presentation slides

HEN 2.0 FOUNDATIONAL ACTION
LEADER FELLOWSHIP (ALF)
WEBINAR #7
June 15, 2016
11:00 AM – 12:00 PM CT
Welcome & Introductions
Katie Harris, Program Manager, HRET |11:00-11:05 AM
AGENDA
THE INSTITUTE FOR HEALTHCARE
IMPROVEMENT (IHI)
•
•
•
•
Kathy Duncan
Tracey James (Fellow)
Jane Taylor
Kathy Luther
UPDATES SINCE OUR LAST WEBINAR
• HRET HEN 2.0 QI Office Hours: Sepsis Project Focus
– Webinar: July 6, 2016 11:00am - 12:00pm (CST)
Register
here: https://hret.adobeconnect.com/qiofficehours201
60603/event/registration.html?campaign-id=Website
• Your project’s PowerPoint report template due August 15th
• Project report template here
• Required!
OBJECTIVES FOR TODAY
• State the value of plotting data over time
• Explain the basics of sampling
• Discuss structures to put into place that
increase sustainability of improvement
Discussion of Action Items
Kathy Duncan, Improvement Advisor, IHI | 11:05 – 11:25
TELL US ABOUT YOUR OPPORTUNITY TO
“COACH” A COLLEAGUE
HOW DID IT GO?
DEVELOP A DRIVER DIAGRAM FOR YOUR
IMPROVEMENT PROJECT
“TWEET” A REVIEW OF COIN
SPINNING VIDEO
REDUCING HYPOGLYCEMIC EPISODES IN
HOSPITALIZED DIABETICS
Tracey James
[email protected]
Neshoba County General Hospital-Nursing Home
Philadelphia, MS
AIM AND BACKGROUND
Aim
Background
<10.24% patients receiving insulin or
other hypoglycemic agents will
experience hypoglycemia requiring
D50 by August 26, 2016.
October 2015 monitoring data
revealed a rate of 20% for
hypoglycemia requiring D50 in
patients receiving insulin or other
hypoglycemic agents. Our July
through September 2015 rate was
17.07%. All HEN participating
hospitals in our state had a baseline
rate of 4.1%. This data reveals a
distinct opportunity for improvement
in patient safety.
Neshoba County Hospital Performance Improvement Project Record
Project Title: Glycemic Control, Reducing Episodes of Hypoglycemia
Project Lead: Sid Hill
Project Start Date: 12/09/2015
1) Problem Statement: description of the problem and its effect
Hypoglycemia in inpatients receiving insulin or other hypoglycemic agents
occurs at above benchmark rate in our facility, placing patients at risk for harm
and adverse outcomes.
2) Current State: description of the current state, its processes and problems
October monitoring data revealed a rate of 20% for hypoglycemia in patients
receiving insulin or other hypoglycemic agents. Our baseline data reveals a rate
of 17.07% for the months of July through September of 2015.
Best Practice/Literature Search:
For all Mississippi hospitals
participating in HEN 2.0, the baseline rate of hypoglycemia in patients receiving
insulin or other hypoglycemic agents was 4.1% for 7-9/2015. For all HENparticipating hospitals nationwide, the baseline rate for 7-9/2015 was 5.1%.
Nursing 2015 Critical Care, Volume 10, Number 1 relates the consensus
inpatient glycemic control goal statement of the American Diabetes Association
(ADA) and the American Association of Clinical Endocrinologists (AACE) to avoid
hypoglycemia (blood glucose < 70 mg/dL) in all inpatients.
Team Members Involved: Sid Hill Nurse Manager, Tracey James Quality
Improvement, Jessica Pickering RDLD, Medical Staff present at Med Staff
meeting 3/14/16 and 5/9/16; Robyn Burns, PharmD; Mitze Singleton Lab
Director; P&T committee physicians(Dabbs, Boyles, Guild)
5) Solutions: Action plan and findings of tested solutions
Root Cause
Tested Solution
Responsible
Due
Findings
Sid
12/19/15
50% bkft documentation
40% lunch documentation
0% supper documentation
Possible Nutrition
documentation gaps
Monitor Meal Percentage
documentation for 2 weeks for
baseline data
Possible poor nighttime po
intake. HS snacks not being
provided to diabetic patients
Discussed HS snack options with
Tracey/Jessica Pickering
dietician on 12/9/15. Dietician to
RD LD
serve as advisor to team once
baseline data complete
Nursing Education re: importance of Sid
adequate documentation of PO intake
in diabetic patients; Audit records for
improvement
12/9/15
There are HS snacks available on the
unit, but we are not sure if they are
being offered.
