1

Applying Quality Improvement Skills to Stroke Care

11th Annual Stroke CollaborativeToronto, 20 October 2008

Dr. Ben Chan, MD MPH MPA

CEO, Ontario Health Quality Council

2

What is Quality?

“Quality health care means doing the right thing at the right time in the right way for the right person and having the best results possible.”

3

Attributes of Quality & High Performing Health System

• Effective• Efficient• Equitable• Accessible• Safe• Patient-centred

• Focused on population health

• Integrated• Appropriately

resourced

4

What is Optimal Stroke Care?

• Population health• low physical activity, overweight• smoking, excess etOH, stress• diet (low fruits/veggies, hi fat/sodium)• lack of awareness of signs & sx

5

What is Optimal Stroke Care?

• Stroke prevention in primary care• screening - for DM (q3yrs), cholesterol (q1-3 yrs),

BP• diabetes - BS control (A1c<7, FBG 4-7, 2 hr

postprandial 5-10)• BP control (140/90 or 130/80 if DM, kidney dis)• ASA (if past TIA, stroke, CAD, DM, etc.)• coumadin (if atrial fib)• lipid control / statin (w/ risk stratification)

6

What is Optimal Stroke Care?

• Acute Stroke Management• tPA within 3 hrs onset• CT/MRI asap• dedicated stroke unit admission• dysphagia assessment• tight BS control

7

What is Optimal Stroke Care?

• Post stroke treatment• access to dedicated stroke rehab unit (in-pt, cmty)• carotid imaging & endarterectomy/stent (if

indicated)• LTC unit with stroke experience• post-stroke depression mgt (SSRI, etc.)

8

Which Areas Have Biggest Room for Improvement?

• Population Health• Stroke prevention in Primary Care• Acute management of stroke• Post-stroke treatment

9

How Are We Doing With Quality?

10

Effectiveness – Chronic Disease Management

11

INSERT Bar Chart from report – page 91

12

13

Avoidable Complications of DM, CAD

14

Avoidable Complications With Better Management of DM, CAD

15

16

Preventable Risk Factors

17

Preventable Risk Factors

18

How Do We Move…

• From Strategy…

• To Action?

19

QI Tools & ApproachesArea Approaches

Population Health Policy Changes Public Education

Stroke Prevention – Primary Care Acute Stroke Mgt

Post-Stroke Care

QI Tools for Changing the Way Care is Delivered

20

Before Fixing the Problem…• Diagnose the underlying root causes• Consider differential diagnosis of causes• Prioritize which causes to address first• If not sure which causes to tackle first,

collect some data

21

Process Mapping

22

A process map gives you…

• An overview of the complete process• A visual aid to effectively plan• Ideas from all different types of staff

What you need…• Blank wall• Yellow stickies• Facilitator – focus on main scenarios

(what happens 80% of time)

23

Analyzing the MapFrom the patient perspective:

– How many steps are there for the patient?– How many times is the patient passed from

one person to another?– What is the approximate task time?– What is the approximate wait time?– How many steps add no value for the

patient?

24

• eliminated?

• Combined with other steps

• Done in different order?

• Done elsewhere? Reduce wasted travel?

• Done by someone else more effectively / efficiently?

• Done in parallel instead of sequentially?

• Where are bottlenecks? Need to shift capacity to here?

For each step, ask if it can be:

25

Example: Routine Labs in Primary Care

Pt Appointment Labs needed?Give Pt

RequisitionLab Done

Yes

No

Abnormal?

No

Yes

Book earlier f/u, or call pt

26

Alternate Process

Scheduled Apptmt,

Review Recent Labwork

Pre-book lab for before next

apptmt in 3 mo

Show up forLab apptmt?

No

Yes

Lab Done

Reminder to pt before lab apptmt

RN calls pt x 2, rebook

27

Ishikawa Diagrams

28

Ishikawa Diagrams• Put problem at right• Draw spine• Draw offshoot lines for categories of causes• Draw offshoots for causes of causes

– Use “Five Why’s” technique to elicit root causes

• Identify those causes which you can impact• Prioritize as a group the most NB causes

29

Why Aren’t Labs Done?

