Meredith Rodriguez: Welcome everybody, I see that a few are still trickling in so i'm going to give us just a couple more minutes, let everyone join and then we'll get started here shortly.
Meredith Rodriguez: there's just a few more coming on, but why don't we go ahead and get started.
Meredith Rodriguez: So, welcome to our final learning session on quality improvement, and this is the final session phase one tech workforce development collaborative we've gone through.
Meredith Rodriguez: 697 of our pediatric readiness areas of focus and today and will be our final one on quality improvement methodology.
Meredith Rodriguez: So let me just jump in with our acknowledgement and disclaimer the emergency medical services for children, innovation and improvement Center is supported by the health resources and services administration krista.
Meredith Rodriguez: Of the US Department of Health and human services as part of the following award number.
Meredith Rodriguez: totaling 3 million was zero percent finance non governmental sources, the contents are those are the authors and does not necessarily represent the official views of nor an endorsement by herself hhs or the US Government for more information, please visit her sit back.
Meredith Rodriguez: And, as usual, the recording of this session will be posted to our website here under the following link.
Meredith Rodriguez: is continuing education, we have no conflicts of interest to disclose here are stealing learning objectives and reminder, you must attend the live session to be eligible for credit.
Meredith Rodriguez: And let me see where we are working very thoroughly on trying to get to all your seed credits, the nursing see was on a rolling basis, so please be patient with me, so there is a lot of y'all and she's working as hard as you can to get the nurse and credits out to you all.
Meredith Rodriguez: After today's session we will work on getting the pre hospital principal taxi awarded to all that attended the live sessions.
Meredith Rodriguez: Quick reminder and we want to hear your thoughts, so when you see this icon we have a couple questions throughout today's talk to go ahead and put your ideas or experiences in the chat box.
Meredith Rodriguez: And so we have two speakers today, the first one being myself, I am.
Meredith Rodriguez: The associate product manager for both our collaborative and our state partnerships domains.
Meredith Rodriguez: As well as to a certain extent, or disaster for a little bit longer, and then you have heard from lewiston solace before.
Meredith Rodriguez: He is our EIC director of operations but has spent quite a long career in the pre hospital space around quality and safety, it is, I say resident QA expert and so you'll hear kind of his expertise today.
Meredith Rodriguez: Just a quick reminder.
Meredith Rodriguez: These two registration we extended to tomorrow so end of the day, tomorrow you still have some time to sign up for phase two if you would like to.
Meredith Rodriguez: You should have received a link to register for that and send it out a couple times with please email me if you're interested in participating in phase two.
Meredith Rodriguez: And don't have your link and I will I will send it to you, and as a reminder here the different project areas that you can choose from.
Meredith Rodriguez: Focusing either on the petrol equipment supplies and medication policies and procedures or keratin competency, so you have a lot of leeway within each of these areas.
Meredith Rodriguez: To kind of build a project that you like really have your own choosing, and we also have several tracks are msc program managers around pipe recruitment or a directory, we can talk more about that in the breakout.
Meredith Rodriguez: If you're looking for a project idea really where to start that was kind of the design behind the environmental scan worksheets that came with each of the focus areas, those are really designed to help you walk through those focus areas and identify.
Meredith Rodriguez: gaps or areas that could could really use improvement and those would be a great area to design a product around you can also if you have taken the 2021 national pediatric readiness assessment that's a great place to start as well.
Meredith Rodriguez: If you're ready to get your ED nurse manager should know.
Meredith Rodriguez: and have your score in your gap analysis, if not, you can contact your state or territory msc program manager.
Meredith Rodriguez: And they can work with you to to get back to you and I will show you how to get that the how to find their contact information here at the end um.
Meredith Rodriguez: Quick snapshot again of what phase two will look like and each month we're going to focus on a different aspect of the QA project.
Meredith Rodriguez: process which Louis and I are going to detail for you today and really kind of give you an idea of what this process looks like.
Meredith Rodriguez: so that you can really determine if this is something you want to be involved with so many seeds the days and i'll show you the calendar on the next page is not a huge amount of time.
Meredith Rodriguez: But really our goal here is just to get you set up to really understand how this process would work and really get to a point where you can implement maybe your first pdsa cycle, you probably won't have time to finish differs pdsa cycle, by the time collaborative ends in June.
Meredith Rodriguez: And so, as we get into some of these later dates where you're communicating progress or by June 2 sort of evaluating your progress.
Meredith Rodriguez: and deciding if you're going to continue or adapt or Dr abandoned.
Meredith Rodriguez: At this stage kind of later we may be getting a little creative where you can kind of maybe imagine what your project might be and add some some data in there and we'll show you we kind of did that, with an example project for today's webinar so you'll see how you could go about that.
Meredith Rodriguez: So, here it is i'm at a glance we just have we have two dates in March i'll get into more depth on each of these dates days kind of consistent and the next slide.
Meredith Rodriguez: But approximately one April one May to June again these red dates similar as phase one has been are just coaching sessions, where you can come and have your questions answered, and we can spend a little more time working through your project.
Meredith Rodriguez: And once again here's kind of the topics of each day and as a oh I don't think I.
Meredith Rodriguez: pointed this out on this side is that for each of these sessions, you as a participant will be filling out one to two sides.
Meredith Rodriguez: That that you're going to share with the group with information about your projects so um so the way this will work is read sessions are going to be 90 minutes long.
Meredith Rodriguez: The first 10 minutes or so we're going to do welcome and overview of the topic of the day.
Meredith Rodriguez: And then go into small breakout rooms, which each we'll have a Q I coach and that's where you'll present your side here's mine statement here this morning.
Meredith Rodriguez: And, as a group will kind of discuss and will really work to improve them and give you some direction some advice or maybe.
Meredith Rodriguez: learn from each other, so this is really where this idea of a quality improvement collaborative really comes together.
Meredith Rodriguez: And then we'll come back to the main room for the last 20 minutes or so, to review the topic for the next session so.
Meredith Rodriguez: say in the first session we're working on your aim statement and your stakeholders, the next session will be working on measurement so the last 20 minutes or so will prep you to get ready to think about how you might measure how you might implement measures for your project.
