Inducing Efficiently Inducing Efficiently optimizi optimizing - - PowerPoint PPT Presentation

Inducing Efficiently Inducing Efficiently

• ptimizi
• ptimizing outpati

ng outpatient i ent induction nduction of labour

• f labour

Janet Lyons

MD MPH CCFP FRCSC

Henry Woo

MD FRCSC

Medical Lead, High Risk Obstetrics MSA President, BC Women’s hospital BC Women’s Hospital

No Disclosures

Decision to Induce Patient called in Arrives LDR Monitor Provider called Provider arrives Monitor Provider called Discharged Home

Pr Process…..

• cess…..

• 1. Delay - long patient visit times
• 2. Patients inadequately prepared
• 3. Providers lack knowledge of process

The identified issues…

• 1. Delay - long patient visit times
• Designated induction RN
• Scheduler
• 2. Patients inadequately prepared
• RN phone script
• 3. Providers lack knowledge of process
• Reworking IOL request form
• Provider feedback form

The identified solutions…

Next Steps….

• Visit times went from 5.5 hours to

2.5 hours!

• Feedback from providers and

patients ++positive

• Less visits = shorter induction

times

• 90% on time

Surgical Start Time

Changing OR Culture

• Dr. Marijo Odulio

I have no disclosures or conflicts.

Background – Realities

• Limited OR time
• Doing more MIS (minimally invasive surgery) which requires more OR

time than open cases

• Growing surgical waitlist
• On average gynecological surgeries at

UHNBC were starting at 0823

• Only 4% of gynecological surgeries

started on time

• 60% of cases were running over time

Objective & Strategy

• Improve patient care by reducing wait time for surgery
• Efficiently use our limited OR time
• PQI Project: Surgery Start (start on time)

Aim Statement

By June 30, 2018, at least 50% of the Gynecology surgical slates at UHNBC will meet the benchmark of starting surgery at 0800. This will result in efficient use of OR time and allow more surgeries to be completed.

Team Members

• Dr. Marijo Odulio

Obstetrician/Gynecologist

• Dr. Jamil, Akhtar

Anesthetist Jodi Temoin, RN Perioperative Manager Jana O’Neil, RN Perioperative Coordinator Lead Kim Frost, RN Clinical Nurse Educator for the OR

• Dr. Laura Brough

Chief of Staff for UHNBC Shelley Movold, RD Physician Quality Improvement Coach

PDSA Cycle #1

Have the surgeon in the OR at 0745 to:

• Provide leadership to the room
• Improve communication between team members
• Assess whether the room was ready for the first operation in terms of

equipment needs

• To perform surgical time out

Surgical Start Times

7:55:12 AM 8:05:17 AM 8:15:22 AM 8:25:26 AM 8:35:31 AM 8:45:36 AM 8:55:41 AM 11/9/2017 18/09/2017 2/10/2017 30/10/2018 20/11/2017 27/11/2017 8/1/2018 12/1/2018 15/1/2018 22/01/2018 29/01/2018 6/2/2018 13/02/2018 19/02/2018 26/02/2018 5/3/2018 Cut Time Linear (Cut Time) 0:00 0:02 0:05 0:08 0:11 0:14 0:17 0:20 0:23 0:25 0:28 0:31 0:34 0:37 0:40 0:43

Odulio’s Surgical Start Times Odulio’s Time to Position and Prepare the Patient

PDSA Cycle #2 and #3

2) Continue to have the surgeon in the room & have the IVs inserted before the patient enters the operating room. 3) Have patient in the room at 0730 rather than 0745

PDSA Cycle #3 Results (Patient in the OR at 0730)

• 10 slates to date & 7 surgical starts on or before 0800
• 3 cases that were late:
• Case got bumped for emergency c-section (1018)
• Anesthetist was late (0820)
• 2 RNs in the OR training and case had a large set up (0812)
• no ORs ran overtime (past 1530)
• were able to add emergency cases to some OR slates

High Impact-High Value Lessons Learned

• Change takes time especially when it involves culture
• change. Expect resistance and be persistent!
• Start small and build your improvement projects
• Big things can happen when you have a vision and are

willing to put in the effort!

