Quality improvement introduction and qi research
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Quality Improvement: Introduction and QI Research. Michael L. Rinke, MD Division of Quality and Safety August 31, 2012. 2. Overview. Why do you care about Quality Improvement? Systems Based Approach to Quality Improvement Model for Improvement Pediatric Quality Improvement Research

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Quality improvement introduction and qi research

Quality Improvement: Introduction and QI Research

Michael L. Rinke, MD

Division of Quality and Safety

August 31, 2012


Quality improvement introduction and qi research

2


Overview

Overview

  • Why do you care about Quality Improvement?

  • Systems Based Approach to Quality Improvement

  • Model for Improvement

  • Pediatric Quality Improvement Research

  • Conclusion


Why do you care about quality improvement

Why do you care about quality improvement?

On average, … children in the study received 46% … of the indicated care. They received 68% … of the indicated care for acute medical problems, 53% … of the indicated care for chronic medical conditions, and 41% … of the indicated preventive care. Quality varied according to the clinical area, with the rate of adherence to indicated care ranging from 92% … for upper respiratory tract infections to 34% … for preventive services for adolescents.

FAIL!


Overestimating performance

Overestimating Performance

FAIL!

Randolph, Fried, Loeding, Margolis, Keyes, Lannon: Pediatrics, 2005.


Variation in performance

Variation in Performance

FAIL!

Randolph, Fried, Loeding, Margolis, Keyes, Lannon. Pediatrics, 2005.


How many deaths

How many deaths?


Quality improvement introduction and qi research

“In the last decade, the National Highway Traffic Safety Administration has received complaints of 34 fatalities related to sudden acceleration of Toyota vehicles, far more than for any other automaker. At least 22 additional deaths related to Toyota acceleration problems have been alleged in lawsuits and police reports.”


More fail

More fail

  • On average, 5% to 20% of US residents get the flu annually, and more than 200,000 persons are hospitalized for flu-related complications each year.

  • About 36,000 Americans die on average per year from flu complications.


The math

The math

  • Toyota:

    • 56 deaths in 10 years

    • 1 death every 2 months

  • Flu:

    • 36,000 deaths per year

    • 1 death every 15 minutes (in a “good” year)

FAIL!

?


How hazardous is health care derived from leape amalberti

How Hazardous Is Health Care?(derived from Leape & Amalberti)


Institute of medicine report to err is human

Institute of Medicine Report: To Err is Human

Preventable medical errors

  • 44,000 - 98,000 deaths in US annually

  • 8th leading cause of death in US

  • Annual cost = $29 billion

  • IOM conclusion: the majority of problems are systemic, not the fault of individual providers


Why is qi important to you

Why is QI Important to You?

  • These projects will help you keep your patients healthy

  • ACGME Requires all fellows to participate in a Quality Improvement Project

  • American Board of Pediatrics requires Quality Improvement Project for Maintenance of Certification

  • Your Nursing staff are very invested in improving care and are looking for your help

  • You can make an Academic Career from QI


What medical errors have you seen what caused these medical errors

Why is QI Important to You?

What medical errors have you seen?What caused these medical errors?


Victorian aphorism

Victorian aphorism

“A good doctor is better than a bad doctor,

and almost as good as no doctor at all”


How do we provide safe and high quality care to every patient

How do we provide safe and high quality care to every patient?


Change the system

Change the System


Systems based approach to qi

Systems Based Approach to QI


What system should we change in adolescent medicine

What System should we change in Adolescent Medicine?


The model for improvement

The Model for Improvement

  • Why do we need a model for improvement?

“The definition of insanity is continuing to do the same thing over and over again and expecting a different result”

−Albert Einstein


Quality improvement introduction and qi research

Act

Plan

Study

Do

Model for Improvement

Whatare we trying

to accomplish?

How will we know that

a change is an improvement?

What changes can we make

that will result in improvement?


Three fundamental questions for improvement

Three fundamental questionsfor improvement

  • What are we trying to accomplish?

  • How will we know that a change is an improvement?

  • What changes can we make that will result in an improvement?


Three fundamental questions for improvement1

Three fundamental questionsfor improvement

  • What are we trying to accomplish?

  • How will we know that a change is an improvement?

  • What changes can we make that will result in an improvement?

Aim

Measures

Ideas


What are we trying to accomplish a written aim is

What are we trying to accomplish?A written aim is…

  • A statement of the accomplishments expected from a team’s improvement effort

  • A touchstone to sharpen / maintain focus

  • A communication tool within a group & between the group and larger system

  • A tension-creating reminder to aid in building will


Sample aim statement

Sample Aim Statement

By January 2012, improve preventive and developmental services provided to children <5

We will achieve this by implementing six core changes for prevention & development, so that:

  • > 65% of parents report receiving age-appropriate guidance & education in a way that meets their informational needs

  • > 75% of young children (birth – 5y) have an age-appropriate structured developmental screening


What aim should we use in adolescent medicine

What Aim should we use in Adolescent Medicine?


