1 Presenter Disclosure Information FINANCIAL DISCLOSURE: Nothing to Disclose Stacey Stoeckle-Roberts...

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Presenter Disclosure Information

FINANCIAL DISCLOSURE:Nothing to Disclose

Stacey Stoeckle-RobertsGoals and Conceptual Framework for the MASCOTS Quality Improvement Project

UNLABELED/UNAPPROVED USES DISCLOSURE:Nothing to Disclose

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MASCOTS – QIP MASCOTS – QIP Phase IIIPhase III

Using data to improve Using data to improve acute stroke care in acute stroke care in

Michigan Michigan

M ASC O T S

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The Paul Coverdell National The Paul Coverdell National Acute Stroke RegistryAcute Stroke Registry

May, 2001, CDC program announcement May, 2001, CDC program announcement – Development of Prototypes for the Paul Coverdell Development of Prototypes for the Paul Coverdell

National Acute Stroke RegistryNational Acute Stroke Registry

PurposePurpose::– To design and pilot test real-time data and To design and pilot test real-time data and

analysis prototypes in statewide samples that analysis prototypes in statewide samples that will measure the delivery of care to patients with will measure the delivery of care to patients with acute strokeacute stroke

Required ActivitiesRequired Activities– 2L. To develop and implement a plan to use data 2L. To develop and implement a plan to use data

to improve acute stroke careto improve acute stroke care

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Why a Registry?Why a Registry?

To monitor the adherence to To monitor the adherence to evidence based guidelines in careevidence based guidelines in care

To identify those areas where To identify those areas where

quality improvement initiatives are quality improvement initiatives are most necessarymost necessary

To develop a tracking system to To develop a tracking system to monitor improvements in the monitor improvements in the delivery of acute stroke caredelivery of acute stroke care

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Mascots:

Oversight Team Data Management Coverdell Grant

Michigan Department

of Community Health

Quality Improvement ExpertiseStroke/CVD Network

Oversight Team

AmericanStroke Association

Clinical Content- GWTG

Measurement PackageOversight Team

Quality Improvement Support

Quality ImprovementProject

Participating Hospitals

MASCOTS Quality Improvement Partnership

Improvement vs. Improvement vs. ResearchResearch

ImprovementImprovementAim: Improvement of careAim: Improvement of care

Methods:Methods:• Test observableTest observable• Stable biasStable bias • Just enough dataJust enough data• Adaptation of the Adaptation of the

changeschanges

• Sequential testsSequential tests

Clinical ResearchClinical ResearchAim: New knowledgeAim: New knowledge

Methods:Methods:• Test blindedTest blinded• Eliminate biasEliminate bias• Just in caseJust in case• Fixed hypothesesFixed hypotheses• One large testOne large test

© 2002 Institute for Healthcare Improvement

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AgendaAgenda Review of MASCOTS and Burden of stroke Review of MASCOTS and Burden of stroke Define goals of the quality improvement Define goals of the quality improvement

projectproject Conceptual framework for the quality Conceptual framework for the quality

improvement planimprovement plan Description of Description of Get With The Guidelines – Get With The Guidelines –

StrokeStroke (GWTG) (GWTG) Demonstration of the Patient Management Demonstration of the Patient Management

ToolTool Breakout SessionsBreakout Sessions

– Refine the aim statement of each hospitalRefine the aim statement of each hospital– Assess current status of each hospitalAssess current status of each hospital– Determine and plan for steps to be taken before Determine and plan for steps to be taken before

next learning sessionnext learning session

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MASCOTS Update MASCOTS Update &&

Quality ImprovementQuality Improvement GoalsGoals

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Stroke in the United StatesStroke in the United States

Stroke remains the 3rd leading cause Stroke remains the 3rd leading cause of death in the US: 160,000 of death in the US: 160,000 deaths/yeardeaths/year

Stroke is a leading cause of serious, Stroke is a leading cause of serious, long-term disability in the USlong-term disability in the US

22% of men and 25% of women who 22% of men and 25% of women who have their first stroke die within one have their first stroke die within one year. year.

Only 50-70% of stroke survivors Only 50-70% of stroke survivors regain functional independence, 20% regain functional independence, 20% are institutionalized within 3 months.are institutionalized within 3 months.

AHA Heart and Stroke Statistical Update 2001

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Estimated Direct and Estimated Direct and Indirect Costs of Indirect Costs of

StrokeStroke

American Heart Association. 2002 Heart and Stroke Statistical Update. 2001.