Value of Physician Quality Improvement (PQI)

• Provides clinicians an opportunity to be directly involved in projects that

improve patient care

CHALICE OF QI

In Search of Appropriateness

PQI Summit Presentation

• Dr. Raymond Dong
• Nov. 19, 2018

Disclosure

τ Nothing to disclose

Benchmark Wait Times for Echocardiography (BC)

τUrgent

within 1 day

τSemi-urgent

within 7 days

τRoutine

within 30 days JPOCSC 10 + 2 MONTHS

Institute of Medicine Six Aims For Improvement

Safe Effective Patient-centered Timely Efficient Equitable Effective Timely

Appropriate Use Guideline Score

Rarely Appropriate 1 – 3 May Be Appropriate 4 – 6 Appropriate 7

• 9

Aim Statement

To increase the Appropriate Use Guideline Score (AUGS) of outpatient echoes, referred to the JPOCSC from GP offices by an average of 1.5 by June 2018

ECHO REFERRAL APPROPRIATE USE GUIDELINE TOOL APPROPRIATE (AUG SCORE OF 7 – 9)

STRUCTURAL HEART DISEASE VALVULAR (Initial Evaluation, with reasonable suspicion) SYMPTOMS CONSISTENT WITH CARDIAC ETIOLOGY ; CORONARY ARTERY DISEASE SUSPECT MASSES ; SOURCE OF EMBOLISM HEART FAILURE NEW DIAGNOSIS ; SYSTOLIC DYSFUNCTION DIASTOLIC FUNCTION ASSESSMENT RE-EVALUATION TO GUIDE THERAPY (INCLUDING DEVICE THERAPY) ARRHYTHMIA ATRIAL FIBRILLATION (new diagnosis) MALIGNANT VENTRICULAR DYSRHYTHMIAS CARDIOMYOPATHY INITIAL EVALUATION ( Restrictive, Infiltrative, Hypertrophic) RE-EVALUATION ONLY IF CHANGE IN CLINICAL STATUS OR PHYSICAL EXAMAINATION PERICARDIAL SUSPECT PERICARDIAL DISEASE ; ASSESSING POSSIBLE TAMPONADE PHYSIOLOGY RE-EVALUATION IF CLINICALLY SUSPICIOUS FOR RECURRENT PERICARDIAL EFFUSION VALVULAR HEART DISEASE RE-EVALUATION ONLY IF THERE IS A CHANGE IN CLINICAL STATUS OR PHYSICAL EXAMAINATION SUSPECT PULMONARY HYPERTENSION

RARELY APPROPRIATE (AUG SCORE OF 1 -3)

ROUTINE SURVEILLANCE LEFT VENTRICULAR FUNCTION (WITH NO CHANGE IN CLINICAL STATUS) < 3 YEARS – MILD VALVULAR STENOSIS WITHOUT CLINICAL CHANGE (NATIVE AND PROSTHETIC) PRESYNCOPE/SYNCOPE NO SIGNS OR SYMPTOMS OF CARDIOVASCULAR DISEASE ROUTINE PRE-OP EVALUATION NO SIGNS OR SYMPTOMS OF CARDIOVASCULAR DISEASE INFREQUENT PACs and PVCs WITHOUT OTHER EVIDENCE OF CARDIOVASCULAR DISEASE ROUTINE EVALUATION OF HTN WITHOUT SIGNS OR SYMPTOMS OF HEART DISEASE ROUTINE SURVEILLANCE OF CHF < 1 YEAR WHEN THERE IS NO CHANGE IN CLINICAL STATUS

4 Questions for Reflection

1) Is the patient asymptomatic ? 2) Is this echo for routine surveillance ? 3) Does the patient have a previous echo result ? 4) Does the patient have a change in clinical status or cardiac exam ?

