john v. hartline, md, faap · 2018-02-21 · john v. hartline, md, faap clinical professor,...

John V. Hartline, MD, FAAP

◦ Clinical Professor, University of Wisconsin, Madison

◦ Editor-in-Chief, NeoReviewsPlus©

Janet H. Muri, MBA

◦ President, NPIC/QAS

Stephen A. Pearlman, MD, MSHQS, FAAP

◦ Clinical Professor, Jefferson Medical College

◦ Director, NPM Fellowship, Jefferson Medical College

◦ Attending Neonatologist, Christiana Care Health System

Look in the mirror – you’re part of this too!

Conflict of Interest:

◦ All three presenters have experience with Part 4 ABP MOC

projects which are ongoing at this time.

◦ Such experience will contribute to the content of the

presentation, but the presentation’s aim is to foster creativity

toward development of new quality improvement projects

by the attendees.

No off-label use of anything will be discussed

Leadership is a teachable skill

Leadership is an essential piece of QI

Today’s meeting is to embark on leading change in

your unit through quality improvement, and

To meld quality improvement activities to MOC

requirements

Practice gaps identified

Content to fill the gaps

Suitable QI topic

Measurement and

benchmarking

Optimal care practice or

practices (care bundle)

Implementation of

change

Tracking of impact

◦ Process

◦ Outcome

• Sustainable Improvement

Create list of potential topics

Delineate criteria for success

Establish list of required data

Plan an interventional strategy

Formulate a data review and analysis plan

Understand use of data analysis in QI

Take home a plan!

The elephant in the room.

A source of anxiety for some.

New, therefore unfamiliar.

Necessary?

Goal: Marriage of effective, interesting and needed

quality improvement with qualification for MOC.

•4-part program that you begin once you have passed your initial certification examination. •Evaluates the same 6 ACGME core competencies measured throughout training. •Competencies are assessed in 5-year cycles, as defined by Maintenance of Certification.

Program of ABP by criteria of ABMS

To support physicians’ need to maintain certification in their practice areas

Four part program:

◦ Part 1 : maintain license

◦ Part 2 : life-long and needs-based learning

◦ Part 3 : knowledge examination

◦ Part 4 : quality improvement, patient satisfaction

Visit the ABP website at www.abp.org

Contact the ABP:

→ Initial Certification: gpcert@abpeds.org

→ Subspecialty Certification: sscert@abpeds.org

→ Maintenance of Certification: moc@abpeds.org

→ By phone: (919) 929-0461

Stephen A. Pearlman MD, MSHQS Clinical Professor of Pediatrics, TJU

Attending Neonatologist, CCHS

The reason that most Quality Improvement Initiatives

do not succeed is because people don’t go through the

proper steps of change management.

The science may be good but if you can’t get people to

follow what you want to accomplish you are doomed

to failure.

Diagnosis Unfreezing Movement Refreezing

Northcraft, GB, Neale, MA 1994

Published in the Harvard Business Review

Defined the most common reasons that organizational

changes fail

Develop strategies to overcome the reasons for failure

Very applicable to health care

Eight stages recommended

Convince key people

that change is really

needed

Link ideas and solutions

to an overall vision that

people can understand

and remember

Find ambassadors to

go out and keep the

vision clear in

everyone’s mind

This step is

necessary to keep

moving things

forward

Success in and of

itself is a powerful

motivator

Analyze what went

well and what needs

more improvement –

think PDSA cycles

or CQI

Change will only

stick if it becomes

part of the culture

within your

organization

Habits

Power/Influence

Limited Resources

Misunderstandings

Saving Face

Fear of the Unknown

Tolerance of

Ambiguity

Communication

Ensure staffing supports change

Participation

Promote perceptions of fairness

Negotiate

Manipulation and Coercion

Incentives

Pilot program

“Although all improvement involves

change, not all changes are

improvement”

Institute for Healthcare Improvement

Develop a list of possible QI projects

Group Exercise # 1

“What needs to be better?”

“What do we know about the root cause(s) related to the

problem?”

“What behavior(s) could be changed to impact the

outcome?”

“What are the essential data needed for this project?”

