Patient Safety/Quality Improvement

Project OverviewAriane Marie-Mitchell,

MD, PhD, MPH

Health Care Problem

• State reason for action• Provide supporting data if available

Example: Health Care Problem

There is a much longer delay for 1st dose delivery of antibiotics ordered between 11pm and 7am compared to day time averages

This results in wasted time from the nurses and pharmacists, wasted medications, and poor quality of patient care

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Historical Data – The Problem

4

Stakeholder Analysis• Who is involved? Who is affected?• Try Mind Mapping• Start interviewing- qualitative baseline data

StakeholderAnalysis

ProvidersNurses

Pharmacists

Patients

Patientfamilies

Admin./PSR

Couriers

Charge nurse

• What are you trying to accomplish?• Specify

– numeric goals (how good?)– time frame (by when?)– patient population/system (for whom?)

Define the Aim

K. Shannon, 2012

Aim for Quality Health CareSafe — Avoid injuries to patients from the care that is intended to help them. Safety must be at the forefront of patient care.Timely — Reduce waiting for both patients and those who give care. Prompt attention benefits both the patient and the caregiver. Effective — Match care to science; avoid overuse of ineffective care and underuse of effective care. Efficient — Reduce waste. The health care system should constantly seek to reduce the waste and the cost of supplies, equipment, space, capital, ideas, time and opportunities. Equitable — Close racial and ethnic gaps in health status. Race, ethnicity, gender and income should not prevent anyone from receiving high-quality care.

Patient-Centered — Honor the individual and respect choice. Each patient’s culture, social context and specific needs deserve respect, and the patient should play an active role in making decisions about her own care.

IOM, 2001

Example. Specific Aim

• “Decrease delivery delay in 1st dose antibiotic by 50% between 2300 and 0700 on units 6100-6300 by February 20, 2012”

Identify Measures of Change

• Outcome Measurese.g. Duration of delay in administration of 1st dose antibiotics

• Process Measurese.g. % of antibiotic following forms fillede.g. % of fax orders with telephone follow-up

• Balancing Measurese.g. Staff satisfaction

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• Fishbone Diagrams• Flowcharts

Cause-Effect Analysis

Constructing a Fishbone Cause and Effect Diagram

– Get the right people in the room– State and clarify the “effect”– Brainstorm list for 4 Ms/P involved in the

process or effect interested in– Brainstorm causes for each of these– For each cause ask “why” 5 times to get to

underlying causes

K. Shannon, 2012

K. Shannon, 2012

Example: Fishbone Diagram

Communication

System FailuresMachines

Process

Different levels of knowledge

Poor process understanding

Poor MD RN communication

Understaffed 2300-0700Old fax machines

Repeat orders via fax

Unreliable tube system

Unaware of effect on

ABX Delay

No EMR = extra steps

# of pharmacy units open

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Constructing a Flowchart

Start/EndStart/End

Process/Task

DecisionDecision

Sequence

Input/Output

Delay

Document

Prescription RenewalThe process begins when the patient requests renewal.The Product of Value is that the prescription is delivered.

(need more info)

(enough info provided)

Name, DOB, Medication, Dose,Frequency, Pharmacy

Review chart: medication sheet, last visit, next visit, other parent or pharmacy info

Call patient

Phone call

Call for Medicaid Prior Approval

Discuss with clinician

(consistent) (not consistent)

(PA not needed) (PA needed)

Page 2

Example:Flowchart

Select Change• Focus on a change concept

eliminate waste, improve work flow, optimize inventory, change work environment, improve patient interface, manage time, reduce variation, improve error proofing, improve service

• Perform effort vs yield analysis

Low effortLow yield

High effortLow yield

High effortHigh yield

Low effortHigh yield

Evidence Review

• Identify relevant literature or best practice models

• Who else has thought about this problem and tried to fix?

