Transcript: Implementing Changes To Improve Performance on the IQI or PSI Measures
Speaker: Joseph Jensen, M.D., Associate Chief Medical Officer for Quality and Safety, University of Arkansas for Medical Sciences Medical Center
Interviewer: Lise Rybowski
Date: May 2012
Audio format: Implementing Changes To Improve Performance on the IQI or PSI Measures (MP3 audio file; 12 min., 29 sec.)
Interviewer: On behalf of the Agency for Healthcare Research and Quality, I'd like to welcome you to a series of interviews designed to orient and educate users of the AHRQ Quality Indicators Toolkit for Hospitals. This toolkit was designed to support hospitals seeking to improve their performance on the AHRQ Inpatient Quality Indicators (IQIs) and the Patient Safety Indicators (PSIs).
Subject: Today we're focusing on the process of implementing changes in the hospital to improve performance on the IQIs and PSIs. Section D of the toolkit is devoted to the topic of implementing improvements. You can find that section, including a tool designed to help you create an implementation plan, on the AHRQ Web site at http://www.ahrq.gov/qual/qitoolkit. Once you are on that page, open the roadmap and select section D.
I'll be speaking today with Dr. Joseph Jensen, who is the associate chief medical officer for quality and safety at the University of Arkansas for Medical Sciences Medical Center. Dr. Jensen, thanks for taking the time to speak with me today.
Dr. Jensen: Sure. Thank you.
Interviewer: I'd like to start by asking what actions are most important for hospital teams to take when they are implementing strategies to improve performance on the AHRQ QIs.
Dr. Jensen: The implementation planning is really critical. Virtually everyone in health care is well intentioned and wants to have good outcomes and wants to have good performance. But really it's difficult to get to true performance improvement without an organized plan, an organized structure to reach those results. So the improvement methods overview and project charter tool in the AHRQ toolkit are excellent implementation planning tools. They are really industry standard and they really are just fine tools to use.
A checklist-driven tool, we found, is very important just as a memory aid to help us remember to be sure we've included all the models, all the important parts in our plan, and to be sure that we get those checked off as we go through the plan. The larger organizations have several opportunities for improvement and one other thing of particular importance that AHRQ has provided is a very nice prioritization matrix for you to look at the actual information at your hospital to determine where is your best opportunity and the opportunity you should pursue first towards performance improvement.
If you think this implementation plan is critical, and I think the AHRQ toolkit really helps you answer this, you really should come out of this at the end with two questions in mind. The first question being, "What is the objective you are trying to improve" and again, in specific terms. The second question is, "How can it be measured? How do you know when you are there when you've achieved your goal and your objective?"
There are some details that are important when developing implementation strategies. One that we found important is being able to understand exactly what you are trying to improve and how to measure it. Another important factor, in fact a factor we found critical, is to have some individual who we refer to as the "honcho" for a particular project. These are all team projects and they don't work if the team is not involved. But someone really has to be the champion for the project. That individual is the person that's ordinarily associated with the project and is the person that really makes sure that the ends are tied together makes sure the project works.
It's also really critical to have leadership buy-in. At a minimum, your senior hospital leaders have to acknowledge that this work is important and understand that it is important and be willing to support it. If you don't have leadership buy-in for a project, it's probably not going to go anywhere. Then it's also important to really look at these projects as multidisciplinary projects, because they truly are. They are projects that cross the professional boundaries of medicine, nursing, respiratory therapy, the other allied health sciences, administration, and really every entity that contributes to the care of a patient.
Interviewer: Tell me more about the role of the honcho in your organization.
Dr. Jensen: Well, in our organization, particularly for the major project we've done recently, our honcho is our patient safety officer. It may be other individuals for other projects, but our patient safety officer is a really good example. Our patient safety officer is Marinelle Paladino. She is a long-time experienced nurse in several different areas of nursing. She is well known and well respected throughout the institution. She has a passion for this work, she knows that it's important, and she's able to express that passion across to other individuals. Probably what's as important as anything else is that when Marinelle speaks, everyone listens, and that's become really important in making a project work.
Interviewer: You mentioned that there are a number of implementation tools in the toolkit. How do you think hospitals can use those tools to get off to a good start in their implementation process?
Dr. Jensen: The implementation toolkit is really a very comprehensive set of tools. Probably if you had to drill down to one page of it, there is one called the "Improvement Methods Overview." That one page really is a very nice summary of exactly how to plan a PI project. It has information about defining the objective, being able to measure the objective, putting out some initial plans and implement the known best practices, and measuring and analyzing results and identifying whether this is going to be a project that works for your institution. That one page really is probably the most important page of the entire toolkit.
The rest of the toolkit has excellent guidelines for specific areas. I've mentioned before that there is a prioritization matrix that may be helpful. There's also a project charter plan here that is of importance in that it helps you build the group and identify the group and give the specific tasking to the group that's going to address these performance improvement projects.
