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Quality Improvement: Introduction and QI Research
Michael L. Rinke, MDDivision of Quality and SafetyAugust 31, 2012
2
Overview
Why do you care about Quality Improvement?
Systems Based Approach to Quality Improvement
Model for Improvement
Pediatric Quality Improvement Research
Conclusion
Why do you care about quality improvement?
On average, … children in the study received 46% … of the indicated care. They received 68% … of the indicated care for acute medical problems, 53% … of the indicated care for chronic medical conditions, and 41% … of the indicated preventive care. Quality varied according to the clinical area, with the rate of adherence to indicated care ranging from 92% … for upper respiratory tract infections to 34% … for preventive services for adolescents.
FAIL!
Overestimating Performance
Preventive Service Rates
01020
3040506070
8090
100
Pe
rce
nt
Up
to
Da
te
Estimated
Actual
Randolph, Fried, Loeding, Margolis, Keyes, Lannon: Pediatrics, 2005.
FAIL!
Variation in Performance
Randolph, Fried, Loeding, Margolis, Keyes, Lannon. Pediatrics, 2005.
FAIL!
How many deaths?
“In the last decade, the National Highway Traffic Safety Administration has received complaints of 34 fatalities related to sudden acceleration of Toyota vehicles, far more than for any other automaker. At least 22 additional deaths related to Toyota acceleration problems have been alleged in lawsuits and police reports.”
More failOn average, 5% to 20% of US residents get the flu annually, and more than 200,000 persons are hospitalized for flu-related complications each year.
About 36,000 Americans die on average per year from flu complications.
The math
Toyota:56 deaths in 10 years1 death every 2 months
Flu:36,000 deaths per year1 death every 15 minutes (in a “good” year)
?FAIL!
How Hazardous Is Health Care?(derived from Leape & Amalberti)
1
10
100
1,000
10,000
100,000
1 10 100 1,000 10,000 100,000 1,000,000 10,000,000
Number of encounters for each fatality
To
tal
liv
es
lo
st
pe
r y
ea
r
REGULATEDDANGEROUS(>1/1000)
ULTRA-SAFE(<1/100K)
HealthCare
Mountain Climbing
Bungee Jumping
Driving
Chemical Manufacturing
Chartered Flights
Scheduled Airlines
European Railroads
Nuclear Power
Institute of Medicine Report: To Err is Human
Preventable medical errors44,000 - 98,000 deaths in US annually8th leading cause of death in USAnnual cost = $29 billion
IOM conclusion: the majority of problems are systemic, not the fault of individual providers
These projects will help you keep your patients healthyACGME Requires all fellows to participate in a Quality Improvement ProjectAmerican Board of Pediatrics requires Quality Improvement Project for Maintenance of CertificationYour Nursing staff are very invested in improving care and are looking for your helpYou can make an Academic Career from QI
Why is QI Important to You?
What medical errors have you seen?
What caused these medical errors?
Why is QI Important to You?
Victorian aphorism
“A good doctor is better than a bad doctor,
and almost as good as no doctor at all”
How do we provide safe and high quality care to every patient?
Change the System
Systems Based Approach to QI
What System should we change in Adolescent Medicine?
The Model for Improvement
Why do we need a model for improvement?
“The definition of insanity is continuing to do the same thing over and over again and expecting a different result”
−Albert Einstein
What are we trying to accomplish?
How will we know thata change is an improvement?
What changes can we makethat will result in improvement?
Model for Improvement
Act Plan
Study Do
Three fundamental questionsfor improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in an improvement?
Three fundamental questionsfor improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in an improvement?
Aim
Measures
Ideas
What are we trying to accomplish?A written aim is…
A statement of the accomplishments expected from a team’s improvement effort
A touchstone to sharpen / maintain focus
A communication tool within a group & between the group and larger system
A tension-creating reminder to aid in building will
Sample Aim Statement
By January 2012, improve preventive and developmental services provided to children <5
We will achieve this by implementing six core changes for prevention & development, so that:
> 65% of parents report receiving age-appropriate guidance & education in a way that meets their informational needs
> 75% of young children (birth – 5y) have an age-appropriate structured developmental screening
What Aim should we use in Adolescent Medicine?
How will we know if a change is an improvement?
“All improvementis change,
but not all changeis an improvement”
Measures for improvement
Answering the question, How will we know that a change is an improvement? usually requires a balanced set of 4 to 8 measures
Goal: creating data collection methods that are “just enough” – small sample sizes, regular collection intervals – not “just in case”
You’ve got a good measure…
…when it:
Is related to the aim & linked to key changesIs easy to collect
Fits into clinical flow (e.g. the billing sheet)Already being collected
Is simpleShows improvement quickly
You’ve got a good measure…
…when it:
Is meaningful & understandable to participantsCan be displayed graphically over timeCreates a tension for change
Sample measures
% of Type II DM patients with HgbA1C < 7
% of asthma patients with management plan updated at last visit
% of families with ‘excellent’ satisfaction with amount of waiting time during visit
% of patients who saw the provider they preferred to see at last visit
What Measures should we use in Adolescent Medicine?
What are we trying to accomplish?
How will we know thata change is an improvement?
What change can we makethat will result in improvement?
Model for Improvement
Act Plan
Study Do
“Trust in G-d, all others bring data”-Edward Demming
Uses of the PDSA Cycle
Developing a change
Testing a change
Implementing a change
Act
• What changesare to be made: none
• Next cycle: test w/ all nurses for one week
PlanObjective: Test nursereview imms. first
Predictions: feasible, more accurate
Plan: 1 day, 3 nurses, check records & place post-it before resident sees
Study
Compare data to predictions: feasible, no problems, no errors noted; & residents liked it
Do
Carry out the plan
Document: problems& benefits, count immunization errors
Law of ReformNiccolo Machiavelli (1513)
“There is nothing more difficult to manage, more dubious to accomplish, nor more doubtful of success … than to initiate a new order of things.
The reformer has enemies in all those who profit from the old order and only lukewarm defenders in all those who would profit from the new order.”
The first idea is rarely the best idea
Repeated Use of the PDSA Cycle
Proposals, Theories,
Ideas
Changes That Result in
Improvement
A P
S D
APS
D
A P
S DD S
P A
Learning fr
om Data
What Small Tests of Change should we use in Adolescent Medicine?
Pediatric Oncology Quality Improvement Projects: CLABSI
Proportion of Children Up-to-date for Hep A Immunization
Domains of QI research:
Quality of care / compliance with guidelinesImplementationPatient safetySystems & operationsPatient satisfactionDissemination / diffusion
Resources for QI Research:SQUIRE Guidelines: Standards for Quality Improvement Reporting Excellence
Pediatrics Quality Reports: Looking for studies
Institute for Healthcare Improvement (IHI)
Armstrong Institute Greenbelt Course
Division of Quality and Safety: Marlene Miller, Nichole Persing, Michael Rinke
4 Conclusions:
1. Improving Patient Quality and Safety is one of your central jobs as a physician• Thousands of people die each year from lapses in
Patient Quality and Safety2. To improve Patient Quality and Safety you have to
change the system3. We must study changes to know if changes improve
the system• Model for Improvement
4. Pediatrics is working hard to improve Patient Safety and Quality: GET INVOLVED!
“One does not discover new landswithout consenting to lose sightof the shore for a very long time”
-Andre GideNobel laureate in literature
Thank You
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