Enhancing Quality Improvement for Patients ( EQuIP )

1. Enhancing Quality Improvement for Patients (EQuIP) Equipping Louisiana with a Quality Future.

2. What is this and why do it? • School-wide initiative • Engage residents and fellows in systems-based quality improvement and patient safety (QI/PS) projects. • Neither fully top-down nor fully bottom-up. • Is this one of those ACGME things I have to do?

3. What you should do… • Check out hospital QI/PS committees to determine if you would like to join them. • Examine your surroundings – how can we make the system better for patients? • Work with your program to identify a project. • Each project should have tangible objectives and measurable outcomes.

4. EQuIP Projects – Core Principles • Residents and fellows are in a good position to know what needs improving. • Improvement requires change. • Watch out for unintended consequences. Richard Tejedor, MD, “Performance Improvement Projects: Core Principles of Project Acceptability,” LSU QI Forum 2013.

5. EQuIP Projects – Core Principles • Importance • Have you measured a performance gap? • Will the project be high- or low-impact? • Is an intervention likely to improve health outcomes or improve patient safety? • Scientific Acceptability • Does the evidence support the initiative? • Endorsed national initiatives are preferred. • Do you need IRB review? Richard Tejedor, MD, “Performance Improvement Projects: Core Principles of Project Acceptability,” LSU QI Forum 2013.

6. EQuIP Projects – Core Principles • Feasibility (or, usability) • Is your plan actionable? • Do you have measurable data elements? • Should be routinely generated. • Absolute performance • Unintended consequences • Is your intervention appropriate for all entities? • Race, sex, age, comorbid conditions, etc. • Concentrate on outcome measures rather than process measures. Richard Tejedor, MD, “Performance Improvement Projects: Core Principles of Project Acceptability,” LSU QI Forum 2013.

7. Sample Projects • Comparison of pre- and post-operative med compliance after implementation of an instruction sheet for patients. • Retrospective chart review to evaluate current guidelines for neutropenic fever. • Gap analysis of current practice discovered no intervention was needed. • Autopsy Quality Assurance (AQuA): Correlating clinical diagnosis with autopsy results; improving physician awareness of autopsy procedures; decrease turn-around-time for autopsies at ILH. • Discovered significant gaps in provider knowledge regarding autopsies; implementing system changes to decrease turn-around-time (Ongoing).

8. Sample Projects • Less-ideal projects: • e.g., Basic administrative functions with no impact on patient care or outcomes. • Projects that do not track measurable patient outcomes. • Enhancing medical knowledge – is it QI? • Patient education – when is it QI?

9. EQuIP Project Review Form • Completed for each EQuIP project • Available at: www.medschool.lsuhsc.edu/equip • Turn in to EQuIP office (vharki@lsuhsc.edu) • Document project goals – i.e. targeted patient outcomes • Addresses IRB and hospital requirements • EQuIP facilitates communication.

10. Improvement Methodologies

11. Improvement Tools

12. Root Cause Analysis (RCA) • A review of the systems and process factors that contributed to a variance in performance (e.g. sentinel event). • Does NOT focus on individual performance.

13. Root Cause Analysis (RCA) Progress from special causes in clinical process to common causes in the organization. Repeatedly ask “Why?” to dig deeper and find out why things happened the way they did. Identify changes that could be made to reduce risk of event occurring again.

14. Root Cause Analysis (RCA) Thorough Credible Must include participation by organizational leadership and individuals most closely associated with the processes and systems under review. Provide consistent explanations for all findings (including “no problem” or “not applicable”). Review of any relevant literature. • Determine ALL factors most directly associated with event. • Analyze underlying systems and processes through a series of “Why?” questions. • Identify risk points and determine what improvements could decrease likelihood of a repeat event.

15. Root Cause Analysis (RCA) Action Plans • Products of RCAs – identify strategies that organization will implement to reduce the risk of similar events in the future. • Names: • Person(s) responsible for implementation • Timeline for implementation • How effectiveness of intervention will be measured.

