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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]