Choosing and Prioritizing QI Project July 21, 2017 Anthony T. Petrick MD Director, Minimally Invasive and Bariatric Surgery Geisinger Health System, Danville, PA Co-Chair, MBSAQIP Data and Quality Committee
Disclosures I have no financial disclosures related to this study
Objectives 1) Recognize sources for quality improvement initiatives 2) Understand available tools to help prioritize quality improvement projects 3) Attendees should have the ability to identify and design quality improvement projects at the completion of this session 3
Introduction 4
Introduction
Assemble CORE QI Team MBS Director Bariatric Surgeons Fellows Residents MBS Coordinator MBS Clinical Reviewer Administrative Support Any Bariatric Team Members QI Experts Operations Leaders 6
Assemble CORE QI Team Establish Leaders Leaders Purpose Time Commitment Physician Champion 1) Provide physician leadership 2) Remove barriers, ensuring dedicated time for the team leaders and members to work on improvement, 3) Holding team members accountable for reaching milestones. 4) Facilitate communication to the broader service line employees about the goals and successes. Variable Duration of the initiative Division of Quality and Safety Executive Champion Copyright Geisinger Health System 2011 1) Provide administrative leadership 2) Remove barriers, ensuring dedicated time for the team leaders 3) Holding team members accountable for reaching milestones. 4) Facilitate communication to the broader service line employees about goals and successes Not for reuse or distribution without permission Variable Duration of the initiative 7
Data Sources 1. Review Data 1. SAR Site Summary (Risk Adjusted)
Data Sources 1. Review Data 2. Online Benchmarking Reports (Unadjusted) 9
Data Sources 1. Review Data 3. Internal Data (HCAPS) 10
Data Sources 1. Review Data 3. Internal Data (Quality Manger, Statit ) 11
Data Sources 1. Review Data 3. Internal Data (Quality Manger, Statit ) 12
Introduction
Benchmark Data 2. Identify the Problem High Outlier = QI opportunity* * see Standard 7.2 for details 14
Benchmark Data 2. Identify the Problem Note the H indicating that this site is a high statistical outlier for this model. Center is required to do QI project to address LRYGB Reoperation. Center is needs improvement, but not a high outlier. Center may choose to to do QI project for LRYGB Leak, but is not required and may choose a different area of focus.
Benchmark Data 2. Identify the Problem Drill down using Case Occurrences Report 16
Benchmark Data 2. Identify the Problem Real-time via Online Reports (not risk-adjusted): 17
Benchmark Data 2. Identify the Problem HCAPS Drill Down 18
Benchmark Data 2. Identify the Problem 3. Internal Data (Quality Manger, Statit ) 19
Benchmark Data 1. Review Data If Data doesn t reveal a problem, look for 1) Gaps in resources or care services? 2) Issues regarding timeliness of care? 3) Gaps in patient compliance or follow-up? 4) Issues related to patient satisfaction or procedure effectiveness? 5) Educational gaps for patients or staff? 2. Identify the Problem 20
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Prioritization Matrix 2. Identify the Problem POTENTIAL BENEFIT 1. High Benefit / Low Effort (low hanging fruit make highest priority!) 3. Low Benefit / Low Effort (prioritize when all goals for patient safety and satisfaction have been met) 2. High Benefit / High Effort (prioritize when necessary) 4. Low Benefit / High Effort (ignore these) EFFORT/RESOURCE UTILIZATION
QI Prioritization 2. Identify the Problem High Benefit / Low Effort (Rapid) 1) Shorter cycle (months) 2) Application of existing EMR tools 3) Impacts limited sites of care or number of providers High Benefit / High Effort (Comprehensive) 1) Longer time frame (1 yr +/-) 2) Multi-site, many providers 3) Complex Epic design/development needs (limited tool kit use, need for redesign) Low Benefit / Low Effort ( Light ) 1) Very rapid project cycle (< 120 days) 2) Single, simple EMR need, if any 3) Single care site or 1 3 providers impacted Low Benefit / Low Effort 1) Limited, if any, financial or quality outcomes anticipated 2) Involves wide scope of care sites and/or providers 3) Limited if any clinical and administrative leadership 4) Limited resources deployed to support projects
2. Identify the Problem Problem Statement 2. Identify the Problem 3. Propose Intervention Elements 1) Clearly identify a specific problem you want to solve through your QI project 2) Identify your baseline and goal metrics 3) Identify the timeline for meeting this goal 24
Problem Statement 2. Identify the Problem Our predicted (adjusted) observed rate for LRYGB Reoperation was 7.33% in 2012-13, which makes us a high outlier in this model. Our goal is to lower our LRYGB Reoperation to the expected rate of 3.03% by July 1, 2014. 1 Specify Problem 2 Baseline Goal & Metrics 3 Timeline
Introduction
Propose Intervention 3. Propose Intervention Gather all members of the MBS Committee to discuss all possible factors contributing to the problem Conduct literature review may reference ASMBS Guidelines and Position Statements http://asmbs.org/resource-categories/positionstatements May choose to implement a Root Cause Analysis tool such as The 5 Whys, SIPOC, or a Fishbone Diagram Document a plan for intervention 27
Root Cause Analysis 3. Propose Intervention 1) List all the potential causes of the problem 2) Prioritize down to a manageable size 3) Pick one of the main problems 4) Do the following steps to find the Root Cause i. State the Main Cause ii. Ask Why Main Cause happens iii. Ask Why the Cause in B happens iv. Ask why the Cause in C happens => Root Cause 28
Root Cause Analysis 3. Propose Intervention 1) Potential causes of the problem a) Surgeon experience b) Anastomotic technique c) Diagnostic accuracy.. 2) Prioritize down to a manageable size 3) Pick one of the main problems 4) Do the following steps to find the Root Cause Our predicted (adjusted) observed rate for LRYGB Reoperation was 7.33% in 2012-13, which makes us a high outlier in this model. Our goal is to lower our LRYGB Reoperation to the expected rate of 3.03% by July 1, 2014. 29
Root Cause Analysis 3. Propose Intervention Do the following steps to find the Root Cause i. State the Main Cause => Xray studies show SBO ii. iii. iv. Why Main Cause happens => Excessive small bowel dilation Why the Cause in B happens => EGD at end of each case Why the Cause in C happens [Root Cause] => No bowel clamp and air used instead of CO 2 Our predicted (adjusted) observed rate for LRYGB Reoperation was 7.33% in 2012-13, which makes us a high outlier in this model. Our goal is to lower our LRYGB Reoperation to the expected rate of 3.03% by July 1, 2014. 30
Operational Definitions 3. Propose Intervention Unambiguous Measurable and actionable Specifies the measurement method, procedures and equipment when appropriate Clinical data (chart reviews) vs. administrative data Client logs vs. a computer database Defines specific criteria for the data to be collected Define all inclusions and exclusions For percentages or rates, or ratios, define the criteria for inclusion in the numerator and denominator Always ask How might somebody be confused by this definition? Lloyd, R. Quality Health Care (2004) Jones and Bartlett
Measure Care Delivery Background: We have little systematic information about the extent to which standard processes involved in health care a key element of quality are delivered in the United States. Results: Participants received 54.9% of the recommended care 32