Enhancing Your Skills in Stroke Quality Improvement & Data Analysis: Using Data to Drive Outcomes

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1 Enhancing Your Skills in Stroke Quality Improvement & Data Analysis: Using Data to Drive Outcomes Christy Franklin, BSN, MS, CNRN and Lynn Hundley, RN, MSN, APRN, CNRN, CCNS, ANVP Disclosures Christy Franklin has no actual or potential conflict of interest in relation to this presentation. Lynn Hundley has no actual or potential conflict of interest in relation to this presentation. 1

2 Objective Describe how the use of stroke performance measures enhances adherence to guidelines and promotes interventions known to improve outcomes, provide an example of utilizing data to identify and address improvement opportunities and explain the collection of monthly data points for stroke performance measures. Your Mission (should you choose to accept it ) Identify the PI mission for your program: Create a cultureof process improvement and decision making that is patient-focused, and data driven Ideally, this culture should: Support the organizations core values Enable growth Allow for the provision of safer, more effective care at a lower cost 2

3 Examples of Scientific Methodology Examples of Scientific Methodology 3

4 Comparison of Frameworks FOCUS / PDCA PDCA DMAIC Training Within Industry (TWI) 1 Find a process to improve Organize team that knows the process 2 Clarify current knowledge of the process Plan Define No defined step, but pre-work/planning is needed Plan Measure Break Down the Job 3 Understand causes of process variation Plan Analyze Question Every Detail 4 Select the process improvement Plan, Do, Check Do, Check Improve Develop the New Method 5 Act Act Control Apply the New Method Tools Business Case Problem Statement Key Players Customer(s): Function Part/Process Sponsor: Team Members: ED Admission Flow Created By: Mary Ellen Smith Updated By: Aaron Maynard, Jim Morgan Last Updated: August 31, 2009 Effect Severity: 1-10 Failure Mode Controls Detection: 1-10 Success Measures and Goal Causes People Equipment Materials Occurrence: 1-10 In Scope Out of Scope RPN Risk Priority Number RPN = S x O x D = Milestones Late for work Communication Plan Methods Measure s Environ. 4

5 Quality is a process not an event -Anonymous Clinical Practice Guidelines Guidelines are the basis for protocols for treating the Acute Stroke Patient e.g. BAC - Drive the quality care of stroke patients GWTG-Stroke helps facilities ensure continuous improvement of stroke treatment by aligning clinical care with evidence-based guidelines 5

6 Evidence-Based Practice A problem-solving approach to the delivery of health care Integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values Highest quality of care and best patient outcomes can be achieved Design the Process: Using Guidelines to Develop Tools for Facilitating Best Practice Stroke-specific policies/protocols that are routinely reviewed Stroke-specific order sets Stroke-specific documentation tools NIHSS ED stroke alert flow sheet Frequent VS and Neuro Assessment Patient Education and Stroke Risk Reduction Dysphagia Screening 6

7 Tools are in place.now what? Are our processes ensuring adherence to the clinical guidelines? Do they promote interventions to improve outcomes? Data Collection How? Sampling vs 100% abstraction Inter-rater reliability/ validation process Home grown database/ Registry (e.g. Get With The Guidelines, Coverdell) When? Retrospective vs prospective data Who? Who will collect the data? EHR integration? What works for your organization? 7

tools and resources QI field staff support Submission of CMS Core Stroke Measures and other data Real time

8 Data Collection What data should we collect? Door to Treatment data Core measure data Outcome data Why? Get With The Guidelines-Stroke Access to the most up-to-date research and scientific publications Clinical tools and resources QI field staff support Submission of CMS Core Stroke Measures and other data Real time performance feedback reporting for continuous quality improvement External Benchmarking Door to Treatment Goals 8

stakeholders as well as posted to Intranet for review by staff Door-to-Treatment team meets

9 Data Review Regular review of data points will address areas needing improvement For example, at SMMC: Stroke program performance measurement data is distributed monthly to interested stakeholders as well as posted to Intranet for review by staff Door-to-Treatment team meets monthly to review treated patient cases Multidisciplinary stroke leadership team meets quarterly to review data 9

10 Monthly Presentation of Data Performance Measurement Reporting Form Monthly Presentation of Data Stroke Report Card 10

11 Quarterly Presentation of Data Reviewed by stroke leadership team at quarterly meeting PPT format Process Improvement: Examples from SMMC Documentation of discharge NIHSS Stroke alert lab TAT 11

The Guidelines During the original t-pa clinical trial the NIHSS was completed at baseline prior to treatment, at 2 hours post-treatment, at 24 hours, at 7-10 days, and at 3 months.

