Quality Improvement - Children's Mercy Hospital

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Transcript Quality Improvement - Children's Mercy Hospital

Healthcare Quality and Improvement

A Primer

Our current medical world

• Issues about the quality of healthcare are daily news items • Medical profession is in a “fishbowl” I

Healthcare Safety Medicine vs.. Airline Industry

•

Headline: “Can you be as safe in a hospital as you are in a jet?”

• Medical mistakes in hospitalized patients account for a minimum of 120 deaths annually • This equates to a crash of a Boeing 747 every week killing all on board.

Healthcare Costs Errors

• •

Headline: “Medication errors in

2006 added $3.5 billion to the cost of healthcare”

Headline:

“80,000 catheter-related bloodstream infections occur in intensive care units in the US each year”

Healthcare Effectiveness

Acute URIvisits/10,000 with antibiotic prescription

Healthcare Backlash

Boston Globe

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Headline: “We pay for medical errors”

• By Richard Lord and Dr. Marylou Buyse. 9/12/ 2007 • “WHAT IF your mechanic forgot to replace the lug nuts after changing one of your tires and you got into a serious accident when the wheel came off? You wouldn't expect your mechanic to send you a bill for the repairs, would you?” • “Unfortunately, that's what happens in healthcare; we pay a high price for mistakes.”

Boston Globe

• “Healthcare entities should not be rewarded financially when such preventable errors occur. Hospital acquired infections offer one example.” • “No other industry generates revenue from mistakes. Preventable errors should not be part of the usual cost of healthcare.”

Can we fix this?

• The train is out of the station and it’s heading towards YOU • Hop on…….or prepare to be trampled

National Healthcare Quality Organizations

Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov

Health Care Quality www.consumer.gov/qualityhealth/index.html

Joint Commission on Accreditation of Healthcare Organizations (JCAHO) www.jcaho.org

. National Committee for Quality Assurance www.ncqa.org

. Quality Interagency Coordination (QuIC) Task Force www.quic.gov

. URAC (also known as the American Accreditation Healthcare Commission) www.urac.org

U.S. Consumer Gateway: Health www.consumer.gov/health.htm

U.S. News Online www.usnews.com/usnews/nycu/health/hehome.htm

Quality Improvement

Basic ingredients

• Clinical knowledge and experience

• QI basic concepts

• Systems approach

Objectives

• Quality problems in health care • Define quality • Who, what, why and how of quality improvement • Key elements of a good QI project • Quality improvement vs.. research • Joint Commission • National Patient Safety Goals

Our current medical world Contributing factors

• Knowledge and technology explosion • Barriers to translation of scientific knowledge into clinical practice • Increasing complexity of healthcare needs • Outdated processes and systems for complex multidisciplinary healthcare delivery

Our medical world

Past and future

• Cottage industry – Individual patient focus – “I know it when I see it” • Integrated healthcare system – System focus – Evidence based

Our current medical world Accelerating factors

• Multiple studies and reports – widespread and frequent incidence of medical errors – lack of consistency in the care received in different facilities and from different providers • Explosion of healthcare quality interest and organizations • Institute of Medicine Reports –

To Err is Human: Building a Safer Health System

(1999) –

Crossing the Quality Chasm

(2001)

Quality Chasm/Gap

• Defined by the IOM • The difference between what is scientifically sound and possible and the actual practice and delivery of health services • Illustrates the need for healthcare quality improvement efforts

Quality problems

Healthcare services

• Underuse • Overuse • Misuse • Variation • Fragmentation

Institute of Medicine Quality Aims

• Name the 6 quality aims identified by the IOM

Institute of Medicine

Quality Aims

• Safe • Effective • Patient centered • Timely • Efficient • Effective

Institute of Medicine

Quality Aims

•

Safe

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Avoid injury to patients from the care that is intended to help them

• Examples –

Prescription of medication that patient is allergic to

– –

Failure to address an abnormal lab or Xray result Failure to perform the correct procedure

Institute of Medicine

Quality Aims

•

Effective

• Issues about the quality of healthcare are daily news items • Medical profession is in a “fishbowl” I

Defining Quality

• “Quality is a way of thinking about work; quality is about achieving excellence nothing less” • IOM definition of quality – The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge

Defining Quality

• Quality is… –

A system-wide issue

– An individual performance issue rarely

Quality is a major team sport

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 Improvement

Key elements

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

QI vs. Informal Improvement

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

Systems change

• Individual or group • May be knowledge informed; rarely data • Experiential, anecdotal • Innovative • Informal process • • Episodic • No explicit responsibility. Usually hierarchical

Individual change

Quality Improvement Work

• Team oriented • Requires team skills – Collaboration – Meeting skills – Value all perspectives • Develop local new useful knowledge to inform health care processes

QI vs. Informal Improvement

Systems change

• Individual or group • May be knowledge informed; rarely data • Experiential, anecdotal • Innovative • Informal process • • Episodic • No explicit responsibility. Usually hierarchical

Individual change

Quality Improvement

Methods and Terms

• • •

What is Root Cause Analysis?

