SELECTING AND DESIGNING A QUALITY IMPROVEMENT PROJECT Introduction to Quality Improvement: Karen...

SELECTING AND DESIGNING A QUALITY IMPROVEMENT PROJECT

Introduction to Quality Improvement:

Karen Greer, MD, MPHDirector, Ambulatory PediatricsSt. Barnabas Hospital

Quality Is…

Review: Definition Of Quality

Quality: Meeting the needs and exceeding the expectations of those we serve. Deliver all and only the care that the patient and family needs.

√ Doing the right thing

(evidence based)

= For every patient (equal care)

====== Every time====== (consistent care)

Review: What Is Healthcare Quality Improvement?

Healthcare Quality Improvement: The body of knowledge, attitudes, and skills necessary to efficiently influence and continuously improve the multiple elements of care delivery within a medical practice.

Review: The Six Aims of Healthcare Quality Improvement

Safe: Patients should not be harmed by the care that is intended to help them.

Effective: Provide services based on scientific knowledge to all who could benefit and refrain from providing services to those not likely to benefit (Avoid underuse and overuse).

Patient-Centered: Care should be respective of and responsive to individual preferences, needs, and values.

Timely: Reduce unnecessary waits and harmful delays for both those who receive and those who give care.

Efficient: Avoid wasting of equipment, supplies, ideas and energy.

Equitable: Provide care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socio-economic status.

- Institute of Medicine

Choosing a Project

QI projects can focus on: 1. structure: how the system of care is configured

and/or its components 2. process: how care is delivered 3. outcomes: mortality, functional status, satisfaction,

quality of life

Choosing a Project

So…where do you begin?Ideas for projects can come from a variety of

sources: Everyday experiences while performing clinical duties Hospital quality improvement goals and standards Clinical Guidelines Local, State and Federal/National Guidelines or

Requirements Current or Ongoing Projects

Choosing a Project: Everyday Experiences

“Strange…this patient’s vaccination status is up to date according to the clinic chart, but it’s not up to date in the immunization registry.” Has this occurred with other patients? What are the possible reasons for the discrepancy?

“This patient didn’t show up for his follow-up weight check/asthma check/ vaccination visit…again.” How often has this occurred for this patient? For other patients? What processes are in place to notify patients about their

appointments? This patient was just discharged from the inpatient service

and is here for a follow-up visit, but I have no idea what happened during the admission.” Is this a standard occurrence? How can this be avoided in the future? What communication occurs between providers?


“Oops—her throat culture was positive last week, but I’m not sure if she received antibiotics. Dr. Brown usually documents his treatment on the lab report, but Dr. Green writes a new note. And Dr. White, well…” Is there a standardized system for lab follow-up?

Three different shifts, three different attendings, three different antibiotics chosen to treat an abscess…” Is there a standard protocol or guideline for treatment? Is there scientific evidence to support the use of a particular antibiotic?

“This is the third time I have made this referral/appointment. They keep repeating the same tests.” How are referrals and follow-up appointments tracked? What communication occurs between providers?

“I tried to recall this patient for chlamydia treatment, but her number is disconnected.” What do I do now?” How often are patients asked for demographic updates during registration?

During the visit? Is there a better way to communicate with patients?


“This patient did not take his Concerta while he was admitted last week. I guess that explains his behavior…” Does the intake process include a medication reconciliation

component? Is that process consistent? If the medication was stopped for a reason, was it documented? Are all patient medications reviewed upon discharge?

“Each note has a different list of asthma medications. I can’t tell which ones he’s actually using.”

“This patient’s mom just complained that she waited over two hours to be see this doctor, but saw another patient arrive and leave before she did. What was her appointment time? Is there some way to quantify how

long she actually waited? Are there identifiable delays in the registration process? In the triage

processs? In other sections of the visit? What communication occurs between patient and staff?


