uganda quality improvement

M A R I E L L E N L A N E , M D A S S O C I A T E P R O F E S S O R O F P E D I A T R I C S

C O L U M B I A U N I V E R S I T Y M E D I C A L C E N T E R D I V I S I O N O F C H I L D A N D A D O L E S C E N T

H E A L T H

Quality Improvement

What is Quality?

“The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

To Err Is Human

Ø Released November 1999 by the Institute of Medicine

Ø Every year, 44k-98k people could die from a medical error ¡  Types of Error

÷  Diagnostic ÷  Treatment ÷  Preventive ÷  Other

Ø Over half of medical errors are preventable

Ø Annual Cost of Errors = $17 Billion - $29 Billion

Making Quality Improvement Count

“We can only get the most complete, credible, and useful information by studying structure, process, and outcome in conjunction.”

AVEDIS DONABEDIAN

What is Quality Improvement?

�  Recognize that there is a gap between care as it is and care as it could and should be for your patients

�  Working to change the systems that deliver care �  Knowing that not all changes are improvements but

all improvement involves change. �  Requires involvement of a team �  “Doing things right”

Why focus on improvement?

�  Pediatric health care delivery varies significantly across providers and between communities.

�  Preventive services have been shown to be among the most effective of clinical services.

�  Recognize that there is a gap between care as it is and care as it could and should be for your patients.

Institute for Healthcare Improvement Triple Aim

7

�  Improve the Health of the Population � Enhance the Patient Experience of Care

¡  Quality, Access, Reliability and Satisfaction

� Reduce, or At Least Control, the Per Capita Cost of Care

� www.ihi.org

NICHQ

The National Initiative for Children’s Healthcare Quality

�  Mission: “ to eliminate the gap between what is and what could be in health care for children, with a focus on primary care and the most vulnerable children.”

�  Their initiatives have included: asthma, ADHD, CSHCN, children in foster care, preventive healthcare, obesity, breastfeeding

�  www.nichq.org

Linked aims of improvement.

Batalden P B , Davidoff F Qual Saf Health Care 2007;16:2-3

©2007 by BMJ Publishing Group Ltd

Learning Objectives in QI

�  The ability to critically evaluate the knowledge base supporting good patient care (EBM)

�  An understanding of the gap between prevailing practices and best practices

�  Understanding the steps necessary to close the gap �  Participating in closing the gap between prevailing

and best practices �  Closing the “knowing-doing”gap

Model for Improvement

Act Plan

Study Do

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in an improvement?

The Model for Improvement

�  NICHQ “85/15 Rule” �  Improving outcomes = 85% systems and 15%

individuals �  Need to understand the system, not focus on

changing workers. �  “Every system is perfectly designed to achieve the

results it gets”.

Key Stakeholders

�  Key individuals or groups �  Who can either influence or may be affected by your

QI activity �  Includes: end-users, senior leadership, front line

staff �  Need to consult with your Key Stakeholders!

�  Who are your Stakeholders?


Act Plan

Study Do




What Are We Trying to Accomplish?

Aim: A written statement of the accomplishments expected from each pilot team’s improvement efforts

Different forms are useful: ¡  A general description of aim ¡  Specific patient population ¡  Some guidance for carrying out the work ¡  Time specific ¡  Measurable

Global Aim Statement

�  “Big picture” statement of what you are trying to accomplish

�  Represents shared goals

SMAART Aims

�  Specific: Understandable, unambiguous �  Measurable: Numeric goals �  Actionable: Who, what, where, when �  Achievable (but a stretch)/Realistic

¡  Context of support(division/dept/hosp priority?) �  Relevant to stakeholders and organization

¡  Strategic, Compelling, Important

�  Timely: with a specific timeframe

“AIMS for Improvement”

�  6 main themes are promoted in the Institute of Medicine Report in 2001, Crossing the Quality Chasm: A New Health Care System for the 21st Century

�  Safe �  Effective �  Patient Centered �  Timely �  Efficient �  Equitable


Act Plan

Study Do




Effective Measurement

�  How will we know that change is an improvement?

