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HEALTHCARE QUALITY IMPROVEMENT. Stephen E. Muething, MD April 6 th , 2006. As an Academic Physician, is it important for me to become knowledgeable about quality improvement?. It’s interesting, but not necessary. QI is for the administrative folks, not for academics. - PowerPoint PPT Presentation
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HEALTHCARE QUALITY IMPROVEMENT
Stephen E. Muething, MDApril 6th, 2006
As an Academic Physician, is it important for me to become knowledgeable about quality improvement?
• It’s interesting, but not necessary.• QI is for the administrative folks, not for
academics.• I am already focused on Clinical Care, Teaching
and Research.• I guess, otherwise you wouldn’t be giving this
talk.
What does Quality Improvement have to do with
Clinical Care
CROSSING THE QUALITY CHASM
Institute of Medicine
2001TIMELY
EVIDENCE-BASEDEQUITABLE
PATIENT/FAMILY-CENTEREDEFFICIENT
SAFE
Percent of Diabetic Medicare Enrollees Receiving Annual Eye Examinations (1995-96)
20.0
30.0
40.0
50.0
60.0
70.0P
erc
en
t o
f D
iab
eti
c E
nro
llees
Re
ceiv
ing
An
nu
al E
ye E
xam
ina
tio
ns
(1
995
-96
)
Percent of Diabetic Medicare Enrollees Receiving Annual Eye Examinations (1995-96)
80 or More (0)60 to < 80 (3)40 to < 60 (232)20 to < 40 (71)Less than 20 (0)Not Populated
Percent of Diabetic Medicare Enrollees Receiving Annual HgbA1c Testing (1995-96)
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0P
erc
en
t o
f D
iab
eti
c E
nro
llees
Re
ceiv
ing
An
nu
al H
gb
A1
c T
est
ing
(1
99
5-9
6)
Percent of Diabetic Medicare Enrollees Receiving Annual HgbA1c Testing (1995-96)
80 or More (0)60 to < 80 (6)40 to < 60 (104)20 to < 40 (177)Less than 20 (19)Not Populated
Percent of Diabetic Medicare Enrollees Receiving At Least One LDL Blood Lipids Test in a Two-Year Period (1995-96)
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0P
erc
en
t o
f D
iab
eti
c E
nro
llees
Re
ceiv
ing
At
Le
ast
On
e B
loo
d L
ipid
s T
est
(19
95
-96
)
Percent of Diabetic Medicare Enrollees Receiving Blood Lipids Testing (1995-96)
80 or More (0)60 to < 80 (8)40 to < 60 (52)20 to < 40 (193)Less than 20 (53)Not Populated
Nutritional status in CF
• What is the variation across CF centers in the US?
• How long have we known that it’s worth working on?
0%
20%
40%
60%
80%
100%
Urgent Intervention Need/Failure Risk of Same
High-Risk Pediatric PatientsPediatric Patients in “Urgent Nutritional Need”/“Failure”
or at Risk of “Urgent Intervention Need”/“Failure” by Center
Percent of CF patients with weight for age below 10th percentileincludes only patients who are less than 19 years old
stratified by type of insurance
10%
15%
20%
25%
30%
35%
40%
45%
50%
Month
Pe
rce
nt
of
CF
pa
tie
nts
Private Government
Last update: 10/28/05 by H. Atherton, Data Source: Disease Management Database
How will we know that a change is an improvement?
What are we trying to accomplish?
What changes can we make that will result in improvement?
The Improvement ModelThe Improvement ModelThe Improvement ModelThe Improvement Model
Plan
DoStudy
Act
Plan Always includes a prediction
Do Study
Did my prediction hold? What assumptions need revision?
Act Adapt Adopt Abandon
PDSAPDSAPDSAPDSA
Changes That Result in
Improvement
A P
S D
APS
D
A P
S DD S
P ADATA
Very Small Scale Test
Follow-up Tests
Wide-Scale Tests of Change
Implementation of Change
EvidenceBest PracticeTestable Ideas
Use of PDSA cyclesUse of PDSA cyclesUse of PDSA cyclesUse of PDSA cycles
•S - Specific•M - Measurable•A – Actionable•R – Reliable•T – Time bounded
Charter AimCharter AimCharter AimCharter Aim
• We will reduce central venous catheter infection rates throughout the hospital from 3/1000 device days to 0.8/1000 device days.
