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QI Studies That Work
The keys to developing and implementing successful quality improvement programs.
Kent Steinriede
Publish Date: October 27, 2008   |  Tags:   Regulatory Affairs

QI studies soon will become more a part of daily life in surgery centers. In 2009, Medicare will require information on QI studies performed in ASCs as part of its Pay for Performance initiative. Accreditation agencies and insurers are also becoming more interested in QI studies and initiatives. Read on if you're looking for a worthwhile quality improvement study to undertake. We talked to a tech who tackled prophylactic antibiotics, an endo center director who improved the accuracy of patient records and an ASC administrator hoping to decrease cancellations.

12 QI Ideas

  • Surgery starting on time
  • Time-outs done before every case
  • Post-op infections
  • Patient satisfaction survey responses
  • Hospital transfers
  • Cost of implants
  • Presence of physical exam pertinent to surgery performed on the H&P
  • Medical/surgical necessity and appropriateness of procedures performed
  • Trends found on occurrence reports
  • High-risk procedures (such as laparoscopic cholecystectomy)
  • Pediatric pain assessment
  • Delayed discharge from PACU/step-down

The right antibiotics
In search of ways to reduce infection rates, Julie Adelchanow, CST, looked at the use of prophylactic antibiotics before surgery. She set up a one-week study that included 90 patients who went to the Surgery Center of South Bay in Torrance, Calif. Ms. Adelchanow and her colleagues gathered information about the antibiotics used, dosage and time of dosage. When she compared her findings to the recommendations of the Centers for Disease Control and Prevention, the American Society of Health-System Pharmacists and other organizations, she was surprised by what she learned.

Only 65 percent of the patients received the correct dosage. Obese patients were often under-dosed. In 13 percent of the cases, procedures were performed after the antibiotic's window of efficacy had lapsed. Not everyone was underdosed, says Ms. Adelchanow, who is in charge of quality improvement and accreditation. "I was surprised to learn of the cases that didn't require antibiotics," she says. Indeed, half of the patients who received prophylactic antibiotics didn't need them, based on the CDC recommendations. Once the staff and physicians became reacquainted with the CDC recommendations, infection rates decreased.

Quality improvement is a never-ending job. In fact, it's more a way of looking at the world than a process or technique. The concept of QI came to the United States by way of the manufacturing success of Toyota Motor Corp. in the 1970s and 1980s. In Japanese, the word for continuous quality improvement is kaizen. (Note that "Zen" is half of the word.)

But the idea didn't originate in Japan. After World War II, American statistician and management consultant W. Edwards Deming helped Japan reinvent its manufacturing economy. Mr. Deming's total quality management ideas appealed to Japanese executives, who started using them in the production of everything from radios to hatchbacks.

As Japan became a business success story in the 1980s, the idea of kaizen came to America. But what does making cars have to do with outpatient surgery? The need for continuous improvement - in patient safety, staff safety, patient flow and efficiency. Mr. Deming boiled his total quality management ideas down to four words: plan, do, study and act.

1. Plan
With so many areas to study, where do you start? Always give patient safety top priority, says Lucia Musterer, RN, clinical director at The Endo Center of Voorhees, N.J. Feedback between staff and management will bring urgent safety issues out in the open.

Benchmarking is a good method of identifying issues to study. FASA and AAASC have clinical benchmarking services that let ASCs compare themselves with other centers in several key areas, including infection rates, cancellations, transfers to other facilities and patient satisfaction on a national or regional level. Other organizations such as the Institute for Quality Improvement - sponsored by the Accreditation Association for Ambulatory Health Care - and the Surgical Outcomes Information Exchange (SOIX) also have benchmarking programs.

Sometimes you don't know how well you're doing until you look at the statistics. For example, at the Surgery Center of South Bay, the staff didn't know that patients were staying in the recovery room longer than the national average until they looked at data from SOIX. So Ms. Adelchanow and her staff started researching and brainstorming. They found that for many procedures, especially ophthalmic surgery, the patients didn't need to take off their clothes and wear a gown. This change shaved several minutes off the time the patient spent in pre-op and recovery.

2. Do
When looking for ways to improve quality, you'll sometimes have to experiment a bit. At The Endo Center, Ms. Musterer and her staff were looking for ways to improve the accuracy of patient records. Originally, patients were asked to sign a consent form and verify the accuracy of their name, date of birth and address as soon as they arrived at the center. However, many patients were nervous about their procedure when they arrived and didn't pay much attention to the accuracy of the form. This left many errors in the records. So Ms. Musterer tried having the patient verify his personal information a short time later, in the pre-op area. During the time-out, when they were a little more relaxed, patients were asked about their information. "We're killing two birds with one stone," says Ms. Musterer. This little change improved the accuracy of the records, she says.

