Health Care Quality: A Twenty Year Revolution

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HEALTH CARE QUALITY A Twenty Year
Revolution Tri-Cities Quality Forum October 14,
2008
A. BLANTON GODFREY, Ph.D. DEAN. COLLGE OF
TEXTILES JOSEPH D. MOORE DISTINGUISHED
UNIVERSITY PROFESSOR, NORTH CAROLINA STATE
UNIVERSITY
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MEDICAL TEXTILES
LaamScience
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BIOTEXTILES
Quill
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INTRODUCTION

• U.S. Healthcare in the 1980s
• For each problem, fix blame
• Review problems months after they happen
• No change in processes, belief its a people
  problem
• Industry Quality Management in 1980s
• Focus on prevention not problem fixing (TAT 8)
• Understanding that the system (process) is key
  to quality, the people work in the system
• Providing support to people doing the real work
  (education, tools, software)

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Institute of Medicine Conclusions

• There are serious problems in quality
• Between the health care we have and the care we
  could have lies not just a gap but a chasm.
• The problems come from poor systemsnot bad
  people
• In its current form, habits, and environment,
  American health care is incapable of providing
  the public with the quality health care it
  expects and deserves.
• We can fix it but it will require changes

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OUTLINE

• Accreditation Standards
• Learning from Industry
• Emergence of the Institute for Healthcare
  Improvement
• Focus on Process
• Best Practices Rapid Replication

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ACCREDITATION STANDARDS

• JCHAO (Joint Commission)
• ISO 9000 Series of Standards
• Other accrediting bodies in Canada, Australia,
  U.K., New Zealand, Malaysia, Philippines, India,
  Thailand, Taiwan, Mongolia,

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JCAHO Acute Myocardial Infarction (AMI) Quality
Measures CardioCard 1

• ACUTE MYOCARDIAL INFARCTION NATIONAL QUALITY
  MEASURES (9 Primary measures 2 sub-measures)
• Measures8 are time-sensitive
• AMI-1 Aspirin at Arrival
• AMI-2 Aspirin Prescribed at Discharge
• AMI-3 ACEI or ARB for LVSD
• AMI-4 Adult Smoking Cessation Advice/Counseling
• AMI-5 Beta Blocker Prescribed at Discharge
• AMI-6 Beta Blocker at Arrival
• AMI-7 Median Time to Fibrinolysis
• AMI-7a Fibrinolytic Therapy Received Within 30
  Minutes of Hospital Arrival
• AMI-8 Median Time to Primary PCI
• AMI-8a Primary PCI Received Within 90 Minutes of
  Hospital Arrival
• AMI-9 Inpatient Mortality

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SAS Institute, Inc. Health Metrics Dashboard Data
Architecture
RAPID CARDIOCARD
ETL DATA Quality DATA Integration
PATIENTS Patient Birth Date Gender Admission
Data Discharge Data
Data Marts
SAS BI Server
Statistical Validation
Staging Platform
MEDICINES Patient Medicine Date Order
Information
metadata
OLAP
DIAGNOSES ICD-9 Patient Diagnosis Date Admit
/Discharge
PROCEDURES ICD9 Patient Procedure Date
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LEARNING FROM INDUSTRY

• National Demonstration Project
• Error-proofing healthcare
• Quality Systems extended to healthcare
  organizations
• Malcolm Baldrige National Quality Award
• Toyoto Production System
• Lean Six Sigma
• Simulation

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NATIONAL DEMONSTRATION PROJECT

• 21 leading healthcare providers partnered with 21
  leading companies to share methods
• Eight-month experiment proved that industrial
  methods work in healthcare
• Experiment extended three years then

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NDP RESULTS REPUBLISHED
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LESSONS LEARNED (2002)

• Spending too much time analyzing processes can
  slow the pace of change.
• Getting action is more important than getting
  buy-in. Improvement is a matter of changing the
  process, not blaming the people. The shift of
  blame from individuals to processes is not 100
• Measurement is very difficult for health care,
  and health care is far behind. (BSC, SPC, IT, MR)
• There need to be consequences for not being
  involved in improvement.
• Waste is pervasive in health care improvement is
  the best way to save money.

