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Introduction to Quality Improvement: SELECTING AND DESIGNING A QUALITY IMPROVEMENT PROJECT Karen Greer, MD, MPH Director, Ambulatory Pediatrics St. Barnabas Hospital
Quality Is… • “The degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” • - Institute of medicine, Medicare, A strategy for Quality Assurance, ed.,
Review: Definition Of Quality • Quality: Meeting the needs and exceeding the expectations of those we serve. Deliver all and only the care that the patient and family needs. √Doing the right thing (evidence based) =For every patient (equal care) ====== Every time ====== (consistent care)
Review: What Is Healthcare Quality Improvement? • Healthcare Quality Improvement: The body of knowledge, attitudes, and skills necessary to efficiently influence and continuously improve the multiple elements of care delivery within a medical practice.
Review: The Six Aims of Healthcare Quality Improvement • Safe: Patients should not be harmed by the care that is intended to help them. • Effective: Provide services based on scientific knowledge to all who could benefit and refrain from providing services to those not likely to benefit (Avoid underuse and overuse). • Patient-Centered: Care should be respective of and responsive to individual preferences, needs, and values. • Timely: Reduce unnecessary waits and harmful delays for both those who receive and those who give care. • Efficient: Avoid wasting of equipment, supplies, ideas and energy. • Equitable: Provide care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socio-economic status. - Institute of Medicine
Choosing a Project • QI projects can focus on: • 1. structure: how the system of care is configured and/or its components • 2. process: how care is delivered • 3. outcomes: mortality, functional status, satisfaction, quality of life
Choosing a Project • So…where do you begin? • Ideas for projects can come from a variety of sources: • Everyday experiences while performing clinical duties • Hospital quality improvement goals and standards • Clinical Guidelines • Local, State and Federal/National Guidelines or Requirements • Current or Ongoing Projects
Choosing a Project: Everyday Experiences • “Strange…this patient’s vaccination status is up to date according to the clinic chart, but it’s not up to date in the immunization registry.” • Has this occurred with other patients? • What are the possible reasons for the discrepancy? • “This patient didn’t show up for his follow-up weight check/asthma check/ vaccination visit…again.” • How often has this occurred for this patient? For other patients? • What processes are in place to notify patients about their appointments? • This patient was just discharged from the inpatient service and is here for a follow-up visit, but I have no idea what happened during the admission.” • Is this a standard occurrence? • How can this be avoided in the future? • What communication occurs between providers?
Choosing a Project: Everyday Experiences • “Oops—her throat culture was positive last week, but I’m not sure if she received antibiotics. Dr. Brown usually documents his treatment on the lab report, but Dr. Green writes a new note. And Dr. White, well…” • Is there a standardized system for lab follow-up? • Three different shifts, three different attendings, three different antibiotics chosen to treat an abscess…” • Is there a standard protocol or guideline for treatment? • Is there scientific evidence to support the use of a particular antibiotic? • “This is the third time I have made this referral/appointment. They keep repeating the same tests.” • How are referrals and follow-up appointments tracked? • What communication occurs between providers? • “I tried to recall this patient for chlamydia treatment, but her number is disconnected.” What do I do now?” • How often are patients asked for demographic updates during registration? During the visit? • Is there a better way to communicate with patients?
Choosing a Project: Everyday Experiences • “This patient did not take his Concerta while he was admitted last week. I guess that explains his behavior…” • Does the intake process include a medication reconciliation component? • Is that process consistent? • If the medication was stopped for a reason, was it documented? • Are all patient medications reviewed upon discharge? • “Each note has a different list of asthma medications. I can’t tell which ones he’s actually using.” • “This patient’s mom just complained that she waited over two hours to be see this doctor, but saw another patient arrive and leave before she did. • What was her appointment time? Is there some way to quantify how long she actually waited? • Are there identifiable delays in the registration process? In the triage processs? In other sections of the visit? • What communication occurs between patient and staff?
