Enhancing Quality Improvement for Patients (EQuIP)

Equipping Louisiana with a Quality Future.

What is this and why do it?

• School-wide initiative• Engage residents and fellows in systems-based

quality improvement and patient safety (QI/PS) projects.• Neither fully top-down nor fully bottom-up.

• Is this one of those ACGME things I have to do?

What you should do…

• Check out hospital QI/PS committees to determine if you would like to join them.

• Examine your surroundings – how can we make the system better for patients?

• Work with your program to identify a project. Each project should have tangible objectives and

measurable outcomes.

EQuIP Projects – Core Principles• Residents and fellows are in a good position to know

what needs improving.• Improvement requires change.• Watch out for unintended consequences.

Richard Tejedor, MD, “Performance Improvement Projects: Core Principles of Project Acceptability,” LSU QI Forum 2013.

EQuIP Projects – Core Principles

• Importance– Have you measured a

performance gap?– Will the project be high-

or low-impact?– Is an intervention likely

to improve health outcomes or improve patient safety?

Richard Tejedor, MD, “Performance Improvement Projects: Core Principles of Project Acceptability,” LSU QI Forum 2013.

• Scientific Acceptability– Does the evidence

support the initiative?• Endorsed national

initiatives are preferred.

Do you need IRB review?

EQuIP Projects – Core Principles

• Feasibility (or, usability)– Is your plan actionable?– Do you have measurable

data elements?• Should be routinely

generated.

• Absolute performance– Unintended

consequences– Is your intervention

appropriate for all entities?• Race, sex, age, comorbid

conditions, etc.– Concentrate on outcome

measures rather than process measures.

Richard Tejedor, MD, “Performance Improvement Projects: Core Principles of Project Acceptability,” LSU QI Forum 2013.

Sample Projects• Comparison of pre- and post-operative med compliance

after implementation of an instruction sheet for patients. • Retrospective chart review to evaluate current guidelines for

neutropenic fever.– Gap analysis of current practice discovered no intervention was

needed.• Autopsy Quality Assurance (AQuA): Correlating clinical

diagnosis with autopsy results; improving physician awareness of autopsy procedures; decrease turn-around-time for autopsies at ILH.– Discovered significant gaps in provider knowledge regarding

autopsies; implementing system changes to decrease turn-around-time (Ongoing).

Sample Projects

• Less-ideal projects:– e.g., Basic administrative functions with no impact on

patient care or outcomes.– Projects that do not track measurable patient outcomes.

• Enhancing medical knowledge – is it QI?

• Patient education – when is it QI?

EQuIP Project Review Form• Completed for each EQuIP

project– Available at:

www.medschool.lsuhsc.edu/equip– Turn in to EQuIP office

(vharki@lsuhsc.edu)• Document project goals – i.e.

targeted patient outcomes• Addresses IRB and hospital

requirements– EQuIP facilitates communication.

Improvement Methodologies

Improvement Tools

Root Cause Analysis (RCA)

• A review of the systems and process factors that contributed to a variance in performance (e.g. sentinel event).

• Does NOT focus on individual performance.

Root Cause Analysis (RCA)Progress from special

causes in clinical process to common causes in the

organization.

Identify changes that could be made to reduce

risk of event occurring again.

Repeatedly ask “Why?” to dig deeper and find

out why things happened the way they

did.

Root Cause Analysis (RCA)

Thorough• Determine ALL factors most

directly associated with event.

• Analyze underlying systems and processes through a series of “Why?” questions.

• Identify risk points and determine what improvements could decrease likelihood of a repeat event.

Credible• Must include participation by

organizational leadership and individuals most closely associated with the processes and systems under review.

• Provide consistent explanations for all findings (including “no problem” or “not applicable”).

• Review of any relevant literature.

Root Cause Analysis (RCA)Action Plans• Products of RCAs – identify strategies that

organization will implement to reduce the risk of similar events in the future.

