Applications to Practice Grace Propper, MS, RN, CPNP, NNP-BC - - PowerPoint PPT Presentation

Quality Improvement: Applications to Practice

Grace Propper, MS, RN, CPNP, NNP-BC

• Review CQI Principles and Methodologies
• Explore applications to everyday practice
• Discuss data use in quality improvement

OBJECTIVES

HOW SAFE IS AIR TRAVEL?

• Last major crash in

continental U.S.

• November 12 –

American Airlines Flight 587, an Airbus A300, crashes into a Queens neighborhood in New York City when the plane's vertical tail fin snaps just after takeoff. All 251 passengers and nine crew members on board are killed as well as five people on the ground.

HOW SAFE IS BEING A PATIENT?

• 1999 – IOM report – U.S.

hospitals KILL 100,000 persons per year with medical mistakes

• 2001 – To Err is Human

brings attention to this public health crisis

• 2014 – How many are we

still harming?

• Nationally?
• At your hospital?

No No ma matter er how w well ll clinicians linicians ar are tra rain ined ed an and m motivated, tivated, i if f humans mans ar are involv volved, ed,

ER ERROR ROR IS INE S INEVIT VITABLE ABLE

The e Solutio lution: n:

St Stop bla laming ing the in indiv ivid idual ual – fix ix the system tem Train in team skil ills ls through gh Team Train inin ing Imple lemen ment t hardwi wired ed safet fety y syst stems ems

COM OMMUNICAT MUNICATION ION FAILURE LURES

A factor in…

• 80% of adverse events/close-calls
• (VA National Center for Patient Safety Executive Summary, 2007)
• 66% of sentinel events
• (White et al, 2005)
• 50% of OR errors
• (Gawande et al, 2003)
• 31% of OB/GYN adverse events
• (Joint Commission Sentinel Event Alert - Issue 12)

Joint Commission. (2011). Sentinel Event Statistics Data - Root Causes by Event Type (2004 - Third Quarter 2011)

Joint Commission. (2011). Sentinel Event Statistics Data - Root Causes by Event Type (2004 - Third Quarter 2011)

Joint Commission. (2011). Sentinel Event Statistics Data - Root Causes by Event Type (2004 - Third Quarter 2011)

Team Work Produces

Studies in diverse patient populations demonstrate relationship between teamwork and – Improved clinical processes – Reduction in medical errors – Improved surgical team performance – Increased adherence to guidelines – Decreased length of stay – Increased functional status – Decreased mortality

Salas et al. What are the critical success factors for team training in health care? Joint Commission Journal Quality Safety. 2009;35:398-405.

Continuous Quality Improvement (CQI):

• A journey to satisfy the needs and exceed the expectations of
• ur customers
• A means of performance improvement
• Aligned with our Mission to deliver world class,

compassionate care, advance our understanding of health and disease and to educate healthcare professionals

What does CQI Encompass?

Patient Care Patient Safety Employee Satisfaction Administrative & Operational function Regulatory Requirements Employee Safety Patient Satisfaction

CQI Principles

• All work is part of a process
• Quality is achieved through people
• Decision making is done with facts
• Patients and customers are our first priority
• Quality requires continuous improvement
• CQI focuses on the process not the person

Find a process to improve

• Administration, Program of Distinction (POD) Groups, other

Committees charter a CQI team

• Criteria used to prioritize opportunities for improvement

– High Risk – High Cost – High Volume – Problem Prone – Patient Safety related

• A sentinel event is an unexpected occurrence involving death or serious physical or

psychological injury, or the risk thereof.

• Examples include: Suicide - Rape - Loss of limb – Elopement -Death

Sentinel Event Root Cause Analysis

• A process for identifying the contributing factors that underlie variations in

performance; includes the occurrences of the sentinel events, adverse event or close calls.

• Process that features interdisciplinary involvement of those closest to and/or most

knowledgeable the situation to find out:

• What happened?
• Why did it happen?
• How can we prevent it?
• How do we know we made a difference?

Proactive Risk Assessment

• FMEA – Failure Modes Effects Analysis
• Lean /Six Sigma

Core Measures of Excellence…

…are a variety of evidence-based, scientifically-researched standards of care which have generally been shown to result in improved clinical outcomes for patients.