Monthly (first
week of the
month for the
previous
month)
30% compliance with meal
documentation, 0% compliance with
HS snack documentation on records
audited Jan 2016. See graph for
progress
3/3/16- Increased focus on
documentation of HS snack intake
has appeared to result in better use
of HS snacks and improvement in
outcomes as measured by reduction
in hypoglycemia rate.
Pursue Wireless Accucheck system to Sid/Mitze
prevent nurse failure to document
and to promote a consistent chart
location for accucheck information.
6/2016
Nutrition Documentation
Gaps
3) Goal: How will we know the project is successful? SMART goal
Specific
< 10.24 % patients receiving insulin or other hypoglycemic
agents
Measurable
will experience hypoglycemia requiring D50 by August 26,
2016.
Action Oriented The HEN 2.0 project goal is to reduce harm by 40% in a one year time frame
Realistic
ending September 2016. This goal reflects a 40% reduction in our
Time Bound
hypoglycemia rate.
Investigation depicting the problem’s root causes.
4) Root Cause Analysis:
Accucheck Documentation
Gaps
People; Equipment/Materials/Supplies; Communication;
Systems/Processes/Procedures; Environmental factors; Behavior/Practice/Skills factors
•
5 Why’s
Initial retrospective chart review indicated gaps in documentation of meal intake and
accucheck results. Sid Hill is to perform a 2 week review of accucheck results and related
meal percentage documentation for use in determining root causes. This review began on
12/9/15.
6) Check: Summary of the solutions’ results, overall goal success, and any supporting metrics
No patient-specific HS snacks are provided for diabetic patients. Nurses did not understand
that floor stock nutritional supplies were intended to be used for diabetic HS snacks, and they
needed instruction regarding best choices of HS snacks.
7) Act: Action taken as a result of the Check (Adopt, Adapt, Abandon). What is the plan to sustain results?
•
There are many different locations nurses can document accuchecks in our EHR. It is very
difficult to track accucheck documentation because there are too many possible locations for
the information.
2/2016 There is no consistent practice of discontinuation of oral hypoglycemic for inpatients
or altering their home diabetic medication regime at admit to account for the acute illness
and change in dietary intake while hospitalized.
Goal and Metrics
% of patients on diabetic meds who
experience hypoglycemia requiring D50
Baseline
Target
Current
17.07%
<
10.24%
1/2016 0% 2/2016 7%
4/2016 0% 5/2016
3/2016 4%
6/2016
3/3/16 Continue to monitor documentation on 10 patients per month and work individually with nurses who need instruction regarding diabetic care.
6/2016 Begin systematic approach to physician engagement in glycemic control best practices and standardization through P&T and Med Staff PI committee.
Neshoba County Hospital Performance Improvement Project Record (cont.)
