Process of Quality

Improvement—

The Colorado Experience

Leslie Jameson MD

University of Colorado

Department of Anesthesiology

Change!!!!

Who?

Me??

You??

Everyone!!!

Why?

PUBLIC RegulatorsMedical Community

Want to create change in medical practice

Result in improved measured outcome

Patient satisfaction (high hospital ratings)

Lower morbidity (eg, infection, readmission, LOS)

Reduced medical costs (no morbidity)

Motivator

Personal satisfaction (the most effective motivator)

Money (2015 CMS QCDR )

Money (Credentials)

Money (Highly rated hospital-Patients)

Money (Licensure, ABA certification)

How?

MEASURE discrete a selected medical process

(eg, SCIP, PQRI requirements)

Assess DOCUMENTED Care that is important

EDUCATE participants

Make a group process or an individual one

MEASURE for Change in Practices

Maintain gains

PROVIDE CONTINOUS PERFORMANCE

REASSESSMENT–Medicine and public

Lucian Leap’s Statement on

Change

(Author of Too Err is Human IOM Report)

1. Errors & Failure are caused by system breakdowns not

individual carelessness.

2. Changing systems (clinical actions) is hard work and

requires serious commitment, leadership and

perseverance.

1. Must overcome TRADITION, TRADITION

while we MOTIVATE MOTIVATE MOTIVATE!!!

3. Most powerful method for reducing harm is feed back, learning

from the best, and working in collaboration .

Adapted from JAMA FEB 3 2015; 313(5):467-8)

ASPIRE

Here is how my

department approached change

and quality improvement for the

last 8 years.

Use objective data

2006 –AIMS

2009 –Started a weekly report

Generic

By Location

SCIP activities

Admin always asking for 100%

Anonymous

Educated “poor” performers privately

When 1-2 items worked OK

WEEKLY EMAIL

Issues with Generic

Faculty were accountable and not accountable

Non-physician caregivers had variable buy in

and no responsibility except a conversation with

???

Residents were too busy and came from so many

locations, they just forgot or could not remember

how to do some of the obscure charting.

2010--Provider and Location

Report

LIST of measures for this year

Preop antibiotics, Normothermia

2011--Issue was what we

measured

The Measures were not

ours.

Measures seemed to not

matter

More pressure to use

administrative measures

In room time,

turnover time,

“fast” 3 seconds late

too bad

Assumption: Our measures

Our commitment

INSIDE--Social pressure to perform

within a standard was being diluted

by growth

Needed to be explicit

OUTSIDE—Increased pressure for

more measures—

Hospital requests all financial (time

related),

Departmental wanted to improve the

bottom line with clinical care

New Measures-1st Rule

CURRENT Measurable ACTIVITY

Example

Measure: Lung protective ventilation practices

expected

Automatic tidal volume, PEEP and RR recorded

Action:

Values must be ADJUSTED based on patient

characteristics

New Measures--2nd Rule

YES!!!!!

There must be some evidence about best practices

Meta analysis, several review articles, best practice guidelines

which rates the evidence

NO!!!!!

One of my partners like to do it that way

When I was a resident that’s what they taught me

TRADITION, TRADITION

Process

ALL members submitted suggestions

Applied 85% rule-- 85% group could

participate 50% of the time.

Measures could be administrative but with

agreed clinical consequences.

EXPECTED outcome goal or consequence

Anticipated as actions became habits would

change actions (eg, reversal of

nondepolarizing muscle relaxants)

Consensus won

Our List—1.0

Antibiotics—stayed by popular (hospital?) demand

Temperature—Good evidence on SSI and we would

no longer freeze in the OR.

Ultrasound for Central Line Placement—good

evidence for line infection and sepsis.

Plus the hospital would have to provide more devices

Reversal of Nondepolarizing Muscle Relaxants—

increased frequency of re-intubations in PACU and

floor

Start with Education

Rubber hits the Road

Will we comply with our own measures????

Well sort of

Now had a Director of

Perioperative Services saying

we would have 100%

compliance on clinical

measures and 80%

compliance on time measures

(another story).

AT 8 Months

Still well, not exactly

Added a few more measures -- v. 2.0

PONV—hospital metric we agreed with

Epic Quality reporting available so now but not yet

mandatory.

