Quality Improvement in Palliative Medicine

1. Quality Improvement in Palliative Medicine Using Rapid Cycle Techniques to Improve Care-and Have Fun! David Levin, M.D. Senior Medical Director, Sentara Healthcare dmlevin@sentara.com www.capc.org

2. Models For Improvement • Many different models • Six Sigma • CQI, TQM, etc… • Rapid Cycle Change (RCC)

3. Models For Improvement • “If all you have is a hammer, everything looks like a nail.” • “There is no certainty. There is only opportunity.” • “V for Vendetta”

4. Model for Improvement Act Plan Study Do What are we trying to Accomplish? How will we know that a changeis an improvement? What change can we make that will result in improvement? Source: IHI

5. AIM • What are we trying to accomplish? • Time Specific • Measurable • Defines Population Bad: We will have fewer falls in our hospital. Good: Reduce # falls by 50% in 3 months.

6. Tips for Setting Aims • State the Aim clearly • Define “what by when” • Choose stretch goal that will force fundamental change. • Avoid Aim “Drift”... • Don’t back off • …But OK to refocus • smaller scope but not “drift”

7. Measure • How will we know a change is an improvement? • Specific Quantitative Measure • A “Compass” - are we heading in the right direction? Fall Rate: # falls / # hospital bed days % Patients with pneumonia who received antibiotics within 4 hours of admission.

8. Measurement Types An Example: Improving bowel hygiene for patients on pain medications • Process - What the system is doing? • Ex: % Patients on Bowel Rx + Pain Rx • Outcomes – What is the impact on the patient? • Ex: %Patients with good bowel Fxn. • Balancing – Were there unintended consequences? • Ex: Pain Scores, Episodes of Diarrhea

9. Measurement Tips • Mix of Process & Outcomes • Frequent, small samples • Just enough data • Use existing data if possible • If using a form: • Design with user in mind • Provide clear instructions/definitions • Test it on a few users first (this is an RCC too!)

10. Change • What changes can be made that will lead to an improvement? • All Improvement requires change but… • ...Not all changes lead to improvement • Early: hunches, intuition • Later: Based on what is learned for each cycle

11. Model for Improvement Act Plan Study Do What are we trying to Accomplish? How will we know that a changeis an improvement? What change can we make that will result in improvement?

12. The PDSA Cycle for Learning & Improvement Act Plan • Objective • Questions and • predictions (why) • Plan to carry out the cycle • (who, what, where, when) • Plan for data collection • What changes • are to be made? • Next cycle? Study Do • Complete the • analysis of the data • Compare data to • predictions • Summarize • what was • learned • Carry out the plan • Document problems • and unexpected • observations • Begin analysis • of the data Source: IHI

13. Frequent Small Changes Sample for Learning Ambiguity is OK DARE TO THINK SMALL!! Act Act Act Act Act Plan Plan Plan Plan Plan Study Study Study Study Study Do Do Do Do Do Rapid Cycle Change Model Improvement “The team with the most cycles wins!”

14. Act Plan Study Do Accelerating Improvement Using the Model for Improvement • What cycle can we complete by next Tuesday? • Willing to compromise on scope, size, rigor, and sophistication. • Drop Down “Two Levels”. Source: IHI

15. Decrease the Time Frame for a PDSA Test Cycle • Years • Quarters • Months • Weeks • Days • Hours • Minutes Drop down next “two levels” to plan Test Cycle! Source: IHI

16. Other Ways to Accelerate FAILURE • Share widely • Avoid “analysis paralysis” • Expect “lessons learned” • Ban the “F-word” • Celebrate, have fun! • Own the problem, not the geography • “Let’s try it once. How bad can that be?”

17. Does Rapid Cycle = Less Risk ? Rapid Cycle Approach Traditional Approach Result?? R e w a r d Do Plan Time

18. Forming Teams

19. Forming Teams “Play with those who will play with you” • Consider systems/processes affected • Different disciplines • Different parts of the system/process • Avoid nay-sayers • System Leadership • Clinical/Technical expertise • Day-to-day leadership

20. Rapid Cycle Change: Lessons from the Real World

21. Example #1: Normothermia Change Statement Aim: Within 4 months 100% of surgical patients will maintain normothermia throughout the perioperative period. Measures: Within 14 days we will achieve 100% compliance with putting caps on all patients in preoperative holding area. Within 60 days we will achieve 100% of patients arriving in PACU with body temperature > 36 C. Changes: 1) Develop procedure for placing caps on all patients in preop holding. 2) Test and refine “capping” procedure with 10 patients per day during first 4 days.

22. Process Measurements • Small Frequent Samples • Show Trends Over Time. • Share Results with Staff

23. Outcomes Measurement: PACU Temp Begin

24. Example #2 • VAP Prevention in the ICU • Implement VENT Bundle • MDR Form to remind/track results.

25. Process Measure Clinical Outcome Measure Clinical Improvement

26. What would be a good balancing measure for the VAP project? • Re-intubation rate • Others?

27. Example #3 • Palliative Care “Soft Data” • Develop form to collect on all patients. • Test multiple versions on small samples. • Deploy large scale after testing.

28. Discussion/Questions… Please be sure to: • Unmute your phone only when speaking. • Use the “Raise Hand” feature to ask a question.

29. Group Exercises • Watch One • Do One (or more…)

35. Discussion/Questions… Please be sure to: • Unmute your phone only when speaking. • Use the “Raise Hand” feature to ask a question.

36. Group Exercise #2

37. References • http://www.ihi.org/IHI/Topics/Improvement/ • Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. For further discussion or questions feel free to email me: dmlevin@sentara.com