a stepwise approach to quality improvement...a stepwise approach to quality improvement michelle...
TRANSCRIPT
A Stepwise Approach to Quality Improvement
Michelle Mourad, MD
Director of Quality and Safety, Division of Hospital Medicine
UCSF Medical Center
Why do we fail to do simple things that improve care?
Hand Hygiene 60% reliable
Central Line Bundles 70% reliable
VTE Bundles 80% reliable
Progress
Time
Actual prac
2ce
Quality Gap
What is QI ?
What is QI?
Yay QI
QI is about producing reliable and sustainable change.
Yay Sepsis! I’m 2red
þ Foley out þ DVT ppx þ Pain Control þ Daily BM
Yay QI!
Start with a story…
• Mayoral election in Romania
• Neculai Ivascu incumbent mayor
… “ I know he died, but I don’t want change.”
I’ll ask you a ques-on…
Do you work in a great hospital?
• Do you work in a great hospital? – What’s keeping it from being great? – Do the leadership and faculty want
greatness? Do you?
• If we all want to work at a great hospital…
You as a leader
• Doctors not trained as leaders
• Doctors make poor followers.
Objectives
• Understand how the principles of QI can help you achieve PCQN vision
• Guide you through a stepwise approach to improvement
• Understand how PCQN data can be used for improvement
You log into the PCQN website after a recent Palliative Care faculty meeting…
Turns out despite a lot of work, your institution is still below the group average
n=35 N=149
20.00%
40.00%
60.00%
80.00%
3 All Sites
Comparison Data for Site 3
Day 1 to Day 2 Score Improvement (exlcuding those with a Day 1 Score of 0)
Stages of QI – Kübler Ross Style
Shock – Is that my data?
Denial – That can’t be my data
Anger – The measurement strategy must be flawed
Bargaining – Our patients are sicker
Depression – No one else is doing any better
Acceptance – We should probably try to improve
Emot
iona
l Res
pons
e
Time
How do we improve care?
• Set the vision for improvement
• Understand the Problem
• Identify Areas for Improvement
• Devise a Measurement Strategy
• Prioritize small tests of change
• Measure Change
• Message value & Sustain the change
Using a QI framework to improve care
• Set the vision for improvement
– Understand the Problem
– Identify areas for Improvement
– Devise a measurement strategy
– Prioritize small tests of change
– Measure change
– Sustain the change
8:40
Vision • Align, Define & Inspire
• Focus on why, not what or how.
As a leader of change, the GOAL is not to make every body do what you want, the goal is to inspire people to
believe what you believe
The BI will eliminate all preventable harm by 2020.
Using a QI framework to improve care
– Set the vision for improvement
• Understand the problem
– Identify areas for improvement
– Devise a measurement strategy
– Prioritize small tests of change
– Measure change
– Sustain the change
9:15
The problem = Persistently high pain scores
Equipment Process People
Materials Environment Management
The problem = Pain management
- Sicker patients - Pain meds not stocked - Staffing on the floors
- Lack of Nursing buy in
- Unclear Physician buy in
- No timely orders
Fishbone Diagram
Equipment Process People
Materials Environment Management
The Problem
primary cause
secondary cause
The effect The Cause
Equipment Process People
Materials Environment Management
Table exercise – Create a Fishbone – 10 minutes
Equipment Process People
Materials Environment Management
- Sicker patients - Pain meds not stocked - Staffing on the floors - Not reliably measuring
pain scores
- Lack of Nursing buy in
- Unclear Physician buy in
- No timely orders - Teams wont let PC
write orders - Rounding only once
a day
What did you come up with?
- Need more chaplain / SW support
- Existential pain, not treated with opiates
- More cancer patients
- PCAs take too long to order
Fishbone = structured brainstorming about why you have the problem
Use as a guide for data you may want to collect
Use data to ensure you are fixing the right problem
Equipment Process People
Materials Environment Management
The problem = Timely pain management
- Sicker patients - Pain meds not stocked - Staffing on the floors
- Lack of Nursing buy in
- Unclear Physician buy in
- No timely orders
Fixing Nurse & Physician buy in
Is different than fixing Hme to pain med
delivery
Case example: Patient Satisfaction
• Goal: Improve Patient Satisfaction with MD Communication
• Intervention: Teach hospitalists best practices in patient communication
• Outcome: No improvement WHY?
• Data: Patient comments all report dissatisfaction with communication between hospitalist & specialists which was not improved.
We discover
• Hour long delays between recs & orders
• Nurses not giving doses promptly
• Pa2ents aren’t asking for PRN meds
• No a\ernoon reassessment
– Set the vision for improvement
– Understand the problem
• Identify areas for improvement
– Devise a measurement strategy
– Prioritize small tests of change
– Measure change
– Sustain the change
9:55
Using a QI framework to improve care
Identify areas for improvement
• Go and see for yourself • Keep asking why until you get to the root of things
Identify Areas for Improvement (current state)
PCS Rounds (day 1)
Informal ✔ in w/ primary teams
FAMILY MTGS
Write notes with
“official recs”
45 year old woman with malignant bowel obstruction due to colon cancer with nausea, vomiting and abd pain, progressive
inability to take oral meds/hydration
3 hrs 1 hr 3 hrs 2 hrs
PCS Rounds (day 2)
• Team (or you) wrote orders “just before they went home.
• Patient unaware of “new” regimen. • Did not ask for additional PRNs • Nurse didn’t provide info on available meds
Day 2 pain scores unchanged
Write orders OR
Page team with updated
recs
Removing Obstacles
• Ask your team why don’t people do this already?