Quality Improvement

Question 1

What measures to use in QI project?

Answer 1

• Outcome measures (e.g. average A1c level - consider DEFINED standards when looking for outcomes)
• Process measures (e.g. patients having A1c monitored q6 months)
• Balancing measures/unintended consequences (e.g. other lab tests being forgotten because patients are only getting A1c’s done)

Question 2

Analysis to use to set goals in QI?

Answer 2

Set goals (generally improvements fall under SEPTEE domains – Safe, Effective, Patient-Centered, Timely, Efficient, Equitable)

• Perform a root cause analysis to systematically identify a problem and contributors.
• Eg. 5 why’s tool or Fishbone (cause and effect) diagram)

Question 3

Who should be on the team of a QI project?

Answer 3

• Technical expert
• Clinical leader
• Additional team members (ensure administrative people, IT, patients, and other ‘key players’ are included)
• Sponsor (e.g. institutional leadership)

Question 4

How is consumer satisfaction used as a measure of quality of care?

Answer 4

Controversial:

• No widely held definition of ‘satisfaction’ exists
• Methodological inconsistencies across studies
• Vulnerable population
• Not appropriate to solely rely on

If using:

• Ensure families are reassured of anonymity
• Data collated by staff not providing care to the survey population
• Families are given contact info for person outside of department for support

Question 5

How to define a good death

Answer 5

• Social construction that changes over time and context, and role (e.g. physicians may be more narrowly focussed on symptoms)
• Cultural variation also accounts for some differences - some cultures may want more aggressive treatment than others

Empirical research suggest multidimensional approach:

• Physical experience (symptoms, functional status)
• Psychological experience
• Social experience (roles and relationships with other
• Spiritual/existential experience (may be more important as death nears and often not accounted for in QOL measures)
• Nature of healthcare (appropriateness of care and interventions, relationships with providers)
• Life closure and death preparation (financial, personal affairs, funeral planning, etc. and sense of life completion, reflection)
• Circumstances of death

Question 6

Location of death

Answer 6

• Most ‘good death’ literature based upon hospital care
• However, majority of care in the dying trajectory occurs in community/home/outpt settings

E.g. LTC

• Adequacy of staffing
• Facility environment and size
• Capacity of staff
• Bonds between staff and residents

Question 7

Measurement of quality of death

Answer 7

• Good Death Questionnaire
• Good Death Inventory
• Tools generally focus upon retrospective accounts of family or caregivers
• Significant variability in design, reliability, and validity

Question 8

Language around defining goals at end of life

Answer 8

• ‘Good death’ is enormously personal with ‘no one right way’
• Oxford promotes defining and meeting goals at end of life, as these can vary over time and require ongoing communication and negotiation
• Action-oriented approach with the patient as expert