12 The Guidelines During the original t-pa clinical trial the NIHSS was completed at baseline prior to treatment, at 2 hours post-treatment, at 24 hours, at 7-10 days, and at 3 months. Today, hospital protocols vary in the frequency of NIHSS. SMMC interest in hospital outcomes SMMC Adopted Process NIHSS to be completed: Acute stroke and TPA patients Upon arrival, 2 hours post TPA, 24 hours post TPA, with any change in status, and upon discharge Non-treated patients Upon admission, with change in status, and upon discharge. 12

clear understanding of who was responsible for doing the assessment Uncover root cause

13 Identified the Problem - FOCUS Found a problem that we were not following our own established protocol Organized a team of Stroke Unit nurses and manager Clarify No clear understanding of who was responsible for doing the assessment Uncover root cause -Team model with unclear responsibility for certain discharge tasks Startimprovement cycle 13

14 Plan Do Plan Team clarified discharge roles and educated staff Bedside RN made responsible for completing NIHSS with assessment on day of discharge Education planned Do Staff educated, target set and process implemented. Check - The Data % NIHSS at Discharge 14

PI in Action Improvement seen, but not where we wanted to be Team opted to move towards an accountability process Chart review and staff member discharging patient without a documented NIHSS was

15 PI in Action Improvement seen, but not where we wanted to be Team opted to move towards an accountability process Chart review and staff member discharging patient without a documented NIHSS was identified Staff member received a memo with cc to nurse manager regarding the failed measure P-D-C-A Continue to monitor data monthly Continue to review each chart failing measure to identify discharging nurse December 2014 all 62 patients had documentation of discharge NIHSS for 100% compliance 15

FOCUS - Lab Turnaround Time 2008 -Identified problem that reporting of some lab results exceeded 45 minute NINDS goal Team organized including stroke coordinator, ED managers and staff, and

16 FOCUS - Lab Turnaround Time Identified problem that reporting of some lab results exceeded 45 minute NINDS goal Team organized including stroke coordinator, ED managers and staff, and laboratory personnel Clarified current process Stroke Alert Lab TAT Originally obtained time of collection from laboratory system (time entered by the lab tech) Blood being tubed to main lab No way of tracking when blood left ED? Delay in actual transport? Delay in lab acknowledging receipt of specimen Very high avg door to collection time 16

17 PI in Action Focus-PDCA Stroke alert blood draw basket created and placed in CT scan room of ED Bright yellow stroke sticker placed on outside of specimen bag to indicate stroke alert (run labs stat) Began monitoring time of when ED nurse documented the blood was drawn rather than using the time lab stated it was drawn Stat lab included in new ED construction ED tech to draw blood and hand-deliver to stat lab (no tube system use) PI in Action Truer picture of where to focus efforts in improving TAT Blood being drawn quickly Actual delay in getting the specimen to lab Data sent to ED/lab for review each month indicating which patients failed measure Much improved avg door to collection time 17

18 NHC: DTN Project Overview DMAIC Project Description: In 2011, 24 ED Stroke Patients were treated with rt-pa out of a total ischemic stroke patient population of 558 patients (4.5%). Of the 24 patients, only 4 (16%) had a door-to-needle time of 60 min or less. Timely use of rt-pa benefits the patient in the following ways: Drug Effectiveness: 33% probability of a higher-score recovery outcome vs. no treatment Increased Benefit: Increased probability of favorable outcome at 3 months post-event as OTT (Last known well to rt-pa administration) decreased showing statistical significance (p=0.005<<0.05) Project Scope: All stroke patients eligible for rt-pa (LKW). Start: Patient arrival at ED / End: Administration of rt-pa Project Goal:Achieve median DTN time of 60 min or less. What we wanted to know: How does the process perform? 2011 DTN Performance DMAIC What we found: The process is displaying more variation than our goal can permit. 18

