When things get messy: QI on the front lines David Frost MD FRCPC Site Director, CTU Director, Toronto Western Hospital University Health Network, University of Toronto
CSIM Annual Meeting 2017 The following presentation represents the views of the speaker at the time of the presentation. This information is meant for educational purposes, and should not replace other sources of information or your medical judgment. Learning Objectives: • To illustrate QI principles and change management using real examples • (Hopefully), you can learn from our experiences- positive and negative • To appreciate the pitfalls of certain cognitive biases as they relate to QI • To generate discussion and share experiences around real life QI
Disclosures I have no conflicts to declare
Actually just one disclosure… I am a clinician teacher with some local hospital administrative responsibility as site lead and CTU director for GIM. I have some medical leadership training, but zero quality improvement training. Fortunately I have colleagues who do…
Unintended consequences https://youtu.be/vYglvcLwkK4?t=7s
4 projects from Toronto Western Hospital • For each initiative, 1. Motivation for change 2. Stakeholder engagement and design of intervention 3. Intervention 4. Outcome measures and anticipated result 5. What really happened 6. What we didn’t expect 7. Course correction 8. Current status
1) GIM Ambulatory Strategy • Replacement of longstanding, model of 2 halfday clinics per weeks with residents and multiple attendings in each clinic, often simultaneously covering ward patients, accepting referrals from community family MDs
2) Acute Care of the Elderly GIM Unit • Building ACE unit from ground up, integrating with existing GIM service
3) General Internist embedded in Family Practice • Situating a general internist in the hospital’s Family Health Team to provide consultations 1/2 day per week
4) Non-Teaching GIM ‘team’ • Building a faculty-only overflow service to limit CTU team size
Motivation for change
GIM Ambulatory Strategy • GIM at UHN has had sustained increases in inpatient volumes on order of ~5-6% per year for about 5 years • Pressure to decrease admissions • Pressure to decrease length of stay without increasing readmissions • Educational goals (Royal College) not being met • Recognition that existing ambulatory structure did not meet needs
ACE Unit • Increasing number of elderly GIM inpatients with complex needs • Evidence for decreased ALC days, decreased length of stay, improved patient satisfaction elsewhere • Variability between hospital wards in ability to respond to behavioural and other issues in the elderly
GIM clinic in Family Practice • Unnecessarily complex process for conventional referrals between family practice and GIM • Many patients with complex comorbidities discharged from hospital; frequent readmissions • Funding opportunity; sessional fee for specialist halfday at family practice
Traditional workflow Consultant Referral Form 1 Clarification or more info requested 2 3 Appointment info given to FMD 4 office 5 FMD office contacts patient with appointment details (FMD staff might be unfamiliar with details of consultant’s office) sends patient to attend specialist appointment (probably unfamiliar office) 6 Consult letter (maybe) with plan that may o may not be what the FMD had been seeking Family Physician Frost DW, Toubassi D, Detsky, AS. Canadian Family Physician 2012; 58: 825-28
Non-teaching GIM ‘team’ • Increasing CTU team census • Concern re: service to education ratio • Number of patients covered overnight • Residency program to impose cap in team size
Stakeholder Engagement and Design of Intervention
GIM Ambulatory Strategy • Hospital administration • GIM physician staff (survey then retreat) • Referring physicians (rounds attendance) • Working group with physician and hospital administrative representation
ACE Unit • Allied health personnel, nursing, hospital administration, physician leadership • Patient representatives • Site visits to other facilities with ACE units • Spot audit of proportion on GIM patients who meet proposed criteria (~30%) • Steering committee with broad representation (administrators, allied health personnel, nursing, physician)
GIM clinic in Family Practice • S urvey of family physicians at the site, soliciting feedback on patient population, preferences around logistics, communications • Informal discussion with family physician colleagues, department head
Non-teaching GIM ‘team’ • GIM physician staff input • Hospital administration
Interventions
GIM Ambulatory Strategy • Discontinue previous ambulatory clinic structure • Clinics 5d per week • “Rapid Referral” from ED 3 x ½ days (no triaging, liberal referral criteria- safe for discharge, internal medicine problem requiring urgent assessment, not better served by existing specialty clinic)
GIM Ambulatory Strategy • Post-discharge clinic 2 ½ days per week- referrals from ward • HTN clinic weekly • Longitudinal GIM clinic weekly • Dedicated attending for 2 or 4 week block in ambulatory clinic
ACE Unit • Patients meeting (rather liberal) criteria are identified on admission and assigned to designated wa r ds; different admission order set used • Automatic PT, OT, and SW consults • Specific interdisciplinary planning meeting (above usual IP rounds) • All nursing and allied health working on these 2 wards have specialized geriatrics training • Communal dining area, music therapy, recreation therapy
GIM clinic in Family Practice • Patients with multiple medical problems who do not need more subspecialty care, but more ‘complex care’, diagnostic dilemmas , undifferentiated presentations, patients in whom a ‘second opinion’ is requested, patients at high risk of presenting to ER with a general medical issue • General internist is given an examination room and existing clinic administration and nursing support (1/2 day per week)
GIM clinic in Family Practice • Family MDs refer via EMR, specialist reviews request with access to patients’ whole electronic chart • Patient is booked in usual family practice, seen on site, immediately dictate letter • Direct communication by email with ‘bottom line’ from consultation
Non-teaching GIM ‘team’ • Pilot during 3 traditionally busiest months (Jan-Mar) • An attending will be MRP for a 2 week period, and will provide all necessary medical care to the patients admitted to the service • Anticipate caring for around 16 patients on such a service, which would decrease CTU volumes by around 4 patients per team
Outcome measures, anticipated results
GIM Ambulatory Strategy • Number of referrals and patients seen, wait times, report from ED physicians whether referral avoided, CTU team sizes, readmission rate • Anticipated result: Diversion of stable patients away from ward because of guaranteed prompt internal medicine assessment. Better followup leading to decreased readmission rate
ACE Unit • Improvement in several parameters- falls, catheter use, ALC days, length of stay, patient experience, LTC as destination
GIM clinic in Family Practice • Improved communication, better patient experience, more prompt GIM assessments, increased referring MD satisfaction with consultation process
Non-teaching GIM ‘team’ • Number of patients diverted from CTU teams, attending physician experience
What really happened…
GIM Ambulatory Strategy • Worked nearly as anticipated (patients diverted from ED and ward, high trainee satisfaction) • Referrals (intended to be scanned and sent to clinic) often never arrived; patients would arrive at clinic, and staff would not have reason for referral • Billings not quite as high as anticipated
GIM Ambulatory Strategy • Rapid referral patients needed more followup visits than anticipated • Lack of faculty longitudinality was at times a serious problem
ACE Unit • Admitting order set (paper) was 6 pages long and nobody used it • Admitting order set was reduced to 2 pages long and nobody used it • Admission criteria included the ISAR score- nobody knows what this is • The (few) patients who were admitted had decreased falls, decreased catheter use, positive experience
ACE Unit • We did not expect so few patients to be admitted to ACE • Orientation to ACE unit for rotating residents was more difficult than expected
GIM clinic in Family Practice • High volume of referrals • High degree of provider satisfaction • Far more patients with single symptom for workup, diagnostic dilemma than anticipated. In a consecutive sample of 100 referrals, NONE were referred for comanagment of complex comorbidities • Charts in this practice became fully electronic
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