Quality Improvement. Timothy L. Ricks, D.M.D., M.P.H. Nashville Area Dental Officer

Transcription

1 Quality Improvement Timothy L. Ricks, D.M.D., M.P.H. Nashville Area Dental Officer Kristina Rogers, B.S. Nashville Area Statistician/Improvement Advisor 1

2 Quality Components Risk Management Patient Safety Peer Review Quality Assurance Strategic Planning Quality Improvement 2

3 What is Quality? It depends on the stakeholders perspectives From a provider view: Did the treatment I provided work? Are we using the best available equipment and procedures? From a health administrator s s view: Were the patients satisfied with the care they received? Was there a good cost-benefit ratio? From a patient s s view: Did my provider listen to my concerns? Did my provider spend enough time with me? From a tribal council s s view: Were all patients in need treated adequately? Is the clinic financially independent? 3

4 Quality Components Risk Management Patient Safety Peer Review Quality Assurance Strategic Planning Quality Improvement 4

5 Risk Management Risk management is all about mitigation of risk. Risk to Patients Patient Safety Activities Risk to Providers Malpractice - FTCA Risk to the Organization CMS Accreditation Organizations AAAHC, JCAHO DEA 5

6 Risk Management Read the IHS Risk Management Manual: The manual: Provides an overview of who is covered under FTCA & under what conditions Provides guidance on how to avoid malpractice issues (how to work with patients) 6

7 Quality Components Risk Management Patient Safety Peer Review Quality Assurance Strategic Planning Quality Improvement 7

8 Patient Safety Patient safety is indistinguishable from the delivery of quality care. IOM, 2004 To Err is Human - a landmark report by the Institute of Medicine in National Patient Safety Goals 8

9 Patient Safety Some possible dental patient safety issues: Sterilization Dental waterlines Disinfection of equipment/chairs Physical hazards Radiation Rubber dam use Medications/anesthesia Others? 9

10 Quality Components Risk Management Patient Safety Peer Review Quality Assurance Strategic Planning Quality Improvement 10

11 Two types: Peer Review Ongoing Peer Review (routine) Focused Peer Review (for cause) How often should it be done? Ongoing quarterly At least annually by external reviewer Who can do peer reviews? Dentists-dentists; DDS or RDH-RDH ADO can do them, but don t t just count on that. 11

12 Peer Reviews in our Area Provider Mean (all data elements) N. Data Entry M. Prosthodontic Treatment L. Prevention K. Periodontal Treatment J. Orthodontics I. Pediatric Dentistry H. Res to rative G. Oral Surgery F. Endodonic Treatment E. Dental Emerg ency Treatment D. Radiographs C. Drugs Administered or Prescribed B. Exam and Treatment plan A. Every Visit 0% 10% 20% 30% 40% 50% 60% 70% 80% 12

13 Quality Components Risk Management Patient Safety Peer Review Quality Assurance Quality Improvement Strategic Planning 13

14 What is Quality Assurance? Quality Assurance evaluation of performance/quality of care that is reactive, retrospective, policing, and sometimes punitive. Quality Improvement a formal approach at evaluating performance and systems that is proactive, both prospective and retrospective, non-punitive, and focused on improving care to patients. 14

15 Which of the following has a QA focus? Which staff member failed to transfer the call to the correct extension? Are we creating an environment encouraging clinicians to report errors? How do we reduce production errors on the widget line? Patient had a bad outcome; were the doctors or nurses at fault? What could we do to increase the efficiency of chart filing? 15

16 Quality Components Risk Management Patient Safety Peer Review Quality Assurance Strategic Planning Quality Improvement 16

17 Strategic Planning Where are you going? What are your priorities? How are you going to get where you are going? 17

18 Strategic Planning in Dental Written Quality Improvement/Performance Improvement Plan Written HP/DP Plan Written overall Strategic Plan (short-term term and long-term goals) 18

19 Quality Components Risk Management Patient Safety Peer Review Quality Assurance Strategic Planning Quality Improvement 19

