HEALTHCARE QUALITY IMPROVEMENT

Stephen E. Muething, MDApril 6th, 2006

As an Academic Physician, is it important for me to become knowledgeable about quality improvement?

• It’s interesting, but not necessary.• QI is for the administrative folks, not for

academics.• I am already focused on Clinical Care, Teaching

and Research.• I guess, otherwise you wouldn’t be giving this

talk.

What does Quality Improvement have to do with

Clinical Care

CROSSING THE QUALITY CHASM

Institute of Medicine

2001TIMELY

EVIDENCE-BASEDEQUITABLE

PATIENT/FAMILY-CENTEREDEFFICIENT

SAFE

Percent of Diabetic Medicare Enrollees Receiving Annual Eye Examinations (1995-96)

20.0

30.0

40.0

50.0

60.0

70.0P

erc

en

t o

f D

iab

eti

c E

nro

llees

Re

ceiv

ing

An

nu

al E

ye E

xam

ina

tio

ns

(1

995

-96

)

Percent of Diabetic Medicare Enrollees Receiving Annual Eye Examinations (1995-96)

80 or More (0)60 to < 80 (3)40 to < 60 (232)20 to < 40 (71)Less than 20 (0)Not Populated

Percent of Diabetic Medicare Enrollees Receiving Annual HgbA1c Testing (1995-96)

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0P

erc

en

t o

f D

iab

eti

c E

nro

llees

Re

ceiv

ing

An

nu

al H

gb

A1

c T

est

ing

(1

99

5-9

6)

Percent of Diabetic Medicare Enrollees Receiving Annual HgbA1c Testing (1995-96)

80 or More (0)60 to < 80 (6)40 to < 60 (104)20 to < 40 (177)Less than 20 (19)Not Populated

Percent of Diabetic Medicare Enrollees Receiving At Least One LDL Blood Lipids Test in a Two-Year Period (1995-96)

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0P

erc

en

t o

f D

iab

eti

c E

nro

llees

Re

ceiv

ing

At

Le

ast

On

e B

loo

d L

ipid

s T

est

(19

95

-96

)

Percent of Diabetic Medicare Enrollees Receiving Blood Lipids Testing (1995-96)

80 or More (0)60 to < 80 (8)40 to < 60 (52)20 to < 40 (193)Less than 20 (53)Not Populated

Nutritional status in CF

• What is the variation across CF centers in the US?

• How long have we known that it’s worth working on?

0%

20%

40%

60%

80%

100%

Urgent Intervention Need/Failure Risk of Same

High-Risk Pediatric PatientsPediatric Patients in “Urgent Nutritional Need”/“Failure”

or at Risk of “Urgent Intervention Need”/“Failure” by Center

Percent of CF patients with weight for age below 10th percentileincludes only patients who are less than 19 years old

stratified by type of insurance

10%

15%

20%

25%

30%

35%

40%

45%

50%

Month

Pe

rce

nt

of

CF

pa

tie

nts

Private Government

Last update: 10/28/05 by H. Atherton, Data Source: Disease Management Database

How will we know that a change is an improvement?

What are we trying to accomplish?

What changes can we make that will result in improvement?

The Improvement ModelThe Improvement ModelThe Improvement ModelThe Improvement Model

Plan

DoStudy

Act

Plan Always includes a prediction

Do Study

Did my prediction hold? What assumptions need revision?

Act Adapt Adopt Abandon

PDSAPDSAPDSAPDSA

Changes That Result in

Improvement

A P

S D

APS

D

A P

S DD S

P ADATA

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

EvidenceBest PracticeTestable Ideas

Use of PDSA cyclesUse of PDSA cyclesUse of PDSA cyclesUse of PDSA cycles

•S - Specific•M - Measurable•A – Actionable•R – Reliable•T – Time bounded

Charter AimCharter AimCharter AimCharter Aim

• We will reduce central venous catheter infection rates throughout the hospital from 3/1000 device days to 0.8/1000 device days.

Example Example Example Example

18 18 19 24 22 32 27 23 7 10 7 11 8 7 8 6 7 7 14 15 14 6 14 5 12 7 7 5

6003

5772

7060

7586

7557

7572

8401

8154

2699

3005

2636

2943

3091

2707

2648

2722

3176

2771

3115

3148

3064

3145

2871

2848

3025

3017

3215

2785Device

Days

Infections

CCHMC Central Venous Catheter (CVC) AssociatedLaboratory Confirmed Bloodstream Infections (LCBIs)

4.2

2.2

1.81.9

4.94.8

2.22.22.6 2.3

4.0

1.8

4.64.5

2.5

3.0

2.6

3.7

2.7

3.3

2.62.8

3.2

2.9

3.2

2.7

3.1

3.0

0

1

2

3

4

5

6

7

8

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

FY2003 FY2004 FY2005 FY2006

Infe

ctio

ns

per

100

0 D

evic

e D

ays

CVC-LCBIs CY2004 Average Control Limits (Based on CY2004 Average)

