1. Quality Improvement in Healthcare: Residency and Beyond
Lisa Knight, MD
Quality Improvement Lecture 2
September 18, 2014

2. Lecture Outline The importance of QI efforts in healthcare
Basics of a QI project
PDSA cycle
AIM statement
Project Planning Document
Writing Your Introduction Section of your QI paper
Refresher on Residency QI Upcoming Deadlines

3. Patient Protection and Affordable Care Act
Pay for performance
Value-based purchasing
Bundled payments
One lump sum
Old method was fee for service
P4P is payment model that rewards physicians, hospitals, medical groups, and other healthcare providers for meeting certain performance measures for quality and efficiency. It penalizes caregivers for poor outcomes, medical errors, or increased costs.
Bundled payments—defined as the reimbursement of HCPs on the basis of expected costs for clinically-defined episodes of care. It has been described as a “middle ground” between fee for service reimbursement (in which providers are paid for each service rendered to a patient) and capitation (in which providers are paid a “lump sum” per patient regardless of how many services the patient receives)

4. Why Quality Improvement?
A gap exists between the quality of care that is possible and the actual quality of care delivered to persons living in the U.S.
Due to the seriousness of these shortcomings there is increasing importance that physicians and residents learn and use modern QI methods and tools
Infant mortality in the US per 1000 live births is DOUBLE that of other leading nations
--Between 44,000 and 98,000 Americans die each year in hospitals due to mistakes in their care
--The US ranks last among 19 industrialized nations in regard to the number of deaths each year resulting from medical errors
--Infant mortality rate is DOUBLE that of other leading nations
--US health care expenditures are the highest in the world and are projected to DOUBLE by the year 2017

5. “Every system is perfectly designed to get the results it gets”
This means that the US healthcare system is perfectly designed to:
Achieve 44,000 to 98,000 inpatient deaths per year due to medical errors
Have twice the infant mortality rate of other nations
Do all that for twice the cost per person of other industrialized countries
You can respond in 1 of 3 ways
Ignore it
Blame someone else (insurance, malpractice, Obama….)
Do something about it
And that’s where you come in. With a lot of will as well as skill in QI methods, you can make a dent in these troubling statistics
The only way to get different results is to
CHANGE THE SYSTEM

6. Institute of Medicine Reports
(1999) To Err is Human: Building a Safer Health System
Put the spotlight on how tens of thousands of Americans die each year from medical errors
Effectively put the issue of patient safety and quality on the radar screen of public and private policymakers
(2001) Crossing the Quality Chasm: A New Health System for the 21st Century
Described broader quality issues
Defined six aims for care delivery and redesign

7. The IOM has proposed 6 specific aims for improvement
Healthcare should be:
Safe
Effective
Patient-Centered
Timely
Efficient
Equitable
Avoiding injury from care that is meant to be helpful
Avoiding underuse or overuse of services
Providing respectful, responsive, individualized care
Reducing waits and harmful delays in care
Personal characteristics such as gender, ethnicity, SES, and geographic location
Avoiding waste of equipment, supplies, ideas, and energy
Providing equal care regardless of personal characteristics

8. How do we go about changing the system?
Plan Do
Study
Act
5-Step Process for Improvement
Select the opportunity for improvement
Study the current situation
Analyze the causes
Develop a theory for improvement
Select the team
Model for Improvement
Establish a
future plan
AIM
What are we trying to accomplish?
CHANGES
What change can we make that will result in improvement?
MEASURES
How will we know that a change is an improvement?
Ideal
Future
PLAN DO
STUDY
ACT
Implement the
Improvement
Study the
results
PLAN DO
STUDY
ACT
PLAN DO
STUDY
ACT
Present Situation

9. When selecting a QI topic…
Go for low-hanging fruit
Ensure Organizational support and participation will be provided for this improvement process
In the beginning, go for obvious concerns
--Variations in care—there is substantial variation in a service your facility provides, and/or you find that other centers do not practice in the same way

10. Low-Hanging fruit in the Endocrine Division
No Show rate
Endocrine patients
Healthy Lifestyles patients
Medication compliance in adolescents with diabetes
Diabetes school forms
Motivation to make lifestyle changes in Healthy Lifestyles patients
QI is about taking these things that we see as “flaws” in the current system and our ability to provide proper care for our patients, and finding ways to improve them
Safe
Effective
Patient-Centered
Timely
Efficient
Equitable