United States: 2002Hospital/Nursing Home $24.5 billion

Physicians/Other Professionals $2.4 billion

Home Health Care $3.1 billionDrugs/Other Medical Durables $0.8 billion

Indirect Costs $18.6 billion

Direct Costs

$30.8 billion

Total Cost = $49.4 billion

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Paul Coverdell National Acute Stroke Registry

September, 2001 Four awards were given to:

– Univ. of Cincinnati, OH.– Emory University/GA PRO, GA.– Mass General/MA PRO, MA.– MSU/MASCOTS, MI

May 2002, 1 year extension granted

Funding extended in 2002 for IL, OR, CA, NC to

develop registries

Each of the original 4 states have begun Each of the original 4 states have begun

implementation of a quality implementation of a quality improvement

project

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Purpose of MASCOTS QI ProjectPurpose of MASCOTS QI Project

To utilize the information To utilize the information obtained from MASCOTS to obtained from MASCOTS to develop and implement a develop and implement a plan that will positively plan that will positively impact acute stroke impact acute stroke treatment, care and treatment, care and outcomes in Michigan.outcomes in Michigan.

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Quality Improvement Project Quality Improvement Project TargetsTargets

Performance MeasuresPerformance Measures– Timing of assessments/interventionsTiming of assessments/interventions– Use of NIH stroke scaleUse of NIH stroke scale– Dysphagia screeningDysphagia screening– Use of antithrombotics and Use of antithrombotics and

anticoagulantsanticoagulants Medical record documentation of Medical record documentation of

items critical in the delivery of items critical in the delivery of optimal stroke careoptimal stroke care– Reason for non use of tPAReason for non use of tPA– Medical history elements: A-fib, previous Medical history elements: A-fib, previous

stroke/TIA, smoking, dyslipidemia, stroke/TIA, smoking, dyslipidemia, diabetes mellitus, HTN, previous CAD/AMIdiabetes mellitus, HTN, previous CAD/AMI

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Goal Setting and Goal Setting and Benchmarking for the Benchmarking for the Quality Improvement Quality Improvement

ProjectProject

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BenchmarkingBenchmarking

Has been used widely in the Has been used widely in the industrial quality arena industrial quality arena

Incorporates four basic comparisonsIncorporates four basic comparisons– With selfWith self– With othersWith others– With standardsWith standards– With best practicesWith best practices

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Determining the Benchmark for Determining the Benchmark for the MASCOTS QIPthe MASCOTS QIP

MethodsMethods– MASCOTS benchmark measures of top MASCOTS benchmark measures of top

performance were generated using a performance were generated using a modified Achievable Benchmark of Care modified Achievable Benchmark of Care (ABC(ABCTMTM) methodology. This modified ) methodology. This modified methodology used a pared-mean of the methodology used a pared-mean of the top three performing hospitals with the top three performing hospitals with the qualification that at least 10 valid qualification that at least 10 valid observations were available from a observations were available from a candidate hospital for the indicator candidate hospital for the indicator under consideration. under consideration.

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Increase to 100% the proportion of Increase to 100% the proportion of cases seen by an ED physician within 10 cases seen by an ED physician within 10

minutes of arrivalminutes of arrival

Mean=Mean=

19.91%19.91%

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Increase to 100% the proportion of cases Increase to 100% the proportion of cases having an acute stroke team consult within 15 having an acute stroke team consult within 15

minutes of arrival minutes of arrival **if arrival is if arrival is << 180 minutes from stroke symptom onset 180 minutes from stroke symptom onset

Mean=Mean=

24.32%24.32%

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Increase to 100% the proportion of cases Increase to 100% the proportion of cases with imaging studies completed by 25 with imaging studies completed by 25

minutes minutes *if arrival is *if arrival is << 180 minutes from stroke symptom onset 180 minutes from stroke symptom onset

Mean=Mean=

5.86%5.86%

2020

Increase to 100% the proportion of Increase to 100% the proportion of cases with a documented NIH stroke cases with a documented NIH stroke

scalescale* * if arrival is if arrival is << 180 minutes from stroke symptom onset 180 minutes from stroke symptom onset

Mean=Mean=

22.05%22.05%

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Increase to 100% the proportion of Increase to 100% the proportion of cases having dysphagia screening prior cases having dysphagia screening prior

to oral intaketo oral intake

Mean=Mean=

39.25%39.25%

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Increase to 100% the proportion of Increase to 100% the proportion of cases discharged on antithrombotics cases discharged on antithrombotics

without documented contraindications without documented contraindications

Mean=Mean=

97.80%97.80%

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Increase to 100% the proportion of Increase to 100% the proportion of cases with A-fib discharged on cases with A-fib discharged on

anticoagulants anticoagulants

Mean=Mean=

82.69%82.69%

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Increase to 100% the proportion of Increase to 100% the proportion of smokers who receive cessation smokers who receive cessation

counselingcounseling

Mean=Mean=

25.95%25.95%

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DocumentationDocumentation

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Increase to 100% the proportion of cases Increase to 100% the proportion of cases with documented reasons for non use of with documented reasons for non use of

tPA therapytPA therapy

Mean=Mean=

20.54%20.54%

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Decrease to 0% the proportion of cases Decrease to 0% the proportion of cases with ND recorded for previous stroke/TIA with ND recorded for previous stroke/TIA

Mean=Mean=

38.98%38.98%

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Decrease to 0% the proportion of cases Decrease to 0% the proportion of cases where ND is listed for antithrombotic tx. where ND is listed for antithrombotic tx.

