rapid cycle pi danielle scheurer, md, mscr chief quality officer medical university of south...
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Rapid cycle PIDanielle Scheurer, MD, MSCR
Chief Quality Officer
Medical University of South Carolina
Objectives
Know how and why you need to have a disciplined approach to PI
Understand the importance of the reliability of interventions
Understand the importance of validating and evaluating interventions over time
Quality-Process Improvement
worse better
worse betterQuality
Quality
After
Before
Quality
worse betterQuality
After
QualityQuality Assurance
Quality Improvement
Bell Curve:Patient Population
Tail
better
Improvement and standardization in processes reduces variation (narrows the curve) and raises quality of care for all (shifts entire curve toward better care).
Quality-Process Improvement: Bridges the Implementation Gap
Implementation Gap
Scientific understanding
Patient care
Prog
ress
Time
The BEST quality is local
• “Bottom up” approach
• Problems and remedies come from the “front line”
• Often come from frustration of seeing processes that are:– Highly variable, unpredictable, not reproducible
– Potentially or actually harmful
– Inefficient or redundant
• Different areas have different quality issues, although some are ubiquitous– Medication errors
– Infection rates
Structure approach to PI
Ensure you are narrowing the scope of the problem to be addressed
Ensure you measure and analyze the problem, before you jump to a remedy
Ensure the remedy will “fix” the problem you are trying to solve
Force you to validate that the remedy was effective
Get a team
Champion: Overcome barriers
Process Owner: The driver
Facilitator: The navigator
Front line staff: Essential team members
Identify the problem
What is the problem?
Who identified it?
When was it identified?
When and where is it occurring?
Pick something that matters to you, and state WHY it matters
Who else cares about the problem (who are the stakeholders?) to assist with resources
Measure it
How can the data be collected (survey, administrative data, chart review)?
Is it valid/accurate?
Is it a manual process or automated?
Is there a clear definition of the outcome (or can it be interpreted different ways)?
Who is going to measure?
Can you sample?
Direct observation is the best way to determine what is actually happening
May want more than 1 type of measure: Process, outcome, structural, balancing
Problem Analysis: What is causing the problem?
• Time of day, day of week
• Department specific / system wide
• Inefficient staffing (numbers or skill set)
• Poor communication
• Inadequate process or policy
• Lack of controls to keep the problem from occurring
• Poor individual performance (usually not the only issue)
• Pick an appropriate process analysis tool to further analyze the problem/process
Remedy the critical issues
Pick a remedy based on the problem analysis.
What are the barriers?
What evidence is there that it will have an impact (has someone tried and succeeded or failed)?
How “reliable” is the intervention?
Do you need >1 intervention to make it nearly impossible to recur?
Remedies (in order of reliability)
Education
Reminders
Checklists
Order sets
Protocols
Pathways
Templates
“Hard stop” order entry
Operationalize
How are you going to make it work?
How will the barriers be removed?
What assistance is required from leadership?
What is the plan to roll out and implement solutions?
Changes thatresult in
Improvement
P
DS
A
P
DS
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P
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P
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Time
Big Idea
Real time problem solving
Validate
How will we know we made a difference, what is your goal?
What are you measuring?
How often are you measuring it?
Is the measure meaningful?
Are you measuring “unintended consequences”?
Evaluate
How to sustain the improvement?
Who is responsible for monitoring and measuring over time?
What is the plan to react if the measures slip?
How will future staff be made aware of the new process?
Summary Have a structured and disciplined approach to PI,
with an executive summary
Always involve front line staff to determine what is actually happening, and what is feasible for change
Figure out the stakeholders and involve them early and often
Keep good records of what you have done and why
Example: Hand Hygiene
Recognized we had a problem
Formed a team
Determined how to measure (blended secret shopper and unit audits)
Analyzed the problem Education
Rewards
Medication administration
Accountability
Hand Hygiene
Remedies Education: Massive
Reward system: Incentives for all staff
Accountability system: Reports to leaders
Defined workflow for medication administration
Operationalized
Validate
Evaluate monthly