M&M Discussion Framework Knowledge System Practice Adverse - - PowerPoint PPT Presentation

M&M Discussion Framework

Communication Context Knowledge System Practice Adverse Event Other

Equipment Process People Materials Environment Management

• EMR does not provide

SIRS alerts

• POC lactate machine
• Diagnostic testing and

source control not available 24/7

EX: Sepsis Mortality

• Enough blood culture

bottles

• The right abx are not

available quickly

• Sicker patients
• ED crowding
• Trauma patients take

priority

• No incentives for good

sepsis performance

• No resources for data

collection

• No system for audit and

feedback

• Time to antibiotics
• Enough fluid

administration

• Triage to right level of care
• Staffing in ED
• PharmD in ED
• Provider knowledge of

sepsis guidelines

• Culture not to call for VS

changes

QI Project Application Form

QI Project Application Form

Adapted for UCSF from ABP

Project Basics

• 1. Quality Improvement Project Title.
• 2. Quality Improvement Project Leader (faculty member, only one needed per project).
• 3. Briefly comment on the Quality Improvement Project Leader’s experience, highlighting any experience and

expertise relevant to quality improvement.

• 4. Start date of the project.
• 5. End date of project.
• 6. Date of Application.
• 7. Please comment on the involvement of trainees (residents, students, etc.) in this project.

Core Project Components

Improvement Aims

• 8. Briefly describe the problem the QI project addresses. What is the nature and severity of the problem? What

is the gap between current practice and what is possible? Why did you choose to work on this problem? Please limit response to 300 words or less.

• 9. What is the specific aim of the QI project? In your response, identify the patient population and measurable,

time-specific objectives of the project. Please limit response to 300 words or less.

QI Project Application Form

• 10. Which institute of Medicine Quality Dimensions are addressed by the project? (Check all that apply).

Safety Timeliness Effectiveness Equity Efficiency Patient-Centered Measurement

• 11. Provide information for each measure used in the project by completing the measures specification template.

Outcome measure (describe, include measurement and target/goal): Balancing measure (describe, including measurements if applicable): Process measure (describe, including measurement if applicable):

• 12. If you used sampling, describe the project’s sampling strategy and why it is appropriate.
• 13. How often are data reviewed; what is the data collection cycle for the project? (Check one.)

Monthly Quarterly Other (specify)

• 14. Explain data collection process.

QI Project Application Form Interventions

• 15. Describe the project’s intervention(s) or changes for improvement. Why were they selected? All projects

should have at least two cycles of change.

• 16. What are the two biggest barriers (known or anticipated) to implementing the interventions/changes, and

how will you address the barriers? Results, Analysis, and Reporting

• 17. At what level are data analyzed and reported? (Check all that apply.)

Individual physician level Clinic-group level Aggregated across multiple clinic-groups

• 18. How often are results (performance feedback) provided to participants? (Check one.)

Monthly Quarterly Other (specify)

• 19. How are results tracked by the project leaders and reported to participants (performance feedback)? Run

charts and control charts are basic statistical process control charting methods, and the ABP strongly recommends that projects include one or both as the method of tracking results. If your project is not using run or control charts, explain why you are using an alternative format.

• 20. Explain how the project uses data to guide improvement.

QI Project Application Form

• 21. What are the results to date for each measure? Provide the most recent chart for each measure, using

aggregate data (across all participants). Comment briefly on the results. Select the QI project’s score on the Improvement Progress Scale from the table below. Explain the basis for the score. (Check one.) Improvement Progress Scale1 1.0 Design Phase Project design complete. 1.5 Baseline All participant teams formed. Baseline measurement begun. 2.0 Local adaptations Teams meeting routinely. Interventions being adapted for local factors by teams. All teams planning first tests of change (PDSAs). 2.5 Tests of change & data collection Teams have conducted first tests of change (PDSAs). All teams reporting data. No improvement in quality measures yet. 3.0 Modest process improvements All teams have conducted multiple tests of change (PDSA cycles). Process measures beginning to show improvement. 3.5 Improvement Process measures continue to improve. Some improvement in at least one outcome measure. 4.0 Significant improvement Evidence of sustained improvement in outcome measures. Halfway toward accomplishing all aims (goals). Plans for spread of improvements are formulated. 4.5 Sustainable improvement Sustained improvement in most outcome measures. 75% of aims (goals) achieved. Spread of improvements has begun. 5.0 Outstanding sustainable results All interventions implemented. All aims achieved. Improvements have spread to new settings.