• Surgical Care Improvement Project (SCIP): Post-Op blood glucose

control / urinary catheters, death among surgical inpatients with serious treatable complications, Iatrogenic pneumothorax rates, post- op respiratory failure, Pulmonary embolism, DVT, wound dehiscence, accidental puncture / lacerations, hip fracture mortality

• Children’s Asthma: specific medication use
• Emergency Department : departure/admit times, timeliness to diagnosis,

pain management

• Imaging Efficiency: MRI for Lumbar spine; mammography follow up, use
• f contrast material
• Central Line Associated Bloodstream Infection (CLABSI)

CORE MEASURE OF EXCELLENCE

• CMS (the Center for Medicare & Medicaid Services)

established the (Core) Measures in 2000 and began publicly reporting data relating to the (Core) Measures in 2003

• CMS ties some parts of reimbursement to reporting the data;

in some cases reimbursement is tied to how well we deliver specific elements of care (Value-Based Purchasing)

HIGH RELIABILITY UNIT (HRU) – UNIT BASED TEAM MEETINGS

• Prevent Failure (a breakdown in operations or functions)
• Metrics throughout the hospital

– Preventing CLBSI – Falls – Pressure Ulcers – DVT’s

• Best practice guides or “Process Points” reviewed for each metric (do

you have the tools you need to be successful in the care you give to patients?)

• Reviewed monthly by team and administrators

PROGRAM OF DISTINCTION (POD) – SERVICE LEVEL TEAM MEETINGS

• Strategic Alignment for long-term commitment with goals derived

from an advisory group

• Metrics consistent with HRU throughout the hospital

– Preventing CLBSI – Falls – Pressure Ulcers – DVT’s

• Reviewed monthly by service line and unit leaders
• Methodologies aligned with performance excellence and recognition

programs —Analytics, Lean Processes, Evidence-based Practices, Educated Staff, Culture of Safety

• Find a process to improve
• Organize a team that knows the

process

• Clarify current knowledge of

the process

• Understand causes of process

variation

• Select the process improvement

Methodology for Improving a Process

• Pediatric Early Warning Score – PEWS
• ED to Floor for Asthmatic Patients
• Direct Admits
• Safe Sleep
• Home Management Plan of Care - Asthma Action Plan
• Early recognition of sepsis through the electronic medical record
• Preventing Central Line and Catheter Associated Urinary Tract Infections
• Time to pain medication for long bone fractures
• Minimizing pain during procedures for the pediatric patients - “Ouch less”
• Reducing Use of CT Scans in Pediatrics
• Medication Reconciliation

Examples of Pediatric CQI projects

STAFF INVOLVEMENT

CAUSE AND EFFECT DIAGRAM

EFFORTS TO REDUCE CENTRAL LINE INFECTIONS

• Reduce utilization
• Standardizing Practice: Task force assembled to reiterate best practice for

insertion and maintenance

• Concurrent drill downs on all central line associated blood stream infections

by Healthcare Epidemiology and unit/ caregiver staff (CLBSI RCA tool completed)

• Unit reports and trends shared with staff and posted
• Organizational priority and awareness
• Celebrate success

4/22/2015 27

VENTILATOR-ASSOCIATED PNEUMONIA/EVENTS: HOLD THE GAIN!

Continued use of the ventilator-associated pneumonia (VAP) bundle

DVT Prophylaxis PUD Prophylaxis Head of Bed ≥ 30° Sedation vacation Daily review of necessity/early removal

• Reduce utilization

Reducing Hospital Acquired Infections

Reducing Hospital Acquired Infections

ASTHMA ACTION PLAN

JC: Home Management Plan of Care Given to Patient/Caregiver

CHILDREN'S ASTHMA CARE

Implementation of EMR form and real time feedback Forced Completion fields

PGY -1 Training

Total Home Management Plan of Care Compliance Rates

CHILDREN’S ASTHMA CARE

Implementation

• f EMR

Forced completion of fields PGY-1 Training Formal Guidelines

DATA

SHARE SUCCESSES

DATA

Surviving Sepsis and Septic Shock

• Mortality rates associated with

sepsis

• 30-50% for severe sepsis
• 50-60% for septic shock
• Severe sepsis is the leading

cause of death in the non- coronary ICU

• Sepsis kills approximately 1,400

people worldwide every day Early Detection and Treatment of Severe Sepsis

A Call to Arms in New York State

• The case of Rory Staunton
• 12 year old boy who passed away from unrecognized and untreated sepsis after

discharge from a New York City hospital emergency room.

• 2013 NYS DOH issues a mandate for all hospitals to produce clinical care

guidelines for evidence-based recognition and treatment of sepsis.  Adult and Pediatric treatment protocols for both ED and inpatient.  Education of hospital staff: Physician/Resident, RN, Pharm, Laboratory.  Data submission for public reporting of outcomes (2014).

