It s not about the quantity but the quality: A QI Workshop for Dummies John Raimo, MD Sara Cerrone, MD Semie Kang, DO Sean LaVine, MD 1 Quality Improvement 1.) Understand how to use a fishbone diagram and process map to analyze patient safety concerns 2.) Develop an AIM statement and PDSA cycle 3.) Develop techniques on how to start a quality improvement curriculum 2
WHY QUALITY IMPROVEMENT??? Quality within health care is an expectation.not benefit or bonus ACGME is mandating programs develop quality improvement curricula Health care is NOT nearly as safe as it should be 3 PROCESS MAPS 4
Process Maps Visual representation of the sequence of actions that comprise the process Uses Document the process Analyze and Improve the Process Orientation/Education Teaching the process 5 Process Maps Symbols Start/End Step Flow/Direction or Input or Output Delay or Wait Decision/Question Link to Another Page 6
Process Maps Common Pitfalls Map the actual process; not what you d like it to be Engage those involved in the process Define the start and end before you begin Sample Process Map Process for administering medications in the hospital Patient Encounter Rx Ordered RN Gets Rx Rx Given Each step can have much more detail 8
Process Ends Medication Administration Process Patient Encounter Does MD/DO Think Rx is needed? Yes Decides on Rx/Dose Orders Rx in CPOE Pharmacy sees order Pharmacy Reviews Dosing Decides on Rx/Dose Pharmacy Verify? Pharmacy calls provider for clarification Provider modifies order Pharmacy prepares Rx Rx tubed to RN station Rx sits in tubing station RN sees Rx RN verifies order RN checks Rx/Dose RN checks time for admin. RN brings Rx to patient RN verify patient ID/DOB RN explains Rx to patient Rx taken 9 Group Exercise Process Map Select particular issue of the case Outline sequence of events be specific 10
Fishbone Diagrams for Cause and Effect Analysis 11 What is a fishbone? The purpose of the fishbone is to dig deeper and to identify underlying causes of adverse events A visual tool to brainstorm a root cause analysis Can be used on any type of problem and is most effective when used in a group setting Organizes thoughts into a focused discussion A way to prioritize further analysis of specific causes to the root problem being examined 12
How is a fishbone structured? The problem statement is placed at the head of the fish Major categories causing the problem are placed on the bones Further contributing causes under each category are placed on the splinters 13 What is a fishbone? 14
Fishbone: METHOD MATERIAL PEOPLE How do I get my residents to show up to grand rounds?! ENVIRONMENT FINANCES MEASUREMENTS 15 Fishbone METHOD No attendance policy PEOPLE Patients Timing of grand rounds Residents Attendings No schedule posted Accessibility to computer Location always changing/hard to find Chiefs No interest in the topic How do I get my residents to show up to grand rounds?! Elevators ENVIRONMENT NO FOOD or COFFEE! MATERIAL Bad speaker 16
Once fishbone is complete: Go back and highlight areas that can use the most improvement Set realistic goals Enforce the corrective actions that are agreed upon as a group and see change happen! 17 Group Exercise Fishbone Diagram Problem Statement Head Major Categories Bones Contributing causes Splinters 18
AIM Statement and PDSA cycle 19 AIM STATEMENT AND PDSA CYCLE 1.) AIM Statement Our Goal Be Specific How much improvement Over what time period Ex: Reduce number of daily labs ordered by house staff teams by 25% over the next 6 months. 20
AIM STATEMENT AND PDSA CYCLE 2.) Select a team who do we need to implement these changes Ex: Residents, Interns, Site Director, APD s, Chief Residents 21 AIM STATEMENT AND PDSA 3.) PDSA how we can make a change 22
AIM STATEMENT AND PDSA CYCLE P(PLAN) What intervention can be made to result in improvement Ex: Create a daily process by which labs ordered per patient by each team are tallied. 23 AIM STATEMENT AND PDSA CYCLE D (Do) How and When will we implement our plan? Ex: Create an excel document, tally daily labs by chief residents and site director each day. Send out report card to teams each week. Implement plan in 1 week. 24
AIM STATEMENT AND PDSA CYCLE S (Study) What objective measures can we look at to determine if our plan is successful? Ex: After 1 month of providing weekly report cards, look at any change in percentage of daily labs ordered by house staff teams. 25 AIM STATEMENT AND PDSA CYCLE A (ACT) Based upon results, what changes can be made to ensure we reach our goal? What issues can we anticipate? Ex: Send out more frequent report cards? Improve EMR to prevent daily lab ordering? 26
Group Exercise AIM Statement and PDSA Cycle Aim Statement Specific Goal Select Team Plan, Do, Study, Act (what shortcomings do you expect) 27 Questions?? 28
Thank You Contact Information: John Raimo jraimo@northwell.edu Sara Cerrone scerrone12@northwell.edu Semie Kang skang2@northwell.edu Sean LaVine slavine@northwell.edu 29
