14 Jun 3 Simple Ideas to Improve PI Projects
By: Jennifer Milton, BSN, MBA, CCTC
Like most of you, I speak, read and listen to a tremendous amount of information on transplant topics involving quality and/or federal policies. Scorecards, standards, monitoring outcomes, and how to “thoroughly” do a “thorough” review are among my favorite topics.
While writing a blog focused on making chart audits/scorecards more valuable, I found myself doing some deeper thinking on another mandate brought into high fashion by Medicare’s QAPI requirements—Process Improvement.
To remain in compliance with the COPs, we need to have ‘evidence we used data to drive improvements’ in addition to all of the items that need to be memorialized in the quality structure. Given the incredible human effort we already dedicate to process improvement, minor shifts in data collection and communication might yield even bigger results/improvements.
Some ideas are discussed below that may be helpful to leverage existing process improvement activities to improve efficiency and effectiveness.
Kill two birds with one stone
Your quality committee should evaluate data already being collected & analyzed to determine which indicators might be leveraged to ‘kill two birds with one stone’.
Metrics tracking clinical outcomes could be used to examine financial performance. As an example, if you track rejection rates in the first-year post transplant, consider adding two additional questions/checkboxes to your audit to capture the treatment type (steroids versus biologic agents) and treatment setting (inpatient versus ambulatory). With these expanded indicators, the QAPI staff or committee can continue to track the prevalence of rejection, and also establish a baseline for the ‘cost’ of treatment. Armed with this data, the center might find evidence they need to access resources to shift treatment to the ambulatory setting for first and additional doses. Tracking how different providers chose to treat rejection may enhance protocols, and standardize—or even reduce—the use of biologic agents.
Tying length of stay to the daily costs of care can be helpful to maximize case rate reimbursement to increase the revenue for future de-novo transplants, particularly with a focus on those days that exceed the benchmark. Another meaningful expansion might be monitoring not only re-admission but also if the re-admission occurs within global periods.
Hospitals that already use MIDAS, Crimson, and other tools should be able to readily shift to obtain financial information. For centers without these tools, using total charges is a reasonable proxy and still quite helpful for cost reduction/revenue enhancement strategies.
Don’t Re-Invent the Wheel
I think most agree that Medicare’s emphasis on bi-directional communication has been instrumental in breaking through silos at our institutions. We make every effort to ensure transplant quality data is reported up through hospital quality meetings, and that hospital-wide quality issues are reported back down to the transplant QAPI meetings. However, less emphasis has been placed on ‘horizontal’ communication between organ programs within single transplant centers.
Quality leadership should evaluate the effectiveness of their own horizontal processes. Are improvements made by the liver QAPI team routinely digested by your adult and/or pediatric kidney, liver, lung and other QAPI committees? By “digested,” I mean: are issues looked at with an eye for “Could this also happen to our program, and would these recommendations make our program stronger?” rather than just a brief sharing of issues occurring in one program at joint or steering committees. We need to establish a process to hardwire the sharing of problems and solutions in one organ program to another.
Let’s take a look at an example of a thorough review of an adverse event—a disease transmission—that occurred in one program. In this case, a new liver recipient is now positive for TB. Corrective actions are developed which include creating and deploying a standardized screening tool for latent disease, coordinator training on the new tool and the importance of screening, and the development of triggers for pre-transplant infectious disease evaluation. At the following months’ individual organ QAPI meetings a summary of the adverse event, thorough review, as well as a review of the recommendations and tools should occur. It is likely that the other organ programs would enhance patient safety by adopting the same tools and training. A form or tool could be developed to memorialize each programs’ review of the issue, and provide a section to solicit input for ideas and feedback to the original program that may strengthen corrective actions.
Other areas where this communication and deployment of a ‘horizontal communication tool’ could be successful include: Successes at reduction in LOS, protocols/practices for vaccination enhancement, and reduction in no-show rates.
Expanding this practice to include improvement activities outside of your center is also a great idea, especially if other centers are willing to share some of their corrective actions. Some centers have ‘sister’ centers in their governance network where this type of sharing could add tremendous value to operations and patient safety.
Don’t Put the Cart Before the Horse
Medicare’s QAPI requirements push us to define and describe the methodology our center utilizes to conduct process improvement (a methodology of the center’s choosing). No matter the ‘denomination’ (such as Lean A3 or PDSA), methodologies are designed to ensure a deep analysis of the problem occurs BEFORE constructing solutions. Despite this, centers (read: surgeons) often jump immediately to deploying corrective actions when an adverse event or other need for process improvement arises. Sometimes the quick decision is that ‘no corrective action’ is needed.
Quality methodologies hardwire systematic processes—and we all know that ‘action’ is never the first step. Jumping to ‘action’ without study, planning, and analysis often results in solutions that are short-lived and create downstream problems. Certainly, it’s understandable that a quick conclusion or action may be needed to remedy a patient safety issue, but thoughtful analysis and planning should be initiated simultaneously to tweak or revise actions.
As an example, a patient in their first week post living donor kidney paired exchange suffered a graft failure, and the team concluded the patient had an undiagnosed hypercoagulable state. M&M reviewed the patient’s course, past medical history and literature, and ultimately no changes were indicated.
Upon review by an external peer team, it was evident that the dialysis unit had reported multiple de-clotting procedures during the period the patient was waiting for a paired exchange. The center’s evaluation protocol required a hypercoagulable work-up for patients with a history multiple de-clotting or revised AVF, but the patient did not have that history at the time of referral/listing. The external peer team discovered the same contributing factor in a second case two years earlier.
Perhaps if the center would have applied this principal (analyze before action) to the first graft failure, improvements in waitlist management could have been applied two years earlier, and perhaps the additional failure could have been avoided.
This is, in essence, the process CMS expects… a “thorough review”. This means to really improve, follow an established methodology, deeply analyzing for contributing factors in all phases of care, in all systems, before finalizing a decision.
What do you think?
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