overview of the pa pqc and goals for the day robert ... · learning objectives for today 1....

Overview of the PA PQC and Goals for the Day

Robert Ferguson, MPHJewish Healthcare Foundation

© 2019 JHF, PRHI, HCF, & WHAMglobal 1

Learning Objectives for Today1. Describe the PA PQC’s aims, activities, timeline, and quality

measures

2. Describe how the PA PQC serves as an action arm of the PA Maternal Mortality Review Committee

3. Discuss how to prioritize the PA PQC topics and create a PA PQC quality improvement plan for your site

4. Describe key interventions for hemorrhage, severe hypertension, the ACOG Fourth Trimester, opioid-exposed newborns, screening pregnant women for SUDs, or maternal opioid use disorder


Learning Objectives for Today (cont.)1. Identify action items for your team’s PA PQC quality improvement

plan

2. Describe how and why you would access the VON NAS Universal Training Program

3. Describe how and why you would access the PA PQC Online Data Portal and Dashboard


Jewish Healthcare Foundation


JHF and its operating arms, including WHAMglobal, are helping to standup, administer, and facilitate the PA PQC

Perinatal Quality Collaboratives (PQCs)PQCs are networks of teams working to identify processes that need to be

improved and quickly adopt best practices to achieve collective aims across prenatal, labor/birth, newborn, and postpartum services


PA PQC Aims Reduce maternal mortality and morbidity

Improve Identification of and Care for Pregnant and Postpartum Women with Opioid Use Disorders (OUD)

Improve Identification of and Care for Opioid-Exposed Newborns (OEN)


Handout: PA PQC Brief

PA PQC is Leveraging Statewide Efforts Serves as an action arm of the PA Maternal Mortality Review

Committee (MMRC)

Coordinates with DOH’s, DHS’, and DDAP’s Multi-Disciplinary Workgroup on Infants with Substance Exposure (MDWISE) to disseminate guidelines


PAPQC

PAMMRC

The Power of PQCs as Action Arms: CA Example


50% Maternal Deaths

per 100,000 Live Births

Formation of the PA PQCMarch of Dimes facilitated the PA PQC Task Force

JHF and WHAMglobal helped to form the statewide PA PQC Advisory Group


PA PQC Formation


Maternal Mortality Quality MetricsJason Baxter, MDStacy Beck, MD

Maternal Mortality Driver Diagram Work GroupLoren Robinson, MD, MSHP

Hyagriv Simhan, MD, MS

Advisory GroupState agencies, providers, health system associations, provider associations, health plans, community-based

organizations, researchers, foundations, quality improvement collaboratives, and advocates

Neonatal Abstinence Syndrome (NAS) Driver Diagram Work Group

Kimberly Costello, DOOpioid Use Disorder (OUD) Driver Diagram Work Group

Elizabeth Krans, MD, MSc

Quality Improvement Methods Work GroupMichael Posencheg, MD

OUD Quality Metrics Work GroupMarian Jarlenski, PhD, MPH

Policy Work GroupAasta Mehta, MD, MPP

NAS Quality Metrics Work GroupScott Lorch, MD

PA PQC Support Partners


Online Data Submission Portal and Dashboards

VON NAS Universal Training Program and VON Days Audit

Additional Facilitation for Learning Collaboratives & Quality

Improvement

A Journey through the PA PQC


HOW IT WORKS FROM THE PROVIDER’S PERSPECTIVE AND THE ROLE OF HEALTH PLANS AND STAKEHOLDERS

Handout: PA PQC Timeline

Step 1: Form a Team Provider Champion for the Maternal Health Team

Provider Champion for the Neonatal or Pediatric Team

Administrative ChampionData Collection and Reporting Lead

Multi-Disciplinary Team for Quality Improvement and Learning

Community-Based Organizations Recommended by the Provider Team

Your team is not alone…the health plans also formed a team.