July 2003 thru February 2006

All Code Events Outside Critical Care Areas w BVMV or CC or Both 2.1.06

0.22

0.3

0.1

0.32

0.1

0.15

0.2

0.28

0

0.2

0

0.1

0.2

0.3

0.4

O-D 03 J-M 04 A-J 04 J-S 04 O-D 04 J-M 05 A-J 05 J-S 05 O-D 05 J-M 06

Co

de

s p

er

10

00

Pa

tie

nt

Da

ys

Baseline Rate = 0.27(25 per 92188 days)

Pilot 3.1.05 A6S

4.11.05 A6S, A6N, B5E

Hosp Educ 2.1.05

Go Live 6.1.05 Full Hosp

MRT Implementation = 0.15(5 per 33173 days)

Post MRT = 0.11(6 per 52494 days)

Infections 7 10 10 11 8 11 13 11 3 5 5 7 6 13 7 3 12 5 10 4 9 3 2 0 1 1 1 1

Vent Days

2113

1955

2535

2761

2336

2437

2039

1957

782

809

804

974

897

1008

969

951

932

738

933

832

835

661

728

473

585

652

558

643

CCHMC Ventilator Associated Pneumonias (VAPs)

4.5

12.9

3.2

12.9

4.8 4.5

2.7

1.61.81.51.7

0.0

10.810.7

6.8

7.2

6.7

7.2

6.26.2

3.8

5.6

6.4

3.4

4.03.95.1

3.3

0

2

4

6

8

10

12

14

16

18

20

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

FY2003 FY2004 FY2005 FY2006

Infe

ctio

ns

per

100

0 V

enti

lato

r D

ays

VAPs CY2004 Average Control Limits (Based on CY2004 Average)

July 2003 thru February 2006

Infections 16 14 9 16 13 16 11 22 10 9 4 7 7 8 10 8 7 5 7 13 8 7 7 8 4 8 2 2

1666

1626

1552

1665

1596

1493

1590

1785

635

643

581

608

558

529

543

528

607

648

674

651

628

749

632

611

642

527

607

568Procedure

days

CCHMC Surgical Site Infections - Class I & Class II Combined

0.4

0.3

1.11.21.0

0.90.6

1.0

0.80.7

1.2

1.6

1.4

0.7

1.21.3

1.8

0.8

1.0

1.3 1.3

0.6

1.5

1.1

1.5

1.5

2.0

0.9

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

FY2003 FY2004 FY2005 FY2006

Infe

cti

on

s p

er

10

0 P

roc

ed

ure

Da

ys

CI & CII SSIs CY2004 Average Control Limits (Based on CY2004 Average)

July 2003 thru February 2006

Direction of Desired Change

Adverse & Sentinel Events

1

2

3

4

Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

2004 2005 2006

Re

po

rted

Oc

cu

rre

nc

es

Adverse Events (22 Total)

Sentinel Events (23 Total)

March 2004 thru February 2006

Improving Outcomes:Hbg A1c after Family

ChoiceHgb A1c 5 to 10 weeks after New Diagnosis Diabetes May-Jan

7.00

7.50

8.00

8.50

9.00

9.50

Before Choice N/R (n=78) After Choice BBT (n=72) After Choice N/R (n=20)

Insulin Therapy

Hg

b A

1c

Percent of Patients on A6S That Go Home Without Delay

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2/7/

2004

n=1

8

2/28

/200

4 n=

23

3/20

/200

4 n=

17

4/10

/200

4 n=

20

5/1/

2004

n=2

0

5/22

/200

4 n=

18

6/12

/200

4 n=

21

7/3/

2004

n=2

0

7/24

/200

4 n=

12

8/14

/200

4 n=

20

9/4/

2004

n=2

0

9/25

/200

4 n=

20

10/1

6/20

04 n

=20

11/6

/200

4 n=

13

11/2

7/20

04 n

=20

12/1

8/20

04 n

=20

1/8/

2005

n=2

0

1/29

/200

5 n=

20

2/19

/200

5 n=

20

3/12

/200

5 n=

20

4/9/

2005

n=1

0

4/30

/200

5 n=

10

5/21

/200

5 n=

11

6/11

/200

5 n=

10

7/2/

2005

n=1

0

7/23

/200

5 n=

10

8/13

/200

5 n=

10

D/C within 4 hours of meeting d/c goals Median Goal

Time of Day Patients Are Discharged

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Aug. 03 Jan. 04 Dec. 04

1st Shift08:00-15:00

2nd Shift15:00-23:00

Evidence Based Practice Provided on Inpatient Unit

0%20%40%60%80%

100%

Evidence Based Practice Provided Goal Median

(Data through Mar 03 based on original measures - measures modified Apr 03)

ANY COMMENTS?

ANY QUESTIONS?

THANK YOU!

Stephen E. Muething, M.D.