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University of ColoradoAnesthesia Training Program

Quality Improvement Handbook

Darlene B. Tad-y, MD, Lisa Price, MD, Dimitriy Levin, MD, Jeffrey Glasheen, MD

Alison Brainard, MD, Melanie Donnelly, MD

References:

IHI Open School Basic Certificate of Completion (http://www.ihi.org/offerings/IHIOpenSchool/Courses/Pages/OpenSchoolCertificates.aspx. Accessed June 3, 2012)

Headrick LA. Learning to improve complex systems of care. In: Collaborative Education to Ensure Patient Safety. Washington, DC: HRSA Bureau of Health Professions 2000:75-88

Neuhauser D, Myhre S, and Alemi F. Personal Continuous Quality Improvement Workbook. Seventh Edition, April 2004 (http://www.a4hi.org/education/eduQIWB.cfm Accessed June 3, 2012)

http://www.a4hi.org/education/eduQIWB.cfm

http://www.ihi.org/offerings/IHIOpenSchool/Courses/Pages/OpenSchoolCertificates.aspx

Dear QI Teams,

Welcome to the anesthesia QI program! This handbook will guide you and your team through the steps of quality improvement to help you succeed in completing your QI project. The handbook is meant to be a team effort. The timeline and checklist will help you stay on track in order to maximize the time you will have during the year. This guide will include some cues to help accomplish the necessary tasks during each meeting. It will also include a list of resources available to help you accomplish the tasks. Meeting times: It is up to the faculty and residents in each group to find time to meet that works for all. We are providing a $100 stipend to each group to help fund some food and drink at a meeting or two. The best tool to use for helping you find good meeting times is likely to be doodle which we can help you use. You are free to modify the timeline and be more aggressive with your tasks as these could likely be accomplished in less time then 1 year.

The faculty may have access to many resources and people to help you accomplish your tasks but if not we have 3 folks specifically designated to work with perioperative services or our department on patient safety and QI activities. Their contact information will be in this packet.

If at any time you would like Melanie, Alison to work with you at any of your meetings please reach out to us. If you need coverage for a meeting please call and we will do our best to sub in as needed. We know the first year will be the toughest and we want to help all of the groups succeed.

At the end of the year you will all be asked to evaluate each other and the program. We will absolutely count on your feedback to help us shape the second year of this program. If things come up during the year that you need to feedback to us please don’t hesitate to call or email. This year is learning year for all of us as we figure out how to teach this critical set of skills to the residents and each other.

Sincerely,

Melanie Donnelly and Alison Brainard

2 | Q I H a n d b o o k

Table of Contents

Contacts:

Melanie Donnelly

[email protected], 603-568-5413

Alison Brainard

[email protected],

Kezia Windham, Risk Manager for Anesthesia


Kaci Meddings, Quality Improvement Clinical Specialist RN


Nicole Babu, Perioperative Patient Safety RN



Section

Overview of Curriculum

Step 1. Understanding the Event/Obstacle

Step 2. Identifying areas for improvement

Step 3. The Ideal Process: Proposing Interventions for Change

Step 4a. Measures of improvement

Step 4b. Statement of goals and objectives

Step 5. Implementing Tests of Change: PDSA (plan,do, study, act) Cycle

Step 6. Presentation and Summary

mailto:[email protected]





Global aim

Empower residents to create changes they think are important to their work environment and to improve patient and provider experiences, using quality improvement/patient safety methods.

SMART aim

Over the course of the academic year, residents will perform a root cause analysis of an adverse event/near miss OR obstacles to care, develop a flowchart outlining the process which allowed the event to occur, identify an area for improvement, and develop a quality improvement project (using PDSA methodology) that is ready for implementation with a CA3 leading the project and a faculty advisor.

Objectives and skill sets

Knowledge Describe the elements of a PDSA cycle

Skill Select an adverse event/near miss/obstacle to care which you intend to address

Skill Demonstrate use of fishbone or other tool to complete a root cause analysis

Skill Demonstrate use of a process map/flowchart to deconstruct the process of care surrounding the event/near miss/obstacle

Skill Demonstrate how to write a SMART aim statement

Skill Design an intervention using PDSA methodology that is ready to be launched.

Attitude Rate adverse event reporting and RCA as a valuable exercise.

Products to be submitted:

September 1 Pre-test for residentsOctober 1 Event/Obstacle that was chosen

Understanding the problem worksheetMarch 1 Process map/flowchart

RCA tool – Fishbone or otherSMART AIM statement

May 1 Evaluations

June 1 PDSA project outlinesJune 15 Post test

Milestones met in graduated way

Systems based practice 1: Coordination of patient care within the health system

Systems based practice 2: Patient safety and quality improvement

Practice Based learning and improvement 1: incorporation of quality improvement and patient safety initiatives into personal practice (level 3 now, level 4 in future)

Practice-based Learning and Improvement: ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on self-evaluation and life-long learning.