20 Quality Improvement Plan-Do Do-Study-Act (PDSA) Cycle Small scale tests and multiple cycles of testing should be used to build knowledge about needed changes. There is no wrong or right aspect to test. Initial testing sparks ideas that can lead to other o tests. You should brainstorm ideas for change that might lead to an improvement with other clinic staff. Changes are tested by using Plan-Do Do-Study-Act (PDSA) cycles. This is essentially the scientific method. Each PDSA cycle will create information that can be used to determine how close you are to meeting your objectives. Rapid cycle PDSAs will allow you to obtain quick feedback and the opportunity to change testing components along the way. The Model for Improvement (shown below) is used to construct PDSA cycles. 20

21 Quality 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? 21

22 The PDSA Model PLAN: Plan a change or test of how something works. DO: Carry out the plan. STUDY: Look at the results. What did you find out? ACT: Decide what actions should be taken to improve. 22

23 QI - PLAN State objective of the test Make predictions Develop plan to carry out the test (who, what, where, when) 23

24 QI - DO Carry out the test Document problems and unexpected observations Begin analysis of data 24

25 QI - STUDY Complete the analysis of the data Compare test data to predictions Summarize what was learned 25

26 QI - ACT What changes are to be made? What will be the objective of the next cycle? 26

27 Important Aspects of the PDSA These are inherently done all of the time. Can you think of an example? Short-cycle (rapid) PDSAs allow for quick evaluations of minor changes made. A single QI project might involve multiple PDSAs. 27

28 Quality Improvement is not a one- time process! The PDSA Cycle requires that the process be continued the Act part of the cycle Continuous Quality Improvement helps: Maintain the positive steps you ve already taken Continuously improve quality of care 28

29 Example #1: Tracking Codes Organization: Nashville Area Dental Date: 13 April 2009 PDSA Topic: Dental Tracking Codes PDSA Cycle #: 1 PURPOSE/OBJECTIVE OF CYCLE: Improve use of dental tracking codes in the Area What are we trying to accomplish? To determine how many clinics are using the new dental disease tracking codes (established in Feb. 2009) and how often. The codes determine disease prevalence rates and are only effective if used d on all patients at the examination appointment. How will we know that a change is an improvement? If 100% of eligible patients receive tracking codes at the examination appointment. What change can we make that will result in an improvement? First, evaluate who is using the codes. Then determine the next course of action (conference call, training at the Area Dental Meeting, personal phone calls, s) e 29

30 PLAN: the change, data collection and predict What are we testing? Compliance in using dental disease tracking codes. Who are we testing the change on? At this point, all of the Area dental programs When are we testing? April 17, 2009 Where are we testing? Through comparison of electronic data obtained from the Area Statistician. Predictions: What do we expect to happen? 3 clinics are using the codes 100% of the time 5 clinics are using the codes 50% of the time 8 clinics are not using the tracking codes at all What data do we need to collect? Tracking codes (IH40-49), 49), from an SCOM search in RPMS Who will collect the data? Tim Ricks When will the data be collected? April 10, 2009 Where will the data be collected? From RPMS SCOM report in DDS package 30

31 DO: Carry out the change/test; collect data and begin analysis What happened? 1. Catawba, Cherokee, Chitimacha, Choctaw, Micmac, Oneida, Indian Township, Poarch, Seminole, and St. Regis have all begun using the different tracking codes. 2. Each clinic was evaluated for % of time that they used the caries risk codes (IH40-43), 43), the caries presence codes (IH44-46), 46), the periodontitis presence codes (IH47-48), 48), and the new sealant code (0007). 31

32 STUDY: Complete analysis of data, summarize what was learned, and compare the data to predictions. Predictions and results were as follows: 1. It was predicted that 3 clinics are using the codes 100% of the time. In fact, no one is using the codes 100% of the time. However, 4 clinics are using the caries presence codes 100% of the time. 2. It was predicted that 5 clinics are using the codes 50% of the time. t Four of the 16 dental programs in the Area are using the codes at a least 50% of the time. 3. It was predicted that 8 clinics are not using the tracking codes at all. However, 10 of the 14 dental clinics that utilize RPMS (Penobscot, Onondaga, and Seneca do not) are using the codes some. This is great news and indicates that with a little tweaking, all of the clinics may use the tracking codes. 32