Severe Sepsis Recommendations

Adult and Pediatric Evidence-based Studies

• 1. Early Detection
• 2. Early Treatment
• Sepsis

Resuscitation Bundle

• 3. Monitor reliability and
• utcomes

Severe Sepsis Recommendations

• 1. Early Detection
• 2. Early Treatment
• Sepsis

Resuscitation Bundle

• Sepsis

Management Bundle

• 3. Monitor reliability and
• utcomes

Literature is available upon request!

Pediatric Critical Care Medicine, 2005, Vol.6, No.1

PAPER TO ELECTRONIC

CERNER SEVERE SEPSIS SCREENING PROCESS

RN Task Alert with SIRS criteria

CERNER SEVERE SEPSIS SCREENING PROCESS

RN Task Form

Early Detection and Treatment of Severe Sepsis

Recognition to Immediate Treatment The Pediatric Acute Sepsis Multiphase Power plan

WHERE WE STAND NOW

• 2 sepsis-suggestive vitals within a 5hr period will trigger a task to fire in Cerner for the

bedside nurse to evaluate their patient for severe sepsis.

• If an infection is suspected, the RN contacts the physician for a sepsis workup and pertinent
• rgan dysfunction testing. RN documents name of physician and date/time notified.
• If the screen is found to be negative, complete the task as “No.” The alert will not fire again

for an 8 hour period. It should not be left incomplete.

• If organ dysfunction is present, the patient meets the criteria for severe sepsis. Further work

up is needed with consideration of the Pediatric Acute Sepsis Multiphase Power plan.

• CQI will conduct a full review on all positive patients to gauge compliance and provide results

to the floor staff. Compliance will also be reported for task completion.

Cerner Severe Sepsis Screening Process (Floor Presentation)

WHERE WE STAND NOW

• Initial assessment for “Potential Infection” is completed in triage. If answered yes, the

rule is suppressed for 2 hours. If answered no, the alert will fire as often as every 2- hour period as a patient may meet 2 SIRS criteria.

• The alert will trigger a task to fire in Cerner for the bedside nurse to evaluate their patient for

severe sepsis. The physician is also notified by alert if currently in the patient record.

• If an infection is suspected, the RN contacts the physician for a sepsis workup and pertinent
• rgan dysfunction testing. RN documents name of physician and date/time notified.
• If the screen is found to be negative, complete the task as “No.” The alert will not fire again

for a 2 hour period. It should not be left incomplete.

• If organ dysfunction is present, the patient meets the criteria for severe sepsis. Further work

up is needed with consideration of the Pediatric Acute Sepsis Multiphase Power plan.

• CQI will conduct a full review on all positive patients to gauge compliance and provide results

to staff. Compliance will also be reported for task completion.

Cerner Severe Sepsis Screening Process For Pediatric Patients In the ED

THE ROAD TO ROLL-OUT…

• CQI data coordinator reviews alerts daily, tracks compliance, unanswered alerts &

accuracy, and # alerts, weekly results graphed & forwarded to unit.

• CQI data coordinator forwards CNS/NM a great catch, missed opportunity and

unanswered alerts weekly

• Positive cases receive a full review by CQI staff and are tracked in our Surviving

Sepsis database

• Monthly discussions of positive case reviews at the POD with Quarterly review of
• utcomes data.
• Monitoring of compliance and accuracy by CQI continues for 3 months then the unit

CNS/NM reviews daily reports. (available in Crystal Reports: Nursing Quality & Outcomes: Sepsis).

• CQI continues to conduct reviews on cases staff answered yes to alert.

Mandatory RN comments help to determine accuracy! Cerner Severe Sepsis Reporting

Monthly POD Case Reports

• Proactive risk assessment
• A team based, systematic approach for identifying the ways a process or

design can fail, why it might fail, and how it can be made safer.

Failure Mode and Effects Analysis (FMEA) Joint Commission Requirement

• What performance improvement initiative has our department implemented

recently?

• Hint: It MUST be supported by data

53

FMEA

FMEA

RPN-(Risk Priority Number) = Frequency rating X severity rating X detection rating.