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LESSONS LEARNED (2002)

• Balance is important.
• Health care lacks a training infrastructure.
• Clinical outcomes are critical.
• Definitions of quality in health care must
  include the entire patient experience not just
  clinical outcomes and cost.
• The executive leader doesnt always have to be
  the driver of change.

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BASIC TOOLS
Box Plots
Brainstorming
Cause-and-effect Diagrams
Graphs and Charts
Histograms
Mistake Proofing
Pareto Analysis
Process Control Plans
Process Flow Diagrams
Scatter Diagrams
Statistical Process Control
Stratification
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ADVANCED TOOLS
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CREATIVITY TOOLS(See The Creativity Tools Memory
Jogger)

• Brainwriting
• Brainstorming
• Imaginary Brainstorming
• Knowledge mapping
• Morphological Box
• Picture Associations
• Biotechniques
• Purpose Hierarchy
• TILMAG
• Word Associations
• Problem Reformation
• Heuristic Redefinition

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DESIGN FOR SIX SIGMA TOOLS

• VOC
• QFD
• NPD Process
• FDM
• FMEA
• High-level design
• Concept selection
• Hypothesis testing
• Tolerance design
• Reliability prediction
• Robust Design
• Prototyping
• DFA/DFM
• Pugh Chart
• C E Matrix
• Simulation

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To Err is Human

• Cost of preventable errors in the U.S. is between
  17-29 billion per year
• gt 2 of admissions experience an Adverse Drug
  Event (ADE)
• Medication-related errors 4,700 per admission
• Estimate is that 98,000 preventable deaths occur
  each year due to medical errors

Kohn, Linda, et al. To Err is Human Building a
Safer Health System. Washington, DC. National
Academy Press, 2000.
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Error Proofing

• Improvement of work operations, including
  materials, machines and methods, with the aim of
  preventing problems due to human error.

Improve Work Operations Fit to Human Beings
Improve Human Beings Fit to Work Operations
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Principles of Error Proofing
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Principles of Error Proofing
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Error-Proofing Results
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QUALITY SYSTEMS EXPANDED TO HEALTHCARE

• Malcolm Baldrige National Quality Award was
  extended to healthcare.
• Hospitals began exploring how the Toyota
  Production System can be used to dramatically
  change care.
• Leading hospitals have discovered and are now
  using Lean Six Sigma.

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SIMULATION

• Training of airline pilots
• Experts create training plans
• Simulators are used for training
• Crises are built into training
• No one is certified until they pass
• Apprentice programs also
• Historic way to learn
• Masters pass down skills

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Measuring Behavior--BEFORE
Scatter-Plot rendering of Pre-Simulation Clinical
Test Performance Measurement Results -- Variance
from Best-Practices Protocols
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Measuring Behavior--AFTER
Scatter-Plot rendering of Post-Simulation
Clinical Test Performance Measurement Results --
Variance from Best-Practices Protocols
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Healthcare Value-Based Analytics
V A L U E
Preventative Research Measures
Academic Medical Centers
Leveraging the Power of Bio-Informatics Analytics
Health Predictive Research Indicators
Researchers Hospitals
Clinical Outcomes
Clinical Disease Registries
Data Repositories
ANALYTICAL COMPLEXITY
Charles Coleman, SAS Institute
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INSTITUTE FOR HEALTHCARE IMPROVEMENT

• Foundation was the National Demonstration Project
  for Improving the Quality of Healthcare.
• Expansion of project to become a permanent
  organization called IHI.
• Grown to become a leader in quality improvement
  thinking in health care.

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INSTITUTE FOR HEALTHCARE IMPROVEMENT MISSION

• We are a reliable source of energy, knowledge,
  and support for a never-ending campaign to
  improve health care worldwide.

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IHIs No Needless List

• No needless deaths
• No needless pain
• No helplessness
• No unwanted waiting
• No waste
• for anyone

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FOCUS ON PROCESS

• Robert Wood Johnson Foundation project
• Leading hospitals focused on flow.
• Hospitals rethinking cardiovascular surgery
  process
• Rethinking medication errors as a process
• Emergency room redesign

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PURSUING PERFECTION

• Robert Wood Johnson Foundation created a special
  project to create role model healthcare providers
  by focusing efforts on first creating two
  perfect processes.
• Seven U.S. organizations were selected out of
  over 250 applicants.
• Each received financial grant and support.

