Welcome to the OPQC NAS July Action Period Call

Transcription

1 Welcome to the OPQC NAS July Action Period Call Thank you for joining; our webinar will start shortly! In the mean time; please sign in the chat box with the names of all webinar participants and hospital affiliation.

2 Welcome! Neonatal Abstinence Syndrome Project July Action Period Call Ohio Perinatal Quality Collaborative July 2015

3 The line will be placed on Group Mute To ask a question: Click on the Raised Hand icon You can type your question into the Chat Box You can use *6 to come off of GROUP MUTE (and *6 to go back on).

4 Agenda Time Topic Presenter 3:00 pm Welcome & Agenda Review Susan Ford, RN 3:05 pm Data Overview June Results Rick McClead, MD 3:15 pm NAS Orchestrated Testing Lloyd Provost, MS Heather Kaplan, MD 3:45 pm Team Discussion Q&A All teams 3:55 pm Next Steps Save the Date Fall Learning Session Data Submission Reminder MPR/PDSA Reminder Susan Ford

5 NAS Participating Sites 2014 Promedica ProMedica Toledo Children s Bay Park Mercy Children s Hospital St. Rita s Medical Center Lima Memorial Health System Marion General Nationwide Upper Valley Dublin Methodist Dayton Children s Medical Center Mt. Carmel West Nationwide Doctor s Good Samaritan Hospital Dayton Springfield Regional Miami Valley Medical Center Southview Medical Center Soin Medical Center Fort Hamilton Kettering Cincinnati Children s Atrium Medical Center Good Samaritan Mercy Hospital Fairfield Hospital Mercy Anderson UH Cincinnati Bethesda North The Christ Hospital Hospital Mercy Health West Nationwide Riverside Methodist Nationwide Grant Mercy Regional Medical Cleveland Center Lorain Fairview Hospital Clinic Hillcrest Hospital Elyria Medical UH Rainbow Babies Center -UH MetroHealth & Children s Akron Children s Summa Mercy Medical Akron Children s Center Canton OhioHealth MedCentral Mansfield Aultman OSU Nationwide Children s Adena Regional Medical Center Southern Ohio Medical Center Nationwide Mt. Carmel St. Ann s Mt. Carmel East Licking Memorial Health System Genesis Healthcare System Trumbull Memorial Akron Children s St. Elizabeth Health Center/Mahoning Valley 1/2014 start Level 3 and Level 2 teams 4/2014 start Level 2 teams

6 Key Driver Diagram Project Name: OPQC Neonatal NAS Leader: Walsh GLOBAL AIM To reduce the number of moms and babies with narcotic exposure, and reduce the need for treatment of NAS. SMART AIM By increasing identification of and compassionate withdrawal treatment for full-term infants born with Neonatal Abstinence Syndrome (NAS), we will reduce length of stay by 20% across participating sites by June 30, KEY DRIVERS Prenatal Identification of Mom Implement Optimal Med Rx Program Improve recognition and nonjudgmental support for Narcotic addicted women and infants Attain high reliability in NAS scoring by nursing staff Optimize Non-Pharmacologic Rx Bundle Standardize NAS Treatment Protocol Connect with outpatient support and treatment program prior to discharge Partner with Families to Establish Safety Plan for Infant INTERVENTIONS All MD and RN staff to view Nurture the Mother- Nurture the Child Monthly education on addiction care Fulltime RN staff at Level 2 and 3 to complete D Apolito NAS scoring training video and achieve 90% reliability. Swaddling, low stimulation. Encourage kangaroo care Feed on demand- MBM if appropriate or lactose free, 22 cal formula Initiate Rx If NAS score > 8 twice. Stabilization/ Escalation Phase Wean when stable for 48 hrs by 10% daily. Establish agreement with outpatient program and/or Mental Health Utilize Early Intervention Services Collaborate with DHS/ CPS to ensure infant safety. Partner with other stakeholders to influence policy and primary prevention. Engage families in Safety Planning. Provide primary prevention materials to sites.

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16 Site Specific Graphs Site specific data, as well as regional aggregate charts are now in your hospital s folder on SharePoint. This month we are excited to introduce enhancements to the monthly charts which provide more information in an easy to read table below your graphs. The data on your graphs has not changed. If you have any questions or comments about this new format please feel free to contact us!

