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Quality Improvement in Ambulatory Care

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Title: Quality Improvement in Ambulatory Care


1
Quality Improvement in Ambulatory Care
  • Daniel P. Dunham MD, MPH
  • Assistant Professor of Medicine
  • Northwestern University
  • Feinberg School of Medicine

2
What is Quality?
  • Doing the right things right
    W. Edwards Deming (Pioneer of
    the quality movement in industry)

3
Institute of Medicine in the US
  • Health care quality is the degree to which health
    services for individuals and populations increase
    the likelihood of desired health outcomes and are
    consistent with current professional knowledge.

4
Patients/Clients Perspective
  • Choice of methods
  • Information given to clients
  • Technical competence
  • Interpersonal relations
  • Mechanisms to encourage continuity
  • Appropriate constellation of services

5
Institute of Medicine in the US
  • Effective
  • Safe
  • Patient centered
  • Timely
  • Efficient
  • Equitable

6
Earliest Quality Metrics
  • In ancient China, physicians were paid only when
    their patients were kept well and often not paid
    if the patient got sick. If a patient died, a
    special lantern was hung outside the doctors
    house. Upon each death another lantern was
    added.

7
History of Quality Movement in Health Care
  • Practice Standards governing who could practice
    medicine to the first century C.E. in India and
    China.
  • 1140 Medical Licenses were awarded in Italy.
  • 1917-US, American College of Surgeons compiled
    the first set of minimum standards for US
    hospitals to find and eliminate poor care. This
    evolved into the Joint Commision on Accredition
    of Healthcare Organizations.(JCAHO)

8
Hx(cont.)
  • 1951-JCAHO has developed standards and evaluated
    the compliance of health care organizations.
  • 1960s-Awareness of Injury Control due to lessons
    from Viet Nam

9
Hx(cont.)
  • 1980s weakness in the JCAHO inspection process,
    new management techniques, and rising costs lead
    to reassessment of accreditation.
  • 1984 Luciane Leape MD,pediatric surgeon,
    investigated cardiac surgery. Chart-review study
    in NY created a data base to understand incidence
    and prevalance of preventability, negligence,
    and malpractice.

10
Hx(cont.)
  • 1991 Harvard Medical Practice Study revealed
    adverse events in 3.7 of all hospitalizations in
    review of 30,121 charts and 28 of these were
    labeled negligent. Nearly 20 of all events
    occurring in hospitals were due to medication
    problems.

11
Center for Medicare and Medicaid Services(CMS)
  • Began releasing mortality rates for hospitals in
    1980s
  • Some State Governments provide risk-adjusted
    mortality rates for cardiac surgery by hospital
    and surgeon.

12
Sentinel Event
  • 1994 Betsy Lehman, health columnist for the
    Boston Globe, died of overdose of Cisplatin, she
    was taking for Breast CA at the Dana-Farber
    Cancer Institute in Botston.

13
Federal Policy
  • 1999 the Institute of Medicine published To Err
    is Human Building a Safer Health System
  • Estimated 44-98,000 patients die preventable
    deaths annually in hospitals in the US with a
    cost of 38-50 billion.
  • These are errors of comission, omission might be
    higher.

14
Accreditation
  • 1996, JCAHO was stung by medical reports of its
    triennial surveys. Several hospitals who won top
    accreditation status, were found to have
    experienced tragic sentinel events involving
    preventable death or injury to patients.
  • JCAHO instituted a sentinel-event policy.

15
Role of Large Payors
  • Leapfrog group(1999) is an effort sponsored by
    business roundtable to leverage purchasing power
    and improve patient safety.
  • Composed of more than 140 public and private
    organizations that provide health benefits.
  • Represent more than 34 million health care
    consumers in all 50 states

16
Leapfrog Group
  • They directed patients to hospitals that show
    compliance with practices.
  • 1) Computerized physician order-entry systems 2)
    Board-certified or elibigle Intensivists in ICU
    3) Hospital referrals for complex treatments
    based on hospital volumes

17
CPOE Cost Savings
  • Brigham and Women researchers found that CPOE
    could reduce serious medications errors by at
    least 55, resulting in cost savings at that
    hospital between 5-10 million annually.
  • 32 of hospitals have CPOE system wholly or
    partially in place.
  • 2 of hospitals require physicians to use CPOE
    system.

18
Cost of Adverse Drug Event
  • Brigham and Womens study showed 10.7 non
    intercepted Serious medication errors per 1000
    patient-days.
  • The cost per adverse drug event is estimated to
    exceed 2,000
  • The cost of CPOE is 1,000,000 to start, and
    500,000 to maintain annually.

