An Introduction to Quality Improvement

Kevin D. O’Brien, MDFellow’s Research Conference

July 23, 2014

Outline

• Cost Outcomes• IHI, AHA and APM

– Cost and Outcomes:– 2 examples: SE Alaska, Denver Health

• The IHI Model for Improvement• A UWMC Example:

– Cost and Outcomes– Overcoming Barriers

• Potential Training and Resources

US Healthcare is Expensive-1…

US Healthcare is Expensive-2…

http://www.forbes.com/sites/danmunro/2012/12/30/2012-the-year-in-healthcare-charts/

…but Outcomes are Poor

http://www.forbes.com/sites/danmunro/2012/12/30/2012-the-year-in-healthcare-charts/

The IHI Model for Improvement, AIM-PDSA:AIM: Aim, Improvement, Measures

1. Aim: What are we trying to accomplish? A good aim:• Issue important to those involved• Is specific, measurable, and addresses these points: How good? By when? For whom

(or what system)? • Struggling? Remember STEEP (Safe, Timely, Effective, Efficient, Equitable, and Patient-

centered)

2. Measures: How will we know a change is an improvement? • Outcome Measures = Where are we ultimately trying to go? • Process Measures = Are we doing the right things to get there? • Balancing Measures = Are the changes we are making to one part of the system

causing problems in other parts of the system?

3. Changes: What changes can we make that will result in improvement? • 5 ways to develop changes: Critical thinking, benchmarking, using technology,

creative thinking, and change concepts. • Change concepts: Eliminate waste, improve work flow, optimize inventory, change the

work environment, producer/customer interface, manage time, focus on variation, focus on error proofing, focus on the product or service.

The IHI Model for Improvement, AIM-PDSA:PDSA: Plan-Do-Study-Act

• Plan: Plan the test or observation, including a plan for collecting data.

• Do: Try out the test on a small scale. • Study: Set aside time to analyze the data and

study the results. • Act: Refine the change, based on what was

learned from the test.

CARE COORDINATION AND LENGTH OF STAY INITIATIVE ON THE ADVANCED

HEART FAILURE SERVICE: RESULTS AND KEY SUCCESS FACTORS TO DATE

SEPTEMBER 26, 2013

ROBB MACLELLAN, MDKEVIN O’BRIEN, MD

VANDNA CHAUDHARI

Organizational Alignment

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UW Medicine Performance Improvement Council

UWMC FY2013 PI Goals

Supply Chain Revenue Cycle Transformation of Care

Inpatient Capacity Reduce Practice Variation

Inpatient Capacity:• Reduce LOS and Optimize Care via Standardization• Cardiology, Cardiac Surgery, Otolaryngology/HNS

• Remove Waste and Optimize the Patient’s Value Stream• Standardize Clinical Pathway Milestones and Decisions

• Reduce Readmits• Improve D\C Times

Table 1. Scope of the Problem: Pre-PI (July 2012 to February 2013) Measures for the UW Advanced Heart Failure Service

Measure Median Pre-PI Value(July 2012 - February

2013)

Target Value

Type of Measure

O/E LOS Rate 1.61 <1.00 Outcome Measure

O/E Mortality Rate 1.41 <1.00 Outcome Measure

30-day HF Readmissions (%)

20.2 No Balancing Measure

Table 2. Key Measures: Data Sources, Methods of Calculation and Measure Types.

Measure UW Data Source

Method of Calculation

Type of Measure

Estimated LOS (days) Census database

Bed Days/Discharges per month

“Working” Outcome

Daily Census CORES database

Census for Each Day “Working” Outcome

O/E LOS Rate HPM* and UHC

2012/13 Risk Model Case Mix Adjusted

1° Outcome

O/E Mortality Rate HPM* and UHC

2012/13 Risk Model Case Mix Adjusted

1° Outcome

30-day HF Readmissions (%) HPM* 1° BalancingDirect Costs/Case HPM* 2° Outcome

*HPM = Horizon Performance Management system maintained by UWMC Finance and Center for Clinical Excellence (CCE) for quality measures.

