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Resident QI Curriculum, version 2.0

Windy Stevenson, MDMedical Director, Doernbecher Quality Program

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How has quality evolved? 1800’s: Quality Assurance- credentialing, accreditation

Did the dog get fed? Who forgot to feed the dog?

1900’s (mid): Statistical Quality Control & CQI- variations, profilingHow many times a week do we forget? Who’s the worst offender?

1900’s(late) : Outcomes analysis- systems thinking, patient focusedIs the dog maintaining a healthy weight? Is Beech right for the job? Can we make it easy for Beech to feed the dog? Is the dog being fed the cat’s food?

2000’s: Rise of Big ManagementIf we post our results to the whole neighborhood, will the dog get fed more often?

Last 5 years: Quality Cacophony- seeking the sweet spot of transparency, efficiency, outcomes, and patient centeredness

Does data demonstrate that we transparently, accountably, efficiently, effectively, safely, timely, equitably provide canine sustenance in a dog-friendly way?

Today: Cacophony with a mandate-The whole concept of pet ownership is at stake, here, Beech!

Concepts courtesy Donald Fetterolf, President of the American College of Medical Quality

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Where is that sweet spot?

Healthcare is a business, but taking care of a patient is not.

-Victor Traztek, Mayo Clinic Scottsdale

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Learning about donkeys (and carts)

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My donkey is pathetic!

15 kg

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Your first PDSA cycle

15 kg

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My wagon doesn’t have a back stop!

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My donkey is up in the air!

Is that really our problem? What OUTCOME matters? What causes have we not yet explored?

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You don’t have to study other people’s wagons unless you intend them to use your modification(s)

Get enough data to take the next step ASK WHY Beware of random folks walking up asking you to design

donkey weights or backstops for wooden carts

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Systems

Every system is perfectly designed to achieve the results it gets.

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Where do you start? Project Selection... Do we have a problem? What is our problem? Will fixing our problem improve quality?

– IOM Dimensions- Safety, Timeliness, Equity, Efficiency, Effectiveness, Patient Centeredness

Is the outcome important? Why do we care? Why? Why? – To providers? To patients or families?

Are we likely to be able to overcome foreseeable barriers? Is the project meant to improve an observable process? Is it within our scope to make this change? Is this reasonable? Is it focused enough to make success

likely in our timeframe? Does the cost of effort seem to be in good balance with

likelihood of returns? Are people already passionate or curious?

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Where do you start?

You already do

this every

day!

There is no such thing as being too focused.

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Ambulatory problem lists are incomplete and inaccurate

So, let’s start fixing them!• How do we define success?

• Failed attempt to measure “completeness”

• What kids do we start with? Diagnosis Based?

All patients with asthmaAll obese patientsAll patients seen by geneticsAll former preemies

Age Based?Start with all newbornsTarget a certain WCC

Exclusion based? (The Sarah Green effect)Should we focus on the kids who are normal??

Other ideas?

• Who owns the list? • What is it even for?

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What are we even trying to accomplish?

Provide Safer CareSave time

Populate the problem list in an efficient way that will support/drive good patient care

Populate the problem list of obese children to efficiently drive good patient outcomes

Why obesity? What practice settings? What ages? Residents? Attendings? All? How good do we want to be?

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Our AIM

>95% of patients >2yo seen by a provider in the gen peds clinic or Westside clinic (including acute care; excluding healthy lifestyles) who have a BMI >85%ile will have “BMI; category” listed on their problem list

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Is our Aim Statement SMART?

Specific we chose ONE thing Measurable we can prove we’ve impacted it Actionable there are no known insurmountable barriers Realistic it’s within our scope Timely we’ll do it within a time frame

Aim:>95% of patients >2yo seen by a provider in the gen peds clinic or Westside clinic (including acute care; excluding healthy lifestyles) who have a BMI >85%ile will have “BMI; category” listed on their problem list

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WHY? The Doernbecher Purpose…

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Measurement

We MEASURE!Outcomes measuresProcess measuresBalancing measures

When we try to improve a system we do not need perfect inference about a pre-existing hypothesis: we do not need randomization, power calculations, and large samples. We need just enough information to take a next step in learning.

– Donald Berwick

AIM:

>95% of patients >2yo seen by a provider in the gen peds clinic or Westside clinic (including acute care; excluding healthy lifestyles) who have a BMI >85%ile will have “BMI; category” listed on their problem list

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Measurement

AIM:

Outcomes measures:Are we getting there?

Process measuresAre we doing the right things to get there?

Balancing measuresAre we messing things up by getting there?

On time delivery

% populated

#packages

Resident time spent

Donkey lifespan

Clinic delays

MEASURES:

Not everything that can be counted counts, and not everything that counts can be counted.

Albert Einstein, US (German-born) physicist (1879 - 1955)

>95% of patients >2yo seen by a provider in the gen peds clinic or Westside clinic (including acute care; excluding healthy lifestyles) who have a BMI >85%ile will have “BMI; category” listed on their problem list

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The baseline data

37% overall success (457/1220 patients)

Adolescent Campus Peds West32

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Percent of patients >2yo with BMI >85%ile with problem listed

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Age and BMI

2-3yo 4-6yo 7-9yo 10-12yo 13-15yo 16-18yo05

101520253035404550

Percent of pts with BMI>85% with populated problem list, by age

(years)

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Testing

MEASURES: % problem lists populated

TEST:

AIM:

REMEMBER:Populate your problem lists!

>95% of patients >2yo seen by a provider in the gen peds clinic or Westside clinic (including acute care; excluding healthy lifestyles) who have a BMI >85%ile will have “BMI; category” listed on their problem list

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Testing

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Testing

MEASURES: % problem lists populated

TEST: PosterTEST: Use BPA and Smartset to drive careTEST: ???

AIM:>95% of patients >2yo seen by a provider in the gen peds clinic or Westside clinic (including acute care; excluding healthy lifestyles) who have a BMI >85%ile will have “BMI; category” listed on their problem list

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Current status

Future state taking shape

Smart set in EPIC- PDSAs underway Obtaining heights on acute care visits Ongoing data pull being finalized EPIC requests for populating problem list from an order and

driving PCP appointment generation

Pt >2yo checked in and ht/wt recorded

EPIC uses ht and wt to generate BMI and

flags if >85%ile

Provider sees banner under

Quality issues and clicks associated

smart set

Family stops at desk to get appt

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Next steps

Final adjustments to the EPIC product Flip the switch Start measuring and reporting

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Using Six Sigma and Lean methodologies, I will invoke Deming and Shewart’s approaches while conducting a Kaizen event to reduce the muda through process mapping, aggregate patient-level data, and reliability analysis to create a standardized deliverable.

Be as smart as you can, but remember that it is always better to be wise than to be smart - Alan Alda

I know a way to make this system work better tomorrow.

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Take Home Points

Real (sustainable) change comes from changing systems, not changing within systems

Understand the problem before you hypothesize the causes

Be specific about what you want to accomplish, and why

Focus on patients

Start before you think you are ready

Don’t get paralyzed by lack of research-level data or by how much there is to do

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What if you want to know more?

IHI Open School– http://ihi.org/IHI/Programs/IHIOpenSchool/WhatstheIHI

OpenSchool.htm

Call me, page me, email me– 4-1321– 15763– lammersw@ohsu.edu