1 Adapted with permission from the Institute for Healthcare Improvement’s Assessment Scale for Collaboratives at

www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools .

QI Project Application Form

Physician Participation

At UCSF physicians must be involved for a minimum of 6 months, with a minimum of 2 cycles of change.

• 22. Describe what is expected of each physician participating in the project. What is the physician’s role in

implementing the intervention(s); collecting, submitting and analyzing data; participation in team meetings; and modifying the intervention(s) based on the data?

Physician Attestation Processes

• 23. Pediatricians seeking MOC credit must complete the ABP Attestation Form, which is co-signed by the Project

Leader or by a “Local Leader”, depending on the project’s structure. This co-signing Leader is responsible for adjudicating any disputes with physicians who wish to claim credit for MOC. Because this process could affect a physician’s certification status, the co-signing Leaders should be physicians who are active participants in the approved projects. Because of the nature of the UCSF projects, Project Leaders will complete the Attestation Form and it will be co-signed by Glenn Rosenbluth as a “Local Leader”

• 24. Provide the most recent progress report (e.g. a snapshot of the wiki-site). How and how often does the

project leadership keep key stakeholders informed of progress and results?

• 25. Explain how the project is HIPAA compliant.
• 26. Does the project have IRB approval? (Check one.)

We did not seek IRB approval because it is not required. We did seek IRB approval because we hope to disseminate our results.

PHM QI Workshop Case: Neonatal Readmission

Summary: Term male infant admitted with fever at 2 days of age and treated for early onset GBS sepsis without complications  Re-admitted at 3 weeks of age with seizure and lethargy in the setting of hypoglycemia, hyponatremia, and dehydration. Admission #1: “fever”

• HPI: Term M infant born at home without complications & exclusively breastfeeding. On DOL#2-3

he developed decreased feeding frequency over 24hrs (no PO intake x 8hrs); decreased UOP (last wet diaper >18hrs ago). He has been sleepy but arousable. Rectal temp is 38.9C at home.

• PMHx:
• Prenatal: 29yo G2P1-2 mother; GBS-; other serologies unremarkable
• Birth: NSVD @ 39wks GA; midwife-attended home birth; Apgars 9/9; BW 3400gm
• SHx: Lives in Ukiah with mother, father, 15mo sibling. Mother had prior successful homebirth +

exclusively breastfed sibling. Recent social stressors: father lost job 1mo ago, mother has h/o postpartum depression.

• ED Course: Febrile, tachycardic, lethargic infant. Sepsis work-up initiated. Umbilical line placed for

IVF and antibiotics; Ampicillin and Gentamicin administered.

• Hospital Course:
• Sepsis: BCx +GBS @ 12hrs; UCx, CSF Cx negative  IV abx x 10 days.
• Dehydration / Feeding Difficulty: IVF x 3 days  formula supplementation + minimal

breastfeeding (mother could not room-in due to young sibling + distance from home).

• Discharge: DOL#12.

Admission #2: “poor feeding”

• HPI: 3-week-old M infant brought to ED for lethargy, dehydration. Infant had difficulty with

breastfeeding (diminished supply, poor latch) so family started supplementing with formula (mixed w/ extra water to conserve powdered formula), cow’s milk, goat’s milk, tea, and water.

• ED Course: Poorly responsive, tachycardic infant with witnessed seizure in triage. Diagnostic

evaluation revealed hyponatremia (Na 122), hypoglycemia (glucose 40), and dehydration.

• PICU Course:
• Metabolic derangements: hyponatremia and hypoglycemia corrected with IVF.
• R/o sepsis: work-up with empiric antibiotics x 48hrs negative.
• NAT work-up: negative.
• Tox work-up: negative.
• Dehydration / Feeding Difficulty: IVF x 2 days  Infant able to feed well PO with formula via

bottle.

• Transfer: Pediatric Hospitalist service on HD#3.

What Happened?

What Is Quality Improvement and Why Should Pediatric Hospitalists Care?

