Continuous Quality Improvement

1
Continuous Quality Improvement

• Evidence Based Medicine
• In practice

2
CQI

• Means to improve individual health care
• Means to improve systems of care delivered
• Means to improve care delivered by individual
  physicians
• Means to educate physicians
• Evidence based care guidelines for specific
  processes
• CQI as learning tool for specific processes
  through self audit and evaluation
• Learning CQI techniques as component of
  continuous professional development

3
Importance

• Accreditation Council on Graduate Medical
  Education (ACGME) has added two new compentencies
  for residents
• Practice based learning and improvement
• Systems based practice the ability to
  effectively call on system resources to provide
  care that is of optimum value
• Standard competencies medical knowledge, patient
  care, communications and interpersonal skills,
  professionalism

4
ABIM certification and recertification

• 2000 ABIM changes recertification process to
  program of Continuous Professional Development
• New incorporation of principles of CQI into self
  evaluations (based upon national guidelines for
  best care)

5
Importance after residency

• Use by insurance companies, medicare/medicaid,
  clinics, hospitals for individual and systems
  performances
• Use by patients
• Use by individual as means of CME

6
What is health care quality?

• IOM degree to which health services for
  individuals and populations increase the
  likelihood of desired health outcomes and are
  consistent with current professional knowledge
• Importance of multiple perspectives in
  determining quality of care

7
CQI model

• 1. Aim what is the goal?
• 2. Measurement
• Structural hospital teaching status,
  accreditation, etc
• Process specific care (beta blocker use)
• Outcomes end results of care
• 3. Ideas for change
• 4. Testing and Learning
• Langley et al. The Improvement Guide a practical
  approach to enhancing organizational performance,
  1996.

8
Delirium in hospitalized elderly

• Importance marker of increased mortality and
  decline in functional status
• Background
• Delirium is often not identified in the hospital
• Delirium is associated with certain risk factors
• Evidence suggests that the risk of developing
  delirium can be decreased in high risk patients
• Identification is key to prevention

9
Delirium CQI process

• Aim To reduce the number of patients on the
  geriatric medical service who develop delirium
  during their hospital stay
• Measurement
• Process patients assessed for delirium or risk
  for delirium (underlying dementia)
• Outcomes patients who develop delirium before
  and after proposed changes
• Ideas for change prompt on CIS note template for
  
• Assessment for risk/development of delirium
• Medication review
• Review for restraints, catheters, iv lines
• Testing and Learning self audit

10
Audit Sheet

• 1. Assessment for or diagnosis of underlying
  cognitive impairment or dementia in history,
  physical exam or problem list
• 2. Assessment for or diagnosis of delirium
  included in history, physical exam or problem
  list
• 3. CAM or other validated tool used to
  assess/screen for development of delirium during
  hospital stay
• 4. Delirium developed during hospital stay
• 5. Delirium contributed to increased length of
  stay or need for higher level of care at discharge