Quality Improvement
Turning Evidence-Based Insights and Best Practices into Meaningful Change
Quality Improvement Domain Function: Design and carry out QI projects to address key focus areas identified during quality planning. Each project should have a SMART aim statement as well as outcome, process, and balancing measures with clearly defined numerators/denominators. Appropriate methodology is used to identify interventions (i.e. Pareto Charts, Driver Diagrams, Failure Modes and Effects Analysis, etc.). Diverse teams, including front-line staff, test change ideas with PDSA cycles, implement, and scale up. Run and Control Charts are leveraged to evaluate impact of interventions and monitor for holding gains. QI metrics should become quality control measures after project completion.
Facilitated by:
- Core Anesthesiology QPS Team
- Quality Executive Council
- Quality Champions
Our Approach
QI initiatives may be inspired by any of the other three domains, including focus areas established in quality planning, signals from quality control measures, and/or safety event(s) triaged and analyzed through quality assurance.
The Department’s Quality Improvement work is guided by structured design and strategic alignment. Each initiative is expected to:
- Identify project leadership and sponsorship
- Address departmental quality priorities
- Overcome clearly defined clinical or operational challenges
- Include measurable aim statements and performance metrics
- Apply evidence-based improvement methodology
- Monitor progress through regular review and reporting
We use templated forms for project planning
We provide templated forms to help teams plan their projects and coaching in the use of QI tools
Our outstanding analytics developer, Jacob Aaronson, assists teams in extracting and synthesizing data
We have a QI project project management database to promote momentum for active initiatives and serve as a reference of past efforts
We encourage our quality champions to disseminate their findings according to SQUIREQI reporting standards
Selection of Recent QI Accomplishments
We are now at the 97th percentile nationally for the AHRQ PSI-11 scorecard for Postoperative Respiratory Failure. This is in large part thanks to a multidisciplinary workgroup’s efforts to implement proven interventions across the pre-, intra-, and post-operative phases of care.
We continue to make significant strides in reducing our environmental footprint through sustainability efforts. After eliminating use of the volatile anesthetic Desflurane, a greenhouse gas that is 2, 540x more harmful than CO2, we focused our efforts on reducing waste from bulk storage of nitrous oxide (most of which is lost to the atmosphere before clinical use). Over the last few years, we have partnered with the hospital to decommission all nitrous oxide pipelines, while enabling staff to use smaller and less wasteful cylinders where clinically appropriate. Our use of this environmentally harmful gas has declined to near-zero as a result.
We developed a comprehensive safety program to reduce the risk of operating room fire.
We attained level 1 certification as a Pediatric Trauma center through the development of the Opioid Stewardship Program, which included creating key indicators to identify pediatric patients at increased risk of opioid misuse and implementing an active Naloxone BPA that triggers for pediatric patients being discharged home with an opioid.
We are optimizing a safety event tracking and reporting platform within the Electronic Health Record.