Kick Start Your QI Using Defect Analysis for a Successful Resident Quality Improvement Curriculum
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1 Kick Start Your QI Using Defect Analysis for a Successful Resident Quality Improvement Curriculum Muhamad Elrashidi, M.D. Megan Krause, M.D. Joe Skalski, M.D. Mike Wilson, M.D. Chief Medicine Residents Mayo Clinic Rochester, Minnesota APDIM Spring Conference Chief Residents Workshop April 30, 2013 Disclosures None
2 December 1999 The Institute of Medicine (IOM) reported that medical errors Cause up to 98,000 deaths Cause more than 1 million injuries each year in the United States April 2013 It is unclear if large-scale efforts have translated into significant improvements in the overall safety of patients. Adverse events still occur About 33% of hospital admissions have at least 1 adverse event Patients are still harmed Classen DC, Resar RK, et al. Global Trigger Tool shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs. April 2011;30(4): OIG Report: Adverse events in hospitals: National incidence among Medicare beneficiaries. November 2010.
3 10 Hospitals in North Carolina Landrigen CP, et al. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med 2010; 363: Objectives 1. Become familiar with defect analysis as a QI methodology 2. Utilize defect analysis as a generator of QI projects 3. Learn how to incorporate defect analysis within a pre-existing QI curriculum or as a foundation for a QI curriculum 4. Highlights of various QI curriculum models
4 What are the barriers to successful QI projects/curriculum at your institutions?
5 What is Defect Analysis? Model/framework to engage frontline stakeholders to: Identify defects Collect data Suggest strategies for improvement Complete a project in 30 days Surface Scope Validate Select Specific Work Design Strategy Finish Project
6 Frontline Defect Driven Project Design Most implemented QI projects are top down Problems with the top down approach Suboptimal stakeholder analysis of frontline staff Suboptimal frontline buy-in Many defects in the trenches go unnoticed Top down approaches have not worked Frontline Approach Toyota Corporation ~40,000 production changes annually 98% originate from the frontline! Small day to day defects at the frontline can lead to adverse events
7 Structured Frontline Visit Step 1: Organize a unit visit Specific Duties Select a mix of frontline staff (6-8) Select a small leadership team Arrange for at least 60 minutes of conversation Arrange for a location on the unit for the conversation Desired Outcome A cross section of staff working on the unit are invited Enough time for all staff to have an opportunity to discuss their work A location of the conversation where there are minimal interruptions Luther K, Resar RK. Tapping front-line knowledge. Healthcare Executive Jan/Feb;28(1):84-87
8 Structured Frontline Visit Step 2: Have participants describe their job Specific Duties Establish a non-threatening atmosphere Limit this part of the conversation to the first 10 or 15 minutes Purpose of this portion of the conversation is to understand the work and the work environment Desired Outcome Trust from the frontline staff that this is not about assessing their personal work performance Participants who are willing to talk about the work, how they do it, and how they add value to the patients and the organization Luther K, Resar RK. Tapping front-line knowledge. Healthcare Executive Jan/Feb;28(1):84-87 Structured Frontline Visit Step 3: Assess the work environment using anchoring questions Specific Duties Use questions like: Tell me what causes a bad day for you? Tell me about the last time a case was delayed? Tell me about what makes some diabetics more difficult to see? Use these questions to learn about both clinical and non clinical situations Center questions around identified defects where actual harm discussions are avoided but the potential of harm is present Steer discussion away from solutions Desired Outcome Find a specific example of a defect around which you can anchor subsequent questions about frequency, type of patient involved, previous attempts to fix Blame free environment In a 60-minute conversation, defects should be easily surfaced and compiled on a written list Luther K, Resar RK. Tapping front-line knowledge. Healthcare Executive Jan/Feb;28(1):84-87
9 Structured Frontline Visit Step 4: Debrief Specific Duties First, debrief the questioning team Follow with a debrief with the frontline team Desired Outcome Generate a list of defects that the frontline has surfaced Achieve buy-in from the frontline for possible action Achieve buy-in from the questioning team as to the need for action Luther K, Resar RK. Tapping front-line knowledge. Healthcare Executive Jan/Feb;28(1):84-87 Real Life Example Frontline engagement We spend our time answering unnecessary pages with Medicine hospital service Why does your day not go as efficiently as it could? Surface Scope Validate Select Specific Work Design Strategy Finish Project