30

Reasons Why Labs Not Done

Reasons:• Pt can’t understand

instructions• Language barrier• Lab hours inconvenient• MD forgot to order lab• Pt lost the requisition• Pt forgot• Pt missed apptmt – weather,

emergency• Pt not seen for months (e.g.

gets med refills by phone)

Change ideas?• • • • • • •

•

31

Lots of Great Ideas…

• What next?

32

33

Aim Statements for QI Projects

• What are we trying to accomplish?

– “Improve diabetes care for our patients.”

34

Aim Statements for QI Projects

• What are we trying to accomplish?

– Improve diabetes care for our regular patients in the Bay St, May St. and Gray St. clinics. Increase the % of these patients hitting their targets for BP, cholesterol & AIC to 75%. Do this by March 2009.

35

Well Designed Aim Statements

Is it clear?Is it measurable?Is time specified?Is the target population identifiable?Can you hear the promise for better

patient outcomes?

36

Measures:How Will We Know a Change is

an Improvement? • outcome measures

– e.g. A1C, BP, chol

• Process measures– e.g. use of recommended drugs, % getting regular labs– e.g. improved team functioning

• Consider balancing measures – Unintended consequences

37

Example: Pt Self-Mgt

• Let’s implement patient self-management over the next few months. We’ll show a nifty bar chart of how our results for A1C & cholesterol improved before and after.

Good or bad idea?

38

Quality Measurement• Measure frequently throughout course of

project• Get early feedback on impact of changes• Correct course or accelerate

39

Annotated Run Charts% of patients who have set >= 1 written pt mgt goal in past 6 months

23 24 21 23

31

10

34

46 47 50

0

10

20

30

40

50

April

May

June Ju

ly

Augus

tSep

tOct

Nov

Dec Jan

Time Period

Per

cen

t

new

doctor

Test new tool

New tool w Group sessions

40

Where Do I Get the Data???

41

Data Sources• Ideal:

– Disease registries• Regular queries from electronic medical record• Stroke registry

• Alternate: small periodic samples– Defect check sheets– Mini-surveys

42

Defect Cause Check SheetQuality Improvement Project:_____________________________Defect / Defect Cause of Interest: ________________________Instructions to Recorders on When to Record a Defect:_____Type of patients or services being observed for defects:____Setting: _________________________________________________Time Frame for Data Collection: __________________________Data Recorders:_________________________________________

Defect or Defect Cause Count

MD did not order

Patient lost requisition

Lab hours/location inconvenient

43

Sampling PlansMethod Description Example

Block Sampling

Make x observations consecutively. Do this at regular intervals.

Every Monday morning, give a mini-survey to the first 10 patients that arrive.

Systematic Sampling

Make observations on the every y-th patient.

I want 10 observations per week. I see 100 patients per week. So, I’ll give every 10th patient a mini-survey.

44

What Changes Can We Make That Can Result in

Improvement?

45

Source of Change Ideas• Best practices literature • other QI initiatives• Your own system analysis• Ideas from your peers• Your own brainstorming

46

What Changes Can We Make That Can Result in

Improvement?• Avoid jumping immediately to the

perceived panacea solution• Consider best practice examples for

implementation from elsewhere• Conduct careful analysis of system, root

causes, cause & effect, process maps before implementing changes

47

ImplementationExample: Pt Self-Mgt

• We’re going to create a committee. In the next four months they’re going to research pt self mgt tools. We’re going to carefully select a package of materials. Then we’re going to have extensive in-service sessions to train all the staff on how to use the materials.

48

Implementation Example:Pt Self Management

• Pt self management seems like a great idea. There are many different tools out there. We’re also not sure who’s the best person on our team to deliver different components of self management – the doctor, nurse, dietician, counsellor. Let’s systematically test different ways of implementing this and see what works best in our environment.

49

Alternative Approach from QI Science

• Implementing Change: PDSA cycles• Plan, Do, Study, Act• Testing predictions • Learning from small tests of change• Rapid cycle improvement

50

What should a PDSA look like?

Write It down!

ObjectiveWhat do you want to learn/try?

PlanWho, what, where, when?MeasurementPredict outcome as a group

DoJust do it!

StudyWhat worked? What didn’t? Predict correctly?

