1. Ariane Marie-Mitchell,
Preceptor and 3-4 students, meet weekly
Patient Safety/
Quality Improvement
Project Overview
Ariane Marie-Mitchell,
MD, PhD, MPH

2. Health Care Problem State reason for action
Provide supporting data if available

3. Example: Health Care Problem
There is a much longer delay for 1st dose delivery of antibiotics ordered between 11pm and 7am compared to day time averages
This results in wasted time from the nurses and pharmacists, wasted medications, and poor quality of patient care

4. Historical Data – The Problem
They even had baseline data that shows the problem

5. Stakeholder Analysis Who is involved? Who is affected?
Try Mind Mapping
Start interviewing- qualitative baseline data

6. Stakeholder Analysis Charge nurse Providers Nurses Patients Couriers
families
Illustrates a mind mapping technique to identify stakeholders. More detail could be added regarding the needs, wants and expectations of each stakeholder.
Admin./PSR
Pharmacists

7. Define the Aim What are you trying to accomplish? Specify
numeric goals (how good?)
time frame (by when?)
patient population/system (for whom?)
K. Shannon, 2012

8. Aim for Quality Health Care
Safe — Avoid injuries to patients from the care that is intended to help them. Safety must be at the forefront of patient care.
Timely — Reduce waiting for both patients and those who give care. Prompt attention benefits both the patient and the caregiver.
Effective — Match care to science; avoid overuse of ineffective care and underuse of effective care.
Efficient — Reduce waste. The health care system should constantly seek to reduce the waste and the cost of supplies, equipment, space, capital, ideas, time and opportunities.
Equitable — Close racial and ethnic gaps in health status. Race, ethnicity, gender and income should not prevent anyone from receiving high-quality care.
Patient-Centered — Honor the individual and respect choice. Each patient’s culture, social context and specific needs deserve respect, and the patient should play an active role in making decisions about her own care.
The good news is that we know what we want…
IOM, 2001

9. Example. Specific Aim
“Decrease delivery delay in 1st dose antibiotic by 50% between 2300 and 0700 on units by February 20, 2012”

10. Identify Measures of Change
Outcome Measures
e.g. Duration of delay in administration of 1st dose antibiotics
Process Measures
e.g. % of antibiotic following forms filled
e.g. % of fax orders with telephone follow-up
Balancing Measures
e.g. Staff satisfaction

11. Cause-Effect Analysis
Fishbone Diagrams
Flowcharts
Type of tool needed depends upon nature of problem

12. Constructing a Fishbone Cause and Effect Diagram
Get the right people in the room
State and clarify the “effect”
Brainstorm list for 4 Ms/P involved in the process or effect interested in
Brainstorm causes for each of these
For each cause ask “why” 5 times to get to underlying causes
K. Shannon, 2012

13. K. Shannon, 2012

14. Example: Fishbone Diagram
Process
Communication
Unaware of effect on
Poor MD RN communication
Different levels of knowledge
Repeat orders via fax
Poor process understanding
ABX Delay
Old fax machines
Understaffed
Unreliable tube system
No EMR = extra steps
# of pharmacy units open
Machines
System Failures 14

15. Constructing a Flowchart
Start/End
Input/
Output
Process/
Task
Delay
Decision
Document
Sequence

16. Prescription Renewal The process begins when the patient requests renewal. The Product of Value is that the prescription is delivered.
Example:
Flowchart
Call patient
(need more info)
Phone call
(enough info provided)
Name, DOB, Medication, Dose,
Frequency, Pharmacy
Review chart: medication sheet, last visit,
next visit, other parent or pharmacy info
(consistent)
(not consistent)
Discuss with clinician
(PA not needed)
(PA needed)
Call for Medicaid Prior Approval
Page 2

17. Select Change Focus on a change concept
eliminate waste, improve work flow, optimize inventory, change work environment, improve patient interface, manage time, reduce variation, improve error proofing, improve service
Perform effort vs yield analysis
High effort
Low yield
High effort
High yield
Low effort
Low yield
Low effort
High yield

18. Evidence Review Identify relevant literature or best practice models
Who else has thought about this problem and tried to fix?
Critically appraise and describe how relates to your project aim