Meredith Rodriguez: So kind of your participation expectations for phase two you will be expected to share your work and the way this is going to work is the Sunday preceding the Thursday session.
Meredith Rodriguez: will have you submit your side, the link that I will send to you and then those slides will be sent to every small breakout and their coach to review and prior to the session.
Meredith Rodriguez: So, because of this, you must be working on a project to participate in face to simply just observing it will not be permitted, and the sessions will not be recorded for later viewing.
Meredith Rodriguez: So once again fees to do the cliff area registration and have until the end of the day, tomorrow, to decide if you'd like to participate in phase two and then we will kick off.
Meredith Rodriguez: Phase two on march 17 talking about key stakeholders and investments so you'll hear a little bit more for me via email if you've signed it up, if you chose to sign up for phase two and, once again, if you haven't got your link email me, and I can send it to you.
Meredith Rodriguez: So i'm shifting back to February focus on quality improvement methodology for today quick agenda go through kind of the overview on the importance of quality improvement and talk about a little bit of the difference between quality improvement in quality assurance.
Meredith Rodriguez: And they will introduce our model to how we approach to it, which is leading the is a model for improvement we'll walk through that and.
Meredith Rodriguez: How do you begin and then we'll dive into what is a pdsa cycle and how to go about doing a pdsa cycle.
Meredith Rodriguez: And then we're going to go into some breakout sessions, where you'll hear from some wonderful practitioners from around the country who have been working on QA projects in the pediatric readiness space.
Meredith Rodriguez: So with that i'm going to turn it over to do is to take us through the first part.
Louis Gonzales: Thank you meredith and welcome everyone to.
Louis Gonzales: As meredith stated, there are last session of phase one to die, which just happens to be one of my top three favorite topics to talk about.
Louis Gonzales: So we're going to just dive right into it our purpose today is to really further our understanding of how quality improvement methodology can be employed in pediatric readiness.
Louis Gonzales: And we're going to try to use some some specific examples and provide you with kind of a roadmap, of how to do this, how to do it simply and try not to make it too too complex.
Louis Gonzales: and hopefully we'll answer some of the questions that you may have had about what this face to kind of thing will look like.
Louis Gonzales: And if we don't answer your question before you'll ask your question because we're happy to answer them so we're going to just dive right into this, if my tools work.
Louis Gonzales: There we go so we're going to start off with.
Louis Gonzales: A little bit of what is this QA thing, what is it really and how does it different from this other thing that we may have heard of called QA so quality improvement and quality assurance.
Louis Gonzales: And why is all this stuff really important and, of course, part of what we want to talk about is how does it help me with improving pediatric emergency care in my specific setting.
Louis Gonzales: So that's what we're going to do and we're going to provide a roadmap for you so hopefully give you something you can you can do something with, especially in phase two so we're going to start off with For those of you.
Louis Gonzales: Those who know me know, one of my favorite authors is is someone named Simon cynic and Simon cynics has written a number of.
Louis Gonzales: Books on different types of topics and one of them is is start with your why and just a reminder of our particular why, when talking about quality improvement in pediatric emergency care is our Why is really about.
Louis Gonzales: Improving the care that we we each of you and your specific settings which whatever setting that may be.
Louis Gonzales: Why we do what we do and why we do what we do is really not about quality improvement, I doubt that any of you have on the sign outside your organization door is quality improvement, but really it's about.
Louis Gonzales: Children and how we take care of the best and providing mercy care to them, so the y is really about our children.
Louis Gonzales: But quality improvement is a big part of our how it's how we take care of them and how we take care of them to the best possible way.
Louis Gonzales: And within each of our own institutions and so process of how is what we're going to really focus on quality improvement but there's no question that our real focus is still about children and how we take care of them and in your specific setting on pediatric emergency care.
Louis Gonzales: So let's talk a little bit about what this quality improvement thing is person has a broad definition of quality improvement there are many definitions will see it up there, but there's some key words in this definition that I think are important for us to kind of keep in mind.
Louis Gonzales: I broke out the definition into three different segments here, but really started with the first one it's systematic, meaning there is a specific process.
Louis Gonzales: That we go through, and the process is really defined in science it's defined in a way that has been proven to be effective.
Louis Gonzales: In terms of improving the quality of whatever you're looking at in our case it's the quality.
Louis Gonzales: Of pediatric emergency care, but it could be anything else but it's systematic in that there is an actual process that involves specific systems that we try to impact.
Louis Gonzales: and quality improvement is continuous it's not static it continues to move the targets move sometimes.
Louis Gonzales: but so do our process, these are processes are not static hopefully they're not, and so we change things and sometimes the outcomes.
Louis Gonzales: Or the desired outcome changes and so again it's continuous in that as things change the process of quality improvement changes as well.
Louis Gonzales: and quality improvements really about improvement, obviously, because that's the name but it's more than just me saying hey I made some improvement.
Louis Gonzales: it's more about can I measure that and can I measure that, in a way that demonstrates this really was improvement.
Louis Gonzales: And that improvement led to what we want, which is an improvement in the services that that I provide or my organization provides.
Louis Gonzales: Or the health status, the health of the people that I serve in this case the children that we serve.
Louis Gonzales: And that's what we're looking for in quality improvement is that we can actually measure the improvement and that improvement actually leads us to better services in taking care of children or.
Louis Gonzales: Improved outcomes for those children and that's one way to look at quality improvement and again our target population for our aspect of quality improvement that we're talking about today is the pediatric population.
Louis Gonzales: Alright, so let's talk just real briefly about this, these two different terms of quality improvement in quality assurance and probably if we pulled all of you.
Louis Gonzales: You may have most of you probably heard both terms and some of you i'm sure know the differences, so we just want to kind of real briefly.
Louis Gonzales: Talk about the differences and both quality assurance and quality improvement, they each have their purpose and they each have their place.
Louis Gonzales: In in the work that we do to improve but they're different perspectives so let's talk about quality assurance first if we looked at the outcomes for a specific patient population.
