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Healthcare Quality and Improvement

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Title: Healthcare Quality and Improvement


1
Healthcare Quality and Improvement
  • A Primer

2
Our current medical world
  • Issues about the quality of healthcare are daily
    news items
  • Medical profession is in a fishbowl

I
3
Healthcare SafetyMedicine vs.. Airline Industry
  • Headline Can you be as safe in a hospital as
    you are in a jet?
  • Medical mistakes in hospitalized patients account
    for a minimum of 120 deaths annually
  • This equates to a crash of a Boeing 747 every
    week killing all on board.

4
Healthcare CostsErrors
  • Headline Medication errors in 2006 added 3.5
    billion to the cost of healthcare
  • Headline 80,000 catheter-related bloodstream
    infections occur in intensive care units in the
    US each year

5
Healthcare EffectivenessAcute URIvisits/10,000
with antibiotic prescription
6
Healthcare BacklashBoston Globe
  • Headline We pay for medical errors
  • By Richard Lord and Dr. Marylou Buyse. 9/12/ 2007
  • WHAT IF your mechanic forgot to replace the lug
    nuts after changing one of your tires and you got
    into a serious accident when the wheel came off?
    You wouldn't expect your mechanic to send you a
    bill for the repairs, would you?
  • Unfortunately, that's what happens in
    healthcare we pay a high price for mistakes.

7
Boston Globe
  • Healthcare entities should not be rewarded
    financially when such preventable errors occur.
    Hospital-acquired infections offer one example.
  • No other industry generates revenue from
    mistakes. Preventable errors should not be part
    of the usual cost of healthcare.

8
Can we fix this?
  • The train is out of the station and its heading
    towards YOU
  • Hop on.or prepare to be trampled

9
National Healthcare Quality Organizations Agency
for Healthcare Research and Quality (AHRQ)
www.ahrq.gov Health Care Quality
www.consumer.gov/qualityhealth/index.html Joint
Commission on Accreditation of Healthcare
Organizations (JCAHO) www.jcaho.org. National
Committee for Quality Assurance www.ncqa.org.
Quality Interagency Coordination (QuIC) Task
Force www.quic.gov. URAC (also known as the
American Accreditation Healthcare Commission)
www.urac.org U.S. Consumer Gateway Health
www.consumer.gov/health.htm U.S. News Online
www.usnews.com/usnews/nycu/health/hehome.htm
10
Quality Improvement Basic ingredients
  • Clinical knowledge and experience
  • QI basic concepts
  • Systems approach

11
Objectives
  • Quality problems in health care
  • Define quality
  • Who, what, why and how of quality improvement
  • Key elements of a good QI project
  • Quality improvement vs.. research
  • Joint Commission
  • National Patient Safety Goals

12
Our current medical worldContributing factors
  • Knowledge and technology explosion
  • Barriers to translation of scientific knowledge
    into clinical practice
  • Increasing complexity of healthcare needs
  • Outdated processes and systems for complex
    multidisciplinary healthcare delivery

13
Our medical worldPast and future
  • Cottage industry
  • Individual patient focus
  • I know it when I see it
  • Integrated healthcare system
  • System focus
  • Evidence based

14
Our current medical worldAccelerating factors
  • Multiple studies and reports
  • widespread and frequent incidence of medical
    errors
  • lack of consistency in the care received in
    different facilities and from different providers
  • Explosion of healthcare quality interest and
    organizations
  • Institute of Medicine Reports
  • To Err is Human Building a Safer Health
    System(1999)
  • Crossing the Quality Chasm(2001)

15
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16
Quality Chasm/Gap
  • Defined by the IOM
  • The difference between what is scientifically
    sound and possible and the actual practice and
    delivery of health services
  • Illustrates the need for healthcare quality
    improvement efforts

17
Quality problemsHealthcare services
  • Underuse
  • Overuse
  • Misuse
  • Variation
  • Fragmentation

18
Institute of MedicineQuality Aims
  • Name the 6 quality aims identified by the IOM

19
Institute of MedicineQuality Aims
  • Safe
  • Effective
  • Patient centered
  • Timely
  • Efficient
  • Effective

20
Institute of MedicineQuality Aims
  • Safe
  • Avoid injury to patients from the care that is
    intended to help them
  • Examples
  • Prescription of medication that patient is
    allergic to
  • Failure to address an abnormal lab or Xray result
  • Failure to perform the correct procedure

