using a qi framework to improve care
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– 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
11:05
Using a QI framework to improve care
Why measure change?
• Allows you to understand the impact of your changes
• Allows you to feedback performance to those doing well & those struggling to improve performance
• Allows group to see progress to goal
Case Example: Run Chart
Nov Dec Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Jan Feb2012 2013
4%
8%
12%
16%
20%
PERCENT OF PATIENTS DISCHARGED BY NOON 2013
% Discharge by Noon
Median
Target
Audit & Feedbac
k
Tee time implemented Case Manager
on leave
Baseline
Improvement in Pain Scores
Weeks 1-12 Avg.
Max.
Min.
58%
100%
35%
Weeks 13-24 Avg.
Max.
Min.
68%
95%
40%
Pitfall of averages:• Aggregate data dilutes measurements• Does not allow evaluation over time
Improvement in pain scores Day 1 to Day 2
1 3 5 7 9 11 13 15 17 19 21 2350556065707580859095
100
Did We Improve?
100
80
60
40
20
0
Jan-Mar April-June July-Sept Oct-Dec Jan-Feb0%
10%
20%
30%
40%
50%
60%
70%
% o
f pts
with
pai
n im
prov
emen
t
Baseline periodPlanning period
Intervention period
47%
41%
52%
67%
Goal = 57%
44%
Try the next test of change
– Understand the problem – Convince others there is a
problem– Identify areas for improvement– Prioritize small tests of change– Devise a measurement
strategy –Measure change
• Sustain the change11:15
Using a QI framework to improve care
Coaching & Celebrating Success
• Identify early wins
• Recognition does not have to be big
• Recognize this is a marathon – small wins to a big goal
How do we engage others in the problem?
• Appeal to both sides of our doctor brain:
Finding your story
Data visualization
Inspiring data
Your data should tell your story
1854 in London. Cholera strikes. In just 10 days, over 500 people have been killed in one neughborhood. No one understands the source.
Except John Snow, an epidemiologist who realized the pump at the corner of Cambridge & Broad street must be the source.
Take home Lessons
Fishbone Diagram
Equipment Process People
Materials Environment Management
The Problem
primary cause
secondary cause
The effectThe Cause
Identify Areas for Improvement
PCS Roun
ds
Call the primary team after each patient is seen with clear to-do now recs
Informal ✔ in
w/ primar
y teams
Write notes with
“official
recs”
Offer to write orders for the team if they
are busy?
Call the bedside nurse to let him/her know of new orders?
One team memb
er does PM
check in
Gives patient information card on their pain regimen
Write note with updated PM recs
Page team with updated recs
Nurse updates the card for patient
Process:(actions)
Outcomes(patient level results)
Structure(adherence to the
program)
- Antibiotics Stocked- EMR alert created- Changes to ED staffing
- Sepsis Mortality- Cost- LOS
- Lactate drawn- Blood cultures prior to antibiotics- Time to sepsis bundle delivery - Time to MD evaluation
Balancing Measures(potential harm)
- Allergic Reactions- Antibiotic Resistance- C. Difficile
Remember the three measurementsFour
High Effort
High Impact
Low Effort
Low Impact
Thankless tasks
Easy Wins
Call the primary team after each patient is seen with clear to-do now recs
One team memb
er does PM
check in
Gives patient information card on their pain regimen
Write note with updated PM recs
Improvement in pain scores Day 1 to Day 2
1 3 5 7 9 11 13 15 17 19 21 2350556065707580859095
100
Did We Improve?
100
80
60
40
20
0
Coaching & Celebrating Success
• Identify early wins
• Recognition does not have to be big
• Highlight how these short term wins are contributing to the bigger vision
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