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QI: “Just Do It!”

QI: “Just Do It!”. Emergency Medicine Residents July 31st, 2003 Jamie Jones, QI Consultant, QIHI Dr. Sarah McPherson, PGY-5. Quality & Change. About process NOT performance New way of practicing care NOT top down change Its about redesigning the system we work in NOT working harder.

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QI: “Just Do It!”

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  1. QI: “Just Do It!” Emergency Medicine Residents July 31st, 2003 Jamie Jones, QI Consultant, QIHI Dr. Sarah McPherson, PGY-5

  2. Quality & Change • About process NOT performance • New way of practicing care NOT top down change • Its about redesigning the system we work in NOT working harder

  3. My QI Experience • Is it important to teach residents HQI? • What is the best way to teach residents HQI? • Does the Emergency Medicine program adequately teach HQI? • If not, how could we do a better job at teaching HQI skills?

  4. The Answers to My Questions 1. Do Residents need to learn HQI? Absolutely YES…. • Knowledge of QI principles and skills is not innate. • Residents need to know how to make their workplaces and the care they provide to patients better. • Residents are part of the frontline staff and are therefore uniquely able to identify potential areas for improvement in the healthcare system.

  5. 2. What is the best way to teach residents QI? • Many different approaches • After reviewing the literature and discussing with other residents and medical staff, I think that..

  6. Theory should be taught and then practiced • Every resident should be involved in a yearly, small scope project to utilize skills firsthand • The format should be encouraged to be group based to minimize excess workloads and to teach teamwork skills • Dedicated time should be given to the teaching of QI • Regular evaluation of QI education

  7. 3. Do the Emergency residency programs adequately teach QI? Maybe…. • In the last 4 years we have had a 1 day QI workshop and 1 core rounds session (2 hrs) addressing QA/QI theory • Few QI projects have involved residents; even fewer have been initiated by residents

  8. 4. How could we do a better job at teaching HQI? I propose that we should start a structured program for HQI so that all residents get to be involved….

  9. What are the Goals of our Proposal? • To challenge residents to regularly ask the following questions: • Why do we do what we do? • How do we know that what we are currently doing works well? • How do we identify specific parts of a process that require improvement? • How can we change to do our work better?

  10. To develop a system where residents, attending physicians, and other members of the health care team can work together on clinical and educational improvements • To continually improve care delivered by residents • To teach residents the principles and clinical skills of HQI and the improvement model (PDSA)

  11. QI in ED Residency Program • Schedule and Content: 3 Scheduled QI Days each year: • July 31st - Setting the context for QI in Emergency Residency programs • Mid-September ‘03 - Moving forward with measurement • Mid-January ‘04 - Successes & Holding the Gains

  12. Schedule and Content: • July 31 ‘03 • Major principles of QI • team based philosophy • culture of change • The Improvement Model • Brainstorm ideas and develop resident projects

  13. Schedule and content: • Mid-September ‘03 • PDSA Cycles • moving forward with testing • measurement & graphing

  14. Schedule and content: • Mid-January ‘04 • Share Successes • How will we hold the gains? • How will we spread successes?

  15. What the IOM said….. • Trying harder will not work anymore • Only redesign of our health care systems • Crossing the Quality Chasm, May 2001

  16. What is Best Care? S - Safe T - Timely E - Efficient E - Effective E - Equitable P - Patient Centered It’s a STEEEP Climb to Quality! Adopted from D. Ballard, Baylor Healthcare Organization

  17. Calgary Health Region Goal: “To become a national leader in the delivery and measurement of quality health care.”

  18. QIHI • Does not “own” quality • A support service to provide consultation & information for decision-making Individual clinical departments/programs are ultimately responsible and accountable for quality of care.

  19. Integrative Process for QI Projects Regional Quality Council QI Team • Quality Issues/ • Problems • Front Line Staff • Management • Executive QI Team Portfolio/Departmental Quality Councils (Multidisciplinary) QI Team • Clinical Enhancement Team • Clinical Enhancement Physician • QI Consultant • QI Data Coordinator • Health Record Analyst • Data/Systems Analyst QIHI Resources

  20. QI Methodology Healthcare Quality Improvement Practical 11 step problem solving process The Improvement Model Plan - Do - Study - Act Methodologies require QI teams Tools & techniques

  21. QI Principles • Empower front line employees • Focus on process • Structured problem solving • Patient focused • Decisions based on data

  22. More QI Principles • Reliance on tools • Emphasis on visual presentation • Promote innovation, learning and reasonable risk taking • Cycle for learning and improvement

  23. Plan Do Act Study “Trial and Learn” Plan - Do - Study - Act measuring results and acting on them Re-evaluate and Continuous Improvement “act, capture the gain and start all over”

  24. A Few Required Understandings... • Does baseline data support there is a “problem”? • What are we hereafter? • Does everyone on team understand the aim? • Do we understand our process?

