A Framework for Quality Improvement

Transcription

1 U019 - Integrating QI into the Derm Practice A Framework for Quality Improvement Margo Reeder, MD Assistant Professor Director of Quality Improvement UWSMPH July Quality is increasingly part of our jobs Quality: The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Institute of Medicine (IOM) Quality Improvement: Quality improvement (QI) consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups. Health Resources and Services Administration (HHS) What does to mean to provide high quality care? 1

2 7/29/16 What does to mean to provide high quality care? A framework for thinking about QI in your practice Other Models Lean Streamline the system by eliminating waste and emphasizing customer driven outcomes Toyota Production System Six Sigma (DMAIC) Define, Measure, Analyze, Improve, Control IHI- QI and PDSA Institute for Healthcare Improvement,,, 2

3 Other Models Lean Streamline the system by eliminating waste and emphasizing customer driven outcomes Toyota Production System Six Sigma (DMAIC) Define, Measure, Analyze, Improve, Control IHI- QI and PDSA Institute for Healthcare Improvement,,, Birth of a QI Project Patient presents for nbuvb Patient late to clinic Float nurse in clinic 2 nbuvb machines Orders dose in computer Software update New bulbs with dose adjustment Wrong dose given to patient 4 stages of a QI project INNOVATION What is your idea for improvement? PILOT Think little test IMPLEMENTATION Make a change in a defined system Model for Improvement What are we trying to accomplish? Measure How do we know that a change is an improvement? Change What change can we make that will result in improvement? SPREAD Create a new standard in the system Associates in Process Improvement W. Edwards Deming, PhD BS engineering PhD in Mathematical physics Statistician Spent much of career working in post WWII Japan Developed sampling for US census Partnered with Dr. Walter Shewhart PDSA cycles Systems of Profound knowledge W. Edwards Deming, PhD Quality is everyone s responsibility

4 Deming s theory of Profound Knowledge Example: Patient burns with phototherapy Appreciation of a system Appreciation of a system AIM Psychology and behavior Variation AIM Psychology and behavior Variation Theory of knowledge Theory of knowledge Model for Improvement What are we trying to accomplish? Measure How do we know that a change is an improvement? Change What change can we make that will result in improvement? Writing an What are we trying to accomplish? (specifically) Associates in Process Improvement WWDDD? If you do not know how to ask the right question, you discover nothing. Crafting an How much? For whom? By when? Example: Refill routine topical acne medications within 24 hours for patients age <18 by January 2017 Example: Schedule Mohs for 100% of patients with SCC on nose within 4 weeks by July 2017 Example: Decrease sun seeking behavior in our patients 4

5 n t confuse an with your Mission Example: Patient burns with phototherapy Mission 1. Decrease biopsy follow up time Mission 2. Increase access to dermatology 1. Results to patient within 10 days of biopsy for 90% of single lesions by July For changing pigmented lesion, see 90% of patients within 14 days by January 2017 AIM Psychology and behavior Appreciation of a system Theory of knowledge Variation : phototherapy For whom: patients presenting for nbuvb at a single clinic By when: December 2016 How much: 95% reduction in grade 2 or 3 erythema ratings (burn) Measurement How do we know we that a change is an improvement? Example: Decrease the number of phototherapy burns (grade 2,3) at clinic A by 95% by December 2016 W. Edwards Deming Nobody should try to use data unless he has collected data. Where to get data Sources: Medical records Electronic Paper Survey Other providers, nurses, staff, techs Path reports Patient feedback surveys Because it s for QI IRB may be expedited review, if needed Publication/presentation IRB rules are different at every institution 5

6 Types of Measurements Outcome measures What are you trying to improve Process measures Variables that might affect your outcome measure Balance measures Change in one area of the system affecting another Measurement: phototherapy Safety training Software $ Increased signs Number of burns Time of visit Patient satisfaction Room utilization Staff time # of patients Outcome Measures Process Measures Balancing Measures Outcome Measures Process Measures Balancing Measures Clinical documentation of extra patient counseling on risk for burns (new medication, ambient sun, etc) Clinical documentation of extra patient counseling on risk for burns (new medication, ambient sun, etc) Time of visit Cost of new technology or phototherapy machine Outcome Measures Process Measures Balancing Measures Outcome Measures Process Measures Balancing Measures Clinical documentation of extra patient counseling on risk for burns (new medication, ambient sun, etc) Time of visit Cost of new technology or phototherapy machine Number of burns in phototherapy Clinical documentation of extra patient counseling on risk for burns (new medication, ambient sun, etc) Time of visit Cost of new technology or phototherapy machine 6

7 Changes How can we improve the system to achieve our aim? Change concepts Eliminate waste Improve work flow Optimize inventory Change environment Interface of customer/ producer Time management Minimize variation Limit error Change the product or service Change: phototherapy Posted signs in phototherapy room Patient and staff education Software upgrade Space planning Decrease staff variation Automated ordering system Assembling Your Team Team Who are the stakeholders? Examples: physicians, nurses, pharmacists, schedulers, building maintenance, residents, medical students, patients Appreciation of a system Choosing a project AIM Psychology and behavior Variation Theory of knowledge 7

8 Choosing a Project Daily annoyances (often most satisfying) Hospital metrics (multidisciplinary) Sentinel events or error reporting system (Safety) Dermatology quality measures Choosing a Project Daily annoyances (often most satisfying) Hospital metrics (multidisciplinary) Sentinel events or error reporting system (Safety) Dermatology quality measures AAD Approved Measures (DataDerm) Biopsy follow-up Melanoma: Continuity of Care Recall System Melanoma: Coordination of Care Melanoma: Overutilization of Imaging Studies Melanoma pathology reporting TB prevention in patients on biologics Cancer stage documentation Medication documentation Assessment of Psoriasis Disease ivity Assessment for Psoriatic Arthritis Tuberculosis Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier Clinical Response to Oral Systemic or Biologic Medications Preventive Screening Protocol for Transplant Patients Mohs for sbcc on the trunk Mohs for SCCis and KA Type SCC on The Trunk that are 1 cm or smaller Listing of SCC AJCC Reporting Criteria Listing of BCC Subtyping on the Biopsy Report cumentation of Patient Input for Treatment Type cumentation of discussion w/patients about potential use of field-directed therapies prior to destruction of inic Keratoses (17004 code) Use of Biopsy Site Photos or Directional Diagrams Prior to Surgery Biopsy Clinical History Anatomic Location Accuracy Biopsy Reporting Time Clinician Biopsy Reporting Time Pathologist Safe Effective Patient-centered Timely Efficient Equitable Remember the IOM PDSA cycle AIM MEASURES CHANGES 8

9 7/29/16 PDSA What question are we trying to answer? What are we trying to achieve? What happened? Measurements How did what happened compare with our plan? What is the next step? Think little: PDSA examples : Decrease the number of phototherapy burns (grade 2,3) at clinic A by 95% by December 2016 Have 2 nurses run the phototherapy during a single clinic session New order entry procedure Patient checklist placed in phototherapy room Update written patient information at initial visit In reality. Change is complicated Questions? Margo Reeder, MD mreeder@dermatology.wisc.edu 9