�  Build measurement into daily work routine �  Data should be easy to obtain and timely �  Small samples over time – 20 -30 charts �  Use Quantitative and Qualitative Data �  Goal is to measure improvement over time

�  Outcome, Process and Balancing Measures

Measurement for Research vs QI source: IHI

Measurement for Research

Measurement for Learning and Process Improvement

Purpose To discover new knowledge

To bring new knowledge into daily practice

Tests One large “blind test” Many sequential, observable tests

Biases Control for as many as possible

Stabilize the biases from test to test

Data Gather as much data as possible, “just in case”

Gather “just enough” data to learn and complete another cycle

Duration Can take long periods of time to obtain results

“Small tests of significant changes” accelerates the rate of improvement

Counting out loud

�  “You cannot measure what you don’t count” – Charlie Homer, NICHQ

�  “ I feel” statements �  Vaccine rates, smoking screening etc

Measurement Types

� Outcome Measures – voice of the customer, are we achieving our AIM?

� Process Measures – voice of the workings of the system, are the steps performing as planned?

� Balancing Measures – what happened to the system as we improved the outcome and process measures?

� PDSA cycle measures – may be quantitative or qualitative

Data Presentation in QI - Run charts

�  Visual display of change over time �  Calls for more frequent measurement points �  Annotate the run chart to document changes/PDSA

cycles �  Demonstrates impact of PDSA cycles on change over

time �  Better than bar graphs for QI �  Takes into account context

Example of a run chart demonstrating compliance with a standard procedure.

Perla R J et al. BMJ Qual Saf 2011;20:46-51

Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.

Percentage of Patients with Asthma with a Priority Level

Goal 75%


Act Plan

Study Do




Tests of change

�  What changes can we make that will result in an improvement?

�  Requires both change concepts and PDSA cycles �  PDSA cycles allow us to put a change into effect on a

temporary basis and learn about its potential impact �  Think small, test, then spread

PDSA cycle for Learning and Improvement

� Plan: objective, questions and predictions, plan to carry out the cycle ( who, what, where, when)

� Do: carry out the plan, document problems and unexpected observations

�  Study: complete the analysis of the data, compare the data to predictions, summarize what was learned

� Act: what changes are to be made?, next cycle?

Cycles might include:

�  Reminder systems – Signs �  Simplification of processes – Prescreening forms,

Reorganization of workspace, simplify ordering system

�  Structuring the system to do the right thing at the right time and place – Proper Identification of patients

�  Testing new interventions to determine what works best in a particular setting – Where/Who/ When do we change the system

Repeated Use of the PDSA Cycle

Hunches Theories

Ideas

Changes That Result in

Improvement

A PS D

A PS D

D SP A

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change



What change can we make that will result in improvement?


Use of the PDSA Cycle

�  Developing a change �  Testing or adapting a change �  Implementing a change �  Spreading change to the rest of your organization

Key: Testing on a Small Scale

�  Test the new approach on the members of the team before introducing it to others

�  Do cycles on the smallest scale possible – Conduct the test with one physician, with one patient for one day

�  Failed cycles are learning opportunities

Tips for Success for Successful Cycles v Improvement occurs in small steps

v Communicate and review regularly to improve plan

v Failed changes=learning opportunities v Pick easy changes

Implementation vs Spread

�  Implementation: Implementation is taking a successful change that has been tested and making a permanent change to the way the entire pilot population or pilot clinic does their work.

�  Spread: Spread is the process of taking a successful implementation from a pilot clinic and replicating that change or package of changes beyond the pilot clinic into other parts of the organization, into other organizations, or into a new area of focus.

Spread of Change

�  Moves a successful implementation process from a pilot population or unit to another unit

�  Replicates the Change Package in other parts of the organization

�  Units adopting a change need to plan how to best adapt it to their unit

Successful Improvement Experiences

�  Use health data to set priorities (baseline data) – look for gaps in care

�  Master the professional subject matter as a learner (EBM)

�  Set Project Priorities (AIM statement) �  Have a clear definition of a target community �  Select projects that can be completed in the time

allocated to the QI work �  Emphasize interdisciplinary teamwork

All Improvement requires change Not all change is an improvement

Projects from the past 10 years

Screening Tests Vision, Hearing, Blood Pressure, Lipids, Lead, Anemia, TB, BMI%, Newborn Screen

