an introduction to quality improvement
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An Introduction to Quality Improvement. Kevin D. O’Brien, MD Fellow’s Research Conference July 23, 2014. Outline. Cost Outcomes IHI, AHA and APM Cost and Outcomes: 2 examples: SE Alaska, Denver Health The IHI Model for Improvement A UWMC Example: Cost and Outcomes - PowerPoint PPT PresentationTRANSCRIPT
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An Introduction to Quality Improvement
Kevin D. O’Brien, MDFellow’s Research Conference
July 23, 2014
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Outline
• Cost Outcomes• IHI, AHA and APM
– Cost and Outcomes:– 2 examples: SE Alaska, Denver Health
• The IHI Model for Improvement• A UWMC Example:
– Cost and Outcomes– Overcoming Barriers
• Potential Training and Resources
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US Healthcare is Expensive-1…
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US Healthcare is Expensive-2…
http://www.forbes.com/sites/danmunro/2012/12/30/2012-the-year-in-healthcare-charts/
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…but Outcomes are Poor
http://www.forbes.com/sites/danmunro/2012/12/30/2012-the-year-in-healthcare-charts/
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The IHI Model for Improvement, AIM-PDSA:AIM: Aim, Improvement, Measures
1. Aim: What are we trying to accomplish? A good aim:• Issue important to those involved• Is specific, measurable, and addresses these points: How good? By when? For whom
(or what system)? • Struggling? Remember STEEP (Safe, Timely, Effective, Efficient, Equitable, and Patient-
centered)
2. Measures: How will we know a change is an improvement? • Outcome Measures = Where are we ultimately trying to go? • Process Measures = Are we doing the right things to get there? • Balancing Measures = Are the changes we are making to one part of the system
causing problems in other parts of the system?
3. Changes: What changes can we make that will result in improvement? • 5 ways to develop changes: Critical thinking, benchmarking, using technology,
creative thinking, and change concepts. • Change concepts: Eliminate waste, improve work flow, optimize inventory, change the
work environment, producer/customer interface, manage time, focus on variation, focus on error proofing, focus on the product or service.
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The IHI Model for Improvement, AIM-PDSA:PDSA: Plan-Do-Study-Act
• Plan: Plan the test or observation, including a plan for collecting data.
• Do: Try out the test on a small scale. • Study: Set aside time to analyze the data and
study the results. • Act: Refine the change, based on what was
learned from the test.
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CARE COORDINATION AND LENGTH OF STAY INITIATIVE ON THE ADVANCED
HEART FAILURE SERVICE: RESULTS AND KEY SUCCESS FACTORS TO DATE
SEPTEMBER 26, 2013
ROBB MACLELLAN, MDKEVIN O’BRIEN, MD
VANDNA CHAUDHARI
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Organizational Alignment
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UW Medicine Performance Improvement Council
UWMC FY2013 PI Goals
Supply Chain Revenue Cycle Transformation of Care
Inpatient Capacity Reduce Practice Variation
Inpatient Capacity:• Reduce LOS and Optimize Care via Standardization• Cardiology, Cardiac Surgery, Otolaryngology/HNS
• Remove Waste and Optimize the Patient’s Value Stream• Standardize Clinical Pathway Milestones and Decisions
• Reduce Readmits• Improve D\C Times
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Table 1. Scope of the Problem: Pre-PI (July 2012 to February 2013) Measures for the UW Advanced Heart Failure Service
Measure Median Pre-PI Value(July 2012 - February
2013)
Target Value
Type of Measure
O/E LOS Rate 1.61 <1.00 Outcome Measure
O/E Mortality Rate 1.41 <1.00 Outcome Measure
30-day HF Readmissions (%)
20.2 No Balancing Measure
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Table 2. Key Measures: Data Sources, Methods of Calculation and Measure Types.
Measure UW Data Source
Method of Calculation
Type of Measure
Estimated LOS (days) Census database
Bed Days/Discharges per month
“Working” Outcome
Daily Census CORES database
Census for Each Day “Working” Outcome
O/E LOS Rate HPM* and UHC
2012/13 Risk Model Case Mix Adjusted
1° Outcome
O/E Mortality Rate HPM* and UHC
2012/13 Risk Model Case Mix Adjusted
1° Outcome
30-day HF Readmissions (%) HPM* 1° BalancingDirect Costs/Case HPM* 2° Outcome
*HPM = Horizon Performance Management system maintained by UWMC Finance and Center for Clinical Excellence (CCE) for quality measures.
