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Colleen's First QI Project, Part 10: Lessons Learned and Moving Forward

By IHI Open School | Tuesday, April 2, 2013

Editor’s Note: For the past two months, Colleen McCormick, a fourth-year medical student from Wright State University in Ohio, has used the IHI Open School Quality Improvement Practicum to conduct her first quality improvement project. This is Colleen's final 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


During the past 10 weeks, I have written posts about a palliative care initiative at a hospital in Dayton, Ohio. An interprofessional team from the hospital identified a gap in patient care: We were not encouraging end-of-life care in our most critical units. More specifically, palliative care was only being consulted for 3% of the patients in our medical ICU, and based on a review of patient charts we felt that 26% of our patients could benefit from it. Our goal, as a start, was to provide palliative care for 9% of the medical ICU patients.

The medical literature provided a strong argument for us to turn this gap into an improvement project, as palliative care utilization can lead to improved patient and family satisfaction, improved provider satisfaction, and even decreased costs and decreased hospital stay. With our team, we developed educational sessions for the medical ICU nurses and the trauma team, and implemented a decision-making tool for the nurses and physicians to use.

Since implementation of that tool three weeks ago, we have seen our process measures improve tremendously. This week, all of the patients passing through the medical ICU had screening tools on their charts, and nearly all of the tools were completed correctly. The ICU nurses have adapted to the change, are pleased with the tool, and are excited about improving care for their patients. Several ICU physicians are champions for the project, and they have been asking nurses to report each patient’s screening score during morning rounds. With all of these improvements in such a short time, we feel that we are on the right track to increasing palliative care utilization in this hospital.

During the previous week, we saw our first palliative care consults since implementation of the tool: two consults were placed, which equaled 9% of the patients passing through the medical ICU. We achieved our goal for the first time! However, the screening tools completed by our ICU nurses showed that nine patients (39%) could have benefitted from a consult. (Nine percent is our aim for the first phase of the project, but in the end we hope all patients who could benefit from palliative care are offered that level of care.)

If you’ve followed my posts, you also know we’ve been struggling a bit to change physician behavior.

Last week, we received a suggestion to review a 2009 article by Kenneth Cohn: “Changing physician behavior through involvement and collaboration.” I found this article very helpful. We do have some physician champions and positive deviants (e.g., incorporating the tool into daily rounds), and we will continue to support these aspects of the initiative. The article reminded us to celebrate our small wins. We have already made some significant changes in the day-to-day operations of the medical ICU. Now, it’s time to let the staff know what they have accomplished, and celebrate this progress!

(We also enjoyed the part of the article entitled “healthy competition.” This strategy has been used at our hospital for other initiatives, and we think it may work in our initiative, too!)

So, where do we go from here?

I think it’s clear that we still need to support physician behavior change, and we need to give the change some time to happen. Also, we need to start thinking about our goals for the future. As the nurses are now comfortable and satisfied with the tool, it’s time to spread the tool to other intensive care units, and other floors of the hospital. Patients we see in the ICU may be at their sickest, but that doesn’t mean they won’t need palliative care when they are discharged or transferred to another unit. We need transparency and care coordination (and some healthy competition) throughout the hospital. By scaling up the project at this point, we can increase the presence of palliative care and slowly start to change the culture in each unit. We have scheduled times at two large hospital meetings in the next month to bring our project to the attention of the rest of the hospital, share our wins thus far, and talk about our next steps. We will continue to educate the staff and encourage the physicians and nurses on board to make palliative care a part of their daily considerations.

If you have ideas about how we can improve our project, please pass them along! I will write periodic updates about our progress and barriers, and I look forward to your feedback. Thank you for sticking with me through the first phase of this quality improvement project!

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