What Quality Improvement theories are relevant to

PPE compliance?

PDSA and Peer Review Theories

What is the PDSA theory? Plan, Do, Study,

Act Used for

continuous improvement

As it is a cycle it requires constant changes to the ongoing process

Diagram taken from http://www.iso9001consultant.com.au/PDCA.html

PDSA cycle Plan: Recognize the need for change and plan it. Do: Test the change initiative by carrying out a

small-scale study. Study: Review the study, the results and identify

what you have found. Act. Take action based on the above: If it was

not successful, redo the cycle focusing on a different area. If it was successful, incorporate what you learned to plan new improvements, and begin the cycle again.

Adapted from the American Society for Quality’s Project Planning and Implementing Tools paper.

Study example:

“Plan-do-study-act cycles as an instrument for improvement of compliance with infection control measures in care of patients after cardiothoracic surgery”

Van Tiela, F.H., Elenbaasb, T.W.O., Voskuilenc, B.M.A.M., Herczega, J., Verheggend, F.W., Mochtarb, B., & Stobberingh, E.E. (2006). Journal of Hospital Infection, 62,(1).

Van Tiela et al (2006) Journal of Hospital Infection, 62,(1).

Example from study on improvement of compliance with infection control measures

in care of patients after cardiothoracic surgery

Plan: 1. Identify potentially modifiable risk factors for wound infections in patients after cardiothoracic surgery. 2. Develop a pragmatic strategy to modify or prevent the occurrence of these risk factors.

Do: 1. Collect baseline data, e.g. rates of compliance regarding the chosen indices of correct procedure (baseline measurement). 2. Carry out the planned intervention strategy. 3. Collect basic data, e.g. rates of compliance regarding the chosen indices of correct procedure (follow-up measurement).

Study: 1. Analyse data. 2. Summarize the results. 3. Identify problems in the implementation of the designed intervention.

Act: 1. Determine the overall success or failure of the intervention. 2. Identify potential modifications to improve the intervention strategy. 3. Update the intervention with solutions for the identified problems. 4. Prepare for the next PDSA cycle.

Could the model be useful in ensuring PPE compliance?

The short answer is “Yes”, although continuous monitoring would need to be implemented, possibly through peer reviews, and further education.

Clipart taken from: http://www.istockphoto.com/stock-illustration-6514236-clipboard-list.php

Where organisations go wrong...

Failing to complete the STUDY and ACT step

Failing to complete the whole cycle Completing the plan but not

implementing it.

What is Peer Review Theory?

Peer review is synonymous with, but not limited to, retrospective medical record review.

Among other methods, cases are identified through generic screens for adverse events.

Peer review is conducted in committees.

Peer Review Theory

Medical Peer Review: negligence and misconduct issues

>Nursing peer review

Peer Review Theory “The Health Care Quality Improvement Act of 1986 is, ostensibly,

meant to protect the public from incompetent physicians by allowing those physicians on peer review committees to communicate in an open and honest environment and thus weed out incompetent physicians, without the specter of a retaliatory lawsuit by the reviewed physician. However, the consequences of the Act have instead helped promote an environment that protects those physicians on a peer review committee when they distort the review process for their own gain, by maliciously disciplining those physicians that may be in political or economic competition.”

Hall, B.J. (2011). The Health Care Quality Improvement Act of 1986 and Physician Peer Reviews: Success or Failure? Retrieved from: http://www.usd.edu/elderlaw/student_papers_f2003/health_care_quality_improvement_act.htm

Issues with peer review... No supervision “reasonable belief” standard No effective oversight of hospital

peer review proceedings to protect the physician and ensure that peer review decisions are evidence based.

Possible inappropriate personal motives

How these issues could be resolved...

According to Kinney, E.D. (2009). Rigorous adherence to established principles of

procedural due process in the design of peer review proceedings that are eligible for HCQIA immunity.

Establish higher standards for the evidence that must be demonstrated to meet the “reasonable belief” standard.

Ensure that hospitals’ conduct of inappropriate peer review proceedings are subject to consequences that are effective deterrents to the abuse of peer review.

Provide more effective oversight of hospital peer review proceedings to ensure more accountability from the hospital and participating physicians that peer review proceedings are fair and accurate.

Could the model be useful in ensuring PPE compliance?

Committees would need to be set up Greater accountability needs to be

taken by the hospital and the committee

External committees Further trainings Non-compliance issues dealt with