PROPOSED TIMELINE FOR TASKS AND TOOLS TO COMPLETE TASKS

Month Task tools

July -Grand rounds/roll out

-Begin to look for cases of adverse events/near misses/obstacles to care. These can be your own or you can ask faculty and nurses who work in perioperative locations for ideas

-Groups formed- CA3, CA2, CA1 , Faculty advisors

Background resources about QI/patient safety

--Understanding and responding to adverse events by Vincent

--The Wrong Patient, Chassin

--Wake up Safe

-Groups distributed to faculty and residents

September -Choose event/obstacle to focus upon as a group

-Understand the problem

- Create a process map/flowchart of care for the event/obstacle of choice. This can initially be created by the group but then needs to broadened by interviewing others who are involved with the process (nurses, tech’s, patients etc)

-Start working on Root Cause Analysis. This will involve identifying factors which played a role in the event taking place or obstacle being an impediment to patient care. Initially the group may begin filling in the fishbone diagram. This should be a multidisciplinary process under ideal circumstances. If this cannot be accomplished in a group setting it at least must be performed in interviews with other medical professionals and/or providers involved in the event/obstacle.

- Handbook

-RCA Guidelines

-Wake up Safe article

(RCA and process map)

-Contributory factors classification

-Fishbone diagram

-RCA investigation process

-Vanderbilt Matrix

Oct/Nov - Further develop the process map/flowchart for process surrounding event/obstacle, filling it in with data collected by group members

-Further develop the RCA based on group findings.

-Have a discussion regarding the factors identified using the “5 why’s” tool to help get to the root cause of the problem. This may involve, again, discussions with other providers/professionals outside of the group.

- At this point the group may be ready to proceed with next steps OR they may need to get more data to complete the flowchart and RCA prior to proceeding.

-When selecting which area you are choosing for improvement use the “degree of impact” chart in your faculty handbook to help guide you to and high impact/low effort area to focus on.

-Group members should be tasked with performing a literature review to help you create an evidence based approach to the area you have

-5 why’s tool

-tools listed above

-SMART aim addressed in faculty handbook

Step 1: Understanding the Problem surrounding the Event/Obstacle you have chosen – The What, Why, Who, When and WhereWriting the Problem Statement. The problem statement should have the form:

“WHAT is wrong - WHERE it happened - WHEN it occurred – TO WHAT EXTENT it occurs – I KNOW THIS BECAUSE…”

Answer the following questions to help you write your problem statement:1. What is the problem your team is addressing? Be specific, describe the scope/severity of the problem.

a. Why is it a problem? List at least 3 reasons for why the problem needs consideration b. Describe the problem as it pertains to your hospital.

2. Who are the stakeholders involved? a. List at least 5 stakeholders. For each stakeholder, answer the next 2 questions:b. How are these stakeholders involved?c. What do they stand to gain or lose by fixing the problem?

3. When has this been a problem? And when do you plan to address the problem?a. Consider time periods prior to when data was being collected.b. Generate a rough timeline for key milestones. Try to be realistic and take your schedules into

consideration.4. How bad is the problem (ie what is the extent)?5. What is the data that supports your statement?

a. Where does this data come from? Locally? In the literature? b. Use objective data to quantify the reasons for why your problem is significant.c. This may involve even an informal survey of your colleagues or others who work in your area, or it may

also involve QI reports or PSN’s that have been filed.

Visualizing your problem.

1. Draw a flowchart/process map for the obstacle/event you have selected to address.

2. Construct an outline of you RCA using a your tool of choice or a fishbone diagram


What is a process map? A tool used to identify value, reduce waste, and improve the work process.

How do I make one?

1- Identify process to be mapped

2- Collect information to create map

3- Take initial process map to managers and staff to be be sure you have an accurate map and to get suggestions to how to improve the process

4- Create idealized process map and work towards implementation

5- Continue small scale improvements working towards ideal work process

Step 1: Understanding the Problem – The What, Why, Who, When and Where

What

Why

Who

When

Where


Step 2: Areas for ImprovementReview your process map or fishbone diagram.

1. Which areas of the system or process can you target to improve (ie, identify key gaps)?

2. For each area of improvement, consider these two questions:a. To what degree can you impact the area/system in question?b. How much effort will be required to impact the area/system in question?

3. Please rank the areas in order of impact vs effort required (which box does each area of improvement belong to)?

Degree of Impact( For an example----http://asq.org/healthcare-use/why-quality/impact-effort.html)

High Low

2nd Most desirable Less desirable

High

Effort Required to Impact system

Most Desirable Not desirable

Low

4. Choose the 4 best areas of improvement


Step 3: The Ideal Process – Proposing Interventions for ChangeNow that you understand the current process and the areas of waste or inefficiency, consider what the ideal process would look like. What would be different in the ideal setting?