Step 2: Participate in the Learning CollaborativeStart to brainstorm your quality improvement

goal and planIdentify best practices to take back to your

site/system


Step 3: Initiate Quality Improvement Confirm your goal, baseline data, and QI plan with your PA PQC team

When creating your QI metrics, use the PA PQC metrics

Initiate the quality improvement plan

Your team is not alone.

Health plans, community-based partners, and other stakeholders are participating in the PA PQC to help you.

Your team can participate in the VON NAS Universal Training Program, VON Day Quality Audits for NAS, and PA PQC webinars


Handout: Driver Diagrams and

Measurement Specifications


You may be eligible to receive stipends to support your site’s data collection for the PQC!

PQC sites can apply for the Patient Safety Fellowship Awards

To apply, describe your existing comprehensive pregnancy program, quality improvement process, and the results.

*Please apply by April 30*

Handout: Patient Safety

Fellowship Awards

Step 4: Report Aggregate DataTrend your results over time for all the required metrics

and for the optional metrics that pertain to your quality improvement projectCompare your results to your peers and regionsYour team is not alone. Health plans can provide feedback on the claims-based

metrics.


Step 5: Share Your Experience at the Next Learning CollaborativeReport out on your:GoalPopulation/contextual factorsKey interventionWhat is working well and not working wellResults

Did you encounter a policy barrier?◦ The PA PQC Policy Wok Group will look into it.


Email Jessica at [email protected] to

join the Policy Group


The PA PQC is designed to help the sites drive improvement and adopt best practices around the three targets.

If the PA PQC does not help your team do this, let us know.

The NEPaPQC is Part of the PA PQC


The Northeastern PA PQC (NEPaPQC)

James A. Cook, MD

Executive Director & Neonatal Lead, NEPaPQC


WWW.NEPAPQC.ORG

[email protected]

(570) 214-2297

Background• Funded through Geisinger Health Plan/Geisinger Clinic Quality Pilot Fund

July 2018 – June 2020

• Goal: Establish Regional Perinatal Collaborative (NEPaPQC) to address OUD during pregnancy and NAS.

• Target: Hospitals, Health Systems, and Insurers in NE Pa

• Now working together with the PA PQC

NEPaPQC Service Area

• Bradford• Carbon• Centre • Clinton• Columbia• Juniata• Lackawanna • Luzerne• Lycoming • Mifflin• Monroe

• Montour• Northumberland • Pike• Schuylkill• Snyder• Sullivan • Susquehanna • Tioga• Union • Wayne • Wyoming

22 Counties

NEPaPQC Team• Executive Director & Neonatal Lead: James A. Cook, MD

• Obstetrics Lead: Gary Stoner, MD

• Maternal-Fetal Medicine Lead: A. Dhanya Mackeen, MD

• OB Nursing Leads: Mary Weaver, RNElissa Concini, MSN, RNC-OB, C-EFM

• Project Manager: Karena M. Moran, PhD

Our Role in PA PQC• Regional point of contact for hospitals, health systems, and providers

• Provide direct, in-person support and guidance as needed:• Quality improvement knowledge and capacity• Data collection and reporting• Other support upon request

• Focus:• Improve identification of OUD in pregnancy through use of a validated

universal screening tool• Support Aims and Metrics of the PA PQC

Questions and Answers

PA PQC

www.whamglobal.org/[email protected]

NEPaPQC

[email protected]

Update on the PA MMRC


CAROLYN BYRNES, MPH, CPH

SPECIAL ADVISOR TO THE SECRETARY OF HEALTH, PA DOH

PA PQ Quality Improvement Framework


MIKE POSENCHEG, MD, ASSOCIATE CHIEF MEDICAL OFFICER, VALUE IMPROVEMENT, PENN MEDICINE

An Introduction to Quality Improvement Methods

Michael A. Posencheg, M.D.Medical Director, Intensive Care Nursery, Hospital of the University of Pennsylvania

Professor of Clinical Pediatrics, Perelman School of Medicine at the University of PennsylvaniaApril 24, 2019


Objectives• To discuss the foundation of Quality Improvement

• To explain a framework for a QI project:• Problem Statement• Goal/SMART Aims• Understanding the current process• Designing interventions / ideas for improvement• Discuss the importance of measurement• Develop a project plan – 30/60/90 day

• Provide an example of a project to illustrate these points.


