Introduction to Quality of Health Care

1. Introduction to Quality of Health Care Sources: Restuccia JD (2003); Quality of Health Care in the United States: Practice and Promise USAID: Session 1 Introduction to Quality

2. “What is Quality?”

3. What is Quality? • Carrying out interventions correctly according to pre-established standards and procedures, with an aim of satisfying the customers of the health system and maximizing results without generating health risks or unnecessary costs.

4. What is Quality Assurance? • All of the activities that make it possible to define standards, to measure and improve the performance of services and health providers so that care is as effective as possible.

6. Quality Assurance • Define Quality (Standards, norms, guidelines) • One cannot measure that which one has not defined • Measure Quality (The variation in standards) • One cannot improve that which one has not measured • Improve Quality (Comply with norms)

9. Quality of Health Care “Degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with professional knowledge.” - Institute of Medicine (IOM)

11. Strengths of the United States Health Care System • Modern, well-equipped hospitals and ambulatory facilities • Highly trained physicians, nurses and other medical personnel • Availability of high technology diagnostic and therapeutic procedures

12. Weaknesses of the United States Health Care System • Overuse and inappropriate care • Underuse of effective care • Misuse and error in medical care • Inefficiency and waste

13. Assessment of US Health Care System to Achieve 6 Aims “In its current form, habits, and environment, American health care system is incapable of providing the public with the quality of health care it expects and deserves.” - IOM Committee on Health Care in America

14. “Every Defect is a Treasure” • Japanese saying: every defect is a treasure because identifying a defect enables us to find the root cause and to eliminate it and, thus, to make improvements in the future • If defects are jewels, recent investigations to identify and quantify defects in US health care have discovered a treasure chest (or Pandora’s box)

15. Weaknesses of the United States Health Care System • Overuse and inappropriate care • Underuse of effective care • Misuse and error in medical care • Inefficiency and waste

16. Overuse(Rate of Inappropriate Use) • Advanced Antibiotics for Otitis Media 30% • Antibiotics Used for the Common Cold 60% • Heart Revascularization 10-20% • Hysterectomies 16-80% • Hospital Admissions: 5-15% • Hospital Days of Care: 10-30%

17. Overuse(Rate of Inappropriate Use) Other procedures commonly overused: • Bed Rest for Low Back Pain • Prostate Specific Antigen Testing • Ultrasound in Uncomplicated Pregnancy • Sedation of elderly patients

18. Weaknesses of the United States Health Care System • Overuse and inappropriate care • Underuse of effective care • Misuse and error in medical care • Inefficiency and waste

19. Underuse (Financial Access) • Over 40 million people are uninsured at any point in time • Over 75 million are uninsured as some time during the year • About an equal number are severely underinsured • The majority of the uninsured and underinsured are the working poor and their dependents

20. Underuse(Rate of Use of Effective Care) • Beta-blockers in Elderly Heart Attack Victims 21% • Pneumococcal Vaccine in Elderly: 28% • Appropriate Dx and Tx of Hypertension: 30% • Physician Advice to Quit Smoking: 37% • Eye Examination in Diabetics: 46% • Pharmacotherapy of Depression: 45%

21. Weaknesses of the United States Health Care System • Overuse and inappropriate care • Underuse of effective care • Misuse and error in medical care • Inefficiency and waste

22. Misuse • Adverse drug events (ADEs) caused by medication errors occur in 1.8/100 hospital admissions • ADEs add $4,700 per admission • 20% of ADEs are life threatening • There are an estimated 500,000 preventable medication errors per year causing 7,000 deaths

23. Misuse • An estimated 2.9% – 3.7% of hospital admissions have an adverse event (from all causes) • Over 1 million adverse events per year • Estimated national cost of adverse events is $38-50 billion per year – almost half preventable (2-4% of total health costs)

24. Misuse • An estimated 180,000 deaths per year due to adverse events (= 3 jumbo jet crashes every two days) • Between 44,000 - 98,000 due to preventable adverse events • More deaths than due to motor vehicle accidents (43,438), breast cancer (43,297) or AIDS (16,516)

25. Weaknesses of the United States Health Care System • Overuse and inappropriate care • Underuse of effective care • Misuse and error in medical care • Inefficiency and waste

26. Inefficiency and Waste • Waits and Delays • Operating Room Throughput • Emergency Department Diversions • Time to Treatment of Coronary Conditions • Medical Records Availability • Mismatch Between Capacity and Demand

27. Assessment of US Health Care System to Achieve 6 Aims “In its current form, habits, and environment, American health car is incapable of providing the public with the quality of health care it expects and deserves.” - IOM Committee on Health Care in America

