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The Quality Imperative 22 st Annual Pre-Convention Society of Pediatric Nurses April 19, 2011

The Quality Imperative 22 st Annual Pre-Convention Society of Pediatric Nurses April 19, 2011. Clinical Practices Committee. Agenda. Welcome Defining the Quality Imperative Taking action: Implementing a process or performance initiative Interactive Sessions

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The Quality Imperative 22 st Annual Pre-Convention Society of Pediatric Nurses April 19, 2011

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  1. The Quality Imperative22st Annual Pre-ConventionSociety of Pediatric NursesApril 19, 2011 Clinical Practices Committee

  2. Agenda • Welcome • Defining the Quality Imperative • Taking action: Implementing a process or performance initiative • Interactive Sessions • Group Presentations Measuring success • Making an Impact- patient outcomes • Q & A

  3. Objectives • Define the quality imperative. • Identify 5 pediatric specific nurse sensitive indicators. • Describe performance improvement methods/tools: • PDCA • EBP model • Interpret data graphs to assess quality improvement metrics. • Discuss mechanisms to evaluate impact of quality improvement in pediatric care.

  4. What is the Quality Imperative? • The term comes from the title of a book written in 1999 by John Kimberly & Etienne Minvielle. • The book focused on the concerns about how to maintain/improve quality while addressing issues of access to healthcare and containing costs. • Two of the important topics covered were implementing continuous quality improvement and evaluating quality outcomes against best practice.

  5. Why is the Quality Imperative Important for Pediatrics? • Pediatric patient quality of care involves dynamic and complex phenomena. • Each population has unique language and focused areas with no current common language across all specialty areas. • Pediatric quality efforts are further challenged as most of the work on patient safety to date has focused on adult patients

  6. Quality improvements can have a positive effect on: • Efficiency • Effectiveness • Equity • Timeliness • Patient-Centeredness • Safety • Healthcare associated costs • Satisfaction

  7. Commonly used measures of quality in nursing care • The National Database of Nursing Quality Indicators (NDNQI) was established by the ANA in 1998 and endorsed by the National Quality Forum. • These nurse sensitive measures reflect the structure, process and outcome of nursing care. • Structure=supply, skill level & education of nurses • Process=assessment, interaction & RN job satisfaction • Patient Outcomes=those that improve if there is a greater quantity or quality of nursing care.

  8. Structure/Process Nurse Sensitive Indicators (NDNQI) • Nursing Staff Skill Mix • Nursing Hours per Patient Day • Assault/Injury Rates • Nurse Turnover Rate • RN Education/Certification • RN Survey • Practice Environment Scale • Job Satisfaction

  9. Clinical Nurse-Sensitive Indicators(NDNQI) • Pressure Ulcer Prevalence • Patient Falls • Restraint Prevalence • PIV Infiltration Rate • Urinary Catheter-associated Tract Infection • Central Line Catheter Blood Stream Infection • Ventilator Associated Pneumonia

  10. NDNQI Pediatric Nurse Sensitive Indicators • The following were identified for more specific attention for pediatrics: • Pain assessment-intervention-reassessment (AIR) cycle • Peripheral IV infiltrates

  11. Other Clinical Nurse-Sensitive Indicators • Medication Error Reduction • Cardiopulmonary Arrest Reduction • Asthma Readmissions • Immunization Rates

  12. Other organizations addressing pediatric quality measures: • AHRQ (Agency for Healthcare Research & Quality • CHA (Child Health Corporation of America—new joint organization of CHCA, NACHRI & N.A.C.H. • NQF (National Quality Forum) • OCHSPS (Ohio Children's’ Hospitals Solutions for Patient Safety) National Children’s Network • Efforts to coordinate pediatric QI work • Alliance for Pediatric Quality is collaborative effort of NACHRI, CHCA, American Academy of Pediatrics, and American Board of Pediatrics

  13. Quality of Care and Research • Quality improvement and practice-based research have many similarities. • Both are systematic and use processes based on disciplined inquiry. • QI projects use a systematic method to evaluate data about processes and outcomes and recommend interventions. • Practice-based research is used to differentiate quantitatively the effects of interventions. Houser, J & Bokovoy, J. Clinical Research in Practice: A guide for the Bedside Scientist, Jones & Bartlett, 2006