Interviewer: As hospitals are implementing changes, what do you think are the most important actions they should take to have the best chance to make their targeted improvements?
Dr. Jensen: Of course, the initial actions are planning a good project that's important to the hospital and important to the patients, and ideally is a project that's able to be improved by implementing known best practices and benchmark standards. So that goes back to the careful planning, understanding the objectives, and ensuring that you can measure what you are trying to improve.
With that said, at the start of the project, there are several things downstream that really are critical to the project working out. It's probably really important to understand the concept of adult learning principles and how they apply to health care professionals. Health care professionals, of course, are adult learners and they learn best when they are taught things that are relevant to their practice and relevant to what they do everyday.
We think it's important because of this to widely publicize the results and it's certainly helpful to ensure the success of a project to celebrate some early quick wins. We had the first areas that worked out really well. We really widely publicized those and ensure that everyone knows that we're getting really good results that are what we're hoping for with the project.
It turns out that it's important to understand the incentives for improvement for health care professionals and for organizations. And although there is a lot of talk about financial incentives and pay for performance, it turns out that at the end of the day, it's important to understand that virtually every health care professional is very strongly motivated to want to do the right thing for their patients. That's the thing that makes them tick and the things that really makes them come to work is being able to help your patients. So if you can just show that the improvement that you are generating from this project is making a difference in making lives better for their patients and making their patient care better, and making the staff work environment better, then you'll have the motivation for your staff that will be able to make a project succeed.
Interviewer: Now, I would think that sometimes things don't work out the way you anticipate. Have you had to make any midcourse corrections?
Dr. Jensen: We did. And we have one project that involves making twice weekly safety rounds in our intensive care units where we got a group of individuals together—which included a senior hospital administrator as well as senior nursing, physicians, respiratory therapists, and other members of the ICU community—and visited at the bedside and looked at specific patient safety items to determine if they had been complied with, and if they hadn't, was there a barrier that we needed to address?
Those were things such as were the central lines dressed appropriately, were the ventilator tubing secured appropriately, and things like that. It turns out that at the start of that project, it was pretty well known when we would be making those rounds. While I absolutely don't think that there was any bad intent from this, it turns out that in their effort to try to comply with the project and I think try to be on the team, our staff made a special effort to be sure all those things were done at the time that they knew those rounds were going to occur.
That wasn't what we wanted to measure; what we wanted to measure is how those actions were being taken during times that were not announced. So we actually had to change our pattern of rounding to an unannounced pattern. When we did that, we had lower scores for a while until we were able to show that these are important things that need to be done all the time, not just getting ready for rounds a couple of times a week.
Interviewer: For my last question, could you talk about the signs that an improvement initiative is working or not working?
Dr. Jensen: There are really two facets to that question. Those would be the subjective facet and the objective facet. Objectively, you would tell that by following your results. Hopefully, you've designed your project in such a way where you are able to get reliable results and review them in an ongoing manner as the project goes forward. That will give you the information that you need to decide whether this is working out or whether it's not working out and there is something about the project or process that needs to be changed to get to the result that you are seeking.
A much more difficult area to measure is the subjective aspect of that question. That is the concept of culture change. Although these projects typically involve a change in process and a change in practice to known best practices for the benefit of patient care, what you'd really like to end up with at the end of the day is actually a cultural change to where that new practice is inculcated as the standard practice for the particular unit, because that's the change that's going to result in this performance improvement continuing beyond just the project.
That's more difficult to measure, but you can measure that with staff interviews and with informal feedback, and with observing the teams during times when they don't know that they are being observed in off hours, and just getting sort of a sense of the pulse of the staff about how well the performance improvement changes are being accepted and how well they are being done when no one is looking.
Interviewer: Thank you so much, Dr. Jensen, for offering this great advice and for sharing your experience with the AHRQ QIs. As we've been saying, the AHRQ Quality Indicators Toolkit includes a whole section of tools about implementing improvements. You can download the tools from the AHRQ Quality Indicators Toolkit by going to http://www.ahrq.gov/qual/qitoolkit. Click on the link for the roadmap, and select Section D, Implementing Improvements. The roadmap is a great way to orient yourself to the implementation tools as well as all the other tools in the toolkit.
I also suggest checking out a video recording that you can use to introduce the toolkit to quality improvement teams and other staff. You can find the video and other materials from a Webinar about the toolkit by clicking a link at the bottom of the toolkit page or by going directly to http://www.ahrq.gov/qual/qitoolkit/webinar0215/index.html. Again, this is one in a series of audio interviews about the use of specific tools in the quality improvement process, so please check the toolkit pages for additional interviews and watch for announcements from AHRQ. Thank you for listening.