QUALITY IMPROVEMENT IN HEALTHCARE RESIDENCY AND BEYOND Lisa

QUALITY IMPROVEMENT IN HEALTHCARE: RESIDENCY AND BEYOND Lisa Knight, MD Quality Improvement Lecture 2 September 18, 2014

LECTURE OUTLINE • The importance of QI efforts in healthcare • Basics of a QI project • PDSA cycle • AIM statement • Project Planning Document • Writing Your Introduction Section of your QI paper • Refresher on Residency QI Upcoming Deadlines

PATIENT PROTECTION AND AFFORDABLE CARE ACT • Pay for performance • Value-based purchasing • Bundled payments • One lump sum

WHY QUALITY IMPROVEMENT? • A gap exists between the quality of care that is possible and the actual quality of care delivered to persons living in the U. S. Infant mortality in the US per 1000 live births is DOUBLE that of other leading nations • Due to the seriousness of these shortcomings there is increasing importance that physicians and residents learn and use modern QI methods and tools

“EVERY SYSTEM IS PERFECTLY DESIGNED TO GET THE RESULTS IT GETS” • This means that the US healthcare system is perfectly designed to: • Achieve 44, 000 to 98, 000 inpatient deaths per year due to medical errors • Have twice the infant mortality rate of other nations • Do all that for twice the cost person of other industrialized countries • You can respond in 1 of 3 ways • Ignore it • Blame someone else (insurance, malpractice, Obama…. ) • Do something about it The only way to get different results is to CHANGE THE SYSTEM

INSTITUTE OF MEDICINE REPORTS • (1999) To Err is Human: Building a Safer Health System Ø Put the spotlight on how tens of thousands of Americans die each year from medical errors Ø Effectively put the issue of patient safety and quality on the radar screen of public and private policymakers • (2001) Crossing the Quality Chasm: A New Health System for the 21 st Century Ø Described broader quality issues Ø Defined six aims for care delivery and redesign

THE IOM HAS PROPOSED 6 SPECIFIC AIMS FOR IMPROVEMENT • Healthcare should be: • Safe Avoiding injury from care that is meant to be helpful • Effective Avoiding underuse or overuse of services • Patient-Centered Providing respectful, responsive, individualized care • Timely Reducing waits and harmful delays in care • Efficient Avoiding waste of equipment, supplies, ideas, and energy • Equitable Providing equal care regardless of personal characteristics

HOW DO WE GO ABOUT CHANGING THE SYSTEM? 5 -Step Process for Improvement Establish a future plan Plan Act Study the results 1. 2. 3. 4. 5. Model for Improvement Select the opportunity for improvement Study the current situation Analyze the causes Develop a theory for improvement Select the team CHANGES MEASURES Implement the Improvement Present Situation What change can we make that will result in improvement? How will we know that a change is an improvement? Do Study AIM What are we trying to accomplish? ACT PLAN STUDY DO Ideal Future

When selecting a QI topic… • Go for low-hanging fruit • Ensure Organizational support and participation will be provided for this improvement process

LOW-HANGING FRUIT IN THE ENDOCRINE DIVISION • No Show rate • Endocrine patients • Healthy Lifestyles patients • Medication compliance in adolescents with diabetes • Diabetes school forms • Motivation to make lifestyle changes in Healthy Lifestyles patients 1. 2. 3. 4. 5. 6. Safe Effective Patient-Centered Timely Efficient Equitable

A HEALTHCARE –RELATED PDSA CYCLE: PLANNING STAGE 5 -Step Process for Improvement 1. Select the Opportunity for Improvement • No-Show rate in the Pediatric Endocrine clinic 2. Study the current situation • Define why improvement in this area is necessary Ø Health risk of the patient who doesn’t show Ø Health risk of the patient seeking an appt, but unable to book Ø Poor staff utilization Ø Loss of multiple streams of revenue • Collect and/or review baseline data in your problem area Ø Track the following for one month 1. 2. 3. 4. 5. Select the opportunity for improvement Study the current situation Analyze the causes Develop a theory for improvement Select your team Model for Improvement AIM: What are we trying to accomplish MEASURES: How will we know that a change is an improvement CHANGES: What change can we make that will result in improvement • Total number of patient appointments scheduled • Total number of patients seen No Show Rate = 35% ACT PLAN STUDY DO

