Patient Safety/ Quality Improvement Project Overview

1. Patient Safety/ Quality Improvement Project Overview Ariane Marie-Mitchell, MD, PhD, MPH

2. Health Care Problem • State reason for action • Provide supporting data if available

3. Example: Health Care Problem • There is a much longer delay for 1st dose delivery of antibiotics ordered between 11pm and 7am compared to day time averages • This results in wasted time from the nurses and pharmacists, wasted medications, and poor quality of patient care

4. Historical Data – The Problem

5. Stakeholder Analysis • Who is involved? Who is affected? • Try Mind Mapping • Start interviewing- qualitative baseline data

6. Charge nurse Providers Nurses Stakeholder Analysis Couriers Patients Patient families Admin./PSR Pharmacists

7. Define the Aim • What are you trying to accomplish? • Specify • numeric goals (how good?) • time frame (by when?) • patient population/system (for whom?) K. Shannon, 2012

8. Aim for Quality Health Care Safe— Avoid injuries to patients from the care that is intended to help them. Safety must be at the forefront of patient care. Timely — Reduce waiting for both patients and those who give care. Prompt attention benefits both the patient and the caregiver. Effective— Match care to science; avoid overuse of ineffective care and underuse of effective care. Efficient— Reduce waste. The health care system should constantly seek to reduce the waste and the cost of supplies, equipment, space, capital, ideas, time and opportunities. Equitable — Close racial and ethnic gaps in health status. Race, ethnicity, gender and income should not prevent anyone from receiving high-quality care. Patient-Centered— Honor the individual and respect choice. Each patient’s culture, social context and specific needs deserve respect, and the patient should play an active role in making decisions about her own care. IOM, 2001

9. Example. Specific Aim • “Decrease delivery delay in 1st dose antibiotic by 50% between 2300 and 0700 on units 6100-6300 by February 20, 2012”

10. Identify Measures of Change • Outcome Measures e.g. Duration of delay in administration of 1st dose antibiotics • Process Measures e.g. % of antibiotic following forms filled e.g. % of fax orders with telephone follow-up • Balancing Measures e.g. Staff satisfaction

11. Cause-Effect Analysis • Fishbone Diagrams • Flowcharts

12. Constructing a Fishbone Cause and Effect Diagram • Get the right people in the room • State and clarify the “effect” • Brainstorm list for 4 Ms/P involved in the process or effect interested in • Brainstorm causes for each of these • For each cause ask “why” 5 timesto get to underlying causes K. Shannon, 2012

13. K. Shannon, 2012

14. Example: Fishbone Diagram Process Communication Unaware of effect on Poor MD RN communication Different levels of knowledge Repeat orders via fax Poor process understanding ABX Delay Old fax machines Understaffed 2300-0700 Unreliable tube system No EMR = extra steps # of pharmacy units open Machines System Failures

15. Constructing a Flowchart Start/End Start/End Input/ Output Process/ Task Delay Decision Decision Document Sequence

16. Call for Medicaid Prior Approval Example: Flowchart Call patient (need more info) Phone call (enough info provided) Name, DOB, Medication, Dose, Frequency, Pharmacy Prescription RenewalThe process begins when the patient requests renewal.The Product of Value is that the prescription is delivered. Review chart: medication sheet, last visit, next visit, other parent or pharmacy info (not consistent) (consistent) Discuss with clinician (PA needed) (PA not needed) Page 2

17. Select Change • Focus on a change concept eliminate waste, improve work flow, optimize inventory, change work environment, improve patient interface, manage time, reduce variation, improve error proofing, improve service • Perform effort vs yield analysis High effort High yield High effort Low yield Low effort Low yield Low effort High yield

18. Evidence Review • Identify relevant literature or best practice models • Who else has thought about this problem and tried to fix? • Critically appraise and describe how relates to your project aim

19. Example: Evidence Review Background  • Pneumonia = 600, 000 Medicare hospitalizations/yr • Previous Medicare Guidelines recommend antibiotic treatment within 8 hrs of hospital arrival. Methods  • Retrospective cohort study design • 18, 209 Medicare patients (>65 yrs) hospitalized with community-acquired pneumonia (July 1998-March 1999) • Outcomes: • severity-adjusted mortality (in hospital and 30 day) • readmission within 30 days of discharge • length of stay (LOS) Conclusions  • Antibiotic administration <4 hours of arrival was associated with decreased mortality and LOS among a random sample of older inpatients with community-acquired pneumonia who had not received antibiotics as outpatients. Houck, P, et al. Timing of Antibiotic Administration and Outcomes for Medicare Patients Hospitalized With Community-Acquired Pneumonia. Arch Intern Med. 2004;164:637-644.

20. D S P A A P S Act Plan D A P S D Study Do Test a Change Repeat, Tweak, Stop Who,What, When, Where Analyze Results Collect Data

21. Plan • Specify a hypothesis • Use SMART Objectives Specific - have a single purpose Measurable - tied to a result statement Attainable/realistic - know your barriers and resources Responsibilities clear – tie names to each objective Time connected - clear completion dates (consider creating a timeline)

22. Example: SMART Objectives • Interview charge nurse, nurses, couriers and pharmacists during a full overnight shift (11p-7a) by day 7- Jose • Conduct a literature review of best practices by day 7- Paymonh • Meet as a team to do cause-effect analysis by day 9- team • Collect quantitative data on initial state using Form 1a by day 10- Brent and Craig • Meet as a team to discuss potential interventions by day 12- team • Discuss intervention plan with pharmacists, couriers and nurses and implement by day 16- Jose and Paymohn • Collect quantitative data on follow-up state using Forms 1b and 2a by day 20 and analyze- Brent and Craig

23. Do • Two types of data • Qualitative e.g. interviews, focus groups, suggestion boxes show quotations, summarize themes • Quantitative e.g. anything that can be counted show run charts, bar charts, pie charts… • How did you collect the data? • What sample did you use and what was your reasoning?

24. Study • Qualitative Data • Quantitative Data • What did you learn? • Where does this lead you?

25. Example: Qualitative Data • Parents observed speech problems by age 4 and as young as 11 months • “Around 10 months I noticed she was not starting to talk like my other children did” • A minority of children received Early Intervention • “I asked the doctor about it but they were just like oh, he’ll grow out of it” • “We were supposed to have a lady come to the house and stuff but it was impossible because I was working full-time and he was at daycare”

26. Automated BMI% calculation Incorporated BMI% into nursing data collection Added BMI% to vitals

27. Act • How does your data inform your understanding of the health care problem? • How does your data influence your interpretation of how to improve the system? • What will you do next?

28. Sustainability • What barriers do you perceive to sustaining the change? • What resources are available to sustain the change? • What is the cost-benefit of the old process versus the new process?

29. References • References for literature cited • Names of faculty/staff interviewed • Location of sites where processes observed, or any other relevant info

30. ≠ D S P A A P S Act Plan D A P S D Study Do Quality Research Improvement Aim(s) Hypotheses Next steps Methods Measures Results

31. Quality Improvement Research Systematic investigation designed to contribute to generalizable knowledge Project involves introducing an untested intervention and data is being collected to establish scientific evidence of its efficacy • Intervention is demonstrated, known, or widely accepted • Project limited to implementing a practice to improve quality of care • Performance data collected for clinical, practical or administrative purposes only IRB approval required *** IRB approval not required but ask if uncertain or if considering publication

32. IHI Open School QI Practicum • Optional • Receive additional guidance and a Certificate • Sign agreement with faculty mentor • Submit aim/plan and receive feedback • Submit cause-effect diagram, PDSA cycles, run chart, and summary