Arpi Bekmezian, MD

Director of Quality and Safety, Division of Pediatric Hospital Medicine Associate Medical Director of Quality and Safety, UCSF Benioff Children’s Hospital Assistant Clinical Professor, Department of Pediatrics

Katey Hoffman, MD

Clinical Quality Liaison, UCSF-Marin General Hospital Pediatric Care Affiliation Assistant Clinical Professor, Department of Pediatrics ?? Pediatric Hospitalist, Marin General Hospital

Learning Objectives

• 1. What are errors and adverse events, why do

they occur and how can they be prevented?

• 2. How can M&M be used in QI?
• 3. What is Quality Improvement (QI) and why

is it important?

• 4. What are the basic principals, methods and

key steps for a successful QI projects?

Outline

• Case Presentation (10min)
• QI Background (15min)
• QI Workshop (50min)
• Questions & Open Discussion (15min)

Admission #1: Neonatal Fever

• CC: Fever in neonate
• HPI: 2 day old term male newborn; admitted directly from home

with one day of low-grade fever, decreased UOP, lethargy.

– Prenatal: 29yo G2P1-2 mother; blood type B+, GBS-, other serologies unremarkable; uncomplicated pregnancy – Birth: NSVD @ 39wks GA; home birth with midwife attendance; Apgars 9/9; birthweight 3400gm – Postnatal: exclusively breastfeeding, difficulty maintaining latch – DOL#2-3: decreased feeding frequency over 24hrs (no PO intake x 8hrs); decreased UOP (last wet diaper >18hrs ago); infant sleepy but arousable; rectal temp 38.9C

• Family called midwife for advice  Direct admit to ICN under care
• f pediatric hospitalist

Admission #1: Neonatal Fever

• Pertinent Social History:

– Family lives in Ukiah, CA

• Mother, father, 15mo sibling
• Prior successful homebirth, exclusively breastfed sibling

– Social stressors

• Father lost his job 1mo ago
• Mother with h/o post-partum depression
• Admission Physical Exam:

– VS: T 38.7, HR 180, BP 55/25, RR 68, O2 sat: 98% – Weight: 3100gm (⇓300gm from BW) – General: Lethargic, pale, poor tone, minimally responsive to stimulation – HEENT: sunken anterior fontanel, conjunctivae clear, dry mucous membranes – CV: Tachycardia, no murmur, bounding pulses 3+, cap refill 4-5 seconds – Respiratory: tachypneic, no retractions, lungs clear – Abdomen: soft, non-distended, non-tender, no HSM – GU: nml male – Neuro: decreased tone, symmetric moro

Admission #1: ICN Hospital Course

• Neonatal Sepsis

– BCx +GBS @ 12hrs – UCx, CSF cx negative – IV antibiotics x 10 days (via umbilical line / PIV)

• Dehydration / Feeding difficulty

– MIVF x 3 days – Formula supplementation of breastfeeding – Discharge weight 3300 gm (⇓ 3% from BW)

• Social

– Mother could not room-in because 15mo sibling at home

• Discharge home on DOL#12

Admission #2: Poor Feeding

• 10 days later, family presents to outside hospital ED…
• CC: poor feeding, lethargy
• Triage:

– Appearance: lethargic, poor reactivity, dry mucous membranes – Vitals:

• Weight 3200 gm (⇓ 6% from BW; -100gm from d/c weight)
• VS: T 36.0C, HR 188, RR 44, O2 sat 97% on RA

– Witnessed SEIZURE lasting 90 sec (tonic-clonic jerking of LUE, eye deviation)

• Labs:

– Electrolytes: Na 122 | Cl 94 | BUN 11 K 3.3 | HCO3 16 | Cr 0.3 – CBC: 11.1 32 Glucose 40 431 14.2

Admission #2: Poor Feeding

• ED Interventions:

– Seizure:

• Ativan IV x 1
• Urine toxicology screen

– Hyponatremia:

• 3% NS bolus x 1  D5NS IV @ maintenance

– Hypoglycemia:

• D10W bolus IV x 2

– R/o Sepsis:

• Blood, urine, CSF studies  Ampicillin & Cefotaxime IV
• Transfer to Tertiary Care Center PICU

Further History

• Feeding difficulties:

