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The Quality Imperative 22 st Annual Pre-Convention Society of Pediatric Nurses April 19, 2011. Clinical Practices Committee. Agenda. Welcome Defining the Quality Imperative Taking action: Implementing a process or performance initiative Interactive Sessions

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the quality imperative 22 st annual pre convention society of pediatric nurses april 19 2011

The Quality Imperative22st Annual Pre-ConventionSociety of Pediatric NursesApril 19, 2011

Clinical Practices Committee

agenda
Agenda
  • Welcome
  • Defining the Quality Imperative
  • Taking action: Implementing a process or performance initiative
  • Interactive Sessions
  • Group Presentations Measuring success
  • Making an Impact- patient outcomes
  • Q & A
objectives
Objectives
  • Define the quality imperative.
  • Identify 5 pediatric specific nurse sensitive indicators.
  • Describe performance improvement methods/tools:
    • PDCA
    • EBP model
  • Interpret data graphs to assess quality improvement metrics.
  • Discuss mechanisms to evaluate impact of quality improvement in pediatric care.
what is the quality imperative
What is the Quality Imperative?
  • The term comes from the title of a book written in 1999 by John Kimberly & Etienne Minvielle.
  • The book focused on the concerns about how to maintain/improve quality while addressing issues of access to healthcare and containing costs.
  • Two of the important topics covered were implementing continuous quality improvement and evaluating quality outcomes against best practice.
why is the quality imperative important for pediatrics
Why is the Quality Imperative Important for Pediatrics?
  • Pediatric patient quality of care involves dynamic and complex phenomena.
  • Each population has unique language and focused areas with no current common language across all specialty areas.
  • Pediatric quality efforts are further challenged as most of the work on patient safety to date has focused on adult patients
quality improvements can have a positive effect on
Quality improvements can have a positive effect on:
  • Efficiency
  • Effectiveness
  • Equity
  • Timeliness
  • Patient-Centeredness
  • Safety
  • Healthcare associated costs
  • Satisfaction
commonly used measures of quality in nursing care
Commonly used measures of quality in nursing care
  • The National Database of Nursing Quality Indicators (NDNQI) was established by the ANA in 1998 and endorsed by the National Quality Forum.
  • These nurse sensitive measures reflect the structure, process and outcome of nursing care.
    • Structure=supply, skill level & education of nurses
    • Process=assessment, interaction & RN job satisfaction
    • Patient Outcomes=those that improve if there is a greater quantity or quality of nursing care.
structure process nurse sensitive indicators ndnqi
Structure/Process Nurse Sensitive Indicators (NDNQI)
  • Nursing Staff Skill Mix
  • Nursing Hours per Patient Day
  • Assault/Injury Rates
  • Nurse Turnover Rate
  • RN Education/Certification
  • RN Survey
    • Practice Environment Scale
    • Job Satisfaction
clinical nurse sensitive indicators ndnqi
Clinical Nurse-Sensitive Indicators(NDNQI)
  • Pressure Ulcer Prevalence
  • Patient Falls
  • Restraint Prevalence
  • PIV Infiltration Rate
  • Urinary Catheter-associated Tract Infection
  • Central Line Catheter Blood Stream Infection
  • Ventilator Associated Pneumonia
ndnqi pediatric nurse sensitive indicators
NDNQI Pediatric Nurse Sensitive Indicators
  • The following were identified for more specific attention for pediatrics:
    • Pain assessment-intervention-reassessment (AIR) cycle
    • Peripheral IV infiltrates
other clinical nurse sensitive indicators
Other Clinical Nurse-Sensitive Indicators
  • Medication Error Reduction
  • Cardiopulmonary Arrest Reduction
  • Asthma Readmissions
  • Immunization Rates
other organizations addressing pediatric quality measures
Other organizations addressing pediatric quality measures:
    • AHRQ (Agency for Healthcare Research & Quality
    • CHA (Child Health Corporation of America—new joint organization of CHCA, NACHRI & N.A.C.H.
    • NQF (National Quality Forum)
    • OCHSPS (Ohio Children\'s’ Hospitals Solutions for Patient Safety) National Children’s Network
  • Efforts to coordinate pediatric QI work
    • Alliance for Pediatric Quality is collaborative effort of NACHRI, CHCA, American Academy of Pediatrics, and American Board of Pediatrics
quality of care and research
Quality of Care and Research
  • Quality improvement and practice-based research have many similarities.
  • Both are systematic and use processes based on disciplined inquiry.
    • QI projects use a systematic method to evaluate data about processes and outcomes and recommend interventions.
    • Practice-based research is used to differentiate quantitatively the effects of interventions.

