The Palliative Care Quality Network s Quality Improvement Collaborative. Kara Bischoff, MD PCQN Spring Conference May 13, 2015

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1 The Palliative Care Quality Network s Quality Improvement Collaborative Kara Bischoff, MD PCQN Spring Conference May 13, 2015

2 Agenda: Session 1 The QI landscape in PC How the PCQN can help you excel The PCQN QI Collaborative: What we ve been up to Where we re headed Seeking your input

3 QI skills session Agenda: Session 2

4 The QI Landscape in PC Palliative care is good for patients! But could it be even better? Increasingly, palliative care is being challenged to demonstrate its quality objectively The Joint Commission s Advanced Certification Medicare s Physician Quality Reporting System

5 Measuring the Quality of PC National Quality Forum Achieve consensus on a set of preferred practices for palliative and hospice care Measuring What Matters Recommend a narrower portfolio of performance measures for hospice and palliative care programs to use internally for QI

6 AAHPM and HPNA s Measuring What Matters

8 PCQN to the Rescue Metric MWM Definition PCQN Definition Our Data Symptom Screen % pts with screening for physical symptoms (pain, dyspnea, nausea, and constipation) % pts with 0, 1, 2, 3 or 9 in pain, nausea and dyspnea fields and Y or N in BM field on any day 68%

9 PCQN to the Rescue Metric MWM Definition PCQN Definition Our Data Symptom Screen % pts with 0, 1, 2, 3 or 9 in pain, nausea and 68% dyspnea fields and Y or N in BM field on any day Treatment Preferences % pts with screening for physical symptoms (pain, dyspnea, nausea, and constipation) % pts with documentation of preferences for lifesustaining treatments % pts discharged alive with an AD or POLST completed 25%

10 AAHPM and HPNA s Measuring What Matters You are working hard to collect this data! We want to make it work for you.

11 PCQN A collaborative of PC teams committed to improving the care of seriously ill patients and their families.

12 PCQN QI Collaborative Eight PCQN teams originally Multi-pronged intervention: 3-hour, interactive didactic session to teach QI methods and begin a coordinated QI project Monthly calls to review data, discuss stumbling blocks, learn from best performers Ongoing support & mentorship

13 Using a QI Framework to Improve Care 1. Set the vision for improvement 2. Understand the problem(s) 3. Identify areas for improvement 4. Prioritize small tests of change 5. Devise a measurement strategy 6. Monitor your progress 7. Assess & adjust 8. Sustain the change

14 Using a QI Framework to Improve Care 1. Set the vision for improvement 2. Understand the problem(s) 3. Identify areas for improvement 4. Prioritize small tests of change 5. Devise a measurement strategy 6. Monitor your progress 7. Assess & adjust 8. Sustain the change

15 Rate of pain improvement Choose an Area of Focus Examined baseline PCQN data Chose an area that appealed to all teams 100% 80% 60% 79% 77% 74% 71% 70% 64% 60% 40% 20% 0% PCQN QI Collaborative Sites

16 Set an Improvement Goal Each team chose a SMART goal: Specific Measureable Achievable Relevant Time-Bound Ex: Increase the % of pts with mod/severe pain who have an improvement in their pain from 1 st to 2 nd assessment by 10%, averaged over the year.

17 Emotional Response 5 Stages of QI Kübler-Ross Style Acceptance We should probably try to improve Denial That can t be my data Depression This is hopeless - no one else is doing any better Bargaining Yes, but our patients are sicker Anger The measurement strategy must be flawed Time

18 Truly Lead As a leader of change, the goal is not to make every body do what you want, the goal is to inspire people to believe what you believe. Talk about WHY not HOW

19 Using a QI Framework to Improve Care 1. Set the vision for improvement 2. Understand the problem(s) 3. Identify areas for improvement 4. Prioritize small tests of change 5. Devise a measurement strategy 6. Monitor your progress 7. Assess & adjust 8. Sustain the change

20 Where are our Quality Gaps? Why doesn t pain consistently improve? Use direct observation Ask all members of your team Keep asking why (why, why, why ) Mini-root cause analyses

21 Fishbone Brainstorm Equipment Process People Not enough PCAs Few educational materials Pall care doesn t write orders Recs communicated after rounds Few consults for pain Personnel turn-over, under-staffed MD/RN education and priority setting The Problem Stocking meds on floors Lack of other pain mgmt modalities RN:Patient ratios No discussion of pain at IDT Separate pain mgmt svc Little recognition for Success in pain mgmt Materials Environment Management

