A Stepwise Approach to Quality Improvement

Michelle Mourad, MD

Director of Quality and Safety, Division of Hospital Medicine

UCSF Medical Center

Why do we fail to do simple things that improve care?

Hand Hygiene 60% reliable

Central Line Bundles70% reliable

VTE Bundles80% reliable

Prog

ress

Time

Best practice

Actual practice

Quality Gap

What is QI ?

What is QI?

Yay QI

QI is about producing reliable and sustainable change.

Yay Sepsis! I’m tired

Foley out DVT ppx Pain Control Daily BM

Yay QI!

Start with a story…

• Mayoral election in Romania

• Neculai Ivascu incumbent mayor

… “ I know he died, but I don’t want change.”

I’ll ask you a question…

Do you work in a great hospital?

• Do you work in a great hospital? –What’s keeping it from being great?–Do the leadership and faculty want

greatness? Do you?

• If we all want to work at a great hospital…

You as a leader• Doctors not trained as leaders

• Doctors make poor followers.

Objectives

• Understand how the principles of QI can help you achieve PCQN vision

• Guide you through a stepwise approach to improvement

• Understand how PCQN data can be used for improvement

You log into the PCQN website after a recent Palliative Care faculty meeting…

Turns out despite a lot of work, your institution is still below the group average

3 All Sites20.00%

40.00%

60.00%

80.00%

n=35N=149

Comparison Data for Site 3

Day 1 to Day 2 Score Improvement (exlcuding those with a Day 1 Score of 0)

Stages of QI – Kübler Ross Style

Shock – Is that my data?

Denial – That can’t be my data

Anger – The measurement strategy must be flawed

Bargaining – Our patients are sicker

Depression – No one else is doing any better

Acceptance – We should probably try to improve

Emot

iona

l Res

pons

e

Time

How do we improve care?

• Set the vision for improvement

• Understand the Problem • Identify Areas for

Improvement• Devise a Measurement

Strategy • Prioritize small tests of

change• Measure Change• Message value & Sustain the

change

Using a QI framework to improve care

• Set the vision for improvement– Understand the Problem– Identify areas for Improvement– Devise a measurement

strategy – Prioritize small tests of change–Measure change– Sustain the change 8:4

0

Vision• Align, Define & Inspire

• Focus on why, not what or how.

As a leader of change, the GOAL is not to make every body do what you want, the goal is to inspire people to believe

what you believe

The BI will eliminate all preventable harm by 2020.

Using a QI framework to improve care

– Set the vision for improvement• Understand the problem– Identify areas for improvement– Devise a measurement

strategy – Prioritize small tests of change–Measure change– Sustain the change

9:15

The problem = Persistently high pain scores

Equipment Process People

Materials Environment Management

The problem = Pain management

- Sicker patients- Pain meds not stocked

- Staffing on the floors

- Lack of Nursing buy in- Unclear Physician buy in

- No timely orders

Fishbone Diagram

Equipment Process People

Materials Environment Management

The Problem

primary cause

secondary cause

The effectThe Cause

Equipment Process People

Materials Environment Management

Table exercise – Create a Fishbone – 10 minutes

Equipment Process People

Materials Environment Management

- Sicker patients- Pain meds not stocked

- Staffing on the floors

- Not reliably measuring pain scores

- Lack of Nursing buy in- Unclear Physician buy in

- No timely orders

- Teams wont let PC write orders

- Rounding only once a day

What did you come up with?

- Need more chaplain / SW support

- Existential pain, not treated with opiates

- More cancer patients

- PCAs take too long to order

Fishbone = structured brainstorming about why you have the problem

Use as a guide for data you may want to

collect

Use data to ensure you are fixing the right problem

Equipment Process People

Materials Environment Management

The problem = Timely pain management

- Sicker patients- Pain meds not stocked

- Staffing on the floors

- Lack of Nursing buy in- Unclear Physician buy in

- No timely orders

Fixing Nurse & Physician buy in

Is different than fixing time to pain med

delivery

Case example: Patient Satisfaction

• Goal: Improve Patient Satisfaction with MD Communication

• Intervention: Teach hospitalists best practices in patient communication

• Outcome: No improvementWHY?

• Data: Patient comments all report dissatisfaction with communication between hospitalist & specialists which was not improved.

We discover

• Hour long delays between recs & orders

• Nurses not giving doses promptly

• Patients aren’t asking for PRN meds

• No afternoon reassessment

– Set the vision for improvement– Understand the problem

• Identify areas for improvement– Devise a measurement

strategy – Prioritize small tests of change–Measure change– Sustain the change

9:55

Using a QI framework to improve care

Identify areas for improvement

• Go and see for yourself• Keep asking why until you get to the root of things

Identify Areas for Improvement(current state)

PCS Roun

ds(day 1)

Informal ✔ in

w/ primar

y teams

FAMILY

MTGS

Write notes with

“official

recs”

45 year old woman with malignant bowel obstruction due to colon cancer with nausea,

vomiting and abd pain, progressive inability to take oral meds/hydration

3 hrs1 hr 3 hrs 2 hrs

PCS Roun

ds(day 2)

• Team (or you) wrote orders “just before they went home.

• Patient unaware of “new” regimen.• Did not ask for additional PRNs• Nurse didn’t provide info on available

meds

Day 2 pain

scores unchang

ed

Write orders

ORPage

team with updated

recs

Removing Obstacles

• Ask your team why don’t people do this already?