EZ Medicine Quality Council - SCIC Newsletter

EZ MEDICINE QUALITY COUNCIL-SCIC EZMQC-Strategic Clinical Improvement Committee -Quarterly

September 2018

Dr. Ward Flemons is a medical advisor to the Health Quality Council of Alberta and the forSave the Date!! mer Vice-President of Quality, Safety and Health Information for the Calgary Health University of Alberta Region. He practices as a respirologist and DoM and Alberta sleep medicine specialist at the Foothills Medical Centre and is a Professor of MediHealth Services nd cine at the University of Calgary. Ward has 2 Annual led and participated in several large reviews QI Collaborative day! th both of Alberta's and other province's health Nov 16 , 2018 systems. He works with patients / families 0800-1230 who have experienced serious patient harm Bernard Snell Hall events in healthcare. He chairs two Patient Safety and Quality certificate courses for the University of Calgary and Health Quality Dr Ward Flemons-Guest Speaker for 2nd Annual QI Collaborative Day Council of Alberta. Dr Flemons also lectures widely within the province and nationally on Patient Safety and Quality Improvement

Quality Improvement Education

The Quality Improvement team in PGME and the SCIC Quality Consultant is willing to train your residents by providing a 4-hour EPIQ workshop. We have scheduled four workshops between July and December 2018. If you want to send all your residents or just some of them, please email Shirley Auvigne- auvigne@ualberta.ca We can accommodate large numbers if given enough lead time to recruit facilitators and to book a room.

As QI is now part of the RCPSC accreditation standards, we want to ensure that you have access to training opportunities for your residents but also for any faculty that may be interested.

PGME Sessions are scheduled for:

Up Coming QI Events:

September 27 Thurs 12:30 pm

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October 29 Monday 12:30 pm

Quality Summit: Calgary- Oct 17 and 18, 2018 

December 7 Friday 8:00 am

Training Numbers for Academic Year 2017/2018:

Alberta Health Services RAH Clinical Innovation Symposium– Nov 1, 2018(12pm-4pm)

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IHI Conference: Orlando

Florida December 9-12, 2018

Nearing 500 Trained! Actual total to date is 476 and AHS Yellow belts are steadily increasing with the current total at 59. 

EPIQ Site training took place at the Glenrose Rehab Hospital with 20 Attendees on June 16, 2018.

Pecha Kucha Pecha Kucha is a visual story telling presentation style that this year’s 2nd Annual QI Collaborative day will be utilizing to share the human side of QI projects.

Come check this out on Nov 16, 2018!

https://designmaketeach.com/2014/02/24/pechakuchanight/

Featured Quality Improvement Projects Using Quality Improvement (QI) Methodology to Develop a Standardized QI Educational Curriculum Currently, core internal medicine residents at the University of Alberta do not have a standardized quality improvement (QI) educational curriculum. Our goal was to develop and implement a formal QI curriculum using QI principles by providing all core internal medicine residents the Evidence-based Practice for Improving Quality (EPIQ) training course, have resident teams develop potential QI projects during the course, identify resident QI champions to coach future EPIQ sessions, and align residents to active QI projects with staff physicians and multidisciplinary teams.

Three cycles of the EPIQ course were delivered to PGY-1, PGY-2 and PGY-3 cohorts (110 residents). Residents were grouped into teams of 6-10 to learn QI principles through developing potential QI projects. Residents then presented their QI projects at an assigned academic half-day in April 2018 and were evaluated by a designated QI consultant.

A post-EPIQ course survey was conducted to evaluate knowledge acquisition of QI principles, likelihood to take part in future QI projects, and interest in becoming an EPIQ facilitator. 98% of residents felt they had acquired a basic understanding of QI principles (56% increase from the baseline survey), 94% of PGY-2 and PGY-3 residents preferred this method of learning QI to the previous years (predominantly self-directed learning and completion of online modules), 40% more residents are interested in pursuing a QI project, and 17% of residents are interested in being EPIQ facilitators.

Overall, the written and verbal feedback obtained from residents has been overwhelmingly positive. Developing a QI curriculum using validated QI tools highlighted the areas of change opportunity supporting change acceptance and sustainment. As more residents and staff physicians become comfortable using QI principles and become engaged in QI projects, this will foster an atmosphere within our hospitals and healthcare system to create positive change in the future.

Project leads: Dr. Anca Tapardel and Dr. Caity Collins Congratulations! This project was selected to be presented at both the UAH and RAH Medical Grand Rounds and at the CSIM Annual Meeting October 10-13, 2018 at the Banff Centre in Banff, Alberta.

Targeting Incomplete Bowel Preparations for Inpatient Colonoscopies GI physicians reported frustration with the high rate of incomplete inpatient bowel preps for colonoscopy. The bowel prep process involves drinking a laxative to allow for visualization during colonoscopy, for adequate diagnosis and treatment. In turn, poor bowel preps result in less visibility and thus, poorer health outcomes, repeat procedures, higher health care costs, and diminished patient experience.

For this quality improvement (QI) project, an interdisciplinary team that perform inpatient bowel preps completed QI tools to identify numerous gaps that may be contributing to the high rate of poor inpatient bowel preps. These gaps included bowel prep order variability, timing, education, lack of tracking, intolerance, and lack of communication between units.