What is a system?An interdependent group of:◦People◦Processes◦ Items (tools)

…working together toward a common purpose.

Improving medical care requires system redesign…

“Every system is perfectly designed to get the results it gets.” – Paul Batalden

The definition of insanity is doing the same thing over and over and expecting to get a different result.

1. Pick a number from 3 to 9

2. Multiply your number by 9

3. Add 12 to the result from step 2

4. Add the 2 digits together

5. Divide result of step 4 by 3

6. Convert the number to a letter: 1=‘A’, 2=‘B’, etc.

7. Write down the name of a country that begins with the letter

8. Go to the next letter in the alphabet

9. Write down the name of an animal (but not a bird or insect) that begins with that letter

10. Write down the color of that animal.

What It Takes To ImproveWill to change the current system◦ Understanding the human side of change

Ideas about changes that will improve the system◦ Including a theory that links changes to outcomes

Execution of the ideas◦ Including a way to distinguish successful from unsuccessful changes

An Effective QI Program

Will

Ideas ExecutionQI

Different related approaches

Bar-be-que?

Model for Improvement


• Three questions for the basis of a project charter and anchor the work.

• Ideas from question three can be tested using PDSA cycles to make improvement as well as learn about the system of care.

Lean/Six Sigma


• Lean = Waste Reduction• Six Sigma = Variation Reduction

• Fishbone Diagram• 5 Whys• Value Stream Maps• Spaghetti Diagram• FMEA

The 5 Key Principles for Improvement1. Knowing why you need to improve.

2. Having a feedback mechanism to know if improvement is happening.

3. Developing an effective change that will result in improvement.

4. Testing a change before attempting to implement.

5. Knowing when and how to make the change permanent.

The Problem Statement


The Problem StatementProblem/Opportunity statement should answer these questions:

• What is occurring or What are we missing?• When did the problem start?• Where is the occurrence?• Extent (Gap) of the problem or opportunity

Example:• In FY18 (When), the CLABSI rates (What) were 4 times higher

than expected (Extent) in the NICU (Where).

Goals / SMART AIM


What are we trying to accomplish?A SMART Aim Statement• Specific

• Measurable

• Actionable• Realistic

• Time-bound

“To reduce the incidence of CLABSIs to less than 2 per 1000 catheter days in NICU patients by December 2013.”

Understanding the Current State


Process Mapping Purpose◦ Visually document a process◦ Understand the existing process and problems◦ Quickly identify improvement opportunities within the process◦ Helps communicate inside and outside the organization

Key Principles◦ Documentation is not substitute for observation◦ A flowchart is a means not an end◦ Boundaries what to map should come from your project charter◦ Involve a cross-representation of those who work in the process to create the map◦ Process maps are meant to be used

Current vs. Future StateCurrent State◦ Captures the project as it works today; including waste◦ Most projects should include a current state map

Future State◦ The ideal process; waste eliminated◦ Created by asking “What would we do if we didn’t at have any of

the restrictions we have today?”◦ Helps see the work in a new way and generate creative ideas

Which Process Map is For You?Process Map Description When to Use

High Level Process Map•View from 30,000 Feet•Depicts major elements and their interactions•5-8 steps total

•Early in the project to identify boundaries and scope

Detailed Process Map •A detailed version of the High Level Process Map•Fills in the all the steps within the high level steps

•To see a detailed process in a simple view•Helps to identify and follow decision points

SIPOC

Process snapshot that captures information that is critical to a project

•To come to agreement on project boundaries and scope•To verify that process inputs match the outputs of theprocess•Quality issue

VSM (Value Stream Map)•Captures all key flows (of work, information, materials) in a process and important process metrics•Requires a current and future state to be done

•To identify and quantify waste•Helps visualize the improvement opportunities•Flow or time issue

Swim Lane FlowchartEmphasizes the “who” in “who does what” •To study handoffs between people and/or work groups in

a process•Especially useful with administrative (service) processes

Spaghetti Map Depicts the physical flow of work or material in a process •To improve the physical layout of a workspace (unit,office, floor)

Reducing MRSA Colonization• This diagram is called a

Fishbone, Cause and Effect or Ishikawa Diagram.

