Resident Longitudinal QI Projects”Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.“ ACGME Common Program Requirements
Specifically, ACGME would like us to Identify strengths, deficiencies and limits in one’s knowledge
and expertise Set learning and improvement goals Systematically analyze one’s practice using quality
improvement methods (PDSA), and implement changes with the goal of practice improvement
Incorporate formative evaluation feedback into daily practice Locate, appraise and assimilate evidence from scientific studies
related to patients’ health problems
Its not just ACGME…ABIM’s Maintenance of Certification
Maintenance of Certification
PIM- Professional Improvement Module
More PIM
Objectives
1) Understand how to develop an
Aim Statement
Measurement Plan
Improvement Plan
2) Understand rapid cycle improvement
• State the aim clearly • Include numerical goal and time frame that
require fundamental system change • Set stretch goals• Avoid aim drift• Be prepared to refocus the aim
Step #1 - Setting the AIM – What are we trying to accomplish?
Step #2 - Establishing measures –How will we know that a change is an improvement?
• Plot data over time• Seek usefulness, not perfection• Use sampling• Integrate measurement into the daily routine• Use qualitative and quantitative data
Baseline Data (HgA1C)
HgA1C after 6 months
Step #2 - Establishing measures –How will we know that a change is an improvement?
HgA1C is the outcome, but the most important data is to determination the intervention’s
effectiveness.
Evaluate your current management and Nationally recognized guidelines. How do they differ?
Data to collect1. How many patients met with the pharmacist2. When? Early enough to detect change in HgA1C?
Plan, Do-Each patient will meet with pharmacist to evaluate medications
Step #3 – Overall Plan for Improvement
• Avoid “the same” responses• Implement recommended practices
guidelines• Think processes and systems of work
– Simplify processes– Reduce waste or unnecessary redundancies
• Creative thinking • Appropriate use of new or existing
technology
“Every system is perfectly designed to get the results it gets.”
Paul Batalden, M.D.
The Model for ImprovementPDSA
The Improvement Guide (Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. San Francisco, California, USA: Jossey-Bass Publishers, Inc.; 1996
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?
The Cycle- Plan, Do, Study, Act
Also known as: PDCA (Check instead of
Study) The Deming Cycle/Wheel The Shewart Cycle The Learning and
Improvement Cycle
PlanSequence:
1) Gather background data on the current system.
2) Describe your tactic (intervention) 3) Predict outcome4) List tasks needed5) Plan for collection of data
DO – Carry it Out
• Implement (preferably on a small scale)
• Document problems and unexpected observations
• See plan through to completion• Motivations to carry it out
Study or Check – What did we learn?
• Review the Data / take survey
• Compare the data to your predictions
• What worked or went well? What did not?
• Summarize and Reflect on what was learned -- Draw Conclusions
ACT
ACT
• Adopt it
• Abandon it
• More study needed
• Modify overall aim, measure, or plan
• Create new plan
Rapid Cycle - Multiple Cycles
Overall AIM Increase documented eye
exams for our diabetes population by 45% in the next 12 months
Time
Expect Challenges and Barriers
Cycle #1 – Contact Eye Doctors
Cycle #2 – Patient Fax Back Form
Cycle #3 – Front Office track down eye results
Cycle #4 – Computer Network with eye doctors
Cycle #5 – Reminder letter from PCPs
Implement Final Changes
Discouraged… So, your patient’s are no more healthy than when you started… The system in which you function isn’t working- now you have
data to support that. Re-analyze the system, identify areas you can change, areas
that are ineffective, areas that are chaotic. Start a new PDSA cycle to tease out what parts of these areas
can be changed Design an intervention, implement it, gather data and analyze
it… Shampoo, rinse, repeat.
How to manage your panel in Powerchart (sort of)
Any Diabetic Patient
click
click
Say “ok”
Not very helpful!
Modify display under Components tab
Double Click
Name and MRN‘To Row,’ everything else to ‘Page’
Upcoming Longitudinal QI Projects Interns- Start with HgA1C (UNM Clinics) and Hypertension (VA).
Except NE Heights- you’re special
Upper levels Options!!! If you are interested in switching projects, consider HgA1C (at VA),
Hypertension (at UNM), Lipid Guidelines
QI Projects Plug (aka how to improve your CV and future employability)
Inpatient Influenza Vaccination Project Increase the frequency of inpatient influenza vaccine screening,
Increase the number of patients who receive flu vaccine by the time of discharge
Improve documentation of reasons for not administering flu vaccine among inpatients.
Improving influenza vaccination among residents, fellows, and faculty. Influenza vaccination status was not known for 60% among UNM physicians last
year.
Lower the barriers for receiving the influenza vaccine (i.e., working with different groups to find convenient times/locations for influenza vaccination)
Improve collection of documentation
Hand washing on 4-west 4 West is among the worst floors for hospital acquired c-diff
RN’s are working on a hand washing initiative
People are watching! You may be placed in a raffle to win coffee and/or candy
Improved Discharge of Behaviorally Challenged Patients from 4west MHC order sets
Improved medication compliance after transfer
Improved coordination of security
CIWA Project- more about that later RN driven improvement in CIWA protocol
Less GTT’s, less MICU transfers, less sitter use, less oversedation
QI Projects Plug (aka how to improve your CV and future employability)
Dr. Langsjoen- early probiotics in patient’s receiving antibiotics
Dr. Crowell- Sepsis bundle- lots of opportunity for lactates between 2 and 4 Pulm/Crit care people.
Stand out on your application
PSN Project, improved documentation, reporting
7-Day Readmits- Still in development
Hospitals will not be reimbursed for 30 day readmits- starting with low-lying fruit by evaluating 7-day readmits
MICU transfers
Outpatient pain management Also still in development-
Increasing Advanced Directives completed in clinic setting Sign prompting patients to ask about advanced directives
QI Projects Plug (aka how to improve your CV and future employability)