19. Example: Evidence Review
Background 
Pneumonia = 600, 000 Medicare hospitalizations/yr
Previous Medicare Guidelines recommend antibiotic treatment within 8 hrs of hospital arrival.
Methods 
Retrospective cohort study design
18, 209 Medicare patients (>65 yrs) hospitalized with community-acquired pneumonia (July 1998-March 1999)
Outcomes:
severity-adjusted mortality (in hospital and 30 day)
readmission within 30 days of discharge
length of stay (LOS)
Conclusions 
Antibiotic administration <4 hours of arrival was associated with decreased mortality and LOS among a random sample of older inpatients with community-acquired pneumonia who had not received antibiotics as outpatients.
Houck, P, et al. Timing of Antibiotic Administration and Outcomes for Medicare Patients Hospitalized With Community-Acquired Pneumonia. Arch Intern Med. 2004;164:

20. Test a Change Repeat, Tweak, Stop Who,What, When, Where Analyze
Act
Plan
Study Do
Who,What,
When, Where
QI and Research seem similar, particular when talking about testing an intervention
Analyze
Results
Collect
Data A P S D

21. Plan Specify a hypothesis Use SMART Objectives
Specific - have a single purpose
Measurable - tied to a result statement
Attainable/realistic - know your barriers and resources
Responsibilities clear – tie names to each objective
Time connected - clear completion dates
(consider creating a timeline)

22. Example: SMART Objectives
Interview charge nurse, nurses, couriers and pharmacists during a full overnight shift (11p-7a) by day 7- Jose
Conduct a literature review of best practices by day 7- Paymonh
Meet as a team to do cause-effect analysis by day 9- team
Collect quantitative data on initial state using Form 1a by day 10- Brent and Craig
Meet as a team to discuss potential interventions by day 12- team
Discuss intervention plan with pharmacists, couriers and nurses and implement by day 16- Jose and Paymohn
Collect quantitative data on follow-up state using Forms 1b and 2a by day 20 and analyze- Brent and Craig
Gets built over course of project depending upon results of prior objective

23. Do Two types of data How did you collect the data?
Qualitative
e.g. interviews, focus groups, suggestion boxes
show quotations, summarize themes
Quantitative
e.g. anything that can be counted
show run charts, bar charts, pie charts…
How did you collect the data?
What sample did you use and what was your reasoning?

24. Study Qualitative Data Quantitative Data What did you learn?
Where does this lead you?

25. Example: Qualitative Data
Parents observed speech problems by age 4 and as young as 11 months
“Around 10 months I noticed she was not starting to talk like my other children did”
A minority of children received Early Intervention
“I asked the doctor about it but they were just like oh, he’ll grow out of it”
“We were supposed to have a lady come to the house and stuff but it was impossible because I was working full-time and he was at daycare”

26. Automated BMI% calculation
Incorporated BMI%
into nursing data collection
Added BMI% to vitals

27. Act
How does your data inform your understanding of the health care problem?
How does your data influence your interpretation of how to improve the system?
What will you do next?

28. Sustainability What barriers do you perceive to sustaining the change?
What resources are available to sustain the change?
What is the cost-benefit of the old process versus the new process?

29. References References for literature cited
Names of faculty/staff interviewed
Location of sites where processes observed, or any other relevant info

30. ≠ Quality Research Improvement Aim(s) Next steps Hypotheses Methods
Act
Plan
Study Do
QI and Research seem similar, particular when talking about testing an intervention
Methods
Measures
Results A P S D

31. Research Quality Improvement
Intervention is demonstrated, known, or widely accepted
Project limited to implementing a practice to improve quality of care
Performance data collected for clinical, practical or administrative purposes only
Systematic investigation designed to contribute to generalizable knowledge
Project involves introducing an untested intervention and data is being collected to establish scientific evidence of its efficacy
IRB approval required
*** IRB approval not required
but ask if uncertain or if
considering publication

32. IHI Open School QI Practicum
Optional
Receive additional guidance and a Certificate
Sign agreement with faculty mentor
Submit aim/plan and receive feedback
Submit cause-effect diagram, PDSA cycles, run chart, and summary