28. IOM’s Six Aims for Improvement • Safety • Effectiveness • Patient-centeredness • Timeliness • Efficiency • Equity

29. Safe Care • A patient receiving medical care should be as safe as he is in his own home • Example: Computerized physician order entry system to prevent medication errors • Example: Surgeons “sign your site” of the body part that will be operated upon

30. Effective Care • Avoid overuse and underuse of services • Example: Redesign processes based on best practices such as ensuring that patients at risk for heart disease take appropriate medications • Example: Implement utilization management to reduce inappropriate hospital use

31. Patient Centered Care • Respect patient needs, preferences, and culture • Example: Give patient access to his own medical record • Example: Give patients information on alternative treatments and decision-making in treatment choice

32. Timely Care • Reduce waits for those who receive and who give care • Example: Availability of appointments after work hours and on weekends • Example: Email and telephone access to physicians and nurse practitioners • Example: “Open access” to physicians and nurse practitioners

33. Efficient Care • Reduce waste of facilities, equipment, supplies, and people • Example: implement inventory management systems to reduce amount of drugs and other supplies • Example: Use flexible staffing systems based on patient numbers and needs to adjust number of nurses per patient care unit

34. Equitable Care • Reduce racial, ethnic, geographic and socio-economic differences • Example: Provide interpreters for non-English speaking patients • Example: Train more physicians from minority racial and ethnic groups • Example: Establish universal health insurance coverage

35. Purpose of Health Care System “To reduce continually the burden of illness, injury, and disability, and to improve the health status and function of the people of the United States” - President’s Advisory Commission on Consumer Protection and Quality

36. Focus of Quality Quality must be defined in terms of experience and outcomes of the patient and the population that generates patients

37. Levels of Needed Health Care System Change Patient Microsystem (patient units, physician offices) Organization (hospitals, medical groups) Environment (insurers, purchasers, government)

38. Levels of Needed Change • The patient’s experience • The functioning of small units (“microsystems”) that provide patient care • The functioning of organizations that contain microsystems • The environment of policy, payment, accreditation and regulation

39. Levels of Needed Health Care System Change • All levels of the system must work together to meet the patient’s needs • The patient must be at center, the first priority of the health care system • The major question to ask in changing the system or in treating the patient must be, “Is this the best thing we can do for the patient?”

40. Examples of Efforts by Provider Organizations to Achieve the IOM’s Six Aims

41. Cincinnati Children Hospital Medical Center • Includes families of hospitalized children in morning physician rounds • Permits adolescent patients with chronic diseases (e.g., juvenile diabetes) to set their own schedule of treatments and activities and to make entries into their medical records • Pays physicians for involvement in major quality management activities

42. Cambridge Health Alliance • Developed registries for chronic patients to identify needed diagnostic and therapeutic interventions, help teach patient self-management, and track patient outcomes • Provides translators for over 30 languages • Works with governmental agencies to establish coverage programs for the uninsured

43. Tallahassee Medical Center • Conducts surveys of satisfaction on every inpatient and outpatient and shares results broadly • Implemented palliative care project to ensure that terminal patient receive comfort care instead of intensive care • Put communication devices in ambulances, moved EKG lab, and changed cardiologist schedule to enable PTCA within 90 minutes

44. Hackensack Medical Center • Hired physician “intensivists” to care of hospitalized medical patients • Developed nursing career ladder to help hire, retain and further train nursing staff • Implemented advanced practice nurses to work with physicians and patients to coordinate care • Implemented daily multidisciplinary patient rounds (physician, nurses, ancillary therapists, etc.) to improve communication and teamwork

45. Brigham and Women’s Hospital • Developed computerized physician order entry system (CPOE) • Physician orders entered via terminals • Test results and treatment summaries transmitted to electronic patient record • Orders screened against knowledge base of rules to detect medication errors • Reduced serious medication errors over 80%

46. CareGroup • Developed internet-based electronic medical record • Allows physicians password protected internet access to patient records • Allows patients password protected internet access to their own records • Allows patients to write in their own record and to request appointments with physicians

47. Rosemont Medical Center • Developed “open access” program for patient appointments • Produced same day access for most patient visits • Reduced average wait time for routine visits from over 2 months to 1 day

48. Massachusetts General Hospital • Implemented utilization management to reduce inappropriate hospital days • Case managers apply MCAP (derivative of the AEP) to facilitate day to day decision making and data collection to change system • Over 10 years, inappropriate days have been reduced by more than 50%

49. SSM Health Care • Continuous Quality Improvement (CQI) - 13 year sustained effort • Alignment of goals and measures of performance throughout the organization • Use team work to solve problems and motivate employees • Human resources are part of strategic plan • Only health care organization to win Malcolm Baldridge National Quality Award

50. Continuous Quality Improvement • Top Management Commitment • Worker Empowerment • Team Work • Customer focus • Application of Scientific Method (Measurement and Reporting) • Recognition of success