john v. hartline, md, faap · 2018-02-21 · john v. hartline, md, faap clinical professor,...
TRANSCRIPT
John V. Hartline, MD, FAAP
◦ Clinical Professor, University of Wisconsin, Madison
◦ Editor-in-Chief, NeoReviewsPlus©
Janet H. Muri, MBA
◦ President, NPIC/QAS
Stephen A. Pearlman, MD, MSHQS, FAAP
◦ Clinical Professor, Jefferson Medical College
◦ Director, NPM Fellowship, Jefferson Medical College
◦ Attending Neonatologist, Christiana Care Health System
Look in the mirror – you’re part of this too!
Conflict of Interest:
◦ All three presenters have experience with Part 4 ABP MOC
projects which are ongoing at this time.
◦ Such experience will contribute to the content of the
presentation, but the presentation’s aim is to foster creativity
toward development of new quality improvement projects
by the attendees.
No off-label use of anything will be discussed
Leadership is a teachable skill
Leadership is an essential piece of QI
Today’s meeting is to embark on leading change in
your unit through quality improvement, and
To meld quality improvement activities to MOC
requirements
Practice gaps identified
Content to fill the gaps
Suitable QI topic
Measurement and
benchmarking
Optimal care practice or
practices (care bundle)
Implementation of
change
Tracking of impact
◦ Process
◦ Outcome
• Sustainable Improvement
Create list of potential topics
Delineate criteria for success
Establish list of required data
Plan an interventional strategy
Formulate a data review and analysis plan
Understand use of data analysis in QI
Take home a plan!
The elephant in the room.
A source of anxiety for some.
New, therefore unfamiliar.
Necessary?
Goal: Marriage of effective, interesting and needed
quality improvement with qualification for MOC.
•4-part program that you begin once you have passed your initial certification examination. •Evaluates the same 6 ACGME core competencies measured throughout training. •Competencies are assessed in 5-year cycles, as defined by Maintenance of Certification.
Program of ABP by criteria of ABMS
To support physicians’ need to maintain certification in their practice areas
Four part program:
◦ Part 1 : maintain license
◦ Part 2 : life-long and needs-based learning
◦ Part 3 : knowledge examination
◦ Part 4 : quality improvement, patient satisfaction
Visit the ABP website at www.abp.org
Contact the ABP:
→ Initial Certification: [email protected]
→ Subspecialty Certification: [email protected]
→ Maintenance of Certification: [email protected]
→ By phone: (919) 929-0461
Stephen A. Pearlman MD, MSHQS Clinical Professor of Pediatrics, TJU
Attending Neonatologist, CCHS
The reason that most Quality Improvement Initiatives
do not succeed is because people don’t go through the
proper steps of change management.
The science may be good but if you can’t get people to
follow what you want to accomplish you are doomed
to failure.
Diagnosis Unfreezing Movement Refreezing
Northcraft, GB, Neale, MA 1994
Published in the Harvard Business Review
Defined the most common reasons that organizational
changes fail
Develop strategies to overcome the reasons for failure
Very applicable to health care
Eight stages recommended
Convince key people
that change is really
needed
Link ideas and solutions
to an overall vision that
people can understand
and remember
Find ambassadors to
go out and keep the
vision clear in
everyone’s mind
This step is
necessary to keep
moving things
forward
Success in and of
itself is a powerful
motivator
Analyze what went
well and what needs
more improvement –
think PDSA cycles
or CQI
Change will only
stick if it becomes
part of the culture
within your
organization
Habits
Power/Influence
Limited Resources
Misunderstandings
Saving Face
Fear of the Unknown
Tolerance of
Ambiguity
Communication
Ensure staffing supports change
Participation
Promote perceptions of fairness
Negotiate
Manipulation and Coercion
Incentives
Pilot program
“Although all improvement involves
change, not all changes are
improvement”
Institute for Healthcare Improvement
Develop a list of possible QI projects
Group Exercise # 1
“What needs to be better?”
“What do we know about the root cause(s) related to the
problem?”
