Inducing Efficiently Inducing Efficiently optimizi optimizing outpati ng outpatient i ent induction nduction of labour of labour Janet Lyons Henry Woo MD FRCSC MD MPH CCFP FRCSC Medical Lead, High Risk Obstetrics MSA President, BC Women’s hospital BC Women’s Hospital
No Disclosures
Process….. Pr ocess….. Monitor Decision to Provider Induce arrives Patient called in Provider Provider called called Arrives LDR Monitor Discharged Home
The identified issues… 1. Delay - long patient visit times 2. Patients inadequately prepared 3. Providers lack knowledge of process
The identified solutions… 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 •
• 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 Next Steps….
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 8:55:41 AM 8:45:36 AM 0:43 Odulio’s Surgical Start Times Odulio’s Time to 0:40 0:37 0:34 8:35:31 AM Position and 0:31 0:28 0:25 8:25:26 AM Prepare the Patient 0:23 0:20 0:17 8:15:22 AM 0:14 0:11 0:08 8:05:17 AM 0:05 0:02 0:00 7:55:12 AM 11/9/2017 18/09/2017 2/10/2017 30/10/2018 8/1/2018 12/1/2018 29/01/2018 6/2/2018 13/02/2018 19/02/2018 26/02/2018 5/3/2018 20/11/2017 27/11/2017 15/1/2018 22/01/2018 Cut Time Linear (Cut Time)
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) τ Urgent within 1 day τ Semi-urgent within 7 days τ Routine within 30 days JPOCSC 10 + 2 MONTHS
Institute of Medicine Six Aims For Improvement Safe Timely Timely Effective Efficient Effective Patient-centered Equitable
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 τ Score echo referrals during a 5 week run-in (baseline) phase (Jan/18) τ Mail out educational tool to 100 MDs τ Score referrals post-tool and collate weekly data for 3.5 months τ Analyze 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 τ Reducing weekly echoes by 27% means a SAVINGS of 40 studies each week. τ Cost of echo is $375.00 per study. 40 less studies per week = NET SAVINGS of $ 15,000.00 or $780,000.00 / year τ This will lead to appropriate studies done on the right person, in the right place, and at the right time.
Future Plans υ Distribute the educational tool to the rest of the referring community physicians υ Spread the strategy for change to the cohort of inpatients and ER referrals υ Disseminate this knowledge to other echo labs within Fraser Health υ Seek administrative authority to prioritize Appropriate echo referrals
Teams a eams at the f t the fro rontlines ntlines of the op of the opioid ioid crisis are driving system change to crisis are driving system change to improve c improve care. are. #BOOSTqi @bccfe @ccsmd PQI Summit – November 2018
Speaker 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 @ccsmd
Disclosures 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
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 overdose mortality
Majority started on OAT, minority retained on therapy for adequate period Bohdan Nosyk On behalf of the Health Economic Research Unit at the BC Centre for Excellence in HIV/AIDS
B.C. Coroner’s data… Suboxone saved Sabrina?
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