Basics Michelle S. Gabriel, RN, MS, ACHPN Palliative Care Clinical - PowerPoint PPT Presentation

Quality Improvement Basics Michelle S. Gabriel, RN, MS, ACHPN Palliative Care Clinical Nurse Specialist VA Palo Alto Health Care System July 16, 2015

Integrating Palliative Care and Intensive Care IPAL-ICU: 2

IPAL-ICU is designed to provide a central venue for sharing: ➔ Expertise ➔ Evidence ➔ Tools 3

IPAL-ICU Resources ➔ IPAL-ICU Portfolio ➔ Improvement Tools (ICU) ➔ Patient & Family Resources (ICU) ➔ Reference Library (IPAL-ICU) ➔ Professional Education (IPAL-ICU) ➔ Premier Programs ➔ Research Resources (ICU) ➔ Professional Organizations & Awards ➔ Journals (ICU) ➔ Leadership & Advisory Board (IPAL-ICU) 4

IPAL-ICU: Leadership & Advisory Board 5

Audience Poll ➔ What is your discipline? – MD/APRN – RN – SW – Chaplain – Other? 6

Audience Poll ➔ What is your area of specialty? – Intensive Care – Palliative Care – General Medicine – Other Specialties 7

Audience Poll ➔ How much experience have you had with process improvement/quality improvement efforts? – Novice – Have participated as a team member – Have led a team – Have coached other teams 8

Learning Objectives ➔ By the end of this webinar, participants will be able to: – List the four steps of the Deming Cycle (PDCA) – Create a SMART goal – Practice a 5 Why’s analysis 9

Why Focus on Improving Quality and Processes in ICUs? ➔ One of the sites where med errors are most likely to occur (http://healthpolicy.ucsf.edu/content/icu-outcomes) ➔ ICU patients vulnerable to experiencing adverse outcomes (http://healthpolicy.ucsf.edu/content/icu-outcomes) ➔ Known risk for burnout among ICU providers (http://www.thefreelibrary.com/Burnout+in+critical+care+nurses%3a+a+literature+review.- a0312827884) 10

PDCA 11

Case Study ➔ A 55 yo man with a history of polycythemia vera was admitted to the ICU for recovery post splenectomy for an enlarged spleen. Based on previous conversations with the patient, the ICU medical team confirmed with the family that the patient was a DNR/DNI even in the context of the surgery. The nurse, not having been part of the conversation, questioned the family as to the accuracy of the DNR/DNI order. The family expressed frustration at feeling like they had to justify their wishes. 12

PLAN: Defining the Problem ➔ Purpose: – Understand the current process – Understand the current problem (fact-based) ➔ Things to Consider: – Quantify the current situation – Focus on a problem that you can impact – Validate with data 13

PLAN: Defining the Problem ➔ What is the process? ➔ What problems specifically are occurring? How do you know? ➔ Who is involved? ➔ Who is affected? ➔ Where is it happening? ➔ When is it happening? 14

PLAN: Defining the Problem Standard (desired) level of performance 1. Current level of performance 2. Performance gap 3. The extent of the impact (pain) resulting from the 4. perceived problem Desired Performance Gap Current Performance 15

PLAN: Defining the Problem (Example) ➔ Problem: – Family meetings that occur without the bedside nurse cause inconsistent messages to the patient and family resulting in frustration for families and nurses and other clinicians. ➔ How do you know? – 50% of families queried over the last month reported a lack of confidence that the bedside nurse and the medical team were on the same page one day following a family meeting. 16

PLAN: Action Planning ➔ Developing a SMART aim ➔ Identify root causes ➔ Propose interventions that will address root causes 17

PLAN: SMART Aims ➔ Specific ➔ Measurable ➔ Achievable ➔ Relevant ➔ Time-bound Example: Decrease by 25% the proportion of families reporting a lack of confidence that the bedside nurse and medical team are on the same page one day post a family meeting by Dec 1. 18

PLAN: Root Cause ➔ Purpose: – Uncover the root cause(s) of the problem identified ➔ Things to consider: – Focus on the process, not the people 19

PLAN: Root Cause / 5 Whys ➔ Purpose: – Help identify the root cause of a problem ➔ How to: 1. Write down the specific problem. Ask “Why the problem happens” and write the answer 2. down below the problem. 3. Validate the response. Continue asking “why” and validating until you have 4. identified the root cause of the problem identified in Step 1. This may take fewer or more times than five. 20

PLAN: Root Cause / 5 Whys ➔ Aim: Reduce family’s perception of a disconnect between bedside nurse and medical team. ➔ Why is there a disconnect? – Because the nurse is not consistently at the family meeting ➔ Why is the nurse not consistently at the family meeting? – Because nurses are unable to find coverage during the meeting ➔ Proposed Countermeasure: Establish a mechanism to provide coverage 21

PLAN: Root Cause / 5 Whys ➔ Why are nurses unable to find coverage? – Because meetings are happening at change of shift. ➔ Why are meetings happening at change of shift? – Because that is when the team has completed their patient rounds and education. ➔ Proposed Countermeasure: Suggest that a different time be set aside for family meetings – one that is easier for nurses to attend. 22

DO: Implementation ➔ Run experiments - test your ideas ➔ Start small – Test change on one unit, with one provider, with one patient – Test over a short time period – Test change with a few volunteers ➔ Collect data during the test – Allows prediction of how much improvement will result from change – Qualitative data can be informative 23

CHECK ➔ What happened? ➔ Was it expected? ➔ What would you do differently? 24

ACT ➔ Adopt the changes – What needs to be done to hardwire the improvement ➔ Adapt the changes – What should be done differently? – Run another test of change ➔ Abandon the changes 25

Case Study , Take 2 ➔ A 55 yo man with a history of polycythemia vera was admitted to the ICU for recovery post splenectomy for an enlarged spleen. Based on previous conversations with the patient, the ICU medical team, including the nurse, confirmed with the family that the patient was a DNR/DNI even in the context of the surgery. Ahead of the family meeting, the team reviewed the patient’s previously expressed wishes with the surgeon so that they understood the rationale. The family expressed feeling supported during this uncertain time, and confidence in the team’s ability to support their loved one’s wishes. 26

Audience Poll ➔ How well did this webinar achieve the stated objectives? – By the end of this webinar, participants will be able to: • List the four steps of the Deming Cycle (PDCA) • Create a SMART goal • Practice a 5 Why’s analysis – Not at all – Minimally – Moderately – Completely 27

Audience Poll ➔ How likely are you to apply some of the concepts reviewed during this webinar? – Not at all – Maybe – Absolutely 28

Questions and Comments ➔ Do you have questions for the presenter? ➔ Click the hand-raise icon on your control panel to ask a question out loud, or type your question into the chat box. 29

CAPC Events and Webinar Recording ➔ For a calendar of CAPC events, including upcoming webinars and office hours, visit – https://www.capc.org/providers/webinars-and-virtual-office- hours/ ➔ Today’s webinar recording can be found in CAPC Central under ‘Webinars: 2015 Community-Based Palliative Care’ – https://central.capc.org/eco_player.php?id=290 30