1. Healthcare Quality and Improvement
A Primer
This morning we are going to be focusing on health care quality improvement. This is the 1st part of a 2 part presentation and I welcome your questions and feedback. So why are fellows sitting in a classroom and listening to a discussion about quality improvement? Well, I’d like to set the stage for you a bit

2. Part 2 Review key concepts Move on to other QI methods
Discuss project development
Research vs. QI
National patient safety goals
Joint commission

3. Objectives Quality problems in health care Define quality
Who, what, why and how of quality improvement
Tools and methods
Key elements of a good QI project
Quality improvement vs.. research
QI project development
National Patient Safety Goals
Joint Commission
In the 1st session we discussed quality problems, defined quality and began to discuss improvement methods and terms. We also touched briefly on developing a project and you wrote out a project aim. You were to return today with some further definition of your aim, QI tools and methods you might use and an assessment plan. We will talk more about these. I wanted to briefly review several key points

4. Defining Quality Quality is a team sport Quality is…
A systems-wide issue
An individual performance issue rarely
Quality is a team sport
Just a reminder that quality is a system issue and requires a team effort to produce. Again quality work focuses on system improvement however individuals are held accountable to engage in safe practices

5. Quality at CMH How informed are you?
Rate of compliance with hand washing?
90%
Central line infection rate?
1.2/1000 cath days-PICU
% of codes outside the PICU?
50%
% of inpatients with medication reconciliation performed?
70%
So, how informed are you of QI activites going on here at Mercy? In the 1st quarter of 2007 the correct hand washing technique 90%

6. Quality Improvement
A process of innovation and adaptation designed to bring about immediate positive changes in the delivery of health care in particular settings
systematic
data-guided
multidisciplinary
QI is a deliberate process that is systematic, data informed and multidisciplinary It requires a great deal of collaboration and cannot be done successfully in isolation

7. Quality Improvement and Data
Use data for learning, not judging
“Generate light, not heat”
Use data to report system attributes
Use aggregate not individual data
Do not report data on individual performance
I’d like to make a few comments on the use of data in QI efforts. Regardless of the improvement method used in a project there are some very important messages about the use of data that I’d like to present. Data for individual performance is generally not used until aggregate reporting has achieved a 90-95% rate of success in achieving the desired outcome. At that point you might consider the use of blinded provider data to identify differences among providers

8. Improvement Methods A brief overview
Model for Improvement
Lean
Six Sigma
Trigger tools
Back to our improvement methods. We discussed the model for improvement last time and you were asked to outline a QI project aim and identify tools and methods you would use to implement the project. As I briefly discuss improvement methods I’d suggest you refer back to your outline and update it if needed.

9. Model for Improvement Flexible improvement framework IHI
PDSA methodology
Emphasizes
Aims and measures
Initial small tests of change
Widespread testing
Implementation and spread
As you recall we discussed the model for improvement in November. It is a flexible framework for improvement that uses PDSA methodology. It emphasizes points about the model include

10. Improvement Methods What is LEAN? What is Six Sigma?
Identify a trigger tool
Now we will move on to some other methods. Does anyone want to describe Lean, six sigma, trigger tool?

11. Lean Management philosophy based on 2 key themes Key principles
Continuous elimination of waste
Respect for people and society
Key principles
Value is in the eyes of the customer
Make value flow without interuptions
Improve work flow
Standardize work processes
Pursue perfection
Lean is a very specific methodology focused on eliminating defects by continuously focusing on eliminating waste. The focus is on the customer, who are our patients, needs and lean methods seek to standardize and improve work flow and processes with the ultimate goal of pursuing perfection. Many organizations use lean methods to inform their QI processes

12. Lean
Culture
Stop and fix the problem as soon as it is identified
Toyota manufacturing culture
Process
Measure
Change
Change…..
Lean culture originated in the Toyota manufacturing plants and focuses on stopping. The cycle is measure, change, measure….

13. Lean Project “Improve ED Patient Flow”
Project aim-reduce ED LOS by 50%
Process improvements(reduce waste)
Work standards and evidence-based clinical practice guidelines for all ED staff defined
Batching of orders eliminated
Right supplies and equipment in the right place; eliminated unnecessary S&E
Admission process streamlined
Results
Reduced ED LOS for discharges by 23%
Reduced ED LOS for admissions by 20%
A healthcare example e of a lean project is the following project done in an adult hospital. The project aim was to …and they used lean principles to eliminate waste and improve and standardize work flow processes. This resulted in……In essence they eliminated waste(waiting in the ED) by standardizing processes and improving their work flow

14. Lean What is waste in medicine?
Surgical infection
Preventable adverse drug events
Ventilator assisted pneumonia
Equipment failure
Waiting and lack of flow
Inadequate training or orientation
Unnecessary or poorly designed processes
Not following evidence based practices
Here are some additional examples of waste in medicine. I’m sure all of you could easily identify examples of waste in your area-anyone want to share? At this point you may want to review your project aim and decide of lean methods would assist you in your QI project

