Quality Improvement: Applications to Practice Grace Propper, MS, RN, CPNP, NNP-BC
OBJECTIVES Review CQI Principles and Methodologies Explore applications to everyday practice Discuss data use in quality improvement
HOW SAFE IS AIR TRAVEL? • Last major crash in continental U.S. • November 12 – American Airlines Flight 587 , an Airbus A300, crashes into a Queens neighborhood in New York City when the plane's vertical tail fin snaps just after takeoff. All 251 passengers and nine crew members on board are killed as well as five people on the ground.
HOW SAFE IS BEING A PATIENT? • 1999 – IOM report – U.S. hospitals KILL 100,000 persons per year with medical mistakes • 2001 – To Err is Human brings attention to this public health crisis • 2014 – How many are we still harming? • Nationally? • At your hospital?
No No ma matter er how w well ll clinicians linicians ar are tra rain ined ed an and m motivated, tivated, i if f humans mans ar are involv volved, ed, ER ERROR ROR IS INE S INEVIT VITABLE ABLE The e Solutio lution: n: St Stop bla laming ing the in indiv ivid idual ual – fix ix the system tem Train in team skil ills ls through gh Team Train inin ing Imple lemen ment t hardwi wired ed safet fety y syst stems ems
COM OMMUNICAT MUNICATION ION FAILURE LURES A factor in… • 80% of adverse events/close-calls o (VA National Center for Patient Safety Executive Summary, 2007) • 66% of sentinel events o (White et al, 2005) • 50% of OR errors o (Gawande et al, 2003) • 31% of OB/GYN adverse events o (Joint Commission Sentinel Event Alert - Issue 12)
Joint Commission. (2011). Sentinel Event Statistics Data - Root Causes by Event Type (2004 - Third Quarter 2011) Joint Commission. (2011). Sentinel Event Statistics Data - Root Causes by Event Type (2004 - Third Quarter 2011) Joint Commission. (2011). Sentinel Event Statistics Data - Root Causes by Event Type (2004 - Third Quarter 2011)
Team Work Produces Studies in diverse patient populations demonstrate relationship between teamwork and – Improved clinical processes – Reduction in medical errors – Improved surgical team performance – Increased adherence to guidelines – Decreased length of stay – Increased functional status – Decreased mortality Salas et al. What are the critical success factors for team training in health care? Joint Commission Journal Quality Safety. 2009;35:398-405.
Continuous Quality Improvement (CQI): • A journey to satisfy the needs and exceed the expectations of our customers • A means of performance improvement • Aligned with our Mission to deliver world class, compassionate care, advance our understanding of health and disease and to educate healthcare professionals
Patient Care What does CQI Patient Patient Safety Encompass? Satisfaction Employee Employee Safety Satisfaction Administrative & Regulatory Operational Requirements function
CQI Principles • All work is part of a process • Quality is achieved through people • Decision making is done with facts • Patients and customers are our first priority • Quality requires continuous improvement • CQI focuses on the process not the person
Find a process to improve • Administration, Program of Distinction (POD) Groups, other Committees charter a CQI team • Criteria used to prioritize opportunities for improvement – High Risk – High Cost – High Volume – Problem Prone – Patient Safety related
Sentinel Event • A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. • Examples include: Suicide - Rape - Loss of limb – Elopement -Death Root Cause Analysis • A process for identifying the contributing factors that underlie variations in performance; includes the occurrences of the sentinel events, adverse event or close calls. • Process that features interdisciplinary involvement of those closest to and/or most knowledgeable the situation to find out: • What happened? • Why did it happen? • How can we prevent it? • How do we know we made a difference? Proactive Risk Assessment • FMEA – Failure Modes Effects Analysis • Lean /Six Sigma
