Welcome back, everyone. What a great morning. As we move to the afternoon, our focus is going to be on fulfilling our commitment to effective, efficient, safe, equitable patient-centered care. Truly, what we choose to measure along the way says a lot about us and the goals we want to achieve. It's my pleasure to invite Debbie back to start off this series of talks on best practices for leveraging data to improve our performance. Hand it over to Debbie. So we're going to talk about the do's and don'ts of quality improvement projects in our endoscopy units. This is my disclosure slide. So objectives, we want to talk about monitoring versus what is a study. We'll talk about rationale for having QI programs. Talk about some templates. And then we'll talk about some do's of doing studies and some don'ts. So are you conducting a monitor? Is it an activity or are you conducting actually a study? So you found a problem, and if it's an activity, the problem wouldn't need to change. So if you want a desired outcome, then it becomes a study. Activity should be kept as well. This will let you know if there's a change and if you should look at it again. For example, like handwashing. People always like to do those handwashing studies. You can continue to monitor those throughout the year, but if you see something that needs to change, then it should become a study and you want to see what you can do for corrective action, and then you'll remonitor that once you're done. So why do we have a QI program? And we want to know, are we following best practices? Are there processes that we can change to reduce our cost and the practice overall? And how can we help in the healthcare in general? Are the standard policies for the patient treatment that are followed throughout your practice, are they consistent? Are we treating patients differently in different areas or at different times? So doing the right thing well for the right patient every time is what quality is. The right thing is that it's evidence-based practice. It's based on regulatory guidelines and your standards of practice. How do we know we're doing it well? Well, that's when we go into benchmarking. We want to make sure that we're benchmarking internally or externally. You can use different facility sites, and you can use provider against provider for benchmarking internally. Find opportunities to improve. So how do we improve? Well, you don't know what you don't know. This is where you can do an activity to see if there's an area for improvement within the practice. What is needed to assess the quality? Well, you've got to have a purpose. It needs to be meaningful. You want to improve efficiency of your facility or the effectiveness of the care of your patients. You want to have a goal. This has to be attainable. Don't be unrealistic with your goal. If you can't achieve them, lower that goal a little bit. You want to make sure you're using reliable data. If your data isn't accurate, you're not going to have a meaningful study. So you want to use your improvement that you can measure, and you want to make sure that it's meaningful to your site. How do you achieve a definable outcome? You've got to make sure it's easily measured. Available or easily obtained data will make it easier, and it will save you some time. You want to make sure you have a clear definition of what you're looking for, especially if you have multiple sites or multiple people that are gathering the information for the study. It has to be scientifically valid. You want to make sure your desired outcome is what you want scientifically. You want to know that there can be some risk adjustment. So you want to use statistical techniques to adjust for the severity of the risk. So you're not going to compare a physician who possibly does ERCP with a physician who's a generalist. You want to make sure that it's fair when you're doing the comparison. You want to predict what the outcome should be given the set of the clinical characteristics. Models can be imperfect. The outcomes you should be looking for should be models that are provided and following what your governing body would set in your guidelines. You want to look at your process. You can't change the outcome if you don't change your process. You want to focus on reducing your variations within your unit. Use measurement to understand the process and the opportunities for change. Again, data accuracy is imperative for measurement. You want to set strategic priorities. Maybe you need to improve patient access to services you offer by your group. You might want to meet incentive initiatives. Maybe your group is growing with patient services. This may include your staffing or maybe even your space planning. Your accrediting agency want meaningful quality studies. Maybe you need to improve on payment collections. So what you want to do is you want to think differently. Ideas for change can come from a process or a policy that you may no longer fit the purpose that was intended. Your quality improvement project should be meaningful to the practice. Don't collect data that you're not going to be able to use. Most accreditation agencies are prescriptive as to what systemic approach they want you to use. Review your accreditation agency's standards and be sure to stay up to date with any changes. You want to be clear and concise. Templating your project is a great way to communicate to everyone what you're trying to accomplish. You can identify people that can help you. Involve others. Get the job done. But it also eliminates bias. So you want to make sure that you're getting people that can work with you. Organize your time. It will organize their time. Set up a template for your study project. What's preventing you from meeting your goals? What are the steps that you're going to need to change? Did that work? If it's yes, you can always monitor that down the road. If it's not, you can do another study. You want to standardize what worked and make sure it's in your policies. Things you don't want to do. As we mentioned earlier, don't set unrealistic goals. You'll set yourself up for failure. Set goals that are attainable. And you don't need to reinvent the wheel. Use formats that are already out there. There's a lot of groups that offer templates that they've already used. And look at your organization that does your accreditation. Don't let the dip get you down. Some changes do more harm than good. Remember, you are looking to improve your current process. You don't want to confuse change or activity with progress. Implementation dips can literally be the dip in performance and confidence when one encounters an innovation that requires a new approach. skill or understanding. So give it some time. Sometimes people need time to get used to that new idea. This is an example using a AAAHC format. You want to review the QI program and clearly