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QI, QYOU

QI, QYOU. A Quality Improvement Project on Depression Screening of IBD Patients Using Patients Using PHQ-9A for Adolescents. Lauren Ivanhoe, MSN, RN-BC, CEN Dr. Priya Raj. Learning Outcomes. ENHANCE QI KNOWLEDGE AND SKILLS THROUGH APPLICATION OF IHI TOOLS.

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QI, QYOU

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  1. QI, QYOU A Quality Improvement Project on Depression Screening of IBD Patients Using Patients Using PHQ-9A for Adolescents Lauren Ivanhoe, MSN, RN-BC, CEN Dr. Priya Raj

  2. Learning Outcomes ENHANCE QI KNOWLEDGE AND SKILLS THROUGH APPLICATION OF IHI TOOLS. • Discuss the link between quality improvement and patient outcomes. • Outline a structured approach to quality improvement implementation using the Institute for Health Care Improvement tools and resources.

  3. “We cannot become what we want to be by remaining what we are.” Max Depree

  4. A walk in history • THE AGE – OLD BELIEFS ABOUT QUALITY AND ERROR IN MEDICINE. • Inadvertent patient harm = acceptable and unavoidable • Not “unavoidable” = “bad apple” clinician

  5. Early studies on errors • 1994: “ERROR IN MEDICINE” BY LUCIAN LEAPE (HARVARD) • ICU study found 1.7 errors per day per patient; however there were 178 activities performed with each patient daily – that makes a 1% error rate • 1% error rate = • 2 unsafe plane landings per day at O’Hare • 16,000 pieces of lost mail every hour • THEN CAME PUBLIC AWARENESS

  6. The demand for change

  7. QUALITY IN HEALTH CARE “the degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” Institute of Medicine

  8. QUALITY IMPROVEMENT “The framework we use to systematically improve the ways care is delivered to patients. Processes have characteristics that can be measured, analyzed, improved and controlled.” Agency for Healthcare Research & Quality

  9. Examples in literature • Quality improvement in practice: improving diabetes care and patient outcomes in Aboriginal Community Controlled Health Services. • Association of Hospital Participation in a Regional Trauma Quality Improvement Collaborative With Patient Outcomes. • Golden Hour Protocol for Preterm Infants: A Quality Improvement Project. • Strengthening performance-based financing as a health system approach for quality improvement. • Developing, Implementing, and Evaluating a Multimedia Patient Decision Aid Program to Reform the Informed Consent Process of a Peripherally Inserted Central Venous Catheter Procedure: Protocol for Quality Improvement. • Educating for quality: quality improvement as an activity of daily learning to improve educational and patient outcomes.

  10. Why is QI important? To improve patient health and patient outcomes To enhance patient experience To improve provider experience To reduce healthcare cost and waste To improve efficiency of processes

  11. “Quality is personal — and it begins with you. If quality isn’t your job, what is?” Institute for Healthcare Improvement

  12. IHI Model for Improvement

  13. Systematic Approach to QI

  14. The Importance of a Systematic Approach

  15. QUALITY IMPROVEMENT CASE STUDY Depression Screening of IBD Patients Using PHQ-9A for Adolescents, FY 2019 Advanced Quality Improvement Team 2

  16. What are you trying to accomplish? IHI PROJECT CHARTER

  17. “If you define the problem correctly, you almost have the solution.” Steve Jobs

  18. Step 1: Define the problem The NEED . . . Defining the problem is generally the MOST critical piece of the quality improvement project. What is wrong? When and Where does it occur? How big is the problem (do you have data)? What is the impact of the problem? Be sure to verify with as many stakeholders as possible

  19. THE PROBLEM • Depression rates are up to 25% higher in adolescents with IBD. • The AAP and ICN recommend annual screening. • The current screening practice? ... well, there isn't one. Sample Project Charter | p. 5

  20. Step 2: Describe the project The WHAT… Preliminary measures that you believe may “fix” your problem Must figure out what is “critical to quality” Hint: Keep it simple stupid (KISS) Keep the scope of the project in mind Hint: You cannot solve World Hunger

  21. THE PROJECT • Short-term: Implement depression screening at the community hospital to improve patient outcomes. • Long Term: Spread the new process to the hospital system Sample Project Charter | p. 5

  22. Step 3: Defend the project The WHY… In order to make a case for a project, the number one priority is to create a shared need hint: patient stories (true ones) that show the need for improvement are extremely effective Creating a shared need creates the “wake up call” for your project (a burning platform) The business case (Return on Investment) Use of a Threat/Opportunity matrix can be very helpful with this task

  23. THE RATIONALE • National guidelines are not being followed. • Depression screening associated with: • Improved patient QOL • Improved disease control • Decreased healthcare costs Sample Project Charter | p. 5

  24. Step 4: Expected outcomes What will happen if we embark upon this initiative? What will change? Who will feel the change? What will it look like? What will it feel like? Be specific What are the benefits?