List the next task or test of change
Best Practice Research
Responsible
Team Member
Tracey
Target
Date
-------
Completed
Date
12/11/15
Staff Meeting Nursing Education
Sid
1/2016
Staff Meeting- Nursing Follow-up- Progress review
Sid
2/2016
2/1&2/3
Pharmacy/Quality Improvement HEN data discussion
Tracey/
Robyn
2/2016
2/1/16
Staff Meeting- Nursing Follow-up- Progress review
Sid
3/2016
3/15&3/16
Medical Staff Meeting- Project Update
Tracey
3/14/16
3/14/16
HEN 2.0 Hypoglycemia ADE WebinarForward HEN Webinar from 3/15/16
Tracey
Tracey
3/15/16
3/22/16
3/15/16
3/28/16
Staff Meeting- progress review- Nursing
Sid
4/16
Update Med Staff PI committee on progress
Tracey
4/2016
Staff Meeting- Nursing progress update
Sid
5/2016
Update departmental PI committee on progress
Tracey/Sid
5/2016
5/11/16
Medical Staff Meeting – Provider progress update
Med Staff PI/ P&T/ Begin systematic MD involvement
in process improvement
Nursing Staff Meeting- Progress update
Implement wireless accuchecks
Med Staff Meeting- Provider Update and presentation
of any recommendations from P&T regarding inpatient
diabetic care
Departmental PI Committee-Progress Update
Tracey
5/2016
5/9/16
Tracey
Sid
Sid/Mitze
6/2016
6/2016
6/2016
Tracey
Tracey/Sid
7/2016
7/2016
Comments/Results/Lessons Learned/
Unintended Consequences
Forward SHM 2015“Improving Glycemic Control” and Nursing 2015 article
“ Glycemic Control in Hospitalized Patients” to Sid for use in Nursing
Education
Instruct nurses to document meals, snacks, and accuchecks
4/12/16
Meal % documentation remains inconsistent
Discussed the finding from HEN data collection that our hypoglycemic
episodes appear to be related to oral meds rather than insulin
administration.
Documentation is still poor.
Explained finding of hypoglycemic episodes in inpatients continued on
oral medications.
Action Decision:
Adopt/Adapt/ Abandon (choose
one and describe)
Adopt
Monitor compliance with meal
documentation, 10 charts/month
Continue monitor, determine if
there are specific nurses with doc.
problems. Add monitor of
accucheck doc.
Adapt data review process
Continue monitoring nutrition and
accucheck doc. and counsel
individual nurses.
Good information. Will share with Sid once available on HEN resources
Adopt
Progress in documentation improvement is slow, but we are still doing
well on the goal of reducing ADEs.
Reinforced that the hypoglycemic episodes occur in patients who are
continued on PO meds during hospitalization
Marginally better, no specific nurses are noted to have problems,
widespread inconsistency in documentation. Outcomes are very good
regarding reducing hypoglycemia ADEs.
Success in reducing hypoglycemia episode outcomes despite less than
stellar improvements in processes
Expressed the harm/ADE reduction goal and the HEN data in our hospital
showing a connection between oral diabetic meds during acute care stay
and hypoglycemic episodes
Continue monitor and individual
nurse counseling as indicated.
No new action
Continue current monitoring ,
nursing updates and individual
nurse education
No new action
No new action
MEASURES
Outcome
– Percent of patients receiving insulin or other
hypoglycemic agents who experience
hypoglycemia requiring D50
Process
– Nursing documentation of meal and snack
percentages
– Nursing documentation of AccuCheck results
– Percent of patients requiring D50 who have
had oral diabetic medications continued during
hospitalization
INTERVENTIONS
• Involve dieticians in selection of HS snack options
for diabetics.
• Involve lab to pursue wireless accucheck monitor
system which will remove a barrier to nursing
accucheck documentation.
• Involve pharmacist in identifying hypoglycemic
episodes requiring D50 and in identifying
medication classes which place the patient at
significantly increased risk of hypoglycemic
episodes.
• Educate staff nurses regarding the importance of
nutrition and insulin timing.
INTERVENTIONS CONTINUED
• Work with physicians through Medical Staff
meetings and Medical Staff PI committee
regarding project data and oral diabetic meds
continued during acute care hospitalization.
• Provide resource material regarding diabetes best
practices for Nurse Manager for use in ongoing
nursing education.
• Communicate nursing feedback regarding
documentation improvements monthly.
Diabetic Documentation Improvement Monitor
10 records monitored per month. If a single meal, accucheck or HS snack was
undocumented during a stay, that record failed for that portion of the measurement.
100%
90"/o
....
80"/o
70"/o
60"/o
.. .. ..
50"/o
40"/o
10"/o
•• •
0%
....
.. ·· ,,
Feb-16
Jan-16
Meal% doc
HS snack% doc
• • • • • Accucheck charted
+-
Jan-16
30"/o
0%
0
...