22 Root Cause Analyses Reasons for Inconsistent Pain Management Issue with primary team/interfacing Pain 2 another problem (e.g. depression) Non-opioid-responsive physical pain We weren't consulted for pain management Insufficient pt education or motivation Communication issue with pt Discharge planned soon Concern about somnolence Concern for addiction/abuse Pt preference

23 Using a QI Framework to Improve Care 1. Set the vision for improvement 2. Understand the problem(s) 3. Identify areas for improvement 4. Prioritize small tests of change 5. Devise a measurement strategy 6. Monitor your progress 7. Assess & adjust 8. Sustain the change

24 Map the Current Process A 45 year old man with prostate cancer with bony metastases was admitted for uncontrolled back pain. PC is consulte d by the primary team PC 3 hrs 1 team hr sees the patient FAMILY MTGS 3 hrs Write notes with official recs 2 hrs Write orders OR Page team with updated recs PCS Rounds (day 2) Team wrote orders just before they went home. Patient unaware of new pain regimen. Patient did not ask for additional PRNs. Nurse didn t provide info on available meds. Day 2 pain scores unchanged

25 Redesign & Standardize Process A 45 year old man with prostate cancer with bony metastases was admitted for uncontrolled back pain. PC is consulte d by the primary team Call primary team with clear to-do now recs <1 hr PC Write team 4 hrs notes <1 hr sees the 2 hrs patient Communicate recs to the RN and request help with pt education with official recs Check to ensure pain is improved

26 Using a QI Framework to Improve Care 1. Set the vision for improvement 2. Understand the problem(s) 3. Identify areas for improvement 4. Prioritize small tests of change 5. Devise a measurement strategy 6. Monitor your progress 7. Assess & adjust 8. Sustain the change

27 Where to begin?

28 High Effort One team member does PM check in Thankless tasks Low Impact Easy Wins High Impact Call primary team after each patient is seen with clear to-do now recs Low Effort

29 Get Specific PDSA Worksheet for Testing Change: Describe your test of change Person responsible Deadline Plan: Tasks Person responsible Deadline

30 Using a QI Framework to Improve Care 1. Set the vision for improvement 2. Understand the problem(s) 3. Identify areas for improvement 4. Prioritize small tests of change 5. Devise a measurement strategy 6. Monitor your progress 7. Assess & adjust 8. Sustain the change

31 Will these changes result in improvement? INTERVENTION Not all changes are improvements But all improvements are the result of changes!

32 Decide What to Measure Outcomes (patient level results) Processes (our actions) Structure (attributes of a system)

33 Balancing Measures Have unintended consequences been introduced elsewhere in the system? Example: In a project aimed at pain improvement, track over-sedation or naloxone requirements.

34 What Measures Might We Track? OUTCOME: PROCESS: STRUCTURAL: BALANCING:

35 Data Collection Card

36 Using a QI Framework to Improve Care 1. Set the vision for improvement 2. Understand the problem(s) 3. Identify areas for improvement 4. Prioritize small tests of change 5. Devise a measurement strategy 6. Monitor your progress 7. Assess & adjust 8. Sustain the change

37 Monitoring Progress Frequent, granular data feedback to our teams Benchmark to others Consider public recognition

39 PCQN Sites

40 Single PCQN Site

41 Using a QI Framework to Improve Care 1. Set the vision for improvement 2. Understand the problem(s) 3. Identify areas for improvement 4. Prioritize small tests of change 5. Devise a measurement strategy 6. Monitor your progress 7. Assess & adjust 8. Sustain the change

42 The PDSA Cycle

43 Revised Process Improvement Examples: Train SWs to assist with PM pain re-assessments Assess anxiety in all patients with mod/severe pain Palliative care MD to write pain orders

44 Using a QI framework to improve care 8 1. Set the vision for improvement 2. Understand the problem(s) 3. Identify areas for improvement 4. Prioritize small tests of change 5. Devise a measurement strategy 6. Monitor your progress 7. Adjust 8. Sustain the change

45 Coaching & Celebrating Success Identify early wins Recognition! This is a marathon small wins to a big goal

46 Sustaining the Process Ensure data is readily accessible Design the process to fit into a natural work flow Put ownership in a group

47 Appeal to Both Sides of our Brains

48 Finding your Story

49 The Power of the Collaborative Tests of change found most effective: See patients in pain early Communicate recs to nurse and team right after Afternoon check-in

50 The Power of the Collaborative Additional lessons: About pain: Chronic pain doesn t improve quickly! Association between pain & anxiety/distress About QI process: Use all team members maximally Monthly check-ins are critical Keep track of process changes, not just outcome

Participant Feedback Agree or Strongly Agree 0% 20% 40% 60% 80% 100% Participation in the PCQN QI Collaborative has helped educate my team about quality improvement.