3. Study
For the last two years, Denise Schoell, RN, the center director at the Mercer County Surgery Center in Lawrenceville, N.J., has been looking for ways to decrease the number of cancellations. To do this, she and her staff keep a log where the reasons for cancelled appointments are recorded. The information is entered in a spreadsheet. Ms. Schoell and her staff have learned that one of the major causes of cancellations is that patients have no ride to or from the appointment. Ms. Schoell also learned that many of these patients are elderly. About 75 percent of them were coming for treatment of pain which often kept them from driving.

After studying the results, the solution was clear. "We needed to offer a means of transportation," says Ms. Schoell. Now, when needed, the center pays a taxi to pick up the patient and return them home after the procedure. With surgery patients that arrive and leave alone, it's important to verify that there is an adult at home to receive them when the taxi arrives, says Ms. Schoell.

The taxis are working well. Compared to the cost of canceling surgery, taxi fare is a worthwhile investment, says Ms. Schoell. The cancellation study is ongoing. Ms. Schoell hopes to find other ways to decrease the number of cancellations in the future.

When it comes to equipment, creating a cost analysis study can help a center's management and owners make purchasing decisions. At the Surgery Center of South Bay, one of the center's autoclaves often broke down and needed repair. After looking at the cost of the repairs over six months, as well as the cost of rewrapping and delays in the operating room, Ms. Adelchanow determined that the ailing autoclave had cost the center more than $35,000, about the same amount of money needed to buy a new one. With the study in hand, it was easy for Ms. Adelchanow to convince the owners of the center to buy a new autoclave.

4. Act
Once the problem is identified and a solution has been found, now is the time for action. It's follow-though or "closing the loop," says Ms. Musterer. This is where many organizations fail. This step calls for communicating the new method to the staff and physicians, convincing people to change old habits, and making sure that the new habits stick.

Action might even mean moving the furniture. At The Endo Center, administrators were looking for ways to increase efficiency and reduce costs associated with IV bags. The center used the standard 1,000cc bags, which were heavy. Also, over the years as the daily patient lists grew, storing the bags and prepping the operating rooms became an issue. Storage cabinets for the bags had to be installed in the hallways.

After studying the number of IV bags used and how much fluid was needed, the administration decided to switch to 500cc bags. These bags were easier to carry, took less time to restock and took up less space. The cabinets were removed from the hallway. Now the bags are brought from the center's main storage area by a less expensive, non-nursing staff member, which also helps cut down on payroll expenses.

Once a change is in place, it's important to document the results after the change and revisit the issue a few months later to see if any further improvement can be made.

At the Mercer County Surgery Center, the result of another QI study of cancellations got patients to change their behavior. When Ms. Schoell and her staff looked at the causes of cancellations among orthopedic patients, they found that many cancelled because they hadn't had their pre-admission testing done beforehand. Each patient had received a pre-admission package that explained everything that he needed to do. However, says Ms. Schoell, "We found that the majority of them just didn't open the package at all." The solution: a big sticker on the outside of the package that reads "THINGS TO DO," followed by a list of tasks, such as getting the necessary blood tests, having an EKG and contacting the surgery center at least one week before surgery.

Start at the beginning
Building a team that works in a continuous state of kaizen requires buy-in from every member. Ms. Musterer says that the best way to do that is hire people who are enthusiastic and understand that QI is never ending and demands flexibility. "It starts with the initial interview," she says. "They must be part of a dynamic team."

Then everyone on staff must be aware of the QI goals, which are communicated in staff meetings. Buy-in has to come from each staff member. It cannot be imposed. "We do this by encouraging their autonomy," says Ms. Musterer.

In many Japanese factories, any worker on the assembly line can pull the andon cord when they spot a problem. The andon ("lantern" in Japanese) cord stops the line, which doesn't start again until the root cause of the problem has been identified and the problem solved.

At The Endo Center, each team member is encouraged to think for himself and come up with ways of improving the process, no matter how small. The staff members are often rewarded for their observations or creative solutions with gift cards or bonuses, says Ms. Musterer.

Keep going
QI is never easy and sometimes not satisfying because the results are not always immediate. But you can't avoid it.

QI initiatives are always challenging because they take place on top of the daily routine in a busy center. But it's important to have someone leading the charge in a state of kaizen.

At the Surgery Center of South Bay that person is Ms. Adelchanow. She has been there for more than 22 years, has gone through JCAHO and AAAHC accreditation twice and has designed several QI studies. Never-ending QI has been a lot of hard work, but it's been worth it, she says. "It's paid my salary several times over."