R1 QI Worksheet

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First QI Project

This assignment will be submitted at two points in time:

I. Fourth Friday of Block 3

a) Clinic Approval of Project

b) QI Worksheet: Assemble Your QI Team and Plan Phase

II. Fourth Friday of Block 5

a) QI Worksheet: Do, Study, Act Phases, Reflection, and Lessons Learned

Each task should be submitted to the DFM resident research training coordinator: rrtc@ucalgary.ca

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First QI Project: QI Worksheet

• How to use this worksheet: Type your responses into the correct fields – they will

expand as you type.

• Write in complete sentences and provide as much detail as possible.

• When you create attachments, create an appendix at the end of this document and

reference your attachments in your answers.

Submit your QI Worksheet on or before the dates listed above.

Assemble Your QI Team

Name of Clinic: Pencil Town Clinic

Date: September 5th, 20XX

Role – MOA, Nurse,

MD, EMR specialist,

Clinic Manager, etc.

Responsibilities Name

Residents The residents will facilitate the QI

project by engaging the clinic,

collect data, analyze it, and help

come up with interventions.

1. Yong S. Hanger 2. Aileen H. Bergman 3. Nafeesa Daliyah Malouf 4. Zi Ku

Nurses The nurses will escort patients to the examination rooms and take their weight measurements. They will also help design the interventions.

1. Thierry Rocheleau

2. Sadie Douglas

3. Stanley McIntyre

MOAs The MOAs will perform vital administrative duties in the clinic such as greet patients when they arrive and queue them up for their appointments. The MOAs will also provide another source of perspective on clinic flow vis-à-vis our QI project. They will also help design the interventions.

1. Dennis S. Lam 2. Veda Salcedo Lemus

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Physicians The physicians will see the

patients who move from the

waiting room to the examination

rooms. They will also help design

the interventions.

1. Dr. Lucas Oliveira Barros 2. Dr. Ruth V. Bates 3. Dr. Bonnie R. Coggins 4. Dr. John G. Hansen 5. Dr. Gary B. Johnson

Clinic Manager

Ensure that our QI project

adheres to clinic policy and

procedures and approves project.

Iselda Soliz Valenzuela

EMR Specialist Verify that project is doable from

an EMR perspective

Goodwill Boffin

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Clinic Approval of QI Project

To ensure this project is relevant to your clinic and meets its needs, we require clinic approval for all

resident QI projects.

Instructions: Please select your clinic type in the boxes below, answer the questions, and sign to approve the

residents’ QI project. If your project requires the usage of or modifications to your clinic’s EMR, have the EMR

Specialist/DFM Informatics lead sign-off on your project to indicate the feasibility and timeliness of your use or

requested modification. For example, you may wish to collect a certain type of data, but your EMR cannot search

for it or you may wish to make a change to the EMR that is technically feasible, but not practical given time

constraints, etc.

If you work at one of the three core clinics (CTC, SFMTC, or SHC) and intend to use the EMR as part of your QI

project, you must get approval from Scott Jalbert, the DFM’s Informatics team lead, in addition to the clinic dyads.

Community Clinics or Rural Sites – since there are various types of clinic leadership, this form can be

signed by an individual who oversees and manages clinic affairs.

Clinic Name or Rural Setting: Pencil Town Clinic

Approval Signature:

September 4th, 20XX

Sign Here Date

Core Teaching Site (check one):

CTC ☐ SHC ☐ SFMTC ☐

Clin

ic D

yad

Clinic Manager

Signature

____________________ _____________________

Sign Here Date

Site Medical Lead

_____________________ _____________________

Sign Here Date

EMR Specialist/Informatics

team lead – if needed

September 4th, 20XX

Sign Here Date

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Plan Phase

Topic: CHF Patients’ weights taken at each visit

1) Describe your clinic: Where is your clinic located? How busy is your clinic? What types of

patients frequent your clinic? What makes your clinic unique? Paint a picture of your clinic; by

doing this, your project will be informed by its context.