Core Measures of Excellence… …are a variety of evidence-based, scientifically-researched standards of care which have generally been shown to result in improved clinical outcomes for patients. • Surgical Care Improvement Project (SCIP): Post-Op blood glucose control / urinary catheters, death among surgical inpatients with serious treatable complications, Iatrogenic pneumothorax rates, post- op respiratory failure, Pulmonary embolism, DVT, wound dehiscence, accidental puncture / lacerations, hip fracture mortality • Children’s Asthma : specific medication use • Emergency Department : departure/admit times, timeliness to diagnosis, pain management • Imaging Efficiency : MRI for Lumbar spine; mammography follow up, use of contrast material • Central Line Associated Bloodstream Infection (CLABSI)
CORE MEASURE OF EXCELLENCE • CMS (the Center for Medicare & Medicaid Services) established the (Core) Measures in 2000 and began publicly reporting data relating to the (Core) Measures in 2003 • CMS ties some parts of reimbursement to reporting the data; in some cases reimbursement is tied to how well we deliver specific elements of care (Value-Based Purchasing)
HIGH RELIABILITY UNIT (HRU) – UNIT BASED TEAM MEETINGS • Prevent Failure (a breakdown in operations or functions) • Metrics throughout the hospital – Preventing CLBSI – Falls – Pressure Ulcers – DVT’s • Best practice guides or “Process Points” reviewed for each metric (do you have the tools you need to be successful in the care you give to patients?) • Reviewed monthly by team and administrators
PROGRAM OF DISTINCTION (POD) – SERVICE LEVEL TEAM MEETINGS • Strategic Alignment for long-term commitment with goals derived from an advisory group • Metrics consistent with HRU throughout the hospital – Preventing CLBSI – Falls – Pressure Ulcers – DVT’s • Reviewed monthly by service line and unit leaders • Methodologies aligned with performance excellence and recognition programs — Analytics, Lean Processes, Evidence-based Practices, Educated Staff, Culture of Safety
Methodology for Improving a Process • Find a process to improve • Organize a team that knows the process • Clarify current knowledge of the process • Understand causes of process variation • Select the process improvement
Examples of Pediatric CQI projects • Pediatric Early Warning Score – PEWS • ED to Floor for Asthmatic Patients • Direct Admits • Safe Sleep • Home Management Plan of Care - Asthma Action Plan • Early recognition of sepsis through the electronic medical record • Preventing Central Line and Catheter Associated Urinary Tract Infections • Time to pain medication for long bone fractures • Minimizing pain during procedures for the pediatric patients - “Ouch less” • Reducing Use of CT Scans in Pediatrics • Medication Reconciliation
STAFF INVOLVEMENT
CAUSE AND EFFECT DIAGRAM
EFFORTS TO REDUCE CENTRAL LINE INFECTIONS • Reduce utilization • Standardizing Practice: Task force assembled to reiterate best practice for insertion and maintenance • Concurrent drill downs on all central line associated blood stream infections by Healthcare Epidemiology and unit/ caregiver staff (CLBSI RCA tool completed) • Unit reports and trends shared with staff and posted • Organizational priority and awareness • Celebrate success 4/22/2015 27
Reducing Hospital Acquired Infections VENTILATOR-ASSOCIATED PNEUMONIA/EVENTS: HOLD THE GAIN! Continued use of the ventilator-associated pneumonia (VAP) bundle DVT Prophylaxis PUD Prophylaxis Head of Bed ≥ 30 ° Sedation vacation Daily review of necessity/early removal • Reduce utilization
Reducing Hospital Acquired Infections
ASTHMA ACTION PLAN
CHILDREN'S ASTHMA CARE PGY -1 Training Forced Completion fields Implementation of EMR form and real time feedback JC: Home Management Plan of Care Given to Patient/Caregiver
CHILDREN’S ASTHMA CARE Formal Guidelines PGY-1 Training Forced completion of fields Implementation of EMR Total Home Management Plan of Care Compliance Rates
DATA
SHARE SUCCESSES
DATA
Surviving Sepsis and Septic Shock • Mortality rates associated with sepsis 30-50% for severe sepsis 50-60% for septic shock • Severe sepsis is the leading cause of death in the non- coronary ICU • Sepsis kills approximately 1,400 people worldwide every day Early Detection and Treatment of Severe Sepsis
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