Hunt for Ambulatory Metrics in the Pediatric Neurosciences Gerald Grant, MD Associate Professor Department of Neurosurgery Stanford University Neurosafe 2017
Brain & Behavior QAPI (Quality Assurance/Performance Improvement) Purpose Ensure an effective, ongoing datadriven quality assessment and performance improvement program as recommended by the Centers for Medicare and Medicaid (CMS). The QAPI will monitor and evaluate clinical outcomes and facilitate improvements of identified systems issues that impact quality, safety and effectiveness. Responsibilities Develop and monitor process and outcome measures Develop improvement initiatives based on outcome/process measures, opportunities surfaced in the daily management system, and goals deployed through the hospital. Report results and lessons learned from initiatives on a regular basis Scope The team will provide a multidisciplinary approach for improving outcomes and processes within the Institute of Medicine s six domains of quality (safe, effective, efficient, timely, patient and familycentered, and equitable), guided by the Packard Quality Management System (PQMS). Sponsorship Vice President, Procedures and Diagnostics Transplant, Brain & Behavior, Surgical Sub-specialties Vice President Medical Affairs Vice President Patient Care Services & CNO Members Neuroscience QAPI Chairs: Med Director Stroke Program Medical Director Neuro-critical care CNS Neurosciences Core Team, including Chairs Division Chief of Pediatric Neurosurgery Division Chief of Child Neurology Neuro Radiology Clinical Nurse Specialist- Pediatric Intensive Care Unit Surgical Technician OR Nurse Lead Neurologist NP Neurosurgery Peer Review MD Leader Medical Director(s) Patient Safety Representative Professional Practice Evaluation Program Manager Family Advisor 2
Guideline to Identify and Track Actionable Metrics Discuss CY 2016 dashboard metrics value add towards Quality, Safety, Affordability or Innovation Review metrics from other pediatric transplant centers Identify measurable/meaningful metrics for CY 2017 (US News and world Report) Incorporate evidence based benchmarks for the selected metrics Identify metric owners for continuous improvement Transplant quality team will send out under performing metrics data to the metric owners 2 weeks prior to the quality council meeting Metric owner to present interventions for underperforming metrics Track the implemented intervention for sustainability
Regulatory Update- Successful CMS Transplant Survey Opportunities for improvement for the quality committee: Collaboration with Patient Experience Department to receive real time feedback on transplant patients. Identify measurable interventions for improvement and timely implementation of the measures. Monitor sustainability of the identified interventions. Utilize separate template for reviewable events.
PICU Model of Care Transition to Specialty Care Teams
Specialty Care Team Goals 1.Increase depth of knowledge for specialized care 2.Improve competencies and quality of care 3.Elevate and maintain consistency in quality 4.Strengthen collaborative environment for program development Sub-specialty or service-line defined goals and objectives Annual education & training Participation in QAPI, PIPS, PPEC and other programmatic meetings Dissemination of care improvements and education to general PICU
Specialty Care Teams Specialty Care Team Members PCCM faculty liaison or program director PICU nurse practitioner RN core team 10-15 PICU nurses per team PICU leadership representative Specialty Care Teams ECMO ENT/Complex Airway Neurocritical Care Pulmonary Chronic Care Pulmonary Hypertension Renal Replacement Therapy Solid Organ Transplant Stem Cell Transplant Trauma
Patient Levels of Care PICU IMCU Acute Care Staffing 1:1 or 1:2 1:3 1:4 Frequency of intervention q1 to q2 q2 to q4 q4 to q8 Continuous mechanical support (ventilators, CRRT, ECMO) Mature tracheostomies, stable NIPPV, HD/mechanical PD Level of complexity Continuous invasive monitoring Non-invasive intermittent monitoring Multi-organ dysfunction Critical devices Single-organ dysfunction No critical devices
Leadership Initiative: Quality and Safety in Pediatric Neurosurgery Epilepsy Brain Tumors Concussion Chiari I
Leadership Initiative: Quality and Safety in Pediatric Neurosurgery Epilepsy Brain Tumors Concussion Craniosynostosis Hydrocephalus Chiari I
Chiari I Malformation Who Needs Surgery?
