THE HISTORY OF THE PEDIATRIC ORTHOPAEDIC SOCIETY OF NORTH AMERICA (POSNA) QUALITY, SAFETY, AND VALUE INITIATIVE (QSVI)
The goal of the POSNA QSVI is to provide a unified program at the organizational level to coordinate and share the best ideas and practices for improving quality of care, increasing patient safety, and delivering value. The program was established in 2011, under the leadership of Peter M. Waters, MD, then the incoming POSNA president. He appointed John M. (Jack) Flynn, MD, to organize and launch the QSVI program, with the leadership’s full support and resources.
As the quality improvement program supported by POSNA, the QSVI has 3 goals:
- Develop clinical tools that members can use to improve quality and safety at their institutions.
- Conduct multicenter research trials focused on determining complication rates, the efficacy of safety interventions, and other QSVI questions.
- Educate members on best practices and new developments in the realms of quality, safety, and value.
The impetus for the creation of the QSVI stemmed from the 2000 report from the Institute of Medicine, To Err is Human: Building a Safer Health System,1 which estimated that nearly 100,000 people die each year from medical error in the United States. More than a decade later, published data suggest that adverse events still affect approximately 1 in 10 hospitalized patients,2,3 and up to 40% of these events require admission to an intensive care unit.4
The initial call for support led to commitments from nearly 100 busy surgeons who were willing to dedicate their time and skills. The structure and focus of POSNA QSVI is appropriately bottom up and began with member surveys and membership-derived goals. Three years later, the programs have affected nearly all POSNA members and provided information and support to improve our clinical care to thousands of patients.
The QSVI leadership committee is under the presidential council in the organizational chart of POSNA and reports directly to the presidential line. There is representation from various POSNA committees, such as education and research, specific clinical subspecialty areas, and selected quality improvement experts. It is meant to be nonproprietary and inclusive. Use of quality improvement techniques is encouraged to generate short turn-around times along with a focus on practical real-life questions with real-time answers. Sharing of goals and topics among other subspecialty groups, such as the Scoliosis Research Society, is encouraged and has been highly productive.
QSVI information is disseminated openly in a number of ways. These include focused quality improvement–themed programming at the annual meeting, a new POSNA Web site spearheaded by Paul Choi, and working groups communicating on Microsoft SharePoint sites. Mobile apps, publications, and courses on quality improvement methodology have been developed and coordination with the American College of Surgeons National Surgical Quality Improvement Program is ongoing. The POSNA QSVI is currently being supported through funding from a quality improvement–focused request for proposals, the American Academy of Orthopaedic Surgeons, our fellow subspecialty groups, and our enthusiastic POSNA membership—all with the singular focus of producing higher quality and safer care at a better value for our patients and families.
QUALITY IMPROVEMENT TECHNIQUES AND HOW THEY DIFFER FROM TRADITIONAL RESEARCH TECHNIQUES
Increasingly, quality improvement science is being used to improve patient safety, reduce unwarranted variations in care and outcomes, and produce sustainable changes in systems of care delivery.5–18 In 2006, The Hastings Center defined quality improvement in health care as “systematic, data-guided activities designed to bring about immediate, positive changes in the delivery of health care in particular settings.”19
Quality improvement differs from traditional research in many important ways20 (Table 1). Quality improvement is focused on improving a process, often by implementing existing evidence or reducing unintended variation through standardization. The specific aim is clear. However, the hypothesis (often presented as key drivers necessary for improvement and that prioritize the interventions21) usually evolves over time with new learning. In contrast, traditional research looks to produce new knowledge and begins with a fixed (null) hypothesis that the research tries to prove or disprove. Quality improvement methods emphasize testing theories about organizational processes and systems through experimentation and replication to produce a detailed understanding of factors affecting system performance.22 Improvement is temporal so changes are measured over time. Traditional research typically compares 2 groups.