What does PDSA stand for?

What are Sentinel Events?

Quality Improvement

Methods and Terms

•

Terms

• Sentinel events • Never events • Practice standardization • Adverse events • Harm • Incident reports • Balanced scorecard •

Methods

• PDSA • LEAN • Six sigma • Root Cause analysis • Fishbone diagram • FMEA • Tracers • Trigger tools • Action plans

Improvement Methods

A 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

Model for Improvement

Setting Aims

• Improvement requires setting aims. The aim should be time specific, measurable and define the specific population of patients that will be affected.

SSI Rate

SIP Collaborative

Project Aim

50% reduction

ED Wait Collaborative Project Aim

– 25% reduction in ED length of stay by 6/30/07

Model for Improvement Setting Aims

• What are you trying to accomplish?

Model for Improvement

Establishing Measures

• Teams use quantitative measures to determine if a specific change actually leads to an improvement.

SIP Collaborative

Establishing Measures Measurement

SSI Rate

Collaborative Goal

50% reduction Antibiotic use rate Skin anti-sepsis rate

Model for Improvement

Selecting Changes

• All improvement requires changes, but not all changes result in improvement. • Identify the changes that are most likely to result in improvement.

SIP Collaborative

Establishing Measures Collaborative Goal Measurement

Antibiotic use rate Timing Re-dosing Skin anti-sepsis rate Chlorhexidine Hair removal

Our “Dizzying Complexity” Communication to Admit One ED Patient

ED Wait Collaborative Changes Selected

• Aim: 25% reduction in ED LOS • Measures – ED total LOS – Time from provider to decision re: disposition – Time from decision to discharge/admit • Asthma/wheezing patients – Initiation of Albuterol by RT/RN if emergent • Practice change – Asthma CPG revision • Evidence based practice and process standardization – Floor admission-selected patients receiving continuous Albuterol • Practice and process change

Model for Improvement

Testing Change

• 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.

O4. Decision to Discharge Time

Average total minutes from clinical decision to child leaving the ED

Model for Improvement

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

Model for Improvement

Spreading Change

• After successful implementation of a change or package of changes for a pilot population or an entire unit, the team can spread the changes.

QI Projects?

• Are you doing any?

• How is it going?

• Lessons learned?

QI project development

Essential steps

• Identify a project aim • Develop a plan to achieve the aim – Responsibilities and roles – Improvement methods – Data sources – Timelines • Identify outcome and balancing measures • Use data to identify improvement

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 • 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 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 Improvement and 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 Methods

A 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

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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

Fishbone Diagram

Task Factors

Task design and clarity of structure Availability and use of protocols Availability and accuracy of test results Decision-making aids

Team Factors

Verbal communication Written communication Supervision and seeking help Team structure (congruence, consistency, leadership, etc)

Organizational and Management Factors

Financial resources and constraints Organizational structure Policy, standards and goals Safety culture and priorities

Patient Factors

Condition (complexity and seriousness) Language and communication Personality and social factors

Individual (staff) factors

Knowledge and skills Competence Physical and mental health

Work Environmental Factors

Staffing levels and skills mix Workload and shift patterns Design, availability and maintenance of equipment Administrative and managerial support Environment Physical

C D P DDDDPP P Care Delivery problems (CDPs)

Care deviated beyond safe limits of practice The deviation had at least a potential direct or indirect effect for an adverse outcome for the patient, staff or general public

Examples:

Failure to monitor, observe or act Incorrect (with hindsight) decision Not seeking help when necessary

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

• Ideas/Aims • Methods • Data • Challenges

QI projects

Improvement project ideas

• Care process changes – Hand offs – Scheduling – Medication reconciliation • Implementation of new clinical or administrative practices • Practice standardization

Central Line Infections Defining 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 Infections Stating the project aim

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

Central Line Infections Practice 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 Infections Practice Standardization

Quality at CMH

How 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%

Healthcare Quality Improvement

2007

• Move from cottage industry mode of care delivery to data driven system model of healthcare delivery • Systems approach • Individual blame not the norm • Individual

accountable

Quality Improvement vs. Research It’s Complicated….

•

– 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

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 Commission

Mission

• 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 Improvement

Key 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