STEP 6

Work on maintenance and continuous improvement

Case study from the program RECAP (Rehabilitation, Education for COPD and Added value to the medical practice)

BACKGROUND

The Montreal Chest Institute has been leading important clinical and evaluative research in COPD over the last decades. Some of these applied clinical research projects have been carried out at a provincial level with the goal of developing and evaluating the impact of a self-management program...

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BACKGROUND

The Montreal Chest Institute has been leading important clinical and evaluative research in COPD over the last decades. Some of these applied clinical research projects have been carried out at a provincial level with the goal of developing and evaluating the impact of a self-management program specific to Chronic Obstructive Pulmonary Diseases (COPD) within a context of integration of care. One of these studies published is recognized as a landmark in the approach of care of COPD patients. A multicenter randomized clinical trial was carried out at 7 hospitals in 3 cities of the province of Quebec from February 1998 to July 1999. Patients assigned to the self-management program « Living Well with COPD© » (developed in partnership with the Health Respiratory Network of the FRSQ and Boehringer Ingelheim Canada) with follow-up by a case manager over 1 year experienced an improvement on their quality of life and a reduction of 40% and more in the number of visits to the emergency room and hospitalizations and up to 60% in the number of unscheduled physician visits, compared to the usual care group.

Given the importance of these results, in 2003 the Health Agency of Montreal decided to set out a recurrent budget in order to consolidate an integrated approach of care and first line services, with the objective to reduce the number of hospitalizations and the frequency of emergency room visits. This project would include the addition of different resources and services for COPD patients, among them a medical guard for a respiratory therapists and nursing care offered 24/7, and a strong training component for the various case managers at the first line services.

The Montreal Health Agency also decided to support a specific quality improvement project called "Rehabilitation, Education for COPD and Added-value to the Medical Practice" (RECAP) at the McGill University Health Centre (MUHC).

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Accountability

We decided that we had to be accountable for this project. The best way to do so would be to have an external agency evaluate our work. Hence, the six indicators discussed during the evaluation phase were adopted by the Hospital Quality Department and would be evaluated every year, and also incorporated into the objectives for the improvement of our Canadian Hospital Accreditation.

Sustainability/Maintenance

We have to evaluate after the initial implementation of our program whether we succeed in maintaining the same level of patient care in subsequent years. We have thus appended a table here showing the results for a number of indicators regarding the MUHC's performance:

Quality of Care Indicator	Target (defined success)	2007-2008	2008-2009	Progress evaluation
1. D/C planning tool completed	Above 80%	General Hosp <25% Resp. Hosp 73%	General Hosp <25% Resp. Hosp 72%	Need to be reassessed and for the General hospitals to repeat CDM Quality Care Steps 3 to 6 (second cycle)
2. Referrals to respiratory home services	Above 80%	97%	93%	Reached the objective
3. Evaluations of the pulmonary rehabilitation program	Above 60%	82%	94%	Reached the objective
4. Education for inhalation techniques	Above 80%	87%	86%	Reached the objective
5. Use of spirometry tests	Above 80%	81%	81%	Reached the objective
6. Stop smoking interventions	Above 60%	65%	71%	Reached the objective
7. 30-day re-admission rates	Below 10%	13%	13%	More time will be needed to reach the objective

The RECAP-MUHC Committee still meets to keep track and follow-up on the various implementation phases, and to discuss the new results recorded in terms of the quality of care indicators. This committee also decides whether new interventions are needed to keep this project alive, such as, new resources, tool adaptations, etc.

Closing the Loop

As described in the evaluation phase, one of our results was that the D/C planning tool in the General Hospitals was only completed for less than 25% of the COPD admissions, compared to the Respiratory Hospital, where the tool was completed in more than 70% of the cases. This new problem leads us to a second cycle of improvements, where the objective is to evaluate why the D/C planning tool was successfully used in some environments (Respiratory hospital), but not in others (General hospitals), and to ensure its deployment everywhere.

Another problem that could also be addressed in a second cycle of improvements is the COPD clientele with multiple readmissions. This clientele needs to be part of a new cycle (CDM Quality Care Steps 1 to 6) and likely to require more targeted care that is better adapted to their needs.

It is important to follow-up on the implementation of the improvement process in a sustainable way. However, accountability is essential, and a continuous evaluation of the team's performance and quality indicators is mandatory.