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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 l.jpg

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

Clinical Practices Committee


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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


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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.


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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.


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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


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Quality improvements can have a positive effect on:

  • Efficiency

  • Effectiveness

  • Equity

  • Timeliness

  • Patient-Centeredness

  • Safety

  • Healthcare associated costs

  • Satisfaction


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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.


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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


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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


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NDNQI Pediatric Nurse Sensitive Indicators

  • The following were identified for more specific attention for pediatrics:

    • Pain assessment-intervention-reassessment (AIR) cycle

    • Peripheral IV infiltrates


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Other Clinical Nurse-Sensitive Indicators

  • Medication Error Reduction

  • Cardiopulmonary Arrest Reduction

  • Asthma Readmissions

  • Immunization Rates


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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


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    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


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    Performance Improvement Methods

    • PDCA

    • RCA

    • Six Sigma

    • FMEA

    • Lean

    • EBP models


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    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


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    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


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    Evidence Based Practice:

    Another Method for Quality Improvement


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    Reasons for EBPs

    Improved quality

    Patient safety

    Cost savings

    Implications for clinical and administrative decisions/practices


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    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


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    It Begins with a Clear Focus

    Know what you want to ask


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    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


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    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)


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    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


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    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


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    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.


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    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


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    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


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    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


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    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.


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    Evaluate

    • Measure process

      • Is change being implemented?

    • Measure patient outcomes

      • Are there changes in quality indicators?


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    Interactive Sessions


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    Group Presentation Template


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    Group Presentations


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    Understanding Control Charts 101

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


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    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


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    Q:/education/control chts/


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    • Introduction

    • History

    • Statistical concepts

    • Content

    • Applications

    Q:/education/control chts/


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    • Walter Shewhart (1881-1967)

    • Bell Labs, 1920s

    • Reduce variation in the manufacturing process.

      • Continual process adjustment – increases variation

    Q:/education/control chts/


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    Q:/education/control chts/


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    • 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/


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    • 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/


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

    Run charts

    Control Charts

    Q:/education/control chts/


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    Q:/education/control chts/


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    • 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/


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    Q:/education/control chts/


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    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/


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    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/


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    Definition of Terms (#1)

    * Normal Distribution:

    Special Cause

    Q:/education/control chts/


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    Criteria to Identify Special Cause Variation


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    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/


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    Defects; >=1/item

    Defectives=1/item


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    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/


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    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/


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    Q:/education/control chts/


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    Q:/education/control chts/


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    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/


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    Q:/education/control chts/


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    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/


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    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/


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    Q:/education/control chts/


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    Q:/education/control chts/


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    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/


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    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)


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    Q:/education/control chts/


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    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/


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    Q:/education/control chts/


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    The Quality Imperative

    Making an Impact


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    Keep your Eye on the Ball

    Goal is not the data collection and analysis

    Goal is to improve

    patient outcomes


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    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!


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    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


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    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


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    You want us to change what?!!

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

    D. Berwick, 2003


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    Patient Satisfaction Improved


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    Pain Scores Decreased


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    Results make a Difference

    Captures staff attention

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

    But will it last?


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    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.


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    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.


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    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


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    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


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    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


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    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


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    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.


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    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.


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    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


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    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


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    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


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    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


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    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


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    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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    To make an impact, keep your eye on the ball.Improve patient outcomes!


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    Thank youQuestions???


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