Choosing a Project: Everyday Experiences • In other words, look at the things that: • Slow your day down • Make your job more difficult • Force you to do extra work in order to provide the best care • Frustrate your patients • Frustrate you
Choosing a Project: Hospital Quality Goals and Standards • Current St. Barnabas Hospital Goals: • Reduction of Infection Rates • Hand Hygiene • Isolation Procedures • Equipment Maintenance • Patient Satisfaction • Patient surveys • Patient complaints • Prevention of Falls
Choosing a Project: Hospital Quality Goals and Standards • Medication Reconciliation and Reduction of Medical Errors • Reduction of wrong-sided surgery/procedures • Time Outs • Two patient identifiers • Enhancing Communication between Providers • ER/Inpatient dischargesAmbulatory Clinic • Referrals Tracking/Communication with Consultants • Ensuring Adequate Chart Documentation • Implementation of electronic medical records
Choosing a Project: Clinical Guidelines • Are we compliant with established clinical guidelines? • Asthma Guidelines • Lead Screening • Obesity/BMI Screening and Management • Developmental Screening • Screening and Treatment of Sexually Transmitted Diseases • Treatment and Management of UTI • Management of Febrile Seizures
Choosing a Project:Local, State, and Federal/National Criteria • HEDIS: Health Effectiveness Data and Information Set: • A widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance (NCQA). • HEDIS measures are divided into eight categories: • Effectiveness of Care • Access/Availability of Care • Satisfaction With the Experience of Care • Health Plan Stability • Use of Services • Cost of Care • Informed Choices • Health Plan Descriptive Information.
Choosing a Project:Local, State, and Federal/National Criteria • HEDIS: Health Effectiveness Data and Information Set: • Measures are added, deleted, and revised annually. • Data submission is required by CMS (Centers for Medicare and Medicaid Services) • HEDIS is one component of NCQA's accreditation process. • HEDIS results are used to track year-to-year performance.
Choosing a Project:Local, State, and Federal/National Criteria • QARR: Quality Assurance Reporting Requirements: • Consists of measures from HEDIS plus New York State-specific measures: • In 2012, the measures included: • Well Child Visits in the First 15 Month of Life • Adolescent Preventive Care and Immunizations • Use of Appropriate Asthma Medications • Follow-Up Care for Children Prescribed ADHD medication • Annual Dental Visit • Lead Screening in Children • Like HEDIS, measures can be added or deleted over time.
Choosing a Project:Local, State, and Federal/National Criteria • National Patient Safety Goals: • Established in 2002 to help accredited organizations address specific areas of concern in regards to patient safety • Goals: • Improve the accuracy of patient identification • Improve the effectiveness of communication among caregivers • Improve the safety of using medications • Reduce the risk of health care-associated infections • Accurately and completely reconcile medications across the continuum of care • Reduce the risk of patient harm resulting from falls • Prevent health care-associated pressure ulcers (decubitus ulcers)
Choosing a Project:Local, State, and Federal/National Criteria • New York City Immunization Registry: • Established in 1998 • Required reporting of all vaccines given to patients <18 years of age (also NYS law) • Quarterly reports provide Up-to-Date status of all patients in a given practice • Also used to track distribution and administration of Vaccines For Children (VFC) vaccines • Multiple provider-friendly functions, including pre-populated school forms, vaccine ordering, and recall systems/queries
Choosing a Project:Local, State, and Federal/National Criteria • Newly Implemented Guidelines/Laws • Example: New York State HIV Testing Law • Must offer HIV testing to all patients aged 13-64 years at least once per year. • Must occur in all clinical settings: • Inpatient • Emergency Room • Ambulatory Clinics • Potential Projects: • How do you demonstrate compliance? • How close to compliance were we prior to the enacted law? • Should other testing be done simultaneously?
Choosing a Project: Current or Ongoing Projects • Build on (steal from) the work of others: • Prior QI projects that need a follow-up evaluation • Examples: a former resident’s project that is unfinished or needs a new phase • Prior QI projects that didn’t work and need reassessment • Why didn’t it work? • What might you do differently? • Prior QI projects, but with a different angle: • Examine a different component of the process • Implement a new change to the process
Next Steps • OK, so I’ve picked a topic. Now what?
Next Steps: Model for Improvement • Model For Improvement: • The model has two parts: • Three fundamental questions, which can be addressed in any order. • The Plan-Do-Study-Act (PDSA) cycle to test and implement changes in real work settings.