19
Leapfrong Safety Measures
  • John Birkmeyer, M.D., did research suggesting
    these three patient safety practices could save
    over 50,000 lives a years and prevent over
    500,000 medication errors, if implemented by all
    non-rural hospitals.
  • 10 billion could be saved each year solely from
    the benefits of increased life expectancy for
    patients.

20
Quality Problems
  • Underuse
  • Overuse
  • Misuse

21
Underuse
  • Variation by insurance type, and lack of
    insurance
  • Mammograms
  • Beta Blockers in patients with MI
  • Vaccination
  • HTN control

22
Overuse
  • 21 of all antibiotics given to treat colds
  • 17 of coronary angiographies, 32 of Carotid
    endarterectomies, 17 of EGD are unnecessary
  • 10-27 of hysterectomies

23
Misuse
  • Preventable complications of treatment
  • 22 error in diagnosis
  • 21 non-invasive non drug related treatment
  • 12 mistakes in medication use
  • 8 technical complications of surgery
  • 6 surgical wound complications

24
First Law of Improvement
  • Almost all quality improvement comes via
    simplification of design, layout, processes, and
    procedures.
  • Tom Peters

25
Quality Improvement Program
  • Goal is to raise the level of care-no matter how
    good it may already be through a continuous
    search for improvement.
  • QI asks physicians, managers, and other providers
    to raise the standards.

26
Elements of a QI Program
  • Clinical Quality(Providers Agenda)
  • Service Quality(Patients Agenda)
  • Patient Safety
  • Operational Improvement
  • Measurement

27
Measurement of Quality
  • Achieving results based on evidence based
    medicine
  • Process versus outcome measures

28
Process versus Outcomes
  • Process of care measures of quality assess the
    degree to which providers perform health care
    processes demonstrated to be successful by
    evidence based medicine.

29
National Committee on Quality Assurance
  • NCQA collects data on HEDIS quality measures and
    includes evidence-based measures of health plan
    processes of care.
  • These measures are part on NCQAs health plan
    accreditation program and are used by some
    employers, insurers, and government payers to
    choose health plans.

30
Process Measures for DM
  • Lower HGB A1C
  • Lower lipid Levels
  • Higher use of appropriate ACE inhibitors
  • Better screening for microalbumin
  • Better control of HTN

31
Process Measures for CAD
  • Higher use of ASA
  • Higher use of Better Blocker
  • Higher use of ACE inhibitor
  • Lower Lipid levels
  • Good BP control

32
Process Measures for CHF
  • Higher use of Beta Blockers
  • Higher use of ACE inhibitors

33
Strategies to Improve Physician Performance
  • CME and Educational Material minimally effective
  • Opinion leaders and feedback moderatively
    effective
  • Prompts initially effective but effectiveness
    wanes over time
  • Computer systems effective
  • Aligning Incentives with CQI and multifaceted
    interventions most effective

34
QI Research
  • Builds on previous work found to improve the
    quality of Health Care
  • Can measure process or outcomes
  • Valid and relevant (high risk or high volume
    diseases).
  • Evidence Based Non-evidence-based CQI most often
    fails.

35
QI Research
  • Process measures are easier to study, take less
    time, do not require the use of extensive risk
    adjustment models, can use a smaller sample size,
    and are easy to benchmark
  • Outcome measures are more easily understood by
    lay people(survival, health, well being).
    Usually requires longitudinal follow up.
    (prospective cohorts)

36
QI at NMFF GIM using EMR
  • Process metrics related to HEDIS metrics
  • DM Metrics(Lipids, HTN control, Hgb A1C, UA)
  • CAD Metrics (ASA use, Beta Blockers)
  • CHF (Ace Inhibitor usage)
  • Influenza vaccination
  • Mammogram and Pap smear rate

37
QI at GIM
  • Identifying patients at high risk of ADE and
    contacting provider to assess for intervention.
  • Identifying patients taking Metformin with
    elevated creatinine or none measured.
  • Identifying patients taking statins without lfts
    being checked.

38
Physician Service Metrics
  • Percentage of bumped patients
  • Percentage of patients not seen
  • Frequency of late cancellations
  • Time from patient appointment to discharge
  • Patient Satisfaction

39
Opportunity to Improve Safety(OTIS)
  • Operational improvement
  • Web-based site to enter any incidents in which
    safety can be improved
  • Confidential, accessible, non-threatening
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