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Clinical Quality

Clinical Quality. איכות קלינית בעולם ובהדסה. פרופ' מאיר ברזיס המרכז לאיכות ובטיחות קלינית הדסה והאוניברסיטה העברית ירושלים www.hadassah.org.il/departments/quality. Definitions of Quality (Institute of Medicine)

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Clinical Quality

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  1. Clinical Quality איכות קלינית בעולם ובהדסה פרופ' מאיר ברזיס המרכז לאיכות ובטיחות קלינית הדסה והאוניברסיטה העברית ירושלים www.hadassah.org.il/departments/quality

  2. Definitions of Quality (Institute of Medicine) Degree to which care increases likelihood of desired health outcomes & consistent with current professional knowledge SafeTimelyEffective Patient centered Equitable Efficient Overuse (antibiotics, imaging) Underuse (prevention) Misuse (errors & complications) • Evidence-based • Patient-centered • System-minded

  3. Performance Evaluation Voluntary Quality Indicators Mandatory Performance Evaluation Public Data Including Individual Surgeon Pay for Performance Non-payment for Preventable Complications Challenges: measurement error, socioeconomic confounders, manipulation, denial, gaming

  4. Ego bias: “I’m above the average” (Kahneman & Tversky. Heuristics and Biases. The Psychology of Intuitive Judgment) Stages of Facing Reality* Stage 1. “The data are wrong” Stage 2. “The data are right, but it’s not a problem” Stage 3. “The data are right; it is a problem; but it is not my problem.” Stage 4. “I accept the burden of improvement” * Harvard Professor Don Berwick, Institute for Health Improvement

  5. Donald M. Berwick, MD, MPP, FRCP Professor at Harvard School of Public Health President, Institute for Health Improvement, Boston, Massachusetts, USA “In short, academic medical centers should not just have best knowledge, they should model the best execution…They do not. Unreliability, waiting, lack of focus on patient’s needs and safety are every bit of characteristic of academic medical centers…and that needs not be the case. The same intellectual fervor and talent that allow places like the Brigham to raise the bar in technical clinical care can equally be used to raise the bar in the quality of medical care. …it’s going to take much more acute self-awareness among academicians and academic medical centers…. …a duty to encourage healthcare leaders and clinicians everywhere to become involved in improvement."

  6. Cycles of Improvement (Industry Model) Statistical Process Control PDSA Example: monitoring of surgical infection rate is now recognized as important tool to prevention

  7. Quality of General Intensive Care Survival at Hadassah vs. Israel Average Prof. ElishevaSimchen, Ministry of Health p<0.001 Despite higher severity score, patients had better survival at Hadassah

  8. Quality of Neonatal Intensive Care Survival at Hadassah vs. Israel Average Dr. Zivanit Ergaz, Prof. Ilan Arad & Gertner Institute

  9. Quality of Treatment in Trauma Mortality at Hadassah vs. US level I centers Dr. Yoav Mintz, Ms. Irina Gertcenchtein& Prof. Avraham Rivkind US National Trauma Data Bank from 51 level-I trauma centers, n= 263,524 Hadassah data Israeli National Trauma Registry n=7,391

  10. Hadassah(%)899050836944’ 102’ Quality indicators for myocardial infarction, Hadassah vs. US data Referral to cardiac rehabilitation only 21%

  11. Percent of patients receiving adequate anticoagulation p<0.001 p<0.001 p<0.001 p<0.02 % Surgery A Surgery B Surgery C Gynecology A Gynecology B

  12. Catheter-related Bloodstream Infections Intervention in 108 ICU’s resulted in 66% reduction in rates of catheter-related bloodstream infection

  13. Catheter-related Bloodstream Infections I. Gross, S. Benenson, M. Cohen, C. Bloch • At Hadassah, baseline observations over five months revealed a rate of infection of 13.2% (42/318 catheters), on the high side of reported ranges. • Observations in ICU’s and OR: aseptic conditions not always strictly kept during catheter insertion. • Intervention included discussion of results with staff, training for correct aseptic technique, use of a checklist, and authorization to nurses to feedback and stop physicians breaching asepsis.

