Quality improvement put into practice
Download
1 / 41

Quality Improvement Put into Practice - PowerPoint PPT Presentation


  • 241 Views
  • Updated On :

Quality Improvement Put into Practice. Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation Assistant Professor of Medicine - Mayo Clinic College of Medicine. Case Presentation. 31 y.o. female History of present illness

Related searches for Quality Improvement Put into Practice

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Quality Improvement Put into Practice' - kiefer


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Quality improvement put into practice l.jpg

Quality Improvement Put into Practice

Carl Mottram, BA RRT RPFT FAARC

Director - Pulmonary Function Labs & Rehabilitation

Assistant Professor of Medicine - Mayo Clinic College of Medicine


Case presentation l.jpg
Case Presentation

  • 31 y.o. female

  • History of present illness

    • Non-specific cough, tightness in throat and episodic shortness of breath following URI

    • No wheezing noted by patient or on exam

    • Exam normal other than obesity (BMI 38)

  • LMD orders CXR and spirometry with diffusing capacity


Case presentation3 l.jpg
Case Presentation

  • CXR

  • Spirometry & DLCO

    Pre Post Pred

    FVC 2.102.11 62%

    FEV1 0.89 1.36 31%

    Ratio 42.4 64.5

    DLCO 8.0 30%

    Impression: Severe obstruction with a severe reduction in DLCO. Some improvement with BD


Case presentation4 l.jpg
Case Presentation

  • LMD Action Plan

    • Orders a CT scan

    • Referred to Mayo Clinic for further evaluation


Case presentation5 l.jpg
Case Presentation

  • Outside CT negative

  • Pulmonary, ENT, and GI consults scheduled

  • Pulmonary physician

    • Negative exam

    • Lungs clear, patient had coughing spell during exam, no wheezing or stridor noted

    • Questioned outside spirometry results and orders PFT’s


Case presentation6 l.jpg
Case Presentation

  • Spirometry & DLCO

    Pre Post Pred

    FVC 2.55 2.48 75%

    FEV1 2.27 2.25 79%

    Ratio 89 90.7

    DLCO 24.2 99%

    Impression: Borderline restriction most likely 2 to obesity with no evidence of airflow obstruction or BD response


Pft results affect people l.jpg
PFT results affect people!!!

  • Further testing

  • Labeling (COPD, Asthma, etc)

  • Medicine

  • Disability


Guidelines and standards l.jpg
Guidelines and Standards

  • American Thoracic Society

    • 1987 Revised Spirometry Standards

    • 1991 Reference Values & Interpretation

    • 1994 Revised Spirometry Standards

    • 1995 Diffusing Capacity

    • 1999 Guidelines for Methacholine and Exercise Challenge Testing

    • ATS/ERS 2005 Series; General Laboratory, Spirometry, Diffusing Capacity, Lung volumes, and Interpretation


Guidelines and standards9 l.jpg
Guidelines and Standards

  • American Association of Respiratory Care (AARC)

    • Clinical Practice Guidelines (52)

      • Spirometry

      • Static lung volumes

      • Plethysmography

      • Diffusing Capacity

      • Infant/Toddler Pulmonary Function Tests


Guidelines and standards10 l.jpg
Guidelines and Standards

  • American Thoracic Society

    • ATS Pulmonary Function Laboratory Management and Procedure Manual

      • Updated 2005

    • www.thoracic.org

      • Education

      • Education Products


Clsi s quality system in respiratory care hs4 a2 l.jpg

Patient

Patientassessment

Clinicalinterpretation

application

Path of workflow

QSE

CLSI’s Quality System In Respiratory Care – HS4-A2


Evidence of quality testing l.jpg
Evidence of Quality Testing

  • Spirometry in Primary Care Practice*

    • 30 primary care clinics, 15 trained group /15 usual group

    • 3.4% in usual group and 13.5% in trained group met ATS acceptability and reproducibility criteria

    • 1,012 pt. tests, 2,928 blows (2.89)

    • * Eaton et al, Chest 1999; 116:416-423


Evidence of quality testing13 l.jpg
Evidence of Quality Testing

  • Improving the Quality of Bedside Spirometry

    • Audit of testing outside the PF lab - Cleveland Clinic

    • 15% - ATS acceptability/reproducibility criteria

    • CI Project - 63.5% acceptability/reproducibility

    • Stoller JK. Orens DK. Hoisington E. McCarthy K. Bedside spirometry in a tertiary care hospital: The Cleveland Clinic experience. Respiratory Care. 47(5):578-82, 2002 May


Evidence of quality testing14 l.jpg
Evidence of Quality Testing

  • Wanger J, Irvin C Resp Care 36 (12): 1991

  • 13 hospitals, 7 different systems, 5 Bio-QC (3 men, 2 women)

  • DLCO CV 11.5 - 18.6 with the largest diff. 24 units


Quality improvement put into practice quality assurance l.jpg
Quality Improvement Put into Practice - Quality Assurance

“Systematic” approach of monitoring and evaluating quality.