Example Example Example Example
18 18 19 24 22 32 27 23 7 10 7 11 8 7 8 6 7 7 14 15 14 6 14 5 12 7 7 5
6003
5772
7060
7586
7557
7572
8401
8154
2699
3005
2636
2943
3091
2707
2648
2722
3176
2771
3115
3148
3064
3145
2871
2848
3025
3017
3215
2785Device
Days
Infections
CCHMC Central Venous Catheter (CVC) AssociatedLaboratory Confirmed Bloodstream Infections (LCBIs)
4.2
2.2
1.81.9
4.94.8
2.22.22.6 2.3
4.0
1.8
4.64.5
2.5
3.0
2.6
3.7
2.7
3.3
2.62.8
3.2
2.9
3.2
2.7
3.1
3.0
0
1
2
3
4
5
6
7
8
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
FY2003 FY2004 FY2005 FY2006
Infe
ctio
ns
per
100
0 D
evic
e D
ays
CVC-LCBIs CY2004 Average Control Limits (Based on CY2004 Average)
July 2003 thru February 2006
All Code Events Outside Critical Care Areas w BVMV or CC or Both 2.1.06
0.22
0.3
0.1
0.32
0.1
0.15
0.2
0.28
0
0.2
0
0.1
0.2
0.3
0.4
O-D 03 J-M 04 A-J 04 J-S 04 O-D 04 J-M 05 A-J 05 J-S 05 O-D 05 J-M 06
Co
de
s p
er
10
00
Pa
tie
nt
Da
ys
Baseline Rate = 0.27(25 per 92188 days)
Pilot 3.1.05 A6S
4.11.05 A6S, A6N, B5E
Hosp Educ 2.1.05
Go Live 6.1.05 Full Hosp
MRT Implementation = 0.15(5 per 33173 days)
Post MRT = 0.11(6 per 52494 days)
Infections 7 10 10 11 8 11 13 11 3 5 5 7 6 13 7 3 12 5 10 4 9 3 2 0 1 1 1 1
Vent Days
2113
1955
2535
2761
2336
2437
2039
1957
782
809
804
974
897
1008
969
951
932
738
933
832
835
661
728
473
585
652
558
643
CCHMC Ventilator Associated Pneumonias (VAPs)
4.5
12.9
3.2
12.9
4.8 4.5
2.7
1.61.81.51.7
0.0
10.810.7
6.8
7.2
6.7
7.2
6.26.2
3.8
5.6
6.4
3.4
4.03.95.1
3.3
0
2
4
6
8
10
12
14
16
18
20
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
FY2003 FY2004 FY2005 FY2006
Infe
ctio
ns
per
100
0 V
enti
lato
r D
ays
VAPs CY2004 Average Control Limits (Based on CY2004 Average)
July 2003 thru February 2006
Infections 16 14 9 16 13 16 11 22 10 9 4 7 7 8 10 8 7 5 7 13 8 7 7 8 4 8 2 2
1666
1626
1552
1665
1596
1493
1590
1785
635
643
581
608
558
529
543
528
607
648
674
651
628
749
632
611
642
527
607
568Procedure
days
CCHMC Surgical Site Infections - Class I & Class II Combined
0.4
0.3
1.11.21.0
0.90.6
1.0
0.80.7
1.2
1.6
1.4
0.7
1.21.3
1.8
0.8
1.0
1.3 1.3
0.6
1.5
1.1
1.5
1.5
2.0
0.9
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
FY2003 FY2004 FY2005 FY2006
Infe
cti
on
s p
er
10
0 P
roc
ed
ure
Da
ys
CI & CII SSIs CY2004 Average Control Limits (Based on CY2004 Average)
July 2003 thru February 2006
Direction of Desired Change
Adverse & Sentinel Events
1
2
3
4
Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
2004 2005 2006
Re
po
rted
Oc
cu
rre
nc
es
Adverse Events (22 Total)
Sentinel Events (23 Total)
March 2004 thru February 2006
Improving Outcomes:Hbg A1c after Family
ChoiceHgb A1c 5 to 10 weeks after New Diagnosis Diabetes May-Jan
7.00
7.50
8.00
8.50
9.00
9.50
Before Choice N/R (n=78) After Choice BBT (n=72) After Choice N/R (n=20)
Insulin Therapy
Hg
b A
1c
Percent of Patients on A6S That Go Home Without Delay
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2/7/
2004
n=1
8
2/28
/200
4 n=
23
3/20
/200
4 n=
17
4/10
/200
4 n=
20
5/1/
2004
n=2
0
5/22
/200
4 n=
18
6/12
/200
4 n=
21
7/3/
2004
n=2
0
7/24
/200
4 n=
12
8/14
/200
4 n=
20
9/4/
2004
n=2
0
9/25
/200
4 n=
20
10/1
6/20
04 n
=20
11/6
/200
4 n=
13
11/2
7/20
04 n
=20
12/1
8/20
04 n
=20
1/8/
2005
n=2
0
1/29
/200
5 n=
20
2/19
/200
5 n=
20
3/12
/200
5 n=
20
4/9/
2005
n=1
0
4/30
/200
5 n=
10
5/21
/200
5 n=
11
6/11
/200
5 n=
10
7/2/
2005
n=1
0
7/23
/200
5 n=
10
8/13
/200
5 n=
10
D/C within 4 hours of meeting d/c goals Median Goal
Time of Day Patients Are Discharged
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Aug. 03 Jan. 04 Dec. 04
1st Shift08:00-15:00
2nd Shift15:00-23:00
Evidence Based Practice Provided on Inpatient Unit
0%20%40%60%80%
100%
Evidence Based Practice Provided Goal Median
(Data through Mar 03 based on original measures - measures modified Apr 03)
ANY COMMENTS?
ANY QUESTIONS?
THANK YOU!
Stephen E. Muething, M.D.