In other words, look at the things that: Slow your day down Make your job more difficult Force you to do extra work in order to provide the best

care Frustrate your patients Frustrate you

Choosing a Project: Hospital Quality Goals and Standards

Current St. Barnabas Hospital Goals: Reduction of Infection Rates

Hand Hygiene Isolation Procedures Equipment Maintenance

Patient Satisfaction Patient surveys Patient complaints

Prevention of Falls

Choosing a Project: Hospital Quality Goals and Standards

Medication Reconciliation and Reduction of Medical Errors

Reduction of wrong-sided surgery/procedures Time Outs Two patient identifiers

Enhancing Communication between Providers ER/Inpatient dischargesAmbulatory Clinic Referrals Tracking/Communication with Consultants

Ensuring Adequate Chart Documentation Implementation of electronic medical records

Choosing a Project: Clinical Guidelines

Are we compliant with established clinical guidelines? Asthma Guidelines Lead Screening Obesity/BMI Screening and Management Developmental Screening Screening and Treatment of Sexually Transmitted

Diseases Treatment and Management of UTI Management of Febrile Seizures

Example: NYC DOH Lead Screening Guideline

Choosing a Project:Local, State, and Federal/National Criteria

HEDIS: Health Effectiveness Data and Information Set:

A widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance (NCQA).

HEDIS measures are divided into eight categories: Effectiveness of Care Access/Availability of Care Satisfaction With the Experience of Care Health Plan Stability Use of Services Cost of Care Informed Choices Health Plan Descriptive Information.


HEDIS: Health Effectiveness Data and Information Set:

Measures are added, deleted, and revised annually. Data submission is required by CMS (Centers for

Medicare and Medicaid Services) HEDIS is one component of NCQA's accreditation

process. HEDIS results are used to track year-to-year

performance.


QARR: Quality Assurance Reporting Requirements: Consists of measures from HEDIS plus New York State-

specific measures: In 2012, the measures included:

Well Child Visits in the First 15 Month of Life Adolescent Preventive Care and Immunizations Use of Appropriate Asthma Medications Follow-Up Care for Children Prescribed ADHD

medication Annual Dental Visit Lead Screening in Children

Like HEDIS, measures can be added or deleted over time.


National Patient Safety Goals: Established in 2002 to help accredited organizations address

specific areas of concern in regards to patient safety Goals:

Improve the accuracy of patient identification Improve the effectiveness of communication among caregivers Improve the safety of using medications Reduce the risk of health care-associated infections Accurately and completely reconcile medications across the

continuum of care Reduce the risk of patient harm resulting from falls Prevent health care-associated pressure ulcers (decubitus ulcers)


New York City Immunization Registry: Established in 1998 Required reporting of all vaccines given to patients

<18 years of age (also NYS law) Quarterly reports provide Up-to-Date status of all

patients in a given practice Also used to track distribution and administration of

Vaccines For Children (VFC) vaccines Multiple provider-friendly functions, including pre-

populated school forms, vaccine ordering, and recall systems/queries


Newly Implemented Guidelines/LawsExample: New York State HIV Testing Law

Must offer HIV testing to all patients aged 13-64 years at least once per year. Must occur in all clinical settings:

Inpatient Emergency Room Ambulatory Clinics

Potential Projects: How do you demonstrate compliance? How close to compliance were we prior to the enacted

law? Should other testing be done simultaneously?

Choosing a Project: Current or Ongoing Projects

Build on (steal from) the work of others: Prior QI projects that need a follow-up evaluation

Examples: a former resident’s project that is unfinished or needs a new phase

Prior QI projects that didn’t work and need reassessment Why didn’t it work? What might you do differently?

Prior QI projects, but with a different angle: Examine a different component of the process Implement a new change to the process

Next Steps

OK, so I’ve picked a topic. Now what?

Next Steps: Model for Improvement

Model For Improvement:

The model has two parts:

1. Three fundamental questions, which can be addressed in any order.

2. The Plan-Do-Study-Act (PDSA) cycle to test and implement changes in real work settings.

Model for Improvement Question #1: What are you trying to accomplish?

Setting Aims: The aim should be:

Time-specific Measurable Should define the specific population of patients that will

be affected. Write a clear aim statement with specific numerical goals

Make targets achievable Make targets for improvement clear Be flexible and prepared to refocus

Model for Improvement Question #1: What are you trying to accomplish?

Examples: Adolescent Vaccination Status: Aim: Improve UTD vaccination status for adolescent

patients within 12 months. Time-specific:

Goal for target completion is outlined operational definition of being up-to-date according to

CDC and NYSDOH guidelines Measurable outcome: can review and quantify the number

of vaccines administered, determine the percentage of patients that are considered UTD. Target goal = 90% of patients with UTD status

Population-specific: target population = all adolescent outpatients aged 14 years old, seen during the past 12 months

Developing an Aim Statement

MFI Question #2: How will you know that a change is an improvement?

