1 applying quality improvement skills to stroke care 11 th annual stroke collaborative toronto, 20...
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Applying Quality Improvement Skills to Stroke Care
11th Annual Stroke CollaborativeToronto, 20 October 2008
Dr. Ben Chan, MD MPH MPA
CEO, Ontario Health Quality Council
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What is Quality?
“Quality health care means doing the right thing at the right time in the right way for the right person and having the best results possible.”
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Attributes of Quality & High Performing Health System
• Effective• Efficient• Equitable• Accessible• Safe• Patient-centred
• Focused on population health
• Integrated• Appropriately
resourced
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What is Optimal Stroke Care?
• Population health• low physical activity, overweight• smoking, excess etOH, stress• diet (low fruits/veggies, hi fat/sodium)• lack of awareness of signs & sx
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What is Optimal Stroke Care?
• Stroke prevention in primary care• screening - for DM (q3yrs), cholesterol (q1-3 yrs),
BP• diabetes - BS control (A1c<7, FBG 4-7, 2 hr
postprandial 5-10)• BP control (140/90 or 130/80 if DM, kidney dis)• ASA (if past TIA, stroke, CAD, DM, etc.)• coumadin (if atrial fib)• lipid control / statin (w/ risk stratification)
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What is Optimal Stroke Care?
• Acute Stroke Management• tPA within 3 hrs onset• CT/MRI asap• dedicated stroke unit admission• dysphagia assessment• tight BS control
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What is Optimal Stroke Care?
• Post stroke treatment• access to dedicated stroke rehab unit (in-pt, cmty)• carotid imaging & endarterectomy/stent (if
indicated)• LTC unit with stroke experience• post-stroke depression mgt (SSRI, etc.)
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Which Areas Have Biggest Room for Improvement?
• Population Health• Stroke prevention in Primary Care• Acute management of stroke• Post-stroke treatment
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How Are We Doing With Quality?
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Effectiveness – Chronic Disease Management
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INSERT Bar Chart from report – page 91
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Avoidable Complications of DM, CAD
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Avoidable Complications With Better Management of DM, CAD
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Preventable Risk Factors
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Preventable Risk Factors
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How Do We Move…
• From Strategy…
• To Action?
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QI Tools & ApproachesArea Approaches
Population Health Policy Changes Public Education
Stroke Prevention – Primary Care Acute Stroke Mgt
Post-Stroke Care
QI Tools for Changing the Way Care is Delivered
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Before Fixing the Problem…• Diagnose the underlying root causes• Consider differential diagnosis of causes• Prioritize which causes to address first• If not sure which causes to tackle first,
collect some data
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Process Mapping
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A process map gives you…
• An overview of the complete process• A visual aid to effectively plan• Ideas from all different types of staff
What you need…• Blank wall• Yellow stickies• Facilitator – focus on main scenarios
(what happens 80% of time)
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Analyzing the MapFrom the patient perspective:
– How many steps are there for the patient?– How many times is the patient passed from
one person to another?– What is the approximate task time?– What is the approximate wait time?– How many steps add no value for the
patient?
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• eliminated?
• Combined with other steps
• Done in different order?
• Done elsewhere? Reduce wasted travel?
• Done by someone else more effectively / efficiently?
• Done in parallel instead of sequentially?
• Where are bottlenecks? Need to shift capacity to here?
For each step, ask if it can be:
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Example: Routine Labs in Primary Care
Pt Appointment Labs needed?Give Pt
RequisitionLab Done
Yes
No
Abnormal?
No
Yes
Book earlier f/u, or call pt
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Alternate Process
Scheduled Apptmt,
Review Recent Labwork
Pre-book lab for before next
apptmt in 3 mo
Show up forLab apptmt?
No
Yes
Lab Done
Reminder to pt before lab apptmt
RN calls pt x 2, rebook
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Ishikawa Diagrams
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Ishikawa Diagrams• Put problem at right• Draw spine• Draw offshoot lines for categories of causes• Draw offshoots for causes of causes
– Use “Five Why’s” technique to elicit root causes
• Identify those causes which you can impact• Prioritize as a group the most NB causes
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Why Aren’t Labs Done?
