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This blog post highlights a few of the exceptional quality improvement projects IHI Open School learners are leading.
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Lessons from Ten Exemplary Student-led QI Projects

By Gina Deitz | Monday, February 6, 2017
Student Quality Improvement Projects 2016

Faculty facilitators and this year’s students winners stand at their posters after the storyboard walkaround session at the IHI National Forum. The winner for quality improvement projects was Vivian Wang (center) from Boston University School of Medicine.

A lot of people may think the key highlight of the IHI National Forum is the rousing keynote speeches. But it’s important not to overlook some of the most inspiring work — storyboard presentations from students and trainees.

Every year, over 150 students submit their work in quality improvement, IHI Open School Chapter leadership, and community organizing. A group of interprofessional faculty review the submissions across the categories select three winners to present their storyboards at a special session.

This blog post highlights a few of the exceptional quality improvement projects IHI Open School learners are leading. Students and trainees tackled all types of projects in many settings — offering translation for patients with limited English proficiency, making more effective referrals from birth centers to acute care, and reducing patient wait times. They set clear aims appropriate to the context of their system, used specific improvement methods and tools, highlighted the data that demonstrated improvement, and shared a clear study of their results as they look toward future tests of change.  

We’ve highlighted the overall scholarship winner for a student-led quality improvement project, Vivian Wang, below. You’ll also find nine additional posters, selected as role models based on their use of quality improvement.

Project: In-person Interpreter Participation during Morning Rounds Changes Patient Management in the Pediatric Inpatient Ward

Presenter: Vivian Wang

Program: Boston University School of Medicine

Health care disparities between limited English proficiency (LEP) and English proficient (EP) patients in pediatrics are well described. Data suggest that professionally trained in-person interpreters (IPIs) can better minimize these disparities when compared to ad hoc and phone interpreters. Before October 2014, the BMC pediatric inpatient ward had 30 percent of patients with LEP, but no system in place for utilizing IPIs during daily family-centered morning rounds. Our intervention addresses this disparity by providing IPIs to achieve equitable, patient-centered care for LEP patients and families on the inpatient pediatric ward. We aimed to increase the percentage of morning rounding encounters with professional IPIs for LEP families on the pediatric inpatient ward to 75 percent by January 1st, 2017. At time of presentation at the IHI National Forum, data up to October 2016 showed 62 percent of LEP rounding encounters had care plans discussed in the family’s preferred language with an IPI during most recent PDSA cycle, up from 0% at baseline.

Key Lessons Learned: Quality improvement projects are dynamic, and teams will find the most success with consistent PDSAs. It’s important to maintain open communication between all stakeholders. Although it may take a little more time to develop team optimism and organization, it creates an exponential impact on the successful progression of the project.

Faculty feedback: The project highlighted a great use of QI principles to realize improvement and demonstrated rigor in data collection over time to inform tests of change based on learning. The clarity of each PDSA cycle had clear impact on outcomes. Additionally, the poster itself made great use of a driver diagram to explicitly share the drivers tied to improve performance in the project’s setting.

Project: Clarkston Community Health Center Quality Improvement Initiative: Optimizing Patient Flow

Presenter: Joyce Kim

Program: Emory University School of Medicine

The Clarkston Community Health Center (CCHC) is a non-profit organization founded in 2013 to provide affordable primary and preventative health care to the uninsured refugee and indigent population of the Clarkston community, a major refugee resettlement area located outside the city of Atlanta. The IHI Open School Emory Chapter partnered with CCHC in Spring 2016 to improve clinic processes and subjective experiences at this quickly growing clinic, which is staffed by volunteer health professionals and students. Specifically, this partnership aimed to reduce patient wait and total time at the CCHC by 25 percent by May 1st, 2016. Although the goal of reducing clinic time by 25 percent was not reached, the average total clinic time decreased by nine minutes, and patients and staff reported a subjective improvement in clinic experience.

