a stepwise approach to quality improvement...a stepwise approach to quality improvement michelle...

A Stepwise Approach to Quality Improvement

Michelle Mourad, MD

Director of Quality and Safety, Division of Hospital Medicine

UCSF Medical Center

Why do we fail to do simple things that improve care?

Hand Hygiene 60% reliable

Central Line Bundles 70% reliable

VTE Bundles 80% reliable

Progress  

Time  

Actual  prac

2ce  

Quality  Gap  

What is QI ?

What is QI?

Yay  QI  

QI is about producing reliable and sustainable change.

Yay  Sepsis!   I’m  2red  

þ  Foley  out  þ  DVT  ppx  þ  Pain  Control  þ  Daily  BM    

Yay  QI!  

Start with a story…

•  Mayoral election in Romania

•  Neculai Ivascu incumbent mayor

… “ I know he died, but I don’t want change.”

I’ll  ask  you  a  ques-on…  

Do you work in a great hospital?

•  Do you work in a great hospital? – What’s keeping it from being great? – Do the leadership and faculty want

greatness? Do you?

•  If we all want to work at a great hospital…

You as a leader

•  Doctors not trained as leaders

•  Doctors make poor followers.

Objectives

•  Understand how the principles of QI can help you achieve PCQN vision

•  Guide you through a stepwise approach to improvement

•  Understand how PCQN data can be used for improvement

You log into the PCQN website after a recent Palliative Care faculty meeting…

Turns out despite a lot of work, your institution is still below the group average

n=35  N=149  

20.00%  

40.00%  

60.00%  

80.00%  

3   All  Sites  

Comparison  Data  for  Site  3  

Day  1  to  Day  2  Score  Improvement  (exlcuding  those  with  a  Day  1  Score  of  0)  

Stages of QI – Kübler Ross Style

Shock – Is that my data?

Denial – That can’t be my data

Anger – The measurement strategy must be flawed

Bargaining – Our patients are sicker

Depression – No one else is doing any better

Acceptance – We should probably try to improve

Emot

iona

l Res

pons

e

Time

How do we improve care?

•  Set the vision for improvement

•  Understand the Problem

•  Identify Areas for Improvement

•  Devise a Measurement Strategy

•  Prioritize small tests of change

•  Measure Change

•  Message value & Sustain the change

Using a QI framework to improve care

•  Set the vision for improvement

– Understand the Problem

–  Identify areas for Improvement

– Devise a measurement strategy

– Prioritize small tests of change

– Measure change

– Sustain the change

8:40

Vision •  Align, Define & Inspire

•  Focus on why, not what or how.

As a leader of change, the GOAL is not to make every body do what you want, the goal is to inspire people to

believe what you believe

The BI will eliminate all preventable harm by 2020.

Using a QI framework to improve care

– Set the vision for improvement

•  Understand the problem

–  Identify areas for improvement

– Devise a measurement strategy

– Prioritize small tests of change

– Measure change

– Sustain the change

9:15

The problem = Persistently high pain scores

Equipment   Process   People  

Materials   Environment   Management  

The problem = Pain management

-  Sicker patients - Pain meds not stocked - Staffing on the floors

- Lack of Nursing buy in

- Unclear Physician buy in

- No timely orders

Fishbone Diagram

Equipment   Process   People  

Materials   Environment   Management  

The  Problem  

primary cause

secondary cause

The effect The Cause

Equipment   Process   People  

Materials   Environment   Management  

Table exercise – Create a Fishbone – 10 minutes

Equipment   Process   People  

Materials   Environment   Management  

-  Sicker patients - Pain meds not stocked -  Staffing on the floors -  Not reliably measuring

pain scores

- Lack of Nursing buy in

- Unclear Physician buy in

-  No timely orders -  Teams wont let PC

write orders -  Rounding only once

a day

What did you come up with?

- Need more chaplain / SW support

- Existential pain, not treated with opiates

- More cancer patients

- PCAs take too long to order

Fishbone = structured brainstorming about why you have the problem

Use as a guide for data you may want to collect

Use data to ensure you are fixing the right problem

Equipment   Process   People  

Materials   Environment   Management  

The problem = Timely pain management

-  Sicker patients - Pain meds not stocked - Staffing on the floors

- Lack of Nursing buy in

- Unclear Physician buy in

- No timely orders

Fixing  Nurse  &  Physician  buy  in  

Is  different  than  fixing  Hme  to  pain  med  

delivery  

Case example: Patient Satisfaction

•  Goal: Improve Patient Satisfaction with MD Communication

•  Intervention: Teach hospitalists best practices in patient communication

•  Outcome: No improvement WHY?

•  Data: Patient comments all report dissatisfaction with communication between hospitalist & specialists which was not improved.

We discover

•  Hour  long  delays  between  recs  &  orders  

•  Nurses  not  giving  doses  promptly  

•  Pa2ents  aren’t  asking  for  PRN  meds  

•  No  a\ernoon  reassessment  

– Set the vision for improvement

– Understand the problem

•  Identify areas for improvement

– Devise a measurement strategy

– Prioritize small tests of change

– Measure change

– Sustain the change

9:55

Using a QI framework to improve care

Identify areas for improvement

•  Go and see for yourself •  Keep asking why until you get to the root of things

Identify Areas for Improvement (current state)

PCS Rounds (day 1)

Informal ✔ in w/ primary teams

FAMILY MTGS

Write notes with

“official recs”

45 year old woman with malignant bowel obstruction due to colon cancer with nausea, vomiting and abd pain, progressive

inability to take oral meds/hydration

3 hrs 1 hr 3 hrs 2 hrs

PCS Rounds (day 2)

•  Team (or you) wrote orders “just before they went home.

•  Patient unaware of “new” regimen. •  Did not ask for additional PRNs •  Nurse didn’t provide info on available meds

Day 2 pain scores unchanged

Write orders OR

Page team with updated

recs

Removing Obstacles

•  Ask your team why don’t people do this already?