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Reasons Why Labs Not Done
Reasons:• Pt can’t understand
instructions• Language barrier• Lab hours inconvenient• MD forgot to order lab• Pt lost the requisition• Pt forgot• Pt missed apptmt – weather,
emergency• Pt not seen for months (e.g.
gets med refills by phone)
Change ideas?• • • • • • •
•
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Lots of Great Ideas…
• What next?
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Aim Statements for QI Projects
• What are we trying to accomplish?
– “Improve diabetes care for our patients.”
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Aim Statements for QI Projects
• What are we trying to accomplish?
– Improve diabetes care for our regular patients in the Bay St, May St. and Gray St. clinics. Increase the % of these patients hitting their targets for BP, cholesterol & AIC to 75%. Do this by March 2009.
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Well Designed Aim Statements
Is it clear?Is it measurable?Is time specified?Is the target population identifiable?Can you hear the promise for better
patient outcomes?
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Measures:How Will We Know a Change is
an Improvement? • outcome measures
– e.g. A1C, BP, chol
• Process measures– e.g. use of recommended drugs, % getting regular labs– e.g. improved team functioning
• Consider balancing measures – Unintended consequences
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Example: Pt Self-Mgt
• Let’s implement patient self-management over the next few months. We’ll show a nifty bar chart of how our results for A1C & cholesterol improved before and after.
Good or bad idea?
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Quality Measurement• Measure frequently throughout course of
project• Get early feedback on impact of changes• Correct course or accelerate
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Annotated Run Charts% of patients who have set >= 1 written pt mgt goal in past 6 months
23 24 21 23
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10
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46 47 50
0
10
20
30
40
50
April
May
June Ju
ly
Augus
tSep
tOct
Nov
Dec Jan
Time Period
Per
cen
t
new
doctor
Test new tool
New tool w Group sessions
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Where Do I Get the Data???
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Data Sources• Ideal:
– Disease registries• Regular queries from electronic medical record• Stroke registry
• Alternate: small periodic samples– Defect check sheets– Mini-surveys
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Defect Cause Check SheetQuality Improvement Project:_____________________________Defect / Defect Cause of Interest: ________________________Instructions to Recorders on When to Record a Defect:_____Type of patients or services being observed for defects:____Setting: _________________________________________________Time Frame for Data Collection: __________________________Data Recorders:_________________________________________
Defect or Defect Cause Count
MD did not order
Patient lost requisition
Lab hours/location inconvenient
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Sampling PlansMethod Description Example
Block Sampling
Make x observations consecutively. Do this at regular intervals.
Every Monday morning, give a mini-survey to the first 10 patients that arrive.
Systematic Sampling
Make observations on the every y-th patient.
I want 10 observations per week. I see 100 patients per week. So, I’ll give every 10th patient a mini-survey.
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What Changes Can We Make That Can Result in
Improvement?
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Source of Change Ideas• Best practices literature • other QI initiatives• Your own system analysis• Ideas from your peers• Your own brainstorming
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What Changes Can We Make That Can Result in
Improvement?• Avoid jumping immediately to the
perceived panacea solution• Consider best practice examples for
implementation from elsewhere• Conduct careful analysis of system, root
causes, cause & effect, process maps before implementing changes
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ImplementationExample: Pt Self-Mgt
• We’re going to create a committee. In the next four months they’re going to research pt self mgt tools. We’re going to carefully select a package of materials. Then we’re going to have extensive in-service sessions to train all the staff on how to use the materials.
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Implementation Example:Pt Self Management
• Pt self management seems like a great idea. There are many different tools out there. We’re also not sure who’s the best person on our team to deliver different components of self management – the doctor, nurse, dietician, counsellor. Let’s systematically test different ways of implementing this and see what works best in our environment.
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Alternative Approach from QI Science
• Implementing Change: PDSA cycles• Plan, Do, Study, Act• Testing predictions • Learning from small tests of change• Rapid cycle improvement
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What should a PDSA look like?
Write It down!
ObjectiveWhat do you want to learn/try?
PlanWho, what, where, when?MeasurementPredict outcome as a group
DoJust do it!
StudyWhat worked? What didn’t? Predict correctly?