A HEALTHCARE RELATED PDSA CYCLE: PLANNING STAGE 3. Analyze the causes • Determine factors contributing to no-shows in your population 5 -Step Process for Improvement 1. 2. 3. 4. 5. Select the opportunity for improvement Study the current situation Analyze the causes Develop a theory for improvement Select your team Model for Improvement AIM: What are we trying to accomplish • Describe the current process for patient appt reminders Ø Automated phone call to primary phone in EMR 48 -72 hours before appt 4. Develop a theory for improvement MEASURES: How will we know that a change is an improvement CHANGES: What change can we make that will result in improvement 5. Select your team ACT PLAN STUDY DO

DEVELOP A THEORY FOR IMPROVEMENT: AIM STATEMENT • A good aim is: • Specific • Measurable • Addresses these points: • For whom (or for what system)? • How good? • By when? We will reduce the patient appt no-show rate in the Pediatric Endocrine clinic from 35% to 20% by March 31, 2015 Model for Improvement AIM: What are we trying to accomplish MEASURES: How will we know that a change is an improvement CHANGES: What change can we make that will result in improvement ACT PLAN STUDY DO

DEVELOP A THEORY FOR IMPROVEMENT: CHANGES • Processes formulating ideas for change: • Critical thinking about the current system • Flowchart on the current process • Analyze data on the current system Model for Improvement AIM: What are we trying to accomplish MEASURES: How will we know that a change is an improvement • Benchmarking • Comparing your own process to “best practice” • Take the patient’s perspective CHANGES: What change can we make that will result in improvement • Ask the patient/caregiver for ideas • Using technology ACT PLAN STUDY DO • Text messaging • Social media Office secretary to make phone call to patient’s caregivers 24 hours before appt

DEVELOP A THEORY FOR IMPROVEMENT: MEASURES • Qualitative data: Subjective • Quantitative: Objective Model for Improvement • 3 main types of measures: AIM: What are we trying to accomplish Ø Outcome Measure: • Are you reaching your ultimate result? • No-Show rate in the Pediatric Endocrine clinic (%) Ø Process Measure: • Are the parts/steps in the system performing as planned? MEASURES: How will we know that a change is an improvement CHANGES: What change can we make that will result in improvement • What percent of patients receive a reminder phone call from the secretary Ø Balancing Measure: • Are changes designed to improve one part of the system causing new problems in other parts of the system? • Are the secretaries unable to get their other work done because of time spent calling patients? ACT PLAN STUDY DO

FORMING AN EFFECTIVE TEAM • Identify a QI mentor • Be sure to include members familiar with all the different parts of the process you are trying to improve • Endocrine Team: • Myself: Project Leader • Dr. Whitney Brown: Division Director • Endocrine Clinic secretary

Lisa Knight Whitney Brown The Endocrine Clinic Secretary Reduce the No-Show rate in the Pediatric Endocrine clinic from 35% to 20% by March 31, 2015 No-Show rate (%) = Total number of patients who didn’t show Total number of patients scheduled X 100 Percentage of patients each day who received a phone call 24 hours before their appt Secretary satisfaction with the appt reminder system Secretary to make phone calls to patients 24 hours before their appt

ALWAYS START SMALL Ideal Future • First PDSA cycle: • Only my patients • Not the other 3 endocrine providers • Morning clinic of September 15, 2015 • 10 patients • Increase in • Scale • Scope Present Situation ACT PLAN STUDY DO

QI VS RESEARCH Steal Shamelessly Research Quality Improvement • Form hypothesis • Form a hypothesis • Stick with it until bitter end • Adjust through multiple PDSA cycles to work out kinks • One large test • Sequential tests • T-tests, chi square, p-value • Run charts or Shewhart charts In QI, the goal is to improve the conditions that exist…. not merely to describe what they are And to do that, you need to be able to modify your assumptions and retest your theories based on what you learn in the course of your tests

A HEALTHCARE –RELATED PDSA CYCLE: PLANNING STAGE 5 -Step Process for Improvement 1. Select the Opportunity for Improvement • Hyperglycemia in diabetics after transition from insulin gtt to SC injections 2. Study the current situation • Define why improvement in this area is necessary Ø Continued hyperglycemia may result in: • Prolonged hospital stay • More frequent BG checks • More frequent corrective insulin injections • Added stress/anxiety for child/caregiver 1. 2. 3. 4. 5. Select the opportunity for improvement Study the current situation Analyze the causes Develop a theory for improvement Select your team Model for Improvement AIM: What are we trying to accomplish MEASURES: How will we know that a change is an improvement CHANGES: What change can we make that will result in improvement ACT PLAN STUDY DO