Pencil Town Clinic is a busy family medicine clinic located in the southern district of Stationary

City. For close to a decade, the clinic has provided health care to a wide variety of patient who

present with all kinds of complaints, from the common cold to managing chronic pain. The clinic

has 5 full-time physicians, 3 nurses, 2 MOAs, and 4 residents who work at the clinic 2.5 days a

week. The clinic also has a part-time EMR specialist who visits the clinic once a week to deal with

technical issues and help the staff work more efficiently.

2) Problem/Opportunity statement – What is wrong? What did your practice audit show? Why

bother improving this?

Recently, one of the preceptors was going through her EMR and realized that patients with CHF

were not having their weight measurements taken on a regular basis. We need to have up-to-

date weights on record, so we can track CHF patients’ health – their lives may depend on it.

3) What are the root causes of your practice gap (Use at least one QI tool: e.g., Process map, Cause

and Effect Diagram/Fishbone, 5 Why’s – see the Resident QI Handbook for guidance -

https://is.gd/JaoGR5).

4) Why is this topic important to your clinic?

This topic is important to our clinic because we need to know when patients’ weights fluctuate.

Dramatic changes in patients’ weights may indicate retained fluid.

5) Who will benefit from this project?

The patients will benefit from having informed family doctors and the clinic staff will benefit

from having a more complete EMR and picture of patients’ health.

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6) How did your QI team arrive at this topic?

We held a meeting to discuss potential QI project ideas and one of the physicians mentioned

that one of his patients with CHF died recently and, upon inspection of her EMR, realized that

the patient didn’t have any weight measurements on file, among other things. The physician

suggested that we could use this topic as our resident QI project and the nurses and MOAs

agreed.

7) Aim statement – What are you trying to accomplish? Your aim statement should be clear, time-

specific, location-specific, express what you are trying to improve, and by how much. Use the IHI

format for aim statements demonstrated in the Resident QI Handbook and focus on a process

measure (See Resident QI Handbook).

“By November 10th, 20XX, 95% of patients with CHF who visit Pencil Town

Clinic will have their weights measured and documented in the EMR.”

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ARECCI Results

Instructions: go to http://goo.gl/lgLQyc and click on “ARECCI Ethics Screening Tool.” Answer all of the

screening tool’s questions and send the results to rrtc@ucalgary.ca using the link at the conclusion of

the screening tool.

8) According to ARECCI, you are doing what type of project? Check one – if you get anything other

than “QI Project,” contact rrtc@ucalgary.ca

QI Project Research Project ⃝ Program Evaluation ⃝

9) What is your ARECCI score?

1

10) If your ARECCI score is greater than 5, what explanation can you give for your elevated score?

Not applicable

Baseline Measure – How will we know that a change leads to an improvement?

QI Measure1 Breakdown – provide an answer to each of these:

11) Outcome Measure (this is the “big picture” goal of your project if you were to continue your

project beyond the required one PDSA cycle):

Outcome Measure: To decrease the number of hospital admissions by patients with CHF.

1 Check out Resident QI Handbook for information on the various QI measures: https://is.gd/JaoGR5

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12) Process Measure (Focus on this measure for your R1 PDSA Cycle):

Process Measure: For our QI project, our process measure will be the number of times patients

with CHF have their weight taken versus not taken. We will find this number by reviewing a

month’s worth of patient presentations to see how many patients with CHF had their weights

measured before being sent to examination rooms.

13) Balancing Measures (capture the implications of making a change to one part of the clinical

system or process. E.g., if you are surveying patients, does it slow clinic flow down? Not

necessary for your R1 PDSA Cycle, you just have to acknowledge it by describing one):

In this QI project, a balancing measure would be time, since measuring every patients’ weight

adds time to the flow of patients from the waiting room to the examination room. To check for

this, we’d have to measure patients’ wait times with a stopwatch and average them before the

intervention and during it.

