Transcript Using Quality Research strategies to improve a QI project

Using Quality Research
strategies to improve a QI
project
Associate Professor Helen McBurney
Department of Physiotherapy
Monash University & Latrobe Regional Hospital
Associate Professor
School of Primary Health Care
Monash University
Purpose of this workshop
• To help you identify strategies to improve
the quality of your quality improvement
project.
• The strategies are based on methods
used to improve the quality of a research
project
Identify your problem
What is a current issue in your facility/practice?
Is there an area where you have not reviewed
your practices or procedures for a significant
time?
Is there a journal article that you have reviewed
that uses an evidence based practice
framework and suggests that your practices
may be no longer the ‘best’?
Is there a service delivery issue needing to be
addressed?
Identify your problem
Case Study 1
We need to have 50 more patients receive a
joint replacement in the next 3 months than
in the last 3 months.
There will be no additional beds or staff time
allocated for these procedures.
Questions arising from the problem
Case Study 1
How many joint replacement patients were
there in the past 3 months?
What was the average length of stay?
What was their discharge destination?
What is best practice?
What are reasonable actions or strategies
we can use to address the problem?
Identify your problem
Case study 2
Our HITH program is clearly above the State
average for Length of Stay and for
readmissions in DRG 64a & b
Questions arising from the problem
Case Study 2
What is the State average (and SD or other
statistics) for length of stay?
What is the State average for readmissions?
What is the best practice evidence available
in the literature?
What strategies can we adopt to address
this problem?
Turn the problem into an
answerable question
PICO:
The question should identify:
the patient group or problem (P)
the intervention (I)
any comparison of interest (C)
the outcome (s) of interest (O)
The Comparison is optional all others should be included
Turn the problem into an
answerable question
Case 1
Does the use of the Risk Assessment and
Prediction Tool (RAPT) facilitate safe and
early discharge home from the acute ward
after a hip or knee joint replacement?
Turn the problem into an
answerable question
Case 2
Where does the HITH service we offer for
patients in DRG 64a and b differ from that of
best practice or of a service with below State
average length of stay and readmissions?
Identify standards for
comparison
What measures are to be used?
• These should be identified before you start
• These should be appropriate and realistic
• There should be a good reason for the
selection of the comparison standard
this could be a national benchmark
or a comparison to your own outcomes
Identify standards for comparison
Case 1
Measures:
1.Number of procedures: compared to last 3 months
or the same 3 months last year
2.Length of Stay: comparison with Australia wide
average available for the last year from the
Australian Orthopaedic Association Joint
Replacement Registry
3.Discharge destination: increase in numbers going
directly home compared to last 3 months
4.Safety: number of readmissions within 28 days for
related issue (fall, wound infection etc)
Identify standards for comparison
Case 2
What describes best practice in the
literature?
What is the State average for length of stay
for this DRG?
What is the average for readmissions?
Can we identify another facility like us in size
and patient numbers but doing better in LOS
and readmissions to compare our policies
and procedures?
What resources are needed?
Personnel
Time
Equipment
Data analysis
(many health facilities do not have easy access to
statistics programs for staff)
Are these available?
Costs? – don’t forget to add on costs
What resources are needed?
Case 1
File auditor with time to review >200
records.
RAPT
Data analysis program
All found internally – cost borne by the
organisation
What resources are needed?
Case 2
• Personnel with skills to:
–
–
–
–
Perform literature review
Audit files
Analyse state-wide data
Liaise with other facilities
• Computer and Library access:
– Access on-line data bases and gather journal
papers
– Spread sheet for audit
– Data analysis
– Report writing
What resources are needed?
Case 2
• Telephone / e-mail/ visit to distant health
facility by staff
• Staff time and travel costs
• Not able to be met internally – successfully
applied for a grant from the Department of
Health
Do you need approval?
Management?
Good idea – sell your project as a QI winner
Ethics?
Depends on what you are doing and your actual
method – talk to the Secretary of your ethics cttee
Read NH&MRC guidelines:
National Statement on Ethical Conduct in Human
Research
When does quality assurance in health care require
independent ethical review?
Read Health Commissioners guidelines regarding
information privacy
Approval? Case 1
Application for ethics waiver granted on the
basis that:
The processes were routinely used at other
hospitals
Data collection would be undertaken by a staff
member who would usually have access to the
information
No individual was able to be identified in the
reporting
Approval? Case 2
Application for ethics waiver granted on the
basis that:
The audit was retrospective (no treatment would
be changed)
Data collection would be undertaken by a staff
member who would usually have access to the
information
State data was de-identifed
Any other facility involved was given the
opportunity to refuse to participate
Gathering data 1: Method
Data collection
methods:
File audit
Questionnaire
Survey
Interview
Observation
Measure
Method needs to be:
Decided first
Appropriate
Valid
Reliable
Easily administered
Easily understood
Best solution might involve multiple methods
Gathering data 2: What data?
What information is needed?
In what format?
Example: To get age, would you ask for
Date of birth
Age at a specified date
Age in a category (eg 15-20, 20-25 etc)
What are the advantages and
disadvantages of each method?