33 Act What changes should we make before the next test cycle? Provide a training on tracking codes, perhaps at the May 27th Nashville Area Continuing Education Conference Call. What may be important to emphasize would be how these codes relate to oral health (keeping track of community oral disease rates, establishing recall intervals, grant writing potential, comparisons to national data, etc.). What will the next test cycle be? If education is provided in May, in late July another evaluation in RPMS will be done for all of the clinics to see if improvement was made. Are we ready to implement the change? It seems so. With 10 clinics at least aware of the codes and using them, it may be easy to improve numbers. The goal, especially in tracking disease rates, is to have all patients assessed, however. 33

34 Example #2 ADO Chart Reviews Organization: Nashville Area Dental Date: 13 April 2009 PDSA Topic: Dental Chart Reviews PDSA Cycle #: 1 PURPOSE/OBJECTIVE OF CYCLE: Improvement Area Dental Officer performance in clinical chart reviews What are we trying to accomplish? To determine accuracy of Area Dental Officer chart reviews. How will we know that a change is an improvement? If Area Dental Officer chart review scores are within 2% agreement of chart reviews conducted by dental chiefs at clinics. What change can we make that will result in an improvement? Evaluate chart review scores and if changes to the process need to be made, make them to improve the accuracy of annual chart reviews. 34

35 PLAN: the change, data collection and predict What are we testing? Accuracy of Area Dental Officer chart reviews Who are we testing the change on? Choctaw Health Center When are we testing? April 15, 2009 Where are we testing? In the office CHC will provide electronic chart review data which will be compared to Dr. Ricks chart review data Predictions What do we expect to happen? There is a 95% agreement on chart review sections between the ADO and the Choctaw Dental Chief on chart reviews r conducted April 8, Data What data do we need to collect? Chart reviews from CHC. Who will collect the data? Tim Ricks When will the data be collected? April 15, 2009 Where will the data be collected? In the office CHC will provide electronic chart review data which will be compared to Dr. Ricks chart review data 35

36 DO: Carry out the change/test; collect data and begin analysis What was actually tested? % agreement between the ADO and the senior Federal dentist, Dr. Berg, on chart reviews conducted on two dentists at Choctaw Health Center on April 8, What happened? There was mostly agreement on the chart review elements (see study). This confirms that the Area Dental Officer s s reviews are in line with more senior dentists (or at least the most senior federal dentist in the Area). Observations. Some data elements are judged differently. For example, the Area Dental Officer does not review rubber dam documentation on restorations, although it is an IHS standard. Dr. Berg, however, did evaluate rubber dam documentation. Problems. Dr. Berg was only able to evaluate half of the charts that I did due to time constraints. This could skew the data (the charts with the most deficiencies may not have been reviewed by Dr. Berg). 36

37 STUDY: Complete analysis of data, summarize what was learned, and compare the data to predictions. Chart Review Category Dr. Brian Berg (Choctaw) Dr. Tim Ricks (ADO) Data Points % Compliant Data Points % Compliant Difference A. Every Visit % B. Exam % C. Drugs % D. Radiographs % E. Emergency Tx % F. Endodontic Tx G. Oral Surgery H. Restorative % I. Pediatrics J. Orthodontics K. Periodontal Tx % L. Prevention % M. Prosthodontic Tx N. Data Entry O. Overall Score % 37

38 Act What changes should we make before the next test cycle? The updated Chart Review template should be used when re-testing. What will the next test cycle be? This will need to be re-tested using another dentist in the Nashville Area, probably the Seminole Tribe of Florida in May Are we ready to implement the change? We are still gathering data. If the data shows large discrepancies, then we will need to look at calibrating chart review examiners. 38

39 Example #3 CHC:Hand Hygiene Organization: Choctaw Health Center Date: 4/30/09 PURPOSE/OBJECTIVE OF CYCLE: What are we trying to accomplish? Reduce the risk of health care associated infections (National Patient Safety Goal 7, Joint Commission) How will we know that a change is an improvement? If hand hygiene protocols are followed in the CHC Dental Department What change can we make that will result in an improvement? Educate dental staff about hand hygiene protocols (reinforce previous training) 39