Houser, J & Bokovoy, J. Clinical Research in Practice: A guide for the Bedside Scientist, Jones & Bartlett, 2006

performance improvement methods
Performance Improvement Methods
  • PDCA
  • RCA
  • Six Sigma
  • FMEA
  • Lean
  • EBP models
slide15
PDCA

PLAN- this step is aimed at improvement and focuses on analyzing what is needed to improve and to identify the areas that have opportunities for improvement.

DO- this step involves the implementation of change identified in the PLAN phase.

CHECK - this phase involves examining what was learned and what went wrong.

ACT- this step involves determining cost/benefit of continuing with the

slide16

3

2

SDSA

3

Global Aim

1

Improvement Ramp

A

P

S

D

A

P

D

S

Measures

A

P

Change Ideas

S

D

1

PDSA

Specific Aim

Global Aim

Theme

Assessment

Improvement Ramp

2

16

evidence based practice

Evidence Based Practice:

Another Method for Quality Improvement

reasons for ebps
Reasons for EBPs

Improved quality

Patient safety

Cost savings

Implications for clinical and administrative decisions/practices

topics that have an evidence base
Topics that have an Evidence Base

Prevention and treatment of pressure ulcers

Fall Prevention

Sensory preparation for patients undergoing procedures (Jean Johnson)

Prompted voiding

Palliative Care

Exercise Promotion

Prevention of DVTs

Patient safety practices

Pain management

Hypertension screening and treatment

Prevention of Type II Diabetes

it begins with a clear focus
It Begins with a Clear Focus

Know what you want to ask

slide21

Problem Focused Triggers

1. Risk Management Data

2. Process Improvement Data

3. Internal/External Benchmarking Data

4. Financial Data

5. Identification of Clinical Problem

Knowledge Focused Triggers

1. New Research or Other Literature

2. National Agencies or Organizational

Standards & Guidelines

3. Philosophies of Care

4. Questions from Institutional

Standards Committee

Is this Topic

a Priority

For the

Organization?

Consider

Other

Triggers

No

Yes

Form a Team

= a decision Point

The Iowa Model of

Evidence Based Practice to Promote Quality Care

problem focused triggers
Problem-Focused Triggers

Risk Management Data (e.g. fall rates, infection rates)

Process Improvement Data/QI data (e.g. q 4 hour pain reassessment, DVT prevention)

Internal/External Benchmarking data (e.g. patient satisfaction data around noise, promptness to call button)

Financial data (e.g. total knee care/length of stay, urine collection methods)

Identification of clinical problems (pet visitation, bowel sounds, food guidelines for neutropenic patients, NG placement for children , double gloving)

slide23

Problem Focused Triggers

1. Risk Management Data

2. Process Improvement Data

3. Internal/External Benchmarking Data

4. Financial Data

5. Identification of Clinical Problem

Knowledge Focused Triggers

1. New Research or Other Literature

2. National Agencies or Organizational

Standards & Guidelines

3. Philosophies of Care

4. Questions from Institutional

Standards Committee

Is this Topic

a Priority

For the

Organization?

Consider

Other

Triggers

No

Yes

Form a Team

= a decision Point

The Iowa Model of

Evidence Based Practice to Promote Quality Care

purpose statement
Purpose Statement

Use the PICO method to develop a purpose statement, which will facilitate a focused project.

