1. Emergency Department
Quality Improvement
Abdulaziz Saddique Pharm.D., CPHQ
Associate executive Director for Quality Management
College of Medicine and the University Hospitals

2. Dr. Abdulaziz Saddique 2TIMELY SERVICES IS THE KEY TO QULAITY
EMERGENCY DEPARTMENT SERVICES

3. Why ED Quality Program
To improve quality of care
Provided by the Emergency
Departments to increase the
“early indicator” rates for
serious diseases e.g., MI,
Pneumonia

4. Dr. Abdulaziz Saddique 4
Why ED Quality Program
Patients Outcome Is
Dependant On Initial
Treatment Carried Out In
The Emergency
Department in Timely
Manner.

5. Dr. Abdulaziz Saddique 5
Healthcare Quality Scenario
Activity
Process
(Chain of activities)
Product
3 Process quality
Throughput time, conformance to
protocols, avoidance of wasteful
resource usage
1 Effectiveness
Fit to customer needs,
benefit to the
customer's)
2 Product quality
• Fit to specifications
• Customer satisfaction
• Quality as seen by a peer
4 Organizational
quality
Employee satisfaction
Structures, systems

6. Dr. Abdulaziz Saddique 6
Examples of Indicators
Acute Myocardial Infarction
Community Acquired Pneumonia

7. Dr. Abdulaziz Saddique 7
AMI Indicators
Aspirin at hospital arrival
Beta blocker at hospital arrival unless
contraindicated.
Thrombolytic agent received within 30
minutes of hospital arrival
PTCA received within 90 minutes of
hospital arrival

8. Dr. Abdulaziz Saddique 8
Preliminary Baseline Indicator
Rates for AMI
80.5
61.2
33.3
9.1
80.0
60.8
26.5 27.4
95.2
88.0
85.7 85.7
0
10
20
30
40
50
60
70
80
90
100
Quality of Care Measure
Percent(%)
Michigan National Benchmark
ASA within 24 hrs. BB within 24 hrs. Lytic < 30 min. PTCA < 90 min.

9. Dr. Abdulaziz Saddique 9
Pneumonia Indicators
Initial antibiotic received within 4 hours of
hospital arrival
Initial antibiotic selection for community-
acquired pneumonia (CAP) in
immunocompetent patients
Blood culture performed before first antibiotic
received in hospital
Oxygenation assessment (arterial blood gas
measurement or pulse oximetry)

10. Dr. Abdulaziz Saddique 10
Preliminary Baseline Indicator
Rates for Pneumonia
57.5
59.6
76.2
93.4
59.7 58.8
81.1
93.7
100.0
87.9
95.7
0
10
20
30
40
50
60
70
80
90
100
Quality of Care Measure
Percent(%)
Michigan National Benchmark
n/a
ABX < 4 hrs. Rec. ABX BC Before ABX Oxygenation

11. Dr. Abdulaziz Saddique 11
Whole system Ownership
Primary
Care
ReformingEmergency
Care
See & Treat
A&E
Emergency Services Collaborative
Triage
Bed management
Streaming
M
inors
Majors
Ambulance
SICU
Walk-in
Centre
Social
Care
MICU
Triage

12. Dr. Abdulaziz Saddique 12
Basics of Quality Improvement
Vision, and Mission
Strategy
Innovation
Team Work
Momentum
Growth
Focus
Customer Service
Attitude

13. Dr. Abdulaziz Saddique 13Nothing happens unless first a dream

14. Dr. Abdulaziz Saddique 14
Vision.
The vision of the organization begins
with its leadership.
YOU WILL
MAKE $10000000000

15. Dr. Abdulaziz Saddique 15
Vision
Without vision there will be nothing to look
forward to.
There will be no clear path to follow
It will be a Blind leading Blind

16. Dr. Abdulaziz Saddique 16
Change Requires Shifts in
Knowledge, Skills and Attitudes
Knowledge
Habits
Behavior
Mindset
What? Why?
Want ToHow To?
Skills Attitude and Desire

17. Dr. Abdulaziz Saddique 17
Those who are victorious plan effectively and
change decisively. They are like a great river,
that maintains its course, but adjusts its flow.

18. Dr. Abdulaziz Saddique 18
Process of Strategy Development
Vision, and mission statement and
accountability.
Evaluation of your organizational performance.
Customer’s satisfaction.
Market analysis
Departments functions.
Monitoring of your services.
Updating of your services.

19. Dr. Abdulaziz Saddique 19
If There Is A Better Solution, Find It.

20. Dr. Abdulaziz Saddique 20
Innovation
Development or adaptation of
Indicators
Critical Pathways
Standardized treatment

21. Dr. Abdulaziz Saddique 21
Teamwork Is The Ability To Work Together
Towards A Common Vision. It Is A Fuel That Allows
Common People To Attain Uncommon Results.

22. Dr. Abdulaziz Saddique 22
Why Use Teams ?
Participation allows an individual:
The opportunity to contribute ideas
To experience the change process
To have clear understanding of the
objective
To gain a sense of ownership
To become committed to the process
and become a change advocate

23. Dr. Abdulaziz Saddique 23
Medical Staff involvement
Medical staff are:
The driving force of the healthcare
facility.
The heads of the healthcare teams.
The operators of the organization.
Carry the responsibility of the well
being of the patients.

24. Dr. Abdulaziz Saddique 24
A Little Push In The Right Direction
Can Make A Big Difference.

25. Dr. Abdulaziz Saddique 25
Momentum
Each organization or Administration
have differ motivating factors, find the
most appropriate motivating factor for
your organization to get your Vision
supported.