• Names:– Person(s) responsible for implementation– Timeline for implementation– How effectiveness of intervention will be

measured.

Root Cause Analysis (RCA) – Mock Case

• 49y.o. female.– Mitral stenosis, pulmonary hypertension, atrial fibrillation– Past history: asthma, hyperthyroidism, total hysterectomy

1992. – Meds: Lisinopril 20mg daily; Coumadin 5mg daily; Lasix

20mg daily; Albuterol 2 puffs prn; Propranolol 80mg BID; Propylthiouracil 50mg 3tabs 3x/day.

• Admitted for mitral valve replacement and modified maze ablation for A-fib– Twenty-four hours pre-op, heparinized– Twelve hours pre-op, ACT was greater than 1,000

Root Cause Analysis (RCA) – Mock Case

• During procedure, pt had difficulty with ventilation (peak airway pressure >50)– Endotracheal tube suctioned; aerosol nebs instilled

directly– Pt started developing severe edema of the face, tongue

and abdominal wall– Incision made in peritoneal cavity; large amount of

ascites fluid evacuation• Benadryl, IV epinephrine and IV steroids

administered.– Allergic reaction suspected

Root Cause Analysis (RCA) – Mock Case

• Pulmonary: peak airway pressure eval• Cardiology: – Transesophageal echo to inspect valves, which were

found to be working well. – Pt had evidence of left & right ventricular failure. – Intraaortic balloon inserted into rt femoral artery;

calcium and protamine administered and lungs hyperinflated.

• Wound not closed primarily– Gortex patch sewn circumferentially in wound using

Prolene patch.

Root Cause Analysis (RCA) – Mock Case

• Post-op: pt transferred to MICU– Hemodynamically compromised– Consultants: Pulmonary, Cardiology, Allergy, and

Hematology.• No consensus of etiology

– Treated with FFP, platelets, blood transfusions, epinephrine and steroids.

• Condition continued to deteriorate. Pt pronounced at 6:11 p.m.

Root Cause Analysis (RCA) – Mock Case

What areas/services were impacted?

• OR• MICU• Perfusion• Laboratory• Anesthesia• Pharmacy• Blood Bank• Nursing

• Pulmonary• Cardiology• Allergy• Hematology• Quality

Management• Risk

Management

Proximate Factors

Common Cause Variation

Root Cause Analysis (RCA) – Mock Case

Special Cause Variation

Root Cause Analysis (RCA) – Mock Case

Root Cause Analysis (RCA) – Mock Case

Why did it happen?(Proximate factors)

• Process– What are the steps in the process? – What steps contributed?

• Human factors– What human factors were relevant?

• Equipment factors– How did equipment performance affect the

outcome?• Controllable factors

– What factors directly affected the outcome?• Uncontrollable external factors

– Are these truly beyond the organization’s control?

Proximate Factors

Common Cause Variation

Root Cause Analysis (RCA) – Mock Case

Special Cause Variation(as appropriate)

Root Cause Analysis (RCA) – Mock Case

Human Factors & Information Management – Continue to ask “why”

Root Cause Analysis (RCA) – Mock CaseEquipment Factors – Continue to ask “why”

Cultural Factors – Continue to ask “why”

Root Cause Analysis (RCA) – Mock Case

Uncontrollable Factors – Continue to ask “why”

Wrap-Up:• What did we learn from this case? • What are the things we would do differently

based on this case?• Action Plans for improvement

• “Why?”• Involvement by everyone• No “shame and blame”• Action plans developed

Root Cause Analysis (RCA) – Mock Case

EQuIP - Why do it?

• It’s the right thing to do.• Our patients deserve this.• Our residents and fellows need this.• Improvement is its own reward.

Only through continued self-assessment will we improve.

Questions?

Director of EQuIPMurtuza (Zee) Ali, MD, FACC, FSCAI (email:

mali@lsuhsc.edu)

EQuIP CoordinatorVictoria Harkin, MA (Phone: 504.568.2593; email:

vharki@lsuhsc.edu)