Quality Improvement Case Study Don Buckingham, MBOE Senior Quality Improvement Service Line Coordinator

Quality Improvement Case Study Don Buckingham, MBOE Senior Quality Improvement Service Line Coordinator

Began my QI Journey not quite 10 years ago Capstone Project as EVP Marketing Distribution Submitted in Partial Requirements of MBOE Don Buckingham ** 2008-2009 How Best to Vertically Integrate Our Manufacturing?

Integral Perspective of Systems Thinking Strategic Operations Planning & Deployment Constancy of Purpose Directors CEO Update Stakeholder Analysis Validate Business Model Strategic Policy (Direction) Ideal State Financial Pro Forma Strategic Objectives Governance Compliance Auditing Executive CTS Capabilities Enterprise VSM President s Capability Assessment Current State Contribution Targets Tactical Portfolio (CapEx Planning) Risk Mitigation Mapping Management Total Fulfillment (Costing) Cash Flow Pro Forma (Budgeting) S&OP Pro Forma (Capacity) Value Stream Performance Targets Lean Six Sigma Breakthrough Projects Rapid Improvement Events Future State Operations Lean Foundations Sustainability Five S VWP SWI VSM TPM SMED Error Proof LSW Visual Management Performance Board Continuous Improvement A3 PPS A3 Gap Assessments Progress to Plan Shared Services Lean Foundations Sustainability Five S VWP SWI VSM TPM SMED Error Proof LSW Business Information Systems Strategic Human Resources Learning Accountability Culture Amended 4/3/2013 Don Buckingham All Rights Reserved Don Buckingham All Rights Reserved Enterprise Level Systems Mapping

Integral Perspective of Family Systems

Integral Perspective of Bodily Systems Structural Flow Functions Repair Here Macro-level Meso-level Micro-level

Integral Perspective of Operations Systems First, We Broaden Our Vision Then, We Narrow Our Focus... Repair Here

To Just the Right Level for our Quality Improvement Initiative

Coaching QIE Project Teams at Level Strategic: Journey to Best Outcomes Tactical: Service Line Quality Improvement Portfolio Operational: Quality Improvement Projects

Columbus Section The Global Voice of Quality QIE Case Study: Decreasing the Duration of Discharge Antibiotic Treatment Following Inpatient Uncomplicated Soft Tissue Abscess Drainage Findings From a Quality Improvement Project

Why This Project? = Voice of Our Customer Heal Me/Cure Me: Uncomplicated skin and soft tissue infections and abscesses do not require prolonged systemic antimicrobial treatment Do Not Harm Me: ID Service sets standard to: 1) increase treatment adherence; and 2) decrease antibiotic associated side effects, antimicrobial resistance and patient care costs Voice of Our Profession = Stevens D, et al. Clin Infect Dis 2014;59:e10 52 Schuler CL, et al. Pediatrics 2016;137 Hepburn MJ, et al. Arch Intern Med 2004;164:1669 74.

Opportunity = Voice of Our Hospital 1,677 ED encounters / 4,184 Urgent Care visits 5,861 systemic antibiotic prescriptions Cost is ~$1.35 million would have been $754K if 5 days, based on $130 USD clindamycin Of 418 patients discharged by ID physicians, only 72 (17%) had discharge treatment that was < 5 days (range 0-31 days) with average treatment duration of 8.6 days How Can We Improve?

IHI Improvement Model AIM Run & Control Chart Key Drivers & Interventions What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? PDCA the Changes Act Study Plan Finding the optimal balance between ideal and practical Do

Skin and Soft Tissue Abscess Antibiotic Treatment Duration QI Project Aim Increase prescribing compliance of < 5 days of antibiotic therapy at discharge following inpatient I&D of soft tissue abscesses by the ID faculty from the baseline of 8.6 to 5 days or less by May 2, 2017 and sustain for 6 months Project Lead: Guliz Erdem, MD Medical Director, Infectious Disease Service

QI Multidiscipline Project Team Core Team Project Leader: Guliz Erdem, MD ID Physicians, C5B Nursing staff, Kevin Drewes, PharmD Brian Kenney, MD; Andrew Nordin, MD Project Support Executive Coach: William Barson, MD QI Coach: Don Buckingham, MBOE [Nexus Clinical Science with QI Science]

Decrease Antibiotic Treatment Duration of Abscesses following I&D Project Leader: Guliz Erdem, MD Aim Increase prescribing compliance of < 5 days of antibiotic therapy at discharge following inpatient I&D of soft tissue abscesses by the ID faculty from the baseline of 8.6 to 5 days or less by May 2, 2017 and sustain for 6 months Expand to outpatient/uc and PFK collaboration Key Drivers Accurate baseline duration of prescribed outpatient therapy Physician prescribing culture Physician and staff awareness and understanding Effective monitoring of compliance with suggested standard by all faculty members Interventions Pharmacy records, audit discharge summaries between January 1, 2016 December 31, 2016 Consensus among ID faculty for patients eligible for shorter course of treatment and antibiotic timeouts Develop/implement treatment guidelines following surgical I&D Follow antibiotic resistance rates - Follow readmission rates - Follow complications and inadequate response with surgery - Increase usage of NCH outpatient pharmacy EMR discharge antibiotic order default to 7 days of total therapy - Give feedback to faculty - Periodic chart, pharmacy audits - Cost analysis Updated 8/1/2017

