1. 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

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

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

4. 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

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

6. 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)

7. 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)

8. 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

9. 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.

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

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

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

13. 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?

14. 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

15. 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

16. 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
May choose to implement a Root Cause Analysis tool such as “The 5 Whys”, “SIPOC”, or a “Fishbone Diagram”
Document a plan for intervention

17. 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

18. 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.)

19. 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.

20. 4. Choose PI Methodology & Metrics
DMAIC

21. 4. Choose PI Methodology & Metrics
PDCA/ PDSA

22. 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

23. 4. Choose PI Methodology & Metrics
Custom Fields

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

25. 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.

26. 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!

27. 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).

28. Additional Resources:

29. Quality Improvement = +
for your CENTER
for your PATIENTS

30. QUESTIONS? INNOVATION PROFESSIONALISM EXCELLENCE INTROSPECTION
Website:
Phone:
INNOVATION
PROFESSIONALISM
EXCELLENCE
INTROSPECTION
INCLUSION

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