14) Plan for data collection: Who is collecting the data? What type of data is it? When will they

collect it? How frequently will they collect it? Where is the data coming from? How are they

going to collect it? If you are using a tool for data collection, attach it. Make sure everyone is

on board.

We will get a list of patients for one month’s time and search them out in the EMR. We will use

a simple Yes/No survey to determine how many of these patients had their weights taken

before seeing their family doctors. Our survey will look like this:

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15) How do your measures link to your aim statement? Make sure that your measurements

actually account for what you are trying to improve. For example, if you are increasing how often

patients are inquired about their smoking status, you measure how often they are inquired about

smoking status.

Counting the number of patients with CHF who have their weights taken satisfies our aim

statement because we are trying to improve the number of CHF patients who have their weights

taken. This means there is a direct relationship between our measures and our aim statement.

16) What question(s) do you want to answer with this PDSA cycle (if different from aim

statement)?

What types of patients don’t have their weights taken?

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Baseline Measure Results

17) What are your results? Describe and attach a graph to this document.

Over the course of a month, Pencil Town Clinic saw 321 CHF patients. Out of these 321 patients,

73 had their weights taken, which means we are measuring weights at a 23% success rate. Since

we’re striving to attain a 95% success rate, we have a lot of room for improvement.

18) What do the results tell you?

Our results indicate that we are only measuring the weights for roughly every one in four CHF

patients. Since we want to increase the frequency of weight measurements, we have a lot of

room for improvement. Based on our results, it looks like patients who visit for prescription

renewal frequently do not have their weights taken.

19) Were there any surprises?

It was surprising to see how infrequently we measure CHF patients’ weights.

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20) Based on your baseline findings, what potential interventions could be used?

Since the patients travel with the nurses from reception to the examination room, we think

placing brightly coloured signs at reception and next to the scale will prompt the nurses to take

patients’ weight measurements. Alternatively, we could put a sign on each exam room door that

reads “Did you take the patients’ weight?”

21) What resources would be required to run these potential interventions?

In both cases, signs will need to be printed and put up.

22) What intervention are you going to use?

The doors signs could slow things down: since doubling-back with the patient may add more

time to the clinic workflow than being prompted at the beginning of the trek, we will go with the

brightly coloured signs being placed at reception and at the scale.

Submit your team’s QI worksheet and wait for feedback from your RRTC.

Deadline: Fourth Friday of Block 3

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Do Phase

Your intervention measure quantifies the same thing as your baseline measure.

23) What are the results of your intervention measure? Describe and attach a table.

After implementing the brightly coloured signs, we looked at a month’s worth of CHF patients.

This time, the clinic saw 356 CHF patients and out of this total, 226 were weighed. These results

indicate that we are now operating at a 63% success rate.

24) What challenges did you encounter while implementing your intervention?

Depending on how busy each clinic day was, sometimes the nurses felt rushed trying to get the

patients to the exam rooms and, as a consequence of this busyness, forgot to take patients’

weights. In addition, one of the signs fell off the wall and disappeared sometimes towards the

end of the month.

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Study Phase

25) Compare and contrast your Intervention to Baseline Measure – Provide a table that illustrates

your baseline versus intervention measure.

Our baseline results indicated that in month, the clinic saw CHF 321 patients and weighed 73 of them.

This provided us with a baseline success rate of 23%. During the time that we applied our intervention,

the brightly coloured signs, our clinic saw 356 patients over a month and 226 of these patients were

weighed, which translates to a success rate of 63%.

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26) Was there improvement from your baseline to your intervention measure?

Yes. We succeeded in bringing our rate of weight measurements up from 23% to 63%.

If yes, how so?

We increased our rate of measuring CHF patients’ weights and improved on our baseline

measure.

Why do you think you achieved improvement?