Louis Gonzales: And we essentially graph those and looked at the distribution like what you see in the chart here and keep in mind, each of these boxes is roughly 100 hundred cases of.
Louis Gonzales: whatever's going on with the population that you're looking at so so across the graph these are a lot.
Louis Gonzales: of cases and they're just spread across this graph with the left side of our graph showing the outcome that we want excellent outcomes and the right side of this graph showing.
Louis Gonzales: undesirable outcomes so poor outcomes not the part that we want and then there's the kind of middle of the road ones, which gives us a specific mean and that's what you see here in the Church.
Louis Gonzales: In quality assurance, our focus really is on the outliers meeting the poor outcomes on the far right and are focusing quality assurance says, how do we get those corrected.
Louis Gonzales: So that they meet the specific standard that we want the standard type of whatever it is that we're we're after.
Louis Gonzales: And it's these outliers that's our real focus and in quality assurance, our aim is to try to shift those towards the left, towards the better outcomes.
Louis Gonzales: And our focus, often in in many aspects of quality assurance is on the the the, as you can see here roughly two standard deviations so roughly it's.
Louis Gonzales: Two two and a half percent of this population that we're looking at here in this graph.
Louis Gonzales: So small portion but that's what we're starting that's what they're starting point is looking at this outlier this this group of outliers.
Louis Gonzales: And we're going to shift those to the left with our quality assurance and so when we shift those yes we shifted those those far rights cases so that was good that that's a positive thing and we shipped to them towards a better outcome.
Louis Gonzales: But if you notice on this chart, what do you see that change on the far left or what changed the middle kind of the middle part of its distribution.
Louis Gonzales: Well, nothing.
Louis Gonzales: And the reason it didn't this because that wasn't our focus our focus is really on those outliers ones that didn't meet.
Louis Gonzales: Our specific standard that we're after so quality assurance is is helpful and looking at.
Louis Gonzales: at ways to make sure you achieve a specific standard sub defined standard and it's used more commonly in compliance kinds of matters and that's for many of you may have run into this and it does have a place.
Louis Gonzales: In specific compliance kinds of issues and often those are things that have to do with.
Louis Gonzales: Things like accreditation and and other things that have confined standards, standards, maybe regulatory kind of aspects, so the result is yes, we improve care, but it was minimal because it only affected a small part of the population that we were actually trying to serve.
Louis Gonzales: If we look at that, in contrast to quality improvement same population same case distribution in this graph.
Louis Gonzales: But the difference here in quality improvement is, we want to now focus on the majority of the cases, not the outliers but the majority of the cases and we want to change that.
Louis Gonzales: Obviously, or changes we want them to shift more towards the left, so that we have performance it's more towards the left excellent outcomes.
Louis Gonzales: which, if you do that, it automatically by definition means you have fewer on the right so that's quality improvement is we're trying to focus on the majority, and if you focus on the majority.
Louis Gonzales: Then really it's referred to as focusing on the end liars instead of the outliers and you can.
Louis Gonzales: You incorporate specific changes we refer to them as change strategies specific actions that you implement to try to influence.
Louis Gonzales: The change of outcomes being more towards the excellent side and less towards the poor outcome side.
Louis Gonzales: And those changes in processes are structural elements or other things that influence your outcomes that's quality improvement and so when we implement that we're going to try to shift everything the majority.
Louis Gonzales: towards the left and when we do that we expected distribution this graphic is a little exaggerated, but the idea is over several iterations of changes.
Louis Gonzales: This is really what you would expect to accomplish is small changes over time that can that add up and and actually show the majority of the cases shifting towards the excellent side and, yes, you still have some that are more towards the right.
Louis Gonzales: But notice the ones towards the right in this new graphic are actually closer towards excellent outcomes, then they work towards poor outcomes, as we saw with quality assurance.
Louis Gonzales: So it's repeated changes that come together to change systems and processes that result in better outcomes as a whole, rather than just looking at the outliers.
Louis Gonzales: And that's our very simplistic way, but still an important way of looking at the differences between quality improvement quality assurance if I really look at that super simply.
Louis Gonzales: It looks a.
Louis Gonzales: little bit ahead out i'll show you even simpler view here in a second, but when we look at quality improvement what's involved in that this is what we're going to walk you through in the next few minutes.
Louis Gonzales: it's really taking a specific problem or something that I want to do better with something I want to improve.
Louis Gonzales: identifying a specific goal, what is it that I want improvement and how do I what is that improvement.
Louis Gonzales: Creating what we have all been talking about now for a few weeks called something that's an aim or an aim statement some specific target that's measurable and time defined.
Louis Gonzales: And actionable we take that and then we say okay what strategies can use to create this change this improvement and then, how do I measure that that occurred and then.
Louis Gonzales: When I studied that what am I looking for, and then we think of that as a cyclic kind of activity that's quality improvement it's continuous systematic process, as we saw in the first definition of quality improvement.
Louis Gonzales: it's not.
Louis Gonzales: A nice manual have simple answers every time you have this you do this for a number of reasons, one of those critical reasons is each environment is a little different.
Louis Gonzales: And even if we look at whether it's to hospitals or to Ms agents use for to medical practices they're not exactly a light and each of them may have their own specific environments that cause.
Louis Gonzales: Some things to work well and one, but not as well in the other and so each of them has to be taken, taken kind of individually, but the process, the model that we use is the same.
Louis Gonzales: it's just the way that you implement the your particular strategies or what strategies might be different, so, if you look at that really super simplistically.
Louis Gonzales: Quality Assurance is this rear view mirror approach or Where are you and how did you do, are you trying to go, did you get there, yes or no, did I get there.
Louis Gonzales: And that's quality assurance it's looking backwards it's fairly static because it's a This is where we work that I get to where I wanted to get to.
Louis Gonzales: And it's and it's almost a binary kind of thing, yes or no and that's the compliance aspect, yes, you met the standard or not.
Louis Gonzales: quality improvements, a little different different perspective in that it's looking more forward where you want to be in terms of the ideal outcome, or the ideal process.