16. Root Cause Analysis (RCA) – Mock Case • 49y.o. female. • Mitral stenosis, pulmonary hypertension, atrial fibrillation • Past history: asthma, hyperthyroidism, total hysterectomy 1992. • Meds: Lisinopril 20mg daily; Coumadin 5mg daily; Lasix 20mg daily; Albuterol 2 puffs prn; Propranolol 80mg BID; Propylthiouracil 50mg 3tabs 3x/day. • Admitted for mitral valve replacement and modified maze ablation for A-fib • Twenty-four hours pre-op, heparinized • Twelve hours pre-op, ACT was greater than 1,000

17. Root Cause Analysis (RCA) – Mock Case • During procedure, pt had difficulty with ventilation (peak airway pressure >50) • Endotracheal tube suctioned; aerosol nebs instilled directly • Pt started developing severe edema of the face, tongue and abdominal wall • Incision made in peritoneal cavity; large amount of ascites fluid evacuation • Benadryl, IV epinephrine and IV steroids administered. • Allergic reaction suspected

18. Root Cause Analysis (RCA) – Mock Case • Pulmonary: peak airway pressure eval • Cardiology: • Transesophageal echo to inspect valves, which were found to be working well. • Pt had evidence of left & right ventricular failure. • Intraaortic balloon inserted into rt femoral artery; calcium and protamine administered and lungs hyperinflated. • Wound not closed primarily • Gortex patch sewn circumferentially in wound using Prolene patch.

19. Root Cause Analysis (RCA) – Mock Case • Post-op: pt transferred to MICU • Hemodynamically compromised • Consultants: Pulmonary, Cardiology, Allergy, and Hematology. • No consensus of etiology • Treated with FFP, platelets, blood transfusions, epinephrine and steroids. • Condition continued to deteriorate. Pt pronounced at 6:11 p.m.

20. Root Cause Analysis (RCA) – Mock Case What areas/services were impacted? • OR • MICU • Perfusion • Laboratory • Anesthesia • Pharmacy • Blood Bank • Nursing • Pulmonary • Cardiology • Allergy • Hematology • Quality Management • Risk Management

21. Root Cause Analysis (RCA) – Mock Case Proximate Factors Common Cause Variation Special Cause Variation

22. Root Cause Analysis (RCA) – Mock Case

23. Root Cause Analysis (RCA) – Mock Case Why did it happen? (Proximate factors) • Process • What are the steps in the process? • What steps contributed? • Human factors • What human factors were relevant? • Equipment factors • How did equipment performance affect the outcome? • Controllable factors • What factors directly affected the outcome? • Uncontrollable external factors • Are these truly beyond the organization’s control?

24. Root Cause Analysis (RCA) – Mock Case Proximate Factors Common Cause Variation Special Cause Variation (as appropriate)

25. Root Cause Analysis (RCA) – Mock Case Human Factors & Information Management – Continue to ask “why”

26. Root Cause Analysis (RCA) – Mock Case Equipment Factors – Continue to ask “why” Cultural Factors – Continue to ask “why”

27. Root Cause Analysis (RCA) – Mock Case Uncontrollable Factors – Continue to ask “why” Wrap-Up: • What did we learn from this case? • What are the things we would do differently based on this case? • Action Plans for improvement

28. Root Cause Analysis (RCA) – Mock Case • “Why?” • Involvement by everyone • No “shame and blame” • Action plans developed

29. EQuIP - Why do it? • It’s the right thing to do. • Our patients deserve this. • Our residents and fellows need this. • Improvement is its own reward. Only through continued self-assessment will we improve.

30. Questions? Director of EQuIP Murtuza (Zee) Ali, MD, FACC, FSCAI (email: mali@lsuhsc.edu) EQuIP Coordinator Victoria Harkin, MA (Phone: 504.568.2593; email: vharki@lsuhsc.edu)