On Quality

By Dan Hyman, MD, MMM
Chief Quality Officer, Children's Hospital Colorado

My own journey into the world of quality and patient safety started quite by happenstance and, to be truthful, as a result of misplaced confidence in how good a group of doctors we actually were. Erdenheim Pediatrics, a then six-person private pediatric practice in suburban Philadelphia was well-respected, thriving, and - as we would come to learn - broken. In 1996, we were offered the opportunity to participate in a pilot project that the American Academy of Pediatrics was running with 20 practices, like ours, that were members of the Pediatric Research in Office Settings (PROS) Network. As the partner leading that initiative, I traveled to Chicago with two of our office nurses to learn the principles of the "Model for Improvement" and how we would, during the project, test its implementation in our primary care pediatric practice. The Model for Improvement has been extensively used and taught by the Institute for Healthcare Improvement (IHI) and the National Initiative for Children's Healthcare Quality (NICHQ) in their national programs, and is one of the simpler frameworks for pursuing change in healthcare and other settings. It asks three simple questions that I share with you for your own use in practice (or with your diet and exercise schedule!):

1. What is it that I am trying to accomplish? (Aim statement)
2. How will I know that a change is an improvement? (Measures)
3. What changes can I make that will result in improvement? (Changes)

Practice improvement journey

The particular project we first worked on was improving asthma care in our practice. To say that our initial objective assessment of how effective we were in providing care to children with asthma surprised us would be a tremendous understatement. Not only were we not adhering to the then five-year-old guidelines for diagnosing and treating childhood asthma, we were not even consistent across our group in what we called asthma, how we treated it, or who we diagnosed and treated. Terms like "WARI" (Wheezing Associated Respiratory Infection), "RAD" (Reactive Airways Disease) and "bronchitis" were scattered across our sometimes legible, unstructured notes on unlined white paper, which were mostly, but not always available at the time of the office visit. There simply had to be a better way.

Our practice's improvement journey started with gaining consensus on actually using the term "asthma," agreeing on when we would use the word, and then eliminating the use of other language that served to both confuse and delay effective treatment. Our charts were ultimately modified with structured notes for all visits, starting with asthma follow-up notes, that dramatically increased our rates for classifying disease severity, treating children with anti-inflammatory therapy, and giving them written treatment plans. In subsequent years, we moved on to do additional improvement work at Erdenheim Pediatrics in treating Attention Deficit/Hyperactivity Disorder and in providing preventive services in general, and I moved on several years later to pursue work in quality improvement as a full-time endeavor. That is how I now come to be in Colorado, where I am proud to be the Chief Quality Officer for an excellent hospital that seeks to continuously improve all aspects of the care we provide to patients and families.

Quality and Patient Safety at Children's Hospital Colorado

As a life-long east coaster, Colorado was nowhere on my professional radar screen in 2007, when Dr. Shmerling arrived at Children's Hospital Colorado and soon thereafter initiated, with Dr. Joan Bothner, a search for a Chief Quality Officer, a new position that would be responsible for leading the organization's efforts to improve the safety and quality of care being provided to our patients. I had traveled here for many wonderful winter vacations since college, and thoughts of Vail and Winter Park/Mary Jane surely played a role in my decision to ultimately pursue the opportunity. But the main draw for me was the chance to work in a hospital that - although already viewed as exceptional - also recognized its need to improve and wanted to invest in a program to do just that.

I have been at Children's since September 2008 and feel privileged to work for an organization that is entirely committed to helping our providers and staff achieve their goals - providing the best care to children and families each and every day. I learned something personally 15 years ago when I first started doing improvement work that guides all of my work today. The reasons we didn't achieve what we wanted in my practice back then, and the reasons we sometimes fall short in the hospital today, are never about personal motivation, effort, knowledge or desire. The reasons are instead always about complex systems that depend on many people effectively communicating amongst themselves and with families, and doing so in the setting of a busy, technology - dependent, high stakes environment with multiple competing priorities, and in an industry that is still a combination of imperfect art and ever advancing science. Achieving reliability, safety, effectiveness and efficiency in that world is our great challenge, and it is a challenge that we embrace. We are focused on improvement goals in a number of ways that I would like to share with you and also invite you to join.

Quality initiatives

The Quality and Patient Safety Department at Children's is made up of a number of components including:

• Clinical Quality Improvement
• Patient Safety
• Accreditation Readiness
• Clinical Decision Support
• Clinical Informatics and Analytics

This team of professionals works together and with providers and staff across the hospital to achieve a range of goals. Over the past several years we have been focused on a number of goals, including:
1. Reducing hospital acquired infections (especially Central Line Associated Blood Stream Infections, but also surgical site infections, viral nosocomial infections, and infections caused by multi-drug resistant organisms).
2. Improving medication safety using dosing limits and alerts, protocols for treatment with high risk medications, and improvements in dispensing and administration of medications in the pharmacy and at the bedside.
3. Improving the reliability of patient identification in order to eliminate episodes of care being provided to a patient other than for whom it was intended.
4. Improving team work and communication, starting in high risk settings like the Operating room and other procedural areas. This type of training, often called Crew Resource Management, started in the aviation industry as a result of the recognition that almost all airline disasters were largely the result of communication failures in the cockpit and potentially could have been avoided.
5. Improving the efficiency with which patients are treated, starting with reducing delays between the Emergency Department and the inpatient units.
6. Reducing the rate of "codes" outside the Intensive Care Unit through the use of Rapid Response teams (which families can also activate) and assessment tools to help nurses recognize and communicate signs of clinical deterioration.
7. Reducing falls, pressure ulcers and other complications of care.
8. We are of course also focused organizationally on improving access to our services and improving the patient and family experience with receiving care here.

Ongoing commitment

We have improved our results in many of these areas, and are continuing all of this work today. Our improvement results are increasingly available across the organization on our intranet sites, and also many results will also be posted by the end of the year on www.childrenscolorado.org/quality. We know that we are accountable for our results to our patients, their families, and to the physicians whose trust and referral decisions can and should be based upon the outcomes that we achieve - in terms of effectiveness, safety, patient satisfaction, timeliness, equitability and efficiency. We know we must earn your trust every day and with every patient, and it is my job and privilege to help us do that.

There are a number of ways that we are and will be collaborating with community based primary care physicians in the area of quality and patient safety. These include:
1. Developing collaborative care models between primary care practices and specialty clinics that improve the effectiveness and efficiency of providing care to families when and where they want that care.
2. Managing populations of patients with chronic conditions like asthma using registries and other tools that can reduce the impact of that illness for these children and their families.
3. Building Clinical Decision Support tools in EPIC that assist those physicians using the electronic health record in their practices (and continuing to expand PedsConnect to more practices so as to better integrate care and communicate across the delivery system).
4. Assisting physicians with their Maintenance of Certification requirements.
5. Finally, I would welcome physicians who are interested in serving as members of various committees that oversee our quality and patient safety work at Children's, or participating as a member of a project team.

I appreciate the opportunity to "talk" to you about the efforts we are making to objectively measure and improve the care we provide at Children's Hospital Colorado, and would be happy to dialogue with you about any aspect of this article. I would also be happy to visit your practice and talk with you about your own practice-based improvement efforts. My email is daniel.hyman@childrenscolorado.org and my phone number is (720) 777-8019. 

Thanks for reading.
- Dan