state the purpose and the goal for your study. Is it quantitative? Based on the data, are you currently practicing at your set goal performance? Have you identified the performance goal? It will help you determine if your current performance is acceptable. Did you use a benchmark to determine that goal? You want to compare those current performances to that specific metric, whether it's internal or external. Is your goal SMART? That's a good acronym to use. So S means that it can be translated into an action, right? M, it's measurable. It means quantitative. You want a number. It's achievable. You want to be realistic about what you're able to achieve. For instance, if you want 100% of your patients to have their paperwork ready when they show up at the door, that's unrealistic. If you lower those expectations and work towards a process that maybe you can attain something to make the system work better, that's what you're striving for. Make sure it's relevant. It's got to be related to your organization and what matters. And then it's time bound. It means you've established a date for that completion. It's a QA or a QI. Current performance, if it's equal to or greater than what your goals is set, then that's an activity. Again, that hand washing. Okay, we want 90% of our staff to make sure they wash hands in and out of a patient's room. Well, we found out that they're actually 94%. That's an activity. Continue to monitor that. That's a good idea. Continue with current performance. If it's less than what your goal is, then you could consider a quality improvement study. What kind of things can we do to help people remember to wash their hands coming in and out of those rooms? Practice looking for potential gaps in care during your workday. You can do this by being in your unit, walk around, look for those potential gaps as you have meetings, talk to your staff, see what they're doing. This keeps you in the know on how your staff and your unit are functioning. So a list of some potential QI studies. Some people have done many of these, or maybe even all of them. Use study topics that you can start with monitoring to see if they are an activity based on your expected goals, or do you need to drive it into a study? So this is writing with the 10 easy steps. I actually use the 10 easy steps format. This can actually, and I actually list these specific blocks on my form. I want to state my problem. Why do I want to do this study? What am I looking for? Then I say, you know, what's the goal? What do I want to do with that particular problem? You want to describe how I'm going to collect my data. Well, I'm going to walk around and watch people, you know, wash their hands or not wash their hands, you know, five days a week or three hours a day. Then you're going to describe what actual data you've collected. Reviewing these staff members, I found that X number did or did not follow what our goal was. Then you have to analyze that. What's that data telling you? Are you, you know, at your goal? Are you below your goal? Do you want to compare that to that goal? And then you're going to implement any corrective action. What things can I do to make those staff members wash their hands? Then you're going to re-measure. Give it some time for that change to take place. As we mentioned, that dip may happen, right? You're not going to always, you know, go out of the gate and be 100%. You want to make sure you give the time for people to adjust to that new policy. Then you're going to re-measure. If it worked, awesome. You want to implement any additional corrective actions if needed, but you also want to make sure that you communicate your study and what you've done to change with your governing body. And you want to make sure that the organization is aware, hey, we made these changes. This is what's happened. We have less infection. Staff is not as sick, getting called off or whatever that may be because people are following proper hand-washing technique. Quality improvement should be an ongoing process. You want to have a committee so that once an area for improvement has been identified, you have a culture to support those projects. Listen to your staff suggestions for improvement. They're there on the ground. They're your frontline window to how your facility is working. Listen to them. Listening to them will help them feel supported. They'll feel empowered and they want to improve their daily work. So you want a quality culture. Develop that quality program and you want to develop the culture of change. You want to connect the individual and the organization on each side so that you have that change. The success of a company, organization change initiatives, or transformation requires rigorous consideration of the people side of change. Transformation project plans should include an explicitly defined change leadership program to engage the organization to bring it towards common understanding with common expectations. If you want to learn about culture, listen to the stories. If you want to change the culture, change the stories. Getting everyone on board and engaged and aligned is one of the most challenging aspects of a transformation. Identification of all your stakeholders, have clear and consistent communication, thorough education and training, and appropriate measurements for success. These are critical elements of this change leadership requirement for project success. I know we adopted having our medical directors in on our quality program, our nurse managers. We filter that down to supervisors and even some of our leads to help us collect information, assess the situation, and see if we need a project study or have we met those goals and what they feel would work best for that change. And again, you always want to report back up to your governing body. Development of the quality measurement program is the highest priority to set goals for your performance. You want your physicians, and as I said your staff, to be in an active participant in the program. Medical directors, they're on site, they're in the rooms, they watch staff, they know how things are flowing, your nurses know how things are going, and certainly your nurse managers will be on the floor. There's a lesson here for every practitioner and every specialty. Research and quality improvement not only is an activity for academic centers and funded investigators, but also needs to be part of the culture of everyday clinical practice. I love that. You want to make sure that every day you're looking to make the best quality care for your patients. In summary, you can't improve or manage what you can't measure. Know your leadership's expectations for quality. Be involved when initiating change. Put people there to support what they create.

leveraging data

improve performance

endoscopy units

quality improvement projects

evidence-based practice