What processes are you examining?Example: Adolescent Vaccination Project

processes: Timely well child care and follow-up vaccination visits Accurate and regular reporting to the CIR

MFI Question # 2: How will you know that a change is an improvement?

Establishing Measures: Use quantitative measures to determine if a specific

change actually leads to an improvement.

Establishing Measures

Types of Measures: Outcome Measures: How is the system performing?

What is the result? Number of days to appointment/Time to third next

available appointment Average wait times Average hemoglobin A1c level for population of patients

with diabetes


Types of Measures: Process Measures: Are the parts/steps in the system

performing as planned? Percentage of patients receiving developmental screening

at age 18 months Percentage of patients with lead screening performed at

age 1 and 2 years.


Types of Measures: Balancing Measures: are changes designed to improve

one part of the system causing new problems in other parts of the system? If the goal was to reduce patients’ length of stay in the

hospital, are the readmission rates increasing as a result? Does creating an open access schedule for appointments

decrease availability for well child appointments? Does allowing patients to walk-in for sick visits increase

wait times for patients with scheduled appointments?


Types of Measures: Benchmarks: the “best in class”

“Should reflect the best current assessment of optimal care and efficiency”

Actual vs. expected performance: Is the outcome of a patient above, below, or equal to the

outcome that would be expected for a group of patients with similar underlying conditions and health status?

Percent Compliance: Denominator = the number of times that a provider had

the opportunity to provide an element of recommended care to a patient who was a candidate for that care

Numerator = the number of times that care was provided

Operational Definition Worksheet

MFI Question #2: How will you know that a change is an improvement?

For your first QI project, you must first establish a baseline: Assess current status: how close is it to the target goal? Evaluation of a retrospective period or an immediately

current periodExample: Adolescent project:

Obtain a report from the CIR indicating UTD rate for all 14 year-old adolescents seen in the outpatient clinics during the past 12 months.

Review the actual clinic charts for the same population of patients to determine UTD rate based on chart information.

Compare chart review results to CIR results.

MFI Question #3: What Changes Can be Made that Will Result in Improvement?

Selecting Changes: “All improvement will require change, but not all

change will result in improvement.” Therefore, we must identify the changes that are most likely to result in improvement.

Example: Adolescent Vaccination Project Should we revise our reminder/recall system for

appointments? How?

Developing Change Concepts

PDSA: Plan-Do-Study-Act

The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change in the real work setting — by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method used for action-oriented learning.

PDSA Worksheet

Implementing Changes

After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the team can implement the change on a broader scale — for example, for an entire pilot population or on an entire unit.

Implementing Changes

Implementing Change

Performance Improvement Reporting

Acronym Decoder

AHRQ: Agency for Healthcare Research and Quality: www.ahrq.gov CAHPS: Consumer Assessment Health Plan Survey

HCAPHS: Hospital Consumer Assessment Plan Survey CIR: City Immunization Registry: www.nyc.gov/health/cir CMS: Center for Medicare/Medicaid Services: www.cms.gov COE: Center of Excellence HEDIS: Health Effectiveness Data and Information Set IHI: Institute for Healthcare Improvement: www.ihi.org IOM: Institute of Medicine: www.iom.edu JCAHO/TJC: Joint Commission for Accreditation of Hospitals (now known as

The Joint Commission: www.jointcommission.org NCQA: National Committee on Quality Assurance www.ncqa.org NQF: National Quality Forum www.qualityforum.org NYCDOHMH: New York City Department of Health and Mental Hygiene

www.nyc.gov/health QARR: Quality Assurance Reporting Requirements RHIO: Regional Health Information Organization

References

Crossing the Quality Chasm: A New Health System for the 21st Century. Committee on Quality Health Care in America, Institute of Medicine. National Academy Press, Washington, D.C. 2001.

The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers, San Francisco, 1996.

An Introduction to the Model for Improvement. (Lecture) Robert Lloyd, PhD.

Road Map for Quality Improvement: A Guide for Doctors. Manoj Jain, MD MPH www.mjain.net/medicine/roadmap_for_qualityimprovement.pdf

How to Improve. Institute for Healthcare Improvement. www.ihi.org/IHI/Topics/ImprovementMethods/HowToImprove

Questions?

SELECTING AND DESIGNING A QUALITY IMPROVEMENT PROJECT Introduction to Quality Improvement: Karen...

Documents

Transcript of SELECTING AND DESIGNING A QUALITY IMPROVEMENT PROJECT Introduction to Quality Improvement: Karen...