Individual PQI Project
I. Participating as an Individual
In some practice settings, diplomates may not have access to colleagues with the similar Part IV interests necessary to perform PQI as a group, or diplomates may have clinical interests and quality gaps that are not shared by practice associates. In these and other situations, individual PQI participation is appropriate.
Self-designed projects are best suited for individual PQI participants. These are conceived and formatted by the diplomate to fulfill a perceived or documented quality issue in his or her practice. Such projects do not require approval for use; however, certain constructs in the design and execution of the project must be observed (as specified below), and documentation with record-keeping is required.
Designing your PQI project: A number of elements should be considered when selecting a suitable topic and performing a self-designed PQI project. The following presents a step-by-step process for project selection, development, and completion – the “Plan-Do-Study-Act” cycle – which is followed until the project is concluded.
II. Examples of Individual Process Improvement Projects
One diplomate writes: "Long clinic wait times were decreased through dedicated data collection leading to implementation of adjusted clinic template. I collected data on each patient’s visit to my clinic during six fully-booked clinics. Specifically I collected the time from when they checked in until the time I went to see them, what type of visit (follow-up versus a new or consultative patient), and whether I was seeing the patient with a trainee or a mid-level provider. This was mapped by the time of day and graphically represented. I was able to identify a progressive increase in the time delay, demonstrating that my clinic template was perhaps too aggressive for my patient population. Solutions were generated by presenting the data to my scheduler and to my nurses and we agreed to simply insert a break at lunch, something previously not in my template, to give us an opportunity to 'catch up.' After implementation we continued to track the data and demonstrated a reduction in patient wait times greater than 1 hour."
III. Pre-intervention PDSA Cycle (Cycle #1)
SELECT PROBLEM OR AREA OF INTEREST THAT YOU WANT TO IMPROVE IN YOUR PRACTICE: This first step involves selecting a project area of interest or topic that is relevant to your practice, that you would like to improve, and that is amenable to repeated measurement. In doing so, it is often helpful to evaluate your practice in the light of the six Institute of Medicine Quality Aims: What aspect of your practice could be made safer, timelier, more efficient, more effective, more patient centered, or more equitable? You should choose a topic that has the potential to make a real improvement in your practice. Because the purpose of PQI is to address and improve real issues in your practice, performance topics that do not present challenges or perceived gaps in practice are not appropriate for PQI projects. The possibilities are endless, but some projects that might be relevant include: reduction in atrial fibrillation rate, reduction in blood transfusion, reduction in hospital readmissions, improved discharge summary transmission to other treating physicians, increased mediastinal lymph node dissection rate, reduction in esophageal anastomotic leaks, reduction in postoperative air leaks after lung surgery, etc. The source of the data can be from the electronic medical record, your office, patient surveys, or the STS database. Use of the STS database, not only for data collection but also for benchmarking, is highly encouraged. While the number of patients or measurements will be variable depending on the topic chosen, a general guideline would be: if the individual surgeon is collecting the data, 20-30 patients total is reasonable and sufficient; whereas, if the STS database is used, then the total number of patients for that measurement period would be used.
DEVISE MEANS TO MEASURE IMPROVEMENT and CHOOSE YOUR TARGET LEVEL OF IMPROVEMENT: Initially, this may often be articulated as a quality question from which the metric can be derived. Once you adopt a measurement, set a target level of performance desired in your practice. Obviously you should pick a measure where there appears to be a gap between what is currently thought to be the outcome and what is desired. It is also helpful to predict what you believe your measure will show when applied to your practice. If you predict that your goal will be met on initial measurement, then this is not a suitable topic, and a different project should be chosen to allow this process to improve your practice.
- Area of Interest (Topic): “Time Out” at Bedside Procedures (eg, chest tube)
- Quality Question: In what percentage of bedside procedures in my practice was a “time out” performed and documented?
- Measurement to be Taken: Number of procedures in which a “time out” occurred/total number of bedside procedures x 100%.
- Desired Target Level (Goal) of Performance: “Time out” before beginning a procedure occurs in 100% of cases.
- Baseline Measurement Prediction: I believe that, upon initial measurement, “time out” before the beginning of procedure may have occurred in 70% of cases.
DEVISE A PLAN OR PROCESS FOR COLLECTING DATA: Who will collect the data and how will it be recorded and stored? Remember to protect any personal identifiers and patient identity.
COLLECT YOUR BASELINE DATA: Put your plan into action, making baseline measurements in an unbiased manner and for an appropriate number of cases/data points.
ANALYZE YOUR BASELINE DATA: Compare the observed data with both the predicted result and the optimal desired performance target. Summarize your conclusions and what you have learned. One of two results will be pertinent:
- If the results did not meet your performance target, determine the factors to which you attribute the result and examine all potential root causes (then proceed to Step D below-- ACT).
- If, unexpectedly, the results did meet the performance target, institute a plan to sustain the gain and re-measure at appropriate intervals.
DEVISE PLAN FOR PROCESS IMPROVEMENT: Choose a plan that addresses the perceived root causes for not achieving the performance target. Implement your improvement plan before re-measurement.
IV. Post-improvement PDSA cycle (Cycle #2)
After implementing the improvement plan, REPEAT THE PDSA CYCLE by: 1) making a new set of measurements in an appropriate number of cases/data points; 2) analyzing the re-measurement data; and 3) determining whether the project goal has been met or whether additional action is needed. The PDSA cycle can be repeated to continue to improve the designated process, but for the purposes of MOC, the requirements have been met.
V. Assess Project Impact
When you complete your project, you must prepare a short paragraph stating how the project might positively impact your practice and/or your patients. Example: By appropriately adjusting the schedule of my outpatient clinic to reflect real times spent with the patient and real waiting times for patients yet to be seen, I was able to reduce the number of patients with excessively long waits and improve satisfaction with the care.
VI. Project Template
To assist individual participants in following and documenting the required process, the ABTS has composed an optional digital template, which may be used in completing PQI projects (available here).