• The adverse event or problem is at the “head” of the fish.

• Factors associated with this problem are listed along the “bones” of the fish.

• Each “bone” has a category label.

Identifying Improvement Opportunities


Provost L, Bennett B. What's your theory? Driver diagram serves as tool for building and testing theories for improvement. Quality Progress. 2015 Jul:36-43.

Improving Admission NormothermiaPrimary Drivers

Secondary Drivers/Change Ideas

OutcomeGoal: Improving

Admission normothermia

from 43% to 75% by December

2012

Maintaining Warm

Environment

Reducing Heat Loss

Transfer from IRR to ICN

Staff understanding of

importance of normothermia

Maintenance of warmth during transport

Transfer of baby from resus bed to ICN bed

Timing of admission temperature

Removal of temperature apparatus

Monitoring Infant Temperature

Heat loss through skin/body

Heat loss from head

Literature/evidence availability

Debriefing of “cold baby” events for learning

Display of data in unit to understand improvement

Temperature of the room

Avoiding influx and efflux from IRROverhead Warmer Temperature

The Importance of Measurement


How will we know that change is an improvement?

• The voice of the customer or patient.

• Reflects the problem you are trying to solve.

• Describes how your overall system is performing.

Process Measures

• Steps logically linked to outcome of interest.

• Addresses how key parts of the system is performing.

• Describes what happens to the system as processes and outcomes have changed.

• What are the unintended consequences or alternate explanations?

Balancing Measures

Outcome Measures

Example NICU Family of MeasuresOutcome Measure: • Number of CLABSI per 1000 catheter days

Process Measure: • Hand hygiene compliance• Hub Scrub compliance• Insertion Checklist compliance• Tubing Change compliance• Removal checklist compliance

Balancing Measure: • Need to replace central line• Increased cost of hand hygiene supplies• Infiltrates from peripheral IV use

The Importance of Operational Definitions

If data collected differently by different people, or differently each time collected, it makes it hard to know whether changes in the data are due to the changes tested or from inconsistencies in data collection.

What is a goal?The whole ball or half the ball? Courtesy of Bob Lloyd, IHI

?

Run ChartGraphical display of data plotted in some type of order, usually over time. Also has been called a time series or a trend chart.

Perla, BMJ Qual Saf, 2011

Minimum requirements:

• Line graph of data points• Median line• Indication of goal• Annotations

Why Use A Run Chart?

Perla, BMJ Qual Saf, 2011

Project Management –30/60/90 Day Plan


Project Management Plan - WWWHow do you use Project Management tools?◦ Monitor, record progress on all tasks, at least weekly – use “WWW” or “Tracking Gantt

Chart”◦ Pay particular attention to those that are critical to implementation◦ Revise plan as needed to take into account changes, adapt to meet milestones

Who What When Update

30/60/90 Day Template


Horizon Goal:180 Day Goal:

In the first 30 days, we will know we are successful when:

PPP

The measures/evidence we will use are:

First 30 days action strategies: Who is on point? By When? How Communicated?•••••••••If we are not successful, we will:

Courtesy of Education.ky.gov

An Example Project –Antenatal Steroids


The Problem StatementAt the Hospital of the University of Pennsylvania, only 55% of our infants born between 24 and 34 weeks gestation were exposed to antenatal corticosteroids (ANCS) in calendar year 2017. This is far below the average steroid utilization rate (85%) of units who submit their data to the Vermont Oxford Network. This is important to our patients because ANCS have been shown to reduce mortality, RDS, IVH, and NEC.

