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Colleen's First QI Project, Part 9: Still Trying to Move Our Outcome Measure

By IHI Open School | Wednesday, March 27, 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

We are now entering week 4 of our PDSA cycles, and we are seeing some improvements in the intensive care unit!

Last week, I shared the data after week 1  of our second PDSA cycle, a screening tool that identifies patients for palliative care consults. The nurses in the medical ICU were starting to get a feel for the tool, but many were not filled out correctly. In addition, only one of the ICU patients was identified as possibly benefitting from a palliative care consult. In regard to outcomes, no palliative care consults were placed.

Our team met early last week to review this data. We had representation from the ICU nurses and from palliative care. Together, we reviewed many of the screening tools and discussed our next steps.

Mr. Q, a nurse manager, recommended several small interventions to the education. He would continue to encourage the nurses to complete the screening tools, but would also give additional reminders via e-mail and in person on how to complete the tool correctly. In reviewing the process measures for week 2, I found that his education significantly improved how the nurses filled out the tools. Almost all of the tools were filled out correctly and completely. And the nurses identified 25% of medical ICU patients as possibly benefiting from a palliative care consult!

Next, Mr. Q offered to meet with the trauma nurses and physicians. (Many of the patients who are admitted to our medical ICU are on the trauma service, so targeting these nurses and physicians, we thought, could help us increase palliative care utilization.) The trauma team was energized by Mr. Q’s presentation, and they asked if they could hear from palliative care, as well. This meeting is now scheduled and all are looking forward to it.

In essence, we performed PDSA #1 again with a different group of providers, and at the end we found new champions for palliative care!

Finally, Mr. Q suggested making the screening tool a formal part of nursing rounds. In this particular ICU, the nurses and attending physicians round quickly on each patient in the morning, prior to formal rounds with the medical team. During this morning discussion, nurses are able to share vital information such as overnight events. By sharing the screening score for each patient early in the morning, the attending physician can start to think about the best care plan for the patient, and he will already have palliative care in the back of his mind for those sickest patients. This next PDSA cycle will hopefully be implemented over the next month.

While all of these process improvements and our two PDSA cycles are on the right track, our outcome measure of increasing utilization for palliative care in the medical ICU still isn’t improving. We had zero palliative care consults this week.

This outcome measure is asking for physicians to change their behaviors, and we do not expect it to change overnight. Hopefully with continued emphasis from the nurses, new champions like the trauma nurses and attendings, and screening tools continuing to be completed on each patient, the medical ICU attendings will start to catch on.

We are not disheartened. Already, we are seeing nurses paying more attention to long-term outcomes for their patients, and soon, we hope, many physicians will, too.

What tips do you have for changing physician behavior? I’d love to hear any feedback you might have!

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