  14. Catheter-related Bloodstream Infections Following intervention, improvement in technique was observed; rate of infection declined by 62%, from 13.2% to 5.0% (17/337 catheters, p<0.001). Proportion of catheters remaining without infection (Cox regression) After the intervention p<0.001 Before the intervention Days of catheter

  15. Catheter-related Bloodstream Infections * Rate of infection per 1000 catheter-days ** p<0.001

  16. Catheter-related Bloodstream Infections Pronovost P. et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725

  17. Physicians’ Hand Hygiene at Hadassah Summary of surveys in recent years Rate of hand-washing out of contacts with patients Use of Hadassolhas been widely adopted but rate of hand hygiene unchanged

  18. Surgical Infections in General Surgery N. Minster, M. Zarhia, G. Almogy, A. Rivkind, S. Benenson, M. Cohen • Rate of post-operative wound infection is 8-12%, within the range reported in the literature. • Pre-operative antibiotic administration is documented as given on time in 59% of cases. • A significant proportion of infections are diagnosed after discharge from the hospital. • Infection monitoring is recognized as an important tool to keep rates low.

  19. Quality of Inguinal Hernia Repair in Adults and in Children at Hadassah Complications T. Yemini, M. Badriah, Y. Mintz, R. Udassin, A. Rivkind Satisfactionhigh to very high in 94% of adults and children; problems: waiting & relation with staff *Range in literature varies by motive (voluntary or mandatory)

  20. Quality of Special Surgeries Outcomes of special surgery in the Departments of Ear, Nose & Throat (ENT), Ophthalmology, Plastic and Neurosurgery

  21. Management of Snoring Disorders with Radiofrequency at Hadassah Optimal L. Gordon,S. Catinari, R. Eliashar p<0.005 p<0.01 p≤0.05 %

  22. Lasik (Myopic Corneal Refractive Surgery) at Hadassah Optimal (N=109) N. Orwa, A. Solomon, Y. Frucht-Peri %

  23. Evaluation of Outcomes for Tonsillectomies at Hadassah (2008) O. Frenkel, R. Eliashar

  24. 0 20 40 60 80 Severe moderate high Quality of Reconstruction Surgery After Mastectomy R. Yanko-Arzi, M. J. Cohen, R. Braunstein, E. Kaliner, R. Neuman Dept of Plastic Surgery & Center for Clinical Quality & Safety % A survey of 140 women after reconstructive breast surgery for cancer showed satisfaction related mostly to expectations before surgery. Complications Success Satisfaction Would Recommend Hadassah

  25. Neurosurgical shunt infections I. Paldor, Z. Israel, C. Block with the dept of Neurosurgery Intervention Mortality in infected cases dropped from 50% to 0%

  26. Is the X-ray interpretation by the junior staff on duty correct? Dr. Y. Mintz, Dr. D. Kisselgoff, Y. Gronowitz, A. Shaham, R. Hefez, Dr. D. Shaham - Departments of Surgery, Radiology, and Center for Clinical Quality & Safety

  27. Effect of Translators on Understanding & Satisfaction of Arab Parents Department of Pediatrics & ER, Mt Scopus & Center for Clinical Quality & Safety, Hadassah Hebrew University Medical Center

  28. p<0.001, n=194 The Presence of a Translator Significantly Improved Parental Understanding Regarding Diagnosis, Treatment and Follow-up

  29. Will patient’s empowerment improve efficacy & safety of oral anticoagulation? Self-management for Coumadin H. Goldberg, Y.Ben David, U. Izhar, L. Gordon, T. Baevsky, M.Burzstyn & M.Brezis with the Departments of Cardiothoracic Surgery and Medicine

  30. Patient’s empowerment improves efficacy & safety of oral anticoagulation 60% % of tests within target INR * p<0.001 38% Control Intervention Patient’s knowledge & satisfaction significantly improved

  31. Communicating with Families & Satisfaction with End-of-Life Decisions Departments of Medicine & Center for Clinical Quality & Safety *p<0.005 in favor of the intervention group Communication with families of patients near end of life improves perceived quality of care

  32. International Journal for Quality in Health Care 2008

  33. Conclusion Projects help make healthcare at Hadassah more evidence-based, patient-centered & system-minded. Over 100 projects presented at National Meetings of Israeli Society for Quality in Healthcare; over 48 theses and 19 peer-reviewed publications. Center for Clinical Quality & Safety

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