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The Quality of Health Care

SAW

Source: Harvey

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ACCESS

QUALITY COST

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IOM Study of Health Care Quality

2001

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Dimensions of Quality of Care

Health care should be:

Safe

Effective Patient-centered

Timely

Efficient Equitable

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Studies of Quality and Safety

More than 70 studies document poor quality of

care (Schuster et al, 1998; 2000)

More than 30 studies document medication

errors (IOM, 2000)

Large gaps between the care people should

receive and the care they do receive

true for preventive, acute and chronic across all health care settings

all age groups and geographic areas

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Quality of Health Care Delivered to Adults

in the United States

Methods

Study of >6700 participants in 12 metropolitan areas

439 indicators of quality for 30 conditions

Selected Findings: 46% did not receive recommended care

11% received potentially harmful care

Only 24% of diabetics received 3 or more glycosylated Hgbtests over two-year period

65% of hypertensives receive recommended care

Only 45% of persons with MI receive beta-blockers

McGlynn et al, N Engl J Med 2003; 348:2635-45

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Frequency and Consequences of Medical

Injury During Hospitalization

Methods 18 patient safety indicators (from AHRQ)

994 acute care hospitals in 28 states in year 2000

7.45 million hospital discharge abstracts

Selected Findings: 2.4 million extra days of hospitalization

$9.3 billion excess charges >32,000 attributable deaths

Zhan and Miller, JAMA 2003; 290:1868-74

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Studies of Errors Among

Hospitalized Patients

New York State (1984 data)

3.7% experience injury due to medical care

13.6% of injuries are fatal 58% of injuries are preventable

Colorado and Utah (1992 data)

2.9% experience injury due to medical care

6.6% of injuries are fatal

53% of injuries are preventable

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Studies of Errors Among

Hospitalized Patients

Australia (1992 data)

16.6% experience injury or longer stay due to

medical care 4.9% of injuries are fatal

51% of injuries are preventable

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ALTERNATIVE MODELS TO APPREHENDPROBLEMS OF SAFETY AND QUALITY

Technology

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ALTERNATIVE MODELS TO APPREHENDPROBLEMS OF SAFETY AND QUALITY

TechnologyMorality

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ALTERNATIVE MODELS TO APPREHENDPROBLEMS OF SAFETY AND QUALITY

TechnologyMoralityRationality

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ALTERNATIVE MODELS TO APPREHENDPROBLEMS OF SAFETY AND QUALITY

TechnologyMoralityRationalityPsychology

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ALTERNATIVE MODELS TO APPREHENDPROBLEMS OF SAFETY AND QUALITY

TechnologyMoralityRationalityPsychologyducation

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ALTERNATIVE MODELS TO APPREHENDPROBLEMS OF SAFETY AND QUALITY

TechnologyMoralityRationalityPsychologyducationSystems

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The Doctor(1891) Fildes, Sir Luke (1843-1927)

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Ohio State University heart surgeons (1999)

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Organizational Supports for Change

Redesign care processes

Make effective use of informationtechnologies

Manage clinical knowledge and skills

Develop effective teams

Coordinate care across patient conditions,services and settings over time

Measure and improve performance andoutcomes

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Organizational Supports for Change

Redesign care processes

Make effective use of informationtechnologies

Manage clinical knowledge and skills

Develop effective teams

Coordinate care across patient conditions,services and settings over time

Measure and improve performance andoutcomes

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Redesign Care Processes

System design using the 80/20 principle

Design for safety

Mass customization

Continuous flow

Production planning

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Redesign Care Processes

System design using the 80/20

principle

Design for safety

Mass customization

Continuous flow

Production planning

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JacquesCa

relmansCoffee

potforMasochists

FromDonaldA.Norman,

TheDesignofE

verydayThings

Does good design matter?

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Safe Design

Complex, tightly coupled systems areprone to error (Perrow, 1984; Reason, 1990)

User-centered design principles (Norman,1988)

Visibility

Simplicity

Affordances and natural mappings Forcing functions

Reversibility

Standardization

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Making Anesthesia Safer

Deaths from anesthesia in the

U.S. have declined

dramatically in the last 25years.

Early 1980s: 1 per 10,000

Today: 1 per 200,000

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Making Anesthesia Safer

1985: Anesthesia Patient SafetyFoundation Forum for health professionals, device manufacturers,

regulatory bodies, and others Patient safety newsletter Seed grants in safety research

New technology

Pulse oximeter and capnometer Redesigned machines, standardized

practice guidelines, improved trainingprograms, hospital safety committees

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A New Environment for Care

Applying evidence to health care

delivery

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Applying Evidence to Health Care Delivery

Ongoing analysis and synthesis of medical evidence

Delineation of specific practice guidelines

Enhanced dissemination of evidence and guidelines to the

public and professions

Decision support tools for clinicians and patients

Identification of best practices in processes of care

Development of quality measures for priority conditions

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A New Environment for Care

Applying evidence to health care

delivery

Using information technology

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Using Information Technology

Consumer health

Clinical care

Administration and finance

Public health

Professional education

Research

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Core Functionalities for an Electronic Health

Record System

Health information and data

Results management

Order entry/management

Decision support management

Electronic communication andconnectivity

Patient support

Administrative processes

Reporting & population health

Institute of Medicine, July 2003

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A New Environment for Care

Applying evidence to health caredelivery

Using information technology

Aligning payment policies with qualityimprovement

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Aligning Payment Policies

Investment to improve quality may be hard to

justify on economic grounds alone

Difficult to measure the impact of quality improvement on thefinancial bottom line

Infrastructure investment required up front; savings delayed Those who gain may differ from those who pay

Many U.S. experiments underway to test the

effect of differential payment for higher quality:pay-for-performance

Special payment for priority conditions

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Preparing the Workforce

Restructuring clinical education at first-

stage, graduate, and continuing education

for medical, nursing and otherprofessionals.

Implications for credentialing, funding and

sponsorship of educational programs.

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Toward Improved Health Care

Opinion [Personal experience]

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Toward Improved Health Care

Opinion [Personal experience]

Evidence [Clinical Research]

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Toward Improved Health Care

Opinion [Personal experience]

Evidence [Clinical Research]

Standards [Guidelines]

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Toward Improved Health Care

Opinion [Personal experience]

Evidence [Clinical Research]

Standards [Guidelines]

[Use and Non-Use] Practice

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Toward Improved Health Care

Opinion [Personal experience]

Evidence [Clinical Research]

Standards [Guidelines]

[Use and Non-Use] Practice

[Quality and Safety] Performance

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Toward Improved Health Care

Opinion [Personal experience]

Evidence [Clinical Research]

Standards [Guidelines]

[Use and Non-Use] Practice

[Quality and Safety] Performance

[Outcome and Cost] Value

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Key Points

Quality and Safety are major

challenges for health care

Systems are a key organizing principle,and process redesign is a key strategy

A superior health care system for the

21stcentury is within reach