17 OPQC NAS Project July Factorial Design and Orchestrated Testing Lloyd P. Provost, MS Associates in Process Improvement API

18 Quality Improvement using the Model for Improvement Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? A P S D Changes That Result in Improvement Implementation of Change Hunches Theories Ideas 18 A P S D Very Small Scale Test Wide-Scale Tests of Change Follow-up Tests Sequential building of knowledge under a wide API range of conditions 18

19 Experimental Designs for QI Research Speroff and O Connor, Study Designs for PDSA Quality Improvement Research, Q.Manage Health Care, Vol 13, No.1, 2004 API

20 Why Experiments evaluating more than 1 Change? Two major deficiencies with studying one factor at a time: 1. The first is that there can be interactions between the factors under study that produce the best results. An interaction means that the effect a factor has on the response may depend on the levels of some other factors. 2. The second deficiency in studying one factor at a time is inefficiency. As each factor is changed in turn, the data previously collected to study other factors are set aside and new data are collected. Each set of data supplies information on only one factor. Factorial designs provide an effective alternative to studying one factor at a time. PE book, p API

21 Factorial Designs 1. They allow experimenters to accomplish two functions: determine what works best understand the cause-and-effect system that produced the results. 2. They are most useful to determine the effects of multiple changes (2, 3, or 4 factors) on an outcome variable. 3. In addition to the effects of each individual change (factor), interactions between the factors can be studied. 4. Studying factors at two levels (with and without the change present) requires relatively few runs, leads to a simple analysis, and meets most of the needs of experiments 5. The use of graphical displays (run charts, cubes, paired comparisons, and response plots) can be used with factorial designs to effectively communicate the results of the experiment to others. API

22 R. A. Fisher s Tools for Experimentation Experimental pattern Planned grouping Randomization Replication API

23 Factorial Designs: Testing Changes to Reduce an Infection Rate Change A Change B Infection Rate* Test 1 (baseline) no no 8.0 Test 2 yes no 7.0 Test 3 no yes 8.0 Test 4 yes yes 2.0 Which change caused the improvement? Response Variable Infection Rate Factors Change A, Change B Blocks none identified Levels no (not used) and yes for each factor * 2% change is significant API

24 Using Factorial Designs in an Improvement Network Orchestrated Testing: Coordinate PDSA testing in a network to evaluate Ideas for improvement API

25 ImproveCareNow Orchestrated Testing Matrix ImproveCare Now Teams Enrollment & Data Quality Pre-visit Planning Population Management Self- Management Support Current # Sites # Pts (9/20/12) A, B, C, D * E, F, G, H, I J, K, L, M N, O n/a P, Q, R, S T, U, V W, X, Y, Z, AA, AB AC, AD, Ae Current enrollment data, not target for September 30, 2012 API

26 Why call this Orchestrated Testing? Orchestra Orchestrated Test Sections: the wind section, brass section, string section, percussion section, etc. Led by a conductor who sets and maintains the tempo (speed), dynamics, and interpretation, including articulating style. Multiple test sites that are all different QI Conductor All sections cooperate to create symphony. That means sometimes just resting and not playing All members of the orchestra agree to standardize and tune All orchestra rehearse and perform All sections contribute to the whole; there can be no performance if any section is missing. API Each site has it s own assigned test All sites agree to the standard changes and the test plan Preparation, execution, and reporting by all sites All tests must be completed to have an experiment. Each site gets more out of the experiment than they put in. 26

27 Proposed Factorial for Hospital Readmissions Standard Teaching Handoff Enhanced Teaching and Learning Handoff Current Handoffs Enhanced Communication Current Handoffs Enhanced Communication Current Followup Practices Post- Hospital Followup Current Assessment Early Discharge Needs Assessment Current Assessment Early Discharge Needs Assessment Unit 3 Unit 7 Unit 8 Unit 4 Unit 1 Unit 6 Unit 5 Unit 2 Each test with a different hospital or ward, IHI STAAR project, 2012 API

28 Potential Benefits and Challenges of Orchestrated Testing 1. Increase power for learning (larger sample size) from multiple sites. 2. Factorial designs allows more than one change to be tested at once (including synergy/antagonism) 3. Better design (standardization and replication) than current before & after testing each change independently 4. Bottom line: Potential to learn more, with less resources, and faster. 5. Down side? More complex to set up and manage API

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30 Children s Hospital Neonatal Consortium (CHNC) in partnership with Children s Hospital Association, 2013 Orchestrated testing in planned experimentation allowed simultaneous testing of multiple factors and the interaction of these factors on CLABSI rates. The effect of four factors were studied 1. Monitoring of hub care compliance 2. Use of clean or sterile tubing change technique 3. Monitoring unit policy on limitation of central venous catheter access 4. Assessment of need for central line - The 17 Children Hospitals NICUs were allowed to choose the factors that fit within their practice culture Centers divided into eight groups based on their current practices and willingness to change API

31 CHNC Orchestrated Test Design of the Orchestrated Test API

32 2 4-1 Fractional Factorial Design for Orchestrated Test API

33 Shewhart U Chart for CHNC Orchestrated Test API

34 CHNC Orchestrated Test API

35 CHNC Orchestrated Test API

36 CHNC Follow-up to Orchestrated Test Confirmation and Sustainability (2014) API

37 Results of Confirmation Study 3 Groups of NICU s API

38 Using Factorial Designs in an Improvement Network Orchestrated Testing: Coordinate PDSA testing in a network to evaluate Ideas for improvement API

