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/Client’s 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 doctor’s 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. • 1960’s-Awareness of Injury Control due to lessons from Viet Nam

9. Hx(cont.) • 1980’s 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 1980’s • 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 Women’s 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(Provider’s 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 NCQA’s 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 lft’s 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