  14. Performance Improvement Methods • PDCA • RCA • Six Sigma • FMEA • Lean • EBP models

  15. PDCA PLAN- this step is aimed at improvement and focuses on analyzing what is needed to improve and to identify the areas that have opportunities for improvement. DO- this step involves the implementation of change identified in the PLAN phase. CHECK - this phase involves examining what was learned and what went wrong. ACT- this step involves determining cost/benefit of continuing with the

  16. 3 2 SDSA 3 Global Aim 1 Improvement Ramp A P S D A P D S Measures A P Change Ideas S D 1 PDSA Specific Aim Global Aim Theme Assessment Improvement Ramp 2 16

  17. Evidence Based Practice: Another Method for Quality Improvement

  18. Reasons for EBPs Improved quality Patient safety Cost savings Implications for clinical and administrative decisions/practices

  19. Topics that have an Evidence Base Prevention and treatment of pressure ulcers Fall Prevention Sensory preparation for patients undergoing procedures (Jean Johnson) Prompted voiding Palliative Care Exercise Promotion Prevention of DVTs Patient safety practices Pain management Hypertension screening and treatment Prevention of Type II Diabetes

  20. It Begins with a Clear Focus Know what you want to ask

  21. Problem Focused Triggers 1. Risk Management Data 2. Process Improvement Data 3. Internal/External Benchmarking Data 4. Financial Data 5. Identification of Clinical Problem Knowledge Focused Triggers 1. New Research or Other Literature 2. National Agencies or Organizational Standards & Guidelines 3. Philosophies of Care 4. Questions from Institutional Standards Committee Is this Topic a Priority For the Organization? Consider Other Triggers No Yes Form a Team = a decision Point The Iowa Model of Evidence Based Practice to Promote Quality Care

  22. Problem-Focused Triggers Risk Management Data (e.g. fall rates, infection rates) Process Improvement Data/QI data (e.g. q 4 hour pain reassessment, DVT prevention) Internal/External Benchmarking data (e.g. patient satisfaction data around noise, promptness to call button) Financial data (e.g. total knee care/length of stay, urine collection methods) Identification of clinical problems (pet visitation, bowel sounds, food guidelines for neutropenic patients, NG placement for children , double gloving)

  23. Problem Focused Triggers 1. Risk Management Data 2. Process Improvement Data 3. Internal/External Benchmarking Data 4. Financial Data 5. Identification of Clinical Problem Knowledge Focused Triggers 1. New Research or Other Literature 2. National Agencies or Organizational Standards & Guidelines 3. Philosophies of Care 4. Questions from Institutional Standards Committee Is this Topic a Priority For the Organization? Consider Other Triggers No Yes Form a Team = a decision Point The Iowa Model of Evidence Based Practice to Promote Quality Care

  24. Purpose Statement Use the PICO method to develop a purpose statement, which will facilitate a focused project. P: The specific group of patients that you want to target (e.g. older adult hospitalized patients) P: The clinical condition that you want to address (e.g. pressure ulcers) I: Intervention or treatment- can be therapeutic (e.g. several kinds of dressings), preventative (e.g. vaccination), diagnostic (e.g. blood pressure measurement) C: Comparison (e.g. standard care) O: Expected outcomes (e.g. decreased development of pressure ulcers) University of Illinois at Chicago. (2003). Evidence based medicine. Finding the best clinical literature.Accessed March 30, 2004 from http://www.uic.edu/depts/lib/lhsp/resources/pico.shtml

  25. Benefits of A Well Formulated Purpose Statement Gives direction to find answers more quickly: Directs evidence search to best resources Helps focus reading Assists with developing appropriate implementation and evaluation plan Focuses attention on identified learning needs Keeps team focused Modified from: McKibbons & Marks, (2001). Posing Clinical Questions: Framing the Question for Scientific Inquiry. AACN Clinical Issues, 12(4), 477-481.