19 Process Step: CTA Scan Comments Aspect Question NBH NSH NH NAH How is the impact to DTN known? (Is it - Not known/checklist not with patient -Checklist not with patient - could check Systems quantifiable?) - Acute stroke checklist follows patient -manually write completion time MSTAT for recorded times -Unknown-checklist not always with patient Who is to do the Process -CT tech Step(s)? -CT tech (CT1 preferred due to faster processing time --CT techs Pathways (How clear is this?) -Room 1 only 10 mins vs 30 mins) -2 scanners Seimens preferred for CTA -CT tech -Radioligist notifies ED MD of CT result -Order from MD (requested based on -ED MD consults with neurologist to discussion with neurology) determine if CTA is necessary -Call from ED MD/neuro How does he / she know -Currently creatinine result is awaited before (Outsourced to VRC at night) -Can be verbal order when service is performing exam -ISTAT creatinine done in ED - no delay -Consent obtained if possible-use implied needed? (CTA done when patient has weakness on waiting for result -Call from ED consent if not Connections (How is this signaled?) one side and/or contraindications to tpa) (table weight limit CT 1650 #'s/ CT 2450 #'s) -Can see order in computer -Standard process -Standard procedure How does he / she know -CT tech training -CT tech training/annual competencies what is needed? -Contrast dose 1 cc/pound-max 100cc's -Same level skill training all shifts (How is this -Standard process -Implied consent used if not able to obtain -Contrast load calculated per protocol Activities determined?) -CT tech training consent from patient/family -Same -Check computer to verify no contrast allergy -20g IV necessary to inject contrast (CT 1 allows test bolus of saline prior to -IV checked with saline flush (blown IV could contrast) delay) -Audible alarm for high pressure during -CT tech review images real time for contrast -View images real time to see if contrast is injection flow; contacts radiologist if needed flowing -Images visually checked real time to verify -Alternative contrast options posted in -Monitor for adverse reaction real time contrast was delivered radiology for contrast allergies -Must have internet for transmitting images -Long distance to radiology - patient should -Same with these additions: -Machine does test bolus to check IV; high (Re-visit ED MD/neurology dialogue stay in dept. until determination is made for -Do not use implied conset. Will wait for ED pressure alarm structure) CTA MD to sign before completing exam -Daily QA's done; biomed does preventive How does he / she know (Pts at low risk for CIN; investigating NOT (Have had issues with internet connectivity -Only manualy flush available to check IV maintenance on machines; not posted it is done correctly? waiting for result to do exam) at night - event actio plan?) -No internet connectivity issues reported anywhere Activities (How is this verified?) -Radiologist on back up call - 4/6/2015 What we wanted to know: What is the overall process? rt-pa Admin Process Map Process was mapped with System Stroke Team and there was agreement that this was the basic process from hospital to hospital Variation was noted in the VSM (Value Stream Map) study of the Current State (see next slide) DMAIC What we found: All 4 adult hospitals use the same basic process. What we wanted to know: How does the process flow? Current State VSM Cross-location and cross-functional team walked each adult hospital s process Process observations were made for each process step Process was timed (stopwatch, checklists, timestamps) Current State VSM was assembled based on findings Expected DTN Time for 12/01/11 03/31/12 was 110 min, which is worse than the 2011 baseline Some Hawthorn effect seen after the study began What we found: Most of the process time is spent waiting after the patient is done in Radiology and there are opportunities to improve. DMAIC 19

20 What we wanted to know: What is the impact of our efforts? Impact of Top 3 Priorities #1 Tx Decision #2 Lab Label #3 rt-pa Box DMAIC What we found: Focusing on just the Top 3 improvement priorities alone will address over 70 min of the 110 min expected DTN Time. What we wanted to know: How does our view of risk impact flow? View of Risk DMAIC Aspect H o = Pt. should have rt-pa H o = Pt. should not have rt-pa Burden of Proof Try to prove why not to administer Try to prove why necessary to administer Timeliness Fewer tests and less time to decide More tests and more time to decide TypicalApplication Management of Risk (Control Phase) Effective whentime is critical for patient safety / outcome (i.e. Balloon Angioplasty for AMI) Riskin Txdecision managed by robust process of evaluating patient for contraindication(s) Effective whentime is not very critical for patient safety / outcome (i.e. Radiation for Cancer Patient) Risk in excessively delayed time managed by standardized lists of tests and using tactics to expedite results What we found: Our view of risk will determine the process management approach we take. 20

21 What we wanted to know: How is delay in the TxDecision addressed? #1: Tx Decision Roadmap Mapped with input from EBP research and Stroke Neurologists (red is contraindication) Minimizes delay between receiving required results and issuing an order Included in related physician onboarding documentation DMAIC What we found: This is the EBP and NHC Neurologist accepted TxCriteria. Following this andthe broader process for Acute Stroke will reduce delays in Tx. NHC: Improvement Sustained?? DTN Scorecard for Date Range 1/2014 thru 12/2014 Breakout Tx Time rt-pa Tx CasesGoal (minutes) 60 Above Goal 6 Within Goal 4 N (Reported) 10 % Within Goal 40% NAH 10 Average Time 67 Above Goal 5 Within Goal 17 N (Reported) 22 % Within Goal 77% NBH 22 Average Time 50 Above Goal 1 Within Goal 4 N (Reported) 5 % Within Goal 80% NH 5 Average Time 65 Above Goal 12 Within Goal 25 N (Reported) 37 % Within Goal 68% Average Time 56 Total 37 Median Time 50 Minutes /22/14 2/22/14 3/22/14 DMAIC DTN Time (All NHC) 1/2014 thru 12/2014 4/22/14 5/22/14 6/22/14 Date 7/22/14 8/22/14 9/22/14 10/22/14 11/22/14 12/22/14 21

Celebrate Your Success!! DMAIC NHC Facility Norton Brownsboro 23 Norton Audubon 37 Norton St. Mattews 37 Norton Hospital 21 DTN (mins) Resources/Websites Brain Attack Coalition - www.stroke-site.

22 Celebrate Your Success!! DMAIC NHC Facility Norton Brownsboro 23 Norton Audubon 37 Norton St. Mattews 37 Norton Hospital 21 DTN (mins) Resources/Websites Brain Attack Coalition - American Heart Association/American Stroke Association - Comprehensive Overview of Nursing and Interdisciplinary Rehabilitation Care of the Stroke Patient Guidelines for the Management of Spontaneous Intracerebral Hemorrhage NIHSS Certification - AHA/ASA Representative The Joint Commission - American Association of Neurological Nursing - Get with the Guidelines 22

23 Thank you! 23

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