How To Create Problem Solvers:

Tools in Quality Improvement Education

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Rachel Smith, MS, PA-C

No disclosures or conflicts of interest

Objectives1. Define the basic tenets of quality improvement and

patient safety

2. Explain the role of the triple aim and its relationship to health care

3. Identify the importance of creating a culture of quality and safety

4. Employ techniques to engage students in the subject of quality improvement

5. Implement a quality improvement proposal assignment

6. Integrate patient safety and cost-effectiveness analysis learning strategies into your curriculum

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What is Quality Improvement?

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It's not...

• Quality Assurance

• Quality Control

• Quality Assessment

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What is Quality?

“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, 2012)."

Quality Improvement is a

systematic approach to

improving quality in healthcare

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Quality Improvement Frameworks

• Donnabeian

• Institute of Medicine domains

• Institute for Healthcare

Improvement "No Needless List"

• Dr. Deming's 14 points

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Donabedian Model

(AHRQ, 2011)

Structure

Facility

Infrastructure

Culture

Staffing

Technology

Process

Diagnosis

Treatment

Resources

Preventative health

Time

Outcome

Morbidity

Mortality

Readmission

Quality of life

Cost

Infections

IOM Six Domains

1. Safe2. Effective3. Patient-centered4. Timely5. Efficient6. Equitable

(AHRQ, 2018)

IHI "No Needless" List• No needless deaths (safe)

• No needless pain or suffering (effective)

• No helplessness in those served or serving (patient-centered)

• No unwanted waiting (timely)

• No waste (efficient)

• No one left out (equitable)

(IHI, 2010)

Deming’s 14-point approach

• Focus on improving effectiveness of

organizations

• Applied to fields outside of

healthcare

• Designed PDSA cycle

• This approach led to the

development of LEAN

(ASQ,2019)

3 key questions in the PDSA cycle

Three (Ideas)

What changes can we make that will result in improvement?

Two (Measures)

How will we know that a change is an improvement?

One (AIM)

What are we trying to accomplish?

https://improvement.nhs.uk/documents/2142/plan-do-study-act.pdf

https://improvement.nhs.uk/documents/2142/plan-do-study-act.pdf

PDSA Cycle

https://improvement.nhs.uk/documents/2142/plan-do-study-act.pdf

https://improvement.nhs.uk/documents/2142/plan-do-study-act.pdf

Broader system of linked goals to

improve the overall health system

https://www.verywellhealth.com/triple-aim-4174961

https://www.verywellhealth.com/triple-aim-4174961

Coude Conundrum

PDSA In Action

PDSA CycleAIM: Reduce the number of consults to the urology

service for coude catheter insertion.

• Plan: Nurse training at orientation, nurse

education/demonstration

• Do: Implemented the plan

• Study: Reduced number of consults to urology service,

nurses empowered and now feel comfortable with

coude catheters

• Act: Barrier was supplies and concern with breaking the

red seal, start having coude kits on every unit

Why does QI matter?

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PA Profession

• Play a role in fixing our healthcare system

• Improves patient care and experience

• Adds value

• Unique position for QI due to history of multiple roles

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PA Students

• Practical, marketable skill for the workforce

• Mindset before clinical: Avoid learned helplessness

• Empower!

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https://www.youtube.com/watch?v=rsjj_-5RlkI

Seligman and Maier Learned

Helplessness Experiment

http://animalethics.umwblogs.org/experimentation-2/

http://animalethics.umwblogs.org/experimentation-2/

Learned helplessness

"A phenomenon in which repeated exposure to uncontrollable stressors results in individuals failing to use any control options that may later become available. Essentially, individuals are said to learn

that they lack behavioral control over environmental events, which, in turn, undermines the motivation to

make changes or attempt to alter situations."

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(APA, 2019)

Patient Safety

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https://www.nap.edu/catalog/9728/to-err-is-human-building-a-safer-health-system

https://www.nap.edu/catalog/9728/to-err-is-human-building-a-safer-health-system

To Err is Human, 1999

• Estimated 44,000-98,000 deaths annually

from medical error

• Recommended plan to address patient

safety

(Stelfox, Palmisani, Scurlock, Orav, & Bates ,2006)

Other Mortality Studies

• 195,000 deaths from medical error (AHRQ, 2004)

• 180,000/year in Medicare beneficiaries alone (US HHS, 2008)

• 210,000-400,000/year from systematic review (James,2013)

• Mean calculated from studies= 251,454deaths a year

(Makary M., & Daniel M., 2016)