At D/C At D/C

Mean=Mean=

2.19%2.19%

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Decrease to 0% the proportion of cases Decrease to 0% the proportion of cases with ND recorded for A-fib with ND recorded for A-fib

Mean=Mean=

70.84%70.84%

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Decrease to 0% the proportion of cases Decrease to 0% the proportion of cases with ND recorded for smoking with ND recorded for smoking

Mean=Mean=

6.45%6.45%

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Decrease to 0% the proportion of cases Decrease to 0% the proportion of cases with ND recorded for dyslipidemia with ND recorded for dyslipidemia

Mean=Mean=

58.56%58.56%

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Decrease to 0% the proportion of cases Decrease to 0% the proportion of cases with ND recorded for diabetes mellitus with ND recorded for diabetes mellitus

Mean=Mean=

49.18%49.18%

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Decrease to 0% the proportion of cases Decrease to 0% the proportion of cases with ND recorded for HTN with ND recorded for HTN

Mean=Mean=

19.78%19.78%

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Decrease to 0% the proportion of Decrease to 0% the proportion of cases with ND recorded for previous cases with ND recorded for previous

CAD/AMI CAD/AMI

Mean=53.64%Mean=53.64% Mean=62.90%Mean=62.90%

CADCAD AMIAMI

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How Do We Get How Do We Get There From Here?There From Here?

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Performance Improvement Performance Improvement Model SelectionModel Selection

Systematic ApproachSystematic Approach Allow for Collaborative NatureAllow for Collaborative Nature Proven Track RecordProven Track Record FlexibleFlexible

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Institute for Healthcare Institute for Healthcare Improvement Breakthrough Improvement Breakthrough

SeriesSeries

Collaborative model for improvementCollaborative model for improvement Have completed 26 Collaborative Have completed 26 Collaborative

projects in the USprojects in the US Model can be adapted to fit the needs Model can be adapted to fit the needs

of this projectof this project

The IHI Breakthrough The IHI Breakthrough SeriesSeries

An improvement method that An improvement method that relies on relies on spreadspread and adaptation and adaptation of of existing knowledgeexisting knowledge to to multiple multiple settingssettings to accomplish a common to accomplish a common aimaim..


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Introduction to Introduction to Collaborative LearningCollaborative Learning

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What Is Collaboration?What Is Collaboration?

Joint effort among multiple Joint effort among multiple organizations that share organizations that share resources and informationresources and information

Each organization benefits Each organization benefits individually, even though the individually, even though the organizations are working organizations are working togethertogether


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What Does Collaboration What Does Collaboration Accomplish?Accomplish?

Achieves goals that would not Achieves goals that would not have been attainable for an have been attainable for an organization working on its organization working on its own (both scope and pace)own (both scope and pace)


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Key Elements of Key Elements of Breakthrough Breakthrough ImprovementImprovement

Will to do what it takes to change to Will to do what it takes to change to a new systema new system

Ideas on which to base the design of Ideas on which to base the design of the new systemthe new system

Execution of the ideas Execution of the ideas


IHI Breakthrough IHI Breakthrough SeriesSeries

(6 to 13 months time frame)(6 to 13 months time frame)Select Topic (develop mission)

Planning Group

Develop Framework & Changes

Participants

Prework

LS 1

P

S

A D

P

S

A D

LS 3LS 2

Supports

Email Visits

Phone Assessments

Monthly Team Reports

Congress,

Guides,

Publications

etc.

A D

P

SExpert Meeting


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Learning SessionsLearning Sessions

Everyone learns – everyone Everyone learns – everyone teaches!teaches!

Followed by PDSA cycleFollowed by PDSA cycle Topic of Sessions:Topic of Sessions:

– Sept 8 – Planning for Implementation Sept 8 – Planning for Implementation – January – Implementation, pilot testing January – Implementation, pilot testing

and dealing with barriersand dealing with barriers– April – Monitoring progress, April – Monitoring progress,

refinements and spreadrefinements and spread– July – Results and debriefingJuly – Results and debriefing

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

PlanAct

DoStudy


What is the PDSA Cycle?

