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QUALITY IMPROVEMENT PART 1 1 Rebecca S. (Suzie) Miltner, PhD, RN, CNL, NEA-BC University of Alabama at Birmingham Birmingham, AL Brant J. Oliver, PhD, MS, MPH, APRN-BC MGH Institute of Health Professions Boston, MA OBJECTIVES Describe basic steps in understanding process variation. Use common QI tools to generate ideas for solutions to problems. Describe the structure of a QI Aim Statement. 2 QUALITY IMPROVEMENT (QI) Definition: Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems. Knowledge Skills Attitudes Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice Seek information about outcomes of care for populations served in care setting Seek information about quality improvement projects in the care setting Appreciate that continuous quality improvement is an essential part of the daily work of all health professionals Recognize that nursing and other health professions students are parts of systems of care and care processes that affect outcomes for patients and families Give examples of the tension between professional autonomy and system functioning Use tools (such as flow charts, cause-effect Value own and others’ contributions to outcomes of diagrams) to make processes of care care in local care settings explicit Participate in a root cause analysis of a sentinel event Explain the importance of variation and measurement in assessing quality of care Use quality measures to understand performance Use tools (such as control charts and run charts) that are helpful for understanding variation Identify gaps between local and best practice Appreciate how unwanted variation affects care Value measurement and its role in good patient care Describe approaches for changing processes of care Design a small test of change in daily work (using an experiential learning method such as Plan-Do-Study-Act) Practice aligning the aims, measures and changes involved in improving care Use measures to evaluate the effect of change Value local change (in individual practice or team practice on a unit) and its role in creating joy in work 3 Appreciate the value of what individuals and teams can to do to improve care QUALITY IMPROVEMENT (QI) Definition: Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems. Knowledge Skills Attitudes Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice Seek information about outcomes of care for populations served in care setting Seek information about quality improvement projects in the care setting Appreciate that continuous quality improvement is an essential part of the daily work of all health professionals Recognize that nursing and other health professions students are parts of systems of care and care processes that affect outcomes for patients and families Give examples of the tension between professional autonomy and system functioning Use tools (such as flow charts, causeeffect diagrams) to make processes of care explicit Participate in a root cause analysis of a sentinel event Value own and others’ contributions to outcomes of care in local care settings Explain the importance of variation and measurement in assessing quality of care Use quality measures to understand performance Use tools (such as control charts and run charts) that are helpful for understanding variation Identify gaps between local and best practice Appreciate how unwanted variation affects care Value measurement and its role in good patient care Describe approaches for changing processes of care Design a small test of change in daily work (using an experiential learning method such as Plan-Do-Study-Act) Practice aligning the aims, measures and changes involved in improving care Use measures to evaluate the effect of change Value local change (in individual practice or team practice on a unit) and its role in creating joy in work 4 Appreciate the value of what individuals and teams can to do to improve care Our focus today over the next two sessions. TOOLS AND TECHNIQUES TO INCORPORATE INTO YOUR COURSES Process Mapping Brainstorming Affinity Diagrams Multi-Voting Tests of Change Using Data to Understand Processes Using Data to Evaluate Change Interventions 5 TOOLS AND TECHNIQUES TO INCORPORATE INTO YOUR COURSES Process Mapping Brainstorming QI Workshop Part 1 Affinity Diagrams Multi-Voting Tests of Change Using Data to Understand Processes Using Data to Evaluate Change Interventions 6 MODEL FOR IMPROVEMENT Aim Change Ideas Measurement 7 PROBLEM IDENTIFICATION 8 FIRST, WE (ALWAYS) NEED TO BETTER UNDERSTAND THE PROCESS… 9 PROBLEM: FALLS Falls are a common patient safety problem Falls can have devastating effects (injuries, increased LOS, death) Falls are expensive Falls are “never events” Cox, Thomas-Hawkins, Pajarillo, DeGennaro, & Cadmus, 2015 Dean, 2012 10 FALLS AT AMC FY15 2.42 falls/1000 patient days Estimated Financial Impact: $1.5 million+ 11 WE DO HAVE EVIDENCE OF THINGS THAT WORK: FALL PREVENTION BUNDLE OF CARE Leadership support Use of a standard fall risk assessment tool Fall risk assessments on admission and at regular intervals (to include, medications, mentation, mobility, and history) Use of visual aids (fall risk bracelets) Patient & family education Communication with the healthcare team Frequent Rounding on patients Monitoring compliance & performance with falls interventions. (Agency for Healthcare Research and Quality, 2012) 12 GATHERING DATA TO UNDERSTAND A PROCESS: SUGGESTED STEPS 1. Observe processes (formal and informal) 2. Interview key personnel 3. Collect data 4. Create a process map 13 1. PROCESS OBSERVATION What can you really see when you just look around you? 14 WHAT DID WE OBSERVE? Falls Protocol: Not implemented about 50% of the time Workload: Not possible to round every hour on every patient and meet patients’ other needs. Geography: Pts assigned for continuity, RN experience, patient acuity, but not geography (i.e. lots of extra walking) Technology: Bed alarms don’t connect to call system; nurses turn off frequently Risk Assessment: Every patient at risk Rooms: Rooms are small and full of obstacles 15 2. INTERVIEW KEY PERSONNEL What did the stakeholders tell us? 16 INTERVIEW RESULT THEMES Geography: Layout of the unit