Jennifer S. Myers, MD Professor of Clinical Medicine TEACH, August 2, 2017

To appreciate the synergy between quality improvement and evidence-based practice

To demonstrate when and how quality improvement tools can be used in the Knowledge to Action (K2A) Cycle

Evidence-Based practice?

Quality

improvement?

Safe Timely Efficient Effective Equitable Patient-Centered

IOM Crossing the Quality Chasm, 2001

Evidence-Based

Practice

Quality Improvement

0% of patients eligible for extended venous thromboembolism prophylaxis following surgery for an abdominal malignancy at our hospital were prescribed heparin at discharge.

Only 19% percent of severe sepsis/septic shock patients in our Emergency Department received all the interventions in the sepsis care bundle.

Evidence-Based

Practice

Quality Improvement

“If we do not like the current level of performance, we must choose between change and frustration.” - Don Berwick

IOM Domain of Quality

Quality Improvement Example

Safe

Timely

Effective

Efficient

Equitable

Patient-Centered

Value

No double-check for oral chemotherapy prescriptions

The time to critical value read-back & receipt is over 1 hour

Systolic heart failure patients are not receiving ACE inhibitors

New oncology patients must be seen in 3 different buildings

Hispanic patients are less likely to receive screening colonoscopies

Patients are not sure who the “doctor in charge” is in the hospital

Daily Chest X-rays in the ICU

“QI”

•Many associate QI with old-style,

punitive quality assurance

•QI programs do not provide clinicians

with the data they need

•QI experts do not emphasize the

academic potential of QI work

•QI gurus overemphasize the industrial

origins of QI

Frameworks for Quality Improvement

Model for Improvement

Six Sigma

LEAN

Model for Improve ment -

What are we trying to accomplish?

Find, Organize

How will we know that a change is an improvement?

Clarify

What changes can we make that could result in improvement?

Understand, Select

What are the possible solutions & how do we test them?

Plan-Do

How do we sustain and standardize what we have achieved?

Study-Act

Six Sigma -

Define Measure Analyze Improve Control

Lean -

Specify what customers value

Identify steps in the value stream

Eliminate waste and variation at the root cause

Reduce variation & defects to create flow

Standardize flow, sustain, continuously improve

Frameworks for Quality Improvement

Graham ID, et al. JHECP, 2006.

Model for Improve ment -

What are we trying to accomplish?

Find, Organize

How will we know that a change is an improvement?

Clarify

What changes can we make that could result in improvement?

Understand, Select

What are the possible solutions & how do we test them?

Plan-Do

How do we sustain and standardize what we have achieved?

Study-Act

Six Sigma Define Measure Analyze Improve Control

Lean

Specify what customers value

Identify steps in the value stream

Eliminate waste and variation at the root cause

Reduce variation & defects to create flow

Standardize flow, sustain, continuously improve

K2A Identify problem; know-do gap

Understand local context

Assess barriers / facilitators

Select, Tailor, Implement Intervention

Monitor, evaluate, sustain

Go see

Ask why

Show respect

Take notes!

What You Think It is . . .

What It Actually is . . .

What You Would Like it to Be . . .

The struggle is that this is where everyone wants to start.

You MUST GO AND SEE to verify what is really happening out there

Often difficult to persuade people that their BELIEF ≠ REALITY ON THE GROUND

Good problems are defined by going out and seeing for ourselves…

• Collect stories with humility

• Ask non-leading questions

What’s working well?

What’s not working well?

What would you change?

• Do not need 100 VOC, 5-10 is plenty to start

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0

1

2

3

4

5

6

7

8

9

10Compliance with CVL Bundle

Count

Cum %

1. Why is there lack of compliance with cap changes? Nurses do not know when the cap changes are due

2. Why don’t nurses know when the cap changes are due? The information is only located in the EMR and nurses rarely

document cap and dressing changes in the EMR 3. Why are cap changes rarely documented in the EMR? Nurses go to the patient’s line to find information that is needed

4. Why do nurses go to the patient’s line to find information? The information is easily visible (dressing changes and IV tubing

changes are written on the device) There is not a location for cap changes to be written

5. Why isn’t there a location on the line for cap changes? There is not room on the cap to write when it was changed

Good current state analysis and root cause analysis makes countermeasures obvious

Root Cause Countermeasure

Attending Surgeon perceptions of feasibility; perceptions of patient factors

Gather primary data from patients

Attending Surgeon Concern for adverse events

Rigorously track outcomes during PDSA cycles

Resident awareness of the guidelines

Include guidelines and new process in resident rotation orientation materials

Graham ID, et al. JHECP, 2006.

Test (verb): to find out the nature, quality, or value of something

Implement (verb): to take steps to put into practice

Adapted from Langley, et al. The Improvement Guide, 2009

Monitoring Plan

Statistical Process Control Charts

Control Plan

Visual Management Tools

Visual display (“job aide”)

Visual metrics

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100

90

80

70

60

50

Day

Jo

urn

ey

Tim

e in

Min

ute

s

Displays To make staff

aware of data & information

Controls To guide the action

of staff members

“Implementing” instead of “testing”

Declaring victory too soon

Failure to assess the new process

Failure to adjust based on the assessment

Failing to plan for sustainability

Graham ID, et al. JHECP, 2006.

Process Map

Fishbone Diagram

Pareto Chart

Control Chart

39

PDSA Cycle Size

Visual Controls

jennifer.myers@uphs.upenn.edu