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Obstacles and Successes: Reflections on My First Improvement Project

By IHI Open School | Wednesday, May 29, 2013

Editor’s Note: Colleen McCormick is a fifth-year medical student in the combined MD/MPH Physician Leadership Development Program at Wright State University Boonshoft School of Medicine in Dayton, Ohio. For two months she used the IHI Open School Quality Improvement Practicum to conduct her first quality improvement project. In this final blog post, Colleen reflects on her project and her progress as a student trying to make a change in the health care system. You can catch up on her previous posts here, and view her completed practicum project here.


This spring, I started a project to increase palliative care consultation in the medical intensive care unit at one hospital in our community. We followed the Model for Improvement to implement and monitor our interventions, and were able to reach our aim — to provide palliative care for 9 percent of all medical ICU patients — during the sixth week of the project!

We were thrilled, but we realized our journey was just starting in many ways. We had to make sure the improvement was going to stick.

During the past few weeks, we have continued to monitor our interventions and discuss new PDSA cycles. In the first six weeks, 20 percent of patients who screened positive for a consult received one. In the past four weeks, that dropped to 12 percent of patients. This decrease was concerning; despite our continued interventions, fewer patients who met criteria for palliative care were receiving consults. Further, those numbers meant the consult rate for all patients in the ICU had dropped from 9 percent to 6 percent. Translation: We were no longer meeting our aim.

As we started to think about the process and balancing measures affecting our outcomes, we found some other issues to address. Looking at the trends since week 6, we found that fewer patients were meeting criteria for a palliative care consult (26 percent of patients in the first six weeks versus 18 percent of patients in the last four weeks). In reviewing the screening tools during the past four weeks, I found that many tools were completed incorrectly, so many patients did not receive positive screens who should have. In addition, one patient had two admissions to the ICU during our study period; during the first admission, her scores ranged 7–8 (a positive screen is 5 or above), but on the repeat admission, she only had a score of 2. How many other patients were now being underscored on our tool?

We had started to drift away from our peak progress after six weeks. As we started to think about what might have changed, we realized that:

  • There were new nurses in the medical ICU who had not been exposed to the tool, and therefore weren’t sure how to complete it.
  • The ICU census had been higher in recent weeks; the nurses were busier, with less time available to complete paperwork like our screening tool.
  • Our physician champion was not around these past four weeks (he was getting married!), so we may have lost some momentum by not having him in the unit.

In summary, our interventions hadn’t become a true part of the daily workflow.

While it was discouraging to see this negative drift, we are still highly motivated to continue the initiative because we know it is best for patient care. In the past four weeks, Dr. W (my faculty advisor) and her colleagues on the Cancer Committee looked more closely at the patients who received palliative care consults. They retrospectively analyzed pain scores of palliative care patients pre- and post-palliative care consult, and found that the pain scores were significantly better for patients after the palliative care team got involved. That was good evidence for physicians and administrators, and many in the committee meeting were enthusiastic about using palliative care. Also, this week, Dr. W presented the summary of our initiative to the ICU committee (consisting of many ICU physicians). Many of the physicians were excited about the initiative, although some still expressed resistance to palliative care.

As I look back on the last 10 weeks, I am excited about what we have accomplished. We have increased the discussions about the benefits of palliative care for patients in the intensive care unit, and convinced many nurses, physicians, and hospital administrators that palliative care is beneficial for many patients and families. While we are not meeting our aim right now, we are optimistic that the culture change is happening; palliative care is becoming a part of the institution and the unit.

We will continue to promote palliative care in hospital administration meetings, re-educate the new nurses on the unit, spread the change to other units, and continue supporting and encouraging the physicians to utilize palliative care.

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