The statistical methods used for quality improvement also differ. Statistical process control methods23 are widely used by industries to study the impact of ongoing interventions on outcomes over time. Traditional research typically compares 2 groups and attempts to determine whether they are the same or different using P values or confidence intervals. In quality improvement, data are usually plotted on run and control charts24,25 (Fig. 1). These charts can be used to identify common cause variation (the usual, historic variation seen in the system) or special cause variation (unusual variation possibly introduced into the system by an intervention). The charts are annotated with a median/mean centerline, control limit lines, and a goal line, and indicate the desired direction of change. For independent observations, an observed change in the data is considered a special cause when any of the following are true: (1) there is a “shift,” that is, ≥8 consecutive points are either above or below the mean/median centerline; (2) there is a “trend,” that is, 6 consecutively increasing or decreasing data points; (3) there are “clustered points,” that is, at least 15 consecutive points close to the mean/median centerline; or (4) there is a single point outside the control limits (3 SDs) or 2 out of 3 consecutive points near a control limit (in the outer one third).
Finally, knowledge obtained from quality improvement is typically implemented quickly, with the aim to spread and share the results. In contrast, it has been estimated that it takes an average of 17 years for evidence from traditional research to reach clinical practice.26–28
PROJECTS COMPLETED, UNDERWAY, OR IN PLANNING FOR POSNA QSVI
As a sign of QSVI clinical activity, POSNA had over 70 abstracts on quality, safety, and value submitted in 2014. The 2014 precourse, organized by Mininder Kocher, MD, is focused on QSVI topics and is being organized into an online webinar (developed by Dan Sucato) and a formal publication. Paul Choi maintains a list of ongoing initiatives on our Web site and working groups are communicating through SharePoint. Mobile apps, publications, and courses on quality improvement methodology are ongoing. Plans are in place for a formal quality improvement POSNA tutorial that will be tailored specifically to the pediatric orthopaedic surgeon. POSNA is working closely with the American College of Surgeons National Surgical Quality Program on a specific pediatric orthopaedic initiative to reduce spinal infections nationwide. POSNA also works closely with the American Academy of Orthopaedic Surgeons on a number of combined projects. The support received from the request for proposals, the American Academy of Orthopaedic Surgeons, our fellow subspecialty groups, and our enthusiastic POSNA membership help to ensure participation at the highest level and maintain the focus on producing higher quality and safer care for our patients and families.
To date, clinical guidelines have been developed and implemented to decrease surgical site infections in children undergoing spine surgery with the real-life implications of saving hundreds of children from infections and millions of dollars in cost.29 A smaller project to develop a compartment syndrome alert process has nearly eliminated the need for emergent compartment releases in a busy pediatric trauma center.30 An operating room utilization project saved over a million dollars of lost hospital revenue just by improving the capacity of 1 surgeon.
New processes that leverage the power of new technology are underway. These include the development of a computerized comprehensive checklist that integrates into a hospital’s electronic health record and sophisticated and validated surgical simulation programs to efficiently teach the next generation of surgeons. Don Bae is now coordinating with a national group to develop a surgical simulation laboratory/education built on the highly successful “Top Gun” program at IPOS. The group has created a distal radius fracture casting and cast removal toolkit that included the development of a new higher fidelity distal radius fracture model and a validated way to measure cast saw temperatures.
Tony Stans has developed a supracondylar practice improvement module in cooperation with the American Board of Orthopaedic Surgeons so that quality improvement processes can be incorporated into recertification efforts. Brian Brighton is working with the pediatric National Surgical Quality Improvement Program to collect data across pediatric subspecialties, including orthopaedics, which is well stratified and meaningful. Michelle Caird is taking a leading role in helping to promote radiation safety for children and surgeons in pediatric orthopaedics by developing alliances with our radiology colleagues and is creating a repository of radiation safety literature on our new Web site.
Clinical practice guidelines, standardized clinical assessment and management plans (known as SCAMPs),31,32 and order sets for electronic health records are being created locally and shared openly. Under the oversight of Lori Karol, a great deal of effort has been expended on exploring the creation of a patient registry and support from POSNA. This work has received support and encouragement from a number of our members. Kevin Shea has spearheaded a project that may use resources at the American Board of Orthopaedic Surgery SCRIBE registry to create a pediatric sports quality/performance improvement registry has been presented to the PRISM attendees.
In summary, while the POSNA QSVI was implemented just 3 years ago, a number of successes have already been achieved. Many early projects have been completed and many more are currently underway or in planning.
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