11. A HealthCare –Related PDSA Cycle: Planning Stage
5-Step Process for Improvement
Select the opportunity for improvement
Study the current situation
Analyze the causes
Develop a theory for improvement
Select your team
Select the Opportunity for Improvement
No-Show rate in the Pediatric Endocrine clinic
Study the current situation
Define why improvement in this area is necessary
Health risk of the patient who doesn’t show
Health risk of the patient seeking an appt, but unable to book
Poor staff utilization
Loss of multiple streams of revenue
Collect and/or review baseline data in your problem area
Track the following for one month
Total number of patient appointments scheduled
Total number of patients seen
Model for Improvement
AIM: What are we trying to accomplish
MEASURES: How will we know that a change is an improvement
CHANGES: What change can we make that will result in improvement
PLAN DO
STUDY
ACT
No Show Rate = 35%

12. A HealthCare related PDSA Cycle: Planning stage
Analyze the causes
Determine factors contributing to no-shows in your population
Describe the current process for patient appt reminders
Automated phone call to primary phone in EMR hours before appt
Develop a theory for improvement
Select your team
5-Step Process for Improvement
Select the opportunity for improvement
Study the current situation
Analyze the causes
Develop a theory for improvement
Select your team
Model for Improvement
AIM: What are we trying to accomplish
MEASURES: How will we know that a change is an improvement
CHANGES: What change can we make that will result in improvement
PLAN DO
STUDY
ACT

13. Develop a Theory for Improvement: AIM statement
A good aim is:
Specific
Measurable
Addresses these points:
For whom (or for what system)?
How good?
By when?
Model for Improvement
AIM: What are we trying to accomplish
MEASURES: How will we know that a change is an improvement
CHANGES: What change can we make that will result in improvement
PLAN DO
STUDY
ACT
We will reduce the patient appt no-show rate in the Pediatric Endocrine clinic from 35% to 20% by March 31, 2015

14. Develop a theory for improvement: Changes
Processes for formulating ideas for change:
Critical thinking about the current system
Flowchart on the current process
Analyze data on the current system
Benchmarking
Comparing your own process to “best practice”
Take the patient’s perspective
Ask the patient/caregiver for ideas
Using technology
Text messaging
Social media
Model for Improvement
AIM: What are we trying to accomplish
MEASURES: How will we know that a change is an improvement
CHANGES: What change can we make that will result in improvement
PLAN DO
STUDY
ACT
Office secretary to make phone call to patient’s
caregivers 24 hours before appt

15. Develop a theory for improvement: Measures
Qualitative data: Subjective
Quantitative: Objective
3 main types of measures:
Outcome Measure:
Are you reaching your ultimate result?
No-Show rate in the Pediatric Endocrine clinic (%)
Process Measure:
Are the parts/steps in the system performing as planned?
What percent of patients receive a reminder phone call from the secretary
Balancing Measure:
Are changes designed to improve one part of the system causing new problems in other parts of the system?
Are the secretaries unable to get their other work done because of time spent calling patients?
Model for Improvement
AIM: What are we trying to accomplish
MEASURES: How will we know that a change is an improvement
CHANGES: What change can we make that will result in improvement
PLAN DO
STUDY
ACT

16. Forming an Effective Team
Identify a QI mentor
Be sure to include members familiar with all the different parts of the process you are trying to improve
Endocrine Team:
Myself: Project Leader
Dr. Whitney Brown: Division Director
Endocrine Clinic secretary

17. The Endocrine Clinic Secretary
Lisa Knight
Whitney Brown
The Endocrine Clinic Secretary
Reduce the No-Show rate in the Pediatric Endocrine clinic from 35% to 20% by March 31, 2015
No-Show rate (%) = Total number of patients who didn’t show
Total number of patients scheduled
X 100
Percentage of patients each day who received a phone call 24 hours before their appt
Secretary satisfaction with the appt reminder system
Secretary to make phone calls to patients 24 hours before their appt

18. Always Start Small Ideal Future First PDSA cycle: Increase in Present
Only my patients
Not the other 3 endocrine providers
Morning clinic of September 15, 2015
10 patients
Increase in
Scale
Scope
PLAN DO
STUDY
ACT
PLAN DO
STUDY
ACT
PLAN DO
STUDY
ACT
Present
Situation

19. Steal Shamelessly QI vs Research Research Quality Improvement
Form hypothesis
Stick with it until bitter end
One large test
T-tests, chi square, p-value
Form a hypothesis
Adjust through multiple PDSA cycles to work out kinks
Sequential tests
Run charts or Shewhart charts
In QI you can steal shamelessly…..find out how things work best in other places and emulate those processes
In QI, the goal is to improve the conditions that exist….not merely to describe what they are
And to do that, you need to be able to modify your assumptions and retest your theories based on what you learn in the course of your tests