Model for Improvement Question #1: What are you trying to accomplish? • Setting Aims: • The aim should be: • Time-specific • Measurable • Should define the specific population of patients that will be affected. • Write a clear aim statement with specific numerical goals • Make targets achievable • Make targets for improvement clear • Be flexible and prepared to refocus
Model for Improvement Question #1: What are you trying to accomplish? • Examples: Adolescent Vaccination Status: • Aim: Improve UTD vaccination status for adolescent patients within 12 months. • Time-specific: • Goal for target completion is outlined • operational definition of being up-to-date according to CDC and NYSDOH guidelines • Measurable outcome: can review and quantify the number of vaccines administered, determine the percentage of patients that are considered UTD. • Target goal = 90% of patients with UTD status • Population-specific: target population = all adolescent outpatients aged 14 years old, seen during the past 12 months
MFI Question #2: How will you know that a change is an improvement? • What processes are you examining? • Example: Adolescent Vaccination Project processes: • Timely well child care and follow-up vaccination visits • Accurate and regular reporting to the CIR
MFI Question # 2: How will you know that a change is an improvement? • Establishing Measures: • Use quantitative measures to determine if a specific change actually leads to an improvement.
Establishing Measures • Types of Measures: • Outcome Measures: How is the system performing? What is the result? • Number of days to appointment/Time to third next available appointment • Average wait times • Average hemoglobin A1c level for population of patients with diabetes
Establishing Measures • Types of Measures: • Process Measures: Are the parts/steps in the system performing as planned? • Percentage of patients receiving developmental screening at age 18 months • Percentage of patients with lead screening performed at age 1 and 2 years.
Establishing Measures • Types of Measures: • Balancing Measures: are changes designed to improve one part of the system causing new problems in other parts of the system? • If the goal was to reduce patients’ length of stay in the hospital, are the readmission rates increasing as a result? • Does creating an open access schedule for appointments decrease availability for well child appointments? • Does allowing patients to walk-in for sick visits increase wait times for patients with scheduled appointments?
Establishing Measures • Types of Measures: • Benchmarks: the “best in class” • “Should reflect the best current assessment of optimal care and efficiency” • Actual vs. expected performance: • Is the outcome of a patient above, below, or equal to the outcome that would be expected for a group of patients with similar underlying conditions and health status? • Percent Compliance: • Denominator = the number of times that a provider had the opportunity to provide an element of recommended care to a patient who was a candidate for that care • Numerator = the number of times that care was provided
MFI Question #2: How will you know that a change is an improvement? • For your first QI project, you must first establish a baseline: • Assess current status: how close is it to the target goal? • Evaluation of a retrospective period or an immediately current period • Example: Adolescent project: • Obtain a report from the CIR indicating UTD rate for all 14 year-old adolescents seen in the outpatient clinics during the past 12 months. • Review the actual clinic charts for the same population of patients to determine UTD rate based on chart information. • Compare chart review results to CIR results.
MFI Question #3: What Changes Can be Made that Will Result in Improvement? • Selecting Changes: • “All improvement will require change, but not all change will result in improvement.” Therefore, we must identify the changes that are most likely to result in improvement. • Example: Adolescent Vaccination Project • Should we revise our reminder/recall system for appointments? How?
PDSA: Plan-Do-Study-Act • The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change in the real work setting — by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method used for action-oriented learning.
Implementing Changes • After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the team can implement the change on a broader scale — for example, for an entire pilot population or on an entire unit.
Acronym Decoder • AHRQ: Agency for Healthcare Research and Quality: www.ahrq.gov • CAHPS: Consumer Assessment Health Plan Survey • HCAPHS: Hospital Consumer Assessment Plan Survey • CIR: City Immunization Registry: www.nyc.gov/health/cir • CMS: Center for Medicare/Medicaid Services: www.cms.gov • COE: Center of Excellence • HEDIS: Health Effectiveness Data and Information Set • IHI: Institute for Healthcare Improvement: www.ihi.org • IOM: Institute of Medicine: www.iom.edu • JCAHO/TJC: Joint Commission for Accreditation of Hospitals (now known as The Joint Commission: www.jointcommission.org • NCQA: National Committee on Quality Assurance www.ncqa.org • NQF: National Quality Forum www.qualityforum.org • NYCDOHMH: New York City Department of Health and Mental Hygiene www.nyc.gov/health • QARR: Quality Assurance Reporting Requirements • RHIO: Regional Health Information Organization
References • Crossing the Quality Chasm: A New Health System for the 21st Century. Committee on Quality Health Care in America, Institute of Medicine. National Academy Press, Washington, D.C. 2001. • The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers, San Francisco, 1996. • An Introduction to the Model for Improvement. (Lecture) Robert Lloyd, PhD. • Road Map for Quality Improvement: A Guide for Doctors. Manoj Jain, MD MPH www.mjain.net/medicine/roadmap_for_qualityimprovement.pdf • How to Improve. Institute for Healthcare Improvement. www.ihi.org/IHI/Topics/ImprovementMethods/HowToImprove