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Key Protocols• “Idealized HF” Pathway Protocol:

– Based on UCLA model– Accelerates Tx/LVAD and anticipates Early Discharge:

• Tx/LVAD W/U Starts on Day of Admission• Simultaneous Medical HF Optimization• Discharge Planning Completed by Hospital Day 2• Complete Tx/LVAD Evaluation by Hospital Day 3

• New Protocols (UW-generated) to address other LOS barriers:– IV Diuretic Protocol:

• Standardized approach to aggressive diuresis• Logical target (Weight Loss, not Net I/O)• Minimize use of high-cost, low benefit meds (e.g., Nesiritide)

– Evidence-based Anticoagulation:• Stopped routine anticoagulation of HF patients• Risk-based Table to assess need for heparin “bridging”

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Card B Length of Stay “Run” Chart

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

0

5

10

15

20

25

Cardiology B Average Length of StayDays

HF PathwayInitiated

Median

14.6Median:

10.6

-4 Daysp=0.023

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Card B CORES Census 9/1/2010 – 12/31/2013 Daily Census and 30 Day Moving Average

Date

May-12

Nov-12

Mar-1

3Jul-1

3

Sep-130

5

10

15

20

25

Card

B C

ensu

s

LOS PI ProjectStart

Improved Access: Jul-Dec 2013 Daily Census by 3.1 patients (93 bed days/mo)

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ADV HF QUALITY IMPACT

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Cardiology B: Advanced HF

Service-wide savings FY 2014 YTD

(Heart Transplant Therapies) + (Medical Therapies, all DRGs)

$7,604,474

PI savings FY 2014 YTD1 (Heart Transplant Therapies) +2 (Medical Therapies cardiac DRGs only)

$6,338,740- Pharmacy savings ($542,000)

$5,796,740

PI & service level financial IMPACT

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Part 1: Develop Care Pathway

http://politicaldisconnect.blogspot.com/2008/07/obama-entering-dangerous-mine-field.htmlhttp://thetyee.ca/News/2013/07/11/Clark-Marathon/

PathwayDevelopment

Resistanceto Change(esp. MDs)

No Data/Data as

a “Hammer”

BadTeam

Dynamics

Lack ofSupport

PART 2: NAVIGATE THE IMPLEMENTATION “MINEFIELD”

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Personality Styles and Cardiology B

EXPRESSIVE

AMIABLE

DRIVER

ANALYTIC

Feeling

Thinking

Extroverted Introverted

Merrill and Reid

• Trained to focus on identifying problems (“Barriers”)

• Perfectionist

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Overcoming Barriers to Progress• Regularly-scheduled Card B LOS Meeting:

– Agenda distributed in advance (don’t meet just to meet)– Attendance by Division Head

• Developing Protocols:– Modify existing protocols from respected peer institutions

• Modify 10% rather than create 100%– Many generated internally

• Implement with Plan-Do-Study-Act (PDSA) cycles (http://www.youtube.com/watch?v=xzAp6ZV5ml4):– PDSA a “shop floor” version of the experimental method:

• Easier to get out of Committee• Whole team involved

• Team-based measure of success (Cardiology B LOS)

Donald Berwick, MD, MPP, Founder, Institute for Healthcare Improvement (IHI)

https://www.youtube.com/watch?v=5vOxunpnIsQ

https://www.youtube.com/watch?v=831mdPYGouo&feature=player_detailpage

Don Goldmann, President, IHI - 7 Rules for Engaging Clinicians in Quality Improvement

Challenges for QI Projects• Training in basic QI methods, IHI Open School:

– “Basic Quality Certificate”• Online modules, about 20+ hours• Six modules (QI 101-106) required for MHA students prior to QI project

– Potential Resource: Brenda Zierler, PhD, FAAN

• Mentorship:– Relative paucity of faculty mentors within Division– IHI Open School Practicum– Pair with MHA students?

• Training in QI research methodology:– Potential Resources:

• Tom Staiger, MD• Doug Zatzick, MD

• Potential data sources:– DCDR (De-identified Clinical Data Repository) through ITHS– Potential Resource: Bob Harrington, MD (ID Division)

Potential Training (IHI Open School) and Data (DCDR) Resources

IHI Open School• http://

app.ihi.org/lms/mycatalogs.aspx

DCDR• https://www.iths.org/dcdr