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PURSUING PERFECTIONFocus on Process

• Original goal was to create small number of role
  model hospitals
• Sweden, U.K. and the Netherlands joined project
  at beginning
• Hospitals were to go from 2 perfect processes
  to 5 then many, then extend lessons learned to
  partners

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BEST PRACTICES AND RAPID REPLICATION

• Far faster to get results starting from practices
  (processes) with documented results.
• Most practices can not be copied exactly,
  modification is necessary for different cultures,
  different organizations.
• But learning from others is extremely efficient
  way to get results quickly.

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IHIs 100,000 LIVES CAMPAIGN

• Bold Idea
• Sharing of known best practices
• Spreading internationally

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Some Is Not a Number Soon Is Not a Time

• The Number
• 100,000 Lives
• The Time
• June 14, 2006 9 a.m. ET

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• Deploy Rapid Response Teams
• Deliver Reliable, Evidence-Based Care for Acute
  Myocardial Infarction
• Prevent Adverse Drug Events (ADEs)
• Prevent Central Line Infections
• Prevent Surgical Site Infections
• Prevent Ventilator-Associated Pneumonia

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Campaign Results

• Over 3,100 hospitals enrolled in all 50 states
• Nearly 90 of U.S. hospital beds
• Thousands on national calls
• Unprecedented web activity and new tool
  development
• Related campaigns formed in other countries
• Hospitals reported results monthly
• Best estimate was that over 122,000 lives were
  saved in 18 months

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Examples of Campaign Hospital Success

• 26 Hospitals in the Catholic Healthcare West
  System achieved a 55 system wide reduction in
  Ventilator Associated Pneumonias (VAPs)
• 7 Hospitals have had no VAPs for 16 -27 months
• Sentara Healthcare reported no VAPs for the last
  30 months
• Community Health Network headquartered in
  Indianapolis have maintained VAP-free ICUs for
  32 months

Joint Commission Benchmark September/October
2006
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5 MILLION LIVES CAMPAIGN

• Reduce Surgical Complications
• Prevent Harm from High Alert Medications
• Prevent MRSA Infections
• Reduce Readmissions from Congestive Heart Failure
• Prevent Pressure Ulcers
• Get Boards on Board

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IHI in Malawi andThe Health Foundation Consortium
Program Aim To reduce Maternal and Neonatal
Mortality by 30 in Kasungu, Salima, and Lilongwe
districts by February 2010
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THFC Program Phases
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THFC Coverage

• By Feb. 2010
• 10 CEmOC Hospitals
• 32 Health Facilities (health centres/posts,
  non-CEmOC)
• 729 Communities
• March 2010 2012
• Expand to additional 32 Health Facilities
• ? Scale up of communities

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Reducing Delays in Seeking Receiving Care
Key Drivers to Reducing Delays in
Seeking/Receiving Care to Improve Maternal and
Neonatal Outcomes
DEMAND Reduce Delays in Deciding to Seek
Care Community Mobilisation
Empowered Women
Supportive Community
Intervention leads to 30 reduction in Maternal
and Neonatal Mortality by Feb. 2010 in Kasungu,
Salima, and Lilongwe
Effective Communication Transportation
LINKAGE Reduce Delays in Identifying Reaching
Appropriate Medical Facility Community Health
Facility Partnerships
Family-Friendly Care
Prompt Treatment at Appropriate Facility
Effective Support Systems
Malawi MoH Standards of Care
SUPPLY Reduce Delays in Receiving Quality
Routine Emergency Maternal/Neonatal
Care Quality Improvement
Clinically Excellent Care
Information-Driven Decision-Making
Adapted from Three Delays Framework on
www.unfpa.org/mothers/obstetric.htm
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WHAT HAS WORKED

• Strong Quality System Accreditation Standards
• Center/Institute for Modern Quality Management,
  Improvement, and Sharing of Best Practices with
  Ability for Advanced Training Support
• National Awards to Recognize and Reward Best
  Practices

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• THANKS
• Blanton Godfrey
• blanton_godfrey_at_ncsu.edu
• www.tx.ncsu.edu