Cerebellar Tonsil Position Smith et al, JNS Peds, 2013
Mission : To provide the highest quality of neurosurgical care to the children we treat 1) We will develop, validate, and incorporate disease-specific patient based instruments in the ambulatory setting. 1) These instruments will be disease specific. 1) Seamless integration of quality metrics into our daily workflow. 1) Improve patient care and outcomes. 1) Lead to a national collaborative multi-institutional effort focusing on quality outcome metrics in pediatric neurosurgery 1) Collaboration between Neurosurgery, Stanford Healthcare, Stanford Children s Health, Center for Health Policy, and Center for Quality and Clinical Effectiveness
Challenges New territory. First of its kind Database: Redcap vs. pchoir Chiari I natural history is not defined Operationalize this concert Getting buy in from patients and staff! Education
Problem Statement Clinicians, parents, and children are not adequately informed with quality of life metrics to decide the best course of action or treatment for patients with Chiari I malformations. Background Stanford Children s ambulatory clinic leadership has asked all services to develop quality metrics for the outpatient setting. These metrics currently do not exist for pediatric neurosurgery, a national referral center for children with Chiari malformations. The service has an opportunity to lead the national effort to define the most appropriate quality of life measures. Significant implications to clinical care are possible, especially if the clinicians can better predict outcomes after an intervention, creating value for patients. Lack of quality metrics can lead to inappropriate surgery, missed surgery, or increased disabilities and co-morbid conditions. Target State: SMART Goal Implement quality metrics into the Neurosurgery clinic through integration with diagnosis and treatment for children with the Chiari I malformation. Process measures: -We will improve the number of quality of life surveys completed by new and established patients from 0 to 90% at both Welch and Middlefield sites by the end of September 2017. Average number of new Chiari patients is 5 per month and average number of established Chiari patients is 10 per month. Outcome measure: Within 12 months, convert to the Peds CHOIR database and improve composite outcomes scores following surgery by 20%. Establishing Quality Metrics for Pediatric Neurosurgery Key Drivers Provide time for parents and patients to fill out the form & survey Consistent and standard patient communication/reminders prior to clinic Standard work for staff regarding review and verification of completed surveys Seamless integration of survey workflow into complex clinic processes Sponsor(s): Paul Sharek, MD, Cameron D Alpe Last Updated: 6/26/17 Leader(s): Gerald Grant, MD & Michele Milev Coach: Jake Mickelsen Other Team Members: Stephanie Choi, NP, Christianne Paraz, Elizabeth Interventions Martinez, Alexandra / Countermeasures Cuevas, Evan Arnold New patient coordinator will send out survey immediately after new patient appointment is booked Spanish-speaking families will be provided an in-person interpreter to complete survey Script will be developed for new patient coordinator to introduce survey and explain importance to families 7 day auto-reminder will be built into REDCAP system 4 days prior to clinic, MA will check REDCAP system for survey completion and contact family with instructions if needed 1 day prior to clinic, MA will check REDCAP system for survey completion and contact family with instructions to arrive early if needed Current State: Identify Target / Actual / Gap Actual: There are currently no validated metrics of quality of life in pediatric neurosurgery. Children with Chiari I malformation, which is purely a radiographic diagnosis, are sometimes offered surgery due to progressive symptoms while others are followed more conservatively. Parents and children are demanding a more global assessment of their quality of life before and after surgery. Analysis Sustain Plan ipads available in clinic to help families complete survey Survey completion rates will be tracked visually in workroom to assess performance Activity to sustain Owner Sustain method and frequency Report to Key Focus Areas: 1. Provide preappointment reminders to fill out the survey to patients 2. Standard work for staff regarding review and verification of completed surveys 3. Provide time for patients to fill out the form 4. Seamlessly integrate survey workflow into complex clinic processes Reliability Level: (1) Individuals: Feedback, checklists, training, basic standards (2) Procedures: Embedded standard work, reminders, constraints (3) Systems/culture: Process redesign, built-in quality, automated systems, fail safes, physical structure, social norms, mindfulness Maturity Bars: 0: Untested idea 1: Early tests / PDCA 2: Multiple PDCAs 3: Early implementation 4: Working well in operation Progress Barrier Abandoned Stanford Medicine
Chiari Intake Form
Survey Process Map
Performance improvement in a complex health care environment depends on the cooperation of diverse individuals and groups, allocation of time and resources, and use of effective improvement methods.
Challenges New territory. First of its kind Database: Redcap vs. pchoir Chari I natural history is not defined Operationalize this concept with seamless integration into workflow Getting buy in from patients and staff! Education