Louis Gonzales: And so it's more future oriented and it's a little bit more dynamic, because it takes changes, sometimes to be able to get there.
Louis Gonzales: it's how you get there, those are the actions you're taking to be able to try to get to where you want to be again both ui and QA have a place their perspectives are very different.
Louis Gonzales: So it really kind of depends on what you're looking at if you're looking at something that we meet a specific standard or not that's more of a QA approach if it's more of this where I want to be and we're not there, but i'd like to be there that's more of a QA.
Louis Gonzales: Six years man.
Meredith Rodriguez: Yes, thank you a little delayed.
Meredith Rodriguez: So what we want to take you through now is really kind of one approach to Q I, how do I, how can we go about really implementing kind of all those those those things you saw in the bubble that loose showed you.
Meredith Rodriguez: So, so you know remember this is this is one approach to QA and there there, there are several approaches out there, the model that we use is the Institute for healthcare improvement or ihi model for improvement.
Meredith Rodriguez: it's one of the most it's a common commonly used models of quality improvement, he was in the healthcare industry and and it's really you know.
Meredith Rodriguez: relatively simple in nature, so it consists of three questions and then the sequencing I think these questions is not absolute um but addressing each one is important to really put together kind of a cohesive.
Meredith Rodriguez: Q I approach to a problem.
Meredith Rodriguez: So what are the three questions it's one, what are we trying to accomplish, how will we know that a change isn't improvement and what change can we make.
Meredith Rodriguez: That will result in improvement so we're going to break this down and walk through each of these we'll talk a little bit about the process and the tools that you can use.
Meredith Rodriguez: To get to improvements areas so quick side note the examples here in the following slides are there fictitious they're incomplete they're really just for illustration purposes.
Meredith Rodriguez: I know you know, this is not has not been a real ui project it's really just an example, so the first question, you know what are you trying to accomplish so.
Meredith Rodriguez: You know this this it's focusing on end, meaning like what what what is the performance but the outcome.
Meredith Rodriguez: That we want to see so some might phrase this a little differently, in turn, what is the problem that we're trying to solve.
Meredith Rodriguez: And this is where you can use some tools around root cause analysis or asking you know the five Wise tend to get into really kind of.
Meredith Rodriguez: What is the true problem that you're trying to solve, because sometimes our first inclination of the problem we're trying to solve or what we're really trying to accomplish may not be the true source of the issue.
Meredith Rodriguez: So in defining this we will create a smart game some some can start often start with a global aim for a purpose before you create an aim statement and that's a simpler way to go, and it can really help your QA team better understand issue.
Meredith Rodriguez: So in this example we're going to use this purely fictitious example.
Meredith Rodriguez: And that let's say we, you know we conducted environmental skin of our ED we looked at some past measures surveyed our staff some other things you can do patient satisfaction surveys and and we found that.
Meredith Rodriguez: You know, maybe our pediatric cases with extremity trauma really weren't receiving the appropriate amount of analgesics to treat their pain and so.
Meredith Rodriguez: We kind of processed out map out what I deal with look like, how do we really want this to work, and then we came up with the following.
Meredith Rodriguez: You know, we thought, maybe we can we can increase the number of pediatric patients receiving Jesus by 20% so he said, and I think we can do this by August.
Meredith Rodriguez: So we said by August 1 2023 will increase the appropriate utilization of analgesics to pediatric surgery trauma patients for 20%.
Meredith Rodriguez: So there's your complete smarter team and we've talked about smart names, a couple of times down in previous sessions will talk more about him if he joined us and phase two and really how you make an aim smart, but if I was to take one step back here.
Meredith Rodriguez: and talk about kind of the global aim, and that this so this would have been our globally if we treat pain and children with extremity trauma.
Meredith Rodriguez: We may improve assessment capability improve patient satisfaction and or reduce complications and then I, as I mentioned before, work with our QA team to say okay and.
Meredith Rodriguez: How much do we think we can be can increase the treatment of children and and by when do we think we can do so you're getting really a lot more specific and that's how you move towards making it more this morning.
Meredith Rodriguez: So so once again smart being specific, measurable achievable, realistic and time round, and again this is just a simplified example, but a good way to get there.
Meredith Rodriguez: i'm a little a little side note here, but I think it's really important in reiterating, and this is not one of the three questions in the is a model for improvement, but I think it's really.
Meredith Rodriguez: One that we think is crucially important, and I think he does till she's not distinctively call it out in the model.
Meredith Rodriguez: And that really isn't you're not doing this in a vacuum so really as you heard from Kate last month there's there's tremendous value and taking the time to build a strong team and consider you know all of the players that can help you or who are affected by what you want to do.
Meredith Rodriguez: So this can be involved, your leader or a project manager a QA expert or a Q I coach if you do face to that can be yes for you subject matter experts, we can connect you with those as well.
Meredith Rodriguez: But also, if you're doing on your own really kind of find out who who who knows pizza little well and who can be involved in my project frontline staff and other impacted stakeholders.
Meredith Rodriguez: And then, what you do with them is you know share your aims or ideas or hypothesis, and then as a team, you can really work through creating your own statement and going through some of the next questions in the ihi model.
Meredith Rodriguez: And some tools to think about and we went through these i'm last month's call is really thinking about.
Meredith Rodriguez: Maybe, creating a stakeholder grid where you're really looking at who are kind of all of your major players and how you need to involve them in the project um and then Krishna important is to really kind of look at your organizational leadership in that structure.
Meredith Rodriguez: so that you can get kind of an idea of really who needs to be involved and kept informed of your of your project.
Meredith Rodriguez: And then later has you know I have maybe have more experience with doing this, you can take on some of these.
Meredith Rodriguez: it's a additional but not necessarily crucial aspects of a project that creating a project charter that defines the scope and responsibilities and roles and provides sort of this team with a basic.
Meredith Rodriguez: baseline through I framework so.
Meredith Rodriguez: that's kind of get your team together and really address this first one i'd say together, maybe you have an idea build a team and then really tackle what are we trying to accomplish.
Meredith Rodriguez: So the second question, and really these next two questions, as I mentioned the beginning, can be an either or but let's start with the second question.