Key Lessons Learned: Even if it takes time, it’s very important to identify and engage all potential stakeholders and team members, and develop shared goals and expectations from the outset. These goals and expectations can and should be revisited at regular intervals throughout the project, in order to reach success and maintain accountability as a team. 

Faculty feedback: This project is a role model for using a diverse set of improvement tools, and the poster illustrates a clear iterative learning process through parallel PDSA cycles. The poster also shows how helpful process maps and spaghetti diagrams can be in characterizing potential rate-limiting steps that can undermine improvement efforts.

Project: Early Intervention and Standardization of Management of Postpartum Hemorrhage in the Birth Center Setting

Presenter: Cindy McCullough

Program: Frontier Nursing University

The aim of this quality improvement project was to evaluate whether active management of the third stage of labor (AMTSL) and quantification of blood loss (QBL) measurement would reduce postpartum blood loss and reduce the time of third stage of labor. Baseline data on postpartum hemorrhage (PPH) rates and utilization of AMTSL were obtained from birth center data, revealing a 3 percent PPH rate and a 4 percent utilization of AMTSL. High-fidelity simulations for AMTSL, QBL, and PPH were developed. After the eight-week cycles, 85 percent of births utilized QBL, and 80 percent of births were managed with AMTSL. There was no reduction in total blood loss, and the length of third stage labor was reduced by 20 percent.

Key Lessons Learned: Change truly occurs in small steps — believe in them and you can truly create change with time, patience, dedication, and teamwork! My advisor continually encouraged me to think small and remember that small changes, over time, create a dramatic impact. It’s easy to assume small steps won’t affect real change and to jump to the big picture instead, but this often leaves people feeling overwhelmed when they think of how much needs to be accomplished to get there. Always remember: Small steps can lead to tremendous impact.

Faculty feedback: The presentation was a strong demonstration of clinical impact and a clear illustration of work over time. The project was enhanced by five PDSA cycles and the detailed use of control charts. There was consistency in the aims, interventions, data, and conclusion, and poster made a strong justification for taking on this specific approach to the problem. Not to mention, the clinical outcome improvement was impressive!

Project: Glycemic Control Transformation at Phoenix VAHCS: A QI Initiative

Presenter: Rustan Sharer

Program: Banner University Medical Center Phoenix & Phoenix VA Healthcare System

The 2016 Joint Commission National Patient Safety Goals highlight safe medication administration as well as effective communication as domains of nationwide improvement. Inpatient hypoglycemia falls within both of these areas of improvement, and is a predominantly preventable source of increased length of stay, cost, and morbidity and mortality. At the Phoenix VA Healthcare System (PVAHCS), there was a concerning frequency of inpatient hypoglycemic events during 2015. Our primary aim was to decrease inpatient adverse events related to inpatient insulin administration (e.g. symptomatic blood glucose < 70 or incidents of DKA or HONK with elevated glucose) by 50 percent by January 2017. Our intervention of removing order set resulted in achieving that aim ahead of our goal, although at the cost of our secondary aim, relating to hyperglycemia rates. This work highlights how using systematic approach to quality can identify quick wins where a simple intervention decreases rates of adverse events.

Key Lessons Learned: From the beginning, our goals were to bring awareness of inpatient hypoglycemia and design an order set to help prevent harm to our Veterans. Initially though, we underestimated the importance of identifying all of our key stakeholders. It’s important to ask collaborators to both recommend and then engage other stakeholders early — which ultimately expands the impact of a project. At first, the expansion of our team highlighted the need to improve coordination and communication. However, as our system-level intervention made progress, we were able to avoid late-stage obstacles by leveraging the support of these key individuals early-on. 

Faculty feedback: The baseline data and process chart identified a detailed system analysis, which is essential to inform the potential changes needed to improve performance. Additionally, the results were displayed using control charts, which is the gold standard in quality improvement.