(Makary M., & Daniel M., 2016)

Beyond Mortality• 1 in 10 patients develop an adverse event (AHRQ

Efforts, 2014)

• 1 in 2 surgeries had a medication error and/or adverse drug event (Nanji et al., 2015)

• Over 700,000 emergency department visits per year for adverse medication events (Budnitz et al., 2006)

• More than 12 million patients a year experience a diagnostic error in outpatient care, half of which cause harm (Singh et al., 2014)

• 1/3 of Medicare beneficiaries in skilled nursing facilities experience an adverse event, half were preventable (OIG, 2014)

Types of Error• Adverse event: Any harm that occurs to

a patient due to their medical care or stay in a health care facility

• Error: act of comission or omission leading to undesirable outcome or potential for such an outcome

• Near miss: event that could have had adverse consequences but did not

• Never event: preventable, catastrophic events, 29 identified by National Quality Forum

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(Askin, E., Moore, N., 2014)

Never Events• Surgery on the wrong body part, on the wrong patient, or the wrong procedure performed

• Retention of foreign object after surgery

• Intraoperative or immediate postoperative death in an ASA class 1 patient

• Death or serious disability associated with the use of Death or serious disability from a/an:

Medication error

Patient elopement

incompatible blood products

hypoglycemia

spinal manipulative therapy

electric shock

burn

fall

• Infant discharged to the wrong person

• Death or serious disability associated with patient elopement

• Patient suicide or attempted suicide in a healthcare facility

• Maternal death or serious disability associated with labor or delivery in a low risk pregnancy

• Death or disability associated with failure to treat hyperbilirubinemia in neonates

• Stage 3 or 4 pressure ulcers after admission

• Artificial insemination with the wrong donor sperm or wrong egg

• Line designated for oxygen is carrying the wrong gas

• Any care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or

other licensed healthcare provider

• Patient abduction at any age

• Sexual assault on a patient within the grounds of a healthcare facility

How medical errors happen

https://elearning.rcog.org.uk//human-factors/clinical-error/swiss-cheese-model

https://elearning.rcog.org.uk/human-factors/clinical-error/swiss-cheese-model

Why does patient safety matter?

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PA Students

• Increase awareness of problem

• Decrease shame

• Understanding flaws of our healthcare system

• Responsibility as a provider

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What is a Culture of Safety?

• Acknowledge high risk

• Blame-free

• Collaboration for solutions

• Organizational commitment

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Teaching QI & Patient Safety

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Do PA Programs Teach QI?

70.6 % of programs teach QI and 27% had a mature curriculum

Programs Teaching QI

Yes

No

(Berkowitz, O., Goldgar, C., White, SE., Warner, ML., 2019)

Barriers to teaching QI

• Time

• Experienced faculty

• Challenge making subject interesting to students

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Should we teach QI?• B2.16 The curriculum must include instruction in:

a) patient safety,b) prevention of medical errors,c) quality improvement, andd) risk management.

• PANCE Professional Practice (5%) includes quality improvement and patient safety(NCCPA, PANCE Content Blueprint, 2019)

(ARC-PA Standards, Fifth edition, 2019)

Tools to Teach QI and Patient Safety

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Resources for the Instructor

• IHI Modules

• IHI Toolkit

• AHRQ modules

Teaching Tools in QI

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QI Proposal

• Part of Health Policy course

• Pick a topic

• Topic approval

• Turn in proposal (end of term)

• 25% of final grade

Student Examples

• EMT pediatric dosing chart for rural EMS

• Standardize EMS reports to ED "ring" report

• Patient flow with Accutane and urine pregnancy tests

• Patient meal ordering from television remote

• Order set changes to avoid middle of the night vital signs

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Rubric

QI Proposal

• Encourage creativity

• Work through barriers

• Support submission of proposal to organization

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Additional Opportunities

• Assign IHI Modules

• Pick 1-2 QI proposals to implement

during the clinical year (can use IHI

toolkit)

• AHRQ Case Studies

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Teaching Tools in Patient Safety

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Patient Safety

• Personal story

• IHI Modules and videos

• Web M&M Cases

• Classroom M&M

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Submit Patient Safety Report

• Assignment in health policy class

• Through our hospital’s occurrence

reporting system

Patient Sign Out

• Record a real sign out (HIPAA compliant)

• Game of telephone

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https://www.toerrishumanfilm.com/

https://www.toerrishumanfilm.com/

http://bleedingedgedoc.com/

http://bleedingedgedoc.com/

https://wondery.com/shows/dr-death/

https://wondery.com/shows/dr-death/

"Ultimately, the secret of quality is love. You

have to love your patients, you have to love your

profession, you have to love your God. If you

have love, you can work backward to monitor

and improve the system"

-Avedis Donabedian

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Contact:

Smithr2@amc.edu

Linkedin.com/in/resmithpa

References:• Agency for Healthcare Research and Quality. (2012). Understanding Quality Measurement. Retrieved

from https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/understand/index.html.