• Critically appraise and describe how relates to your project aim

Example: Evidence ReviewBackground • Pneumonia = 600, 000 Medicare hospitalizations/yr• Previous Medicare Guidelines recommend antibiotic treatment within 8 hrs of

hospital arrival. Methods • Retrospective cohort study design

– 18, 209 Medicare patients (>65 yrs) hospitalized with community-acquired pneumonia (July 1998-March 1999)

– Outcomes: 1) severity-adjusted mortality (in hospital and 30 day)2) readmission within 30 days of discharge3) length of stay (LOS)

Conclusions • Antibiotic administration <4 hours of arrival was associated with

decreased mortality and LOS among a random sample of older inpatients with community-acquired pneumonia who had not received antibiotics as outpatients.

Houck, P, et al. Timing of Antibiotic Administration and Outcomes for Medicare Patients Hospitalized With Community-Acquired Pneumonia. Arch Intern Med. 2004;164:637-644. 19

Test a Change

Who,What,When, Where

CollectData

Repeat,Tweak,Stop

AnalyzeResults

Act Plan

Study Do

A PS D

APS

DD SP A

Plan• Specify a hypothesis• Use SMART ObjectivesSpecific - have a single purposeMeasurable - tied to a result statementAttainable/realistic - know your barriers and resourcesResponsibilities clear – tie names to each objectiveTime connected - clear completion dates (consider creating a timeline)

1. Interview charge nurse, nurses, couriers and pharmacists during a full overnight shift (11p-7a) by day 7- Jose

2. Conduct a literature review of best practices by day 7- Paymonh3. Meet as a team to do cause-effect analysis by day 9- team4. Collect quantitative data on initial state using Form 1a by day

10- Brent and Craig5. Meet as a team to discuss potential interventions by day 12-

team6. Discuss intervention plan with pharmacists, couriers and nurses

and implement by day 16- Jose and Paymohn 7. Collect quantitative data on follow-up state using Forms 1b and

2a by day 20 and analyze- Brent and Craig

Example: SMART Objectives

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Do

• Two types of data1. Qualitative

e.g. interviews, focus groups, suggestion boxesshow quotations, summarize themes

2. Quantitativee.g. anything that can be countedshow run charts, bar charts, pie charts…

• How did you collect the data?• What sample did you use and what was your

reasoning?

Study

• Qualitative Data• Quantitative

Data– What did you

learn?– Where does this

lead you?

Example: Qualitative Data1. Parents observed speech problems by age 4 and as young as

11 months “Around 10 months I noticed she was not starting to talk like my other

children did”

2. A minority of children received Early Intervention “I asked the doctor about it but they were just like oh, he’ll grow out

of it” “We were supposed to have a lady come to the house and stuff but it

was impossible because I was working full-time and he was at daycare”

May June July August September October November December Janurary February March0%

20%

40%

60%

80%

100%

55%

75%

84% 85% 85% 85%

91% 91% 90%

97%

21%

47%

93%

87% 87%93%

100% 100%

93%

100%95% 95%

All PracticesOur DataGoal (95%)Pe

rcentage

Example: Quantitative Data

Added BMI% to vitals

Incorporated BMI% into nursing data collection

Automated BMI% calculation

Act

• How does your data inform your understanding of the health care problem?

• How does your data influence your interpretation of how to improve the system?

• What will you do next?

Sustainability

• What barriers do you perceive to sustaining the change?

• What resources are available to sustain the change?

• What is the cost-benefit of the old process versus the new process?

References

• References for literature cited• Names of faculty/staff interviewed• Location of sites where processes observed, or

any other relevant info

Quality ResearchImprovement

Aim(s)Hypotheses

MethodsMeasures

Next steps

Results

Act Plan

Study Do

A PS D

APS

DD SP A

≠

Quality Improvement• Intervention is

demonstrated, known, or widely accepted

• Project limited to implementing a practice to improve quality of care

• Performance data collected for clinical, practical or administrative purposes only

Research• Systematic investigation

designed to contribute to generalizable knowledge

• Project involves introducing an untested intervention and data is being collected to establish scientific evidence of its efficacy

IRB approval required *** IRB approval not requiredbut ask if uncertain or if considering publication

IHI Open School QI Practicum

• Optional• Receive additional guidance and a Certificate

– Sign agreement with faculty mentor– Submit aim/plan and receive feedback– Submit cause-effect diagram, PDSA cycles, run

chart, and summary