M Chilvers (MD)

K Luu (MD)

A Gravelle (RN),

M McIlwaine (PT)

V McMahon (RN)

C Loong (RD)

C Burgess (RN)

K Ebbert (MD)

Accelerating the Rate of Improvement in Cystic Fibrosis Care

Learning and Leadership Collaborative 2

Numbers

1

2

1

37

7 5

5P summary and key improvement opportunities

• Staff satisfaction high

• Patient satisfaction high

o infection control, increased efficiency

• Long clinic wait times

• Patient demographics o Geographically diverse, Healthy

• Assessment of core and supporting

processes o Issues, chronic disease management, growth & nutrition, pulmonary

exacerbation

Out of Clinic Visits

Theme and Global Aim Statement

THEME: Improved Health Outcomes

GLOBAL AIM:

We aim to improve the process of arranging an out of clinic visit for a patient with an increased cough who has been deemed to need an assessment by a health care provider(s).

In the BCCH CF Clinic

The process begins with the decision that the patient needs to be seen

The process ends with the patient being discharged.

ASSESSEMENT

Init

ial

CO

NTA

CT

LOGISTICS CONSULT OUTCOME

Patient: __________________________ Age: 5 or older/<5 years old Reason: ____________________________

Jon / RN / MD receives contact via pager / email / telephone

MD / RN does phone assessment and triages to ED / Resp / Clinic (T/Th)

Jon / RN / MD transfers contact to RN / MD / Jon

MD / RN contacts family

MD / RN does documentation for triage

Jon / RN calls PHYSIO to see if available

Jon / RN calls MD to see if available

PHYSIO sees patient / does cough swab

MD / RN calls Jon to book appt

Jon registers patient

Jon / RN calls resp to confirm space / PFT

Resp calls Jon / RN to confirm space / PFT

Jon / Resp creates requisitions

Jon / RN calls patient to confirm time

Jon / RN confirms appt with MD

Jon transport requisitions / chart

Jon / RN confirms appt with PHYSIO

MD sees Patient (Hx &

exam)

PFTs done

Date

Date

Arrival Time

Location Swab sent to the lab via self / tube / porter

Discharge Time

Jon calls RN to inform appt

1

2

3 4 5

Admission

Blood work

CXR

FLOQswab

Antibiotic

Total time

spent in min

Tally e.g.

Circ

le a

ll

applic

able

Pre-implementation Data We collected data on 14 patients

Patients

Min

ute

s

05

101520253035404550556065707580859095

100105110115120

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Total Clinic Staff Time

Tot Clinic T

Post Implementation

Sibling & confusion about physio

Sibling

13

40

15

24

Private Pay

22

30, Jon away

Prebooked as a f/u appt

20

27

0

5

10

15

20

25

30

35

40

45

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Total Logistic Time - POST Intervention

Cont Logist Clinic T

Playbook Introduced

Multiple PDSA With Measures

Sibling & confusion about

physio

Sibling

13

40

15

24

Private Pay 22

30, Jon away

Prebooked as a f/u appt

20

27

Wet cough + drug challenge

0

10

20

30

40

50

60

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Total Logistic Time - POST Intervention

Playbook introduced

July 13, 2015

Expanded

inclusion Sept

15, 2015

2 1 1 1 1

1

1 3 1 1

2

2 4

3

6

1

2

1 1

1

1

7 6 5 4

1

0

2

4

6

8

10

12

Question 1(Fewer Steps)

Question 2(Less Time)

Question 3(Resources)

Question 4(Work Flow)

Question 5(Overall)

Staff Satisfaction

N/A54.543.532

01020304050607080

%

Patient Satisfaction – Overall out of clinic visit

experience

Pre-Implementation

Post- Implementation

Driver Diagram We aim to improve the process

of arranging an out of clinic visit

for a patient with an increased

cough who has been deemed to

need an assessment by a health

care provider(s).

In the BCCH CF Clinic

The process begins with the

decision that the patient needs to

be seen

The process ends with the

patient being discharged.

By working on the process, we

expect: increased efficiency of

workforce better patient

satisfaction, better staff

agreement & satisfaction, better

community involvement,

improved community education,

patient empowerment, timely and

easy access to those families

who really need it,

It is important to work on this now

because: out of clinic visits are

increasing, we are all busy and

need to manage our time

effectively, there is staff

disagreement on best practices, it

influences out physical space, it

influences other the respiratory

staff, influences infection control

practices

Registry Data:

Adjusted BMI mean percentile:

2012: 49.3; 2013: 47.5

Adjusted mean FEV1, %p

predicted:

2012: 98.0

2013: 96.3

We will decrease the total

amount of time taken by

all team members to

organize an out of clinic

visit by 25% by Sept 2015.

We will have excellent

staff satisfaction around

the RAC process (defined

as score of 4-5 on rating

scale)

We will improve patient

satisfaction around the

process of booking an out

of clinic sick visit by an

average of 20% (1 score

out of 5)

We will decrease the

number of steps it takes to

organize an out of clinic

visit by 50% by Sept 2015

80% of all out of clinic

visits will be seen in RAC

or regular clinic if there is

space by Sept 2015

-time for triaging of sick

patient

-time for booking and

organizing visit

-time of each visit

Same as above, but steps

rather than minutes

Pre and post RAC patient

satisfaction surveys

Post RAC staff

satisfaction survey

Tracking all patients seen

outside of clinic in and out

of RAC

1) Having set RAC clinic

times; 2) Playbook so

RAC better understood; 3)

Created urgent PFT slot

saved for RAC; 4)

Eliminated need for clerk

to bring down reqs and

charts

Positive Feedback – no

plans for change

1) Retreat updates about

QI after NACFC; 2)

monthly QI updates to

team

Trial increased inclusion

criteria (Sept 15, 2015)

Specific Aim Measurement PDSA

Numbers

1 Year

2 RAC

1 Team

37 S

7 Members 5 P’s

Lessons

• Leadership

• Team – Involve key players ASAP

• Don’t get stuck

o Semantics, definitions, tasks

Key Lessons Learned

• Learning process

• Do many mini test of change

• Side projects

• Measurement is invaluable in QI

• Communication is essential with both team

members and with families

Select your team wisely . . . . .

Those in which the force of QI is

strong

QUESTIONS?