How will we know if a change is an improvement

How will we know if a change is an improvement?

“All improvement

is change,

but not all change

is an improvement”


Measures for improvement

Measures for improvement

  • Answering the question, How will we know that a change is an improvement? usually requires a balanced set of 4 to 8 measures

  • Goal: creating data collection methods that are “just enough” – small sample sizes, regular collection intervals – not “just in case”


You ve got a good measure

You’ve got a good measure…

…when it:

  • Is related to the aim & linked to key changes

  • Is easy to collect

    • Fits into clinical flow (e.g. the billing sheet)

    • Already being collected

  • Is simple

  • Shows improvement quickly


You ve got a good measure1

You’ve got a good measure…

…when it:

  • Is meaningful & understandable to participants

  • Can be displayed graphically over time

  • Creates a tension for change


Sample measures

Sample measures

  • % of Type II DM patients with HgbA1C < 7

  • % of asthma patients with management plan updated at last visit

  • % of families with ‘excellent’ satisfaction with amount of waiting time during visit

  • % of patients who saw the provider they preferred to see at last visit


What measures should we use in adolescent medicine

What Measures should we use in Adolescent Medicine?


Quality improvement introduction and qi research

Act

Plan

Study

Do

Model for Improvement

Whatare we trying

to accomplish?

How will we know that

a change is an improvement?

What change can we make

that will result in improvement?


Quality improvement introduction and qi research

“Trust in G-d, all others bring data”

-Edward Demming


Uses of the pdsa cycle

Uses of the PDSA Cycle

  • Developing a change

  • Testing a change

  • Implementing a change


Quality improvement introduction and qi research

Act

Plan

Objective: Test nurse

review imms. first

Predictions: feasible,

more accurate

Plan: 1 day, 3 nurses, check records & place post-it before resident sees

  • What changes

  • are to be made: none

  • Next cycle: test w/ all nurses for one week

Study

Do

  • Compare data to predictions: feasible, no problems, no errors noted; & residents liked it

Carry out the plan

Document: problems

& benefits, count

immunization errors


Law of reform niccolo machiavelli 1513

Law of ReformNiccolo Machiavelli (1513)

“There is nothing more difficult to manage, more dubious to accomplish, nor more doubtful of success … than to initiate a new order of things.

The reformer has enemies in all those who profit from the old order and only lukewarm defenders in all those who would profit from the new order.”


The first idea is rarely the best idea

The first idea is rarely the best idea


Repeated use of the pdsa cycle

A

P

S

D

D

S

P

A

A

P

S

D

A

P

S

D

Repeated Use of the PDSA Cycle

Changes That Result in Improvement

Learning from Data

Proposals, Theories, Ideas


What small tests of change should we use in adolescent medicine

What Small Tests of Change should we use in Adolescent Medicine?


Quality improvement introduction and qi research

http://www.ihi.org


Pediatric oncology quality improvement projects clabsi

Pediatric Oncology Quality Improvement Projects: CLABSI


Proportion of children up to date for hep a immunization

Proportion of Children Up-to-date for Hep A Immunization


Domains of qi research

Domains of QI research:

  • Quality of care / compliance with guidelines

  • Implementation

  • Patient safety

  • Systems & operations

  • Patient satisfaction

  • Dissemination / diffusion


Resources for qi research

Resources for QI Research:

  • SQUIRE Guidelines: Standards for Quality Improvement Reporting Excellence

  • Pediatrics Quality Reports: Looking for studies

  • Institute for Healthcare Improvement (IHI)

  • Armstrong Institute Greenbelt Course

  • Division of Quality and Safety: Marlene Miller, Nichole Persing, Michael Rinke


4 conclusions

4 Conclusions:

  • Improving Patient Quality and Safety is one of your central jobs as a physician

    • Thousands of people die each year from lapses in Patient Quality and Safety

  • To improve Patient Quality and Safety you have to change the system

  • We must study changes to know if changes improve the system

    • Model for Improvement

  • Pediatrics is working hard to improve Patient Safety and Quality: GET INVOLVED!


One does not discover new lands without consenting to lose sight of the shore for a very long time

“One does not discover new landswithout consenting to lose sightof the shore for a very long time”

-Andre Gide

Nobel laureate in literature


Thank you

Thank You


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