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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.



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 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.”

  • 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 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.”

  • 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? 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.”(derived from Leape & Amalberti)


Institute of medicine report to err is human
Institute of Medicine Report: 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.”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? 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.”

  • 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? 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.”

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


Victorian aphorism
Victorian aphorism 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.”

“A good doctor is better than a bad doctor,

and almost as good as no doctor at all”






The model for improvement
The Model for Improvement patient?

  • 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 patient?

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 questions patient?for 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 questions patient?for 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? patient?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 patient?

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



How will we know if a change is an improvement
How will we patient?know if a change is an improvement?

“All improvement

is change,

but not all change

is an improvement”


Measures for improvement
Measures for improvement patient?

  • 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 patient?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 patient?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 patient?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



Quality improvement introduction and qi research

Act patient?

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?



Uses of the pdsa cycle
Uses of the PDSA Cycle patient?

  • Developing a change

  • Testing a change

  • Implementing a change


Quality improvement introduction and qi research

Act patient?

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 Reform patient?Niccolo 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.”



Repeated use of the pdsa cycle

A patient?

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





Proportion of children up to date for hep a immunization
Proportion of Children Up-to-date for Medicine?Hep A Immunization


Domains of qi research
Domains of QI research: Medicine?

  • Quality of care / compliance with guidelines

  • Implementation

  • Patient safety

  • Systems & operations

  • Patient satisfaction

  • Dissemination / diffusion


Resources for qi research
Resources for QI Medicine?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: Medicine?

  • 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 lands Medicine?without consenting to lose sightof the shore for a very long time”

-Andre Gide

Nobel laureate in literature


Thank you
Thank You Medicine?