ActNext steps
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learn as you go small tests, not
(necessarily) small changes
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Multiple PDSA Cycle Ramps
A P
S D
A PS D
A P
S D
D S
P A
Coordination w/ DM educators
Pt self-mgt
A P
S D
A PS D
A P
S D
D S
P A
A P
S D
A PS D
A P
S D
D S
P A
Standing orders, checklists
Try different ways of implementing change concept
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Learning Collaboratives
Support
SPREAD
LW0
LW1
LW2
LW3
Pre- work
Select Topic Participants Reference Panel
Identify Change Concepts
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SK CDM Collaborative• Key Aims for CAD, diabetes
– 75% of diabetes pts with A1C <7.0%– 75% of pts with HDL/Tchol < 4.0– 75% of pts with BP < 130/80
• Access aim: 80% seen on day of choice
• Two waves deployed (Nov 05, Nov 06)
• Enrolment to date:
– 28% of all family physicians in Sask
– All RHAs in province
– Mix of FFS, non-FFS
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Learning Workshops
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Storyboards – Sharing Learnings
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Regional Improvement Teams
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CDM Web-based Patient Registry
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CDM Toolkit - Flowsheets
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KEY MEASURE% of Diabetes Patients with a BP ≤ 130/80
among Wave 1 Practices, Baseline vs Month 9 (Nov 2006)
51.5
75.0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
3 8 23 32 15 18 30 21 31 29 35 11 26 16 1 4 13 2 22 10 27 6 9 24 14 17 20 33 25 34 19 28 7 5
Practices
Monthly Average Baseline Goal
The absence of a practice's bar is due to lack of a baseline value or small counts (i.e., < 6)
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% of diabetes patients prescribed a statinPractice 1 (top left) and the top 5 improvers
Practice 1
Mar-0649.40
Apr49.40
May49.40
Jun48.81
Jul49.60
Aug51.67
Sep51.42
Oct52.89
Nov51.51
Dec54.33
Jan-0753.60
Feb54.83
Mar55.28
Apr57.14
May59.20
Jun59.20
Jul59.67
MonthPercent
Run chart
Median line = 52.89
Mar-06 Ap
rMay Ju
n Jul
Aug
Sep Oct
Nov
Dec
Jan-
07 Feb Mar Ap
rMay Ju
n Jul
30
35
40
45
50
55
60
65
70
75
80
Practice 23 - top improver
Median line = 70
Mar-06 Ap
rMay Ju
n Jul
Aug
Sep Oct
Nov
Dec
Jan-
07 Feb Mar Ap
rMay Ju
n Jul
0
10
20
30
40
50
60
70
80
90
100Practice 31 - top improver
Median line = 50
Mar-06 Ap
rMay Ju
n Jul
Aug
Sep Oct
Nov
Dec
Jan-
07 Feb Mar Ap
rMay Ju
n Jul
0
10
20
30
40
50
60
70
80
90
100
Practice 4 - top improver
Median line = 51.57
Mar-06 Ap
rMay Ju
n Jul
Aug
Sep Oct
Nov
Dec
Jan-
07 Feb Mar Ap
rMay Ju
n Jul
0
10
20
30
40
50
60
70
80
90
100Practice 5 - top improver
Median line = 30.64
Mar-06 Ap
rMay Ju
n Jul
Aug
Sep Oct
Nov
Dec
Jan-
07 Feb Mar Ap
rMay Ju
n Jul
0
10
20
30
40
50
60
70
80
90
100Practice 8 - top improver
Median line = 45.58
Mar-06 Ap
rMay Ju
n Jul
Aug
Sep Oct
Nov
Dec
Jan-
07 Feb Mar Ap
rMay Ju
n Jul
0
10
20
30
40
50
60
70
80
90
100
My practice
Practice 23
Practice 8Practice 5Practice 4
Practice 31
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PDSA Catalogue
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Sask. CDM CollaborativeImprovements in Diabetes & CAD
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OHQC QI Activities in Ontario
• QI improvement & innovation partnership (QIIP)– Aim to improve DM care, FOBT, improved
access– Partnership with MOHLTC
• OHQC resources for quality– QI tools on website– Tools for improving access & office efficiency– QI skills development
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Key Messages
• Use QI science & tools to improve care• Understand root causes of quality
problems first• Set clear aims & targets, continuous
measures, & ideas for improvement• Test-test-test rather than plan-plan-plan
Look for support in implementing QI