1. Importance and timeframe

2. Stakeholders

3. Measures of quality

4. Recognized (EBM) guideline or standard

5. Implementation potential

6. Data collection and tracking

7. Feedback and adjustment

8. Sustainable results

Narrow your list

Group Exercise # 2

Decrease Adverse events (37)

◦ Line infections - 15

◦ Med errors, etc. - 6

◦ “in general” - 4

◦ Hypothermia - 3

◦ Readmission - 2

◦ ROP prevention - 2

◦ BPD prevention - 2

◦ VAP, NEC, PPHN - 1

Better practice behavior (21)

◦ Feeding protocols - 7

◦ Professional communication - 6

◦ Clinical pathways - 3

◦ Care management - 5

Evaluation for infection - 1

Resuscitation - 1

nCPAP criteria - 1

Transfusion - 1

Abstinence Syndrome - 1

Narrow your list

Select QI project to operationalize

Group Exercise # 3

Which problem?

Who’s on the team?

What is the goal?

What will be measured?

How to analyze?

What changes improvement?

How to test changes?

Quality improvement project steps:

◦ How to get a baseline assessment of practice, hospital, collaborative group’s current status?

◦ What education is needed to introduce and implement care bundle? Getting “buy-in”

Need for multidisciplinary cooperation

◦ How best to monitor process: pre- and post- implementation? What are reasonable time cycles for data collection and review?

Outcome:

◦ How to define the measureable outcome(s) that is/are available within timeframe of project and MOC cycles of participant?

◦ How will you plan for sustaining a positive outcome?

20 minutes: then report to all of us

Table representatives: (1 from each)

Table order of choice: RPC determines

Table topics:

◦ Table 1

◦ Table 2

◦ Table 3

◦ Table 4

◦ Table 5

Effecting change: developing implementation plan

Implementation generally includes:

◦ Educational component – evidence base for its use

◦ Timeline to introduce and win-over stakeholders

◦ Follow-up of process change and outcomes, reported

periodically

◦ Review and revise – PDSA cycles

◦ Tools: incentives and reminders

◦ Psychological support – encouragement and applause

Decision: participants

◦ Individual hospital/unit/practice

◦ Multihospital collaborative - from one system/one

practice/state

Decision: Project Leader

ABP Application Form (E-binder, Chapter I)

Key Issues:

• Application Fee: $500; approval for 2 years

• Fee to diplomate to participate

• Offering CMEs

• Length of project

• Data collection method and cycle; reported at what level - by

physician, by hospital

• Data reports, graphs, and results

E-binder, Chapter II

Concise problem statement, project aim and mission

Defining precise steps to confirm participation: contract

with physician/hospital participants

Expectations of each participant - length of involvement,

number of meetings, role in data collection or

submission, disseminating information, teaching,

reviewing data, developing own QI science expertise

Neonatologists/Pediatricians sign onto project

◦ Must participate throughout project (can’t catch up!)

Complete QI science requirement

Commit to meaningful contribution to the project

Contribute to educational programming and implementation

strategy

Applies care bundle to his/her appropriate patients

Attends and participates in 80% of project related meetings

Must be neonatologist or pediatrician

“Champions” the project

Project team:

◦ Must include at least one nurse, and one administrator on project team.

Participates in activities with other sites

Attests to meaningful participation

Receives part 4 credit as well

Free-standing or agenda item on existing QI meeting

Suggested topics: (spread over 5 meetings)

◦ Introduction to MOC project

◦ QI science

◦ Education on problems / “best practice(s)”

◦ Components in process monitoring

◦ Adoption of Care bundle; “process implementation”

◦ Mid-project review

◦ Post-project review

◦ Plan for sustainability

E-Binder, Chapter III

IRB review

Data elements- specific list (format); frequency; population- 100% or sample

Availability: electronically or data abstraction required (Medical Records/IT involvement)

Multi-hospital collaborative: development and execution of data sharing agreement (legal review) for PHI (protected health information)

Data support: abstractors, programmers, and analysts

Data Collection: centralized/de-centralized

Tool: paper/Access or web-based

Data Storage: secure server/installation

instructions

Data Collection training and ongoing support

E-binder, Chapter V

Define your baseline period

Define your pre-intervention, intervention and post-

intervention period

Design report format - by physician, by hospital;

compared to

Determine frequency of reporting back to participants

- concurrently; monthly, quarterly

Tables and graphs

Seeing your progress

Seeing your results

1st Monthly Averages 1st Median Goals 2nd Monthly Averages 2nd Median

Run Chart Example: 2 Contributors

100%1/0

Monthly Proportion of Defects Average Proportion of Defects Control Limits

Control Chart: Shewhart P - Chart Example

7001/0

t I2S2 Example Days-Between Chart

January 2005 thru August 2005

Days Since Previous Event Average Days Between Events Control Limits

Name of topic – why important AIM

What tells you it is a problem (? Measures)

Who are the stakeholders?

