Welcome to this Quality Improvement for Institutions Learning Center lesson titled Engaging the Clinical Team to Develop a Quality-Centered Program. This lesson is number five of a five-lesson series authored by NCDR participant expert Sheila Nichols, who is a Clinical System Analyst, HVTI, and Strategic Operations Administrator at the Cleveland Clinic. Sheila will be sharing her expertise from an academic system perspective. NCDR participant expert Andrea Price, who is from Indiana University Health System. Andrea will be sharing her expertise from a community hospital perspective. And Michelle Hare, MSRN, LSSGB. Lesson number five focuses on conducting a quality or process improvement and managing ongoing program growth. In lesson five, we will discuss quality improvement methodology and tools for leading an improvement project. As mentioned in other lessons, the work of the quality improvement project is accomplished by a team of individuals. We've talked about developing these teams, but let's spend a few minutes discussing how to lead or undergo a quality improvement event. To get started, projects should have clearly defined goals and objectives. This should be expressed in a form of a statement, the AIM statement. An example is reduce post-PCI bleeding. Next, the chair or facilitator should specify expressed leadership support, project scope, available resources or resource constraints, and reporting structure and frequency. Define project reassessment and or refinement intervals. And finally, establish expectations. Members represent their respective discipline department and team. This assumes individual responsibility that contributes to the team's success and commits to the success of the improvement project. It is important to analyze and understand the team member consistency and potential interaction between members. These items may especially be important to establish if you have a committee consisting of varied internal, departmental, and external stakeholders. It is very effective when attendees are able to contribute to the creation of the ground rules. If that isn't possible, consider using the following. Starting and end the meeting on time. Have a prepared agenda with an objective and expected outcomes. Parking lot the items that don't relate to the meeting's objective. Complete action items as committed. Have a willingness to learn from other team members. Leave rank at the door. All members are equals. You can maintain an open, respectful communication, meaning listening actively. Notify the team in advance if you will be absent. And finally, what's said in the room stays in the room. The Plan, Do, Study, Act, or PDSA tool is widely used and accepted tool for process improvement. It's easy to use and follow. The first component or stage of the PDSA is plan. The goal is to recognize an activity and plan a change. Examine your current process and or review the findings from previous analysis. Start by asking the team these basic questions. What are we doing now? How do we do it? What are the major steps in the process? Who is involved? What do they do? What is done well? What and how can it be done better? Based on this information, develop an improvement theory or identify something that needs to be changed and how it needs to change. The next step is Do. The object of this step is to put the new changes in place or start to implement your action plan. Test the change and carry out a small scale study. Be sure to collect data as you go to help you evaluate your plan. The third stage of the PDSA is Study. Review the implemented change, analyze the results, and what you have learned. Using the AIM statement drafted in the plan stage and data gathered during the Do phase, determine did the changes result in an improvement by how much or little? Do you see trends? Were there unintended side effects? The final step is Act. Take action based on what you've learned in the study step. If the team determined the plan resulted in success, standardize the improvement and begin to use it regularly. After some time, return to Stage 1. Plan and re-examine the process to learn where it can be further improved. If your team believes a different approach would be more successful, return to Stage 1. Plan and develop a new and different plan that might result in success. The PDSA cycle is ongoing and should be periodically reviewed or else the project will become disorganized and often terminate causing frustration and setbacks in quality improvement. Results from or outputs from a Quality Improvement Event or PDSA can result in ongoing work groups, decision diagrams and flowcharts, improved or new EHR documentation, revised or new order updates, updated or new protocols, educational materials, or other processes in quality-focused improvement projects. In summary, it's important to celebrate improvements and lessons learned. Communicate results to the program core team through previously discussed channels. Communicate accomplishments to internal and external customers. Take steps to preserve your gains and sustain your accomplishments. Don't put new steps in place and then leave it. Monitor it. Is it working well or does it need adjustment? Make long-term plans for additional improvements. And conduct iterative PDSA cycles when needed. Andrea Price shares best practice from a community hospital in the Indiana University Health System. Another approach that can uncover areas for improvement that's used in Lean Six Sigma is a value stream analysis. This is a method for analyzing the current state in order to design a future state for the series of events that take a service from the beginning of the specific processes until it reaches the patient. When joining the VSA, there was a large data gap, which was causing improvement efforts to be paused. Due to resource allocations and conflicting priorities, abstraction and submission of registry data had been delayed and data was not available to support real-time changes needed for rapid improvement monitoring. In addition to the delay, a deep understanding of the data was lacking, which created a loss of trust with members of the VSA. These items were addressed, and in a few short weeks, data availability was no longer an issue. In the VSA, projects were identified to align with the hospital's goals. One of those efforts included same-day PCI discharge. Since the team was not used to having real-time data, they developed a plan for the cath lab manager to manually track this data. By involving members of the cath PCI registry team on the call, this inefficiency was avoided and the cath PCI registry data was used to pull same-day PCI discharges for the group. Data was provided from the registry at a frequency needed to monitor improvements and make changes to monitor compliance and improve the same-day PCI screening tool. Process practices in academic setting may be different, and Sheila Nichols shares her experience as a Clinical System Analyst, HVTI, and Strategic Operations Administrator at the Cleveland Clinic. When the core group was performing their gap analysis for ICD device-based therapy guideline improvements, they discovered that NYHA class and prior MI were most often missing for documentation. A process improvement team was created, which included the abstractor, quality facilitator, quality manager, mid-level providers, fellows, physicians, and the IT department. This data was reported to the physician champion who was key at analyzing the process to identify areas of opportunity. The results of the improvement event included educating physicians and fellows of the key fields that cannot be inferred and must be documented by licensed independent practitioners, annual education for new fellows, reference documentation guides or pocket cards were developed, hard stops were implemented when warranted, the abstractor would look at the registry data weekly and follow up with physicians regarding clarifications to assure metrics were met. The data was presented each month at department meetings, which allowed us to identify continued opportunities for improvement. This information was then sent back to the improvement team to continually look at the process and identify gaps, putting new measures in place as needed. Then the process or evaluation repeated. Ongoing clinical and program growth is key for advancing your quality program and achieving ongoing improvement for patients. At a defined period, the core group should complete the following, a program assessment. The objective assessment is to provide a systematic analysis and define meaningful and relevant quality improvement activities. This should be done annually unless a significant change occurs, prompting the process to happen sooner. A couple of examples of when this process would occur off cycle could be a key clinical person leaves the organization impacting service delivery or when new national or regional reimbursement criteria are released. The core team can use the tools presented earlier to undergo this assessment process or simply review the data and prior strategic plan to develop the ongoing quality program goals and objectives. During this process, it is important to understand the larger program or organization's needs and framework. Prioritize programmatic tactics to the largest organizational strategy. Align incentives. Finally, it is imperative that new goals and objectives are communicated to various stakeholders, such as leadership, clinical champions, etc. This concludes Lesson 5 of 5, Engaging the Clinical Team to Develop a Quality-Centered Program, Conduct Equality or Process Improvement, and Manage Ongoing Program Growth. Thank you for your participation.

Engaging the Clinical Team to Develop a Quality-Centered Program

NCDR participant experts

quality improvement methodology

Plan, Do, Study, Act (PDSA) tool

value stream analysis