What? When? Where? Extent (Gap)? Why?


Our SMART Aim

To increase the percentage of infants born between 24 and 34 weeks gestation at the Hospital of the University of Pennsylvania receiving antenatal corticosteroids from 55% to 85% by December 2020.

Specific? Measurable? Actionable? Realistic? Time-Bound?


ANCS Administration Process Map

Mother arrives in

triage area

Gestational age of

pregnancy is determined

If 24-34 weeks, order for ANCS is placed in

EMR

ANCS are prepared by pharmacy

ANCS are delivered to Labor and Delivery

Medications are verified

ANCS are administered

to patient


Driver Diagram


Primary DriversSecondary Drivers/Change Ideas

OutcomeGoal: Improving

ANCS administration

from 55% to 85% by December

2019

Patient Identification

Ordering and Pharmacy preparation

Administration of ANCS

Staff understanding of

importance of ANCS

Nurse awareness of availability of medication

Prioritization of ANCS administration

Documentation of administration time in EMR

Delivery of ANCS to Labor and Delivery

Alerting ANCS as a STAT mediation

Availability of computer to place order

Literature/evidence availability

Debriefing of missed opportunities for learning

Display of data in unit to understand improvement

Accuracy of gestational age assessment

Availability of gestational age informationDelay from arrival in triage to assessment

Family of MeasuresOutcome Measure Process Measures Balancing Measures

Antenatal Corticosteroid Administration Rate

Time from admission to ANCS order being placed.

Administration of ANCS before 24 weeks or after 34 weeks.

Time from order to pharmacy delivery of ANCS.

Incidence of hypoglycemia in infants in first 48 hours.

Time from admission to ANCS administration.

Percent accuracy of gestational age documentation on triage form.


Operational Definition of ANCS Administration

The Antenatal Corticosteroid Administration rate is the number of infants whose mothers were administered corticosteroids IM or IV during pregnancy at any time prior to delivery divided by the number of infants born between 24 weeks and 34 weeks.

ANCS Rate = Infants whose mothers received any corticosteroids

All infants born between 24 and 34 weeks gestation


Displaying Data on a Run Chart


Target 0.85

25%

35%

45%

55%

65%

75%

85%

95%

ANCS

Rat

e

Jan-17 - Mar-19

ANCS Rate

PDSA #1 PDSA #2 PDSA #3 PDSA #4

Project Management Plan - WWW


Who What When Update

Jennifer Obtain baseline data for ANCS administration rates

April 30, 2019 Identified source of data.

John Observe process of ANCS ordering by provider in

triage area.

May 15, 2019 Plan to shadow provider each afternoon next week.

Julie Submit request to EMR for report for time between

ANCS ordering and administration.

May 20, 2019 Request submitted – delay due to implementation

freeze.

Joe Chart audit – accuracy of gestational age documentation

May, 30, 2019 Recruited 3 medical students to assist.

What is your QI capacity?1. How familiar were the concepts described here today?

a. I knew it all.b. Some new concepts.c. It could have been written/explained in ancient Egyptian and I would have understood

the same amount.

2. What QI methodology do you use for local project?a. Lean/Six Sigma?b. Model for Improvement?c. A blended approach?d. Other?

3. Do you have QI facilitation skills on your team or available in your hospital?a. Yesb. No


Summary• Outcomes in healthcare are produced by systems.

• You must fundamentally change your system to get a different outcome.

• Choose a QI methodology to use on your local project.• Assess your team’s capacity for QI work.

• The key elements of any QI project have been presented here.• Please use these a guidance in getting your project launched.

• Use the fictitious example provided as a way to understand these elements.


Any questions?


Break


10:35 A.M. TO 10:45 A.M.

