A tool for every task, for every task a tool
Even if you know what you're doing, this kit can help
Let's say you have a pretty robust system of patient safety and quality improvement (QI) and are up on all the latest trends in determining what needs attention and how to make effective changes. You still might benefit from some aspect of the new tool kit for improving your performance on the 28 quality indicators and 17 patient safety indicators of the Agency for Healthcare Research and Quality (AHRQ).
Late in winter, the agency held a webinar to go over the tool kit, including discussion by one of the kit testers — Harborview Medical Center in Seattle — about how even a large tertiary facility with a long history of QI can still learn a new trick or two.
The tool kit includes information on a variety of topics, including:
- determining readiness to change;
- applying quality indicators to the hospital data;
- identifying priorities for quality improvement;
- implementing improvements, including a five-step implementation cycle of diagnosing the problem, planning and implementing best practices, measurement and analysis of results; evaluation of how effective actions were; and evaluation, standardization, and communication;
- monitoring progress for sustainable improvement;
- analyzing return on investment;
- using other resources.
Patient safety indicators
The kit also includes a roadmap that outlines what tools are most effective for each step in the process.
The tool was designed in collaboration with RAND and the University Health System Consortium (UHC), says Joanna Jiang, PhD, senior research scientist at AHRQ's Rockville, MD headquarters. The effort started in 2009. Eleven of the UHC hospitals participated in the development process, and six were involved in the alpha testing. Interestingly, although all the testers made use of different elements of the kit, they all chose to address various patient safety indicators, including:
- death among surgical inpatients with serious complications;
- central venous catheter-related bloodstream infection;
- postoperative pulmonary embolism or deep vein thrombosis;
- postoperative sepsis;
- accidental puncture/laceration;
- obstetric trauma-vaginal delivery without instrument.
During the webinar, the rationale for the emphasis on patient safety was credited to the increased emphasis on those indicators by the Centers for Medicare & Medicaid Services (CMS) through its value based purchasing initiative, and the large number of other measurements and data collection required by other organizations.
The first round of testing of the kit resulted in some concerns among the hospital users — that hospitals need to be sure of their data, that priority setting is hard, and that the tools to assist need to be short and simple. As a result, changes were made that addressed the concerns: a documentation and coding tool that was designed to improve patient safety indicator validity; a flexible prioritization tool that could be tailored to the needs of a particular facility; and simpler tools.
"Our mission for many years has been to improve quality of care," Jiang says. The tools and measures that the agency has developed is one part of that. While most organizations have heard of AHRQ's quality and patient safety indicators, more and more are adopting them now. "We started to see a need to help organizations implement quality improvement projects around those indicators," she says.
The hospital component
After the initial proposal for the kit was made, AHRQ decided that the advisory panel it used to create the kit had to include not just experts on quality improvement and researchers, but also quality officers from hospitals and health systems, Jiang says. "We really wanted the hospital component who would make use of these tools to tell us what they needed up front."
The panel conducted a literature review on the use of hospital indicators and quality improvement strategy, and the findings of that search provided the basis of the tool kit's development. "We wanted the team to determine the principles that would guide the tool kit's design," she says. "We wanted to focus on the most useful key factors — useful to a wide range of hospitals — and make sure that what we created was easy to use."
Once they developed an initial kit, it was field tested at a half-dozen hospitals. During and after the testing, the development team interviewed the users, conducted formal evaluations, and even did site visits. It was these interviews and evaluations that led to some of the addition of coding and documentation guidance and best practices for patient safety indicators.
Jiang says they understand that every hospital is different, and while some have years and years of quality improvement initiatives under their belts, others are just getting started. "It is a master shopping list," she says. "We do not require that they use it from front to back. They can pick and choose what they need from it, and adapt those options so that they fit the situation."
Implementing improvements
Harborview Medical Center in Seattle is one of those facilities with a lot of QI experience, but it still found a lot of help in the kit, says Ellen Robinson, PT, clinical quality specialist at the hospital. "It was designed to make it easier to use the AHRQ software, and we had been using that," she explains. "We thought it could help us do a better job."
For Harborview, Robinson says the best parts of the kit were from section D, about implementing improvements. The eight tools in that section are:
- Improvement Methods Overview;
- Project Charter;
- Examples of Effective PSI Improvement Strategies;
- Selected Best Practices and Suggestions for Improvements (for eight patient safety indicators);
- Gap Analysis;
- Implementation Plan;
- Implementation Measurement;
- Project Evaluation and Debriefing.
"As a nurse or a physical therapist, you might not have all the background you need in quality improvement to do things like a gap analysis," Robinson says. "This gives you easy-to-use tools to help your project management skills and help move a project along."
She also appreciated the roadmap, which helped her to see where she was in the process. "I think we already had a good system in place, and figured the tool kit would be positive for us. And we did not have to start right at the top and work our way through because we were already on the road." But Robinson says it still helped her to identify events and areas that could use a second look and potential improvement projects.
Among the issues that the test brought to her attention was venous thromboembolism (VTE). "It validated that we were giving good care, particularly with chemical prophylaxis," Robinson says. "But now that we know that, we can look at other areas, like mechanical prophylaxis." It also helps to identify events faster than when they were using data from UHC, which could be three months old before they got to it. Now, it is usually not more than a couple weeks old. That means that the same residents who were at the hospital during an event are likely still there, so they can get information on events directly from people who were involved. Some of the hospitals get new data even more often — weekly or even daily, she says. Harborview opts to run it on its biweekly billing cycle.
Patty Calver, RN, Harborview Medical Center's administrative director for quality improvement says she likes the kit because it is another way to meet CMS goals for harm reduction in areas such as hospital-acquired infections. "It is also reactive, rather than predictive," says Calver. That means that they can quickly find cases of possible preventable harm, and find ways to standardize referral of possible cases across all the teams in the hospital.
It allowed Harborview to move from rate-based tracking to something that can lead to real changes based on real cases and can also help the facility figure out exactly what the next step would be if they found an area of possible concern that needs attention.
The webinar for the tool kit can be viewed at Webinar on AHRQ Quality Indicators Tool kit for Hospital http://www.ahrq.gov/qual/qitoolkit/webinar0215/video/, where there are also links to the tools themselves.
For more information on this topic, contact:
- Joanna Jiang, Ph.D., Senior Research Scientist, Agency for Healthcare Research and Quality, Rockville, MD. Telephone: (301) 427-1436.
- Ellen Robinson, PT, Clinical Quality Specialist, Harborview Medical Center, Seattle, WA. Telephone: (206) 744-3000.
- Patty Calver, RN, Administrative Director for Quality Improvement, Harborview Medical Center, Seattle, WA. Telephone: (206) 744-3000.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content