STEP 3

Decide which target to focus on

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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1. Define a number of potential targets
    with your team

Following the gaps in care evaluation and presentations made back to the team, it was easier to find key people that wanted to get involved in improving the care provided to COPD patients.

A new committee was then created, the RECAP-MUHC Committee.  This decision-making and operational committee included the following people:

  1. Hospital administrator/manager (1)
  2. Respirologists (2)
  3. Specialized nurse clinicians (2: medical ward and outpatient clinic)
  4. Consultant from the hospital's Quality Department (1)

The committee's role was to oversee the implementation strategies, to support the changes and their maintenance on the front lines and with management.

We first made an inventory of all the programs and resources available in our institution and easily accessible in our vicinity (community services). These included:

  • the expertise of the pulmonary function labs and respiratory therapists
  • access to hospital and provincial formularies vis-à-vis long-term bronchodilators and combination therapy
  • existing pulmonary rehabilitation programs at the Montreal Chest Institute
  • existing self-management programs in the outpatient clinics, standardized Living Well with COPD (www.livingwellwithcopd.com; password: copd) program materials and training programs (local and provincial)
  • existing stop smoking and stress management programs
  • access to respiratory home-care and community services through existing referral formularies, including well defined eligibility criteria

Based on these strengths, it was easier to prioritize and to determine how ambitious we could adapt our interventions/program/clinical pathways to our needs. The RECAP-MUHC Committee felt that we had the strengths to address many clinical practice changes simultaneously over a short period of time (within 1 year) for the clientele chosen in Step 1 (patients visiting the ER or admitted to the hospital).

 

2. Prioritize the targets that you would like
    to work on

Our specific objectives (measurable intermediate targets) were to:

  • 1. Increase the use of spirometry tests (above 80%) for admitted patients with a primary COPD diagnosis
  • 2. Increase the appropriate use of long-acting bronchodilators (above 80%) for patients with moderate to severe COPD (patients with a FEV1 ≤ 50% or dyspnea MRC 3-5/5)
  • 3. Increase the number of patients being evaluated for a pulmonary rehabilitation program (above 60%), increase references to respiratory home services (above 80%), and increase smoking counselling intervention (above 60%)
  • 4. Increase teaching inhalation techniques (above 80%)
  • 5. Utilization of the D/C planning tool for COPD patients admitted due to exacerbations into the medical and respiratory units (above 80%)

Our interventions in this Phase are directed specifically at enhancing these areas of best practice. They thus become indicators of the quality of our COPD practices "Quality indicators".

Remember that outcomes should be SMART: Specific, Measurable, Attainable, Results-oriented, Time frames.