Quality and Patient Safety in
Respiratory CareCindy Bravo-Sanchez, PhD, MPA, BSRT, RRT-NPS
Lecture Objectives Discuss the six domains of quality care from the
Institute of Medicine (IOM)
Discuss the characteristics of a high reliability organization
Review and demonstrate quality improvement tools and methodologies
Institute of Medicine (IOM) Domains of Quality Care
Safe care: Avoiding harm to patients from the care that is intended to help them.
Effective care: Providing evidence-based care to all who could benefit, and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively).
Patient-centered care: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
Timely care: Reducing waits and sometimes harmful delays for both those who receive and those who give care.
Efficient care: Avoiding waste, including waste of equipment, supplies, ideas, and energy.
Equitable care: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.
Institute of Medicine. (2001). "Crossing the quality chasm: A new health system for the 21st century". Washington, D.C.: National Academy Press. doi:10.17226/10027
High-Reliability Organizations (HRO) in Healthcare
High risk industries – All efforts towards reaching a state of zero failures When applied to healthcare: care that is safe, equitable, effective, efficient, timely and
patient-centered.
5 characteristics of HROs: Preoccupation with failure – Always monitoring for possible threats to safety (pts., staff,
etc.) Sensitivity to operations – Recognize early indicators of threats to organizational
performance Reluctance to simplify – Resist the temptation to simplify observations – Threats to safety
may be complex Commitment to resilience – Recognize and contain errors, avoiding harm Deference to expertise – Include knowledgeable experts (including front line staff) in
order to find a solution
Weick, K.E., and K.M. Sutcliffe. 2007. Managing the Unexpected. 2nd ed. San Francisco: Jossey-Bass.
High-Reliability Organizations (HRO) in Healthcare
HROs stay safe by:
Creating an environment of collective mindfulness – All workers monitor and report problems/unsafe conditions early (easier to fix), before they become substantial threats to patients and the organization.
Creating an inclusive/safe environment – No tolerance for intimidating behaviors within or between teams (including team leaders and front line staff). This helps to increase reporting of safety concerns and avoids the perpetuating of unsafe conditions.
Practicing transparency – Errors should be seen as valuable information and essential to a hospital’s ability to improve patient safety. No news is bad news when it comes to occurrence reporting.
Chassin, M, Loeb, J., 2013, High – Reliability Health Care: Getting There from Here, The Milibank Quarterly, 91.3. Wiley Periodicals Inc.
High-Reliability Organizations (HRO) in Healthcare
Transitioning healthcare organizations towards high reliability requires: Leadership’s commitment to zero harm
Incorporation of an organization-wide culture of safety
Widespread implementation of process/quality improvement tools and methods
Chassin, M, Loeb, J., 2013, High – Reliability Health Care: Getting There from Here, The Milibank Quarterly, 91.3. Wiley Periodicals Inc.
Process/Quality Improvement Methodologies
Change Management – Assisting people with organizational change Planning for change (communication) Managing change (communication, training) Reinforcing change (communication, resistance
management)
PDSA/PDCA – Plan, Do, Study/Check, Act
Lean – Six Sigma DMAIC – Define, measure, analyze, improve, control DMADV – Define, measure, analyze, design, verify Reduce errors/costs and waste/inefficiencies: Continuous rapid quality performance improvement
IHI – Institute for Healthcare ImprovementNAHQ – National Association for Healthcare Quality
Process/Quality Improvement Tools
SMART goals
Plan-Do-Study-Act worksheet
Lean – A3 Improvement plan
Project planning form
Failure Modes + Effective Analysis
Process map (flow chart)
Cause and effect diagram
Run chart and control chart
Organize your Improvement Project
Evaluate and Analyze the
Problem and Solution
Failure Modes and Effective Analysis (FMEA)
A systematic, proactive analysis of a process in which harm may occur Evaluate a new process, or
A proposed change to an existing process
Prioritize improvement needs
ihi.org/ImprovementCapability
FMEA• List all steps in the process
Steps in process:
• What could go wrong?Failure mode
• Why would the failure happen?Failure Effects
• *What would be the consequences of the failure? (1 – 10)Likelihood of occurrence
• *What is the likelihood the failure will occur? (1 – 10) Likelihood of detection
• *Likelihood that the failure mode (if it occurs) will cause severe harm (1 – 10)Severity
• Multiply each *failure mode togetherRisk profile number (RPN)
• List possible actions to improve safetyActions to reduce occurrence of failure
ihi.org/ImprovementCapability
FMEA: External Patient Transport
Steps in process:
Failure mode
Failure Effects
Likelihood of occurrence (1 – 10)
Likelihood of detection (1 – 10)
Severity
(1 – 10)
Risk profile number (RPN)
Actions to reduce occurrence of failure
Initial report (diagnosis,vent settings, etc.)