Reimagine the Ideal Process and describe it here (create an Ideal Process Map here). Please highlight the changes in the new process compared to the current process.

With this new process in mind, what changes need to happen for the old process to become the new? How can those changes be turned into interventions?Please propose 6 interventions that can be implemented to address the gap between the Old Process and the Ideal Process. Rank them according to desirability (most to least).

1.

2.

3.

4.

5.

6.


Step 4a: Measures of Improvement

Generally, there are 3 types of measures that are important to consider when doing quality improvement work.

Outcomes: results-oriented, how does the system impact patients health and wellness? o example: the number of smoking patients who have successfully quit in the last year, HgbA1C

Process: action-oriented, related to how the system works o example: how many diabetic patients have received their annual foot exams in 2010, how many diabetic

patients had Hgb A1C’s drawn Balancing measures: measures of potential adverse consequences of change; are changes designed to improve

the system creating new problems in others areas of the system? o example: extubating people sooner in the ICU to reduce ventilator daysis this resulting in a higher

reintubation rate? Or, by reducing length of stay are we increasing readmissions?)

Outcome Measures Process Measures Balancing measures


Identifying and anticipating balancing measures can be challenging. You may need to engage other disciplines to help you identify those. You may also engage the peri-operative QI professionals who can help you identify these.

Step 4b: Statement of Goals and ObjectivesUsing the 4 areas of improvement identified in Step 2 and metrics identified in Step 3, please write SMART goals and objectives for each one:SMART: Specific, Measurable, Aggressive yet Achievable, Relevant , Time Bound

Area for improvement:

Overall goal:

Objectives:


Overall goal:

Objectives:


Overall goal:

Objectives:


Overall goal:

Objectives:


Be sure to make these ACHEIVEABLE goals!

By including every aspect of the SMART format in your objectives, you will find it easier to identify useful metrics in the next step.

Step 5: Implementing Tests of Change: PDSA Cycle

After gaining a good understanding of the problem, identifying relevant metrics and devising interventions, testing a change can now be attempted. We will only be creating a project that COULD be executed using the PDSA cycle but NOT actually performing it.

The original Model for Improvement included the PDSA cycle. It is a stepwise process in which tests of change can be carried out. The PDSA cycle allows the small tests of change to be incorporated into a larger project by acting as an agent for producing relevant data.

The steps themselves are simple and will help your team move towards change. It cannot be emphasized enough that the first step, Plan, will set the stage for a useful PDSA cycle.

The following pages will help you work through the entire PDSA cycle.


PDSA cycles will be most useful and informative if the PLAN phase is done well. Design interventions that line up with the metrics and goal/objectives.

PDSA Form

PlanWhat is the objective of this test?

What predictions does your team have for this cycle?

Describe the change that your team will be testing?

The plan considered the following methods:

Did you assign responsibilities for collection and analysis of the data? Is training needed? Can the plan be carried out on a small scale? Have you considered people outside the team who will be affected by this plan?

DoHow will you carry out the plan? How will you identify problems with implementing the intervention? How will you identify potential negative consequences of implementing this plan? How will you collect observations while the plan is being implemented? How will you ensure that data is being collected, and being collected reliably?

Study Compare the analysis of data to the current knowledge:

Do the results of the cycle agree with predictions made in the planning phase? Under what conditions could the conclusions from this cycle be different? What are the implications of the unplanned observations and problems encountered during data collection? Do the data help answer the questions posed in the plan?

Summarize the new knowledge that will be gained from the first PDSA cycle of your intervention.

ActWhat changes do you think could be made to the process? And what other people will be affected? What will be accomplished if this cycle is executed? What forces in the organization will help or hinder the changes you think may be made?


Presentation/Executive Summary

In business, the executive summary captures and presents the essence of your business plan. It is meant to be short and sweet, but captures the reader’s attention. The executive summary gets to the point quickly and emphasized conclusions and recommendations. It should generally be no longer than 1-2 pages, and is similar to the research abstracts that are written in the medical field.

Enter key points of your project into the template below:Background– Describe the problem

from your perspective– Include information

about the general problem in the literature

– Describe baseline data/measures at the institution of interest

Methods– Describe time frame,

team members involved, institution

– Include all interventions that would be implemented or attempted

Findings– Provide a brief text

summary what types of results you would develop from your plan

– Provide metrics to measure findings

Conclusions and Recommendations– State the outcome of

your project– Describe the significance

of the project to the local system

– Highlight aspects that are generalizable

– Discuss sustainability of proposed changes


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