The interventions implemented to address these gaps included a standard bowel prep order label, an patient instructional job aide, and a nursing ‘tip sheet’ containing strategies for when a patient is not tolerating the prep. In turn, the number of poor preparation for colonoscopies on the gastroenterology wards decreased by 21% over 3.5 months. During this period of time, there was a 59% use of the standardized label, 70% of standard bowel prep education, and 100% of education for residents and registered nurses when on service.

Patients were surveyed and 91% found the placemat easy to use and 56% of patients would find the placemat helpful if they needed to prep again.

Furthermore, it is anticipated that the process improvements developed here can be easily adopted and sustained by other units. By doing so, we can improve patient experience and health outcomes.

Projects leads: Dr Ali Kohansal and Dr Lindsey Russell

Nutrition Screening Did you know that patients admitted to the medicine units at the U of A hospital are not screened for malnutrition? And did you know that malnutrition is very common amongst medicine inpatients? If we can find a way to notice patients who are malnourished, perhaps a dietician can be included in their care early on. Addressing a patient’s nutrition status could mean a faster recovery and lasting nutritional care.

Our Quality Improvement team wanted to address this gap in patient care. Our goal as a team was to introduce a screening tool for patients upon their admission to flag them for malnutrition. We created a sticker with the two questions that the Canadian Malnutrition Task Force developed to assess malnutrition. Residents on units 5D2, 5D3, and 5D4 asked the two questions on the sticker and if patients answered yes to both, the resident consulted a dietician. Of course, the dietician on the team assessed the patient more fully and created a thorough nutritional plan.

Although our results are preliminary, they look promising. The screening questions appear to reduce the time it takes for a dietician to be consulted (initial data indicates patients receive a consult within 1-3 days vs.1-14days without the screening questions) and potentially reduce the length of stay. We look forward to suggesting that these nutritional screening questions be part of the upcoming Connect Care.

Project leads: Dr. Anca Tapardel, Dr. Suqing Li, and Dr Robert Hurowitz

5C3/4 Project Champions!

Improving Timely Treatment of Patients with Suspected TTP - University of Alberta Hospital (UAH) Thrombotic thrombocytopenic purpura (TTP) is a life-threatening condition that must be treated as a medical emergency to ensure that patients receive timely access to life saving plasma exchange. Plasma exchange, also referred to as plasmapheresis or PLEX, has reduced mortality survival from as high as 90% to 10-20%. UK guidelines recommend initiating plasmapheresis in patients with suspected TTP within 4-8 hours of presentation. A chart audit of 2016 data indicated that patients with suspected TTP was initiated on plasmapheresis in a median time of 9.3 hours at the University of Alberta Hospital (UAH), the only apheresis facility in Northern Alberta.

This QI project aimed to identify and implement salient interventions using cycle time analysis and the Shewhart Plan-Do-Study-Act iterative cycles to decrease the current cycle time to achieve timely plasmapheresis treatment. The greatest delay in patient care was in waiting for central line insertion by a trained physician, with a median wait time of 4.7 hrs. Other delays included 3.3 hour delay for hemolysis lab workup to return to ordering physician, and 4.2 hour delay to book transportation after being diagnosed in an outpatient setting. Among those with >8-hour delays from time of diagnosis to initiation of plasmapheresis, only 17% received plasma infusions.

Several interventions were identified following a chart audit. To address central line insertion as a source of delay, ICU and interventional radiology physicians were informed of urgent need to insert central lines on patients with TTP. Secondly, TTP patients will be prioritized by ICU if presenting between 21:00 – 08:00 to expedite line insertion. Selected dialysis nurses were cross-trained in plasmapheresis and may provide after-hours plasmapheresis coverage. These two interventions addressed the issue of PLEX not being available at UAH between 24:00 – 08:00. Hematology staff were informed to order hemolysis workup as a STAT order to ensure lab work returns within 1 hour, order plasma infusions for those with anticipated long delays to definitive treatment, as well as to book transportation through RAAPID and to verbally request the patient to be transported as level red. Addressing these communication gaps will allow UAH to decrease delays, ultimately improving quality of patient care for those diagnosed with TTP. Project leads: Dr. Linda Sun and Dr. Arabesque Parker “When the critical steps are linked together to help treat TTP patients as a medical emergency this will set the correct chain of events in motion…potentially saving the life of a TTP Patient!”

Access Partnership Project (APP) A great deal has been done this past year in standardizing the process for Referrals within the Department of Medicine and ensuring we are compliant with the College of Physicians and Surgeons and AHS policies. 

The majority (95-99%) of clinics in the DOM is confirming receipt of referral within 7 days, booking appointments within 14 days, declining referrals within 14 days and providing outcome letters within 30 days.

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DoM for clinics and services (98%) have developed Referral Guidelines and standards to support referral sources in providing a complete referral 100% of the time. These guidelines are uploaded to the Alberta Referral Directory.

JULY 31, 2018 the Alberta Referral Directory launched with Open Access to support referral practice.

Search—www.albertareferraldirectory.ca

Up Coming EZMQC-SCIC Meeting: September 20, 2018 Dec 6, 2018 January 23, 2019

Contact Us Pamela Mathura QI Consultant pam.mathura@albertahealthservices.ca

Dr. Narmin Kassam Associate Chair, Clinical Affairs nkassam@ualberta.ca

EZMQC-Strategic Clinical Improvement Committee Dedicated to QI Capacity, Capability and Collaboration Visit Us: https://www.ualberta.ca/department-of-medicine/ezmqc-scic