HVC Curriculum Presentation 6

High Value Quality Improvement
2015-2016 • Presentation 6 of 6
Learning Objectives
• Define QI and its role in high value care
• Explain the rationale for engaging in HVC QI projects
• Explore one commonly used model for quality improvement
• Review high value care project ideas
• Select a quality improvement project focused on a high
value care theme
• Promote a high value care institutional culture
Steps Toward High Value Care1
• Step one: Understand the benefits, harms, and relative costs of the interventions that
you are considering
• Step two: Decrease or eliminate the use of interventions that provide no benefits
and/or may be harmful
• Step three: Choose interventions and care settings that maximize benefits, minimize
harms, and reduce costs (using comparative-effectiveness and cost-effectiveness data)
• Step four: Customize a care plan with the patient that incorporates their values and
addresses their concerns
• Step five: Identify system-level opportunities to improve outcomes, minimize harms,
and reduce health care waste
What is Quality Improvement? 2
• Focuses on the attempt to change a specific aspect of a

field that has been identified as needing improvement
• Works to gain insight into the function of a system and
then change that system for the better (i.e., systems
and processes)
• Focuses on patients (or clients), teams, and data
Why is this important?
HVC QI is an opportunity for you to:
1. Affect the quality, safety, and efficiency of care at your
institution
2. Improve patient-centered care
3. Work collaboratively with quality and safety officers, finance,
and other health system leaders
4. Learn and practice leadership skills
5. Publish or present your results
QI Success in Other Industries 3
• Army Air Corps held a competition in 1935 for the rights to contract with them
for a long-range bomber plane.
• The favorite, a Boeing plane, crashed during competition due to “pilot error”
because the new plane was much more complex than a standard plane – it was
deemed “too much airplane for one man to fly.”
• Army engineers gave the contract to another airline, but trialed a few of the
Boeing planes with the implementation of a checklist for take-off to simplify the
plane’s complexity.
• With the checklist, not a single crash occurred over 1.8 million miles flown. The
Army made a large-scale purchase of the plane and dubbed it the B17.
Adapted from Atul Gawande’s Checklist Manifesto
QI Success in Medicine 4
• Physician at Johns Hopkins, Dr. Peter Pronovost, noticed central line infections were
spiking in his ICU and around the country
• He mapped out the procedure process and noted that there were five simple steps
physicians could take to prevent infections when inserting a central line
• He implemented a simple checklist to ensure standardization of sterile procedure during
insertion
• In the pilot study, rates of central line infections in Michigan ICUs went from 3 per 1000
down to essentially 0, with a decrease in infection rates of 66% in the first 3 months of the
study
• Hospitals involved in the study saved nearly $175 million in costs and more than 1500 lives
QI Models
• PDSA (Plan, Do, Study, Act)
• Lean model: based on time and cost efficiency and what the
customer wants
• Six Sigma: measurement-based strategy that operates through
DMAIC (examines existing processes) and DMADV (creates new
processes)
• Lean Six Sigma principles made famous by Toyota and their
“Kaizen” practices
Langley G, Moen R, Nolan K, et al. The Improvement Guide: A Practical
Approach to Enhancing Organizational Performance. Wiley, 2009.
Sample QI Framework: A3 Roadmap
Problem Target / Aim
Statement
Propose and test
Countermeasure
Current
Condition Metrics
Implement
Root Causes successful
Countermeasures
Small Group Activity: HVC QI Project Ideas
• HVC themes: reducing waste, minimizing harm,
improving communication
• Choosing Wisely lists
http://www.choosingwisely.org/clinician-lists/
• MKSAP Choosing Wisely Recommendations by
specialty https
://hvc.acponline.org/clinrec_mksap.html
Reduce Unnecessary Preoperative Testing
• Internal Medicine resident at NYU involved in a collaborative
project between medicine, cardiology, and anesthesiology
• Goal: to decrease use of unnecessary pre-op cardiac testing
for average-risk patients undergoing low-risk procedures
• Current condition step (chart review) identified pre-
colonoscopy testing as a major contributor
• Root cause analysis underway…
Improving Follow-up among Patients Living with HIV
•Goal: to improve retention in care, increase ART use, and achieve viral
suppression in patients with uncontrolled HIV infection
•Tried to accomplish this by identifying patients with detectable VL who did not
have a scheduled follow-up, and contacting them to make an appointment
•Results showed that many patients did not have follow-up, and those who did
had seen a social worker within the last year
•After intervention, 61% scheduled for follow-up, with 15% showing improved
clinical outcomes after follow-up
•Conclusion: more intensive outreach involving social work and clinicians is
needed in this subset of patients, and automatic social work intervention at
appointments for patients with a history of being lost to follow-up
Next Steps
• Identify stakeholders
• Build a team and assign roles
• Define the problem and the aim of the project
with input from key stakeholders
• Clarify timeline for projects and mentorship plan
QI Resources
Quality Improvement Curriculum Aids
• Road Map for QI: This collaborative product from the AMA, IHI, and CMS introduces the basic
framework of quality improvement to physicians.
http://www.mjainmd.com/medicine/roadmap_for_quality_improvement.pdf
• HVC QI Project Report: Worksheet to help guide residents through their quality improvement
project and to stimulate post-project reflection and lessons learned
• Trinity Health Curriculum on QI from MedEd Portal: This curriculum includes a QI Series Planner,
Facilitator’s Guide and Improvement Workbook for residents. The complete curriculum is
available at MedEd Portal “QI Training Series.”
1.
References
Owens DK, Qaseem A, Chou R, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. High-value, cost-conscious health
care: concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions. Ann Intern Med. 2011 Feb 1;154(3):174-80.
[PMID: 21282697]
2. Massoud MR. Advances in Quality Improvement: Principles and Framework. Quality Assurance Project, QA Brief. Spring 2001.
3. Gawande, Atul. The Checklist Manifesto: How to Get Things Right. New York: Metropolitan Books, 2010.
4. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006
Dec 28;355(26):2725-32. [PMID: 17192537]
5. Landon BE, Hicks LS, O'Malley AJ, et al. Improving the management of chronic disease at community health centers. N Engl J Med. 2007 Mar
1;356(9):921-34. [PMID: 17329699]
6. Djuricich AM, Ciccarelli M, Swigonski NL. A continuous quality improvement curriculum for residents: addressing core competency, improving
systems. Acad Med. 2004 Oct;79(10 Suppl):S65-7. [PMID: 15383393]
7. Holmboe ES, Prince L, Green M. Teaching and improving quality of care in a primary care internal medicine residency clinic. Acad Med. 2005
Jun;80(6):571-7. [PMID: 15917362]
8. Shojania KG, McDonald KM, Wachter RM, Owens DK, eds. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 1:
Series Overview and Methodology). Rockville, MD: Agency for Healthcare Research and Quality (US); 2004 Aug. [PMID: 20734525]

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High Value Quality Improvement

• Focuses on the attempt to change a specific aspect of a

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