Quality improvement put into practice quality assurance16 l.jpg
Quality Improvement Put into Practice - Quality Assurance

  • CLSI’s “Path of workflow” Model

    • Pre-test

    • Testing session

    • Post-test


Quality improvement put into practice pre test quality assurance l.jpg
Quality Improvement Put into PracticePre-testQuality Assurance

  • Pre-test instructions

  • Appropriate order

  • Questionnaire

  • Height* and weight

  • Networked systems

  • Equipment quality assurance program


Quality improvement put into practice pre test quality assurance18 l.jpg

Equipment quality assurance

Validation/Verification

Preventive maintenance

Documentation and records (logbooks)

Mechanical models

Biological models

Quality Improvement Put into PracticePre-testQuality Assurance


Quality improvement put into practice pre test quality assurance19 l.jpg
Quality Improvement Put into PracticePre-testQuality Assurance

  • Mechanical Model

    • 3-liter syringe

      • 0.5, 1-2, 6 second flows

    • Leak checked

    • Stored and used in such a way as to maintain the same temperature and humidity of the testing site

    • Validated based on manufacturer recommendations

2005 ATS/ERS Standards Standardization of Spirometry


Quality improvement put into practice pre test quality assurance20 l.jpg
Quality Improvement Put into PracticePre-testQuality Assurance

Mechanical Model - Plethysmography

  • Validation using a known volume should be performed periodically

  • Model lung with thermal mass to simulate isothermal conditions of the lung.

  • Accuracy 50 ml or 3%

2005 ATS/ERS Standards Standardization of Lung Volumes


Quality improvement put into practice pre test quality assurance21 l.jpg
Quality Improvement Put into PracticePre-testQuality Assurance

  • Mechanical Model – Dilution techniques

  • Analyzer accuracy and linearity

  • N2 washout: Monthly, exhalation volumes should be checked with the syringe filled with room air, and inhalation volumes with the syringe filled with 100% O2.

2005 ATS/ERS Standards Standardization of Lung Volumes


Quality improvement put into practice pre test quality assurance22 l.jpg
Quality Improvement Put into PracticePre-testQuality Assurance

  • Mechanical Models – DLCO

  • Syringe DLCO weekly or whenever problems occur

    • VA BTPS ~ 3.3L

  • DLCO Simulator or BioQC

2005 ATS/ERS Standards Standardization of DLCO


Quality improvement put into practice pre test quality assurance23 l.jpg
Quality Improvement Put into PracticePre-testQuality Assurance

  • Biological Model

    • Normal laboratory subjects

    • Two individuals (13)

    • Establish mean and SD (minimum 20 samples)


Quality improvement put into practice pre test quality assurance24 l.jpg
Quality Improvement Put into PracticePre-testQuality Assurance

Biological Control - Plethysmography

  • At least monthly or whenever errors are suspect 2 reference subjects (biologic controls) should be tested

2005 ATS/ERS Standards - Standardization of Lung Volumes


Quality improvement put into practice pre test quality assurance25 l.jpg
Quality Improvement Put into PracticePre-testQuality Assurance

Biological Control – N2 washout

  • At least monthly or whenever errors are suspect 2 reference subjects (biologic controls) should be tested

2005 ATS/ERS Standards - Standardization of Lung Volumes


Quality improvement put into practice pre test quality assurance26 l.jpg
Quality Improvement Put into PracticePre-testQuality Assurance

Biologic Control – He dilution

  • At least monthly or whenever errors are suspect 2 reference subjects (biologic controls) should be tested

2005 ATS/ERS Standards - Standardization of Lung Volumes


Quality improvement put into practice pre test quality assurance27 l.jpg
Quality Improvement Put into PracticePre-testQuality Assurance