Impact of CHANGE

2010—New EMR

2014 Quadrupled faculty and

mid-level provider numbers

Doubled anesthetizing locations

UCH grew 20%-30% each year

since 2011

Hey, we’re a “System” with 2

large Independent Hospital

Organization with all private

practice physicians

November 2011 --- Radical Change

Public individually identified reporting on

compliance begins

Used public accountability on the web for everything

about us soooooo why not.

Weekly public list (email) with names and values

Performance level established for hospital credentialing

Hospital quality monitoring is public--(really public) all

measures were departmentally reported.

A fire storm of ANGST

More Success with new format???

Theory—people noticed low performance and

helped each other technically so it became “oh,

you just didn’t know how to chart this.”

Activate competitive spirit

????????? (humiliation works)

Criticism

Don’t know the “rules”

I did it and you made a mistake

I’ll just go and change it

Doesn’t matter anyway.

I’m Mad!!!

Criteria for

compliance

•Used KISS principles

•2-3 months of

“learning” before new

criteria “counted”

•Time included

education at grand

rounds or in Resident

Senior Lecture

•Today you can “hover”

over each measure and

get the criteria

I did it and you made a mistake

Data integrity:

Learning where or who or if there was an error with a

list of noncompliant/compliant patients

What it looks like at 3 months

Increasing the Ante

one more time!!!

Off to the Hospital

credentialing.

Credentialing Form

Filed automatically from our IT every 4-6 months

Available to public as in the internet

Added stress but not better

performance

Final Act—Be CMS and Pay people

AA/CRNA-- Monthly Incentive May 2014

Payout is based on total $$ available for month/# of CRNA/AA FTE.

Your payment based FTE

Criteria

I. ELIGIBLE--100% Antibiotic charting

II. 50% PAYOUT if

I. 80% of AIP Goal for On-Time AND 80% of AOP Goal for On-

Time

III. Full Payout if

I. 90%of AIP Goal for On-Time AND 90% of Goal for On-

Time

The 65% & 70% are UCH Goals for On-Time Starts

Effect—better charting but

different care?

THIS IS ABOUT AN IMAGE

NOT AN OUTCOME

The TRAP

Why does it matter?

MONEY

FAME

MONEY

PRESTIGE

MONEY

MORE FAME

MONEY

LOWER BILLS

LOWER COSTS

FAME

CAN WE TELL IF THIS MATTERS?

HOW ABOUT CLOSER TO HOME?

THE QUEST

Did our efforts work?

NOPE—No one in the hospital follows this but it is recorded on every

patient (since 2010).

We can know what works

It matters to us

Did anyone in the hospital

keep track or know what we

were doing?

Was there a global

corrdinating body that got

everyone together?

Ventilator Associated

Pneumonia

Antibiotic measure

Reversal NDMR

6.7

3.2 3.1 3.2

0.9 1.5

2.3

1.0

2007 (N=18) 2008 (N=12) 2009 (N=12) 2010 (N=11) 2011 (N=3) 2012 (N=6) 2013 (N=9) 2014 (N=2)

CLABSI Rate/1000 catheter days

SICU CLABSI Rates 2007-2014

Surgical ICU Sepsis Rates 2007-2014

Source Lab Blood cultures

‘07 ’08 ‘09-‘10 ‘11

What else?

Sometimes things just get

worse

Random numbers?

Dr. Leape again--

The best way to get change

is to make it personal—

your patient,

your friend,

your family

Central line—No infections

from OR for 18 months

NDMR-REVERSAL

Re--intubations in PACU 3/week to 6/year

Pneumonia rate down 50%

PONV

Subjective—much lower N & V

Preemptive treatment much more likely (eg. Propofol

infusion)

Ventilation changes

No real measure but rate of unexpected admit to ICU in

OSA patients lower than non OSA patients.

Conclusion from all this

The final step toward success

Pragmatic Collaboration

We need to recognize the trap (fallacy) that recording

numbers is fraught with human error

Actions

Doing deeds is a celebration of success and uses

numbers as the reminder

Nothing is 100% or 0%--Surgery causes injury. Actions

that contribute to reducing injury matters

Reality –Consolidate your gains

Finally Finally Finally

Plan your outcome goal first!

and measure it yourself

Maintain enthusiasm by seeing success

in your patients