Prescreening Health Assessments Postpartum Depression, Domestic Violence, Over the counter medication use, Developmental Screening, Sweetened Beverage Screening

Workflow Improving the Referral Process, Setting patients as Primary in the EHR, Problem lists in EHR, Transitions of Care in Ambulatory, E prescribe

Care Guidelines Improving Asthma Risk Stratification, Antibiotic Stewardship, BP Management

Improving Anticipatory Guidance Dental Health, Reach out and Read, Maintaining/improving Breastfeeding rates and Trivisol use, Healthy lifestyles

Vaccinations Developing Prevaccination workflow, Improving HAV and HPV vaccination rates

You can begin with: a Chart audit

�  Requires patient panel – frequently clinic based �  Starts with who and what questions – how many

patients have a given diagnosis, what is their treatment vs standard of care

�  Progresses to why and how questions – why are patients not receiving standard of care therapy, how can we redesign the system to improve care

�  Improves care of patients in the individual providers’s panel

What are your gaps in care?

�  Prescreening ? �  Workflow – ordering vaccines? �  Medication management

Sample Project

�  Baseline data – how to get it? �  Who would be on your team? �  Who are the Key Stakeholders? �  AIM statement? �  What would a Key Driver diagram look like?/Secondary

Drivers/Interventions/Possible PDSA cycles �  EBM didactic �  PDSA cycle #1 �  Reassess, further cycles �  What may be some outcome or process measures? �  How to sustain change?

References �  www.ihi.org �  “A Primer on Leading the Improvement of Systems,” Don M. Berwick, BMJ, 312: pp 619-622,

1996. �  “Crossing the Quality Chasm: A New Health System for the 21st Century (March 1, 2001)

www.IOM.edu �  “The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G.

Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers., San Francisco, 1996. �  Batalden P, Berwick D, Bisognano M, splaine M, Baker G, Headrick L. Knowledge domains for

Health Professional Students seeking competency in the Continual Improvement and Innovation of Health Care. Boston, Mass: Institute of Healthcare Improvement:1998.

�  Voss JD, May NB, Schorlin JB, et al. Changing conversations: Teaching safety and quality in residency training. Acad Med. 2008;83:1080-1087.

�  Ogrinc G, Headrick L, Mutha S, Coleman M, O’Donell J, Miles P. A framework for teaching medical students and residents about practice based learning and improvement, synthesized from a literature review. Acad Med. 2003: 78:748-756.

�  Ogrinc G, Headrick LA, Morrison, LJ, Foster, T. Teaching and assessing resident competence in practice based learning and improvement. J Gen Intern Med. 2004;19:496-500.

�  Windish DM, Reed DA, Boonyasai RT, Chakraborti C, Bass EB. Methodological rigor of quality improvement curricula for physician trainees: a systematic review and recommendations for change. Acad Med. 2009;84: 1677-1692.

�  Ambroggio, Lilliam, et al. "Quality Improvement Methods Increase Appropriate Antibiotic Prescribing for Childhood Pneumonia." Pediatrics 131.5 (2013): e1623-e1631.

References

�  Boonyasai RT, Windish DM, Chakraborti C, Feldman LS, Rubin HR, BassEB. Effectiveness of teaching quality improvement to clinicians: a systematic review. JAMA. 2007;298:1023-1037.

�  Batalden PB, Davidoff F. What is “quality improvement” and how can it transform healthcare? Qual Saf Health Care. 1007;16:2-3.

�  Batalden P, Davidoff F. Teaching quality improvement: the devil is in the details. JAMA. 2007;298:1059-1061.

�  Berwick DM. Developing and testing changes in delivery of care. Ann Intern Med. 1998;128:651-656

�  Djuricich A, Ciccarelli M, Swigonski N, A continuous quality improvement curriculum for residentsL Addressing core competency, improving systems. Acad Med. 2004;79:S65-S67.

�  Glasziou, P, Ogrinc, G, Goodman, S, Can evidence-based medicine and clinical quality improvement learn from each other? BMJ Qual Saf 2011;20(Suppl 1):13-i17

�  Ogrinc, G, et.al, The SQUIRE (Standards for Quality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration. Quality and Safety in Health Care. 2008;17(Suppl 1):i13-i32

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