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OSHP Annual Seminar 2017

Practical Improvement

Science in Medication

Safety Jason Timothy Wong, PharmD

PGY1 Health-System Pharmacy Administration ResidentOregon Health and Science University

DATE: Apri l 28, 2017

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Disclosure Statement

Jason Timothy Wong, PharmD

� Potential conflicts of interest: none

� Sponsorship: none

� Presentation is educational in nature and indicates agreement to abide

by the non-commercialism guidelines provided

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Learning Objectives

By the end of this presentation, you will be able to:

� Explain the role of improvement science in healthcare

� Apply improvement science methodology to ensure safe medication

management

� Identify and create an improvement project

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Today’s Agenda

Review the dimensions of

healthcare

Discuss the model for

improvement

Learn to construct a run

chart

Apply the model for improvement

Create a personal

improvement project

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Safe Effective Timely

EfficientPatient

CenteredEquitable

Value Access Prevention

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What is improvement science?

Improvement

� Change that produces visible, positive differences in results

Science

� A system of acquiring knowledge attained through study or practice

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Scientific Knowledge

Profound Knowledge

Greater Improvement

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Model for Improvement

Plan

DoStudy

ActWhat are we trying to accomplish?

How will we know change is an improvement?

What change will result in improvement?

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CE Question 1

1. What is the importance of running iterative PDSA cycles?

A. Each PDSA cycle completed enhances knowledge of the system

B. Quickly determine whether or not the intervention lead to improvement

C. Completely change your project as needed to address your theory on

improvement

D. All of the above

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What are we trying to accomplish?

AIM Statement

� Clear, concise, results oriented

� “What by when statement”

Example: We will have a 50% reduction in hospital readmissions

for patients with congestive heart failure by January 1, 2018

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How will we know change is an improvement?

Outcome measures

Process measures

Balancing measures

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What change will result in improvement?

Making a fundamental change to

the system

� First order change

� Second order change “Every system is perfectly designed to achieve

exactly the results it gets”

Don Berwick, MD, MPP, FRCP

Image from: www.beckershospitalreview.com

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� Objectives� Questions and predictions� Who, what, when, where?� Plan for data collection

� Carry out plan� Document problems� Begin analysis of data

� Complete analysis� Compare data to predictions� Summarize what was learned

� What changes should be made next?� Next cycle?

Plan

DoStudy

Act

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Hunches, Theories,

Ideas

Changes That Result In

Improvement

Small Scale Tests

Follow Up Tests

Wide-Scale Tests

ImplementationOf Change

Plan

DoStudy

Act

Plan

DoStudy

Act

Plan

DoStudy

Act

Plan

DoStudy

Act

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CE Question 2

2. Which of the following is a reason to include a balancing

measure in your improvement project?

A. To ensure you are making progress toward your AIM statement

B. To ensure the changes you have made to one area are not having a

negative effect on another part of your system

C. To ensure you are accurately measuring your outcome

D. All of the above

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What is a run chart?

Graphical display of data plotted over time

Illustration of data to make performance visible

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Median

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1 2 3 4 5 6 7 8 9 10

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Value

Time

TITLE

Goal

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Constructing a run chart

1. Date/observation

2. Value/data

3. Median

4. Goal

Date Value Median Goal

1

2

3

4

5

6

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20

Median

0

2

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1 2 3 4 5 6 7 8 9 10

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# of CrossFit Workouts

Week

Improving CrossFit Class Attendance Summer 2016

Start of OHSU Residency

Goal

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Run chart rule 1

Shift

6 or more consecutive data points

above or below the median

Median

0

5

10

15

20

1 2 3 4 5 6 7 8 9 10

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Measure

Time

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Run chart rule 2

Trend

5 or more consecutive data points

going up or going down

Median

0

5

10

15

20

1 2 3 4 5 6 7 8 9 10

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Measure

Time

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Run chart rule 3

Too many/few runs

A run is a series of points in a row

on one side of the median

Median

0

5

10

15

20

1 2 3 4 5 6 7 8 9 10

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Measure

Data line crosses once Total: 2 runs

Time

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Run chart rule 4

Astronomical data point

Median

0

5

10

15

20

1 2 3 4 5 6 7 8 9 10

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Measure

Time

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Week Date Number of Medication

Errors

1 12/3/16 26

2 12/10/16 17

3 12/17/16 24

4 12/24/16 25

5 12/31/16 19

6 1/7/17 25

7 1/14/17 24

8 1/21/17 22

9 1/28/17 21

10 2/4/17 18

11 2/11/17 18

12 2/18/17 17

Weeks 1 – 6Average: 22.67Maximum: 26Minimum: 17

INTERVENTION

Weeks 7 – 12Average: 20

Maximum: 24

Minimum: 17

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Median

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25

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1 2 3 4 5 6 7 8 9 10

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Medication Errors

Months

Goal

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0

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10

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Week 5 (Before Intervention) Week 15 (After Intervention)

Medication ErrorsINTERVENTION (Week 10)

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Median

10111213141516171819202122232425

1 2 3 4 5 6 7 8 9 10

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INTERVENTION (Week 10)Medication Errors

Months

Goal

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CE Question 33. Please select the following run chart graph that illustrates

improvement over time resulting from your intervention:

