Welcome to Module 5, Session 1 of the Cardiovascular Program Coordinator course. This module is Performance and Quality Improvement with content provided by Susan Rogers and Michelle Wood. After completing this session, the learner should be able to formulate a performance improvement plan for the ACC accreditation process, select proper tools for completing a performance improvement project, analyze available resources to isolate which performance to improve. The agenda for this presentation is divided into four concentrations, first, defining performance and quality improvement, second, describe the steps in a quality improvement process, third, design a performance improvement plan, and fourth, describe tools available to utilize during performance and quality improvement. We will start with the first area of focus, defining performance and quality improvement. It is critical to understand exactly what performance and quality improvement is. It is a series of actions taken to identify, analyze, and improve existing processes within an organization to meet new goals and objectives. There are a variety of quality improvement models and tools. These will provide repeatable steps to follow and create a common language for all involved in quality improvement. The purpose is to understand our processes over time. This is where utilizing your data enables effective decision-making. Tools alone do not guarantee results. An effective quality team must also be assembled. This should include frontline staff who perform the processes every day. Also, leverage your quality department professionals who are experts in QI design, implementation, and evaluation. A robust quality improvement program is very advantageous. It leads to better outcomes, reduces variations in care, improves patient care, increases efficiencies, decreases spending, improves margins, and can assist physicians in their maintenance of a certification. It can be stated that the goals of performance improvement are to improve, simplify, improve, reduce, and ensure. Improving the overall patient care and quality, simplifying by eliminating waste and duplication, improving the reliability, reducing cost of care and extra steps and processes, and ensuring our internal and external customer satisfaction. The second area of concentration in this session is to describe the steps in quality improvement processes. How do you start? The high-level steps of performance improvement are reviewing your current data, or if the process has never been measured before, collect the new data. Identify areas of improvement by looking to see what areas stand out when you review your data or how they can pair with your facility-specific targets. Define your goals. Is your goal to increase time, to decrease time? For instance, decrease exposure, such as in fluoro time in the cath lab. Identify the time frame to improve your processes. You must understand your current process. Be sure you have a clear understanding of what the process is. Compare the protocol or procedure or policy versus the actual bedside process to identify any areas that need further exploration. Define and implement your plan for improvement. Identify solutions to the things that are causing the process not to meet expectations. And finally, evaluate your process. Follow the data for a period of time after implementation. Determine if the new changes appear to be effective, or can you identify new areas causing challenges as a result of this process improvement? After you've moved through these steps, start the process over again. Let's stop for a quick case study. Mary is the coordinator for your hospital's accreditation initiative. She is planning to present a PI project at the time of your accreditation site visit. The resources available to Mary to help her select a project are the Accreditation Conformance Database, or ACD, and her Chest Pain MI Registry Dashboard, or the Outcomes Reports. Using data relevant to your current accreditation will provide your team with a strong baseline and a clear way to measure your process improvement. Data eliminates anecdotal responses. Again, your resources for helping you evaluate your PI projects should not rely upon what others say the problem is, but rather it should come from the data available. The comments from others may be validated with data, but should not be the sole source for information. It is very challenging to show improvement based upon comments only. Starting with our first principle for performance improvement, that is, you should review your data. In this example, we see an excerpt from NCDR Registry that allows us to see how we're doing. We are able to grade ourselves against other facilities and drill down on individual patients when necessary. You should understand the measures and definitions for the data you're working with. When reviewing this information, ask yourself how you compare to other facilities. Are you above or below the 50th or the 90th percentile? What are your facility-specific goals? Are you meeting those? If your hospital is using the ACD or Accreditation Conformance Database, the 50th and 90th percentile will not be available. Neither will comparing yourselves to others. Instead, you will review your data against your facility goals or other benchmarks available, such as literature and best practices. Again, ask yourself if you are performing well or why are you not performing well? As a tip, for anyone using the ACD, when you are looking at the measures year-to-date report, you will see the details link under the calculated measure. This will allow you to drill down into each month's data to pinpoint where each patient fell in that metric. Here is an example of the information you will see when you click the detail button. The link will provide a spreadsheet with the inclusion and exclusion criteria for that metric as well as the linked mandatory essential components and the monthly median results for that measure. Each patient record included in the metric will be available with the lookup code and a link to review each patient record. Having individual records will allow your facility to perform case reviews and or validate the data entered is correct. The accreditation conformance database spreadsheets can assist you in creating graphs. It is not expected that each of you will be fully competent on making control charts and graphs. You may not even have the software to configure control charts easily. While Excel does allow a person to create these, it is something that requires a lot of practice. The chart provided here populates straight from the Excel spreadsheet data on the previous slide. The graph represents the episodes of care involving low and intermediate risk chest pain patients while showing the number of observation hours for each patient. The red line reflects the goals of the benchmark currently at 16 hours. The green line is the median hours for this facility that links the stay, which is approximately 37 hours. As you can tell from this graph, the facility is well above the recommended hours for observation patient length of stay for the low to intermediate risk chest pain patient. Again, creating these graphs takes time and effort and a lot of practice. Please reach out to your quality department professionals to assist you in creating these graphs. It is easy to get overwhelmed when starting the PI process. We'll use the focus methodology that is very helpful. So let's use an example of the low to intermediate risk chest pain patients and observation to help learn focus. We start with find. We look at the data and it shows that the length of stay was greater than 35 hours compared to the recommended 16 hours. As we look at focus, we say, okay, what is wrong? The length of stay is too long. Organize. Who knows about this process? Well, the dedicated observation area or telemetry unit, our frontline staff, the physicians, the non-invasive testing areas, then clarify who and what is involved in this process. The chest pain observation patients, the emergency department, bed placement staff, laboratory, non-invasive testing department, physicians, nurses, et cetera. We understand why is this process not working? This is where you start breaking down the process to find out the delay. Is it getting the patient to the non-invasive department, the tests, getting the tests completed or getting those results made available for clinical decision-making? Is the issue with physician rounding? You will soon discover the root cause as you begin to dig through the process. And then finally select, select the methodology for process improvement. Now the most widely used is PDSA, but there's also DMAIC, Lean Six Sigma, Quick and Easy Kaizen, Total Quality Management, better known as TQM, and many others. Your facility already has a preferred PI methodology, so check with your quality department. If you're not familiar with it, now as we move to the next session, you will be able to better understand the steps to an effective PI project. This concludes module five, session one of the cardiovascular program coordinator course.

Cardiovascular Program Coordinator

Performance and Quality Improvement

ACC accreditation

Performance Improvement Plan

Data Utilization