emergency department quality improvement

Emergency Department Quality Improvement

Abdulaziz Saddique Pharm.D., CPHQAssociate executive Director for Quality Management

College of Medicine and the University Hospitals

Dr. Abdulaziz Saddique 2 TIMELY SERVICES IS THE KEY TO QULAITY EMERGENCY DEPARTMENT SERVICES

Why ED Quality Program

To improve quality of care Provided by the Emergency Departments to increase the

“early indicator” rates for serious diseases e.g., MI,

Pneumonia

Dr. Abdulaziz Saddique 4

Why ED Quality Program

Patients Outcome Is Dependant On Initial

Treatment Carried Out In The Emergency

Department in Timely Manner.


Healthcare Quality Scenario

ActivityProcess

(Chain of activities)

Product

3 Process qualityThroughput time, conformance to

protocols, avoidance of wasteful resource usage

1 Effectiveness Fit to customer needs,

benefit to the customer's)

2 Product quality• Fit to specifications• Customer satisfaction• Quality as seen by a peer

4 Organizational quality

Employee satisfactionStructures, systems


Examples of Indicators

Acute Myocardial Infarction

Community Acquired Pneumonia


AMI Indicators

Aspirin at hospital arrival

Beta blocker at hospital arrival unless contraindicated.

Thrombolytic agent received within 30 minutes of hospital arrival

PTCA received within 90 minutes of hospital arrival


Preliminary Baseline Indicator Rates for AMI

80.5

61.2

33.3

9.1

80.0

60.8

26.5 27.4

95.2

88.0 85.7 85.7

0

10

20

30

40

50

60

70

80

90

100

Quality of Care Measure

Perc

ent (

%)

Michigan National Benchmark

ASA within 24 hrs. BB within 24 hrs. Lytic < 30 min. PTCA < 90 min.


Pneumonia Indicators

Initial antibiotic received within 4 hours of hospital arrival

Initial antibiotic selection for community-acquired pneumonia (CAP) in immunocompetent patients

Blood culture performed before first antibiotic received in hospital

Oxygenation assessment (arterial blood gas measurement or pulse oximetry)


Preliminary Baseline Indicator Rates for Pneumonia

57.5 59.6

76.2

93.4

59.7 58.8

81.1

93.7

100.0

87.9

95.7

0

10

20

30

40

50

60

70

80

90

100

Quality of Care Measure

Perc

ent (

%)

Michigan National Benchmark

n/a

ABX < 4 hrs. Rec. ABX BC Before ABX Oxygenation


Whole system Ownership

PrimaryCare

Reforming Emergency Care

See & TreatA&E

Emergency Services Collaborative

Triage

Bed management

Streaming

Min

ors

Majors

Ambulance

SICU

Walk-inCentre

Social

Care

MICU

Triage


Basics of Quality Improvement

Vision, and MissionStrategyInnovationTeam WorkMomentumGrowthFocusCustomer ServiceAttitude

Dr. Abdulaziz Saddique 13Nothing happens unless first a dream


Vision.

The vision of the organization begins with its leadership.

YOU WILLMAKE $10000000000


Vision

Without vision there will be nothing to look forward to.

There will be no clear path to follow

It will be a Blind leading Blind


Change Requires Shifts inKnowledge, Skills and Attitudes

Knowledge

HabitsBehaviorMindset

What? Why?

Want ToHow To?

Skills Attitude and Desire


Those who are victorious plan effectively and change decisively. They are like a great river, that maintains its course, but adjusts its flow.


Process of Strategy Development

Vision, and mission statement and accountability.

Evaluation of your organizational performance.

Customer’s satisfaction.

Market analysis

Departments functions.

Monitoring of your services.

Updating of your services.

Dr. Abdulaziz Saddique 19If There Is A Better Solution, Find It.


Innovation

Development or adaptation of Indicators

Critical Pathways

Standardized treatment


Teamwork Is The Ability To Work Together Towards A Common Vision. It Is A Fuel That Allows

Common People To Attain Uncommon Results.


Why Use Teams ?

Participation allows an individual:The opportunity to contribute ideasTo experience the change processTo have clear understanding of the objectiveTo gain a sense of ownershipTo become committed to the process and become a change advocate


Medical Staff involvement

Medical staff are:The driving force of the healthcare facility.The heads of the healthcare teams.The operators of the organization.Carry the responsibility of the well being of the patients.


A Little Push In The Right Direction Can Make A Big Difference.


Momentum

Each organization or Administration have differ motivating factors, find the most appropriate motivating factor for your organization to get your Vision supported.