  25. Does data support there is a “problem”?

  26. Background Data • Important to have issue supported with data • Greater confidence • Understand issue • Greater degree of ‘belief’

  27. Background Data • Collect data - Many ways to gather • surveys • new performance data • existing data • qualitative & quantitative

  28. Background Data • Organize data • Display data • graphical display of data is key to sharing the message • ‘a picture is worth a thousand words’ • e.g. histograms, run charts, Pareto charts

  29. Data Drives Decisions • Measurement is for learning NOT for judgement • Research: Just in case measurement • QI: Just enough measurement • “Measures tell a story; • Goals give a reference point”

  30. DATA Cont’d • Measurement helps teams: • manage, learn & improve work processes • communicate & understand the current process & the changes in process “But, I’m not a statistician…!”

  31. That’s ok - it’s easier than it looks! • Random sampling • Pen & paper are fine - don’t wait for information system • Use qualitative data, rather than waiting for quantitative • Collect useful data, not perfect data • Plot your data over time “Run Charts”

  32. EKG Turnaround Time West Roxbury Center (1/22/89 - 2/3/89) 32 data points 9 16 1 4 15 8 13 1 13 16 14 17 7 2 20 2 2 2 18 3 17 2 14 20 1 1 2 7 1 2 15 2 Dr. Peter Norton Average = 8.3 days

  33. Run chart of EKG Turnaround Times Days EKG’s Dr. Peter Norton

  34. Annotated Run Charts • Run charts: • simplify the data • focus attention on trends & ranges • are attention getting • help us evaluate the effect of change activities

  35. Change 1 tested Change 2 tested Observed Data Value (e.g., Infection Rate) Time Order (e.g., Month) Annotated Run Chart • Plot small samples frequently over time

  36. What are we hereafter? Does everyone on the team understand the aim?

  37. Issue Statement • Why is an Issue Statement important? • To focus the project on the biggest issues • To ensure all team members are “on the same page” • To avoid “ Scope Creep” • To begin thinking about measurement

  38. Issue Statement • Three components of an Issue Statement • Direction • Increase, improve, decrease, remove • Measure • # of days, weeks, hours • Cost, wait times, errors, availability • Process • admission process • patient teaching

  39. Issue Statement Reasons for Measurement • Before/after measures are important to quantify improvement • What gets measured tends to get results

  40. Issue Statement • Examples • Decrease the number of patient complaints about length of stay in ED waiting rooms. • Increase, by 25%, the number of patients expressing satisfaction with care experience. • Reduce lab turn around times by 50%.

  41. Paramedic downtime estimated at $500,000Source: Calgary Herald 01/24/03 • Calgary taxpayers spent at least $500,000 paying paramedics to wait in line to drop patients off at Calgary hospitals • “we are very concerned about the number of hours ambulances are tied up in emergency rooms”

  42. EMS Official Demands Province Provide CureCourtesy: Calgary Sun 01/04/03 • “it’s just that the health region needs capacity and EMS needs funding” • “I think the province is dragging their feet and there’s a need to address this politically” • “we need to look at more efficient ways of using existing resources

  43. Ambulance Delay LingersCourtesy: Calgary Sun 02/21/03 • Ambulances are waiting more than one-third longer at hospital emergency wards • “the concern we have is we have fewer ambulances available and spread across a larger area --- it will take us longer to reach people and we don’t want it to happen”

  44. Frustration Shared byPatients and StaffCourtesy: Calgary Herald 02/08/03 • “I’m not sure there’s always evidence the patient is compromised (by a long wait), but it certainly is extremely uncomfortable to be in pain for too long or to be worried and anxious for too long”

  45. Issue Statement • Exercise: • At each table, work as a group to develop an issue statement for the following ‘problem’: EMS has long wait-times in ED hallways

  46. Issue Statement • Goals: • Reduce turnaround time for paramedic units from ‘arrival at ED triage to being available for next call’; without negatively impacting ED waiting room patients while maintaining safe, effective & high quality patient care.

  47. Understanding Work as a Process

  48. HQI - Focus on Process • Consider Juran and Demings 85/15 rule: • At least 85% of problems can be dealt with by improving systems; only 15% are the direct result of people.

  49. Allows you to analyze how a process functions (or doesn’t!) Most processes were never designed – they just developed 40 – 60% of everything that is done in a large complex process is non-value adding How can you possibly improve something unless you know how it works? Diagram the Process

  50. Flowcharts tool used to diagram the process macro or micro Examples Micro Flowchart PROF Bed Flow (ED - Unit 72 - OR) Macro Flowchart ED Consultant Process Diagram the Process

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