15. Six Sigma Focus is to eliminate defects
Nonconformity of a product or service to its specifications
Six sigma processes have variation that result in <3.4 parts/million defects
Now we’ll move on to 6 sigma. How many of you have heard about 6 sigma? Have any of you been involved I 6 sigma projects? The 6 sigma method focuses on eliminating defects which are defined as Six sigma is also a method focused on eliminating defects. Black belts-16 day course; green belts 8 day course. To put this into context….99.9% accuracy has 1 defect for each so, if you are doing liver biopsies you will have 1 death for every 1000 you perform.

16. Why Zero Defects is the Only Acceptable Quality Standard
At 99.9% quality levels in a 250 bed hospital
12 inpatients per year would die due to errors
6 day surgery patients would die
9,742 wrong medications would be delivered
4,923 incorrect laboratory tests would be reported
502 incorrect radiographs would be completed

17. Six Sigma
Systematic and scientific management approach to reduce sources of process variation and improve reliability
Customer and financially focused
Strategic
Uses project management concepts
Strong statistical focus
Focus on “mistake-proofing”
Requires rigorous professional training
Black belts-16 day course; green belts 8 day course

18. Six Sigma Project “Reducing Hospital-Acquired Pressure Ulcers”
5 structured project phases
Define
Measure
Analyze
Improve
Control
Here is a healthcare example of a six sigma project. This project focused on…..It was a customer/patient focused project attempting to eliminate pressure ulcers. In keeping with the project management concepts used in 6 sigma there were 5 structured phases this method emphasizes to conduct the project. Define the problem. Measure the current situation and interventions. Analyze the process and intervention data. Improve the process based on this analysis. Control or sustain the results ((Identfiy what control means))

19. And here are their results
And here are their results. In general 6 sigma requires a considerable statistical expertise, a core group of green and black belts, and a major commitment form the organization to implement and sustain the projects. on this chart you can see the impact on measurement

20. I included this chart just to demonstrate the rigor of the project management concepts including the risk assessment and abatement plan. For example, if pressure ulcers are not managed, how to proceed> the control phase involves having a plan to sustain the results, to monitor performance, identify defects and if identified resolve and re-monitor

21. Trigger Tools
Method for identifying adverse events (harm) and measuring the rate of adverse events over time
Method options
Retrospective review of a random sample of patient records using triggers (clues)
Prospective surveillance of electronic patient records
Goal-to identify areas for improvement and prevent harm
Another improvement method that you may have heard about or used is the trigger tool. Trigger tools are a method of identifying..and measuring the rate of these adverse events. Hospitals have traditionally relied on event reporting of adverse events to identify these areas, and event reports have been found to identify less than 10% of actual errors. Trigger tools allow a more proactive and systematic method of identifying adverse events and have a greater yield. To use trigger tools requires either a…of 20 charts/month or prospective surveillance. The goal of trigger tools is to….and prevent harm/patient injury

22. This is an example of a neonatal trigger tool that was developed
This is an example of a neonatal trigger tool that was developed. This chart gives you some idea of how these work. You can see that this process requires some chart review to uncover the trigger and then decide if an adverse event has occurred. Antibiotic use is the trigger or clue. The adverse event you are trying to identify is nosocomial infection. Using this info you can generate a rate for nosocomial infection in the NICU (data guided), analyze or trend this, create an aim to have 0 nosocomial infections and then identify changes to improve

23. Trigger Tools Your medical world
Are there triggers that could be used in your specialty to identify areas of potential patient harm?
Narcan for opiate OD, Benadryl for a drug allergy, readmission to the hospital for uncovering late surgical site infections, return to surgery….. Would this method be useful in the QI project you are developing?

24. Root Cause Analysis
Process to identify causal factors for variation in performance; “learning from consequences”
Systems and processes focus
Individual performance not a focus
Identifies potential improvements to reduce likelihood of future event
Used in M&M process, sentinel event investigations
On to root cause analysis. Many of you may be familiar with this process. It is a process that is a retrospective assessment of a situation that has already occurred. Like all good QI tools and activities it focuses on systems and processes and not on individual performance. I suspect most of you are familiar with this process and the fishbone diagram