Preparing transportventilator for use (test)
Inaccurate report
Nurse-to-nurse-to-RT verbal hand-off
Consequences:Hyper/hypocarbia, hypoxia, pneumothorax, atelectasis
10
Chance of using Inappropriate vent settings
5 8 = 400
Implement standardized electronic report tool viewable by all (ex. SBAR)
Ventilator not tested prior to use
Ventilator may malfunction while in use
Consequences:hypoxemia, hypercarbia, death
10
Chance of ventilator malfunction or failure
5 5
Chance of severe harm
= 250
Competencies: Implement pre-post transport electronic check-off tool
Total RPN = 650
Compare to other FMEAs
Chance of severe harm
FMEA – Risk Profile Number Comparisons
FMEA RPN
External patient transport 650
Unplanned extubations 850
E-cylinder access and storage 600
Holter monitoring 600
ICU RC supplies 500
Emergency room assignment 650
NICU Bedside PDA Ligation 700
SMART Goals: Unplanned Extubations Specific: Which goal is most specific?
Reduce intensive care unit complications
Reduce unplanned extubations in the PICU to zero within 6 months
Measureable: Which measure will best help to target the outcomes?
Measure each occurrence in real-time using a collection tool designed specifically for the occurrence
Measure each occurrence based on standard electronic record documentation
Actionable: Which actions will best support the specific goal?
Rapid weaning protocol developed and implemented by a multidisciplinary team
Medical staff, nurses and respiratory therapists will be educated regarding the protocol
Respiratory therapist will collect and report the occurrence data
Rapid weaning protocol developed and implemented by one department
Nursing and respiratory therapy receive an email with the protocol
Nursing and respiratory therapy document any occurrences independently
Relevant: Which one of these statements helps to support the specific goal?
There is a clear gap in care since 6% of patients experience unplanned extubations
The average length of stay is 30 days
Time bound: Which one of these statements best supports the specific goal?
The goal will be achieved over the next 4 years, with bi-weekly, monthly, and quarterly meetings
The goal will be achieved over two weeks, with weekly meetings and final report at end of week 2www.decisionskills.comSadowski R, Dechert R. Bandy K, Juno J, Bhatt-Mehta V, Custer JR, et al. Continuous quality improvement: Reducing unplanned extubations in a pediatric intensive care unit. Pediatrics 2004:1.14(3): 628-32
Process Map (Flow chart) Visual presentation of all the steps in a process Current (where are the opportunities to improve?)
Future (what would be the ideal process?)
Involve frontline staff Most healthcare processes are multidisciplinary
ihi.org/ImprovementCapability
Process Map (Flow chart)Current
Randolph, A. G., Wypij, D., & Venkataraman, S. T. (2002). Effect of mechanical ventilator weaning protocols on respiratory outcomes in infants and children: A randomized controlled trial. Journal of the American Medical Association, 288(20), 2561-2568. doi:10.1001/jama.288.20.2561
Ventilated patients
Wean?