Biologic Control – Diffusing Capacity

  • At least weekly

  • Or whenever errors are suspect

  • Or whenever a calibration tank is replaced

2005 ATS/ERS Standards - Standardization of DLCO


Quality assurance biological quality control pf lab l.jpg
Quality AssuranceBiological Quality Control - PF Lab

  • Results “Out of range”

    • Repeat with another technologist

    • Second tech is within limits - record out of range data

    • Second tech out of range - trouble-shoot and document

      BioQC1: ULN LLN SD CV

      FEV1 2.95 2.73 0.05 0.02

      FVC 3.62 3.35 0.07 0.02

      TLC (Pleth) 6.09 5.65 0.11 0.02

      DLCO 24.5 21.5 0.75 0.04


Quality assurance biological quality control dlco l.jpg
Quality AssuranceBiological Quality Control - DLCO

Model A versus B: Mean difference 0.5


Quality assurance subject comparisons dlco l.jpg
Quality AssuranceSubject comparisons: DLCO

Model A versus B - Mean difference 1.5


Quality improvement put into practice test quality assurance l.jpg
Quality Improvement Put into PracticeTestQuality Assurance

  • Testing room environment

    • Environmental interference

  • Technologist’s performance & training - QSE: Personnel

    • Second technologist

  • Meeting ATS/ERS acceptability and repeatability criteria (new guidelines)


Quality improvement put into practice test quality assurance qse personnel l.jpg
Quality Improvement Put into PracticeTest Quality Assurance - QSE: Personnel

  • Technologists

    • Job qualifications

    • Job descriptions

    • Orientation

    • Training

    • Competency assessment

    • Continuing education

    • Performance appraisal


Quality improvement put into practice test quality assurance qse personnel34 l.jpg
Quality Improvement Put into PracticeTest Quality Assurance - QSE: Personnel

  • Competence Assessment

    • Training and on-going performance evaluations

    • NIOSH Spirometry Training Course

      • cdc.gov/NIOSH/topics/spirometry

    • AARC’s Spirometry Training

    • National Board for Respiratory Care

      • CPFT and RPFT exams


Quality improvement put into practice test quality assurance35 l.jpg
Quality Improvement Put into PracticeTestQuality Assurance

  • Lung volumes - DLCO VA 500 ml larger than TLC - ???

  • Technologist Driven Protocols

  • Reference equations


Quality improvement put into practice test quality assurance36 l.jpg
Quality Improvement Put into PracticeTestQuality Assurance

  • Technologist Driven Protocols

  • Flowcharting the process


Quality improvement put into practice post test quality assurance l.jpg
Quality Improvement Put into PracticePost-TestQuality Assurance

  • Maneuver selection

  • Quality review by second technologist

  • “While in-house training may achieve the desired goals, laboratory directors should strongly consider the benefits of formal training programs from outside providers.”

  • Feedback to the technicians concerning their performance should be provided on a routine basis

2005 ATS/ERS Standards General Laboratory


Technician training and feedback improve test quality l.jpg

4.0

Volume grade

3.5

Flow grade

3.0

Quality controlfeedback started

2.5

Site visits andtraining update

2.0

1

2

3

4

5

6

7

Technician Training and Feedback Improve Test Quality

GPA

Year

Lung Health StudyEnright: Am Rev Respir Dis 143:1215, 1991


Quality improvement put into practice post test quality assurance39 l.jpg
Quality Improvement Put into PracticePost-TestQuality Assurance

  • Turn-around time

    • Average TRT: <1 day (15%), 1-2 d (30%), 3-4 d (27%), 5-6 d (15%), >7 d (3%)

      • ATS PFL Registry Abstract AARC 2005, OF-05-037

  • Electronic Medical Record


Quality improvement put into practice does it work l.jpg
Quality Improvement Put into Practice Does it Work?

  • Retrospective review of 18,000 consecutive pts. at Mayo Clinic

  • Ninety percent of the patients were able to reproduce FEV1 within 120 ml (6.1%), FVC within 150 ml (5.3%), and PEF within 0.80 L (12%).

    • Enright PL. Beck KC. Sherrill DL. Repeatability of spirometry in 18,000 adult patients. American Journal of Respiratory & Critical Care Medicine. 169(2):235-8, 2004 Jan 15.


Slide41 l.jpg

“This is fine as far as it goes.

From here on, it’s who you know.”


ad