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Practice-Based Learning and Designing a Quality Improvement Project


Practice-Based Learning and Designing a Quality Improvement Project Richard Schifeling, MD EBM Working Group November 15, 2007 * * * Quality Improvement (QI ... – PowerPoint PPT presentation

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Title: Practice-Based Learning and Designing a Quality Improvement Project

Practice-Based Learning and Designing a Quality
Improvement Project
  • Richard Schifeling, MD
  • EBM Working Group
  • November 15, 2007

Quality Improvement (QI) Experiment
  • You are the hospital administrator at your
    institution in charge of QI
  • Youve just learned that CMS will no longer
    reimburse hospitals for care related to
    preventable cathether-associated urinary tract
  • What do you do?

Administrator reaction
  • Join the writers strike
  • Look for a job in ambulatory care
  • Form a committee to study the impact on your
  • Check with infection control
  • Check with nursing education providers

Beginning Oct. 2008, CMS to withhold payments
  • Catheter-associated UTIs
  • Vascular catheter-associated infections
  • Mediastinitis post- CABG
  • Pressure sores
  • Falls
  • Objects left in patients bodies
  • Air embolism, incompatible blood txs

CMS Methodology
  • No reimbursement for select conditions
  • High cost or high volume or both
  • Would result in higher payment as 2nd Dx
  • Reasonably prevent by using evidence-based

Volume/ Cost of Cath UTIs
  • 1 million cases per year in US- most
    common nosocomial infection
  • Each infection adds 1 hospital day
  • Cost is 500 million per year
  • 40 Medicare pts have urinary cath
  • 20 pts w/ cath get infection
  • lt 1 develop urosepsis

Prevention of UTIs
  • Use catheters only when necessary and only as
    long as necessary- not for convenience of staff
  • Staff training for aseptic management, proper
    irrigation and urine flow
  • Handwashing

Practice-Based Learning Improvement
  • Residents expected to
  • analyze practice experience perform
    practice-based improvement activities
  • locate, appraise, use best practices related to
    their patients health problems
  • appraise clinical studies
  • use information technology to manage info,
    support clinical care, pt education own

Need for quality improvement
  • Institute of Medicine (
  • Quality of Health Care in America
  • To Err Is Human Building a Safer Health Sytem
  • Crossing the Quality Chasm A New Health System
    for the 21st Century 2000

Need for quality improvement
  • Quality of healthcare can be measured
  • Serious, widespread problems in quality
    throughout U.S. healthcare
  • All systems affected managed care,
    fee-for-service, big/ small communities
  • Must change system of healthcare delivery to
    improve quality

Need for quality improvement
  • U.S. healthcare at its best is superb
  • Often it is not at its best resulting in
    population burden measured in
  • lost lives (IOM estimates 98K iatrogenic deaths
    each year in US hospitals)
  • reduced functioning
  • wasted resources

Definition of Quality
  • Degree to which health services for individuals
    and populations
  • increase likelihood of desired outcomes
  • are c/w current professional knowledge

Systems of care/ critical factors
  • Healthcare professionals practice in groups
    systems of care
  • Systems need to prevent/ minimize errors and harm
  • Coordinate care for settings providers
  • Relevant/ accurate healthcare info must be
    available when needed

Classification of quality of care issues/
  • Overuse, Underuse, Misuse
  • Overuse give service for which potential risk
    outweighs benefit
  • Underuse fail to give service for
    which potential benefit outweighs risk
  • Misuse appropriate service given in manner
    leading to avoidable risks

  • Overuse Rx of antibiotic for URI, use urine
    catheter for convenience
  • Underuse lack beta-blocker post-MI, lack
    immunization, lack prenatal care, lack medication
  • Misuse preventable complications like wrong-side

The 100,000 Lives Campaign Getting Started
  • Institute for Healthcare Improvement
Six Changes That Save Lives
  • Deployment of Rapid Response Teamsat the first
    sign of patient decline
  • Delivery of Reliable, Evidence-Based Care for
    Acute Myocardial Infarctionto prevent deaths
    from heart attack
  • Prevention of Adverse Drug Events (ADEs)by
    implementing medication reconciliation
  • Prevention of Central Line Infectionsby
    implementing a series of interdependent,
    scientifically grounded steps called the Central
    Line Bundle
  • Prevention of Surgical Site Infectionsby
    reliably delivering the correct perioperative
    antibiotics at the proper time
  • Prevention of Ventilator-Associated Pneumoniaby
    implementing a series of interdependent,
    scientifically grounded steps called the
    Ventilator Bundle

Prevent Adverse Drug Events by Implementing
Medication Reconciliation
  • Reconciliation A process of identifying the most
    accurate list of all medications a patient is
    takingincluding name, dosage, frequency, and
    routeand using this list to provide correct
    medications for patients anywhere within the
    health care system
  • Requires comparing the patients list of current
    medications against the physicians admission,
    transfer, and/or discharge orders

Medication Reconciliation
  • IOM estimates 7000 deaths annually due to
    medication errors
  • About 50 these errors occur at transition points
    (hosp admit, D/C, transfer to another unit)
  • JCAHO makes medication reconciliation a National
    Patient Safety Goal

Medication Reconciliation
  • Requires change in system
  • Emphasizes teamwork/ efficiency
  • Improves patient safety
  • Can improve medication errors at transition
  • ? Impact on adverse drug events and deaths-
    limited evidence thus far

Institute of Medicine Vision of Future Quality
  • U.S. healthcare will be
  • Safe (avoiding patient injury)
  • Effective (EBM avoid overuse/underuse)
  • Patient-centered (patient values)
  • Timely (reducing waits and delays)
  • Efficient (avoid waste)
  • Equitable (no practice variability based
    on socioeconomics, race, gender, geography)

Institute of Medicine Vision
  • Current care systems cant do the job
  • They rely on outmoded systems of work
  • Need redesigned systems of care for safer,
    high-quality care
  • Need better use of information tech. to support
    clinical and administ. processes

Institute of Medicine Vision
  • Majority of healthcare services address 15 to
    25 conditions
  • Focus attention on chronic care processes for
    these common conditions
  • Evidence-based processes, supported by automated
    clinical info decision support systems promise
    best outcomes

QI project using EBM
  • Consider common chronic care problem that needs
    improvement and has EBM best practice(s)
  • Consider changes in system of healthcare needed
    to improve quality
  • Consider how to measure performance pre-/
    post-intervention complete cycle

QI Project Steps
  • Choose specific area of care or provider
    education to improve
  • Check project idea meets criteria
  • Define best practice
  • Measure current practice
  • Change system to improve practice
  • Measure post-intervention practice

  • Question(Hypothesis)
  • To know where to look, you need a hypothesis to
    guide you.
  • This is the key to any successful research(QI
  • Confronting Quality Problems
  • Underuse of Services
  • Overuse of Services
  • Misuse of Services
  • Variation of Services

AHRQ http// IOM
  • Evidence
  • review of the literature
  • finding similar questions and study designs
  • shows that EBM is fun

Time Allocation
  • Decide your direction
  • Limit the scope
  • Schedule the time
  • Dedicate the time
  • Delegate the tasks
  • Start now!

QI requires a positive attitude and the mindset
to continue to ask questions.