This project demonstrates the need for balancing measures in improvement initiatives: the benefit seen in hypoglycemic events was offset in part by higher rates of hyperglycemic events. By measuring and monitoring both, further improvements can be made to achieve strong performance in both measures to ensure overall improvement actually realized.

Project: Implementation of a Standardized Communication Transfer Tool: Improving Transfers from Birth Center to Hospital Setting

Presenter: Shari Long Romero

Program: Frontier Nursing University

Our team used PDSA cycles to improve the quality of patient transfer from the birth center to hospital setting. Stakeholders participated in literature review, simulation training, co-creation, and implementation of a standardized transfer communication tool, and data collection for evaluation of change. Improvements were found in awareness of transfer guidelines, adherence to transfer guidelines, SBAR communication skills, and provider satisfaction. This tool can be used in any hospital setting as it is simple, easily transferable, and uses common language.

Key Lessons Learned: I learned so much during this project that extends to nearly every setting I see today. As I told my instructor during my reflection the "knowing could not be unknown". I will never again be able to look at circumstances or conditions of people and healthcare with an untouched heart, mind, and attitude toward quality improvement. What seemed insurmountable in the beginning came down to learning the next natural step in small changes that led to big transformations. This global way of approaching client situations has also impacted the community by involving caring and appreciative stakeholders who want to bring the very best to the people they serve.

Faculty feedback: This project highlights a comprehensive use of process, outcome and balancing measures with corresponding run charts.  Not only that, it shows the importance of tracking adherence to the guidelines and protocols set out by a team. Simply creating and implementing guidelines and protocols does not automatically ensure adherence to them!

Project: Improving Event Reporting in the 9th floor CVICU at Clements University Hospital

Presenter: Patrick Roberts

Program: University of Texas Southwestern Medical Center

The health care industry frequently misses opportunities for self-improvement due to the general lack of a standardized process for the collection of event reports. Furthermore, a systematic means of mining vital information from collected event reports does not currently exist in health care. These problems present a barrier to the improvement of patient care not only on an institutional level, but on an industrial level. We formed a quality improvement team in order to investigate the current problem and develop a more systematic means to address both problems. A control chart showing the number of events reported per month increased as a result of the implementation of the anonymous, physical debriefing tool.

Faculty feedback: This presentation had a well-rounded and sophisticated approach to a problem and is a great demonstration of how a process map, key stakeholder analysis, cause and effect diagrams, and a Pareto chart create a strong understanding of one’s system and context. In turn, this will help teams realize both the gaps and opportunities for improving a process.

Project: Improving Hand Hygiene Compliance among Doctors

Presenter: Weixian Alex Tan

Program: Singapore General Hospital

Health care-associated infections (HAIs) result in high morbidity and mortality. Hand hygiene practices are recommended to reduce HAIs. Studies have shown that hand hygiene compliance is commonly lowest among doctors. We aimed to improve hand hygiene compliance among doctors by 10 percent through various interventions over a six-month period. During our project, the median hand hygiene compliance rate increased from a baseline of 53.8 percent to 75 percent, with a median compliance of 69.4 percent. The hand hygiene moment with the lowest compliance was after touching patients’ surroundings, with 37.1 percent compliance.

Key Lessons Learned: If you set a target and have a strategy to achieve it, you can succeed. However, this success does not mark the end of the work as one should continue to strive to sustain positive results and spread their initiatives more broadly!

Faculty feedback: Clear presentation of project aim and methods, and excellent analysis. This project demonstrates the power of leveraging medical students and junior doctors in quality improvement processes pertinent for hospitals and their patients.

Project: Improving Inpatient Care of COPD Exacerbations: Targeting Appropriate Oxygen Supplementation

Presenter: Radha Govindraj and Marianne Bauer

Program: Boston Medical Center

Excess oxygen supplementation in patients with Chronic Obstructive Pulmonary Disease (COPD) exacerbations has been associated with increased mortality. A chart review of patients treated for COPD exacerbations at Boston Medical Center showed oxygen administration orders could be improved. PDSA cycles included creation and distribution of a paper order-set/checklist to internal medicine house staff. Following the introduction of the paper order-set/checklist, there was an increase over time in the percent of patients who received nasal cannula with a formal nasal cannula order, as well as an increase over time in the percent of appropriate titration goals associated with nasal cannula orders.

