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 Michael L. Rinke, MD Division of Quality and Safety August 31, 2012
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? 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 FAIL! Randolph, Fried, Loeding, Margolis, Keyes, Lannon: Pediatrics, 2005.
Variation in Performance FAIL! Randolph, Fried, Loeding, Margolis, Keyes, Lannon. Pediatrics, 2005.
“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 • 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 • 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! ?
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? • 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
Why is QI Important to You? What medical errors have you seen?What caused these medical errors?
Victorian aphorism “A good doctor is better than a bad doctor, and almost as good as no doctor at all”
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
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 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 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… • 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 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? “All improvement is change, but not all change is an 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… …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 measure… …when it: • Is meaningful & understandable to participants • Can be displayed graphically over time • Creates a tension for change
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
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?
“Trust in G-d, all others bring data” -Edward Demming
Uses of the PDSA Cycle • Developing a change • Testing a change • Implementing a change
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 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.”
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
Domains of QI research: • Quality of care / compliance with guidelines • Implementation • Patient safety • Systems & operations • Patient satisfaction • Dissemination / diffusion
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