Project Methods

τScore echo referrals during a 5 week

run-in (baseline) phase (Jan/18)

τMail out educational tool to 100 MDs τScore referrals post-tool and collate

weekly data for 3.5 months

τAnalyze data with SQC Pack software

Educational Tool Introduced

Educational Tool Introduced

Educational Tool Introduced

Learnings

τ 27% of echo referrals were Rarely Appropriate

and a waste of limited resources

τ A CHANGE IDEA using a simple educational tool

was effective in improving appropriateness

τ Quality improvements tools were essential in the

development of this strategy for change.

$$$ and Sense

τReducing weekly echoes by 27%

means a SAVINGS of 40 studies each week.

τCost of echo is $375.00 per study. 40

less studies per week = NET SAVINGS

• f $ 15,000.00 or $780,000.00 / year

τThis will lead to appropriate studies

done on the right person, in the right place, and at the right time.

Future Plans

υDistribute the educational tool to the rest

• f the referring community physicians

υSpread the strategy for change to the

cohort of inpatients and ER referrals

υDisseminate this knowledge to other echo

labs within Fraser Health

υSeek administrative authority to prioritize

Appropriate echo referrals

Teams a eams at the f t the fro rontlines ntlines of the op

• f the opioid

ioid crisis crisis are driving system change to are driving system change to improve c improve care. are.

PQI Summit – November 2018 #BOOSTqi @bccfe @ccsmd

• Dr. Cole Stanley

Medical Lead, BOOST Collaborative Medical Lead, Quality Improvement, Vancouver Coastal Health (VCH) Community Family Physician, Raven Song Community Health Centre, VCH Family Physician, John Ruedy Clinic, St. Paul’s Hospital

Speaker

@ccsmd

• Dr. Stanley
• Travel grants received for conference attendance from the following
• 2017 – Gilead Sciences
• 2016 – Canadian Association for HIV Research (with support from Viiv),

Gilead Sciences

• Mitigating bias
• No discussion of specific HIV or Hep C therapy in this talk

Disclosures

Sab Sabrina rina

4 deaths per day in BC 1 per day in Vancouver

From my perspective, our OAT system is NOT optimized

Retention in methadone and buprenorphine is associated with substantial reductions in the rate of all cause and

• verdose mortality

Bohdan Nosyk On behalf of the Health Economic Research Unit at the BC Centre for Excellence in HIV/AIDS

Majority started on OAT, minority retained on therapy for adequate period

B.C. Coroner’s data…

Suboxone saved Sabrina?

Im Imple plementa mentation tion of HIV trea

• f HIV treatment

tment as p as preven revention tion stra strategy in tegy in 17 Cana 17 Canadia dian n si sites: tes: immedia immediate a te and susta nd sustained o ined outco tcomes mes from from a 35-mon a 35-month th Qua Quali lity ty Im Impr prov

• veme

ement Col

• llab

laborative

• rative

Christina M Clarke, Tessa Chang, Kathleen G Reims, Clemens M Steinbock, Meaghan Thumath, Robert Sam Milligan, Rolando Barrios Figure 5 rule

• Vancouver Native Health Society
• Portland Hotel Society
• Raven Song
• Three Bridges
• Pender
• Downtown Community Health Centre
• Sheway – Pregnancy
• John Ruedy Clinic – HIV Primary Care
• Downtown East Side Connections
• Rapid Access and Assessment Centre
• Substance Use Treatment and

Response Team

• Evergreen Substance Use
• South Addiction Services
• Raven Song Addiction Services
• West End Mental Health Team
• Overdose Outreach Team
• Women’s Intensive Case Management

~4000 clients with opioid use disorder

Aims

• 19/20 (95%) patients initiated on oral OAT
• 19/20 (95%) patients retained on oral OAT for >3

months

?

?

?

Popul

• pulation

ation of

• f

Foc Focus us

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

13-Jul 20-Jul 27-Jul 3-Aug 10-Aug 17-Aug 24-Aug 31-Aug 7-Sep 14-Sep

Proportion with active OAT rx Proportion on therapy >90d

54% of our clients have active OAT prescription 74% of these clients have been

• n OAT for >3 months

95% Goals

Active engagement, enhanced outreach, social determinants of health

Thank Thank You

• u

#BOOSTqi @bccfe @ccsmd EMAIL: boostcollaborative@cfenet.ubc.ca WEBSITE: http://www.stophivaids.ca/oud-collaborative