Rapid cycle PIDanielle Scheurer, MD, MSCR

Chief Quality Officer

Medical University of South Carolina

Objectives

Know how and why you need to have a disciplined approach to PI

Understand the importance of the reliability of interventions

Understand the importance of validating and evaluating interventions over time

Quality-Process Improvement

worse better

worse betterQuality

Quality

After

Before

Quality

worse betterQuality

After

QualityQuality Assurance

Quality Improvement

Bell Curve:Patient Population

Tail

better

Improvement and standardization in processes reduces variation (narrows the curve) and raises quality of care for all (shifts entire curve toward better care).

Quality-Process Improvement: Bridges the Implementation Gap

Implementation Gap

Scientific understanding

Patient care

Prog

ress

Time

The BEST quality is local

• “Bottom up” approach

• Problems and remedies come from the “front line”

• Often come from frustration of seeing processes that are:– Highly variable, unpredictable, not reproducible

– Potentially or actually harmful

– Inefficient or redundant

• Different areas have different quality issues, although some are ubiquitous– Medication errors

– Infection rates

Structure approach to PI

Ensure you are narrowing the scope of the problem to be addressed

Ensure you measure and analyze the problem, before you jump to a remedy

Ensure the remedy will “fix” the problem you are trying to solve

Force you to validate that the remedy was effective

Get a team

Champion: Overcome barriers

Process Owner: The driver

Facilitator: The navigator

Front line staff: Essential team members

Identify the problem

What is the problem?

Who identified it?

When was it identified?

When and where is it occurring?

Pick something that matters to you, and state WHY it matters

Who else cares about the problem (who are the stakeholders?) to assist with resources

Measure it

How can the data be collected (survey, administrative data, chart review)?

Is it valid/accurate?

Is it a manual process or automated?

Is there a clear definition of the outcome (or can it be interpreted different ways)?

Who is going to measure?

Can you sample?

Direct observation is the best way to determine what is actually happening

May want more than 1 type of measure: Process, outcome, structural, balancing

Problem Analysis: What is causing the problem?

• Time of day, day of week

• Department specific / system wide

• Inefficient staffing (numbers or skill set)

• Poor communication

• Inadequate process or policy

• Lack of controls to keep the problem from occurring

• Poor individual performance (usually not the only issue)

• Pick an appropriate process analysis tool to further analyze the problem/process

Remedy the critical issues

Pick a remedy based on the problem analysis.

What are the barriers?

What evidence is there that it will have an impact (has someone tried and succeeded or failed)?

How “reliable” is the intervention?

Do you need >1 intervention to make it nearly impossible to recur?

Remedies (in order of reliability)

Education

Reminders

Checklists

Order sets

Protocols

Pathways

Templates

“Hard stop” order entry

Operationalize

How are you going to make it work?

How will the barriers be removed?

What assistance is required from leadership?

What is the plan to roll out and implement solutions?

Changes thatresult in

Improvement

P

DS

A

P

DS

A

P

DS

A

P

DS

A

Time

Big Idea

Real time problem solving

Validate

How will we know we made a difference, what is your goal?

What are you measuring?

How often are you measuring it?

Is the measure meaningful?

Are you measuring “unintended consequences”?

Evaluate

How to sustain the improvement?

Who is responsible for monitoring and measuring over time?

What is the plan to react if the measures slip?

How will future staff be made aware of the new process?

Summary Have a structured and disciplined approach to PI,

with an executive summary

Always involve front line staff to determine what is actually happening, and what is feasible for change

Figure out the stakeholders and involve them early and often

Keep good records of what you have done and why

Example: Hand Hygiene

Recognized we had a problem

Formed a team

Determined how to measure (blended secret shopper and unit audits)

Analyzed the problem Education

Rewards

Medication administration

Accountability

Hand Hygiene

Remedies Education: Massive

Reward system: Incentives for all staff

Accountability system: Reports to leaders

Defined workflow for medication administration

Operationalized

Validate

Evaluate monthly