25. Care Delivery problems (CDPs)
Fishbone Diagram
Patient Factors
Condition (complexity and seriousness)
Language and communication
Personality and social factors
Individual (staff) factors
Knowledge and skills
Competence
Physical and mental health
Work Environmental Factors
Staffing levels and skills mix
Workload and shift patterns
Design, availability and maintenance of equipment
Administrative and managerial support
Environment
Physical
Task Factors
Task design and clarity of structure
Availability and use of protocols
Availability and accuracy of test results
Decision-making
aids
Team Factors
Verbal communication
Written communication
Supervision and seeking help
Team structure (congruence, consistency, leadership, etc)
Organizational and Management Factors
Financial resources and constraints
Organizational structure
Policy, standards and goals
Safety culture and priorities
Care Delivery problems (CDPs)
Care deviated beyond safe limits of practice
The deviation had at least a potential direct or indirect effect for an adverse outcome for the patient, staff or general public
Examples: Failure to monitor, observe or act
Incorrect (with hindsight) decision
Not seeking help when necessary
The fishbone is often used in root cause analysis and provides a systematic frame work to work through all the potential factors that may have contributed to the situation. If you have been to the Dept of Pediatrics M&M you have seen this used

26. Failure modes and Effects Analysis (FMEA)
Prospective technique
Systematic assessment to
Prevent problems before they occur
Reduce the chance of unintended adverse harm if they occur
Used for high risk procedures or error prone processes
In contrast to root cause analysis is another process is called FMEA. It is a prospective process that involves a systematic assessment of a process to prevent problems before they occur and/or to reduce the chance of a bad outcome if they do occur. This technique is generally used for….Can you think of a situation where this technique might be sueful?(Implementation of a high risk procedure or technique)

27. Now its your turn! Form groups of 4-5 team members
Pick one of the following aims
!00% of all requests for physician consultation include a verbal discussion between the physician requesting the consult and the physician receiving the request
Reduce errors during patient care handoffs: sign out, transfer to another service, etc (right info at the right time, distractions, templates, etc)
Reduce variation in practice for management of __________ by implementing evidence based practice standards
You decide_______________________________
Be prepared to present your plan

28. Now its your turn! Develop a plan to achieve the aim
Who’s on the team?
Responsibilities and roles
Improvement methods
Timelines
Identify outcome and balancing measures
Identify data needed to assess improvement
and sources of data
So, let’s discuss some of the ideas and plans for QI projects you have identified.

29. Now its your turn!
Share the projects you have done or are developing

30. Improvement project ideas
Care process changes
Hand offs
Scheduling
Medication reconciliation
Implementation of new clinical or administrative practices
Practice standardization
There are many ideas and areas that improvement projects can focus on. These include….The next few slides describe a QI project with a focus on practice standardization

31. Central Line Infections Defining the problem
15 million central venous catheter-days per year in ICUs
Attributable mortality for these infections %
Bloodstream infections prolong hospitalization by a mean of 7 days 
Setting the stage

32. Central Line Infections Stating the project aim
Reduce central line infection rate to 0 in the ICU in 12 months

33. Central Line Infections Practice Standardization
Hand Hygiene
Maximal Barrier Precautions upon insertion
Chlorhexidine skin antisepsis
Optimal catheter site selection, with Subclavian Vein as the preferred site for non-tunneled catheters
Daily review of line necessity with prompt removal of unnecessary lines
Approach to change involved standardization of practice. After several small tests of change each of these items were tested and implemented

34. Central Line Infections Practice Standardization
And these were the results. But there is a solution and probably more than one to the aim of reducing central line infections. In this case the group developed a bundle. A bundle is a group of precautionary steps with approximate time and space characteristics that, when executed collectively and reliably, have an enhanced affect on patient outcomes. The bundle provides a "forcing function" for teamwork, and this teamwork has led to outstanding results.

35. Quality Improvement Key elements
Systematic
Data-guided and knowledge informed
Experiential
Innovative
Employs formal explicit methodology
Continuous
Core responsibility of healthcare professionals

36. Quality Improvement Work
Focused on systems
Team oriented
Requires team skills
Collaboration
Meeting skills
Value all perspectives
Develop local new useful knowledge to inform health care processes

37. Quality Improvement vs. Research It’s Complicated….QI
Systematic data-guided activities designed to bring about immediate positive changes in healthcare delivery in local practice settings
An integral part of the ongoing healthcare delivery system
A form of clinical and managerial innovation and adaptation
Combines discipline specific knowledge with experiential learning and discovery
Research
A systematic investigation designed to develop or contribute to generalizable new knowledge
Implementation of research is a separate process and occurs later, if at all
A knowledge seeking enterprise that is independent of routine medical care
You will hear a lot of discussion about what is QI and what is reasearch. And I’m sure sometime during these 2 QI presentations you have found yourself thinking that there is not a huge difference betweeen some QI projects and research. I know this is a hot issue for many IRBs and investigators and I don’t have a perfect answer. Here is my best comparison at this point.