– Mother reports diminished breastmilk supply after 1st hospital discharge and ongoing difficulty with latching – Family purchased powdered formula to supplement; started adding extra water to bottles last week because too expensive – Due to poor feeding, family decided to try additional bottles of cow’s milk, then goat’s milk, then tea and water

• No PCP identified by family; family fired midwife

after 1st hospitalization

Admission #2: Poor Feeding

• Hospital Course

– Seizures

• No further seizures in PICU
• Urine Tox negative
• NAT work-up negative

– Hyponatremia: corrected with IVF over 2 days – Hypoglycemia: corrected with IV dextrose – R/o Sepsis: IV abx x 48hrs; BCx, UCx, CSF Cx neg – Feeding difficulties: starts formula feeding well

• Transferred from PICU to Pediatric Hospitalist Service
• n HD#3

What Happened?

• PICU attending requests review of this case

for potential quality and safety issues related to the readmission:

– Was there a medical error? – Was the adverse event preventable?

What is Quality ?

• IOM: The degree to which health care services for

individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

• AHRQ: Doing the right thing, at the right time, in the

right way, for the right person—and having the best possible results.

Where did Quality come from?

• Started in the Industrial process in 1930s by

Shewhart and introduced to Japanese engineers in 1940s by Deming.

• Gained worldwide recognition in Japanese car

industry.

What is Harm?

• Health care in the US is not as safe as it

should be--and can be.

• 100,000 people/year die in hospitals as a result
• f preventable medical errors.

– Exceed attributable deaths to such MVA, breast cancer, and AIDS.

Unsustainable Health Care Cost

• What physicians know should be done for

patients and what is actually done accounts for

~$20 Billion/year

Health Care vs Industry

• Health care is a decade or more behind high-

risk industries in ensuring basic quality/safety.

• High reliability organizations

– Apple, Motorola, Toyota, commercial aviation – 6 sigma 1: 3.4 million, 10-6

• Health care

– Inpatient admission death 1: 336, 10-4

Error vs Adverse Event

Inpatient Errors

• Nosocomial/hospital acquired infections
• Wrong-site surgery
• Wrong Procedure
• Wrong patient
• Restraint-related injuries or death
• Falls, burns, pressure ulcers
• Medication errors
• Transition errors related to communication (i.e., signout, discharge care).
• Diagnostic errors/delays
• Transfusion errors
• Surgical injuries
• Preventable readmissions
• High error rates with serious consequences are most likely to occur in

ICU, OR, and ED.

Never Events

Why Errors Happen

• Almost inevitable because Healthcare system is so complex
• Usually caused by faulty systems, processes, and conditions

that lead people to make mistakes or fail to prevent them.

• Majority do not result from individual recklessness or the

actions of a particular group

–Not a “bad apple” problem.

Active Error

• Made by individuals:

– Schematic behavior are automatic, practiced, repetitive actions.

• Failure due to a lapse in expected behavior
• Slips can be prevented through standardizing and

simplifying processes and developing reminder systems and forcing functions (i.e., checklists).

– Attentional behavior requires conscious thought and analysis.

• Failure usually reflects incorrect choices
• Mistakes require training, remediation, and occasionally

disciplinary action.

Latent Error

• Underlying system flaws that allow active

errors to reach and harm the patient

• Solutions:

– Favor schematic over attentional behavior (i.e., checklists)

Classes of latent errors Specific examples Patient factors Complexity of illness Health literacy Personality and cultural factors Socioeconomic status Task factors Task design and clarity of structure Availability and use of protocols/checklists Decision-making aids T echnology factors Integration of technology into workflow Potential for technology to create new errors Interoperability Overreliance on technology Individual staff factors Competence Knowledge and skills Physical and mental well-being Asking for help when needed T eam factors T eam structure (congruence, consistency, leadership) Verbal communication Written communication Supervision Work environmental factors Staffing level and skill mix Workload and shift patterns Design, availability, and maintenance of equipment Administrative and managerial support Physical environment Organizational and Management Factors Safety culture and priorities Financial resources and constraints Organizational structure Policies, standards, and goals Institutional context factors Economic and regulatory context Links with external organizations

Reason’s Swiss Cheese Model

• 8.4 holes have to line up for error to seep

through

Six IOM Domains of Quality

• 1. Safe avoiding injuries to patients.
• 2. Effective based on scientific knowledge to all who could

benefit.

