Incubating Success: How We Used Structured Feedback To Reduce A Dangerous Practice

By Rich Bottner, PA-C; Victoria Valencia, MPH |  October 16, 2018 | 

By: Rich Bottner, PA-C and Victoria Valencia, MPH

You submit an issue to your Event Reporting System and never hear back. You discuss the need for institutional improvement with your colleagues around the water cooler, but few things seem to change.

Sound familiar? Instead of passively waiting for quality improvement to happen in hospitals, organizations must be proactive in identifying and developing ideas for change. Modeling open forums like the Dell Medical School Incubator, which was developed in the spirit of traditional Silicon Valley incubators, is one way to accomplish this task.

Places where we have trained and worked have often lacked a structured, specific outlet for QI discussion. Rather, the approach is often piecemeal and uncoordinated. Incubators, in the general sense, take something small and nurture it under controlled conditions. Our incubator ensures that quality improvement and scholarly projects have a solid foundation from which they can grow and flourish. It offers enthusiastic out-of-the-box thinkers the opportunity to flesh out ideas with like-minded individuals and our local experts as well as an environment that encourages ideas, feedback, collegiality and constructive criticism.

The hour-long session meets monthly and focuses on things like abstract, manuscript, and poster review, research project design, and quality and value improvement project plans. We sit in a circle as if around a campfire, listen to a brief presentation about a potential issue, and then deep-dive into “group think” and brain-storming around the presenter’s questions. A moderator helps to keep discussions on track.

Here’s one example of how our incubator brought value to our hospital, patients, and learners.

Our institution uses a sliding scale protocol for potassium replacement. An oral and intravenous version can be ordered. Unfortunately, this has led to misuse. Patients able to tolerate oral potassium are given the IV formulation resulting in adverse events such as thrombophlebitis and hyperkalemia, a burden for nurses given the time required for its administration, and discomfort since IV potassium is often described by patients as at best uncomfortable and sometimes painful. Our faculty and residents recognized this as an issue some time ago, but it wasn’t until Dell Med Incubator provided an outlet for discussion that we were able to make significant improvement.

The initial incubator session helped to better define the problem. We discussed the various components that have led to the IV potassium problem. The initial goal was to change the potassium value at which potassium was automatically administered. But based on group feedback, we recognized a better and more agreeable strategy was to investigate NPO status – everyone in the incubator, and ultimately the institution, could get behind prioritizing PO potassium for patients not on NPO status.

We also identified a need to better structure our data collection. Through incubator networking, we were able to link up with an informatics specialist that assisted in retrieving and analyzing the necessary data reports to show IV administrations over time.

At the end of the session, there was a clear path forward with buy-in from key stakeholders across multiple disciplines. This aspect alone—getting key stakeholders altogether in one room— can often be one of the most challenging aspects of quality improvement in hospitals.

But how did we get all these people together in the first place? We started small.

We scheduled the regularly recurring sessions so department leadership could attend and provide insight. For us, that meant meeting in the early afternoon to try and reach as many faculty and residents as possible before they return to the hospital after rounds. While no hour is perfect, the project team only presented once key stakeholders in cardiology and nephrology could attend and participate in collaborating on a potential intervention together.

Less than one year later, with the hard work of Brian Grundy, an internal medicine resident, policy was changed not only at our institution, but throughout the entire hospital system. At the intervention’s peak, IV potassium misuse was reduced by 60% with no changes in adverse events. Brian shared this work as a plenary oral presenter during the Southern Society of General Internal Medicine meeting and as a poster presenter at the High Value Practice Academic Alliance annual meeting.

Our Dell Med Incubator has led not only to direct improvements in the quality and value of care that we provide to our community, but also to the advancement of academic output of our learners. In this sense, an Incubator session, or a meeting like it, might be a meaningful way for those water cooler chats to turn into impactful change.

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About the Author: Rich Bottner, PA-C; Victoria Valencia, MPH

Richard Bottner is a hospital medicine PA in Austin, Texas and a clinical assistant professor of internal medicine at Dell Medical School. He also leads The B-Team, an interprofessional and multidisciplinary consultation team that offers full-service buprenorphine inductions on medical and surgical wards. The work is supported by the NIDA Clinical Trials Network Dissemination Initiative, through a partnership with the PA Foundation. This article was adapted from the American Academy of PAs. Victoria Valencia, MPH has a background in biology and public health and has worked in clinical research and quality improvement for over five years. She is a data analyst and programmer and uses R to analyze and visualize complex data from clinical research databases and electronic health records to help answer questions around quality, value and appropriateness of care provided to patients. She has co-authored several articles that investigate ways to improve the value of care patients receive while in the hospital.


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