Meredith Rodriguez: And that is how will you know that change is an improvement, and I want to add, how do you know that it changes occurred.
Meredith Rodriguez: Because those can be different two different things right, a change isn't always an improvement, so we need to know a change occurred, what are you going to measure, so that you know, a change.
Meredith Rodriguez: occurred and then, how do you know, it was an improvement So what are the specific measures and and which direction of those measures indicates improvement.
Meredith Rodriguez: And then, finally, you know, is this data available, do you have access to it now take a look at the data systems within your organization look for for standards as a starting place.
Meredith Rodriguez: For change may already be being measured, you know I work with your quality department anyone has really done this, even if primarily with adult cases.
Meredith Rodriguez: So there are may already be collecting this data and then really kind of take a look at that data and think about is this reliable data is it reliably recorded.
Meredith Rodriguez: Or maybe maybe not and maybe that could be one of your first change guys we're gonna find out next one is really good documentation practices is that may be, where you start.
Meredith Rodriguez: So in our example remember our aim was to increased by 20% the number of pediatric extremely trauma cases receiving it will use it, so what we're going to do.
Meredith Rodriguez: Is we're going to create an emr query for the number of children with extremity trauma and then we're going to sort those by those receiving analgesics and then sort those by document can continue to keep indications and identifying adverse events we might also perhaps be approximately.
Meredith Rodriguez: Around South patient satisfaction or decrease pain so where can you look, you can look in your data systems and like I said new standards for your health care, setting or you can create some of your own.
Meredith Rodriguez: So we'll talk a little bit more about measures in a second but let's it really the measures directly reflected with your smarting so what what ideally, would you like to measure.
Meredith Rodriguez: What are you absolutely want to make sure that you include How would you measure it and then next, how can you measure it.
Meredith Rodriguez: Is that feasible, can you actually access that data is it going to be kind of a really involved process to access that data, and if it is maybe there's proxy measures that you can use.
Meredith Rodriguez: And what data is available so, then you really want to make sure you define those measures clearly define those measures so that you know what exactly.
Meredith Rodriguez: you're pulling and what do you want to analyze and then I think probably the most important thing to call out on this side is that remember before you implement any change to collect baseline data.
Meredith Rodriguez: So that will not only give you a great idea of what your starting point is so you really need to know that the changes occurred to know that if it's improvement, you really kind of need to know where you started.
Meredith Rodriguez: This will also help you identify any potential issues with data collection and analysis or being able to feasibly collect the data reliably to collect the data.
Meredith Rodriguez: And so, definitely important to remember to click the baseline data before you implement on your team strategy so even more on measures in a few minutes.
Meredith Rodriguez: Measures can be its own whole talk there's a lot to learn about measures, but just kind of as we're thinking about the the whole process measures is one of them we'll talk some more in a minute.
Meredith Rodriguez: So, finally, the third question and the is a model X asked us to define a change strategy, so what change can you make that will result in improvement, so this is what you're actually going to do.
Meredith Rodriguez: And some find it useful to start to please places, you can start as a key driver diagram.
Meredith Rodriguez: And we have actually included those with all of our focus area guides leading into this, and so, if you remember it kind of has this these boxes and these like smaller boxes coming off each one of those that talks about.
Meredith Rodriguez: General areas of change, you can make like communication and resources and then specific chain team strategies within their that you can.
Meredith Rodriguez: might want to implement, and you can do this with your team, and you can really look through like what are some of our options that we could do what are some of our possible change strategies.
Meredith Rodriguez: You can also use a fish bone or sometimes called a cause and effect diagram so identified barriers to reaching your desired performance.
Meredith Rodriguez: Either way, you know, the objective is to take a look at possible change strategies and then select one that's likely to result in movement and often we before we start with a fairly simple but effective change strategy.
Meredith Rodriguez: You know, so the team can gain a quick win, and this also helps the team kind of refined its own pdsa process, so if you start simple and then really kind of tackle maybe some of those more challenging in strategies.
Meredith Rodriguez: So.
Meredith Rodriguez: So in our example what we're going to do remember in being increasing that by 20% the number of children were receiving analgesics for extremity trauma, so what we're going to do is just post a dashboard.
Meredith Rodriguez: You know our staff may understand the value of analgesics i'm sure they do, but then they may be kind of.
Meredith Rodriguez: Aware of the kind of chronic under utilization or maybe there are other barriers to utilizing it.
Meredith Rodriguez: That we are not sure, so we will just really ensure that the staff are aware of the dashboard and encourage them to view it frequently.
Meredith Rodriguez: So will frequently measure and post our performance for this defined period of time.
Meredith Rodriguez: And, and remember you know our our aim statement was by August 1 2023 we're going to accomplish that and as as we get into pdsa cycles will talk about how that really shouldn't be the.
Meredith Rodriguez: single pdsa cycle so you're going to do, multiple pdsa cycles as a bit there so so we talked about this defined period of time that you're going to try this one change strategy it's going to be much shorter than that.
Meredith Rodriguez: So, in summary kind of these are three questions again so thing, what are you trying to accomplish what do you want to change, do you seek by how much and by women so really that's where you figure smarty.
Meredith Rodriguez: And then measures you know, is this change and improvement and we'll talk about the different measure type structural processor outcome here in a little bit and then changes what changes are strategies really achieve this aim and and can these be measured.
Meredith Rodriguez: And so, with that i'm gonna turn back to Louis to walk you through pdsa cycles.
Louis Gonzales: Thank you meredith and if just that introduction that meredith gave to now we're going to talk about pdsa cycle is that increase your heart rate.
Louis Gonzales: relax, this is actually the simpler part it takes work but it's the simpler part.
Louis Gonzales: I would argue that the first three questions, those that meredith just went through are the most challenging but the better job you do with.
Louis Gonzales: addressing those first three questions, especially with refining your aim statement so it's very clear to you really understanding what.
Louis Gonzales: Your your aim is what your ideal is and how do you you're going to measure that that's the challenging part so let's walk through the pdsa cycle.
