ASK MBSAQIP Agenda ASK MBSAQIP November 10, 2016 Time (CST) Agenda Item Panelist 12:00 Noon Welcome & Introductions Tanya Kimber 12:05 – 1:00 PM Standard 7.2 Quality Improvement “ Taking a Deeper Dive” Amy Robinson- Gerace Accreditation Services Manager ASK MBSAQIP November 10, 2016

Quality Improvement Primer A guide to Standard 7.2 Quality Improvement Process for Accredited Centers

MBSAQIP Accreditation Services Manager Amy Robinson-Gerace MBSAQIP Accreditation Services Manager NO DISCLOSURES

Quality Improvement Process 1. Review Data 2. Identify the Problem 3. Propose Intervention 4. Choose PI Methodology & Metrics 5. Implement Intervention & Monitor Data 6. Present Study Results Standard 7.2 Quality Improvement Process

read Standard 7 carefully Before you get started: read Standard 7 carefully

Assemble your CORE QI Team Before you get started: Assemble your CORE QI Team MBS Director MBS Coordinator MBS Clinical Reviewer Hospital QI Rep (if available)

Online Benchmarking Reports (e.g. patient experience scores) 1. Review Data Data Sources 1 SAR Site Summary 2 Online Benchmarking Reports 3 Internal Data (e.g. patient experience scores)

Benchmark Data If Outlier = “High”, then QI project required* 2. Identify the Problem Benchmark Data If Outlier = “High”, then QI project required* * see Standard 7.2 for details

Center is “needs improvement”, but not a high outlier. Center may choose to to do QI project for LRYGB Leak, but is not required and may choose a different area of focus. Note the “H” indicating that this site is a high statistical outlier for this model. Center is required to do QI project to address LRYGB Reoperation.

Benchmark Data Drill down using Case Occurrences Report 2. Identify the Problem Benchmark Data Drill down using Case Occurrences Report

IMPORTANT: Dedicate time to learning about your SAR data! 2. Identify the Problem Benchmark Data IMPORTANT: Dedicate time to learning about your SAR data!

2. Identify the Problem Benchmark Data Benchmarking data available in real-time via Online Reports (not risk-adjusted):

Prioritize Patient Safety and Outcomes: 2. Identify the Problem Prioritize Patient Safety and Outcomes: If Outcomes Data doesn’t reveal a problem, ask if there are: Gaps in resources or care services? Issues regarding timeliness of care? Gaps in patient compliance or follow-up? Issues related to patient satisfaction or procedure effectiveness? Educational gaps for patients or staff?

Write a Problem Statement 2. Identify the Problem Write a Problem Statement 3 things that must be included in your problem statement: Clearly identify a specific problem you want to solve through your QI Project Identify your baseline and goal metrics Identify the timeline for meeting this goal

Write a problem statement: 2. Identify the Problem Write a problem statement: Our predicted (adjusted) observed rate for All Cause Readmission for LSG was 7.2% in the 2015 calendar year, which makes us a high outlier in this model. Our goal is to lower our LSG readmission rate to the expected rate of 3.72% by December 31, 2016. 1 Specify Problem 3 Timeline 2 Baseline & Goal Metrics

3. Propose Intervention Propose Intervention Gather all members of the MBS Committee to discuss all possible factors contributing to the problem Conduct literature review – may reference ASMBS Guidelines and Position Statements http://asmbs.org/resource-categories/position-statements May choose to implement a Root Cause Analysis tool such as “The 5 Whys”, “SIPOC”, or a “Fishbone Diagram” Document a plan for intervention

Conducting a Simple Root Cause Analysis 3. Propose Intervention Conducting a Simple Root Cause Analysis List all the potential causes of the problem Prioritize down to a manageable size Pick one of the main problems Do the following steps to find the Root Cause State the Main Cause Ask Why Main Cause happens Ask Why the Cause in B happens Ask why the Cause in C happens = Root Cause

4. Choose PI Methodology & Metrics PI Tools & Metrics Must choose Process Improvement Tool or standardized methodology for conducting your QI Project. Choose the PI Tool that works best for your center. (DMAIC & PDCA/PDSA are two most commonly used) Identify metrics and measurement tool Establish project calendar (launch date, data reviewed at quarterly MBS Committee meetings, wrap up date, etc.)

4. Choose PI Methodology & Metrics DMAIC Define Look at data sources to identify an area of improvement related patient safety, efficacy, or experience. Measure Quantify the problem through a methodolical approach to defining defects, metrics, and a detailed process map. Analyze Identify sources of variation and determine root causes. Improve Develop intervention to address the root causes that are critical to quality. Control* Monitor and validate the intervention to ensure a positive outcome, unintended consequences and, sustainability.

4. Choose PI Methodology & Metrics DMAIC

4. Choose PI Methodology & Metrics PDCA/ PDSA

4. Choose PI Methodology & Metrics Choose or create a measurement tool (MBSAQIP Data Registry, Survey, Excel Spreadsheet, etc.) If you want to capture a data point in the MBSAQIP Data Registry that is not already captured, you can create your own using Custom Fields and extract that data via the Case Details and Custom Fields Report

4. Choose PI Methodology & Metrics Custom Fields

5. Implement Intervention & Monitor Data If using MBSAQIP Custom Fields, use Case Details and Custom Fields Report to monitor data:

5. Implement Intervention & Monitor Data Communicate, communicate, COMMUNICATE! MBS Director gathers all stakeholders to ensure engagement and buy-in Intervention must be defined clearly and implemented consistently Data must be monitored closely and often. If desired outcomes are not achieved, adjustments to the protocol should be made.

6. Present Study Results QI Wrap-Up Gather all documentation and data for presentation to the MBS Committee at the annual QI Meeting (see Standard 2.1 for details); compare your data with current national benchmark data if available Review lessons learned, ways to sustain improvement, etc. Keep all records and documentation on file for your next triennial MBSAQIP Site Visit CELEBRATE your efforts and your successes!

Important to remember: QI Projects must be led by the MBS DIRECTOR and engage all members of the MBS Committee. Accredited centers must implement a NEW QI project every year. QI Projects are DYNAMIC and must be monitored over the course of the year. Report progress at each MBS Committee Meeting and document this in your minutes. QI Projects must address a PROBLEM (e.g. if you don’t have any readmissions at your center then don’t choose decreasing readmissions as your QI Project). QI Projects must be DATA-DRIVEN. Develop a metric to measure the effectiveness of your QI project and identify the baseline. Once you begin receiving Semiannual Risk-adjusted Reports (SARs), your center must prioritize QI related to models where the center is found to be a HIGH OUTLIER (see Standard 7.2 for complete details).

Additional Resources: http://www.health.state.mn.us/qi/

Quality Improvement = + for your CENTER for your PATIENTS

QUESTIONS? INNOVATION PROFESSIONALISM EXCELLENCE INTROSPECTION Website: www.facs.org/mbsaqip Email: mbsaqip@facs.org Phone: 312.202.5565 INNOVATION PROFESSIONALISM EXCELLENCE INTROSPECTION INCLUSION

Thank You for attending ASK MBSAQIP! Please join us for our next ASK MBSAQIP! Call on Thursday, December 8, 2016 at Noon CST