40 PLAN: the change, data collection and predict What are we testing? The percentage of time that dental staff wash their hands before and after coming into contact with patients or potentially infectious materials Who are we testing the change on? All dental staff at the Choctaw Health Center When are we testing? Thursday, April 30, 2009 Thursday, May 7, 2009 Where are we testing? Choctaw Dental Department sinks Predictions What do we expect to happen? Dental staff washes their hands 50% of the time before gloving to see a patient. Dental staff washes their hands 10% of the time after de-gloving following a patient visit. Data What data do we need to collect? # of times dental staff wash their hands before and after seeing patients Who will collect the data? Dr. Brian Berg, chief dentist (or designee) When will the data be collected? April 30 May 7 Where will the data be collected? At the CHC Dental Department, using Excel 40

41 Do-Study Study-Act Dr. Brian Berg 41

42 Example #4 CIHA: Disinfection Organization: Cherokee Indian Hospital Authority, Inc. (CIHA) Date: April 30, 2009 PURPOSE/OBJECTIVE OF CYCLE: What are we trying to accomplish? Reduce the risk of health care associated infections (National Patient Safety Goal 7, Joint Commission). Failure to allow time for disinfectant to work could lead to MRSA infections, HIV transmission, or influenza transmission potentially. How will we know that a change is an improvement? If dental assistants wait the required 3 minutes to wipe down chairs after using Cavicide disinfectant What change can we make that will result in an improvement? Establish baseline data to see if dental assistants are waiting 3 minutes before wiping chairs after disinfectant use 42

43 PLAN: the change, data collection and predict What are we testing? Compliance of dental assistants in waiting 3 minutes to wipe down chairs Who are we testing the change on? Dental assistants at CIHA When are we testing? Thursday, April 30, 2009 Thursday, May 7, 2009 Where are we testing? CIHA Dental Predictions What do we expect to happen? Dental assistants wait 3 minutes only 40% of the time to wipe down chairs. The average amount of time dental assistants wait after applying disinfectant is 2.3 minutes. Data What data do we need to collect? The time period between when each dental assistant sprays Cavicide disinfectant and when he/she begins to wipe down the chair (physical disinfection). Who will collect the data? Gayle Guilford, Dental Program Manager When will the data be collected? April 30 May 7 Where will the data be collected? At the CIHA Dental Department, using an Excel spreadsheet 43

44 Do-Study Study-Act Gayle Guilford, RDH, CIHA Dental Program Manager 44

45 Example #5 STOF: CHS Tracking Organization: Seminole Tribe of Florida Dental Program Date: April 30, 2009 PURPOSE/OBJECTIVE OF CYCLE: What are we trying to accomplish? Minimize Contract Health Service referrals in the dental program. Patients at Seminole are a now required to seek primary oral health care at one of the four Seminole dental clinics. How will we know that a change is an improvement? If the number of CHS referrals decreases What change can we make that will result in an improvement? Have dental receptionists at each of the four STOF clinics track referrals using an Excel spreadsheet, and submit those spreadsheets to management at the beginning of each month. 45

46 PLAN: the change, data collection and predict What are we testing? Compliance of dental receptionists in using the newly created Dental CHS Tracking Spreadsheet. Who are we testing the change on? Dental receptionists at Big Cypress, Immokalee, Brighton, and Hollywood When are we testing? April 1, 2009 April 30, 2009 Where are we testing? At the Hollywood Dental Clinic Predictions What do we expect to happen? Only 2 of the receptionists will submit the CHS Tracking spreadsheets on time. Data What data do we need to collect? Tracking spreadsheets Who will collect the data? Kerri Cook, RDH, Dental Prevention Coordinator When will the data be collected? Friday, May 1, 2009 Where will the data be collected? At the Hollywood Dental Clinic 46

47 Do-Study Study-Act Kerri Cook, BSDH, CDHC, Dental Prevention Coordinator, STOF 47

48 Questions? 48