“What behavior(s) could be changed to impact the
outcome?”
“What are the essential data needed for this project?”
1. Importance and timeframe
2. Stakeholders
3. Measures of quality
4. Recognized (EBM) guideline or standard
5. Implementation potential
6. Data collection and tracking
7. Feedback and adjustment
8. Sustainable results
1.
2.
3.
4.
5.
6.
Develop a list of possible QI projects
Narrow your list
Group Exercise # 2
Decrease Adverse events (37)
◦ Line infections - 15
◦ Med errors, etc. - 6
◦ “in general” - 4
◦ Hypothermia - 3
◦ Readmission - 2
◦ ROP prevention - 2
◦ BPD prevention - 2
◦ VAP, NEC, PPHN - 1
Better practice behavior (21)
◦ Feeding protocols - 7
◦ Professional communication - 6
◦ Clinical pathways - 3
◦ Care management - 5
Evaluation for infection - 1
Resuscitation - 1
nCPAP criteria - 1
Transfusion - 1
Abstinence Syndrome - 1
1.
2.
3.
4.
5.
6.
Develop a list of possible QI projects
Narrow your list
Select QI project to operationalize
Group Exercise # 3
Which problem?
Who’s on the team?
What is the goal?
What will be measured?
How to analyze?
What changes improvement?
How to test changes?
Quality improvement project steps:
◦ How to get a baseline assessment of practice, hospital, collaborative group’s current status?
◦ What education is needed to introduce and implement care bundle? Getting “buy-in”
Need for multidisciplinary cooperation
◦ How best to monitor process: pre- and post- implementation? What are reasonable time cycles for data collection and review?
Outcome:
◦ How to define the measureable outcome(s) that is/are available within timeframe of project and MOC cycles of participant?
◦ How will you plan for sustaining a positive outcome?
20 minutes: then report to all of us
Table representatives: (1 from each)
Table order of choice: RPC determines
Table topics:
◦ Table 1
◦ Table 2
◦ Table 3
◦ Table 4
◦ Table 5
Effecting change: developing implementation plan
Implementation generally includes:
◦ Educational component – evidence base for its use
◦ Timeline to introduce and win-over stakeholders
◦ Follow-up of process change and outcomes, reported
periodically
◦ Review and revise – PDSA cycles
◦ Tools: incentives and reminders
◦ Psychological support – encouragement and applause
Decision: participants
◦ Individual hospital/unit/practice
◦ Multihospital collaborative - from one system/one
practice/state
Decision: Project Leader
ABP Application Form (E-binder, Chapter I)
Key Issues:
• Application Fee: $500; approval for 2 years
• Fee to diplomate to participate
• Offering CMEs
• Length of project
• Data collection method and cycle; reported at what level - by
physician, by hospital
• Data reports, graphs, and results
E-binder, Chapter II
Concise problem statement, project aim and mission
Defining precise steps to confirm participation: contract
with physician/hospital participants
Expectations of each participant - length of involvement,
number of meetings, role in data collection or
submission, disseminating information, teaching,
reviewing data, developing own QI science expertise
Neonatologists/Pediatricians sign onto project
◦ Must participate throughout project (can’t catch up!)
Complete QI science requirement
Commit to meaningful contribution to the project
Contribute to educational programming and implementation
strategy
Applies care bundle to his/her appropriate patients
Attends and participates in 80% of project related meetings
Must be neonatologist or pediatrician
“Champions” the project
Project team:
◦ Must include at least one nurse, and one administrator on project team.