A HEALTHCARE –RELATED PDSA CYCLE: PLANNING STAGE 5 -Step Process for Improvement 2. Study the current situation (cont. ) a. Current transition protocol • ½ dose Lantus given at breakfast • Insulin gtt d/c • ½ dose Lantus given at bed • Full Lantus dose given the following night at bedtime Collect and/or review baseline data in your problem area a. Track the following for six months • Average BG level for each patient • In the 4 -6 hours before insulin gtt d/c AND in the 12 hours 1. 2. 3. 4. 5. Select the opportunity for improvement Study the current situation Analyze the causes Develop a theory for improvement Select your team Model for Improvement AIM: What are we trying to accomplish MEASURES: How will we know that a change is an improvement CHANGES: What change can we make that will result in improvement after full Lantus dose given • During the 36 hour transition period • Reoccurrence of urinary ketones after insulin gtt d/c ACT PLAN STUDY DO • Number of correction insulin doses given

Average BG 152 mg/d. L Average BG 276 mg/d. L

A HEALTHCARE RELATED PDSA CYCLE: PLANNING STAGE 3. Analyze the causes a. Determine factors contributing to hyperglycemia • Was the insulin gtt turned off too early? • Are CHO being counted appropriately? • Are patients/caregivers sneaking food/drink into their room? • Are insulin doses being calculated correctly? • Does the current transition protocol give enough insulin? 4. Develop a theory for improvement a. ½ dose Lantus transition protocol provides too little basal insulin b. Will give full dose Lantus at transition 5. Select your team a. Myself b. Dr. Whitney Brown (Endocrine Division Director) c. Dr. Elizabeth Mack (PICU attending) 5 -Step Process for Improvement 1. 2. 3. 4. 5. Select the opportunity for improvement Study the current situation Analyze the causes Develop a theory for improvement Select your team Model for Improvement AIM: What are we trying to accomplish MEASURES: How will we know that a change is an improvement CHANGES: What change can we make that will result in improvement ACT PLAN STUDY DO

Lisa Knight Whitney Brown Dr. Elizabeth Mack Reduce the Average BG level in patients with diabetes in the PICU during the 36 hours following transition from an insulin gtt to SC injections from by 25% by March 31, 2015 Change in Average BG level with Full Dose Transition Change in Average BG level with Half Dose Transition X 100 Percentage of patients who received the full Lantus dose at the time of transition Was there increased confusion about when to administer subsequent doses of Lantus Full Lantus dose to be given at time of transition (then moved to lunch the next day, dinner the day after that, and bedtime on the following day)

Average BG 166. 3 mg/d. L Average BG 217. 8 mg/d. L

Change of 123. 4 mg/d. L Change of 51. 5 mg/d. L

QI WRITE-UP: INTRODUCTION • Background Knowledge: ü Provides a brief, nonselective summary of current knowledge of the care problem being addressed, and the characteristics of organizations in which it occurs • Local Problem ü Describes the nature and severity of the local specific problem or system dysfunction that was addressed • Intended Improvement ü Describes the specific aim of the proposed intervention (changes/improvements in care processes and patient outcomes) ü Specifies who (champions, supporters) and what (events, observations) triggered the decision to make changes • Study Question ü Specifies specific AIM statement of the project § Details precisely the primary improvement-related question and any secondary questions that the study of the intervention was designed to answer

We know what good health care is, that’s not the problem The challenge is to close the gap, the “chasm” between What we know to be good care and The care that people actually receive

NEXT STEPS First Years • Friday, January 30, 2015 § The following are due by end of day: a. Project Planning Document b. Introduction/Background section of QI writeup Second Years • Feb 2015 § Second QI Lecture (Date TBA) • March 31, 2015 § Complete collection of post-intervention data • April 2015 § Poster Presentation Lecture (Date TBA) • Friday, May 8, 2015 § Turn in QI project write-up to me by end of day • Friday, June 19, 2015 § 3 rd Annual Pediatric Residency QI Presentation Day • July 2015 § SCAAP Annual Meeting Poster Presentations (Date TBA)

USC PEDIATRIC RESIDENCY QI WEBSITE http: //pediatrics. med. sc. edu/residency. asp