..
..
.. ...
..
- - --
30"/o
20"/o
..
.. ........................ .
+-
Mar-16
.. . . ..........
-- - --
Apr-16
May-16
Feb-16
40"/o
Mar-16
30"/o
Apr-16
50"/o
May-16
90"/o
20"/o
30"/o
40"/o
50"/o
40"/o
60"/o
60"/o
90"/o
+-
Meal% doc
-•- HS snack% doc
• • • • • Accucheck charted
American Hospital
Association®
HRET
HEALTH RESEARCH &
EDUCATIONAL TRUST
In Partnenmlp with AHA
---
REFLECTIONS
Lessons learned:
• Even with what I would consider to be sub-optimal
success in improvement of the documentation
process, the outcomes have improved.
• It appears that the increased focus on diabetic safety
has produced an actual improvement in diabetic
safety.
• There were 0 hypoglycemic episodes requiring D50 in
March and April 2016.
REFLECTIONS CONTINUED
Barriers encountered:
• Cumbersome EMR makes finding and tracking data
difficult and makes real documentation improvement
difficult as well.
• Improvement Effort Fatigue. Physician improvement and
change efforts were prioritized toward the Sepsis measure
during the early portions of the glycemic control project.
We kept physicians informed and communicated the
correlation with oral hypoglycemics, but delayed
concerted efforts toward process change involving
physicians to maximize chances of successful change.
REFLECTIONS CONTINUED
Overcoming barriers:
• Stage and prioritize your implementation plans.
Realize that lasting improvement takes time and
sustained effort with varied stakeholders.
• Celebrate small successes along the way.
• Communicate the goal and progress regularly
throughout the organization
NEXT STEPS
Supporting spread and sustainability:
• Implement wireless AccuCheck monitoring to ensure all
AccuChecks are automatically documented
• Drive the monitoring and reporting of nursing process
improvements to front-line nurses
• Produce more visual displays of progress
• Work toward more best-practice standardization in the
prescribing of diabetic medications in the inpatient
population
• Pursue a diabetic protocol which guides nursing response
to and documentation of hyper and hypoglycemic
episodes
Measuring For Improvement
Kathy Duncan, Improvement Advisor, IHI | 11:25 – 11:50
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Act
Study
Aim of
Improvement
Measurement
of
Improvement
Developing a
Change
Plan
Do
Testing a
Change
Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W.,
Norman, C. L., & Provost, L. P. The Improvement Guide:
A Practical Approach to Enhancing Organizational
Performance. San Francisco, CA: Jossey-Bass, 1996.
MEASURES TO EVALUATE IMPACT
AND PROGRESS
Outcome
Measures directly relate to the
aim of an initiative
(the “So what?”)
Process
Measures reflect how well
processes in the work get done
around key changes
Balancing
Measures to help avoid causing
detriment to another outcome or
part of the system, e.g., processes,
safety, satisfaction, equity, or costs
AN OPERATIONAL DEFINITION...
…is a description, in quantifiable terms, of
what to measure and the steps to follow to
measure it consistently.
THE VALUE OF MEASURING
• “You measure what you value. Conversely, you
value what you measure.” Brent James
• “We tend to overvalue the things we can measure
and undervalue the things we cannot.” John Hayes
• “Measurement is the first step that leads to
control and eventually to improvement. If you
can’t measure something, you can’t understand
it. If you can’t understand it, you can’t control it. If
you can’t control it, you can’t improve it.” H. James
Harrington
Session 2
RUN CHARTS VS. SUMMARY DATA
100
80
Average of multiple points
before and after change
70
60
50
40
30
Dec
Nov
Oct
Sep
Aug
Jul
Apr
Mar
Feb
date
0
Jan
10
Jun
Change
Made
20
May
Cycle Time (min.)
90
100
80
70
60
50
40
30
20
Dec
Nov
Oct
Sep
Aug
Jul
Apr
Mar
Feb
Jan
date
0
Jun
Change
Made
10
May
Cycle Time (min.)