• 3. Patient-centered individual patient preferences, needs, and

values guide all clinical decisions.

• 4. Timely reducing waits/delays for receiving and giving care.
• 5. Efficient avoiding waste-- equipment, supplies, ideas, energy.
• 6. Equitable not vary in quality because of gender, ethnicity,

geographic location, disability, socioeconomic status, etc.

Institute for Healthcare Improvement Triple Aim

QI Workshop Outline

• Case Review
• Developing QI Initiatives
• Tracking QI initiatives

Group Question

• Can you identify contributing factors that

resulted in the adverse event (re-admission) in this case?

Contributing Factors

• Parental confusion re: infant feeding

– Inappropriate formula mixing / dilution with water – Inappropriate formula / breastmilk alternatives

• Limited family resources

– Inability to purchase sufficient formula – Delay in seeking care

• Lack of PCP communication / hand-off at hospital

discharge

– No PCP identified at 1st hospital discharge – Infant lost to follow-up

Group Question

• Was there a medical error(s)?

– What type?

• Was the adverse event preventable?

Group Question

• How would you organize a forum to review

this case and discuss the contributing factors that resulted in the adverse event?

What is M&M

• What happened, why, how to prevent.
• Not just educational but will effect change

M&M Philosophy

• Avoid attributing blame.
• Nonthreatening, nonjudgmental.
• Openness to discussion and investigation of errors as

evidence of system flaws, not character flaws.

• Denigration will deter participation .
• Goal must be educational and practical.
• Must be linked to improvement of all doctors and not

to the punishment of those who err.

• Mutual respect and desire to improve the lot of

patients.

Type of Cases to Review

• Mortalities
• Submitted cases

– Focus on a much broader set of errors, mainly those that do no

• r minimal harm, and help detect system weaknesses that can

be fixed before the occurrence of serious harm.

• Readmissions (30-day related, unplanned)
• Incident Reports (serious)
• Rapid Response Team / Code Blue calls
• Catheter-related bloodstream infections
• Catheter-associated urinary tract infections
• Patient/family complaints
• AMA discharges

M&M Format

• Confidential
• Multidisciplinary
• Involve trainees: awareness, facilitate discussion,

decreased shame and blame, meaningful improvement in care.

• Knowledge, practice, communication vs system’s

issue.

• Identify system level solutions to prevent future

similar adverse events.

• Action items, f/u, updates

T

• ols for Engineering Change:

Cause-and-Effect Diagram

Physiologic Factors Pharmocologic Factors Drug Administration Errors Ordering Errors

Transcribing Spelling Pharmacokinetics Renal Dilution Time Nurse Route Rate

ADE

Nurse Physician Pharmacist Physician Pharmacy Nurse/Clerk Pharmacist Patient Physician Dietician Patient

Wrong Drug Dose Scheduling Dosage Route Past Allergic Reaction Absorption Weight Age Gender Electrolyte Hepatic Race Pharmacodyamics Expected Drug/Drug Unforeseen Drug/Food Drug/Lab Cognitive Psychiatric Compliance

Patient Errors

Order Missed

Place outcome here

Example: Adverse Drug Events (ADE)

M&M Discussion Framework

Communication Context Knowledge System Practice Adverse Event Other

Group Activity

• How would you organize your M&M

discussion for this case using the proposed framework?

Communication Context Knowledge System Practice Adverse Event Other

Group Question

• What potential solutions could you develop

for your pediatric hospitalist group based on the quality and safety issues raised in this case?

What is Quality Improvement

• Traditional Research

– Trying to figure out the right thing to do.

• QI

– Healthcare delivery science. – How to make sure that the right thing happens every single time. – Elimination of unintended variation in process/product.

What is Quality Improvement

Implementation Gap

Scientific understanding Patient care

Progress

Time

Chasm

BEFORE NOW

• Growing complexity of health care
• more to know, more to do, more to manage, more to watch, and more

people involved.

• Advances in medical science and technology
• increase in the chronic conditions.

Why Do QI

• Accreditation standards for health care systems
• Employer and consumer expectation
• Public reporting of performance information.
• Pay-for-performance initiatives
• Financial penalties
• Ethical imperative, it’s the right thing to do, we’ll

be patients one day

• Accreditation Council for GME
• ABP MOC Part 4

Why Should Pediatric Hospitalists Care About QI ?

