Quality Improvement through PQRST
Dr. Carolyn Shiau, a pathologist working out of Royal Columbian Hospital (RCH) was tired of hearing “because that’s the way it is always done” when looking to make improvements.
In April 2015, she joined the Physician Quality and Regional Safety Team (PQRST) – an initiative funded by SSC to support physician engagement through quality improvement in Fraser Health.
Through educational sessions with the Chair Dr. Curt Smecher (Anesthesiology, Abbotsford Regional Hospital), she learned how to create measures to monitor change through continuous cycles of quality improvement, and how to approach technical staff and senior colleagues with ideas for change.
Armed with these skills, Carolyn set out to improve the quality of histology slides in the lab and improve the percentage of routine cases completed based on regional benchmark turn-around time.
Through rounds of process evaluation, slide quality improved so dramatically that pathologists began to require fewer slides to make a diagnosis. In addition, the bench technologists generated ideas for improvement. Everyone was encouraged to be open to testing an idea for at least one to two weeks before accepting or rejecting it. Weekly meetings saw robust debates between technologists and pathologists that helped create open communication.
In August 2015, with Carolyn’s guidance, the lab revised their priority sequencing of cases through a shift in schedules. Now instead of completing 20-25% of routine case within 72 hours – the lab is completing 75-85% - maintaining this result with no increase in staff and no delay with complex cases. For the clinicians, this helps improve patient flow and it takes less follow-up visits to review results. Today, the culture in the laboratory is one of openness to change and “Let’s give it a try”.
For more information on PQRST, contact Aman Hundal, SSC Initiative Lead, email@example.com or for more specifics on FH’s PQRST, contact Dr. Dayan Muthayan firstname.lastname@example.org
VANCOUVER ISLAND HEALTH
Medical Orders for Scope of Treatment (MOST)
Dr. Valorie Masuda has been working in palliative care for seven years and has helped care for hundreds of people near the end of their lives. Unlike other areas of medical care, palliative care is not about prolonging life and “curing” patients, but about managing a patient’s care to ensure their goals of care are being met as they near death. Dr. Masuda said “I am responsible to make available the tools people can use as they reach the end of their life.”
One of the most effective tools for care teams to use when a patient is palliative is the Medical Orders for Scope of Treatment (MOST). Completed by a physician and patient, the MOST details the medical orders to identify one of six designations for scope of treatment. These designations provide direction on resuscitation status, critical care interventions and medical interventions. More importantly, they ensure that the care being provided is what the patient wants.
Dr. Masuda noticed the lack of completed MOST forms for residents of Cairnsmore Place, a residential facility in Duncan. Without a MOST, there’s a lack of identification of residents entering dying time and lack of understanding their goals of care. Dr. Masuda and her team saw the opportunity to undertake a Physician Quality Improvement project to increase the rate of MOST charts to 100 percent at Cairnsmore Place.
The Physician Quality Improvement initiative is the result of collaboration between Doctors of BC, the Ministry of Health and Island Health. Physicians with quality improvement ideas apply to the program and accepted applications receive one-year of support. This includes quality improvement curriculum delivered in a cohort workshop environment and support from a dedicated team to help their quality improvement project. The projects vary in scope - 2016 cohort projects range from sleep apnea-related heart failure to umbilical cord clamping processes.
Dr. Masuda and her team conducted two surveys; one of residents and one of staff, to determine if residents were discussing their goals of care and if staff were providing treatment that reflected patient’s goals. The team also audited patient charts every three months and encouraged and supported proactive physician visits. After the third quarter of the PQI project, proactive physician visits increased from 30 percent to 82 percent and 97 percent of residents had completed MOST forms. See video.
Working in the operating room at Nanaimo Regional General Hospital, anesthesiologist Dr. Karen Wong saw an opportunity to improve patient care. By working with the Physician Quality Improvement initiative, Karen and her team have made great progress towards more efficient, patient-centered surgical care. Karen and her team developed a patient questionnaire, a screening guide to help triage patients pre-operatively, and a patient education brochure. Arrangements were also made for patients to receive pre-operative phone calls from the NRGH nursing staff to clarify medication and discharge home instructions. During this trial period, participating patients were tracked and evaluations were performed regularly with nursing staff, patients and surgeons’ office assistants.
Results from the project show that the standardized process effectively triages high-risk patients and that regular engagement between health-care teams as well as patients helps identify problems and improves workflow. Importantly, from filling out the questionnaire at their surgeon’s office, to coming in for their surgery, patients responded positively to this new process.
Karen looks forward to ultimately expanding pre-surgical screening to all NRGH surgical specialties and work together with her peers in South and North Island to standardize the process for all of Island Health.
Physician Quality Improvement is the result of the collaboration between Doctors of BC, the Ministry of Health and Island Health. Interested physicians sign-up for one year of quality improvement workshops and lead a quality improvement project. These projects are varied - 2016 cohort projects range from palliative care procedures to improving pneumococcal immunization rates. Physicians interested in PQI should contact PQI manager, Carolyn Carlson (Carolyn.Carlson@viha.ca 250-668-4876) for more information. Physicians are always encouraged to reach out about potential projects.