38. Hastings Report
The Hastings report was issues in 2006 and addressed the ethics of using QI methods to improve quality and safety

39. Quality methods and terms
_5_Sentinel event 1. a tool which uses clue to identify a possible adverse event
_8_Never event 2. an improvement method driven by statistical analysis of data to identify unwanted defects and variation
_9_PDSA 3. a tool used to systematically identify all factors that may have contributed to an adverse situation
_6_LEAN 4. unintended injury from medical care that requires additional treatment or monitoring or results in death
_2_Six sigma 5. an unexpected occurrence involving death, serious injury or the potential for serious injury
_11_Root Cause An an improvement method focused on eliminating waste through analysis of workflow
_3_Fishbone diagram 7. a prospective process which uses a systematic assessment to identify and prevent potential problems
_7_FMEA 8. an event that is reasonably preventable; e.g. pressure ulcer, hemostat left in patient during surgery
_4_Harm 9. a process used in the Model for Improvement to test changes
_1_Trigger tool 10. an error
_12_Action plan 11.a retrospective assessment of an adverse situation that has occurred
_10_Adverse event 12. a plan developed to address deficiencies identified during a root cause analysis

40. Questions?
Before we move on to regulatory issues and joint commission I’d like to take questions from you re: quality improvement, your projects, etc

41. Joint Commission Accrediting organization for healthcare institutions
Sets administrative and practice standards and evaluates compliance
Performs unannounced on-site surveys of accredited hospitals to assess compliance every months
And now we’ll move on to joint commission. I’m going to give you a few highlights about joint commission. They publish over 100 pages of standards that hospitals must comply with to be accredited. You are likely familiar with many of these standards although you may not be aware they originate from the joint commission. H&Ps, how medical staffs are organized and governed, etc

42. Joint Commission Mission
To continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations
Why do they do this? Well, their mission is to…. So, their focus is definitely on performance improvement in the areas of healthcare quality and safety. They publish an annual list of patient safety goals

43. National Patient Safety Goals
Key national safety goals for hospitals
Set by Joint Commission
Updated yearly
Goal is to promote specific improvements in patient safety
Many of these goals are developed based on data about near miss or sentinel events reported to the joint commission data base. There are many other sources for consideration of key patient safety goals. I m going to briefly identify the goals for 20o8

44. 2008 NPSG Goal 1 Improve the accuracy of patient identification.
1A Use at least two patient identifiers when providing care, treatment or services.
This pertains to you as when you assess, treat or perform procedures you must have the correct patient and you do this by identifying patients by name, med record #, DOB

45. 2008 NPSG
Goal 2 Improve the effectiveness of communication among caregivers.
2A For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result.
2B Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.
Goal 2 focuses on communication and there are many components to it. Key elements are verbal orders-write down, read back, abbreviations

46. 2008 NPSG
Goal 2 Improve the effectiveness of communication among caregivers.
2C Measure and assess, and if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.
2E Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.
Reporting of critical test results and handoffs.

47. 2008 NPSG Goal 3 Improve the safety of using medications.
3C Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs.
3D Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.
3E Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.
Goal 3 relates to medication safety and safe practices

48. 2008 NPSG
Goal 7 Reduce the risk of health care-associated infections.7AComply with current World Health Organization (WHO) Hand Hygiene Guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.
7B Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection
Goal 7 focuses on reducing risk of infections acquired in the hospital. Thinking back one of the projects on reducing central line infections focused on this goal

49. 2008 NPSG
Goal 8 Accurately and completely reconcile medications across the continuum of care.
8A There is a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization.
8B A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility.
I know you have heard a lot about this goal-which addresses medication reconciliation. I know there are lots of opinions and angst about this goal. Nationally the same concerns and struggles are occurring so we are not alone

50. 2008 NPSG Goal 9 Reduce the risk of patient harm resulting from falls.
9B Implement a fall reduction program including an evaluation of the effectiveness of the program.
9 concerns falls and reducing their likelihood

51. 2008 NPSG
Goal 13 Encourage patients’ active involvement in their own care as a patient safety strategy.
13A Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.
Goal 13 is a patient centered goal and requires us to involve patients and families to an even greater extent than we have as a patient safety strategy. Patients are told to speak up about unsafe practices; a good example is hand washing and parents have become empowered to stop healthcare providers and ask them to wash their hands

52. 2008 NPSG
Goal 15 The organization identifies safety risks inherent in its patient population.
15A The organization identifies patients at risk for suicide.
We now screen for suicide risk at admission

53. 2008 NPSG
Goal 16 Improve recognition and response to changes in a patient’s condition.
16A The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening.
We have done well with this goal with the implementation of the RRT

54. Quality Improvement Key elements
Systematic
Data-guided and knowledge informed
Experiential
Innovative
Employs formal explicit methodology
Continuous
Core responsibility of healthcare professionals

55. Healthcare Quality Improvement 2007
Move from cottage industry mode of care delivery to data driven system model of healthcare delivery
Systems approach
Individual blame not the norm
Individual IS accountable
Before I discuss qi vs. research let me just summarize my message about quality improvement. In 2007 we need to move…