Team Name: Specimen Mislabeling FMEA Team

• Executive sponsor:
• Co-chairs:
• Facilitator:
• Team Members:
• Mother/Baby –
• Children’s -
• ED –
• Med/Surg-
• ICU –
• Lab Services –
• Blood Bank –
• IT –
• Clinical Transformation –

High Risk, High Volume, Problem Prone

HOSPITAL-WIDE PERFORMANCE IMPROVEMENT INITIATIVE

Scope & Measure: Opportunity Statement:

An opportunity exists to improve the accuracy of specimen labeling beginning with the determination that a patient requires specimen collection (order entry) to the time that the specimen is sent to the lab (Specimen Receiving/Blood Bank). This effort will enhance patient safety and decrease the risk of potential incidents (i.e. blood transfusion error, diagnosing and incorrectly treating erroneous labs due to mislabeling) and near- misses for the inpatient and outpatient populations as evidenced by at least a 30% reduction in Patient Safety Net (PSN) reported events.

HOSPITAL-WIDE PERFORMANCE IMPROVEMENT INITIATIVE

High Risk, High Volume, Problem Prone

COMPARATIVE DATA

60 49 65 54 64 67 36 39 47 51 59 50 43 33 38 20 25 30 35 40 45 50 55 60 65 70

Jan-13 Feb-13 Mar-13 April-13 May-13 June-… July-13 Aug-13 Sept-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Mislabel / Unlabeled Lab Specimens Reported

Unlabeled Specimen, 2, 3%

Requisition & Spec label different, 7, 11%

Requisition & Spec label different &Spec mislabeled, 3, 5% Spec Id in question, 1, 2%

No phlebotomist signature: Sample, 27, 42% No phlebotomist signature: Requisition, 8, 12% No phlebotomist signature: Both, 9, 14%

PT name prob: Sample, 4, 6% MRN prob: Sample, 1, 4% MRN prob: Req, 1, 2% PT Name Discrep, 1, 2% No req received, 1, 2%

Blood Bank Sample Rejections by Reason 2014

STONY BROOK DATA

Data Driven

1. 100 - L&D – Mom & Baby labels are almost identical 2. 80 – Specimen Obtained, multiple distractions during identification/labeling/draw process 3. 80 – Add-ons ordered and additional reqs needed 4. 80 – Order entered after specimen is obtained, and req not available at time of draw 5. 75 – RN does not tasks-off correctly or timely and specimen cannot be processed 6. 70 – Printer prints everything, not just reqs 7. 64 – No “signal” notifying RN that reqs have printed/are available 8. 60 – Labels obtained after specimen is obtained 9. 60 – Patient not actually verified prior to draw. RN assumes that they know the patient 10. 60 – Difficult stick, RN or phlebotomist asks for assistance. Potential for confusion as to who is fully responsible for the process (including verification, labeling, etc.) Top Risk Priority Numbers Data Driven

Specimen Mislabeling FMEA

Top UHC Institutions and Action OI Comparable Groups

• Emory:
• 550 beds, with 24/7 laboratory Phlebotomy Team but due to the acuity of the hospital's

population, the RN's draw off lines, thus a 50/ 50 split due to volume

• They feel that having a 24/7 Lab Phlebotomy team provides the best control
• Per policy - phlebotomist is fired after the third mislabeling
• Req-less except they have a special form for Blood Bank and they have reqs for Anatomic

Pathology and esoteric tests which need special instructions/other information for the blood

• draw. They have many of the same laboratory specialty sections and programs as we do
• Good match for us to benchmark lab parameters/metrics

BEST PRACTICE

FMEA: Specimen Mislabeling

Strategy RPN Details Status

IMMEDIATE CHANGES

L&D:

#1 (100) #2 (80)

• Modify print options – Baby arm band/labels
• Printer in L&D OR corridor – for arm band/labels

Completed Completed SunQuest Collection Manager for Phlebotomy

#3 (80) #4 (80) #6 (70) #8 (60) #9 (60)

• Wireless connectivity confirmed
• Equipment (scanners, printers, etc.) received
• Minor system upgrade
• Staff training
• Roll-out pending (June/July)

Completed Completed In process Pending Pending In room label process

#2 (80) #8 (60)

• Address concerns of Patient Safety Committee
• Develop recommendations for new/revised process

Recommendations made Requisition (paper)-Free Pilot

#6 (70)

• 3rd Audit: Improved “chart done/date/time” compliance (40/63/69%),

and Tasking Issues (now <1%) Ongoing

INTERMEDIARY CHANGES

Modify Requisition Process -

#5 (75) #6 (70)

• Modify process (print via Tasklist or “demand “ instead of order)
• Conduct pilot
• Develop formalized roll-out plan/timeline/educational support
• Dedicated label/req printers on units
• Print to patient location - Fix roaming RIC problem
• Modify Blood Bank reqs with signature reminder/message