• Complex process problems need multidisciplinary

solutions.

• We are at the frontlines seeing and experiencing

system failures, process errors, and performance gaps.

• Improved quality delivers:
• better patient care
• lower costs
• higher reimbursements
• make our jobs more rewarding, interesting, fun.

QI is NOT

• Yelling at people to work harder, faster, or

safer

• More money, more people, more time.
• Creating order sets or protocols and then

failing to monitor their use or effect

• Research (but they can co-exist nicely)
• QA or QC

How to Prioritize Interventions

• High-risk
• High-volume
• Problem-prone
• Regulatory requirements.

Group Question

• What potential QI initiatives could you

develop for your pediatric hospitalist group based on the quality and safety issues raised in this case?

Potential QI Initiatives

• Discharge teaching
• Clinical guidelines for infant feeding / nutrition
• Discharge coordination
• PCP communication / PCP hand-offs

Group Question

• How would you implement and track your

proposed QI initiatives?

Successful QI

• Obsessed with failure.
• Address issues systematically.
• Traditional methods of paper tools, memory, and

hard work will not cut it in complex medical environment.

• Deliberate redesign of processes based on

knowledge of human factors.

• Continuous QI.
• Participation of stakeholders and leadership of
• rganization.

SMART Objectives

Aims are broad, intangible, and abstract. Objectives should follow a SMART framework:

• SPECIFIC: Is the statement precise about what you hope to achieve?
• MEASURABLE: Do the objectives contain a numerical goal? Will you know

if the change resulted in improvement?

• ACHIEVABLE: Is this feasible in the time you have?
• RELEVANT: Does your aim align with strategic goals of your organization?
• TIME BOUND: Do you identify the timeline?
• Example Aim: Improve communication with primary care physicians of

admitted patients

• Example SMART Objective: Improve documented communication with

PCP’s from 54% of discharges to 80% of discharges each month.

QI Methodologies

• Plan-Do-Study-Act (PDSA)
• Six-sigma
• Lean strategies

What are we trying to accomplish? How we will know that a change is an improvement? What change can we make that will result in an improvement?

PDSA Cycle

Langley, Nolan, Nolan, Norman & Provost 1999

ACT PLAN DO STUDY

How to use the PDSA Cycle

• Use plan-do-study-act cycles

to conduct small-scale tests

• f change in real settings

– plan a change – do it in a small test – study its effects – act on what learned

• Team uses and links small

PDSA cycles until ready for broad implementation

ACT

What changes can be made for t he next cycle (adapt change, anot her t est , implement at ion cycle? )

• PLAN
• Obj ect ive
• Predict ion
• Plan for change (who,

what , when, where)

• Plan for dat a collect ion

(who, what , when, where)

• Carry out t he change
• Document observat ions
• Record dat a

DO

Complet e analysis

• f dat a

Compare result s t o predict ions S ummarize knowledge gained

• S

TUDY

Measurement

• Much of quality can and should be

measured.

– How are we doing?

–Answer requires systematic measurement

• f quality via process, balancing and
• utcome measures plotted over time

before and after intervention.

Structure, Process, Outcome Measures

• Structure: resources, management systems, and policy guidelines critical

to sustaining processes over time. Primarily for licensing/accreditation. – Example: intensivists in the ICU to decrease mortality.

• Process: Use the actual process of health care delivery as the indicator of

whether medicine is practiced according to protocol/guidelines. – Example: compliance with extubation protocol.

• Balancing: looks for untoward consequences of improvement

– Example: re-intubations.

• Outcome: the end result of health care, depend on medical care and

genetic, environmental, and behavioral factors. Based on group results. – Example: number of days on ventilator or BPD rate.

How Do I Get Data?

• Administrative databases (UHC, etc)
• Infection Control
• Incident Report
• Patient Complaint/Grievances
• Billing Database
• EMR reports (custom/ready-made)
• QI departmental review
• Survey data (maybe biased)
• Manual chart review (random sample)

Repeated PDSA cycles

Group Activity

• How would you implement and track your

proposed QI initiative (pick one to discuss)?