Team Exercise to Focus QI Plans


ROBERT FERGUSON

Team Exercise to Focus QI Plans1. Begin to prioritize a problem to focus your QI

projects with your PA PQC team (15 minutes) Health plans and community-based partners

can work with the provider teams

2. Begin to draft your QI plan (30 minutes) Start with: problem statement, goal and

SMART objective, and current process


Handout:Setting Priorities

Handout:QI Plan Template

Lunch 11:30 a.m. to 12:30 p.m.


NEPAPQC COHORT CAN BRING THEIR LUNCH TO METROPOLITAN A

Knowledge Cafés: How to Implement Key Interventions


ROBERT FERGUSON

Knowledge Cafes

1. 12:30pm to 12:40pm – Overview and instructions 2. 12:40pm to 12:45pm – Travel to breakout 13. 12:45pm to 1:25pm – Breakout 1 4. 1:25pm to 1:30pm – Travel to breakout 25. 1:30pm to 2:10pm – Breakout 26. 2:10pm to 2:20pm – Travel back to main room


Pick 2 of the 6 breakouts

Knowledge Café Structure

1. Introductions (5 min.)2. Knowledge Café Host(s) describe their process and results3. Facilitator moderates a peer-to-peer discussion

1. Be ready to share your experience, challenges, and successes2. Ask how they collected data for their measures/results


Pick 2 of the 6 breakouts

Team Exercise to Focus QI Plans (Part 2)


PAM BRAUN, HEALTH CARE IMPROVEMENT FOUNDATION

Team Exercise to Focus QI Plans1. Continue to draft your QI plan

(30 minutes) Focus on: Improvement Opportunities, 30-

60-90 Day Plan, and Measurement Plan.

Report out on your main goal and next steps (40 minutes) 1-minute per PA PQC site


Handout:QI Plan Template

Accessing VON NAS Resources and PA PQC Data Portal and Dashboard


ROBERT FERGUSON

VON Universal Training Program NAS Toolkit

NAS Online Lessons Once a center’s core team completes all 18 NAS

lessons, they will become a VON Center of Excellence

NAS Virtual Video Visit and Facilitator Guide


VON Days Quality Audits/NASTwo parts to the audit – unit and patient

Two audits will be performed: July 2019 and July 2021

Eligibility period = April 1, 2019 – June 30, 2019

Audit window = July 8, 2019 – July 12, 2019

Inclusion Criteria

Infants treated pharmacologically for NAS at 7 days of age or less and discharged during the specified 3 month eligibility period

Audits will include up to 30 infants


VON Day Quality Audit Next Steps1. Confirm if the eligibility date for July 2019 audit will work

2. Identify the data collector for each participating site

3. Start the IRB process for each participating site4. Review VON Day materials

1. Manual of Operations2. Frequently Asked Questions3. Unit and Patient Level Data Forms


PA PQC Data Portal and Dashboard


Next Steps and Session Evaluations


PAULINE TAYLOR, JEWISH HEALTHCARE FOUNDATION

Register for the Next Learning Collaboratives

Learning Collaborative Date LocationFriday, June 28, 2019 Hilton Harrisburg

1 N 2nd St, Harrisburg, PA 17101Tuesday, September 24, 2019 Best Western Premier, The Central Hotel

Harrisburg800 E Park DriveHarrisburg, PA 17111

Wednesday, December 11, 2019 Hilton Harrisburg1 N 2nd St, Harrisburg, PA 17101


https://www.whamglobal.org/papqc/get-involved

Session Evaluations and CEUsPlease complete and hand-in your evaluations for CME, CNE, Social Work, and PA Certification Board CEUs

◦ For Social Work CEUs, please be sure to enter your address

◦ For CMEs, please write your 5-digit number for CME retrieval

We design the sessions based on your feedback

© 2018 JHF, PRHI, HCF, HFP 91

Be sure that you have signed the sign-in sheet

Place your name tags and evaluations in the blue bin

© 2018 JHF, PRHI, HCF, HFP 92

Before You Leave

Thank You!


overview of the pa pqc and goals for the day robert ... · learning objectives for today 1....

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