Practice-Based Learning and Designing a Quality Improvement Project

1. Practice-Based Learning and Designing a Quality Improvement Project Richard Schifeling, MD EBM Working Group November 15, 2007

2. Quality Improvement (QI) Experiment • You are the hospital administrator at your institution in charge of QI • You’ve just learned that CMS will no longer reimburse hospitals for care related to preventable cathether-associated urinary tract infections • What do you do?

3. Administrator reaction • Join the writers’ strike • Look for a job in ambulatory care • Form a committee to study the impact on your institution • Check with infection control • Check with nursing education & providers

4. Beginning Oct. 2008, CMS to withhold payments: • Catheter-associated UTI’s • Vascular catheter-associated infections • Mediastinitis post- CABG • Pressure sores • Falls • Objects left in patients’ bodies • Air embolism, incompatible blood tx’s

5. CMS Methodology • No reimbursement for select conditions: • High cost or high volume or both • Would result in higher payment as 2nd Dx • Reasonably prevent by using evidence-based guidelines

6. Volume/ Cost of Cath UTI’s • 1 million cases per year in US- most common nosocomial infection • Each infection adds ~ 1 hospital day • Cost is ~ $ 500 million per year • ~ 40% Medicare pts have urinary cath • ~ 20% pts w/ cath get infection • < 1% develop urosepsis

7. Prevention of UTI’s • Use catheters only when necessary and only as long as necessary- not for convenience of staff • Staff training for aseptic management, proper irrigation and urine flow • Handwashing

8. Practice-Based Learning & Improvement • Residents expected to: • analyze practice experience & perform practice-based improvement activities • locate, appraise, use “best practices” related to their patients’ health problems • appraise clinical studies • use information technology to manage info, support clinical care, pt education & own education

9. Need for quality improvement • Institute of Medicine (www.iom.edu) • Quality of Health Care in America • “To Err Is Human: Building a Safer Health Sytem” 1999 • “Crossing the Quality Chasm: A New Health System for the 21st Century” 2000

10. Need for quality improvement • Quality of healthcare can be measured • Serious, widespread problems in quality throughout U.S. healthcare • All systems affected: managed care, fee-for-service, big/ small communities • Must change system of healthcare delivery to improve quality Chassin MR,JAMA1998;280:1000-5.

11. Need for quality improvement • U.S. healthcare at its best is superb • Often it is not at its best resulting in population burden measured in: • lost lives (IOM estimates 98K iatrogenic deaths each year in US hospitals) • reduced functioning • wasted resources Chassin MR,JAMA1998;280:1000-5.

12. Definition of Quality • Degree to which health services for individuals and populations: • increase likelihood of desired outcomes • are c/w current professional knowledge

13. Systems of care/ critical factors • Healthcare professionals practice in groups & systems of care • Systems need to prevent/ minimize errors and harm • Coordinate care for settings & providers • Relevant/ accurate healthcare info must be available when needed

14. Classification of quality of care issues/ opportunities • Overuse, Underuse, Misuse • Overuse: give service for which potential risk outweighs benefit • Underuse: fail to give service for which potential benefit outweighs risk • Misuse: appropriate service given in manner leading to avoidable risks

15. Examples • Overuse: Rx of antibiotic for URI, use urine catheter for convenience • Underuse: lack beta-blocker post-MI, lack immunization, lack prenatal care, lack medication reconciliation • Misuse: preventable complications like wrong-side surgery

16. The 100,000 Lives Campaign: Getting Started Institute for Healthcare Improvement www.ihi.org/IHI/Programs/Campaign/

17. Six Changes That Save Lives • Deployment of Rapid Response Teams…at the first sign of patient decline • Delivery of Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack • Prevention of Adverse Drug Events (ADEs)…by implementing medication reconciliation • Prevention of Central Line Infections…by implementing a series of interdependent, scientifically grounded steps called the “Central Line Bundle” • Prevention of Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time • Prevention of Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps called the “Ventilator Bundle”

18. Prevent Adverse Drug Eventsby Implementing Medication Reconciliation • Reconciliation: A process of identifying the most accurate list of all medications a patient is taking—including name, dosage, frequency, and route—and using this list to provide correct medications for patients anywhere within the health care system • Requires comparing the patient’s list of current medications against the physician’s admission, transfer, and/or discharge orders

19. Medication Reconciliation • IOM estimates 7000 deaths annually due to medication errors • About 50% these errors occur at transition points (hosp admit, D/C, transfer to another unit) • JCAHO makes medication reconciliation a National Patient Safety Goal

20. Medication Reconciliation • Requires change in system • Emphasizes teamwork/ efficiency • Improves patient safety • Can improve medication errors at transition points • ? Impact on adverse drug events and deaths- limited evidence thus far

21. Institute of Medicine Vision of Future Quality Healthcare • U.S. healthcare will be: • Safe (avoiding patient injury) • Effective (EBM & avoid overuse/underuse) • Patient-centered (patient values) • Timely (reducing waits and delays) • Efficient (avoid waste) • Equitable (no practice variability based on socioeconomics, race, gender, geography) Crossing the Quality Chasm 2000:5-6

22. Institute of Medicine Vision • Current care systems can’t do the job • They rely on outmoded systems of work • Need redesigned systems of care for safer, high-quality care • Need better use of information tech. to support clinical and administ. processes

23. Institute of Medicine Vision • Majority of healthcare services address ~ 15 to 25 conditions • Focus attention on chronic care processes for these common conditions • Evidence-based processes, supported by automated clinical info & decision support systems promise best outcomes

24. QI project using EBM • Consider common chronic care problem that needs improvement and has EBM best practice(s) • Consider changes in system of healthcare needed to improve quality • Consider how to measure performance pre-/ post-intervention & complete cycle

25. QI Project Steps • Choose specific area of care or provider education to improve • Check project idea meets criteria • Define best practice • Measure current practice • Change system to improve practice • Measure post-intervention practice

26. Question(Hypothesis) • To know where to look, you need a hypothesis to guide you. • This is the key to any successful research(QI project) • Confronting Quality Problems • Underuse of Services • Overuse of Services • Misuse of Services • Variation of Services AHRQ: http://www.ahrq.gov/ IOM: http://www.nap.edu/catalog/10027.html?se_side

27. Evidence • review of the literature • finding similar questions and study designs • shows that EBM is fun http://hubnet.buffalo.edu/loginiphome.html

28. Time Allocation • Decide your direction • Limit the scope • Schedule the time • Dedicate the time • Delegate the tasks • Start now!

29. Attitude QI requires a positive attitude and the mindset to continue to ask questions.