0

2

4

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12

1 2 3 4 5 6 7 8 9 10

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Hours

0

2

4

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12

1 2 3 4 5 6 7 8 9 10

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Hours

0

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1 2 3 4 5 6 7 8 9 10

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Hours

A B C

30RUN CHART QUESTIONS?Image from: www.wallpapercave.com

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Case study

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Situation

Patient admitted to

trauma ward

MD obtains medication list from daughter

Phenobarbital 300mg QHS + Phenobarbital 50mg QAM

MD starts phenobarbital

Med rec completed by

PharmD 3 days after

admit

Phenobarbital 97.2mg QD

MD awaiting neuro/geriatric recs (4 days)

Patientcombative

towards staff

Phenobarbital reduced to

97.2 mg QDPSI reported

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Model for Improvement

Plan

DoStudy

ActWhat are we trying to accomplish?

How will we know change is an improvement?

What change will result in improvement?

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What are we trying to accomplish?

There will be a 50% reduction in the number

of medication reconciliation errors per patient measured each

week on the trauma ward by January 1, 2018

AIM Statement

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How will we know change is an improvement?

Outcome Measure

Rate of medication reconciliation errors per

patient

Process Measure

Number of medication reconciliation errors

identified by pharmacist

Balancing Measure

Pharmacist clock out time

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What change will result in improvement?

HYPOTHESIS

If we implement a risk stratification tool, we will reduce the

number of medication errors that will lead to a decrease in

adverse medication related events

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� Objectives� Questions and predictions� Who, what, when, where?� Plan for data collection

� Carry out plan� Document problems� Begin analysis of data

� Complete analysis� Compare data to predictions� Summarize what was learned

� What changes should be made next?� Next cycle?

Plan

DoStudy

Act

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Plan

Plan

DoStudy

ActOBJECTIVE

To reduce the number of medication

reconciliation errors on the trauma ward

PREDICTION

If we reduce the number of medication

reconciliation errors, there will be a

reduction in adverse drug events

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Do

INTERVENTION: Risk stratify patients to alert

pharmacist of prioritizing medication

reconciliation

Plan

DoStudy

Act

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Week Value Median Goal

1 5

2 5

3 5

4 5

5 5

6 5

7 5

8 5

9 5

10 5

11 5

12 5

13 5

14 5

Goal

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10

1 2 3 4 5 6 7 8 9 10

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Risk Stratification Intervention% Error

Week

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Study

PREDICTION

If we reduce the number of medication

reconciliation errors, there will be a

reduction in adverse drug events

Plan

DoStudy

Act

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Goal

0

2

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10

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14

7 8 9 10

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Risk Stratification Med Rec Intervention% Error

Median (before)

Median (after)

Week

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Act

Data from the run chart indicate a

change after the intervention

Where do we go from here?

Plan

DoStudy

Act

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Hunches, Theories,

Ideas

Changes That Result In

Improvement

Small Scale Tests

Follow Up Tests

Wide-Scale Tests

Implementationof Change

Plan

DoStudy

Act

Plan

DoStudy

Act

Plan

DoStudy

Act

Plan

DoStudy

Act

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Your turn!1. What are you trying to accomplish?

� Issue, rationale, AIM statement

2. How will you know change is an improvement?

� Outcome, process, and balancing measures

3. What changes can you make to improve?

� Ideas of change, stakeholders, barriers

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46Image from: www.hrpayrollsystems.net

Thank YouJason Timothy Wong, PharmD

wojas@ohsu.edu

Acknowledgements:

Jason Christensen, PharmD, MBA, MS

Joe Fazio, Rph, MHA, MBI

Seth Hartman, PharmD

Jess Lassiter, PharmD, BCPS

John Mackay, PharmD, BCPS AQ Cardiology

Jake McFarland, PharmD, BCPS

Renita Patel, PharmD, BCPS

Colleen Shipman, PharmD, MPH, BCPS

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2. Institute for Healthcare Improvement. (2016, February). Retrieved from http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

3. Institute of Medicine (U.S.). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, D.C: National

Academy Press.

4. Langley G.J., Moen R.D., Nolan K.M., Nolan T.W., Norman C.L., & Provost L.P. (2009). The Improvement Guide, 2nd ed. San

Francisco, CA: Jossey-Bass.

5. Øvretveit J. Understanding the conditions for improvement: research to discover which context influences affect improvement success.

BMJ Qual Saf 2011;20(Suppl 1):i18–23.

6. McGlynn, E.A., S.M. Asch, J. Adams, J. Keesey, J. Hicks, A. DeCristofaro, and E.A. Kerr. 2003. "The quality of health care delivered to

adults in the United States." New England Journal of Medicine348(26):2635-45.

7. Practical Improvement Science in Health Care: A Roadmap for Getting Results. Harvard edX, 28 Feb. 2016,

https://www.edx.org/course

8. Provost L.P., & Murray S.K. (2011). The Health Care Data Guide: Learning From Data For Improvement. San Francisco, CA: Jossey-

Bass.

9. Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2013). Systematic review of the application of the plan-do-

study-act method to improve quality in healthcare. BMJ Qual Saf, 10(1136), 1-9.