Pending

LONG TERM CHANGES

Electronic Options for Nursing

#3 (80) #4 (80) #7 (64) #9 (60)

Explore technology options such as:

• SunQuest Collection Manager for Nursing
• RFDI Technology (i.e. CenTrak)

Pending Expand Phlebotomy Services

#2 (80) #3 (80) #4 (80) #7 (64) #10 (60)

Develop business plan for 24-hours/day service Pending

Breakthroughs/Successes: Immediate Changes

1. L&D – (RPN #1, 2)

• Modification of printed baby labels & arm bands (addition of “Newborn” and “NB”), to better differentiate

from mother’s ID (completed)

• Improve access to baby labels & arm bands - designated printer placed in L&D OR Corridor

2. SunQuest Collection Manager – (RPN #3,4,6,8,9)

• Phlebotomy Services in the process of rolling out new system utilizing real-time order verification, bar code

verification, and POC label generation (anticipated June/July)

• Will include most lab specimens (Pathology & Blood Bank are not included at this time)
• 3. Requisition-Free Process (ED) and Pilot – (RPN #6)
• 3rd Compliance Audit: Improved “chart done/date/time” compliance (40/63/69%), and Tasking

Issues (now <1%).

Evidence Based

CURRENT SITUATION

FMEA: Specimen Mislabeling

Evidence Based

CURRENT SITUATION

Item Risk Reduction Strategy Implementation Details Responsible Person(s) Due Date Status Plan 1 Printer in L&D OR Corridor for arm bands & labels  Install Wiring  Purchase Printer John Smith Mary Jones July Jack installed printer hooked up/ready. Label coding changes made  Finalizing printer coding.  Ann to inform/ educate staff on new process.  Finalize L&D OR Corridor printer coding  Inform/educate staff (L&D, OB, and NICU)  Move NB labels into production on Thurs, 7/10 2 Modify Newborn Labels  Newborn Label Modification John Smith July Formatting completed. 3 Sunquest Collection Manager for Phlebotomy  Minor Sys Upgrade  Staff Training  Roll-Out Mary Jones July In process (no update, on schedule) Check status at next meeting, 7/23 4 In Room Label Process:

• 1. Dedicated section in chart -

front of chart

• 2. Charts in designated holders in

close proximity

• 3. No labels in/around

room/bedside/binders

• 4. Label bins, holders, binders,

etc, to be removed from in (or

• utside) patient rooms

 Communicate to Nursing Leadership  Develop Implementation Plan: Educational Roll-Out and Physical changes Pam to communicate (finalized) action/plan to identified groups. Nurse Managers to ensure process changes are put into place on their units June/ July The group agreed:  Charts should remain in their (current) dedicated holders/areas  Labels would be kept in the front

• f the chart

 Label bins/holders should be removed No consensus – labels on clipboards (L&D) and RICS (ED)  Implementation details (removing bins) to be discussed at Nurse Manager Group mtg on 6/26 (Allison C)  Process details discussed at Nursing Clinical Practice Council (Liz + Dan) 6/18 and 7/16. To develop label placement/process recommendations in 2 wks (due 7/30) 5 Requisition Process: Tasklist or On-Demand Develop & pilot process before roll-out house-wide Pilot – 15 N and MICU June/ July Allison volunteered one of the 15’s, and Jackie agreed to enroll MICU in the pilot. Dominic presented the “Full Scope” process flow for Order Placed and On- Demand Reprints. The group felt strongly that the BB process should be in alignment. Nancy and Michele met with BB to discuss options (i.e. electronic signatures) See summary on pg 2*** 6 Dedicated Label Printers: Trial Zebra/or similar Printers Contact company to request “trial” of Zebra printers John Smith Dan to reach out to Zebra to discuss trial of label printers in designated areas Capital Budget decreased. Unable to purchase at this time. 7 Fix Roaming RIC Problem: Identify and reprogram RICs to print at patient location NA NA Allison reported that the “roaming RICs” are not the problem anymore. Docs are placing orders when the pt is off the unit at a test or procedure, and the reqs print there (i.e. MRI, Specials, etc.)

• Informational. This should

not be an issue once the reqs print on-demand or via the Tasklist. 8 Improve Blood Bank Requisition Process:  Modify messaging on req Mary to send John a request to modify req Needs to go on top of req

FMEA: Specimen Mislabeling

FMEA: Specimen Mislabeling

Tools of the Quality Trade FOCUS PDCA Lean Methodology Six Sigma Analytics Proactive FMEA RCA Reviews

Robust Performance Improvement

QUESTIONS