• Agency for Healthcare Research and Quality. (2011). Types of Health Care Quality Measures. Retrieved from https://www.ahrq.gov/talkingquality/measures/types.html.

• Agency for Healthcare Research and Quality. (2018). Six Domains of Health Care Quality. Retrieved from https://www.ahrq.gov/talkingquality/measures/six-domains.html.

• Institute for Healthcare Improvement. (2010). Closing the Quality Gap. Retrieved fromhttp://www.ihi.org/about/Documents/IntroductiontoIHIBrochureDec10.pdf.

• American Society for Quality. (2019). W. Edwards Deming’s 14 Points For Total Quality Management. Retrieved from https://asq.org/quality-resources/total-quality-management/deming-points.

• American Psychological Association. (2018).APA Dictionary of Psychology. Retrieved from https://dictionary.apa.org/learned-helplessness.

• Stelfox, HT., Palmisani, S., Scurlock, C., Orav, EJ., Bates, DW. (2006). The “To Err is Human” report and the patient safety literature. Qual Saf Health Care, 15 (3):174-178. doi: 10.1136/qshc.2006.017947

• Makary, M., Daniel, M. (2016). Medical Error- the third leading cause of death in the US. BMJ, 353.doi: https://doi.org/10.1136/bmj.i2139

• Agency for Healthcare Research and Quality (AHRQ). 2014. Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013. Rockville, MD: Agency for Healthcare Research and Quality. AHRQ Publication No. 15-0011-EF. http:// www.psnet.ahrq.gov/resource.aspx?resourceID=28573.

https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/understand/index.htmlhttps://www.ahrq.gov/talkingquality/measures/types.htmlhttps://www.ahrq.gov/talkingquality/measures/six-domains.htmlhttp://www.ihi.org/about/Documents/IntroductiontoIHIBrochureDec10.pdfhttps://asq.org/quality-resources/total-quality-management/deming-pointshttps://dictionary.apa.org/learned-helplessnesshttps://dx.doi.org/10.1136%2Fqshc.2006.017947https://doi.org/10.1136/bmj.i2139

References:

• Budnitz DS, Pollock DA, Weidenbach KN, Mendelsohn AB, Schroeder TJ, Annest JL. 2006. National surveillance of emergency department visits for outpatient adverse drug events. JAMA 296:1858–1866.

• Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. 2015. Evaluation of perioperative medication errors and adverse drug events. Anesthesiology Oct 24 2015. http:// anesthesiology.pubs.asahq.org/article.aspx?articleid=2466532.

• Singh H, Meyer AND, Thomas EJ. 2014. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. BMJ Qual SafSep;23(9):727–731.

• Office of the Inspector General (OIG), US Department of Health and Human Services. 2010. Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. https://oig.hhs.gov/ oei/reports/oei-06-09-00090.pdf.

• Askin, E., Moore, N. (2014). The Health Care Handbook. St. Louis, MO: Washington University in St.Louis.

• Berkowtiz, O., Goldgar, C., White, SE., Warner, ML. A National Survey of Quality Improvement Education in Physician Assistant Programs. J Physician Assist Educ; 30 (1): 1-8. doi: 10.1097/JPA.0000000000000243.

• NCCPA. (2019). Content Blueprint for the Physician Assistant National Certifying Examination (PANCE). Retrieved from https://prodcmsstoragesa.blob.core.windows.net/uploads/files/PANCEBlueprint.pdf

• ARC-PA. (2019). Accreditation Standards for Physician Assistant Education, Fifth Edition. Retrieved from http://www.arc-pa.org/wp-content/uploads/2019/09/Standards-5th-Ed-Sept-2019-fnl.pdf

https://prodcmsstoragesa.blob.core.windows.net/uploads/files/PANCEBlueprint.pdfhttp://www.arc-pa.org/wp-content/uploads/2019/09/Standards-5th-Ed-Sept-2019-fnl.pdf