Download - A Stepwise Approach to Quality Improvement
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A Stepwise Approach to Quality Improvement
Michelle Mourad, MD
Director of Quality and Safety, Division of Hospital Medicine
UCSF Medical Center
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Why do we fail to do simple things that improve care?
Hand Hygiene 60% reliable
Central Line Bundles70% reliable
VTE Bundles80% reliable
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Prog
ress
Time
Best practice
Actual practice
Quality Gap
What is QI ?
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What is QI?
Yay QI
QI is about producing reliable and sustainable change.
Yay Sepsis! I’m tired
Foley out DVT ppx Pain Control Daily BM
Yay QI!
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Start with a story…
• Mayoral election in Romania
• Neculai Ivascu incumbent mayor
… “ I know he died, but I don’t want change.”
I’ll ask you a question…
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Do you work in a great hospital?
• Do you work in a great hospital? –What’s keeping it from being great?–Do the leadership and faculty want
greatness? Do you?
• If we all want to work at a great hospital…
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You as a leader• Doctors not trained as leaders
• Doctors make poor followers.
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Objectives
• Understand how the principles of QI can help you achieve PCQN vision
• Guide you through a stepwise approach to improvement
• Understand how PCQN data can be used for improvement
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You log into the PCQN website after a recent Palliative Care faculty meeting…
Turns out despite a lot of work, your institution is still below the group average
3 All Sites20.00%
40.00%
60.00%
80.00%
n=35N=149
Comparison Data for Site 3
Day 1 to Day 2 Score Improvement (exlcuding those with a Day 1 Score of 0)
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Stages of QI – Kübler Ross Style
Shock – Is that my data?
Denial – That can’t be my data
Anger – The measurement strategy must be flawed
Bargaining – Our patients are sicker
Depression – No one else is doing any better
Acceptance – We should probably try to improve
Emot
iona
l Res
pons
e
Time
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How do we improve care?
• Set the vision for improvement
• Understand the Problem • Identify Areas for
Improvement• Devise a Measurement
Strategy • Prioritize small tests of
change• Measure Change• Message value & Sustain the
change
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Using a QI framework to improve care
• Set the vision for improvement– Understand the Problem– Identify areas for Improvement– Devise a measurement
strategy – Prioritize small tests of change–Measure change– Sustain the change 8:4
0
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Vision• Align, Define & Inspire
• Focus on why, not what or how.
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As a leader of change, the GOAL is not to make every body do what you want, the goal is to inspire people to believe
what you believe
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The BI will eliminate all preventable harm by 2020.
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Using a QI framework to improve care
– Set the vision for improvement• Understand the problem– Identify areas for improvement– Devise a measurement
strategy – Prioritize small tests of change–Measure change– Sustain the change
9:15
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The problem = Persistently high pain scores
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Equipment Process People
Materials Environment Management
The problem = Pain management
- Sicker patients- Pain meds not stocked
- Staffing on the floors
- Lack of Nursing buy in- Unclear Physician buy in
- No timely orders
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Fishbone Diagram
Equipment Process People
Materials Environment Management
The Problem
primary cause
secondary cause
The effectThe Cause
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Equipment Process People
Materials Environment Management
Table exercise – Create a Fishbone – 10 minutes
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Equipment Process People
Materials Environment Management
- Sicker patients- Pain meds not stocked
- Staffing on the floors
- Not reliably measuring pain scores
- Lack of Nursing buy in- Unclear Physician buy in
- No timely orders
- Teams wont let PC write orders
- Rounding only once a day
What did you come up with?
- Need more chaplain / SW support
- Existential pain, not treated with opiates
- More cancer patients
- PCAs take too long to order
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Fishbone = structured brainstorming about why you have the problem
Use as a guide for data you may want to
collect
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Use data to ensure you are fixing the right problem
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Equipment Process People
Materials Environment Management
The problem = Timely pain management
- Sicker patients- Pain meds not stocked
- Staffing on the floors
- Lack of Nursing buy in- Unclear Physician buy in
- No timely orders
Fixing Nurse & Physician buy in
Is different than fixing time to pain med
delivery
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Case example: Patient Satisfaction
• Goal: Improve Patient Satisfaction with MD Communication
• Intervention: Teach hospitalists best practices in patient communication
• Outcome: No improvementWHY?
• Data: Patient comments all report dissatisfaction with communication between hospitalist & specialists which was not improved.
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We discover
• Hour long delays between recs & orders
• Nurses not giving doses promptly
• Patients aren’t asking for PRN meds
• No afternoon reassessment
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– Set the vision for improvement– Understand the problem
• Identify areas for improvement– Devise a measurement
strategy – Prioritize small tests of change–Measure change– Sustain the change
9:55
Using a QI framework to improve care
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Identify areas for improvement
• Go and see for yourself• Keep asking why until you get to the root of things
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Identify Areas for Improvement(current state)
PCS Roun
ds(day 1)
Informal ✔ in
w/ primar
y teams
FAMILY
MTGS
Write notes with
“official
recs”
45 year old woman with malignant bowel obstruction due to colon cancer with nausea,
vomiting and abd pain, progressive inability to take oral meds/hydration
3 hrs1 hr 3 hrs 2 hrs
PCS Roun
ds(day 2)
• Team (or you) wrote orders “just before they went home.
• Patient unaware of “new” regimen.• Did not ask for additional PRNs• Nurse didn’t provide info on available
meds
Day 2 pain
scores unchang
ed
Write orders
ORPage
team with updated
recs
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Removing Obstacles
• Ask your team why don’t people do this already?