Physician’s discretion
9 vent modes
No management recommendations
made
3 or more mode changes
Pressure support 43.3%
Pressure control w/PS
67%
Extubationswith set rate
Process Map (Flow chart)
Future (Ideal)
Therapist-driven protocol
Faster ventilator weaning
Decreased ventilator days
Haas, C. F., & Loik, P. S. (2012). Ventilator discontinuation protocols. Respiratory Care, 57(10), 1649-1662. doi:10.4187/respcare.01895
Cause and Effect (Fishbone) Diagram
People
Policy Environment
Equipment
Staffing
Results/Outcome
(Problem)
Communication
https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/fishbonerevised.pdf
Cause and Effect (Fishbone)Prolonged Intubation
Gutsche, J. T., Erickson, L., Ghadimi, K., Augoustides, J. G., Dimartino, J., Szeto, W. Y., & Ochroch, E. A. (2014). Advancing extubation time for cardiac surgery patients using lean work design doi:https://doi.org/10.1053/j.jvca.2014.05.024
Quality and Patient Safety Measures (Data)
Measuring, analyzing, and reporting quality data helps you to: Track the quality of health care services that we provide. Ensure that a health care process/system is delivering effective,
safe, efficient, patient-centered, equitable, and timely care. Examine many aspects of patient care, including:
Patient and family engagement Patient safety Care coordination Population/public health Efficient use of healthcare resources Clinical process/effectiveness
(The Joint Commission Center for Transforming Healthcare, Centers for Medicare & Medicaid Services)
Run/Control Chart Graph of data over time
Determine if changes to processes are leading to improvement
Variations Common-cause (natural or expected)
Special-cause (causes not inherent in the process)
ihi.org/ImprovementCapability
Run Chart
ihi.org/ImprovementCapability
Control Chart
ihi.org/ImprovementCapabilityhttps://www.youtube.com/watch?v=zvp8qmH3Eos
Upper control limit (UCL) +3 Stdev from the mean
Lower control limit (UCL) -3 Stdev from the mean
Average
Run ChartP
eds
CIC
U U
npla
nned
Ext
ubat
ion
Rat
e per
100
Ven
tila
tor
Day
s
Kaufman, J., Rannie, M., Kahn, M. G., Vitaska, N., Wathen, B., Peyton, C., . . . Dobyns, E. (2012). Interdisciplinary initiative to reduce unplanned intubations in pediatric critical care units. Pediatrics, 129(6), 1594-1600. doi:10.1542/peds2011-2642
# UEX x 100 = Rate of UEX# ventilator days
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
1/2009 4/2009 7/2009 10/2009 7/20101/2010 4/2010 10/2010 12/2010
. . . . . . . .
..
. .
.
. ..
. . ..
.Baseline Median
Goal
Months
. .
RT RetapingPolicy
Systematic Review Sheet Implementation
CICU White Board Daily Use
Hand-off ProtocolBaseline
Control ChartP
eds
CIC
U U
npla
nned
Ext
ubat
ion
Rat
e per
100
Ven
tila
tor
Day
s
Kaufman, J., Rannie, M., Kahn, M. G., Vitaska, N., Wathen, B., Peyton, C., . . . Dobyns, E. (2012). Interdisciplinary initiative to reduce unplanned intubations in pediatric critical care units. Pediatrics, 129(6), 1594-1600. doi:10.1542/peds2011-2642
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
1/2009 4/2009 7/2009 10/2009 7/20101/2010 4/2010 10/2010 12/2010
. . . . . . . .
..
. .
.
. ..
. . ..
.
Goal
Months
. .
RT RetapingPolicy
Systematic Review Sheet Implementation
CICU White Board Daily Use
Hand-off Protocol
Upper control limit
(UCL)
Mean 0.74
Mean 0.44
Upper control limit
(UCL)
Pre-implementation Implementation
Post-implementation
PDSA Plan-Do-Study (Check)-Act
Process for testing a change Plan – Develop a plan
Purpose/SMART goal of the test; prediction of the outcome; cause and effect diagram
Who? What? When? Where? Data to be measured (observations, EMR report)
Do – Test the plan Document unexpected occurrences (flow chart) Collect data during test (process measures)
Study (Check) – Observe/analyze test process and outcomes Expected/ideal outcomes compared to actual outcomes (run/control chart)
Act – Decide if modifications are needed prior to next cycle Repeat until all agree on change outcomes Expected/ideal outcomes compared to actual outcomes Review results and decide whether to adopt, adapt, or abandon new process changes
ihi.org/ImprovementCapability
PDSA WorksheetQuestion Your PlanWhat is your planned change?
What outcome do you predict?
When will you implement the change?
Where will you implement the change?
Which patients will be involved?
Who will implement the change?
How will you measure the change?
How will you help the team track the change?