10 Real Life Example Could focus on this single nursing unit in conjunction with team Focus on single medicine inpatient service Due to geographic admissions, capability to make change in a single unit Surface Scope Validate Select Specific Work Design Strategy Finish Project Real Life Example We will track all pages for 1 day to the service pager and determine necessity Pages were reviewed and the vast majority were needed Surface Scope Validate Select Specific Work Design Strategy Finish Project
11 Real Life Example The pages often come without contact information and unclear urgency Return to the front lines with similar questions Surface Scope Validate Select Specific Work Design Strategy Finish Project Real Life Example Could focus on this single nursing unit in conjunction with single service pager Focus on single medicine inpatient service Due to geographic admissions, capability to make change in a single unit Surface Scope Validate Select Specific Work Design Strategy Finish Project
12 Real Life Example We will track all pages for contact information (name, call back number) Surface Scope Validate Select Specific Work Design Strategy Finish Project Real Life Example Single service pager providing for single nursing unit. Focus on nurse-team communication Surface Scope Validate Select Specific Work Design Strategy Finish Project
13 Real Life Example Brainstorm with frontline providers about different strategies for tackling problem Reminder at nurse units to include name/callback information with text pages Surface Scope Validate Select Specific Work Design Strategy Finish Project Real Life Example Need to perform tests of change to demonstrate effect of strategy Repeat check with improvement in contact information with reminder form at units Surface Scope Validate Select Specific Work Design Strategy Finish Project
14 What are successful components of QI projects/curriculum at your institution?
15 QI Curriculum Models Different ways to structure a QI curriculum: One resident one project Team projects Class project QI elective No single best way All are in use at programs around the country
16 Curriculum Model Overview Solo projects Team projects Class project QI elective Each resident selects an individual QI project Mentor for each resident/project One mentor can work with multiple residents / projects if needed Dedicated time for project work during ambulatory block Project completed over course of 3 year residency Curriculum Analysis Solo projects Team projects Class project QI elective Strengths Resident learns all steps of QI Can select projects in subject areas that are interesting to them Evaluation and accountability of resident performance Good fit for defect analysis Weaknesses Difficulty finding faculty mentors for each resident Projects stall when resident on busy inpatient months High rate of failure
17 Curriculum Model Overview Solo projects Team projects Class project QI elective Small group team of residents works together on project 4 8 residents Many team models are possible depending on individual program schedule Either all same class or mix PGY-1 to PGY-3 One faculty mentor for each project team Curriculum Analysis Solo projects Team projects Class project QI elective Strengths Develops teamwork and collaboration skills Can take on larger QI projects Fewer faculty mentors needed Can pass on projects from year-to-year Weaknesses Each resident not involved in all aspects of QI cycle Variable effort and involvement of residents on team
18 Curriculum Model Overview Solo projects Team projects Class project QI elective Each residency class works through a single QI project Weekly project meetings Designed for residents on ambulatory care block One or more faculty mentors assigned to each residency class Curriculum Analysis Solo projects Team projects Class project QI elective Strengths Can take on large institutional QI projects and make meaningful change to patient care Class bonding and development of skills working in larger groups Weaknesses Large group can lead to variable involvement of residents Not appropriate for defect analysis or smaller projects
19 Curriculum Model Overview Solo projects Team projects Class project QI elective Elective experience dedicated to quality improvement Includes didactics and completion of a hands on QI project Faculty with QI knowledge and experience are assigned to elective Curriculum Analysis Solo projects Team projects Class project QI elective Strengths Self-selection of residents with interest and motivation to do quality improvement Close mentorship from elective faculty Dedicated time for project QI immersion with didactics and project simultaneously Weaknesses Not all residents in program can complete elective Difficulty completing an entire QI project in a short elective period
20 Workshop Summary 1. Become familiar with defect analysis as a QI methodology 2. Utilize defect analysis as a generator of QI projects 3. Learn how to incorporate defect analysis within a pre-existing QI curriculum or as a foundation for a QI curriculum 4. Highlights of various QI curriculum models
21 Jordan Kautz, M.D. Quality Chair, Division of General Internal Medicine John Ratelle, M.D. Incoming Chief Medicine Resident Muhamad Elrashidi, M.D. Megan Krause, M.D. Joe Skalski, M.D. Mike Wilson, M.D.
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