20. A HealthCare –Related PDSA Cycle: Planning Stage
5-Step Process for Improvement
Select the opportunity for improvement
Study the current situation
Analyze the causes
Develop a theory for improvement
Select your team
Select the Opportunity for Improvement
Hyperglycemia in diabetics after transition from insulin gtt
to SC injections
Study the current situation
Define why improvement in this area is necessary
Continued hyperglycemia may result in:
Prolonged hospital stay
More frequent BG checks
More frequent corrective insulin injections
Added stress/anxiety for child/caregiver
Model for Improvement
AIM: What are we trying to accomplish
MEASURES: How will we know that a change is an improvement
CHANGES: What change can we make that will result in improvement
PLAN DO
STUDY
ACT

21. A HealthCare –Related PDSA Cycle: Planning Stage
5-Step Process for Improvement
Select the opportunity for improvement
Study the current situation
Analyze the causes
Develop a theory for improvement
Select your team
Study the current situation (cont.)
Current transition protocol
½ dose Lantus given at breakfast
Insulin gtt d/c
½ dose Lantus given at bed
Full Lantus dose given the following night at bedtime
Collect and/or review baseline data in your problem area
a Track the following for six months
Average BG level for each patient
In the 4-6 hours before insulin gtt d/c AND in the 12 hours
after full Lantus dose given
During the 36 hour transition period
Reoccurrence of urinary ketones after insulin gtt d/c
Number of correction insulin doses given
Model for Improvement
AIM: What are we trying to accomplish
MEASURES: How will we know that a change is an improvement
CHANGES: What change can we make that will result in improvement
PLAN DO
STUDY
ACT

22. Average BG 152 mg/dL
Average BG 276 mg/dL

23. A HealthCare related PDSA Cycle: Planning stage
Analyze the causes
Determine factors contributing to hyperglycemia
Was the insulin gtt turned off too early?
Are CHO being counted appropriately?
Are patients/caregivers sneaking food/drink into their room?
Are insulin doses being calculated correctly?
Does the current transition protocol give enough insulin?
Develop a theory for improvement
½ dose Lantus transition protocol provides too little basal insulin
Will give full dose Lantus at transition
Select your team
Myself
Dr. Whitney Brown (Endocrine Division Director)
Dr. Elizabeth Mack (PICU attending)
5-Step Process for Improvement
Select the opportunity for improvement
Study the current situation
Analyze the causes
Develop a theory for improvement
Select your team
Model for Improvement
AIM: What are we trying to accomplish
MEASURES: How will we know that a change is an improvement
CHANGES: What change can we make that will result in improvement
PLAN DO
STUDY
ACT

24. next day, dinner the day after that, and bedtime on the following day)
Lisa Knight
Whitney Brown
Dr. Elizabeth Mack
Reduce the Average BG level in patients with diabetes in the PICU during the 36 hours following transition from an insulin gtt to SC injections from by 25% by March 31, 2015
Change in Average BG level with Full Dose Transition
Change in Average BG level with Half Dose Transition
X 100
Percentage of patients who received the full Lantus dose at the time of transition
Was there increased confusion about when to administer subsequent doses of Lantus
Full Lantus dose to be given at time of transition (then moved to lunch the
next day, dinner the day after that, and bedtime on the following day)

25. Average BG mg/dL
Average BG mg/dL

26. Change of mg/dL
Change of 51.5 mg/dL

27. QI Write-Up: Introduction
Background Knowledge:
Provides a brief, nonselective summary of current knowledge of the care problem being addressed, and the characteristics of organizations in which it occurs
Local Problem
Describes the nature and severity of the local specific problem or system dysfunction that was addressed
Intended Improvement
Describes the specific aim of the proposed intervention (changes/improvements in care processes and patient outcomes)
Specifies who (champions, supporters) and what (events, observations) triggered the decision to make changes
Study Question
Specifies specific AIM statement of the project
Details precisely the primary improvement-related question and any secondary questions that the study of the intervention was designed to answer

28. We know what good health care is, that’s not the problem
The challenge is to close the gap, the “chasm” between
What we know to be good care and
The care that people actually receive

29. Next Steps First Years Second Years Friday, January 30, 2015
The following are due by end of day:
Project Planning Document
Introduction/Background section of QI write-up
Feb 2015
Second QI Lecture (Date TBA)
March 31, 2015
Complete collection of post-intervention data
April 2015
Poster Presentation Lecture (Date TBA)
Friday, May 8, 2015
Turn in QI project write-up to me by end of day
Friday, June 19, 2015
3rd Annual Pediatric Residency QI Presentation Day
July 2015
SCAAP Annual Meeting Poster Presentations (Date TBA)

30. USC Pediatric Residency QI website