drive our progress?

How should we modify our latest changes?

modified from: The Foundation of Improvement by Thomas W. Nolan et. al


What do we want to achieve?What do we want to achieve?Set an outcome aim.Set an outcome aim. (It should be ambitious, must be measurable and (It should be ambitious, must be measurable and must specify a time-period and a definite population must specify a time-period and a definite population in your hospital.)in your hospital.)

List the outcome aim again, then:List the outcome aim again, then:– ask “why” three times,ask “why” three times,– ask “how” three times,ask “how” three times,– look at the new aim statements, andlook at the new aim statements, and– pick the best onepick the best one

“Function Expansion”



What changes will drive our progress ?What changes will drive our progress ?

Select change(s) to your system, the one(s) Select change(s) to your system, the one(s) most likely to improve outcomes.most likely to improve outcomes.

(Recognize that not all changes improve outcomes (Recognize that not all changes improve outcomes or offer balance.)or offer balance.)



How will we measure our progress?How will we measure our progress?

Define what you will measure quantitatively.Define what you will measure quantitatively.

(Collect data, chart measures regularly over (Collect data, chart measures regularly over specified time-period, and chart against benchmarks specified time-period, and chart against benchmarks & goal lines.)& goal lines.)

Principles of Measurement: Seek usefulness, not perfection. Integrate measurement into the daily routine. Use qualitative and quantitative data. Use sampling.Plot data over time.

Three Types of Measures: 1) Outcomes2) Process3) Balancing measures

(Use a balanced set of measures for all improvement efforts.)



How should we modify our latest changes?How should we modify our latest changes?

Test your changes.Test your changes.

(Run PDSA cycles to learn from the work setting.)(Run PDSA cycles to learn from the work setting.)


Engineering Change:Engineering Change:

Hints for SuccessHints for Success Empower nursingEmpower nursing Expedite order set and protocol passage through appropriate medical staff committeesExpedite order set and protocol passage through appropriate medical staff committees Better to implement an imperfect, compromise change than no change at allBetter to implement an imperfect, compromise change than no change at all Pilot newest changes on smallest scalePilot newest changes on smallest scale Provide hot line or support for difficult implementation situationsProvide hot line or support for difficult implementation situations Use your new system as a shared baseline, with clinicians free to vary based on Use your new system as a shared baseline, with clinicians free to vary based on

individual patient needsindividual patient needs Follow metrics continuously as you implementFollow metrics continuously as you implement Feed metrics back into subsequent PDSA cyclesFeed metrics back into subsequent PDSA cycles Measure, learn, and over time eliminate variation arising from professionals; retain Measure, learn, and over time eliminate variation arising from professionals; retain

variation arising from patientsvariation arising from patients Keep big picture in mindKeep big picture in mind Negotiate ‘speed bumps’Negotiate ‘speed bumps’

– Time delays in getting dataTime delays in getting data– Incomplete buy-inIncomplete buy-in– Go around obstacles instead of through them (can always go back to them later)Go around obstacles instead of through them (can always go back to them later)– Some who disagree with you may be correctSome who disagree with you may be correct– Make changes painless as possible: make it easy to do the right thingMake changes painless as possible: make it easy to do the right thing

QI Theory:QI Theory:Quality Improvement in the HospitalQuality Improvement in the Hospital

Suggested next steps:Suggested next steps:1) Share this primer in QI Theory with other hospitalists in 1) Share this primer in QI Theory with other hospitalists in

your groupyour group2) Identify an important QI project at your hospital2) Identify an important QI project at your hospital3) Lead the QI project using all available resources3) Lead the QI project using all available resources4) Learn from your experience and be among the first to 4) Learn from your experience and be among the first to

mentor other hospitalistsmentor other hospitalists

AcknowledgmentsAcknowledgments

Brent James, MD, MStat (Intermountain Health Care's Institute for Brent James, MD, MStat (Intermountain Health Care's Institute for Health Care Delivery Research): concepts, content, figuresHealth Care Delivery Research): concepts, content, figures

Thomas Nolan, PhD (Institute for Healthcare Improvement): concepts, Thomas Nolan, PhD (Institute for Healthcare Improvement): concepts, content, figurescontent, figures

Greg Maynard, MD, MSc (University of California, San Diego): editorial Greg Maynard, MD, MSc (University of California, San Diego): editorial composition and reviewcomposition and review

Jason Stein, MD (Emory University School of Medicine): editorial Jason Stein, MD (Emory University School of Medicine): editorial compositioncomposition

Quality Improvement in the Hospital Jason Stein, MD Emory Reynolds Faculty Scholar Emory Hospital...

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