P: The specific group of patients that you want to target (e.g. older adult hospitalized patients)

P: The clinical condition that you want to address (e.g. pressure ulcers)

I: Intervention or treatment- can be therapeutic (e.g. several kinds of dressings), preventative (e.g. vaccination), diagnostic (e.g. blood pressure measurement)

C: Comparison (e.g. standard care)

O: Expected outcomes (e.g. decreased development of pressure ulcers)

University of Illinois at Chicago. (2003). Evidence based medicine. Finding the best clinical literature.Accessed March 30, 2004 from http://www.uic.edu/depts/lib/lhsp/resources/pico.shtml

benefits of a well formulated purpose statement
Benefits of A Well Formulated Purpose Statement

Gives direction to find answers more quickly:

Directs evidence search to best resources

Helps focus reading

Assists with developing appropriate implementation and evaluation plan

Focuses attention on identified learning needs

Keeps team focused

Modified from: McKibbons & Marks, (2001). Posing Clinical Questions: Framing the Question for Scientific Inquiry. AACN Clinical Issues, 12(4), 477-481.

slide26

The Iowa Model of

Evidence Based Practice to Promote Quality Care

= a decision Point

Assemble Relevant Research & Related Literature

Critique & Synthesize Research for Use in Practice

Is There

a Sufficient

Research

Base?

Yes

No

Pilot the Change in Practice

1. Select Outcomes to be Achieved

2. Collect Baseline Data

3. Design Evidence-Based

Practice (EBP) Guideline(s)

4. Implement EBP on Pilot Units

5. Evaluate Process & Outcomes

6. Modify the Practice Guideline

Conduct

Research

Base Practice on Other

Types of Evidence

1. Case Reports

2. Expert Opinion

3. Scientific Principles

4. Theory

look at the evidence
Look at the Evidence

Important steps:

Thorough search for evidence

Consider all levels evidence

Use a synthesis table

Critique of evidence

Making the decisions for guiding practice may be difficult

Use the evidence to move forward

slide28

The Iowa Model of

Evidence Based Practice to Promote Quality Care

= a decision Point

Assemble Relevant Research & Related Literature

Critique & Synthesize Research for Use in Practice

Is There

a Sufficient

Research

Base?

Yes

No

Pilot the Change in Practice

1. Select Outcomes to be Achieved

2. Collect Baseline Data

3. Design Evidence-Based

Practice (EBP) Guideline(s)

4. Implement EBP on Pilot Units

5. Evaluate Process & Outcomes

6. Modify the Practice Guideline

Conduct

Research

Base Practice on Other

Types of Evidence

1. Case Reports

2. Expert Opinion

3. Scientific Principles

4. Theory

to pilot or not to pilot
To Pilot or Not to Pilot

Piloting a practice change has important advantages that outweigh the disadvantages, particularly when evidence is not strong.

Benefits of piloting a practice change are:

Work out the “bugs” in protocol, etc.

Determine feasibility in clinical setting.

Determine feasibility in specific practice setting.

evaluate
Evaluate
  • Measure process
    • Is change being implemented?
  • Measure patient outcomes
    • Are there changes in quality indicators?
slide34

Understanding Control Charts 101

Thank you to my colleague Bill Pastor, Clinical Data Operations Manager

slide35

Objectives

  • Overview of the purpose of control charts

Is the process stable and predictable?

Was your intervention effective?

  • Familiarize you with control chart vocabulary
  • Awareness that there are different types of control charts
  • NOT TO MAKE YOU AN EXPERT IN:
  • identifying the types of control chart
  • creating control charts
slide37

Introduction

  • History
  • Statistical concepts
  • Content
  • Applications

Q:/education/control chts/

slide38

Walter Shewhart (1881-1967)

  • Bell Labs, 1920s
  • Reduce variation in the manufacturing process.
    • Continual process adjustment – increases variation

Q:/education/control chts/

slide40

Walter Shewhart (1881-1967)

  • May 16, 1924 one page memo
  • Control chart

Shewart’s boss, George Edwards, recalled “Dr. Shewhart prepared a little memorandum only about a page in length. About a third of that page was given over to a simple diagram which we would all recognize today as a schematic control chart. That diagram, and the short text which preceded and followed it, set forth all of the essential principles and considerations which are involved in what we know today as process quality control.”