90
100
80
70
60
50
40
30
20
Dec
Nov
Oct
Sep
Aug
Jul
Jun
Apr
Mar
Feb
Jan
0
May
Change
Made
10
date
Cycle Time (min.)
90
ELEMENTS OF A RUN CHART
ANNOTATED WITH SUBSTANCE & INTEGRITY
MULTIPLE MEASURES ON A SINGLE CHART
Diabetic Care Measures
Percent Population
Receiving Care
100
% Using Self Mgt Goals
% Foot Exam
% Eye Exam
80
60
40
20
0
1
2
3
4
5
6
7
8
Months
9
10
11
12
13
14
15
HOW BIG IS THE BANANA? LEARNING MEASUREMENT
• Learning the value of operational definitions
• Understanding why operational definitions are an
important part of Question 2 (How will you know
your change is an improvement?) in the Mode for
improvement?
• Revealing common measurement mistakes in
improvement efforts
Participants are put into groups and first told to
write a definition of what is meant by ‘banana size’ .
Afterwards the definition is passed to another group
to compare definitions and measurements with
other groups. Winning definitions will result in the
same answer from both groups.
SUSTAINING IMPROVEMENT
Sustaining Improvement
Kathy Luther, VP, IHI | 11:30 – 11:50
THE RELATIONSHIP OF QUALITY IMPROVEMENT
AND QUALITY CONTROL
Juran Trilogy
Functions for Managers:
• Quality Planning
• Quality Control
• Quality Improvement
Source: Scoville R, Little K, Rakover J, Luther K, Mate K. Sustaining Improvement. IHI White Paper. Cambridge,
Massachusetts: Institute for Healthcare Improvement; 2016. (Available at ihi.org)
DRIVER DIAGRAM:
HIGH-PERFORMANCE MANAGEMENT SYSTEM AT THE FRONT LINE
S1: Standardization
S2: Accountability
S3: Visual Management
*S4:
Problem Solving
*S5:
Escalation
*S6:
Integration
S7: Prioritization
S8: Assimilation
S9: Implementation
S10: Policy
S11: Feedback
S12: Transparency
Source: Scoville R, Little K, Rakover J, Luther K, Mate K. Sustaining Improvement. IHI White Paper.
Cambridge, Massachusetts: Institute for Healthcare Improvement; 2016. (Available at ihi.org)
S13: Trust
•
S1: Standardization
•
S2: Accountability
•
S3: Visual Management
ANY IDEAS?
• *S4: Problem Solving
• *S5: Escalation
• *S6: Integration
•
S7: Prioritization
•
S8: Assimilation
•
S9: Implementation
•
S10: Policy
•
S11: Feedback
•
S12: Transparency
•
S13: Trust
TYPE IN ANY AREA THAT ‘RINGS
TRUE’ FOR YOU………
BRING IT HOME
Katie Harris, Program Manager, HRET | 11:50 – 11:55
RESOURCES FOR FELLOWS
•
•
•
•
IHI Open School (OS) Subscription
IHI-HRET ALF Landing Page: www.ihi.org/HRETALF
Project report template
Topic-specific resources: www.hret-hen.org
packages
CHANGEChange
PACKAGES
Change packages
• Topic -specific driver
diagrams and change
ideas
• Example PDSA cycles
• Descriptions and
guidance on how to use
change package
effectively
• Referenced appendices
ENCYCLOPEDIA OF MEASURES (EOM)
• Catalogued measure
information available on
the HRET HEN website
– HEN Core Topics –
(evaluation measures)
– HEN Core Process
Measures
– HEN Additional Topics
ACTION ITEMS FOR NEXT TIME
• Course: QI 105: The Human Side of Quality Improvement
White Paper: Sustaining Improvement
QI Exercise: Banana Measuring (Video Instructions)
QI Exercise: Banana Measuring (Video Debrief)
Tool: Neshoba County Improvement Project Record
• On your project:
• Identify activities to assure sustainable improvement
• Design a plan to sustain improvement measures over time
THANK YOU!
Find more information on our website:
www.hret-hen.org
Questions/Comments: [email protected]