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Colleen’s First QI Project, Part 8: Learning that Change is Hard

By IHI Open School | Wednesday, March 20, 2013

Editor’s Note: Colleen McCormick, a fourth-year medical student from Wright State University in Ohio, is using the IHI Open School Quality Improvement Practicum to conduct her first quality improvement project.
Every Wednesday during February and March, Colleen will write a blog post about her progress as a student trying to make a change in the health care system. You can catch up on her
previous posts here.

By Colleen McCormick, fourth-year medical student, Wright State University


Last week, we started PDSA cycle #2 — use of a screening tool to evaluate patients for palliative care consults. We developed the tool with input from physicians and nurses on both the ICU and palliative care sides. And as I mentioned last week, we also used feedback from many of the nurses and physicians to continue making improvements.


With the support of our clinical nurse manager, we distributed the tools in the medical ICU setting; we educated the nurses educated in person and via e-mail on how to the use the tool. For all patients in the ICU, the tool was to be placed at the front of the paper chart, so that each time the chart was opened, the nurse or physician would be reminded to review the tool. The tool was designed to assess all patients on the day of admission to the ICU (day 0), on day 3, and on day 6, should the patient still be in the ICU.


Starting at the beginning of the week, we had 13 patients in the medical ICU. Eleven of the patients had a palliative care screening tool at the front of their chart. That means the tool was applied to 85% of the patients in the first week of the intervention. While we are aiming for 100% of our patients to be screened, this wasn’t a bad place to start! 


Next, I looked at the number of patients who should have triggered a consult from the screening tool. In other words, I wanted to know which patients had a score above our threshold and could have benefited from palliative care. (You may recall that we are aiming to increase consults from 3% of patients to 9% of patients in the next six weeks.)


During week 1 of the PDSA cycle, we had one patient that scored above the threshold. Unfortunately, this patient did not receive a palliative care consult. The other 12 patients did not meet criteria for a palliative care consult based on the nursing assessments of the patients. So in summary, our consult rate was 0% in week 1.


As an additional step, I looked through the charts of the patients who had been screened, to compare my own assessments to the assessments of the nurses. The goal was to make sure that the nurses were educated correctly on how to complete the screening tool. As I was looking through these tools, I noticed that some of the screening tools weren’t filled out completely or correctly. Also, I discovered that my assessments were more likely than the nurses’ to trigger palliative care consults. I determined that 5 out of 13, or 38% of the patients, could have benefitted from palliative care.


Why did our assessments differ by so much? I will have to meet with the nursing team members to discuss the differences and consider additional educational sessions with the ICU staff.


This week, we will be having a team meeting to discuss where we are and where we are going. We will be going back to the basics, looking at our fishbone diagram, and brainstorming future PDSA cycles, as our results in week 1 were not as promising as we had anticipated.


Do you have any ideas on other changes we can test?

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