Q:/education/control chts/

slide41

W. Edwards Deming (1900-1993)

  • Champion Shewhart’s model
  • Common and Special Cause

IHI: Institute for Healthcare Improvement

Measuring Quality Improvement in Healthcare, A Guide to statistical Process Control Applications; Raymond G. Carey, Ph.D., Robert C. Lloyd, Ph.D.

Q:/education/control chts/

slide42

Descriptive Statistics (mean, median, mode, min/max, std.dev) – removes time from the analysis

Run charts

Control Charts

Q:/education/control chts/

slide44

same average (Xs=9.0 and Ys=7.5)

  • same correlation (r=.86)
  • same R2 (.667) and std. dev. (1.24)

Q:/education/control chts/

slide46

Descriptive Statistics

Run charts – include time (x-axis), but no analysis of variation

Control Charts – statistically analyze the variation over time; next generation run chart

Q:/education/control chts/

slide47

Are there real change in our mortality cases and percent and BSI rate vs. natural variation? – control charts (statistics)

If real changes, what are the causes for the change? – content knowledge (PI)

Q:/education/control chts/

slide48

Definition of Terms (#1)

* Normal Distribution:

Special Cause

Q:/education/control chts/

slide52

Definition of Terms (#2)

  • Common cause variation:
    • variation arises from intrinsic sources common to the process
    • natural variation that will vary around the mean.
    • predictable within the range defined by the control limits
  • Special cause variation:
    • an unanticipated source of variation;
    • outside the normal variation “out of control”
    • not predictable
  • Control Limits
    • think of them as +/- standard deviations from the mean
  • “in control”
    • a statistical concept <> good or acceptable (an evaluative concept)
    • explicit premise: reducing statistical variation is good

Q:/education/control chts/

slide53

Defects; >=1/item

Defectives=1/item

slide54

Definition of Terms (#3)

  • Variable data: continuous or quantifiable onto an infinitely divisible numeric scale; can have decimals. E.g., time, temp, BP, ALOS
  • Attribute or discrete data: binominal, either occurs or does not occur. E.g., infection, on protocol, in restraints
    • Occurrence & Non-Occurrence: can the denominator be counted? E.g., c-sections vs. falls
    • Defective: one “error” per unit or process; count the defective items. E.g., c-section
    • Defects: can have more than one “error” per unit or process; count the number of defects per item. E.g., # of errors in an RX order.
  • subgroups: the number of observations that comprise the data point.

Q:/education/control chts/

slide55

Example #1: ED-to-Bed

Methodology: We collect SPEED data on all of our cases and report a monthly average time for 20 months.

Q: Variable or Attribute date?

Variable

Q: More than one observation per subgroup?

No

Q: What type of chart?

XmR (Individual Measurement)

Q:/education/control chts/

slide58

Example #2: Antibiotic TAT

Methodology: We collect TAT in minutes for all cases and report for 16 months

Q: Variable or Attribute date?

Variable

Q: More than one observation per subgroup?

No

Q: What type of chart?

XmR (Individual Measurement)

Q:/education/control chts/

slide60

Example #3: Restraints/1000 pt. days

Methodology: We collect the number of restraints per month (not the number of patients in restraints).

Q:/education/control chts/

slide61

Q: Variable or Attribute date?

Attribute (yes/no)

No, you cannot count the number of times X was not in restraints.

Q: Can count occurrences and non-occurrences?

Q: Equal opportunity each month?

No – pt days/mo varies

Q: What type of chart?

U-chart (the defect rate)

Q:/education/control chts/

slide64

Example #4: Medication Errors/1000 pt. days

Methodology: We collect the number of errors per month:

  • Administration
  • Dispensing
  • Monitoring
  • Prescribing
  • Processing
  • defects – more than one per unit
  • defective – only one per unit

Q:/education/control chts/

slide65

Example #4: Medication Errors/1000 pt. days

Methodology: We collect the number of errors per month & there cannot be more than error per order (defects vs. defective)

Q: Variable or Attribute date?