Louis Gonzales: portion which will come after this for three questions in our process and we'll go through each step, a little bit, but it's really pretty simple.
Louis Gonzales: And we're going to walk you through kind of a template or an approach to take with each that if you follow that it actually isn't Is it too difficult again does take work but not too difficult so let's walk through that.
Louis Gonzales: up there it is.
Louis Gonzales: Alright, so when we think about this pdsa cycle, you know most of you probably heard that name of plan do study act.
Louis Gonzales: But before we get into the details of each of those letters let's just kind of talk about the cyclic part, so a cycle is really just saying.
Louis Gonzales: I think if we made this particular change if we change this thing either we introduce some new structural elements into our organization or we introduce some change to process the way that we do things.
Louis Gonzales: To be able to take care of children that particular change that you introduce is is a cycle when we introduce that change observe it and measure it and then.
Louis Gonzales: analyze what did we get from that that's the cycle part but it's a specific teams, so we always start with, and if you notice and one of those earlier slides that meredith had.
Louis Gonzales: One of those slides said as a team, one of the things you can do as a team is hypothesize what do I.
Louis Gonzales: believe will happen if we make this particular change, I believe this may happen or if we make this change this will happen, but it may actually also cause this negative thing So those are.
Louis Gonzales: Those are those ideas that you kick around and then you land on a specific change and that will be one cycle and we measure that cycle.
Louis Gonzales: And then we add a little bit more in complexity to that change so that's what meredith just stated, this you start with something maybe simple.
Louis Gonzales: And then add little bit more complexity on to that and again go through the cycle of plan that out introduce it into your organization or that aspect of your organization that you want to test it within.
Louis Gonzales: implement it out measure observe analyze that whole process again and we continue that in cycles and until you're.
Louis Gonzales: you're closer to the result that you want, and the the expectation is as each cycle continues, if you increase in complexity.
Louis Gonzales: or in impacts of each cycle, then you get closer to the result, meaning the ideal result that you're targeting.
Louis Gonzales: And that may be your initial aim and maybe your next approach your next huge effort might be saying we're going to raise the aim and you change your aim so it's a little bit more difficult.
Louis Gonzales: To achieve but it's still.
Louis Gonzales: Closer to where patients and their families want things to be.
Louis Gonzales: So we can change the result, but we start with one particular name and that name is this particular result, this is what we're aiming for and we're going to get there with cycles that we do have changes over time.
Louis Gonzales: And cycles that increase a little bit in complexity, or in impact over time.
Louis Gonzales: If we look at the sort of my slides don't teams let's try that again.
Louis Gonzales: area.
Louis Gonzales: So, if we look at that, in a very simplistic way, and this is what I think is a simple template you could use, so the first three questions.
Louis Gonzales: If you look at the top of this graphic that's what myriad of just went through again define those very well answer those well have a good grasp on those.
Louis Gonzales: and have some ideas and theories of if we introduce this specific change, then we anticipate this may occur, which is what we want to have happen.
Louis Gonzales: Then, the first step, then in this cycle is this pdsa cycle is the plan part and planning is exactly what it says so again there's no complex language planning as planning.
Louis Gonzales: planning, though, is a critical step here the pdsa cycle, because it is defining exactly what will the change be.
Louis Gonzales: Well, where, will you make that change meaning is it just a portion of your organization that you're going to test to them, which is a bad idea, maybe it's just one area one shift one specific set of patients.
Louis Gonzales: So the where who's going to be doing this, and that means not just who's planning it, but that means, who is actually going to be implementing this specific changes and that's especially this specific providers practitioners, who will be.
Louis Gonzales: The ones who are actually testing this particular teams that you're introducing.
Louis Gonzales: In all of these things that are part of planning, along with the fact that you have to collect data in order for us to be able to measure change the do part pretty.
Louis Gonzales: Straightforward as well, is implementing that particular change from your plan so that's pretty straightforward you planned it out.
Louis Gonzales: And now you're going to implement that again implement it in a small scale typically it's a portion of your organization your institution, so that it's easier to be able to actually test this cycle just a large enough portion that you can actually capture data.
Louis Gonzales: And then of course document what happened and the people who are testing what they experience is important to hear so if there are problems that occurred as a result of the change.
Louis Gonzales: That would be important to document or the other side of that is if there were additional benefits to the change that you hadn't even anticipated.
Louis Gonzales: Those who are implementing the change it's important to document their experiences with the things that we're.
Louis Gonzales: we're good benefits that occurred from that change that may have been outside of the scope, did you even anticipated.
Louis Gonzales: A study part, then as as once we've actually implemented that for some again to do part to be for some specific defined time pdsa cycles were intended to be relatively short but there's no magic to any specific numbers.
Louis Gonzales: It really depends on when you've what you feel you can reasonably do what your staff can tolerate in terms of how much time they're having to to do some of this work, especially collecting the data.
Louis Gonzales: And then having sufficient data to be able to make some decisions off of the study part, then, is that next step of what did you learn what what did this data.
Louis Gonzales: tell you about the change that you made it goes back to what meredith stated earlier, was there a change and we'll show you an example here in a second but what's their teams and did that change.
Louis Gonzales: occur in a positive manner, meaning towards our aim, or was it an opposite direction of brain and how did this.
Louis Gonzales: This compared to those hypotheses that we had before, that that we we tossed around as a team.
Louis Gonzales: And then the next step, of course, is decision time and we call it Act and the act part is I need to act on what am I going to do next.
Louis Gonzales: And I might simple way to think of this as I might adopt that particular change and say let's put that change into place and move to the next step or Mike revise that you know adapt a little bit and and then maybe retest that.
Louis Gonzales: For that particular change that not work or not only did not work.
Louis Gonzales: It actually cause more problems than it actually probably benefit so we're going to abandon that particular change so we make a decision about that particular change that we implemented.
Louis Gonzales: And you might use things you know other tools, like a driver diagram or a fish phone to say you know.
Louis Gonzales: Why did those things occur of meaning, especially if things didn't go as well as you would have liked, so that you avoid having those kinds of things occur with your next change your next cycle.