is a barrier; difficult to move patient room closer Patient Factors: Patient’s with cognitive issues and impaired judgment are most difficult; patient’s not engaged Technology: Bed alarms don’t connect to call system, used to have video monitoring Risk Assessment: low specificity Equipment: difficult to get walkers 17 3. COLLECT DATA: HOW BAD IS IT? ABC Unit AMC: 2.42 per 1000 patient days 18 3. COLLECT DATA 19 4. CREATE PROCESS MAP 20 4. CREATE PROCESS MAP Why? Provides a common picture of a process for the whole team. Helps identify which parts of the system are important to measure. Helps generate ideas for change. (Define, standardize or find areas for improvement in a process.) How? Use symbols to represent steps in the process Start with big picture and develop detail later Need to have people who do the process involved 21 PROCESS MAP SYMBOLS Oval: Denotes the Start or Stop point in the process Diamond: Denotes a decision point in the process Rectangle: Denotes a step in the process or instructions Arrow: Denotes direction Triangle: Measurement point 22 4. CREATE A PROCESS MAP 23 ANOTHER IMPORTANT NOTE… Don’t confuse ideal process with the actual process. 24 QI Part 2 will talk more about collecting and analyzing data. Let’s focus more on process maps right now…. 25 BREAKOUT: PROCESS MAPPING Divide into groups of 6-8 people. You are going to create a process map of a medication administration process. You need to decide the setting and start point. The end point is when person gets medication. 26 TIPS FOR PROCESS MAPPING Ask what happens first, next, and then what happens next. If DEPENDS, then pick the most common next step and follow what happens after, and then go back to follow the other one. Keep it simple Turn the list of steps into a flow chart using symbols 27 PROBLEM SOLVING: TOOLS TO IDENTIFY SOLUTIONS 28 Most of our common problems in nursing do not have easy solutions. How do we get creative and figure out new ideas to try? 29 BRAINSTORMING AND DECISION MAKING TOOLS 30 BRAINSTORMING Creativity Large number of ideas All team members involved Sense of ownership in decisions Input to other tools 31 BRAINSTORMING Common Guidelines Write down ALL IDEAS exactly as spoken; one idea per post-it note/index card. Avoid interpreting Encourage participation by all members No “good” or “bad” ideas No discussion Can build on other’s ideas 32 FALLS CASE STUDY ABC unit is a 30 bed medical unit that is also the internal medicine teaching unit at Academic Medical Center (AMC). There are 4 different teaching teams on the unit on any given day. The unit’s average daily census is 29. There is an average of 10 discharges and admissions every day. The model of care on this unit is all RN with each nurse taking 34 patients in an assignment. Approximately 35% of the patients on any day are total care. Staff satisfaction is high on this unit, but the average staff nurse only has about 2.5 years of experience. After a few years of experience on this unit, many nurses move to ICUs or move on to APN roles after completing their MSN. The Nurse Manager is experienced, well respected, and has a reputation for turning around troubled units. In fact, the falls rate is only indicator that is above the benchmark at AMC. What can we do to decrease the falls rate on this unit? 33 BREAKOUT: BRAINSTORMING What’s the problem? Break into groups of 6-8 people. Work individually for 3-5 minutes and list 6 or more ideas for solutions After 3-5 minutes, go around your group and share your ideas. Place post it notes on the board as you share. 34 DECISION MAKING TOOLS Affinity Diagrams Multi-voting 35 AFFINITY DIAGRAMS Designed to sort a large number of ideas, process variables, concepts, and opinions into naturally related groups. 36 GENERATING SOLUTIONS: BRAINSTORMING AND AFFINITY ANALYSIS Either list can be rank-ordered 37 AFFINITY BREAKOUT Without speaking, sort the cards into "similar" groups based on your gut reaction. If you don't like the placement of a particular card, move it. Continue until consensus is reached. Create headers consisting of a concise 3-5 word description Discuss the groupings and try to understand how the groups relate to each other. 38 MULTI-VOTING Multi-voting is a group decision-making technique used to reduce a long list of items to a manageable number by means of a structured series of votes. 39 HOW TO DO MULTI-VOTING Work from a large list Assign a label to each item Vote for 1/3 to ½ of the items Tally the votes Repeat until down to a small number of items If < 5 team members: remove items with < 2 votes. If 6-15 team members: remove items with < 3 votes. If > 15 team members: remove items with < 4 votes. 40 FINAL COMMENTS Quick solutions to complex problems do not work. Systematic understanding of the process can lead to better solutions to the problems. There are tools that can facilitate your work to understand the process and find solutions to problems. Use them in practice and in the classroom! 41 TOOLS AND TECHNIQUES TO INCORPORATE INTO YOUR COURSES Process Mapping Brainstorming Affinity Diagrams Multi-Voting Tests of Change Using Data to Understand Processes Using Data to Evaluate Change Interventions QI Workshop Part 2 42 PROCESS MAPPING SUGGESTIONS FOR CLINICAL COURSES Assign students to write up and/or map one of the following processes they performed or observed during their last clinical: Medication administration process for routine medication Medication administration process for IV medication Initial shift assessment Rounding Care bundle (falls, CAUTI, CLABSI) Almost anything! 43 INTEGRATING AN IMPROVEMENT PROJECT INTO A ONE SEMESTER CLASS Rapid Cycle Quality Improvement (RCQI) can be incorporated into both didactic and clinical courses over a semester. Prelicensure programs Graduate programs Types of projects: Personal improvement projects Care bundle compliance (falls, CAUTI, pressure ulcer prevention) Larger microsystem or mesosystem changes 44 DATA COLLECTION SHEET Most tools and resources came from www.cautiout.org They recommend two weeks (M-F?) of baseline data collection, then again after interventions. Could be modified for other bundles such as fall prevention, 45 CLABSI, etc. 46