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Key Protocols• “Idealized HF” Pathway Protocol:
– Based on UCLA model– Accelerates Tx/LVAD and anticipates Early Discharge:
• Tx/LVAD W/U Starts on Day of Admission• Simultaneous Medical HF Optimization• Discharge Planning Completed by Hospital Day 2• Complete Tx/LVAD Evaluation by Hospital Day 3
• New Protocols (UW-generated) to address other LOS barriers:– IV Diuretic Protocol:
• Standardized approach to aggressive diuresis• Logical target (Weight Loss, not Net I/O)• Minimize use of high-cost, low benefit meds (e.g., Nesiritide)
– Evidence-based Anticoagulation:• Stopped routine anticoagulation of HF patients• Risk-based Table to assess need for heparin “bridging”
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Card B Length of Stay “Run” Chart
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
0
5
10
15
20
25
Cardiology B Average Length of StayDays
HF PathwayInitiated
Median
14.6Median:
10.6
-4 Daysp=0.023
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Card B CORES Census 9/1/2010 – 12/31/2013 Daily Census and 30 Day Moving Average
Date
May-12
Nov-12
Mar-1
3Jul-1
3
Sep-130
5
10
15
20
25
Card
B C
ensu
s
LOS PI ProjectStart
Improved Access: Jul-Dec 2013 Daily Census by 3.1 patients (93 bed days/mo)
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ADV HF QUALITY IMPACT
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Cardiology B: Advanced HF
Service-wide savings FY 2014 YTD
(Heart Transplant Therapies) + (Medical Therapies, all DRGs)
$7,604,474
PI savings FY 2014 YTD1 (Heart Transplant Therapies) +2 (Medical Therapies cardiac DRGs only)
$6,338,740- Pharmacy savings ($542,000)
$5,796,740
PI & service level financial IMPACT
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Part 1: Develop Care Pathway
http://politicaldisconnect.blogspot.com/2008/07/obama-entering-dangerous-mine-field.htmlhttp://thetyee.ca/News/2013/07/11/Clark-Marathon/
PathwayDevelopment
Resistanceto Change(esp. MDs)
No Data/Data as
a “Hammer”
BadTeam
Dynamics
Lack ofSupport
PART 2: NAVIGATE THE IMPLEMENTATION “MINEFIELD”
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Personality Styles and Cardiology B
EXPRESSIVE
AMIABLE
DRIVER
ANALYTIC
Feeling
Thinking
Extroverted Introverted
Merrill and Reid
• Trained to focus on identifying problems (“Barriers”)
• Perfectionist
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Overcoming Barriers to Progress• Regularly-scheduled Card B LOS Meeting:
– Agenda distributed in advance (don’t meet just to meet)– Attendance by Division Head
• Developing Protocols:– Modify existing protocols from respected peer institutions
• Modify 10% rather than create 100%– Many generated internally
• Implement with Plan-Do-Study-Act (PDSA) cycles (http://www.youtube.com/watch?v=xzAp6ZV5ml4):– PDSA a “shop floor” version of the experimental method:
• Easier to get out of Committee• Whole team involved
• Team-based measure of success (Cardiology B LOS)
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Donald Berwick, MD, MPP, Founder, Institute for Healthcare Improvement (IHI)
https://www.youtube.com/watch?v=5vOxunpnIsQ
https://www.youtube.com/watch?v=831mdPYGouo&feature=player_detailpage
Don Goldmann, President, IHI - 7 Rules for Engaging Clinicians in Quality Improvement
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Challenges for QI Projects• Training in basic QI methods, IHI Open School:
– “Basic Quality Certificate”• Online modules, about 20+ hours• Six modules (QI 101-106) required for MHA students prior to QI project
– Potential Resource: Brenda Zierler, PhD, FAAN
• Mentorship:– Relative paucity of faculty mentors within Division– IHI Open School Practicum– Pair with MHA students?
• Training in QI research methodology:– Potential Resources:
• Tom Staiger, MD• Doug Zatzick, MD
• Potential data sources:– DCDR (De-identified Clinical Data Repository) through ITHS– Potential Resource: Bob Harrington, MD (ID Division)
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Potential Training (IHI Open School) and Data (DCDR) Resources
IHI Open School• http://
app.ihi.org/lms/mycatalogs.aspx
DCDR• https://www.iths.org/dcdr