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

Transcription

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

2 Why do we fail to do simple things that improve care? Hand Hygiene 60% reliable VTE Bundles 80% reliable Central Line Bundles 70% reliable

3 What is QI? Progress Actual prac2ce Quality Gap Time

4 What is QI? QI is about producing reliable and sustainable change. Yay QI Yay Yay Sepsis! QI! I m 2red þ Foley out þ DVT ppx þ Pain Control þ Daily BM

5 Start with a story Mayoral election in Romania Neculai Ivascu incumbent mayor I know he died, but I don t want change. I ll ask you a ques-on

6 Do you work in a great hospital? Do you work in a great hospital? What s keeping it from being great? Do the leadership and faculty want greatness? Do you? If we all want to work at a great hospital

7 You as a leader Doctors not trained as leaders Doctors make poor followers.

8 Objectives Understand how the principles of QI can help you achieve PCQN vision Guide you through a stepwise approach to improvement Understand how PCQN data can be used for improvement

9 You log into the PCQN website after a recent Palliative Care faculty meeting 80.00% Comparison Data for Site % 40.00% n=35 N= % 3 All Sites Day 1 to Day 2 Score Improvement (exlcuding those with a Day 1 Score of 0) Turns out despite a lot of work, your institution is still below the group average

10 Stages of QI Kübler Ross Style Emotional Response Shock Is that my data? Denial That can t be my data Anger The measurement strategy must be flawed Time Depression No one else is doing any better Bargaining Our patients are sicker Acceptance We should probably try to improve

11 How do we improve care? Set the vision for improvement Understand the Problem Identify Areas for Improvement Devise a Measurement Strategy Prioritize small tests of change Measure Change Message value & Sustain the change

12 Using a QI framework to improve care Set the vision for improvement Understand the Problem Identify areas for Improvement Devise a measurement strategy Prioritize small tests of change Measure change Sustain the change 8:40

13 Align, Define & Inspire Vision Focus on why, not what or how.

14 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

15 The BI will eliminate all preventable harm by 2020.

16 Using a QI framework to improve care Set the vision for improvement Understand the problem Identify areas for improvement Devise a measurement strategy Prioritize small tests of change Measure change Sustain the change 9:15

17 The problem = Persistently high pain scores

18 The problem = Pain management Equipment Process People - No timely orders - Lack of Nursing buy in - Unclear Physician buy in Materials Environment Management - Pain meds not stocked - Sicker patients - Staffing on the floors

19 Fishbone Diagram The Cause The effect Equipment Process People primary cause The Problem secondary cause Materials Environment Management

20 Table exercise Create a Fishbone 10 minutes Equipment Process People Materials Environment Management

21 What did you come up with? Equipment Process People - PCAs take too long to order - No timely orders - Teams wont let PC write orders - Rounding only once a day - Lack of Nursing buy in - Unclear Physician buy in - Need more chaplain / SW support Materials Environment Management - Pain meds not stocked - Sicker patients - Staffing on the floors - Existential pain, not treated with opiates - More cancer patients - Not reliably measuring pain scores

22 Fishbone = structured brainstorming about why you have the problem Use as a guide for data you may want to collect

23 Use data to ensure you are fixing the right problem

24 The problem = Timely pain management Equipment Process People Is different than fixing Hme to pain med delivery - No timely orders - Lack of Nursing buy in - Unclear Physician buy in Fixing Nurse & Physician buy in Materials Environment Management - Pain meds not stocked - Sicker patients - Staffing on the floors

25 Case example: Patient Satisfaction Goal: Improve Patient Satisfaction with MD Communication Intervention: Teach hospitalists best practices in patient communication Outcome: No improvement WHY? Data: Patient comments all report dissatisfaction with communication between hospitalist & specialists which was not improved.

26 We discover Hour long delays between recs & orders Nurses not giving doses promptly Pa2ents aren t asking for PRN meds No a\ernoon reassessment

27 Using a QI framework to improve care Set the vision for improvement Understand the problem Identify areas for improvement Devise a measurement strategy Prioritize small tests of change Measure change Sustain the change 9:55

28 Identify areas for improvement Go and see for yourself Keep asking why until you get to the root of things

29 Identify Areas for Improvement (current state) 45 year old woman with malignant bowel obstruction due to colon cancer with nausea, vomiting and abd pain, progressive inability to take oral meds/hydration PCS Rounds (day 1) Write Informal 3 hrs 1 hr 3 hrs notes in w/ FAMILY 2 hrs with primary MTGS official teams recs Write orders OR Page team with updated recs PCS Rounds (day 2) Team (or you) wrote orders just before they went home. Patient unaware of new regimen. Did not ask for additional PRNs Nurse didn t provide info on available meds Day 2 pain scores unchanged

30 Removing Obstacles Ask your team why don t people do this already?