Quality Improvement Tools and Templates

QI perspective both regionally and at the hospital level

One of the goals of this collaborative was to introduce quality improvement tools and models to   interprofessional teams. The creation of an interprofessional team is critical to the success of any quality improvement efforts that cross the traditional professional and work unit boundaries. The interprofessional teams for our collaborative have consisted of Hospitalists, Pathologists, Medical Technologists, Nurses, IT Staff and Quality Improvement professionals. The ability to bring these cross-functional roles together provides the opportunity for teams to work collaboratively to redesign processes of the entire systems that support patient care. During our collaborative, teams have focused on redesigning systems such as lab ordering, specimen acquisition, testing and reporting.  When all of the interested parties focus on the same improvement efforts, the time is takes to make substantial change can be reduced when every team member owns the process and the process changes. 

The Institute for Healthcare Improvement's (IHI) Collaborative Model, as well as the Dartmouth Institute's Clinical Microsystems Improvement Model, was utilized in this program. The teams were provided with tools and didactic training sessions from each of these models to assist them in their improvement efforts.  Some of the teams had quality improvement support from their own organizations and others did not. Support was provided as needed to all of the teams to assist them in achieving their own team’s organizational goals that were established to meet the overall programs goals of optimizing laboratory testing. 

Clinical Perspective

In the first year of the collaborative, the participating teams have focused on reducing unnecessary laboratory orders and blood draws in hospitalized adults.  The targeted populations have varied, based on the key drivers that each team identified at their own institution.

As an example, at one community hospital, analysis of their processes revealed that phlebotomists were often drawing extra tubes of blood – just in case a physician later requested “add-on” lab testing.  On further investigation, the add-on testing turned out to be very rare occurrence, and the hospital was able to eliminate the practice of drawing extra tubes of blood – at an estimated savings of more than 12 Liters of blood each year.

One of the academic medical centers focused on reducing recurrent daily lab orders – orders for laboratory studies that are placed by a physician so that the same labs are drawn for multiple days on end.  As a result of broad educational efforts and changes to the electronic health record order sets, the institution has seen a dramatic shift in how laboratory studies are ordered for hospitalized patients.  Prior to this project, more than 90% of adult patients hospitalized on the Family Medicine and Internal Medicine services had recurring daily lab orders.  Over the past months, we have seen this percentage drop to less than 50 percent. This reflects more thoughtful lab ordering one day at a time and in response to specific clinical questions, rather than on a recurring daily basis.  Simultaneously, the medical center has seen a shift in the type of laboratory studies ordered and a gradual decline in the total number of laboratory studies ordered.  

From a patient perspective, these changes across the region will result in fewer unnecessary needle sticks, reduced volumes of blood draws, lower rates of hospital acquired anemia, and lower transfusion rates.  These are outcomes that have been demonstrated in similar projects of smaller scale.  While these blood tests are not expensive when compared with some other medical tests, the sheer volume of inpatient laboratory testing results in considerable expense for the healthcare system – and the 10 faculty members, the 8 hospitals and the over 70 hospital team members collectively hope to reduce the unnecessary part of these expenses across our collaborating institutions. 

Tools and Templates

This section contains helpful tools and examples on how this collaborative is approaching its quality improvement efforts.  The tools provide a way to document and examine information relevant to the team’s work in this collaborative. They assist the team in breaking down and evaluating potential change ideas as well as documenting a plan for measuring and evaluating their rapid cycle tests of change.

 

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