Resident Longitudinal QI Projects”Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.“ ACGME Common Program Requirements

Specifically, ACGME would like us to Identify strengths, deficiencies and limits in one’s knowledge

and expertise Set learning and improvement goals Systematically analyze one’s practice using quality

improvement methods (PDSA), and implement changes with the goal of practice improvement

Incorporate formative evaluation feedback into daily practice Locate, appraise and assimilate evidence from scientific studies

related to patients’ health problems

Its not just ACGME…ABIM’s Maintenance of Certification

Maintenance of Certification

PIM- Professional Improvement Module

More PIM

Objectives

1) Understand how to develop an

Aim Statement

Measurement Plan

Improvement Plan

2) Understand rapid cycle improvement

• State the aim clearly • Include numerical goal and time frame that

require fundamental system change • Set stretch goals• Avoid aim drift• Be prepared to refocus the aim

Step #1 - Setting the AIM – What are we trying to accomplish?

Step #2 - Establishing measures –How will we know that a change is an improvement?

• Plot data over time• Seek usefulness, not perfection• Use sampling• Integrate measurement into the daily routine• Use qualitative and quantitative data

Baseline Data (HgA1C)

HgA1C after 6 months

Step #2 - Establishing measures –How will we know that a change is an improvement?

HgA1C is the outcome, but the most important data is to determination the intervention’s

effectiveness.

Evaluate your current management and Nationally recognized guidelines. How do they differ?

Data to collect1. How many patients met with the pharmacist2. When? Early enough to detect change in HgA1C?

Plan, Do-Each patient will meet with pharmacist to evaluate medications

Step #3 – Overall Plan for Improvement

• Avoid “the same” responses• Implement recommended practices

guidelines• Think processes and systems of work

– Simplify processes– Reduce waste or unnecessary redundancies

• Creative thinking • Appropriate use of new or existing

technology

“Every system is perfectly designed to get the results it gets.”

Paul Batalden, M.D.

The Model for ImprovementPDSA

The Improvement Guide (Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. San Francisco, California, USA: Jossey-Bass Publishers, Inc.; 1996

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in improvement?

The Cycle- Plan, Do, Study, Act

Also known as: PDCA (Check instead of

Study) The Deming Cycle/Wheel The Shewart Cycle The Learning and

Improvement Cycle

PlanSequence:

1) Gather background data on the current system.

2) Describe your tactic (intervention) 3) Predict outcome4) List tasks needed5) Plan for collection of data

DO – Carry it Out

• Implement (preferably on a small scale)

• Document problems and unexpected observations

• See plan through to completion• Motivations to carry it out

Study or Check – What did we learn?

• Review the Data / take survey

• Compare the data to your predictions

• What worked or went well? What did not?

• Summarize and Reflect on what was learned -- Draw Conclusions

ACT

ACT

• Adopt it

• Abandon it

• More study needed

• Modify overall aim, measure, or plan

• Create new plan

Rapid Cycle - Multiple Cycles

Overall AIM Increase documented eye

exams for our diabetes population by 45% in the next 12 months

Time

Expect Challenges and Barriers

Cycle #1 – Contact Eye Doctors

Cycle #2 – Patient Fax Back Form

Cycle #3 – Front Office track down eye results

Cycle #4 – Computer Network with eye doctors

Cycle #5 – Reminder letter from PCPs

Implement Final Changes

Discouraged… So, your patient’s are no more healthy than when you started… The system in which you function isn’t working- now you have

data to support that. Re-analyze the system, identify areas you can change, areas

that are ineffective, areas that are chaotic. Start a new PDSA cycle to tease out what parts of these areas

can be changed Design an intervention, implement it, gather data and analyze

it… Shampoo, rinse, repeat.

How to manage your panel in Powerchart (sort of)

Any Diabetic Patient

click

click

Say “ok”

Not very helpful!

Modify display under Components tab

Double Click

Name and MRN‘To Row,’ everything else to ‘Page’

Upcoming Longitudinal QI Projects Interns- Start with HgA1C (UNM Clinics) and Hypertension (VA).

Except NE Heights- you’re special

Upper levels Options!!! If you are interested in switching projects, consider HgA1C (at VA),

Hypertension (at UNM), Lipid Guidelines

QI Projects Plug (aka how to improve your CV and future employability)

Inpatient Influenza Vaccination Project Increase the frequency of inpatient influenza vaccine screening,

Increase the number of patients who receive flu vaccine by the time of discharge

Improve documentation of reasons for not administering flu vaccine among inpatients.

Improving influenza vaccination among residents, fellows, and faculty. Influenza vaccination status was not known for 60% among UNM physicians last

year.

Lower the barriers for receiving the influenza vaccine (i.e., working with different groups to find convenient times/locations for influenza vaccination)

Improve collection of documentation

Hand washing on 4-west 4 West is among the worst floors for hospital acquired c-diff

RN’s are working on a hand washing initiative

People are watching! You may be placed in a raffle to win coffee and/or candy

Improved Discharge of Behaviorally Challenged Patients from 4west MHC order sets

Improved medication compliance after transfer

Improved coordination of security

CIWA Project- more about that later RN driven improvement in CIWA protocol

Less GTT’s, less MICU transfers, less sitter use, less oversedation

QI Projects Plug (aka how to improve your CV and future employability)

Dr. Langsjoen- early probiotics in patient’s receiving antibiotics

Dr. Crowell- Sepsis bundle- lots of opportunity for lactates between 2 and 4 Pulm/Crit care people.

Stand out on your application

PSN Project, improved documentation, reporting

7-Day Readmits- Still in development

Hospitals will not be reimbursed for 30 day readmits- starting with low-lying fruit by evaluating 7-day readmits

MICU transfers

Outpatient pain management Also still in development-

Increasing Advanced Directives completed in clinic setting Sign prompting patients to ask about advanced directives

QI Projects Plug (aka how to improve your CV and future employability)