Introduction to Quality Improvement: SELECTING AND DESIGNING A QUALITY IMPROVEMENT PROJECT Karen Greer, MD, MPH Director, Ambulatory Pediatrics St. Barnabas Hospital

Quality Is… “The degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” - Institute of medicine, Medicare, A strategy for Quality Assurance, ed.,

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?

Choosing a Project: Everyday Experiences “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?

Choosing a Project: Everyday Experiences “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?

Choosing a Project: Everyday Experiences 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 dischargesAmbulatory 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.

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

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

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

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

Choosing a Project: Local, State, and Federal/National Criteria Newly Implemented Guidelines/Laws Example: 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 The model has two parts: Three fundamental questions, which can be addressed in any order. 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 Get examples from residents re: their projects.

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

Establishing Measures 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.

Establishing Measures 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?

Establishing Measures 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 Get examples from the residents re: their projects

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 period Example: 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? Nine general groupings of change concepts: Eliminate Waste Improve workflow Optimize inventory Change the work environment Producer/customer interface Focus on time Focus on variation Mistake proofing Focus on product or service

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. A test of change should answer a specific question A test of change requires a theory and a prediction Test on a small scale and collect data over time Build knowledge sequentially with multiple PDSA cycles for each change idea Include a wide range of conditions in the sequence of tests Don’t confuse a task with a test!

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?