First Things First

Quality Improvement is not valid unless we have the infrastructure for it.


Golden Rule

PUT THE HORSE BEFORE THE CARRAGE NOT THE CARRAGE BEFORE THE

HORSE


QI Infrastructure Development

Set up the Standards of Care

Select team members trained in CQI application

Develop an Aim Statement

Develop Policies and Procedures

Develop Indicators for Care

Identify areas of deficiencies

Dr. Abdulaziz Saddique 29The rung of a ladder was never meant to rest upon, but only

to hold your foot long enough to put the other foot higher.


Growth

Setting the standards is the first stepping stone towards quality services.

Your goals should include standards improvement through continuous quality improvement.

Dr. Abdulaziz Saddique 31Obstacles Are Those Frightful Things You See

When You Fail To Focus On Your Goals.


Focus

Focusing on the Goals of your organization or department is essential in removing all obstacles or problem related to your service.

Dr. Abdulaziz Saddique 33Success In Business And Customer Service Go Hand

In Hand.


Customer Service

Quality is dictated by customers not the organization.

Customer satisfaction (either internal or external) is the most valuable assets of the organization.

Dr. Abdulaziz Saddique 35If It Is To Be … It Is Up To Me.


Attitude

Nothing is free, you have to work for your goals and objectives

Make your goals and objectives visible for others

Your staff are your best assets get them involved

Dreams can come true if you want them to.


EDQIP Action Plan

Launch QI conference

Participate in shared-learning sessions

Develop QI projects

Involve all your staff

Identify your customers (internal)

Develop project team

Listen to your customers


Customers Participation Discussion Points

Highlight ED strategies

Speak with DATA

Don’t criticize any one

Compare individual ED rates with peer group and state aggregate rates

Outline your plan for Improvement

Ask for support to your mission


Quality Improvement Strategies in the ED

Join EDQIP!Rapid-cycle initiatives

Multidisciplinary team approach

Share interventions with other hospitals


What Works to Improve Care?Role of Systems-based Improvement

CME and didactic programs have little impact on changing behavior!

Effective strategies includereminder systems

standing orders

clinical pathways or protocols

opinion leaders and physician champions

self-monitoring and feedback

Davis DA, et al. JAMA. 1995;274:700-706.


“QUALITY OF CARE” . . . An elusive concept???

“Like Beauty, quality of care is in the eye of the beholder.

It can't be defined or measured.”

"Quality of care is like the weather;

everyone talks about it,but you can't do anything about it."


ED Quality Improvement Programs

Washington University/ Barnes Hospital:Aim: to decrease waiting time in the ED to < 180 min.

Process:

Patients flow study

Adjusting Hours of Operations

Expediting initial evaluation, reducing turn-around time for lab radiology and expediting specialty consultations

Outcome: The waiting time was decreased to less than 160 min.


Melbourne Metropolitan Hospital

Aim: Decrease ED Length of Stay (LOS), and resolve bed access block

Process: Use of protocols for common conditions

Transparent bed-management processes,

Focus on efficient use of the available beds, particularly through admission and discharge planning.

Outcome: Decrease waiting time in EDLOS, more beds became available for Critical patients


Principles for Integrated Bed Management1. There is an organization led commitment to

manage all hospital beds. 2. There is a centralized point of authority and

accountability for the allocation of all hospital beds.

3. A bed management forum is established to identify and resolve bed management problems. The hospital executive supports this forum.

4. A documented policy framework supports integrated bed management principles.

5. The function of allocating all hospital beds is centralized.


Principles for Integrated Bed Management6. Bed allocation staff has appropriate authority to

allocate beds. 7. Integrated bed management occurs 24 hours

per day, every day. 8. Integrated bed management must be linked

with the needs of inbound and outbound patient traffic

9. Allocation of hospital beds is based on agreed medical criteria.

10. The allocation of beds to clinical units is notional.


Principles for Integrated Bed Management11. A flexible bed base is built into the operating

requirements to meet fluctuating bed demands. 12. Patients are admitted to their correct specialty

ward/unit on admission or within 24 hours where appropriate.

13. A patient’s episode of care is planned from pre-admission/emergency, through admission and discharge back to the community. Patients and carers are partners in this process.

14. An interdisciplinary team plans and coordinates care and support services for a patient’s episode of care.


Principles for Integrated Bed Management

15. Integrated bed management is supported by accurate real time information. Data is continuously collected, audited, analyzed and disseminated to guide resource management and optimize efficiency.


Questions/discussion

emergency department quality improvement

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