21
Institute of MedicineQuality Aims
  • Effective
  • Avoid overuse of ineffective care and underuse of
    effective care
  • Examples
  • Obtaining lab or Xray tests that dont alter
    treatment plan

22
Healthcare EffectivenessAcute URIvisits/10,000
with antibiotic prescription
23
Institute of MedicineQuality Aims
  • Patient centered
  • Provide care that is respectful of and responsive
    to individual patient preferences, needs and
    values
  • Examples
  • Shared decision making for treatment options

24
Institute of MedicineQuality Aims
  • Timely
  • Reduce waits and harmful delays for both those
    who receive care and those who give care
  • Examples

25
Institute of MedicineQuality Aims
  • Efficient
  • Avoid waste including waste of supplies,
    equipment, ideas and energy
  • Example
  • Necessary supplies, personnel, and medications in
    room for patient procedure

26
Institute of MedicineQuality Aims
  • Equitable
  • Provide care that does not vary in quality due to
    gender, ethnicity, geographic location or
    socioeconomic status
  • Example

27
Our current medical world
  • Issues about the quality of healthcare are daily
    news items
  • Medical profession is in a fishbowl

I
28
Defining Quality
  • Quality is a way of thinking about work quality
    is about achieving excellence-nothing less
  • IOM definition of quality
  • The degree to which health services for
    individuals and populations increase the
    likelihood of desired health outcomes and are
    consistent with current professional knowledge

29
Defining Quality
  • Quality is
  • A system-wide issue
  • An individual performance issue rarely
  • Quality is a major team sport

30
Quality Improvement
  • A process of innovation and adaptation designed
    to bring about immediate positive changes in the
    delivery of health care in particular settings
  • systematic
  • data-guided
  • multidisciplinary

31
Quality ImprovementKey elements
  • Systematic
  • Data-guided and knowledge informed
  • Experiential
  • Innovative
  • Employs formal explicit methodology
  • Continuous
  • Core responsibility of healthcare professionals

32
QI vs. Informal Improvement
  • Systematic
  • Data-guided and knowledge informed
  • Experiential
  • Innovative
  • Employs formal explicit methodology
  • Continuous
  • Core responsibility of all healthcare
    professionals
  • Systems change
  • Individual or group
  • May be knowledge informed rarely data
  • Experiential, anecdotal
  • Innovative
  • Informal process
  • Episodic
  • No explicit responsibility. Usually hierarchical
  • Individual change

33
Quality Improvement Work
  • Team oriented
  • Requires team skills
  • Collaboration
  • Meeting skills
  • Value all perspectives
  • Develop local new useful knowledge to inform
    health care processes

34
QI vs. Informal Improvement
  • Systematic
  • Data-guided and knowledge informed
  • Experiential
  • Innovative
  • Employs formal explicit methodology
  • Continuous
  • Core responsibility of all healthcare
    professionals
  • Systems change
  • Individual or group
  • May be knowledge informed rarely data
  • Experiential, anecdotal
  • Innovative
  • Informal process
  • Episodic
  • No explicit responsibility. Usually hierarchical
  • Individual change

35
Quality Improvement Methods and Terms
  • What is Root Cause Analysis?
  • What does PDSA stand for?
  • What are Sentinel Events?

36
Quality Improvement Methods and Terms
  • Terms
  • Sentinel events
  • Never events
  • Practice standardization
  • Adverse events
  • Harm
  • Incident reports
  • Balanced scorecard
  • Methods
  • PDSA
  • LEAN
  • Six sigma
  • Root Cause analysis
  • Fishbone diagram
  • FMEA
  • Tracers
  • Trigger tools
  • Action plans

37
Improvement MethodsA brief overview
  • Model for Improvement
  • Lean
  • Six Sigma
  • Trigger tools

38
Model for Improvement
  • Flexible improvement framework
  • IHI
  • PDSA methodology
  • Emphasizes
  • Aims and measures
  • Initial small tests of change
  • Widespread testing
  • Implementation and spread

39
Model for ImprovementSetting Aims
  • Improvement requires setting aims. The aim should
    be time-specific, measurable and define the
    specific population of patients that will be
    affected.

40
SIP CollaborativeProject Aim

SSI Rate 50 reduction
41
ED Wait Collaborative Project Aim
  • 25 reduction in ED length of stay by 6/30/07

42
Model for ImprovementSetting Aims
  • What are you trying to accomplish?

43
Model for ImprovementEstablishing Measures
  • Teams use quantitative measures to determine if a
    specific change actually leads to an improvement.