Louis Gonzales: And then, ideally, you would then plan your next chain strategy your next change your next cycle.
Louis Gonzales: And that should be more impactful that's the whole complexity thing a little bit more complex and and impactful and that's your next cycle, but somewhere in between there.
Louis Gonzales: it's very helpful, especially to your team who did all this work to celebrate the success is when you had improvements, yes, you may not have reached your aim, especially for aim was high.
Louis Gonzales: But celebrate the work that you did, and the improvement that you did make, and then the cycle begins again with your next pdsa, which is based on the new chain strategy that will be your next one that's maybe a little bit more complex and impactful.
Louis Gonzales: So meredith talk a little bit about measures, measures before and I just want to share a little bit more about those and again, many of you may actually be familiar with this.
Yes.
Louis Gonzales: So this is a model that's pretty common with us, and most of you probably heard of it or you've seen examples of it may not have known you some examples of it, but you did, and these are, this is a way.
Louis Gonzales: That was developed by a physician researcher named the Venus done, the media and that's where the name comes from the data median model.
Louis Gonzales: And it's a way of evaluating quality it actually relates to other work that's similar in terms of systems work but that's a topic for another day.
Louis Gonzales: So the the measures are really divided into three groups structural process and outcomes and structural are really noticed the other name for that in systems work is inputs.
Louis Gonzales: And those are the people, the things the materials, the equipment that the things that are part of the basic structure that don't buy themselves.
Louis Gonzales: That they're not necessarily outcomes are the actual work with patients are the things that are needed before you even start beginning that care to that child.
Louis Gonzales: And so that's the infrastructure part of structural part is is measuring how well, those are in place and how effective they are the second.
Louis Gonzales: Group is referred to as process or the activities of the system and that's really the process, the activities that are needed to be able to get the care done.
Louis Gonzales: And this is a common place where we study and quality improvement because the processes, along with the appropriate structural elements are needed to be able to reach good outcomes.
Louis Gonzales: So processes are you see the examples here, you know they can be the specific procedures of your clinical care they could be the specific diagnostics and how to use or just the therapies themselves, and then the third area that's common in the diabetes on a median model is outcomes.
Louis Gonzales: And this is really what all of us are mostly interested in, but sometimes it's difficult to measure outcomes, especially early on, with some simple QA projects.
Louis Gonzales: But that's where we want to get to is, how does it affect the outcomes of these children that we're trying to improve the care for.
Louis Gonzales: So that's what we talked about before it's changes in their in their health status or even changes in the services that we provide to that particular population.
Louis Gonzales: And, along with that is the opposite of improved care of necessarily opposite, but the opposite of being therapeutic is causing harm, and so we want to decrease harm.
Louis Gonzales: As well that's a good outcome as well, along with some of the things that are gaining in in measure which are satisfaction of patients and families.
Louis Gonzales: And adverse events we just talked about the other area The fourth area that's pretty common, as well as balancing measures and balancing measures are important because they are the other names for them are like side effects measures.
Louis Gonzales: But they're really measuring the things that are not what you want to have occur, not only are they not your aim that the again the opposite of your aim.
Louis Gonzales: They are potential harm or again just some adverse consequence of the change that you implemented and we want to measure those so that.
Louis Gonzales: If if those things occur, we may have to find ways to modify or change strategy, so we minimize those harmful effects, even though we may have had benefits to the patient, we have to minimize those kinds of effects.
Louis Gonzales: See there it is so going back to our example, which is the at the top here you'll see this is our aim statement, so the chain strategy as meredith mentioned is we're going to just just use.
Louis Gonzales: The driver of increasing awareness among staff and our simplistic way of doing this is we're just going to create a dashboard that's going to display our measures of analgesic use over time and the dashboard will remind us about why this is important.
Louis Gonzales: So that the importance of it is clear, and all the staff recognize why we're doing this and then they get to see what how.
Louis Gonzales: How are things really going on but what's the real world like and they get to see what those measures are always important to inform the staff of what we're doing and why.
Louis Gonzales: We need to be as transparent as possible with our QA processes.
Louis Gonzales: and
Louis Gonzales: We want to track, how are we doing and track the the balancing measure of side effects or ever so.
Louis Gonzales: Again, looking at our example, so what data we need, but we might need data that's.
Louis Gonzales: that's documented here here are the children who are receiving analgesics, which of course tells us, those are not and then it's important for us to really dive deeper into that to say there may be.
Louis Gonzales: Appropriate reasons for not receiving analgesics and specific patient and so that's Okay, so it can't always be a simple, yes, no it's important to dive into the process understand better why it may not occur, and there may be again reasonable.
Louis Gonzales: causes for that and that's the reason, if you look at the aim statement again the aim statement states appropriate utilization of analgesics.
Louis Gonzales: Which means if it's contraindicated then great that you thought about the analgesics but great that you also didn't provide it, if it's country indicated for that particular child, so this specific measures that are all listed here different ways, you can measure that.
Louis Gonzales: And these are just this is just us thinking through as a team, how are we going to measure this this game statement that we're about.
Louis Gonzales: Where this change strategy that fits frames.
Louis Gonzales: And so let's say we did that introduce that dashboard and on the lower right of the screen you see a table, this is a really simplistic data we captured we graph that.
Louis Gonzales: And there are two measures here the blue line is that percent of analgesics percent of the target population that received analgesics and then the orange line or adverse events.
Louis Gonzales: or proportion of adverse events so if you look at those two lines here's a question for you and you can post this in the chat but.
Louis Gonzales: Are these all structural are they are process are they all outcome balancing or the accommodation image, but what you think.
Louis Gonzales: And you can post that in the chat box and we'll continue on but let's think about it.
Louis Gonzales: percent analgesics.
Louis Gonzales: proportionate adverse events, a category are those the same category or they take different and post your notes in the chat box we love to hear what you have to say.
Louis Gonzales: i'm going to move on, slides ago.
Louis Gonzales: There yeah so if we can I see a mixture they're absolutely right, they are, and we see.
Louis Gonzales: I see some good answers there so we'll talk more about those in a second.