Attribute (yes/no)

Q: Can count occurrences and non-occurrences?

Yes

Q: Subgroup of equal size?

No, pt. days varies

Q: What type of chart?

P=chart (the defective rate)

slide67

Objectives

  • overview of the purpose of control charts
  • familiarize you with control chart vocabulary
  • awareness that there are different types of control charts

Q:/education/control chts/

the quality imperative

The Quality Imperative

Making an Impact

keep your eye on the ball
Keep your Eye on the Ball

Goal is not the data collection and analysis

Goal is to improve

patient outcomes

making qi meaningful to staff
Making QI Meaningful to Staff
  • Share the data – good, bad and ugly
  • Have staff participate in deciding what problems to tackle
  • Give nurses time to lead and engage in the improvement method
    • PDCA, RCA, EBP, LEAN
    • Link to professional development/advancement
  • Celebrate improvements!
linking qi to patient outcomes
Linking QI to Patient Outcomes
  • National initiatives
    • CHCA recommendations for PIV standards
    • Children’s Hospital Association (NACHRI)-Quality Transition Network
      • Consortium of PICU and heme-oncology units to study interventions that decrease CABSI
      • Statistical power of >80 children’s hospitals
      • 5 years of work saved 365 lives, prevented 3,000 central line infections, avoided $100 million in wasted healthcare expenditures
linking qi to patient outcomes73
Linking QI to Patient Outcomes
  • Local initiatives

C.S. Mott Children’s Hospital – 12W Peds posterior spinal fusion project

    • Patients had difficulty with pain control, nausea, and meeting nutrition and mobility goals
    • Goals included improvement in patient satisfaction with the peri-operative experience and better pain management
    • Nursing led EBP improvement project
you want us to change what
You want us to change what?!!

Invention is hard, but implementation is much more difficult.”

D. Berwick, 2003

results make a difference
Results make a Difference

Captures staff attention

More likely to make practice changes when can see improvement in patient outcomes

But will it last?

sustaining improvement
Sustaining Improvement
  • Hardwiring change is a challenge
  • Emerging models in translational research
    • E. Rogers. (2003). Diffusion of Innovation, (5th ed.). New York: The Free Press
    • Titler, M. & Everett,L. (2001). Translating research into practice: Considerations for critical care investigators. Critical Care Nursing Clinics of North America, 13(4), 587-604.
rogers diffusion of innovations adoption of knowledge
Rogers’ Diffusion of Innovations Adoption of Knowledge

I.

Knowledge

II.

Persuasion

III.

Decision

IV.

Implementation

V.

Confirmation

People move through 5 stages when adopting an innovation: knowledge, persuasion, decision, implementation and confirmation (Rogers, 2003)

Rogers, E.M. (2003). Diffusion of Innovations (5th Ed.). New York, NY: The Free Press.

illusions about implementation
Illusions about Implementation
  • We just need to tell them what to do
  • If it works for them it should work for us
  • Clinicians will remember the change once they are told
    • Once should be enough
    • Clinicians can be more watchful so they will remember to use the new…
  • I just need to find the one right way to implement a practice change
increase the chance of success
Increase the Chance of Success

Bottoms-up topic identification

Staff nurse involvement & commitment

Departmental commitment

Credible evidence

Expectation for change to improve patient care

Compatibility with unit values

Removal of barriers to making practice change

create a culture of change
Create a Culture of Change
  • Need flexibility to accept future changes in practice
  • Build structures that support QI work
    • Clinical practice committees
    • Mentors for staff in QI methods
    • Time for staff nurses to be involved in the work
  • Provide recognition for efforts that improve patient outcomes
  • Disseminate the results together
ethics and quality improvement
Ethics and Quality Improvement

Goal of quality improvement is to make patient care better and align care with accepted standards