44
SIP Collaborative Establishing Measures
Measurement Collaborative Goal
SSI Rate 50 reduction
Antibiotic use rate

Skin anti-sepsis rate
45
Model for ImprovementSelecting Changes
  • All improvement requires changes, but not all
    changes result in improvement.
  • Identify the changes that are most likely to
    result in improvement.

46
SIP Collaborative Establishing Measures
Measurement Collaborative Goal
Antibiotic use rate Timing Re-dosing

Skin anti-sepsis rate Chlorhexidine Hair removal
47
Our Dizzying Complexity
Communication to Admit One ED Patient
48
ED Wait CollaborativeChanges Selected
  • Aim 25 reduction in ED LOS
  • Measures
  • ED total LOS
  • Time from provider to decision re disposition
  • Time from decision to discharge/admit
  • Asthma/wheezing patients
  • Initiation of Albuterol by RT/RN if emergent
  • Practice change
  • Asthma CPG revision
  • Evidence based practice and process
    standardization
  • Floor admission-selected patients receiving
    continuous Albuterol
  • Practice and process change

49
Model for ImprovementTesting Change
  • The Plan-Do-Study-Act (PDSA) cycle is shorthand
    for testing a change in the real work setting
    by planning it, trying it, observing the results,
    and acting on what is learned. This is the
    scientific method used for action-oriented
    learning.

50
O4. Decision to Discharge TimeAverage total
minutes from clinical decision to child leaving
the ED                                         
                                                  
                                                  
                                                  
                              
51
Model for ImprovementImplementing Changes
  • After testing a change on a small scale, learning
    from each test, and refining the change through
    several PDSA cycles, the team can implement the
    change on a broader scale

52
Model for ImprovementSpreading Change
  • After successful implementation of a change or
    package of changes for a pilot population or an
    entire unit, the team can spread the changes.
  •  

53
QI Projects?
  • Are you doing any?
  • How is it going?
  • Lessons learned?

54
QI project developmentEssential steps
  • Identify a project aim
  • Develop a plan to achieve the aim
  • Responsibilities and roles
  • Improvement methods
  • Data sources
  • Timelines
  • Identify outcome and balancing measures
  • Use data to identify improvement

55
Part 2
  • Review key concepts
  • Move on to other QI methods
  • Discuss project development
  • Research vs. QI
  • National patient safety goals
  • Joint commission

56
Objectives
  • Quality problems in health care
  • Define quality
  • Who, what, why and how of quality improvement
  • Tools and methods
  • Key elements of a good QI project
  • Quality improvement vs.. research
  • National Patient Safety Goals
  • Joint Commission

57
Defining Quality
  • Quality is
  • A systems-wide issue
  • An individual performance issue rarely
  • Quality is a team sport

58
Quality Improvement
  • A process of innovation and adaptation designed
    to bring about immediate positive changes in the
    delivery of health care in particular settings
  • systematic
  • data-guided
  • multidisciplinary

59
Quality Improvementand Data
  • Use data for learning, not judging
  • Generate light, not heat
  • Use data to report system attributes
  • Use aggregate not individual data
  • Do not report data on individual performance

60
Improvement MethodsA brief overview
  • Model for Improvement
  • Lean
  • Six Sigma
  • Trigger tools

61
Model for Improvement
  • Flexible improvement framework
  • IHI
  • PDSA methodology
  • Emphasizes
  • Aims and measures
  • Initial small tests of change
  • Widespread testing
  • Implementation and spread

62
Improvement Methods
  • What is LEAN?
  • What is Six Sigma?
  • Identify a trigger tool

63
Lean
  • Management philosophy based on 2 key themes
  • Continuous elimination of waste
  • Respect for people and society
  • Key principles
  • Value is in the eyes of the customer
  • Make value flow without interuptions
  • Improve work flow
  • Standardize work processes
  • Pursue perfection

64
Lean
  • Culture
  • Stop and fix the problem as soon as it is
    identified
  • Toyota manufacturing culture
  • Process
  • Measure
  • Change
  • Measure
  • Change..

