Download - Resident QI Curriculum, version 2.0
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Resident QI Curriculum, version 2.0
Windy Stevenson, MDMedical Director, Doernbecher Quality Program
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How has quality evolved? 1800’s: Quality Assurance- credentialing, accreditation
Did the dog get fed? Who forgot to feed the dog?
1900’s (mid): Statistical Quality Control & CQI- variations, profilingHow many times a week do we forget? Who’s the worst offender?
1900’s(late) : Outcomes analysis- systems thinking, patient focusedIs the dog maintaining a healthy weight? Is Beech right for the job? Can we make it easy for Beech to feed the dog? Is the dog being fed the cat’s food?
2000’s: Rise of Big ManagementIf we post our results to the whole neighborhood, will the dog get fed more often?
Last 5 years: Quality Cacophony- seeking the sweet spot of transparency, efficiency, outcomes, and patient centeredness
Does data demonstrate that we transparently, accountably, efficiently, effectively, safely, timely, equitably provide canine sustenance in a dog-friendly way?
Today: Cacophony with a mandate-The whole concept of pet ownership is at stake, here, Beech!
Concepts courtesy Donald Fetterolf, President of the American College of Medical Quality
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Where is that sweet spot?
Healthcare is a business, but taking care of a patient is not.
-Victor Traztek, Mayo Clinic Scottsdale
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Learning about donkeys (and carts)
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My donkey is pathetic!
15 kg
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Your first PDSA cycle
15 kg
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My wagon doesn’t have a back stop!
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My donkey is up in the air!
Is that really our problem? What OUTCOME matters? What causes have we not yet explored?
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You don’t have to study other people’s wagons unless you intend them to use your modification(s)
Get enough data to take the next step ASK WHY Beware of random folks walking up asking you to design
donkey weights or backstops for wooden carts
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Systems
Every system is perfectly designed to achieve the results it gets.
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Where do you start? Project Selection... Do we have a problem? What is our problem? Will fixing our problem improve quality?
– IOM Dimensions- Safety, Timeliness, Equity, Efficiency, Effectiveness, Patient Centeredness
Is the outcome important? Why do we care? Why? Why? – To providers? To patients or families?
Are we likely to be able to overcome foreseeable barriers? Is the project meant to improve an observable process? Is it within our scope to make this change? Is this reasonable? Is it focused enough to make success
likely in our timeframe? Does the cost of effort seem to be in good balance with
likelihood of returns? Are people already passionate or curious?
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Where do you start?
You already do
this every
day!
There is no such thing as being too focused.
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Ambulatory problem lists are incomplete and inaccurate
So, let’s start fixing them!• How do we define success?
• Failed attempt to measure “completeness”
• What kids do we start with? Diagnosis Based?
All patients with asthmaAll obese patientsAll patients seen by geneticsAll former preemies
Age Based?Start with all newbornsTarget a certain WCC
Exclusion based? (The Sarah Green effect)Should we focus on the kids who are normal??
Other ideas?
• Who owns the list? • What is it even for?
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What are we even trying to accomplish?
Provide Safer CareSave time
Populate the problem list in an efficient way that will support/drive good patient care
Populate the problem list of obese children to efficiently drive good patient outcomes
Why obesity? What practice settings? What ages? Residents? Attendings? All? How good do we want to be?
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Our AIM
>95% of patients >2yo seen by a provider in the gen peds clinic or Westside clinic (including acute care; excluding healthy lifestyles) who have a BMI >85%ile will have “BMI; category” listed on their problem list
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Is our Aim Statement SMART?
Specific we chose ONE thing Measurable we can prove we’ve impacted it Actionable there are no known insurmountable barriers Realistic it’s within our scope Timely we’ll do it within a time frame
Aim:>95% of patients >2yo seen by a provider in the gen peds clinic or Westside clinic (including acute care; excluding healthy lifestyles) who have a BMI >85%ile will have “BMI; category” listed on their problem list
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WHY? The Doernbecher Purpose…
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Measurement
We MEASURE!Outcomes measuresProcess measuresBalancing measures
When we try to improve a system we do not need perfect inference about a pre-existing hypothesis: we do not need randomization, power calculations, and large samples. We need just enough information to take a next step in learning.
– Donald Berwick
AIM:
>95% of patients >2yo seen by a provider in the gen peds clinic or Westside clinic (including acute care; excluding healthy lifestyles) who have a BMI >85%ile will have “BMI; category” listed on their problem list
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Measurement
AIM:
Outcomes measures:Are we getting there?
Process measuresAre we doing the right things to get there?
Balancing measuresAre we messing things up by getting there?
On time delivery
% populated
#packages
Resident time spent
Donkey lifespan
Clinic delays
MEASURES:
Not everything that can be counted counts, and not everything that counts can be counted.
Albert Einstein, US (German-born) physicist (1879 - 1955)
>95% of patients >2yo seen by a provider in the gen peds clinic or Westside clinic (including acute care; excluding healthy lifestyles) who have a BMI >85%ile will have “BMI; category” listed on their problem list
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The baseline data
37% overall success (457/1220 patients)
Adolescent Campus Peds West32
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Percent of patients >2yo with BMI >85%ile with problem listed
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Age and BMI
2-3yo 4-6yo 7-9yo 10-12yo 13-15yo 16-18yo05
101520253035404550
Percent of pts with BMI>85% with populated problem list, by age
(years)
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Testing
MEASURES: % problem lists populated
TEST:
AIM:
REMEMBER:Populate your problem lists!
>95% of patients >2yo seen by a provider in the gen peds clinic or Westside clinic (including acute care; excluding healthy lifestyles) who have a BMI >85%ile will have “BMI; category” listed on their problem list
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Testing
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Testing
MEASURES: % problem lists populated
TEST: PosterTEST: Use BPA and Smartset to drive careTEST: ???
AIM:>95% of patients >2yo seen by a provider in the gen peds clinic or Westside clinic (including acute care; excluding healthy lifestyles) who have a BMI >85%ile will have “BMI; category” listed on their problem list
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Current status
Future state taking shape
Smart set in EPIC- PDSAs underway Obtaining heights on acute care visits Ongoing data pull being finalized EPIC requests for populating problem list from an order and
driving PCP appointment generation
Pt >2yo checked in and ht/wt recorded
EPIC uses ht and wt to generate BMI and
flags if >85%ile
Provider sees banner under
Quality issues and clicks associated
smart set
Family stops at desk to get appt
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Next steps
Final adjustments to the EPIC product Flip the switch Start measuring and reporting
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Using Six Sigma and Lean methodologies, I will invoke Deming and Shewart’s approaches while conducting a Kaizen event to reduce the muda through process mapping, aggregate patient-level data, and reliability analysis to create a standardized deliverable.
Be as smart as you can, but remember that it is always better to be wise than to be smart - Alan Alda
I know a way to make this system work better tomorrow.
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Take Home Points
Real (sustainable) change comes from changing systems, not changing within systems
Understand the problem before you hypothesize the causes
Be specific about what you want to accomplish, and why
Focus on patients
Start before you think you are ready
Don’t get paralyzed by lack of research-level data or by how much there is to do
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What if you want to know more?
IHI Open School– http://ihi.org/IHI/Programs/IHIOpenSchool/WhatstheIHI
OpenSchool.htm
Call me, page me, email me– 4-1321– 15763– [email protected]