Group Question

Putting it all together…

• Summarize the example patient case, identified

quality & safety issues, and resultant QI initiatives / process

20% 93% 85% 77% 79% 95% 87%

estimate 1161 881 259 273 280 91

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

FY'11 FY'12 (pre APeX) Oct'12- June'13 Q1'14 Q2'14 Q3'14 Apr'14

% Documented D/C Communication to PCPs

%Documented Discharge Communication to PCPs N Practice Change

4.9% 4.6% 3.0% 3.6% 4.1% 4.1% 3.8% 4.1% 68 60 38 9 2000 4000 6000 8000 10000 12000 14000 16000 18000 20000 0.0% 2.5% 5.0% 7.5% 10.0% FY11 FY12 FY13 Q1'14 UCSF Comparable UHCs UCSF Readmits

Related and Unplanned Pediatric Hospitalist 30-Day Readmission Rate - UHC

FCR, M&Ms Transitions Taskforce

Quality and Safety Dashboards

Targets, goals and benchmarking to external comparison

• 1. National Healthcare Safety Network: CDC healthcare-

associated infection tracking system

• 2. SPS: Children's Hospitals Solutions for Patient Safety
• 3. Collaborative Alliance for Nursing Outcomes: Registry
• f nursing-sensitive quality and safety indicators
• 4. National Database of Nursing Quality Indicators
• 5. Joint Commission Core Measures

6. Virtual PICU Systems

• 7. University HealthSystem Consortium

Questions & Open Discussion

PHM BOOTCAMP: QUALITY IMPROVEMENT WORKSHEET

• 1. Identify a quality or safety measure that you think could use improvement:
• 2. State a specific AIM: (How good? By when?)
• 3. What are the obstacles to achieving your aim? Are they fixed or modifiable?
• 4. How will you know if there is an improvement? What are your MEASURES?
• a. Outcome measures:
• b. Process measures:
• c. Balance measures:
• 5. Can you think of specific CHANGES that can be made to achieve the improvement?

 Choose one change to test in the first cycle:_________________________________

• 6. Who should be on the team? This may include other MDs, RNs, hospital staff, etc.

depending on what systems will be affected by your proposed changes and improvements.

• a. Project leadership
• b. Technical expertise
• c. Day-to-day leadership

QUALITY IMPROVEMENT REFERENCE SHEET

• 1. Dimensions of Care Quality: Care should be…
• a. Safe: avoiding injury from care intended to help
• b. Effective: providing therapies with proven benefit, avoiding those without
• c. Patient-centered: respectful, individualized, protecting autonomy
• d. Timely: no unnecessary waiting
• e. Efficient: avoid waste of supplies, money, energy, time
• f. Equitable: equal care regardless of patient gender, race, socio-economics
• 2. The Model for Improvement:
• a. Set an Aim: What are you trying to accomplish? Be specific – how much do you

want your outcome to improve and by when?

• b. Establish your Measures: How will you know the changes you make are leading to

improvement?

• Outcome measures: Is your final target value improving?
• Process measures: Are the changes you planned to implement occurring as

you had intended?

• Balancing measures: Is some other part of the care or care system suffering

at the expense of the improvements you are making in one area?

• c. Selecting Changes: What changes can we make that will result in improvement?

Think about the obstacles to achieving your aim and how to change the system to

• vercome them.

Once you have set an aim, established measures and selected changes to make, you are ready to begin your first PDSA cycle.

PLAN: Briefly describe the test: What Change(s) will be implemented and by whom? How will data be collected on outcome, process, and balancing measures? What do you predict will happen? Plan for change/ test: who, what, when, where Test start date: Target test completion date: List the tasks necessary to complete this test (what) Person responsible (who) When Where 1. 2. 3. 4. 5. 6. Plan for collection of data: What Data will be collected? How to collect it? How will you record it? Who is responsible for each step?

Do Study Act Plan

DO: 1) Educate staff; 2) Implement the changes; 3) Record data, problems and observations. Was the cycle carried out as planned? What did you observe that was not part of our plan? STUDY: Compare the result of your test to your previous performance: Did the results match your predictions? If not why not? What did you learn? What further changes need to be made/what actions need to be taken? ACT: Decide to Adopt, Adapt, or Abandon. Adapt: Improve the change and continue testing plan. Plans/changes for next test: Adopt: Select changes to implement on a larger scale and develop an implementation plan and plan for sustainability Abandon: Discard this change idea and try a different one