65
Lean ProjectImprove ED Patient Flow
  • Project aim-reduce ED LOS by 50
  • Process improvements(reduce waste)
  • Work standards and evidence-based clinical
    practice guidelines for all ED staff defined
  • Batching of orders eliminated
  • Right supplies and equipment in the right place
    eliminated unnecessary SE
  • Admission process streamlined
  • Results
  • Reduced ED LOS for discharges by 23
  • Reduced ED LOS for admissions by 20

66
Lean What is waste in medicine?
  • Surgical infection
  • Preventable adverse drug events
  • Ventilator assisted pneumonia
  • Equipment failure
  • Waiting and lack of flow
  • Inadequate training or orientation
  • Unnecessary or poorly designed processes
  • Not following evidence based practices

67
Six Sigma
  • Focus is to eliminate defects
  • Nonconformity of a product or service to its
    specifications
  • Six sigma processes have variation that result in
    lt3.4 parts/million defects

68
Why Zero Defects is the Only Acceptable Quality
Standard
  • At 99.9 quality levels in a 250 bed hospital
  • 12 inpatients per year would die due to errors
  • 6 day surgery patients would die
  • 9,742 wrong medications would be delivered
  • 4,923 incorrect laboratory tests would be
    reported
  • 502 incorrect radiographs would be completed

69
Six Sigma
  • Systematic and scientific management approach to
    reduce sources of process variation and improve
    reliability
  • Customer and financially focused
  • Strategic
  • Uses project management concepts
  • Strong statistical focus
  • Focus on mistake-proofing
  • Requires rigorous professional training

70
Six Sigma ProjectReducing Hospital-Acquired
Pressure Ulcers
  • 5 structured project phases
  • Define
  • Measure
  • Analyze
  • Improve
  • Control

71
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72
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73
Trigger tools
  • Method for identifying adverse events (harm) and
    measuring the rate of adverse events over time
  • Method options
  • Retrospective review of a random sample of
    patient records using triggers (clues)
  • Prospective surveillance of electronic patient
    records
  • Goal-to identify areas for improvement and
    prevent harm

74
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75
Trigger Tools Your medical world
  • Are there triggers that could be used in your
    specialty to identify areas of potential patient
    harm?

76
Root Cause Analysis
  • Process to identify causal factors for variation
    in performance learning from consequences
  • Systems and processes focus
  • Individual performance not a focus
  • Identifies potential improvements to reduce
    likelihood of future event
  • Used in MM process, sentinel event investigations

77
Fishbone Diagram
78
Failure modes and Effects Analysis (FMEA)
  • Prospective technique
  • Systematic assessment to
  • Prevent problems before they occur
  • Reduce the chance of unintended adverse harm if
    they occur
  • Used for high risk procedures or error prone
    processes

79
QI projects
  • Ideas/Aims
  • Methods
  • Data
  • Challenges

80
Improvement project ideas
  • Care process changes
  • Hand offs
  • Scheduling
  • Medication reconciliation
  • Implementation of new clinical or administrative
    practices
  • Practice standardization

81
Central Line InfectionsDefining the problem
  • 15 million central venous catheter-days per year
    in ICUs
  • Attributable mortality for these infections 4-
    20
  • Bloodstream infections prolong hospitalization by
    a mean of 7 days 

82
Central Line InfectionsStating the project aim
  • Reduce central line infection rate to 0 in the
    ICU in 12 months

83
Central Line InfectionsPractice Standardization
  • Hand Hygiene
  • Maximal Barrier Precautions upon insertion
  • Chlorhexidine skin antisepsis
  • Optimal catheter site selection, with Subclavian
    Vein as the preferred site for non-tunneled
    catheters
  • Daily review of line necessity with prompt
    removal of unnecessary lines

84
Central Line InfectionsPractice Standardization
85
Quality at CMHHow informed are you?
  • Rate of compliance with hand washing?
  • 90
  • Central line infection rate?
  • 1.2/1000 cath days-PICU
  • of codes outside the PICU?
  • 50
  • of inpatients with medication reconciliation
    performed?
  • 70

86
Healthcare Quality Improvement2007
  • Move from cottage industry mode of care delivery
    to data driven system model of healthcare
    delivery
  • Systems approach
  • Individual blame not the norm
  • Individual IS accountable

87
Quality Improvement vs. ResearchIts
Complicated.
  • QI
  • Systematic data-guided activities designed to
    bring about immediate positive changes in
    healthcare delivery in local practice settings
  • An integral part of the ongoing healthcare
    delivery system
  • A form of clinical and managerial innovation and
    adaptation
  • Combines discipline specific knowledge with
    experiential learning and discovery
  • Research
  • A systematic investigation designed to develop or
    contribute to generalizable new knowledge
  • Implementation of research is a separate process
    and occurs later, if at all
  • A knowledge seeking enterprise that is
    independent of routine medical care