Participates in activities with other sites
Attests to meaningful participation
Receives part 4 credit as well
Free-standing or agenda item on existing QI meeting
Suggested topics: (spread over 5 meetings)
◦ Introduction to MOC project
◦ QI science
◦ Education on problems / “best practice(s)”
◦ Components in process monitoring
◦ Adoption of Care bundle; “process implementation”
◦ Mid-project review
◦ Post-project review
◦ Plan for sustainability
E-Binder, Chapter III
IRB review
Data elements- specific list (format); frequency; population- 100% or sample
Availability: electronically or data abstraction required (Medical Records/IT involvement)
Multi-hospital collaborative: development and execution of data sharing agreement (legal review) for PHI (protected health information)
Data support: abstractors, programmers, and analysts
Data Collection: centralized/de-centralized
Tool: paper/Access or web-based
Data Storage: secure server/installation
instructions
Data Collection training and ongoing support
E-binder, Chapter V
Define your baseline period
Define your pre-intervention, intervention and post-
intervention period
Design report format - by physician, by hospital;
compared to
Determine frequency of reporting back to participants
- concurrently; monthly, quarterly
Tables and graphs
Seeing your progress
Seeing your results
0
5
10
15
20
25
30
35
40
45
500
1/0
1/0
5 (
n=
26)
02
/01/0
5 (
n=
26)
03
/01/0
5 (
n=
15)
04
/01/0
5 (
n=
26)
05
/01/0
5 (
n=
18)
06
/01/0
5 (
n=
17)
07
/01/0
5 (
n=
18)
08
/01/0
5 (
n=
27)
09
/01/0
5 (
n=
16)
10
/01/0
5 (
n=
15)
11
/01/0
5 (
n=
24)
12
/01/0
5 (
n=
18)
01
/01/0
6 (
n=
29)
02
/01/0
6 (
n=
32)
03
/01/0
6 (
n=
26)
04
/01/0
6 (
n=
16)
05
/01/0
6 (
n=
28)
Mon
thly
Aver
age
1st Monthly Averages 1st Median Goals 2nd Monthly Averages 2nd Median
Run Chart Example: 2 Contributors
0%
20%
40%
60%
80%
100%1/0
1/0
5 (
n=
050)
2/0
1/0
5 (
n=
284)
3/0
1/0
5 (
n=
298)
4/0
1/0
5 (
n=
204)
5/0
1/0
5 (
n=
286)
6/0
1/0
5 (
n=
285)
7/0
1/0
5 (
n=
266)
8/0
1/0
5 (
n=
221)
9/0
1/0
5 (
n=
278)
10/0
1/0
5 (
n=
235)
11/0
1/0
5 (
n=
262)
12/0
1/0
5 (
n=
275)
1/0
1/0
6 (
n=
245)
2/0
1/0
6 (
n=
269)
3/0
1/0
6 (
n=
259)
4/0
1/0
6 (
n=
274)
5/0
1/0
6 (
n=
286)
6/0
1/0
6 (
n=
276)
7/0
1/0
6 (
n=
290)
8/0
1/0
6 (
n=
211)
9/0
1/0
6 (
n=
256)
10/0
1/0
6 (
n=
294)
11/0
1/0
6 (
n=
213)
12/0
1/0
6 (
n=
285)
Def
ecti
ve
Wid
get
s p
er 1
00
Monthly Proportion of Defects Average Proportion of Defects Control Limits
Control Chart: Shewhart P - Chart Example
3
9 9
4
7
3
10
1
6 3 3
4 5
2
10
0
34
10
18
12
15
10
25
5
37
8
27
21
11
0
10
20
30
40
50
60
7001/0
2
01/0
5
01/1
5
01/2
4
01/2
7
02/0
3
02/0
6
02/1
6
02/1
7
02/2
3
02/2
6
03/0
1
03/0
5
03/1
0
03/1
2
03/2
2
03/2
2
04/2
5
05/0
6
05/2
4
06/0
4
06/1
9
06/2
9
07/2
4
07/2
9
09/0
4
09/1
2
10/1
0
10/3
1
11/1
1
2005
Days
Sin
ce P
revio
us
Even
t I2S2 Example Days-Between Chart
January 2005 thru August 2005
Days Since Previous Event Average Days Between Events Control Limits
Name of topic – why important AIM
What tells you it is a problem (? Measures)
Who are the stakeholders?
What should be done to improve?
What ongoing measures should be followed?
◦ What data will you collect?
How will you define success?