  26. The Iowa Model of Evidence Based Practice to Promote Quality Care = a decision Point Assemble Relevant Research & Related Literature Critique & Synthesize Research for Use in Practice Is There a Sufficient Research Base? Yes No Pilot the Change in Practice 1. Select Outcomes to be Achieved 2. Collect Baseline Data 3. Design Evidence-Based Practice (EBP) Guideline(s) 4. Implement EBP on Pilot Units 5. Evaluate Process & Outcomes 6. Modify the Practice Guideline Conduct Research Base Practice on Other Types of Evidence 1. Case Reports 2. Expert Opinion 3. Scientific Principles 4. Theory

  27. Look at the Evidence Important steps: Thorough search for evidence Consider all levels evidence Use a synthesis table Critique of evidence Making the decisions for guiding practice may be difficult Use the evidence to move forward

  28. The Iowa Model of Evidence Based Practice to Promote Quality Care = a decision Point Assemble Relevant Research & Related Literature Critique & Synthesize Research for Use in Practice Is There a Sufficient Research Base? Yes No Pilot the Change in Practice 1. Select Outcomes to be Achieved 2. Collect Baseline Data 3. Design Evidence-Based Practice (EBP) Guideline(s) 4. Implement EBP on Pilot Units 5. Evaluate Process & Outcomes 6. Modify the Practice Guideline Conduct Research Base Practice on Other Types of Evidence 1. Case Reports 2. Expert Opinion 3. Scientific Principles 4. Theory

  29. To Pilot or Not to Pilot Piloting a practice change has important advantages that outweigh the disadvantages, particularly when evidence is not strong. Benefits of piloting a practice change are: Work out the “bugs” in protocol, etc. Determine feasibility in clinical setting. Determine feasibility in specific practice setting.

  30. Evaluate • Measure process • Is change being implemented? • Measure patient outcomes • Are there changes in quality indicators?

  31. Interactive Sessions

  32. Group Presentation Template

  33. Group Presentations

  34. Understanding Control Charts 101 Thank you to my colleague Bill Pastor, Clinical Data Operations Manager

  35. Objectives • Overview of the purpose of control charts Is the process stable and predictable? Was your intervention effective? • Familiarize you with control chart vocabulary • Awareness that there are different types of control charts • NOT TO MAKE YOU AN EXPERT IN: • identifying the types of control chart • creating control charts

  36. Q:/education/control chts/

  37. Introduction • History • Statistical concepts • Content • Applications Q:/education/control chts/

  38. Walter Shewhart (1881-1967) • Bell Labs, 1920s • Reduce variation in the manufacturing process. • Continual process adjustment – increases variation Q:/education/control chts/

  39. Q:/education/control chts/

  40. Walter Shewhart (1881-1967) • May 16, 1924 one page memo • Control chart Shewart’s boss, George Edwards, recalled “Dr. Shewhart prepared a little memorandum only about a page in length. About a third of that page was given over to a simple diagram which we would all recognize today as a schematic control chart. That diagram, and the short text which preceded and followed it, set forth all of the essential principles and considerations which are involved in what we know today as process quality control.” Q:/education/control chts/

  41. W. Edwards Deming (1900-1993) • Champion Shewhart’s model • Common and Special Cause IHI: Institute for Healthcare Improvement Measuring Quality Improvement in Healthcare, A Guide to statistical Process Control Applications; Raymond G. Carey, Ph.D., Robert C. Lloyd, Ph.D. Q:/education/control chts/

  42. Descriptive Statistics (mean, median, mode, min/max, std.dev) – removes time from the analysis Run charts Control Charts Q:/education/control chts/

  43. Q:/education/control chts/

  44. same average (Xs=9.0 and Ys=7.5) • same correlation (r=.86) • same R2 (.667) and std. dev. (1.24) Q:/education/control chts/

  45. Q:/education/control chts/

  46. Descriptive Statistics Run charts – include time (x-axis), but no analysis of variation Control Charts – statistically analyze the variation over time; next generation run chart Q:/education/control chts/

  47. Are there real change in our mortality cases and percent and BSI rate vs. natural variation? – control charts (statistics) If real changes, what are the causes for the change? – content knowledge (PI) Q:/education/control chts/

  48. Definition of Terms (#1) * Normal Distribution: Special Cause Q:/education/control chts/

  49. Criteria to Identify Special Cause Variation

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