Inclusions eligible patient population Patients between 3 months and 21 years of age Patients admitted/discharged from ID service with diagnosis of soft tissue abscess that had incision and drainage done during hospitalization with or without minimal residual cellulitis at the time of discharge Residual cellulitis is defined as at or around 5 cm at discharge

Exclusions ineligible pt. population Complicated SSTI with signs or symptoms indicating systemic involvement and/or uncontrolled comorbidities that may complicate treatment Signs and symptoms indicating systemic involvement are: fever with tachycardia over 8 hours of hospitalization, diaphoresis, fatigue, anorexia, and vomiting that is not due to medication taste Face and neck infections and lymphadenitis Cat scratch disease Hidradenitis suppurativa Pilonidal cyst Perianal abscesses (not buttock abscesses) Burns Wounds requiring a wound vac Patients with immunodeficiency Decubitus ulcers/infected Animal/human bites, foreign body infections Surgical site infections Underlying skin disorders at the site of infection such as severe eczema

2016 Baseline / 2017 Outcome Improvement Days of Abx Therapy Jan 8.35 Feb 7.68 Mar 8.99 Apr 9.15 May 8.25 Jun 9.22 Jul 9.85 Aug 8.89 Sep 7.96 Oct 7.36 Nov 8.35 Dec 8.61 Jan 8.00 6.89 Feb 6.18 Mar 4.85 Apr 4.50 May 5.56 Jun 5.36 Jul 4.94 Aug 4.89 Sep 5.69 Oct 5.21 Nov 5.40 Dec Average days of antibiotic therapy at discharge following inpatient I&D and antibiotic therapy of skin and soft tissue abscesses Desired Direction 14 12 10 8 6 X-Bar Chart* Mar 2017 Treatment protocol began 4 2 0 Feb 2017 Treatment guidelines, education of ID faculty, fellows and staff 2016 2017 Group Means Process Stage Mean Process Stages Control Limits* Goal(s) * A ln(b+ax) transform for right skew was used to determine control limits. Control limits were then reverse transformed to reflect original data metrics. Group Means Group Size 36 17 35 33 35 39 41 32 40 49 32 28 22 18 11 13 12 16 11 17 9 13 14 5

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Percent of Compliance 2016 Process Improvement Prescribing 5 days of antibiotic therapy at discharge following inpatient I&D and antibiotic therapy of skin and soft tissue abscesses Desired Direction Chart Type: p-chart 100 90 80 70 60 50 40 30 20 10 0 Intervention Period 2016 2017 Prescription Compliance Process Stage Mean Process Stages Control Limits Goal(s) # Comply 6 2 5 4 12 10 2 3 9 10 5 4 4 5 6 10 10 11 7 19 7 10 12 5 # Prescribed 37 17 35 33 35 39 41 32 40 49 32 28 22 18 11 13 12 16 11 21 9 13 14 6

Intervention Time Line February 2, 2017: ID attending and fellow meeting for study discussion and introduction. Treatment guidelines required. February 6, 2017 to March 3, 2017: Development of inclusion, exclusion criteria and treatment guidelines, introduction, discussion, teaching of ID faculty, fellows and staff Selection of project for division incentive plan Two division QI meetings with participants Meeting with pediatric surgery department March 11, 2017: Presentation to Chief Medical Officer March 13, 2017:Treatment Protocol started March 21, 2017: Treatment protocol by attending physicians

Flow Discharge Measures of Simple SSTI Admitted to ID Service Updated 2/27/2017

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Percent Readmissions 40% Balancing Readmission Measure Readmissions within 30 days discharge following inpatient I&D and antibiotic therapy of skin and soft tissue abscesses Desired Direction Chart Type: p-chart 35% 30% 25% 20% 15% 10% 5% 0% 2016 2017 Date of Event Readmissions Process Stage Mean Process Stages Control Limits Total Readmits 2 1 3 0 0 0 1 4 1 2 6 6 0 4 0 0 2 0 1 4 1 0 0 0 Total Discharges 37 17 35 33 35 39 41 32 40 49 32 28 22 18 11 13 12 16 11 21 9 13 14 6

Conclusion and Next Steps Standardizing definitions of uncomplicated skin and soft tissue abscesses was critical to success. In addition to improved treatment adherence and decreased side effects; shortening the duration of antibiotic treatment led to decreased patient care costs with no significant change in readmission rates Spreading the intervention to other inpatient units and outpatient settings: Partners For Kids and Urgent Care Clinics

Thank-you! We d now like to open the floor to short speeches disguised as questions.