What happens after the project ends?
Group Exercise # 4:
Presenting your QI Project
What is/are the most important datum/data to collect?
What are the sources of the data?
Who will collect the data?
What datasheet or collection method is used?
How is patient privacy/confidentiality protected?
How will the data be analyzed?
How and how often will data be presented?
E-Binder Chapter VI
Project tracking forms: ◦ Meaningful contribution: by physician: number of hours; dates
and number of meetings attended
◦ QI Science requirement: specifically how it was met
◦ Meetings related to project: date, presenter; topic
◦ Change implementation: how did you accomplish - entity wide changes
◦ Project impact: Completed by Physician/Project Leader only: impact on education, clinical acceptance/utilization/ process changes, changes in outcomes
Was engaged throughout the entire 1+ year
Attended and participated in 75% of meetings
Made “meaningful” contribution to project
Has knowledge of QI science (how ascertained)
NB: Details for each participating physician held at
project site, only attestation form (see ABP site) is sent
to ABP
Did you meet the ABP requirements for a quality
improvement project leader?
◦ I was materially involved in the design of the project.
◦ I was materially involved in the implementation of the project.
◦ I understand the principles of quality improvement.
◦ I was involved for 12 months or more.
◦ I satisfied all of the above criteria under my current ABP
certificate (within my current MOC cycle).
Stephen A. Pearlman MD, MSHQS Clinical Professor of Pediatrics, TJU
Attending Neonatologist, CCHS
“Nothing endures but change”
Heraclitus of Ephesus
5th Century BCE
“the change we are putting in place
Is not sustainable -
And Sustainability is absolutely
Crucial.”
Fiona MacLeod
President of BP Convenience Retail
Incremental
◦ Linear, continuous change
Radical
◦ Multidimensional and multilevel, discontinuous
Hard to maintain a sense of urgency
Inadequate time to teach staff
Inadequate attention to barriers
Lack of leadership support
External factors
◦ Competition
Internal Factors
◦ Keep the patient as the target
◦ Affect on job security, income, job satisfaction
Deming “You can’t manage what you can’t measure”
Continue to measure and benchmark even if project is
officially over
Identify reasons for slippage
◦ RCA on cases without desired outcome
Display Data
◦ Run Charts to visually demonstrate improvement
◦ Storybook Approach
◦ Strategic signage to maintain engagement
Examples
47 days since the last IV infiltrate
108 days between CLABSIs
Create competition
◦ Contests between different units
Rewards
◦ Social gathering to acknowledge the staff’s contribution to
improving patient care
◦ Free movie tickets, parking passes etc.
Institutionalize Change
◦ Clinical Practice Guidelines
◦ Manuals
Ongoing Education and Training
◦ New Residents and Fellows
◦ New Nurses
◦ Staff Turnover
Light a fire – what isn’t what you want it to be?
Meet with colleagues right away!
Set a Part 4 plan for your practice group
Incorporate QI initiatives of NICU and institution
Clinics in Perinatology 2010 (March) Quality Improvement in Neonatal and
Perinatal Medicine (entire content!) – special attention to:
◦ Elsbury DL, Ursprung R. A primer on quality improvement methodology in neonatology. Pp 87-99/
◦ Lloyd RC. Navigating in the turbulent sea of data: the quality measurement journey. Pp 101-122.
Gawande A. Annals of Medicine: The Bell Curve. The NewYorker 06 Dec2004
Perla RJ, Provost LP, Murray SK. The run chart: a simple analytical tool for
learning from variation in healthcare processes. BMJ Qual Saf 2011:20:46-51
(downloaded from qualitysafety.bmj.com)
Perla RJ, Provost LP, Murray. Sampling considerations for health care
improvement. Q Manage Health Care 2013;22(1):36-47.
Steinfield R, Bachert C. Using data to guide improvement [Institute for Healthcare
Improvement] PowerPoint slides - April 2012. Available at
http://patientcarelink.org/uploadDocs/1/8-Using-Data-to-Guide-improvement.pdf