  25. THE EXPECTED OUTCOMES & BENEFITS • Meet national standards. • Promote holistic health care. • Identify and treat at risk patients. Sample Project Charter | p. 6

  26. Step 5: AIM statement SMART Specific – focus on one thing, be concise Measureable – able to measure and directly related to project goal Actionable – can actually be done Realistic – based on resources, ability to control or influence Timely – able to complete project in a timely fashion

  27. THE AIM To increase the annual depression screening rate from 0 to 75% by March 1, 2019 in English-speaking patients aged between 12 to 18 years with an established diagnosis of Inflammatory Bowel Disease, who present for follow-up care to the TCH West Campus Gastroenterology outpatient clinic. Sample Project Charter | p. 6

  28. How will we know that a change is an improvement? IHI PROJECT CHARTER

  29. We measure, of course!

  30. Step 6: QI measures Outcome Measures Actual measurements of the system; often the measure you are trying to target for change; how does the customer “feel” it? Process Measures The Parts and Steps of the process; are they performing as they should? Often lead to the outcome measure Balancing Measures As we make changes in one part of the system, other parts may be disrupted – do we need to put measures in place to prevent unintended consequences?

  31. THE QI MEASURES OF SUCCESS 80% of adolescents who screen positive will receive a formal social work assessment. 75% of in-scope adolescents complete the depression screening. Social Work and Psychology services' burden of care. Sample Project Charter | p. 2

  32. What changes can we make that will result in an improvement? IHI PROJECT CHARTER

  33. Why choosing the right solution is important

  34. Step 7: Assess the current state In order to know if a change has resulted in an improvement, you must have baseline data. EXPLORE THE PROCESS OR SYSTEM YOU ARE TRYING TO IMPROVE WITH TOOLS. Cause/Effect diagram (Fishbone) Interviews Direct observations Surveys Flowcharts Process maps

  35. THE FISHBONE

  36. “Great things are done by a series of small things brought together.” Vincent Van Gogh

  37. Step 8: PDSA planning KEY DRIVER DIAGRAM Visually depicts the theory of the group regarding what factors “drive” or contribute to the achievement of the aim. ACTION PRIORITY MATRIX Diagramming technique that helps you choose which activities to prioritize in order to make the most efficient and effective use of your time and energy. PDSA CYCLES

  38. THE KEY DRIVER DIAGRAM

  39. AQI Matrix Staff/Patient buy-in Creating SOP Staff Training EMR integration Psych/SW availability Space for consultations Impact Policy creation Clinic flow changes Privacy for patients Material availability Effort

  40. INITIAL ACTIVITIES • Engage stakeholders. • Define the current and future state screening practice. • Train clinic staff and social workers. Sample Project Charter | p. 7

  41. CHANGE IDEAS • Create the SOP based on selected tool. • Create parent communication letters. • Train staff on PHQ-9A administration. • Pilot SOP. Sample Project Charter | p. 7

  42. Step 9: Engage the right support • A STAKEHOLDER is any person or group of persons who are: • responsible for the final decision re: the project; • likely to be affected, positively or negatively, by the outcomes you hope to achieve; • in a position to assist or block achievement of the outcomes; • experts or special resources that could substantially affect the quality of your end product; • Can have influence over other stakeholders. Ensure you have created a shared need

  43. KEY STAKEHOLDERS • GI Team (MAs, Nurses, Providers, Leaders) • Clinic administration • Social Workers and leadership • Psychology/Psychiatry Sample Project Charter | p. 1

  44. Step 10: Predict success BARRIERS Need to list all of the barriers that the team believes are possible Need to make a plan to mitigate for each of these Remember to use sponsors and stakeholders to assist with this BOUNDARIES Cannot cure world hunger Be realistic given timeframe and size of project team Decide specifically what is in scope and what is out of scope for the project (aka “scope creep”)

  45. BARRIERS • Staff resistance to change • Burden of additional SW and Psych consultations • Defined screening score Sample Project Charter | p. 1

  46. BOUNDARIES • No new staff • Stick to the defined population (age, language, diagnosis, campus location) • Not measuring QOL or healthcare costs Sample Project Charter | p. 1

  47. CONGRATULATIONS! Your QI Project Charter is complete, so now what?

  48. PDSA Cycles in Action IMPLEMENTING THE PROJECT CHARTER

  49. PDSA implementation Plan Do Study Act At this point the team has a plan. Now is the time to act. Remember SMALL cycles of change Give each PDSA cycle its own timeframe and measure after (more about this later) Be flexible. If there is interference not anticipated change the timeframe on the fly Things will NOT go perfectly All cannot be anticipated If something fails, do not give up, abandon what does not work and move forward

  50. PDSA implementation Change is HARD There will be negativity. The team should plan to have its own cheerleaders Figure out who is positive toward the changes and gravitate toward them SMALL cycles of change CELEBRATE EVERY SMALL WIN!!!!

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