26. Dr. Abdulaziz Saddique 26
First Things First
Quality Improvement
is not valid unless we
have the infrastructure
for it.

27. Dr. Abdulaziz Saddique 27
Golden Rule
PUT THE HORSE BEFORE
THE CARRAGE NOT THE
CARRAGE BEFORE THE
HORSE

28. Dr. Abdulaziz Saddique 28
QI Infrastructure Development
Set up the Standards of Care
Select team members trained in
CQI application
Develop an Aim Statement
Develop Policies and Procedures
Develop Indicators for Care
Identify areas of deficiencies

29. Dr. Abdulaziz Saddique 29
The rung of a ladder was never meant to rest upon, but only
to hold your foot long enough to put the other foot higher.

30. Dr. Abdulaziz Saddique 30
Growth
Setting the standards is the first
stepping stone towards quality
services.
Your goals should include standards
improvement through continuous
quality improvement.

31. Dr. Abdulaziz Saddique 31
Obstacles Are Those Frightful Things You See
When You Fail To Focus On Your Goals.

32. Dr. Abdulaziz Saddique 32
Focus
Focusing on the Goals of your
organization or department is essential
in removing all obstacles or problem
related to your service.

33. Dr. Abdulaziz Saddique 33
Success In Business And Customer Service Go Hand
In Hand.

34. Dr. Abdulaziz Saddique 34
Customer Service
Quality is dictated by customers not the
organization.
Customer satisfaction (either internal or
external) is the most valuable assets of
the organization.

35. Dr. Abdulaziz Saddique 35If It Is To Be … It Is Up To Me.

36. Dr. Abdulaziz Saddique 36
Attitude
Nothing is free, you have to work for your
goals and objectives
Make your goals and objectives visible for
others
Your staff are your best assets get them
involved
Dreams can come true if you want them to.

37. Dr. Abdulaziz Saddique 37
EDQIP Action Plan
Launch QI conference
Participate in shared-learning sessions
Develop QI projects
Involve all your staff
Identify your customers (internal)
Develop project team
Listen to your customers

38. Dr. Abdulaziz Saddique 38
Customers Participation
Discussion Points
Highlight ED strategies
Speak with DATA
Don’t criticize any one
Compare individual ED rates with peer
group and state aggregate rates
Outline your plan for Improvement
Ask for support to your mission

39. Dr. Abdulaziz Saddique 39
Quality Improvement Strategies
in the ED
Join EDQIP!
Rapid-cycle initiatives
Multidisciplinary team approach
Share interventions with other hospitals

40. Dr. Abdulaziz Saddique 40
What Works to Improve Care?
Role of Systems-based Improvement
CME and didactic programs have little impact
on changing behavior!
Effective strategies include
reminder systems
standing orders
clinical pathways or protocols
opinion leaders and physician champions
self-monitoring and feedback
Davis DA, et al. JAMA. 1995;274:700-706.

41. Dr. Abdulaziz Saddique 41
“QUALITY OF CARE” . . .
An elusive concept???
“Like Beauty, quality of care is in the eye
of the beholder.
It can't be defined or measured.”
"Quality of care is like the weather;
everyone talks about it,
but you can't do anything about it."

42. Dr. Abdulaziz Saddique 42
ED Quality Improvement Programs
Washington University/ Barnes Hospital:
Aim: to decrease waiting time in the ED to < 180 min.
Process:
Patients flow study
Adjusting Hours of Operations
Expediting initial evaluation, reducing turn-around
time for lab radiology and expediting specialty
consultations
Outcome: The waiting time was decreased to less
than 160 min.

43. Dr. Abdulaziz Saddique 43
Melbourne Metropolitan Hospital
Aim: Decrease ED Length of Stay (LOS),
and resolve bed access block
Process:
Use of protocols for common conditions
Transparent bed-management processes,
Focus on efficient use of the available beds,
particularly through admission and discharge
planning.
Outcome: Decrease waiting time in
EDLOS, more beds became available
for Critical patients

44. Dr. Abdulaziz Saddique 44
Principles for Integrated Bed
Management
1. There is an organization led commitment to
manage all hospital beds.
2. There is a centralized point of authority and
accountability for the allocation of all hospital
beds.
3. A bed management forum is established to
identify and resolve bed management
problems. The hospital executive supports this
forum.
4. A documented policy framework supports
integrated bed management principles.
5. The function of allocating all hospital beds is
centralized.

45. Dr. Abdulaziz Saddique 45
Principles for Integrated Bed
Management
6. Bed allocation staff has appropriate authority to
allocate beds.
7. Integrated bed management occurs 24 hours
per day, every day.
8. Integrated bed management must be linked
with the needs of inbound and outbound patient
traffic
9. Allocation of hospital beds is based on agreed
medical criteria.
10. The allocation of beds to clinical units is
notional.

46. Dr. Abdulaziz Saddique 46
Principles for Integrated Bed
Management
11. A flexible bed base is built into the operating
requirements to meet fluctuating bed demands.
12. Patients are admitted to their correct specialty
ward/unit on admission or within 24 hours
where appropriate.
13. A patient’s episode of care is planned from pre-
admission/emergency, through admission and
discharge back to the community. Patients and
carers are partners in this process.
14. An interdisciplinary team plans and coordinates
care and support services for a patient’s
episode of care.

47. Dr. Abdulaziz Saddique 47
Principles for Integrated Bed
Management
15.Integrated bed management is supported
by accurate real time information. Data is
continuously collected, audited, analyzed
and disseminated to guide resource
management and optimize efficiency.

48. Dr. Abdulaziz Saddique 48

49. Dr. Abdulaziz Saddique 49
Questions/discussion