39 Orchestrated Testing: Why Should OPQC Do this?

40 Top 5 Reasons We Should Pursue OT

41 5. Neonatal Abstinence Syndrome (NAS) is still a relatively new disease, and is not yet fully understood

42 4. There is still variation in how different hospitals treat infants with NAS and, therefore, an opportunity to learn Morphine Methadone Buprenorphine Phenobarbital Clonidine

43 3. We are doing well, but we can do even better Length of Treatment 13.9 days Length of Stay 20.6 days 47.8% of Exposed Infants Treated

44 2. Together we can tease out the most effective components of care to further refine our current evidence-based, standardized care protocol

45 1. and further improve the outcomes and reduce hospital length of stay for babies with NAS.

46 Orchestrated Testing: What is Our Proposed Plan?

47 Focus on Non-Pharmacologic Care Areas of the care bundle where we are still unsure

48 Focus on Non-Pharmacologic Care Variation Exists

49 Focus on Non-Pharmacologic Care Some early evidence that 22 kcal feeds may be beneficial in reducing LOS

50 Focus on Non-Pharmacologic Care Some early evidence that low lactose feeds may NOT be an important part of care

51 OPQC Factorial Design (2 2 ) Group 22 kcal/oz Standard Low Lactose Standard A No Yes B Yes Yes C No No D Yes No

52 OPQC Factorial Design (2 2 ) Wind Section (A) Low Lactose or BM Standard 20 kcal/oz Standard String Section (B) Low Lactose or BM Standard 22 kcal/oz Standard Horn Section (C) Regular Formula or BM Standard 20 kcal/oz Standard Percussion Section (D) Regular Formula or BM Standard 22 kcal/oz Standard

53 Important Factors (But Not Under Study) Location of Treatment Inborn vs. Outcome Availability of and approach to the use of breast milk Drug Used for Treatment Methadone or Morphine Protocol Used for Treatment OCHA vs. Cincinnati vs. Other

54 Orchestrated Testing: Will You Participate?

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56 Ask Yourself These Questions Is this exciting to you? Are you willing to sail unchartered waters with OPQC as we try out this method of learning? Do you want to help tease out the most effective components of care to develop and further refine our current evidence-based, standardized care protocol? Do you want to be part of continuing to improve outcomes and reduce LOS?

57 Ask Yourself These Questions Are you willing to work with OPQC to select one of 4 groups to participate in? Will you agree to continue the practices of group and not to implement factors not assigned to their group for the duration of the project? Will you agree to keep your pharmacologic care practices the same for the duration of the project?

58 Ask Yourself These Questions Will you be able to collect and submit data regularly? Can you collect data on all babies in whom Finnegan scores are initiated (not JUST those being treated) at your hospital whether in normal newborn or NICU? Do you have buy in for OT from your entire team (physicians, nurses, social workers)?

59 Ask Yourself These Questions IF YES We are excited to have you as part of the core OPQC OT group IF NO You are still part of OPQC and can continue to learn with us, participate in AP calls, collect data, attend learning sessions

60 Orchestrated Testing: Next Steps

61 What to Expect OPQC staff will be in touch to confirm your interest in participate and discuss which group you will join We will provide you with a letter to circulate explaining our plan for pursing an OT design for the next 9 months including an elevator speech to help explain to your colleagues We will be asking for volunteers to help pilot test a new data collect form and draft clearer instructions Thanks to those that already volunteered via the MPR We will be soliciting interested people to serve on a steering committee and/or help lead action period calls for the 4 groups ( learning labs ) Thanks to those that already volunteered via the MPR

62 Timeline July Aug Sept October-June July Learning Session PROJECT KICK OFF Hospitals commit to participate OPQC assigns sites to 1 of 4 groups Test & finalize Data Collection Form Test & finalize Data Collection Instructions Call with Lead Physicians (Aug) Run OT Testing Learning Lab AP Calls Every other Month Group Calls Data Collection & Submission Continue work on other Key Drivers Analyze Results Update & Implement Best Care Practices

63 Questions and Discussion Please Tell Us Does your team have any concerns about participating in orchestrated testing, such as: Data collection logistics Focusing on testing a specific piece of the NAS protocol Continuing to engage team members throughout the next year Sustainability for ongoing NAS work Would anyone from your team be willing to: Be on a steering committee for orchestrated testing? Work on improving the data collection form? Help lead monthly learning labs for small group Action Period calls?

64 Next Steps Let us know if you are interested in participating on a Steering Committee and/or helping to design Orchestrated Testing Please submit NAS Data by July 30th. Remember to please submit and check No Eligible Babies for the Month if there were no NAS patients at your site. Monthly Progress Report was sent to Key Contacts July 20 th, due July 30 th.

65 The OPQC NAS Project is funded by The Ohio Department of Medicaid