ActNext steps

51

learn as you go small tests, not

(necessarily) small changes

52

Multiple PDSA Cycle Ramps

A P

S D

A PS D

A P

S D

D S

P A

Coordination w/ DM educators

Pt self-mgt

A P

S D

A PS D

A P

S D

D S

P A

A P

S D

A PS D

A P

S D

D S

P A

Standing orders, checklists

Try different ways of implementing change concept

53

Learning Collaboratives

Support

SPREAD

LW0

LW1

LW2

LW3

Pre- work

Select Topic Participants Reference Panel

Identify Change Concepts

54

SK CDM Collaborative• Key Aims for CAD, diabetes

– 75% of diabetes pts with A1C <7.0%– 75% of pts with HDL/Tchol < 4.0– 75% of pts with BP < 130/80

• Access aim: 80% seen on day of choice

• Two waves deployed (Nov 05, Nov 06)

• Enrolment to date:

– 28% of all family physicians in Sask

– All RHAs in province

– Mix of FFS, non-FFS

55

Learning Workshops

56

Storyboards – Sharing Learnings

57

Regional Improvement Teams

58

59

CDM Web-based Patient Registry

60

CDM Toolkit - Flowsheets

61

KEY MEASURE% of Diabetes Patients with a BP ≤ 130/80

among Wave 1 Practices, Baseline vs Month 9 (Nov 2006)

51.5

75.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

3 8 23 32 15 18 30 21 31 29 35 11 26 16 1 4 13 2 22 10 27 6 9 24 14 17 20 33 25 34 19 28 7 5

Practices

Monthly Average Baseline Goal

The absence of a practice's bar is due to lack of a baseline value or small counts (i.e., < 6)

62

% of diabetes patients prescribed a statinPractice 1 (top left) and the top 5 improvers

Practice 1

Mar-0649.40

Apr49.40

May49.40

Jun48.81

Jul49.60

Aug51.67

Sep51.42

Oct52.89

Nov51.51

Dec54.33

Jan-0753.60

Feb54.83

Mar55.28

Apr57.14

May59.20

Jun59.20

Jul59.67

MonthPercent

Run chart

Median line = 52.89

Mar-06 Ap

rMay Ju

n Jul

Aug

Sep Oct

Nov

Dec

Jan-

07 Feb Mar Ap

rMay Ju

n Jul

30

35

40

45

50

55

60

65

70

75

80

Practice 23 - top improver

Median line = 70

Mar-06 Ap

rMay Ju

n Jul

Aug

Sep Oct

Nov

Dec

Jan-

07 Feb Mar Ap

rMay Ju

n Jul

0

10

20

30

40

50

60

70

80

90

100Practice 31 - top improver

Median line = 50

Mar-06 Ap

rMay Ju

n Jul

Aug

Sep Oct

Nov

Dec

Jan-

07 Feb Mar Ap

rMay Ju

n Jul

0

10

20

30

40

50

60

70

80

90

100

Practice 4 - top improver

Median line = 51.57

Mar-06 Ap

rMay Ju

n Jul

Aug

Sep Oct

Nov

Dec

Jan-

07 Feb Mar Ap

rMay Ju

n Jul

0

10

20

30

40

50

60

70

80

90

100Practice 5 - top improver

Median line = 30.64

Mar-06 Ap

rMay Ju

n Jul

Aug

Sep Oct

Nov

Dec

Jan-

07 Feb Mar Ap

rMay Ju

n Jul

0

10

20

30

40

50

60

70

80

90

100Practice 8 - top improver

Median line = 45.58

Mar-06 Ap

rMay Ju

n Jul

Aug

Sep Oct

Nov

Dec

Jan-

07 Feb Mar Ap

rMay Ju

n Jul

0

10

20

30

40

50

60

70

80

90

100

My practice

Practice 23

Practice 8Practice 5Practice 4

Practice 31

63

PDSA Catalogue

64

Sask. CDM CollaborativeImprovements in Diabetes & CAD

65

OHQC QI Activities in Ontario

• QI improvement & innovation partnership (QIIP)– Aim to improve DM care, FOBT, improved

access– Partnership with MOHLTC

• OHQC resources for quality– QI tools on website– Tools for improving access & office efficiency– QI skills development

66

Key Messages

• Use QI science & tools to improve care• Understand root causes of quality

problems first• Set clear aims & targets, continuous

measures, & ideas for improvement• Test-test-test rather than plan-plan-plan

Look for support in implementing QI

67

Contact Us

• Email: Ben.Chan@ohqc.ca

• FREE QI tools & resources at: www.ohqc.ca