Act

• What changes are to be made? (implement or adapt the change)• Next cycle?

Plan• Objective• Questions and predictions (why)• Plan to carry out the cycle (who, what, where, when)

Study• Complete the analysis of the data

•Compare data to predictions

•Summarize what was learned

Do• Carry out the plan• Document problems and unexpected observations• Begin analysis of the data


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Learning Session #1Learning Session #1Planning for ImplementationPlanning for Implementation

Begin to assess current statusBegin to assess current status– Do we have standard tools?Do we have standard tools?– Do they reflect the most current standards?Do they reflect the most current standards?– Are they easy to use?Are they easy to use?– Breakout sessionBreakout session

Methods to determine what changes are Methods to determine what changes are necessary necessary – Breakout sessionBreakout session

Begin development of action plan Begin development of action plan – Breakout sessionBreakout session

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Action Period #1Action Period #1

Determine and facilitate the Determine and facilitate the necessary steps for implementation in necessary steps for implementation in your hospital your hospital

* Involve senior leadership * Involve senior leadership – Complete modification of toolsComplete modification of tools– Obtain necessary approval (may differ by Obtain necessary approval (may differ by

hospital)hospital) Contract with Outcomes SciencesContract with Outcomes Sciences Forms committee for modified toolsForms committee for modified tools Approval: Official and Opinion LeadersApproval: Official and Opinion Leaders Other Other

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Plan your measurement strategyPlan your measurement strategy– Who will be responsible for Who will be responsible for

measurements at your hospital?measurements at your hospital?– 30 baseline charts before implementation30 baseline charts before implementation– 10 charts per month minimum during 10 charts per month minimum during

projectproject– 30 charts for remeasurement30 charts for remeasurement

Obtain baseline measurementsObtain baseline measurements

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Coordinate a multidisciplinary Coordinate a multidisciplinary hospital team. hospital team. – Enlist the team in review, revision or Enlist the team in review, revision or

development of documents development of documents – Revise the protocols to close the gaps Revise the protocols to close the gaps

and reflect compliance with current and reflect compliance with current guidelines (templates are in hospital guidelines (templates are in hospital tool kit)tool kit)

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Technology Adoption ProcessTechnology Adoption Process

LaggardsLate

MajorityEarly

MajorityEarly AdoptersInnovators

"The Chasm"

Developed by Everett Rogers - expert in rural sociology

Model can be used to interpret almost any form of innovation

Theory suggests that critical mass typically occurs when about 15 or 20

percent of a target population adopts a new innovation from: "The Coming Ubiquity of Information Technology" in Change, Vol. 28, 3/13/96

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Innovators

Innovators:

Generate new ideas (many not successful)Out of mainstream “Heat Seekers”

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Early AdoptersInnovators

"The Chasm"

Early Adopters:

Key to successful change Links to Innovators and Majority Opinion leaders Take the idea from the innovator and makes the change happen

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EarlyMajority


"The Chasm"

Early Majority:

High degree of interaction with peers Not generally opinion leaders Cautions about change

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LateMajority

EarlyMajority


"The Chasm"

Late Majority: Need early majority to demonstrate change is an improvement Peer pressure to change

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LaggardsLate

MajorityEarly


"The Chasm"

Laggards:

Traditionalists Passionate about viewpoint Focus more on Early Adopters

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LaggardsLate

MajorityEarly


"The Chasm"

Choose your team and project ambassadors carefully

Select Early Adopters as change agentsPresent evidence of successful changes to Late Majority for peer pressure

and motivationDo not expend excessive energy on Laggards or Traditionalists

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Collaborative Action Period Collaborative Action Period ActivitiesActivities

Monthly Conference CallsMonthly Conference Calls

Project Leader Monthly ReportsProject Leader Monthly Reports– Generated from monthly data Generated from monthly data

abstraction and feedback abstraction and feedback

E-mail communication to E-mail communication to communicate questions and communicate questions and share experiencesshare experiences

Participating HospitalsParticipating Hospitals

University of University of Michigan Medical Michigan Medical CenterCenter

Ingham Regional Ingham Regional Borgess HospitalBorgess Hospital Bronson Methodist Bronson Methodist

HospitalHospital Saint Mary’s Mercy Saint Mary’s Mercy

Medical Center, Medical Center, Grand RapidsGrand Rapids

St. Joseph TawasSt. Joseph Tawas Metropolitan Metropolitan

Hospital Hospital Detroit Receiving Detroit Receiving

HospitalHospital Sparrow HospitalSparrow Hospital St. Mary’s SaginawSt. Mary’s Saginaw St. John Health St. John Health

System DetroitSystem Detroit Northern Michigan Northern Michigan

HospitalHospital

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Thank YouThank You

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