Gathering data: Resources
• Identify the resources needed for your
data collection in more detail
• For questionnaires or surveys:
how many copies, how many pages, how will they be
distributed & returned, who will computerise the
responses, short response or multiple choice or a
combination, how will analysis be conducted
• For interviews:
• For audits:
• Measurements:
Gathering data 3: Source
Identify the important sources of data
People:
–
–
–
–
–
–
patients,
carers,
therapists,
managers,
students,
therapy assistants
Decide sample size
– power analysis?
Information:
– journal papers
– medical records
– local / state /
commonwealth
government reports or
data bases (ABS)
– other databases held
by NGOs such as
AOA, NHF
Managing Data
Concerns:
privacy and/or confidentiality
accuracy
retention
Get data into computer format compatible
with analysis program as soon as possible
De-identify as soon as possible
Data Management: Case 1
• File audit data (past 3 months) entered to
excel spread sheet as raw data and as
RAPT scores
• Data directly imported into SPSS
• Same spread sheet used for data entry for
all patients over the next 3 months
Data Management: Case 2
Literature review
used standard procedures to record databases
searched & search outcomes, inclusions and
exclusions, quality review procedures
File Audit
set up as an excel database with direct entry of data by
auditing staff member
VAED data
Received as an excel file with >12,500 cases and
imported into SPSS
Comparison with other hospital
Notes taken for all contacts and information
Data Analysis
Quantitative
Frequencies
Level of data:
Nominal (young, old)
Ordinal (0-4, 5-9, 10-14)
Continuous (actual age)
Number of groups for
comparison
Number of time frames for
comparison
Select appropriate form of
statistical analysis
Qualitative
Transcribe responses
accurately
Analyse for common ideas
or themes
Independent analysis by
more than 1 person
Discuss and agree findings
Disagreement resolved by?
Data Analysis Case 1
• Audit all cases from previous 3 months
• Collect RAPT at pre-admission for all
cases admitted in next 3 months
• Outcomes – number of hip or knee joint
replacements, LOS, discharge destination,
readmission in <30 days
Data Analysis Case 2
Quantitative
• Data from file audit
• Match audit data to VAED
– Compare LOS and
readmission rates
• Analyse issues identified
in audit
– Coding queries
• Identify other hospital for
comparison
– LOS
– readmissions
Qualitative
• Description of policy and
procedures at Hospital A
and B
• Analysis of similarities
and differences
• Analysis of differences in
context
• Possibilities for changes
• Recommendations to the
organisation
What do the results mean?
Quantitative
• Statistical significance
– Has the intervention
caused a change in the
mean score of the group for
an outcome?
• Clinical Importance
– Is the mean change that
has occurred important
enough in the ‘real world’ to
suggest that the
intervention should be
adopted as normal
practice?
Qualitative
• Describe what your
participants think
• Describe their feelings
• Describe their
perceptions
• Collect their ideas for
service improvements
Results Case 1
Jan –March, 71 patients
63% female
41 H: 19 L, 22 R
30 K: 15 L, 15 R
Mean age
70.25
Destination LOS acute
Home 45% 6.38
Rehab 55% 7.38
Readmit
4.2% (3)
April – June, 120 patients
56% female
59 H: 13 L, 46 R
61 K: 24 L, 37 R
Mean age
68.29
Destination LOS acute
Home 57% 6.11
Rehab 43% 6.66
Readmit
4.2% (5)
Results: Case 2
• Literature review reveals few studies that
have tested the same antibiotics and few
that have randomised home versus
hospital care – ‘best practice’ is difficult to
identify – patients clearly have a
preference for home based care.
• Audit of files shows 276 patients with DRG
64a or 64b in one year as hospital n=124,
home n=115 or mixed n=37 treatment.
Results: Case 2
• State wide data shows 12,510 patients
with DRG 64a or 64b in one year as
hospital n=9,764, home n=1,604 or mixed
n=1142 treatment.
State wide mean HITH LOS
6.23 days
Our mean HITH LOS
7.56 days
Comparison hospital HITH LOS 5.22 days
Results: Case 2
Between hospital program differences:
Policy:
Procedures:
staffing, travel, patient selection
antibiotic selection, delivery doses,
delivery routes, review procedures
How do we change our practice?
• Based on the evidence, do we need to
change?
– policy
– procedures
– train personnel
– get new equipment
• What can we do to ensure any change is
sustainable?
– make it easy for everyone
Change in practice – Case 1
• Use of RAPT score at preadmission is
now routine and guides advice regarding
time in hospital and likely discharge
destination
• More patients go directly home
• No increase in readmissions
• Higher level of activity in acute ward
• Reduced waiting list
Change in practice - Case 2
• Results are open for discussion between
the research team, the HITH team and the
Quality unit of the hospital
• Options include:
– using the data to persuade management of
the need for greater consistency in staffing for
the HITH unit
– reviewing coding by the HIMU
Where to from here?
• Next session in Ararat on 5th September
• At this session we will consider how to
report the results
– To management
– As an abstract for a conference
– As a conference paper or poster
– As a journal paper
Where to from here?
• Work on your project and bring your
results along
• Questions: e-mail me
[email protected]