PROCESS MAP What is a process map? -an examination of a case where you define the current sequence of activities, including when decisions were made -review the process so that you can see where shortcomings could arise that ultimately lead to a negative event How do you create a process map? -As a group, start at the beginning of the case and begin to outline the sequence of events. -Use a circle to indicate both the start and end of the process map. -Use a Rectangle ) to enclose any activity or task performed. -Use a Diamond to enclose any decision -Use to enclose any activity or task where there could be a potential delay -Use to represent moving from one action to another. At the end of your process map it should look something like this: Now you have an idea about the process that lead to this negative event now let s consider causes
FISHBONE DIAGRAM What is a Fishbone Diagram? -also known as a cause and effect diagram -a tool used to identify all possible causes for an event or problem -useful for brainstorming sessions How to make a Fishbone Diagram? 1.) As a Team, agree on a Problem Statement that encompasses the main issue involved in the case/event; Place that statement in a box on the far right of your piece of paper (this is your fish s head). Then make a line horizontally across the paper, from your fish head to the far left (this is your fish s spine) 2.) Next, start brainstorming major categories of causes of the problem. If you are running into difficulty, you can use broad categories such as: a. Methods b. Technology c. People d. Materials e. Environment Write these headings at the end of each line coming off your fish s spine (these are your fish s ribs) 3.) Now ask yourself why does this problem happen as it would relate to each category, these reasons will be your branches. 4.) Continue to ask yourself and the group, why does this happen and explore deeper levels of causes. 5.) Now look at your diagram, these are all the possible things that could ultimately lead to your problem. As a group, you see where the problem can lie and also have a better idea of areas you can focus your attention to make a positive change. Now you know both the process and potential causes for what occurred
AIM STATEMENT and PDSA CYCLE You again have read through this case, you understand the process and possible causes of what happened. You now want to prevent similar events from occurring. Where do we go from here. We can think about formulating a goal and then come up with a plan to implement that goal. Put the plan into action, see the results, and modify the plan based upon those results. Basically an AIM statement and PDSA Cycle! What is an AIM statement? It s your objective, what you are trying to accomplish, your goal. Your AIM statement should include what you are trying to accomplish (measurable outcome) and over what time period. (ex: We want to decrease the usage of restraints by 20% on all hospital wards within the next 6 months) Also, consider the members of the team whom you will need to implement that goal (hospital administrators, physicians, nurses, technical expert, quality officer, CEO, etc). What is a PDSA cycle? After coming up with an AIM statement, its time for action.plan- Do- Study-Act Plan- What exactly are we going to do? Act- What changes are we going to make based upon these findings Do-When and How we did it? Study- What were the results? 1.) Plan- the change you can make that will result in an improvement, what intervention can be made? 2.) Do- When will you implement your plan and how will you do so? 3.) Study- What objective measures will you look at to determine if your plan is successful? 4.) Action- Based upon your results, what changes can be made to ensure you reach your go?
It s not about the quantity but the quality: A QI Workshop for Dummies CASE Mr. Smith is a 60 year old man with a history of hypertension and insulin-dependent diabetes who presents to the Emergency Department with complaints of fevers and cough. Mr. Smith has a fever of 102.5 o F, heart rate of 110bpm, BP of 120/75, RR of 24 and O2 sat of 95% on 2L O 2 via nasal cannula. Laboratory studies are remarkable only for a WBC of 14,000 with 10% bands. CXR shows an infiltrate in the left lower lobe. The patient is admitted to medicine with a diagnosis of sepsis secondary to community acquired pneumonia and is started on ceftriaxone and azithromycin. The next morning, the patient complains of increasing dyspnea. Vitals: T 102 o F; HR 116; BP 105/60; RR 24; O2 sat 92% on 2L NC The patient becomes unresponsive and pulseless. Code blue is called and CPR initiated. The patient has Pulseless Electrical Activity on the monitor. During the code, the patient receives one dose of epinephrine 1mg IV Push and is intubated. ROSC is achieved after 2 minutes of CPR. The code team orders a CXR to confirm placement of Endotracheal tube. After 5 minutes, the XRay technician hasn t come yet. The MICU has a bed available and the decision is made to transfer the patient now and get the confirmatory XRay after. Approximately 2 minutes after arrival in the MICU the patients O2 saturation starts to drop and the patient again becomes pulseless. During the code, the MICU team only hears breath sounds over the right lung field. ACLS is performed for 30 minutes but the patient expires.