1. Continuous Quality Improvement Evidence-Based Medicine In Practice…

2. CQI Means to improve individual health care Means to improve systems of care delivered Means to improve care delivered by individual physicians Means to educate physicians – Evidence-based care guidelines for specific processes – CQI as learning tool for specific processes through self audit and evaluation – Learning CQI techniques as component of continuous professional development

3. Importance Accreditation Council on Graduate Medical Education (ACGME) has added two new competencies for residents – Practice-based learning and improvement – Systems-based practice: “the ability to effectively call on system resources to provide care that is of optimum value” – Standard competencies: medical knowledge, patient care, communications, and interpersonal skills, professionalism

4. ABIM certification and recertification… 2000: ABIM changes recertification process to program of Continuous Professional Development New: incorporation of principles of CQI into self evaluations (based upon national guidelines for “best care”)

5. Importance after residency… Use by insurance companies, Medicare/Medicaid, clinics, hospitals for individual and systems performances Use by patients Use by individual as means of CME

6. What is health care quality? IOM: “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” Importance of multiple perspectives in determining quality of care

7. CQI model 1. Aim: What is the goal? 2. Measurement – Structural: hospital teaching status, accreditation, etc – Process: specific care (beta blocker use) – Outcomes: end results of care 3. Ideas for change 4. Testing and learning Langley et al. The Improvement Guide: a practical approach to enhancing organizational performance, 1996.

8. Delirium in hospitalized elderly Importance: marker of increased mortality and decline in functional status Background – Delirium is often not identified in the hospital – Delirium is associated with certain risk factors – Evidence suggests that the risk of developing delirium can be decreased in high-risk patients – Identification is key to prevention

9. Delirium: CQI process Aim: To reduce the number of patients on the geriatric medical service who develop delirium during their hospital stay Measurement: – Process: patients assessed for delirium or risk for delirium (underlying dementia) – Outcomes: patients who develop delirium before and after proposed changes Ideas for change: prompt on CIS note template for – Assessment for risk/development of delirium – Medication review – Review for restraints, catheters, iv lines Testing and Learning: self audit

10. Audit Sheet 1. Assessment for or diagnosis of underlying cognitive impairment or dementia in history, physical exam, or problem list 2. Assessment for or diagnosis of delirium included in history, physical exam, or problem list 3. CAM or other validated tool used to assess/screen for development of delirium during hospital stay 4. Delirium developed during hospital stay 5. Delirium contributed to increased length of stay or need for higher level of care at discharge

11. Author Debra Bynum, MD, Assistant Professor, Division of Geriatric Medicine and Director of the UNC Hospitals Acute Care of the Elderly Inpatient Unit, Chapel Hill, North Carolina