51 Participant Feedback Agree or Strongly Agree 0% 20% 40% 60% 80% 100% Participation in the PCQN QI Collaborative has helped educate my team about quality improvement. 83% Participation in the PCQN QI Collaborative has helped motivate my team to engage in quality improvement. 82% Our team has been more successful in our QI efforts because of participation in the PCQN QI Collaborative. 73% I m interested in continuing to participate in the Collaborative. 83%

52 Most Valuable Aspects Getting ideas from other teams (4). Seeing the comparative data, quickly and easily (4). Having to report on each call about our progress (3). Having specific assignments to act on between calls (2). Hands on learning and feedback. The education seminars have been enlightening. Guidance on what data to collect and how to collect it.

53 Areas for Improvement More active participation by all members. Let's find another project to do!

54 Next Steps Select a 2 nd area of focus: An area in need of improvement at PCQN sites A metric that s measurable with PCQN data A metric that can be directly impacted by palliative care consultants An area of interest to hospitals leadership and the field

55 Next Steps Next area of focus: Improve advance care planning documentation for patients who prefer to limit aggressive care POLST completion AD completion

56 Next Steps Make the Collaborative work for you! Jump start our 2 nd QI project Ongoing monthly conference calls Active mentorship between monthly calls Record our activities at PCQN.org

57 Seeking your Input How could the QI Collaborative best serve your team? Do you already have a process for QI? Could the QI Collaborative augment your efforts? What are the barriers to participating? How could we lower them?

58 The Palliative Care Quality Network s Quality Improvement Collaborative Kara Bischoff, MD PCQN Spring Conference May 13, 2015

59 Agenda: Session 2 QI skills session Formulate a SMART goal 5 Whys Driver Diagram Plan a test of change Devise a measurement strategy

60 Next Area of Focus Improve advance care planning documentation for patients who prefer to limit aggressive care POLST completion AD completion

61 Baseline Data Of patients discharged alive and not FULL CODE: 100% 80% 60% 40% 20% 23% 36% 46% During consult Prior to consult 0% Advance directive POLST Either anytime

62 Understand the Problem

63 5 Whys Why don t we control pain well? Patients don t ask for their PRNs Patients don t know what they re written for We don t tell patients about their meds Patients wouldn t remember it anyhow Patient education cards!

64 5 Whys Why don t we complete POLSTs routinely (for pts who are not Full Code)?

65 A Theory of Change

66 Driver Diagram Structured chart to provide a theory of change.

67 Goal 1 Drivers 2 Drivers 3 Drivers Tests of Change Driver Diagram

68 Goal Driver Diagram

69 Driver Diagram

70 Tests of Change

71 Goal 1 Drivers 2 Drivers 3 Drivers Tests of Change Driver Diagram

72 Decide What to Measure Outcomes (patient level results) Processes (our actions) Structure (attributes of a system)

73 Wrap-Up Palliative care teams are increasingly being expected to demonstrate their quality objectively The PCQN can help Our QI Collaborative seeks to facilitate and empower QI efforts Our 2 nd project will focus on ACP documentation We d love to have you join!

74 Questions? (and obligatory feel-good photo)

75 See you Tuesday June 2 nd, 12-1pm for our next conference call kara.bischoff@ucsf.edu

76 Driver Diagram

77 Driver Diagram

78 Set a SMART Goal Specific Measureable Achievable Relevant Time-Bound Consider monthly variation, benchmark, consider where you re starting, complexity

79 QI is a Four-Legged Stool Education: Ensure knowledge and skills are sufficient for the change. Systems Change: Change staffing, protocols, create hard stops, and electronic shortcuts. Data audit & feedback: Provide people with performance data. Let them know you are watching and you care. Culture Change: Change the way you talk about the problem. Create a vision.

A Stepwise Approach to Quality Improvement. Michelle Mourad, MD Director of Quality and Safety, Division of Hospital Medicine UCSF Medical Center

A Stepwise Approach to Quality Improvement Michelle Mourad, MD Director of Quality and Safety, Division of Hospital Medicine UCSF Medical Center Why do we fail to do simple things that improve care? Hand