Application of the Clinical Improvement Equation in a

Application of the Clinical Improvement Equation in a Maternal Child Nursing Course Mimi Pomerleau DNP, RNC-OB Post-Doctoral Fellow, VA Quality Scholars Program Kristine Ruggeiro Ph. D, PNP Brant Oliver, Ph. D, MS, MPH, APRN-BC Faculty Senior Scholar, VAQS Program www. mghihp. edu

Why care about quality?

THE FORMULA FOR IMPROVEMENT (Batalden, 2003) Clinical Improvement Equation EBP Determination Execution (PDSA, etc. ) Did You Know Poster Generalizable Scientific Evidence • “Traditional Research” • Guidelines • Position Statements + Particular Context • Microsystem Green Books • 5 P Assessments • Culture Measured Performance Improvement Balanced Measures • clinical • functional • satisfaction • costs

“Did You Know” Poster • • • Evidence based practice clinical issue Review literature Summarize Synthesize to poster format Share

THE FORMULA FOR IMPROVEMENT (Batalden, 2003) Quality Improvement Group Project Rotation 2 EBP Determination Generalizable Scientific Evidence • “Traditional Research” • Guidelines • Position Statements + Particular Context • Microsystem Green Books • 5 P Assessments • Culture Execution (PDSA, etc. ) Measured Performance Improvement Balanced Measures • clinical • functional • satisfaction • costs

“Clean Room” Context Assessment • • • OR suite Restaurant 5* hotel Motel 6 Teenager’s bedroom

Systems thinking Individual - personal From Dolansky, M. A. & Moore, S. M. (2013). Quality and Safety in Nursing Education: The Key is Systems Thinking. Online Journal of Issues in Nursing. October. PMID: 18922279

www. slideshare. net Macrosystem (Facility, Healthcare System) Market and Geopolitical System (Policy) Mesosystem (Department) “A health care clinical microsystem can be defined as the combination of a small group of people who work together in a defined setting on a regular basis—or as needed—to provide care and the individuals who receive that care (who can also be recognized as members of a discrete subpopulation of patients. )”

A clinical microsystem must… • Do the job • Meet patient’s needs • Meet staff needs for respect, challenge, growth, joy, & earnings • Maintain self as an organization mission, values, finances, image Same criteria for any adaptive system

Microsystems Context Assessment: The “ 5 Ps” • Purpose - Our aim and mission. • Patients - Our reason for doing our work. • Professionals - Our staff who work in the trenches to take care of patients. • Processes - Our system of inter-related events that constitute the microsystem. • Patterns - Our way of doing our work (Measurements, Data, Run Charts) (Nelson, E. C. , Batalden, P. B. , Godfrey, M. M. , Lazar, J. S. ( 2011) Value by Design Developing Clinical Microsystems to Achieve Organizational Excellence. Jossey-Bass San Francisico, CA. )

5 P Assessment of the Microsystem Purpose Why does the microsystem exist? www. clinicalmicrosystem. org

5 P Assessment of the Microsystem Patients: Who are the people that the micro-system serves? www. clinicalmicrosystem. org

5 P Assessment of the Microsystem Professionals: Who are the people that comprise the clinical microsystem? www. clinicalmicrosystem. org

5 P Assessment of the Microsystem Processes: How does the clinical microsystem function? www. clinicalmicrosystem. org

Bar Chart Good to compare data during a specified time period Why are patient’s not adhering to their treatment plan? 50 45 40 35 30 25 20 15 10 5 0 I forget Takes too long Doesn't make a difference Makes me feel worse Other 16

5 P Assessment of the Microsystem An example of a flow process diagram… www. clinicalmicrosystem. org

5 P Assessment of the Microsystem Patterns: How does the microsystem behave? Measuring team performance -measurement data -run charts www. clinicalmicrosystem. org

Patterns • Run chart Number of Patients Seen by Nutritionist in CF Clinic B by Month 60 50 40 30 20 10 Run chart template ноя-13 сен-13 июл-13 май-13 мар-13 янв-13 ноя-12 сен-12 июл-12 май-12 мар-12 янв-12 0

Pareto Chart Reasons for poor patient satisfaction 140 100, 0% 90, 0% 120 80, 0% 100 70, 0% 60, 0% 80 50, 0% 60 40 40, 0% Frequency 30, 0% Cumulative Percentage 20, 0% 20 10, 0% llin g co tri m a M mun ge ed icat io t Pr ion n ov iss id er ues Te ma ch nn e ni ca r ls kil ls Po or Ph on e Bi rra fe im Re tt ai w ng Lo ls 0, 0% es 0 Pareto chart template “ 80 /20 Rule” • Pareto ranks a data set & displays it graphically in descending order from left to right • Second line is added to identify the cumulative percentage • Quickly establishes priority list for improvement actions

5 P Data Dashboard Purpose: why does unit exist-understand the current state-link to DYK Patterns: Run charts ноя-13 сен-13 май-13 июл-13 янв-13 мар-13 сен-12 ноя-12 май-12 60 50 40 30 20 10 0 июл-12 Process: Uncover current state Process flow chart Fish bone diagram янв-12 • Age • Average LOS • common diagnosis мар-12 Patients: Professionals: • Who’s on the team • What do they do • What are their beliefs? 40 30 20 10 0 Next steps: what would you like to do? • Develop Global Aim for a future QI project: • Specific aim • Change idea-PDSA cycle QI team members: 1. 2. 3…. . 22

Challenges • • Clinical units did not know about quality Frustration finding data in EHR Limited time on unit- specialty focused clinical topic Is 5 P microsystem assessment appropriate for the context? Is there something better?

Student Comments: • “I felt it was very relevant to the new generation of nursing - now more than ever” • - “It was simple to conduct our survey of the floor and analyze the process flow” • - “The dashboard survey was not too time-consuming and kept things nice and concise” “wanted more space to report on our findings” • Understand important but want more OB/Pedi content • Limited clinical time could not see how QI project helped to mastery needed clinical skills • Communication breakdown between instructors in courses • Clinical faculty not on board with assignment

Recommendations: • Incorporate the QSEN competencies in all nursing courses and build assignments throughout the curriculum. • Revisions to the assignment to focus on clinical practice issue that is seen in the clinical setting. • Communication between faculty • Collaborate with the next course in the curriculum to reinforce QI skills and Identify change ideas and performance measures. • Perhaps include a 1 page reflection of process