Louis Gonzales: let's go on to our summary and really putting it all together so in phase two, this is really what you're doing is in phase two you're going to create an aim and define something that you can accomplish that meets all the aim.
Louis Gonzales: characteristics you're going to identify specific change strategies and you're going to pick one that you're going to start off with as your first cycle.
Louis Gonzales: And then determine how will you measure that and you'll consider among the structural process outcomes and balancing measures.
Louis Gonzales: and determine that determine how you're going to measure it within your specific organization using whatever resources, you have.
Louis Gonzales: And data system resources, especially and then you're going to actually implement your pdsa cycle so plan it out so you'll describe your plan you'll implement it.
Louis Gonzales: As mayor to state that there's not enough time for for you to complete their actually implemented in the time that we have, so we may have to do some modifications like maybe some hypothesized or or.
Louis Gonzales: sample data to be able to present to practice presenting you know the what your findings were and what your next actions may be.
Louis Gonzales: And how you would interpret what you find and reflecting on what changes, you would need to make next, including what's your next cycle needy so identifying cycle number two.
Louis Gonzales: that's the most simplest way of looking at phase two right there.
Louis Gonzales: But if we.
Louis Gonzales: can be there, it is so if we look at it even more simplistically, and this is my roadmap for yet it looks a little complex.
Louis Gonzales: It it's actually fairly straightforward the colored boxes on the first two lines are your three questions.
Louis Gonzales: three key questions and it model or there, but if you follow this particular process it actually will guide you through what do I do next.
Louis Gonzales: And if you need help with how to do those that's what we'll be doing and phase two in an individual coaching sessions is, we will coach you through how to do those.
Louis Gonzales: Help arrive at the answer your specific three key questions, then you begin your first pdsa cycle and then the fourth line there of the Multi colored boxes, there are your plan do study act.
Louis Gonzales: And you'll you'll incorporate each of those your implement each of those hopefully celebrate your success with your your real data or sample data.
Louis Gonzales: And then you'll make a decision about do I continue on with another cycle, which is is the ideal one or you move on to some other your next q&a project.
Louis Gonzales: And, in a nutshell that's your roadmap for your feet.
We.
Meredith Rodriguez: yeah yeah.
Meredith Rodriguez: So I don't see a lot of questions in the chat and we're going into breakout so you can ask those there and the essence of time.
Meredith Rodriguez: Quick reminder about the face to quality improvement projects i'll have the system, so the link to register for phase two is is tied to the original registration so it's an individual link to you so.
Meredith Rodriguez: I will have the system resend you your link after this afternoon, so that if you want to register register for phase two you'll have it um quick reminder on how to find the pediatric readiness score you need nurse manager should know.
Meredith Rodriguez: where you can contact your msc program manager, and this is really if you're interested, but not only if you're interested in.
Meredith Rodriguez: Joining phase two but also if you'd like to to implement some pediatric readiness efforts on your own the national pediatric readiness assessment and the gap analysis you receive when you take it is a really good place to start.
Meredith Rodriguez: If you don't think you've taken it, you can visit PS ready.org and you can take the assessment right now it's only a paper version that unfortunately have to score by yourself.
Meredith Rodriguez: and doing some updates to the system and, eventually, I think later this year you'll be able to go back on their take the assessment and probably in quite a while you'll you'll they'll have the the gap analysis backup for you to.
Meredith Rodriguez: See credits, as I mentioned at the beginning, will get those to you as best as we can.
Meredith Rodriguez: And then, I just wanted to highlight, in the last couple of minutes and because I want to shift to our breakout rooms, out of respect for our speakers, but for those of you that maybe are not joining us for phase two there's still opportunities to work.
Meredith Rodriguez: On improvement, and we have some quality improvement collaborative coming up over the next several years.
Meredith Rodriguez: That will have the you're welcome to become a part of, so we are here with the workforce development collaborative phase two running through June.
Meredith Rodriguez: and August, are going to kick off a mental and behavioral health collaborative this will be specifically ED focus so it'll be on on developing a clinical care pathway for children, presenting with acute suicidality to the ED.
Meredith Rodriguez: next one will be around the same time, launching a disaster networking collaborative this one i'll be really about growing the pediatric voices in.
Meredith Rodriguez: PDF within disaster planning efforts within your region so working with your healthcare coalition's or disaster coalition's.
Meredith Rodriguez: pediatric brain is quality collaborative two point O also ED focus but.
Meredith Rodriguez: For those of you who may be aware of the PR PC version 1.0 this will be kind of another iteration of that with some additional improvement bundles.
Meredith Rodriguez: Including the original ones on winning children's and kill children in kilograms recognition in charge of abnormal vital signs in a facility transferring a few others, and we hope to have some information out soon regarding that one.
Meredith Rodriguez: we're going to relaunch this peck workforce development collaborative so a second iteration of this one in September of 2023.
Meredith Rodriguez: And then I want another one on pediatric disaster response so this will have six specific bundles one on you know pitching tracking and family reunification another one on.
Meredith Rodriguez: The medical home, and so a couple other there and then finally another collaborative on pediatric medical recognition which so similar to a stroke or semi.
Meredith Rodriguez: Several States have pediatric medical recognition programs, and that will be about growing those programs So if you want to hear about any of these upcoming collaborative subscribe to our newsletter.
Meredith Rodriguez: And that will give you an efficient notification on all the upcoming collaborative.
Meredith Rodriguez: So now let's go ahead and transition to our breakout sessions i'm going to put all the links here in the chat for you.
Meredith Rodriguez: We have some great speakers today talk about sort of the quality improvement efforts that they have gone through them, and those are on the agenda but let's see here in essence of time, let me put these in here and we can head on over there, to the breakout rooms.
appears should at least ready i'm sorry.
Meredith Rodriguez: couple other places, you can find these links isn't working on putting them in the chat they are on the calendar invite that I sent to you all they.
Meredith Rodriguez: Are on the website there on the agenda and now in chat.
Meredith Rodriguez: So, give us a few minutes to get over there and get this started and we.
Oh.