American College of Physicians - https://edhub.ama-assn.org/steps-forward/module/2702507Sadowski R, Dechert R. Bandy K, Juno J, Bhatt-Mehta V, Custer JR, et al. Continuous quality improvement: Reducing unplanned extubations in a pediatric intensive care unit. Pediatrics 2004:1.14(3): 628-32
Our planned change is: To reduce the number of unplanned extubations/dislodgements (UEX)Action plan 1: Assemble and train multidisciplinary team Action plan 2: Expedited weaning protocolAction plan 3: Standardized sedation protocol
Our predicted outcome is: UEX rates will be reduced with the implementation of all action plans
We will implement the change in the following time frame: Phase I: 2 yrs. of pre-protocol data capture; Cause and effect; Development of action plansPhase II: 1 yr. implementation of all action plansPhase III: 1 yr. of analysis-tracking trends – improvement cyclesPhase IV: Post-protocol data capture and communication of findings
We will implement the change in the following location: PICU
We will involve the following patient population: All patients requiring an artificial airway (Orotracheal, nasotracheal, or tracheostomy) will be monitored for any UEX occurrences
The following team members will implement the change: Medical staff, nursing, respiratory care
The following members will be involved in measuring the change by: UEX per 100 days, by age group (Little et al, 1990); RTs will track UEX details (data form used): Root cause analyses
We will track and communicate the results of our planned change by: Bi-weekly, monthly, quarterly meetings
PDSA WorksheetPlan Do Study Act
https://edhub.ama-assn.org/steps-forward/module/2702507
To reduce the number of unplanned extubations/dislodgements (UEX)Phase I: 2 yrs. of pre-protocol data capture; Cause and effect; Development of action plans
Phase II: 1 yr. implementation of all action plans: Action plan 1: Assemble and train multidisciplinary team Action plan 2: Expedited weaning protocolAction plan 3: Standardized sedation protocol
Phase III: 1 yr. of analysis-tracking trends –improvement cycles (focused PDSA cycles)
Results reviewed and the decision was made to adopt the new protocols
Lean – A3Process Improvement Plan
3. Future StateIdeal process (process
map)/outcome (benchmark/target measures)
2. Current StateProcesses (process map), policies, quality metrics?; What can be improved?
1. Reason for Action
Identify issue (SMART goals)
6. Run PilotPilot new process; multiple PDSAimprovement cycles: Who, what when, where, how; quality data
5. Possible Solutions
Best attainable solution; New process (process map)
4. Present Gaps
Cause and effect, 5 whys; Challenges to ideal outcome
9. Continuous Monitoring for Sustainment
Plan for initial and long-term monitoring of system (data);
Feedback loop for all stakeholders
8. Evaluate Outcomes
Expected vs. unexpected outcomes (graphs, run/control charts)
7. Wide Implementation
Stepwise implementation: Unit by unit, floor by floor; feedback loop
https://edhub.ama-assn.org/steps-forward/module/2702507#resource
Project planning formTeam: Nancy, Chris, John Project: Reduce unplanned extubations in the PICU to zero within 6 months
Drivers (planned improvements in process)
Process Measures (data collectedto monitor the improvement steps)
Goal (Outcome data measures monitor the end result of the improvement)
1. Protocol education RTs, RNs, Medical staff
% of pediatric ICU staff will have documented use of education materials.
90% of Peds ICU staff will have documented used of education materials
2. Documentation of UEX events % RTs educated on UEX event documentation
90% of RT Peds ICU staff will have documented education for UEX event data collection
3. Peds ICU white board daily use # days of white board daily use (Unit director)
All improvement implementation dayswill be tracked for white board use –documentation sheet by unit director
4.
Driver # Change Idea Tasks to Prepare for Tests
PDSA LeadPerson
Timeline (T=Test; I=Implement; S=Spread)
Week
1 2 3 4 5
1. Video; pamphlet Coordinate with IT and education department
Staff will be provided with link; pamphlets
Nancy T I S
2. RT schedule for training
Reserve training space and print Ed. material
Schedule training sessions
Chris T I S
3. White boards in PICU and CICU
Purchase and request wall mounting
White board implementation
John T I S
ihi.org/ImprovementCapability
Final Points Always include front line staff representation in all stages of an
improvement project
Include all departments involved in the process in question
Communicate with all stakeholders regarding planning, implementation, and monitoring.
Include feedback from all levels of the organization
Encourage occurrence reporting (incl. near-miss, good catches)
Transparency regarding quality metrics
Close the loop
Improvement efforts never end
Spread mindfulness of quality improvement and patient safety
Thank you!Questions?
Top Related