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 it’s 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)

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 • Illustratesthe 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 don’t 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. 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 QI vs. Informal Improvement

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. 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 QI vs. Informal Improvement

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

36. 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 Quality ImprovementMethods and Terms

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

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

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

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