We think we gained this improvement because our brightly coloured signs raised awareness in

the clinic and prompted the nurses to think of taking patients’ weights whenever they

transferred patients to the examination rooms.

What observations can you make?

It appears that clinic busyness impacts the frequency of patients’ weights being taken.

If there was no improvement, was there a neutral impact or did things get worse?

Not applicable – there was improvement.

What explanation can you give for this lack of improvement?

Not applicable

27) If your project involved an EMR intervention (such as an alert, template, etc.), did the change

in the EMR make a difference? How did it influence your QI project’s area of improvement?

For this PDSA cycle, we did not modify the EMR, we simply used it to check to see how often

patients were being weighed.

28) Would you recommend regular, general use of this specific EMR intervention?

Since there was no EMR intervention, this question is not applicable.

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Act Phase

29) Would you recommend standardizing your change? If yes, why? If no, why not?

Since the posters are easy to use and we achieved some improvement by using them, we

recommend that Pencil Town Clinic continue to use the posters.

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Reflection

30) If you had additional questions to be answered by your PDSA cycle (Q.16, above), did your

project answer them? If yes, how so?

We wondered what types of patients were more likely to not be weighed and observed that

individuals who were visiting the clinic for a prescription renewal were often not weighed.

31) If you were to do your project over again, what would you do differently?

If we could do the project over again, we’d post the posters to the wall using a longer lasting

fastener. We’d also have a team huddle at the end of each week to assess how our QI project is

performing. Also, we could deploy an intervention aimed at patients like placing signs in the

waiting room that encourages them to ask to be weighed prior to their appointment.

32) What would your next PDSA cycle look like?

Since we are moving closer to the goal of our aim statement, we could maintain the brightly

coloured posters and add the reminder signs to the exam rooms. This would provide the nurses

with three reminders to take patients’ weights.

33) Based on your experience of running your first PDSA cycle, what would be needed to keep this

project going in the long run?

In order for this project to run long-term, we need complete clinic buy-in. We need someone to

review the EMR on a regular basis to determine how often patients’ weights are being taken and

to develop additional checks. For example, maybe the physicians could double-check the EMR to

ensure that each patient has his/her weight taken or the MOAs at reception could remind the

nurses. Furthermore, the clinic needs to have ongoing meetings where they discuss the results

of this QI project and ideas for habituating the act of taking patients’ weight measures.

34) In terms of sustaining improvement, what data should be collected in order to track the

change?

The presence and absence of patients’ weight measurements in the EMR.

35) Who would be involved in sustaining this change?

The nurses, MOAs, and physicians at Pencil Town Clinic.

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36) How could your clinic translate your results into process or practice changes?

The clinic now knows how it is handling CHF patients’ weight measurements, so it can use the

results of this QI project in a couple of ways. First, the clinic can implement additional reminders

for nurses and staff to take patients weight measurements, regardless of why they’re visiting the

clinic. Second, the clinic could buy some more permanent reminder signs and combine them

with verbal reminders. By doing these two things, the clinic will move closer to attaining their

goal of 95% of patients.

37) What can your clinic learn from this project?

First, the clinic now knows how it is performing in terms of taking CHF patients’ weight

measures. Second, the clinic can learn that a simple intervention can lead to improvement.

Third, the clinic can learn that the responsibility of attaining its aim statement is a shared and

should not fall squarely on the nurses, but the team of clinical staff. For example, MOAs could

help remind nurses to take the weight measurements and physicians could gently remind them

to take the measurements if they forget.

38) Why was it important to involve clinic staff in your project?

The staff needed to be involved because they are the ones who will carry the project forward

once the residents graduate, so they needed to be in on the project design and execution.

Indeed, having the staff select a topic fostered clinic buy-in and contributed to the jump in

success rates from 23% to 63%.

Submit your team’s QI worksheet and wait for feedback from your RRTC.

Deadline: Fourth Friday of Block 5