1. Continuous Quality Improvement Evidence-Based Medicine In Practice…

2. CQI • Means to improve individual health care • Means to improve systems of care delivered • Means to improve care delivered by individual physicians • Means to educate physicians • Evidence-based care guidelines for specific processes • CQI as learning tool for specific processes through self audit and evaluation • Learning CQI techniques as component of continuous professional development

3. Importance • Accreditation Council on Graduate Medical Education (ACGME) has added two new competencies for residents • Practice-based learning and improvement • Systems-based practice: “the ability to effectively call on system resources to provide care that is of optimum value” • Standard competencies: medical knowledge, patient care, communications, and interpersonal skills, professionalism

4. ABIM certification and recertification… • 2000: ABIM changes recertification process to program of Continuous Professional Development • New: incorporation of principles of CQI into self evaluations (based upon national guidelines for “best care”)

5. Importance after residency… • Use by insurance companies, Medicare/Medicaid, clinics, hospitals for individual and systems performances • Use by patients • Use by individual as means of CME

6. What is health care quality? • IOM: “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” • Importance of multiple perspectives in determining quality of care

7. CQI model • 1. Aim: What is the goal? • 2. Measurement • Structural: hospital teaching status, accreditation, etc • Process: specific care (beta blocker use) • Outcomes: end results of care • 3. Ideas for change • 4. Testing and learning • Langley et al. The Improvement Guide: a practical approach to enhancing organizational performance, 1996.

8. Delirium in hospitalized elderly • Importance: marker of increased mortality and decline in functional status • Background • Delirium is often not identified in the hospital • Delirium is associated with certain risk factors • Evidence suggests that the risk of developing delirium can be decreased in high-risk patients • Identification is key to prevention

9. Delirium: CQI process • Aim: To reduce the number of patients on the geriatric medical service who develop delirium during their hospital stay • Measurement: • Process: patients assessed for delirium or risk for delirium (underlying dementia) • Outcomes: patients who develop delirium before and after proposed changes • Ideas for change: prompt on CIS note template for • Assessment for risk/development of delirium • Medication review • Review for restraints, catheters, iv lines • Testing and Learning: self audit

10. Audit Sheet • 1. Assessment for or diagnosis of underlying cognitive impairment or dementia in history, physical exam, or problem list • 2. Assessment for or diagnosis of delirium included in history, physical exam, or problem list • 3. CAM or other validated tool used to assess/screen for development of delirium during hospital stay • 4. Delirium developed during hospital stay • 5. Delirium contributed to increased length of stay or need for higher level of care at discharge

11. Author • Debra Bynum, MD, Assistant Professor, Division of Geriatric Medicine and Director of the UNC Hospitals Acute Care of the Elderly Inpatient Unit, Chapel Hill, North Carolina