Quality improvement is intrinsic to healthcare delivery and an obligation for professionals

QI efforts must be governed by ethical principles

ethical requirements
Ethical Requirements

Social or scientific value

Scientific validity

Fair subject selection

Favorable risk/benefit ratio

Respect for participants

Independent review

Bailey, M., Bottrell, M., Lynn, J., & Jennings, B. (2006). The ethics of using QI methods to improve health care quality and safety. Hastings Center Special Report, AHRQ grant # 1R13HS13369.

independent review
Independent Review

Low risk QI should have same review and standards as routine health care delivery

High risk QI should undergo orderly review within usual arrangements for clinical supervision or by an advisory group

IRB review tends to delay or make QI projects less feasible

QI-IRB should be developed to prevent poorly conceived projects and to separate projects that should be considered research

Bailey, M., Bottrell, M., Lynn, J., & Jennings, B. (2006). The ethics of using QI methods to improve health care quality and safety. Hastings Center Special Report, AHRQ grant # 1R13HS13369.

ethical expectations for qi
Ethical Expectations for QI

Patients should expect medical record will be used to guide improvement with suitable protection for privacy

Clinicians should expect to be engaged in QI activities and that those activities may disclose flaws in care and the need for change

Institutions should expect to ensure that QI has ongoing investment and that projects have appropriate supervision

transparency
Transparency
  • Institutions beginning to share outcomes with healthcare consumers on external websites
    • Ex. UMHS now posting peds indicators for PICU, PCTU, NICU, trauma and transplant. Will be adding asthma, cystic fibrosis, and endocrinology
  • Challenges
    • Presentation of data in consumer-friendly ways
    • Limited consumer understanding of QI benefits/limitations
    • Inconsistencies in what is reported to the public
    • Consumer skepticism
patient family centered approach
Patient/Family-Centered Approach
  • Use of parent/patient surveys
    • Press-Ganey data
    • Discharge surveys from institutions
    • Surveys from patient care programs
    • Telephone follow-up after discharge
  • Use patient/family-centered care committees to help identify QI initiatives and projects
  • Include patients/families in QI project workgroups
pediatric quality indicators
Pediatric Quality Indicators
  • Data on pediatric quality measures collected on national level by multiple organizations
    • Children’s Hospital Association (NACHRI) – Quality Transformation Network
    • Child Health Corporation of America (CHCA)
    • Agency for Healthcare Research & Quality (AHRQ)
    • OCHSPS National Children’s Network
  • Efforts to coordinate pediatric QI work
    • Alliance for Pediatric Quality is collaborative effort of NACHRI, CHCA, American Academy of Pediatrics, and American Board of Pediatrics
pediatric quality indicators90
Pediatric Quality Indicators

Hospital level indicators

Accidental puncture or laceration

Pressure ulcers

Foreign body left in during procedure

CLBSI

CAUTI

VAP

Iatrogenic pneumothorax

Iatrogenic pneumothorax in neonates

Neonatal mortality

Pediatric heart surgery mortality

Pediatric heart surgery volume

Postoperative hemorrhage or hematoma

Postoperative respiratory failure

Postoperative sepsis

Postoperative wound dehiscence

Transfusion reactions

Adverse drug events

Injuries from falls and immobility

Preventable readmissions

Venous thromboembolism

Area level indicators

Asthma admissions

Diabetes short-term complications

Gastroenteritis admissions

Perforated appendix admissions

Urinary tract infection admissions

pediatric quality indicators91
Pediatric Quality Indicators
  • Many indicators are physician-controlled more than nursing specific
  • Many nursing indicators have been borrowed from adult care
    • Reflect NDNQI measures
  • Need to improve focus on nursing indicators for pediatrics
    • Consider different indicators for different settings across care continuum
    • Consider emphasis on wellness and prevention measures (immunizations)
    • Consider trends in pediatric challenges (childhood obesity)
  • Useful reference: Patient Safety & Quality – An Evidence-Based Handbook for Nurses

http://www.ahrq.gov/qual/nurseshdbk/

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