88
Hastings Report
89
Questions?
90
Joint Commission
  • Accrediting organization for healthcare
    institutions
  • Sets administrative and practice standards and
    evaluates compliance
  • Performs unannounced on-site surveys of
    accredited hospitals to assess compliance every
    18-39 months

91
Joint CommissionMission
  • To continuously improve the safety and quality of
    care provided to the public through the provision
    of health care accreditation and related services
    that support performance improvement in health
    care organizations

92
National Patient Safety Goals
  • Key national safety goals for hospitals
  • Set by Joint Commission
  • Updated yearly
  • Goal is to promote specific improvements in
    patient safety

93
2008 NPSG
  • Goal 1 Improve the accuracy of patient
    identification.
  • 1A Use at least two patient identifiers when
    providing care, treatment or services.

94
2008 NPSG
  • Goal 2 Improve the effectiveness of communication
    among caregivers.
  • 2A For verbal or telephone orders or for
    telephonic reporting of critical test results,
    verify the complete order or test result by
    having the person receiving the information
    record and "read-back" the complete order or test
    result.
  • 2B Standardize a list of abbreviations, acronyms,
    symbols, and dose designations that are not to be
    used throughout the organization.

95
2008 NPSG
  • Goal 2 Improve the effectiveness of communication
    among caregivers.
  • 2C Measure and assess, and if appropriate, take
    action to improve the timeliness of reporting,
    and the timeliness of receipt by the responsible
    licensed caregiver, of critical test results and
    values.
  • 2E Implement a standardized approach to hand
    off communications, including an opportunity to
    ask and respond to questions.

96
2008 NPSG
  • Goal 3 Improve the safety of using medications.
  • 3C Identify and, at a minimum, annually review a
    list of look-alike/sound-alike drugs used by the
    organization, and take action to prevent errors
    involving the interchange of these drugs.
  • 3D Label all medications, medication containers
    (for example, syringes, medicine cups, basins),
    or other solutions on and off the sterile field.
  • 3E Reduce the likelihood of patient harm
    associated with the use of anticoagulation
    therapy.

97
2008 NPSG
  • Goal 7 Reduce the risk of health care-associated
    infections.7AComply with current World Health
    Organization (WHO) Hand Hygiene Guidelines or
    Centers for Disease Control and Prevention (CDC)
    hand hygiene guidelines.
  • 7B Manage as sentinel events all identified cases
    of unanticipated death or major permanent loss of
    function associated with a health care-associated
    infection

98
2008 NPSG
  • Goal 8 Accurately and completely reconcile
    medications across the continuum of care.
  • 8A There is a process for comparing the patients
    current medications with those ordered for the
    patient while under the care of the organization.
  • 8B A complete list of the patients medications
    is communicated to the next provider of service
    when a patient is referred or transferred to
    another setting, service, practitioner or level
    of care within or outside the organization. The
    complete list of medications is also provided to
    the patient on discharge from the facility.

99
2008 NPSG
  • Goal 9 Reduce the risk of patient harm resulting
    from falls.
  • 9B Implement a fall reduction program including
    an evaluation of the effectiveness of the program.

100
2008 NPSG
  • Goal 13 Encourage patients active involvement in
    their own care as a patient safety strategy.
  • 13A Define and communicate the means for patients
    and their families to report concerns about
    safety and encourage them to do so.

101
2008 NPSG
  • Goal 15 The organization identifies safety risks
    inherent in its patient population.
  • 15A The organization identifies patients at risk
    for suicide.

102
2008 NPSG
  • Goal 16 Improve recognition and response to
    changes in a patients condition.
  • 16A The organization selects a suitable method
    that enables health care staff members to
    directly request additional assistance from a
    specially trained individual(s) when the
    patients condition appears to be worsening.

103
Quality ImprovementKey elements
  • Systematic
  • Data-guided and knowledge informed
  • Experiential
  • Innovative
  • Employs formal explicit methodology
  • Continuous
  • Core responsibility of healthcare professionals

104
Quality Improvement Work
  • Focused on systems
  • Team oriented
  • Requires team skills
  • Collaboration
  • Meeting skills
  • Value all perspectives
  • Develop local new useful knowledge to inform
    health care processes
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