Key Lessons Learned: We recognized the importance of starting our intervention with a small group before working on applying it uniformly across the whole institution. We also recognized the importance of creating a low-effort intervention in order to ensure sustainability.

Faculty feedback: This team took a comprehensive approach to address the problem and made excellent use of quality improvement methodology. Use of SMART aims and development of a project charter helped them move in the right direction. From there, a superb use of the checklist helped drive the improvement of the clinical process.

Don’t miss the data display (via the run charts) on the poster: it greatly contributes to understanding the impact of the team’s interventions.

Project: Naloxone Distribution and Training for Outpatient Veterans with High Risk Opiate Use

Presenter: Katie Raffel

Program: University of California, San Francisco Internal Medicine

We designed and implemented new clinic work flow with the aim of distributing naloxone to marginally housed veterans with high-risk prescription or recreational opiate use. Our team’s licensed vocational nurse (LVN) contacted high-risk patients, identified by electronic medical record (EMR), through use of telephone or in-person contact to arrange clinic visits dedicated to naloxone training. At these visits, LVNs and RNs distributed naloxone kits and trained patients in their use. MDs retroactively prescribed naloxone upon LVN/RN request. Utilizing this workflow, 91 percent of identified patients with high-risk opiate use were trained and had access to naloxone. We found that the interdisciplinary collaboration and front-line staff ownership facilitated this intervention's success and sustainability. 

Key Lessons Learned: Engagement and buy-in from front-line staff is extremely important. Our LVN champions created immense momentum for naloxone education and distribution.

Faculty feedback: This is a wonderful use of a quality improvement project to leverage a clinical site and a community site to help address a pressing societal problem from a population approach. The project goals were clear, as was the intervention plan.

Project: Reducing Preventable Readmissions for Patients with Diabetes on the Parkland Hospitalist Units

Presenter: Tim (Huan Ting) Chang

Program: University of Texas Southwestern Medical Center

Patients with diabetes are at an increased risk for 30-day, all-cause readmissions, which inflict additional financial and health burden on the patient and the hospital. The national benchmark 30-day all-cause readmission rate for patients with diabetes from 2010 is 19.8 percent, and within the hospitalist units at Parkland Hospital, the rate rests at 18.7 percent. While the two percentages are not truly comparable due to the six-year time lapse and population difference, our quality gap analysis found additional opportunities to further reduce preventable readmissions for patients with diabetes admitted at Parkland Hospital.

Key Lessons Learned: Making cultural changes in a health care setting requires patience — it takes time and continuous enforcement of changes. It is difficult to implement interventions that require work space and cultural change in a short-term, student-led QI project, but weekly meetings with my project mentor, my physician QI officer, and my QI education advisor proved to be very helpful in keeping me on track.

Faculty feedback: The project made excellent use of QI methodology that isn’t seen as often, such as the demonstration of completing a gap analysis to help inform the strategies used for improvement.

A special thank you our QI faculty reviewers:

Mary Dolansky, PhD, RN, Associate Professor, Case Western Reserve University School of Nursing; Director, QSEN Institute, Director of Interprofessional Integration and Education Center of Excellence in Primary Care, VA Quality Scholars Program Senior Nurse Fellow, Louis Stokes Cleveland VA

Sherril Gelmon, DrPH, Director, Health Systems and Policy PhD Program and Professor of Public Health, Portland State University

James Moses, MD, MPH, Medical Director of Quality Improvement at Boston University School of Medicine/Boston Medical Center; Academic Advisor, IHI Open School

Learn more about students work on community organizing projects in this blog post.

                                   

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