What should be done to improve?

What ongoing measures should be followed?

◦ What data will you collect?

How will you define success?

What happens after the project ends?

Group Exercise # 4:

Presenting your QI Project

What is/are the most important datum/data to collect?

What are the sources of the data?

Who will collect the data?

What datasheet or collection method is used?

How is patient privacy/confidentiality protected?

How will the data be analyzed?

How and how often will data be presented?

E-Binder Chapter VI

Project tracking forms: ◦ Meaningful contribution: by physician: number of hours; dates

and number of meetings attended

◦ QI Science requirement: specifically how it was met

◦ Meetings related to project: date, presenter; topic

◦ Change implementation: how did you accomplish - entity wide changes

◦ Project impact: Completed by Physician/Project Leader only: impact on education, clinical acceptance/utilization/ process changes, changes in outcomes

Was engaged throughout the entire 1+ year

Attended and participated in 75% of meetings

Made “meaningful” contribution to project

Has knowledge of QI science (how ascertained)

NB: Details for each participating physician held at

project site, only attestation form (see ABP site) is sent

to ABP

Did you meet the ABP requirements for a quality

improvement project leader?

◦ I was materially involved in the design of the project.

◦ I was materially involved in the implementation of the project.

◦ I understand the principles of quality improvement.

◦ I was involved for 12 months or more.

◦ I satisfied all of the above criteria under my current ABP

certificate (within my current MOC cycle).

Stephen A. Pearlman MD, MSHQS Clinical Professor of Pediatrics, TJU

Attending Neonatologist, CCHS

“Nothing endures but change”

Heraclitus of Ephesus

5th Century BCE

“the change we are putting in place

Is not sustainable -

And Sustainability is absolutely

Crucial.”

Fiona MacLeod

President of BP Convenience Retail

Incremental

◦ Linear, continuous change

Radical

◦ Multidimensional and multilevel, discontinuous

Hard to maintain a sense of urgency

Inadequate time to teach staff

Inadequate attention to barriers

Lack of leadership support

External factors

◦ Competition

Internal Factors

◦ Keep the patient as the target

◦ Affect on job security, income, job satisfaction

Deming “You can’t manage what you can’t measure”

Continue to measure and benchmark even if project is

officially over

Identify reasons for slippage

◦ RCA on cases without desired outcome

Display Data

◦ Run Charts to visually demonstrate improvement

◦ Storybook Approach

◦ Strategic signage to maintain engagement

Examples

47 days since the last IV infiltrate

108 days between CLABSIs

Create competition

◦ Contests between different units

Rewards

◦ Social gathering to acknowledge the staff’s contribution to

improving patient care

◦ Free movie tickets, parking passes etc.

Institutionalize Change

◦ Clinical Practice Guidelines

◦ Manuals

Ongoing Education and Training

◦ New Residents and Fellows

◦ New Nurses

◦ Staff Turnover

Light a fire – what isn’t what you want it to be?

Meet with colleagues right away!

Set a Part 4 plan for your practice group

Incorporate QI initiatives of NICU and institution

Clinics in Perinatology 2010 (March) Quality Improvement in Neonatal and

Perinatal Medicine (entire content!) – special attention to:

◦ Elsbury DL, Ursprung R. A primer on quality improvement methodology in neonatology. Pp 87-99/

◦ Lloyd RC. Navigating in the turbulent sea of data: the quality measurement journey. Pp 101-122.

Gawande A. Annals of Medicine: The Bell Curve. The NewYorker 06 Dec2004

Perla RJ, Provost LP, Murray SK. The run chart: a simple analytical tool for

learning from variation in healthcare processes. BMJ Qual Saf 2011:20:46-51

(downloaded from qualitysafety.bmj.com)

Perla RJ, Provost LP, Murray. Sampling considerations for health care

improvement. Q Manage Health Care 2013;22(1):36-47.

Steinfield R, Bachert C. Using data to guide improvement [Institute for Healthcare

Improvement] PowerPoint slides - April 2012. Available at

http://patientcarelink.org/uploadDocs/1/8-Using-Data-to-Guide-improvement.pdf

Thank you!

johnvhartline@aol.com

jmuri@npic.org

spearlman@christianacare.org

john v. hartline, md, faap · 2018-02-21 · john v. hartline, md, faap clinical professor,...

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