Group FQuality
Willie Jackson, IIILisa KanarekJennifer KimVatrice Perrin
So Why Care About Quality Anyway?
Accessibility to, actual provision of, and outcomes of health services are consistently substandard
Gap between current practices and realistic, optimistic practice possible today (considering technology, medical advancements, etc.)
Highest spender (US) on health expenditures (50% of global HC spending) has 16% uninsured…why?
Why We Care…The Reality
At least 44,000 Americans die each year as result of medical errors.
Deaths due to medical errors exceed the number attributable to 8th leading cause of death.
More people die in given year as result of medical errors than from MVA’s, breast cancer or AIDS.
Medication errors alone estimated to account for over 7,000 deaths annually.
Total national costs of preventable adverse events are estimated to be between $17 billion and $29 billion.
To Err is Human, IOM, 1999
Why We Care…Adult Care Standards
Adults receive recommended and appropriate health care approximately ½ of the time Overall care – 55% Acute care – 54% Preventive care – 55% Chronic care – 56%
Source: McGlynn, EA, et al, “The Quality of Health Care Delivered to Adults in the US,” NEJM, Vol. 348, No. 26.
Why We Care…Pharmacy Pholeys
There are as many as 7,000 deaths annually in the United States from incorrect prescriptions (Carmen Catizone, National Association
of Boards of Pharmacy)
Told The Washington Post as many as 5% of the 3 billion prescriptions filled annually are incorrect… That’s 150 MILLION WRONG
prescriptions!Source: http://www.consumeraffairs.com/news/pharmacy_errors.html
Why We Care…Medical Mishaps
Indianapolis -- two premature infants died and a third was in critical condition after being given adult-size doses of medication, prompting hospital officials to review drug-handling procedures.
Adult doses of the blood-thinner Heparin were somehow placed in a drug cabinet at the Newborn Intensive Care Unit of Methodist Hospital, said Sam Odle, chief executive of Methodist and Indiana University Hospitals. The hospital said human error was to blame.
Source: http://www.msnbc.msn.com/id/14883323/
Why We Care…Media Martyr
© 2004 Express Scripts, Inc. All Rights Reserved.
Betsy LehmanBoston Globe Health Reporter
Died December, 1994 after
receiving an accidental four-
fold overdose of
chemotherapy.
“Celebrity illness can help
change public attitudes.
There is no shortage of
precedents.”
Boston Globe, May 23, 1994
Defining the Issue
So what IS quality?
“Quality of care 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…How care is provided should reflect appropriate use of the most current knowledge abut scientific, clinical, technical, interpersonal, manual, cognitive, and organization and management elements of health care.”
Source: Lohr, 1990 - by Committee to Design a Strategy for Quality Review and Assurance in Medicare
Quality History
Guilds responsible for product service and quality (1200-1800)
Evolution of US practices in 1800’s (Industrial Revolution)
Craftsmanship Factory system Taylor system (Frederick W. Taylor)
Increase productivity by assigning factory planning to specialized engineers.
New emphasis on productivity had negative effect on quality. Inspection departments created to detect defective products.
Quality History cont’d.
20th century: Process-oriented and WWII Emergence of Quality Improvement Leaders
Joseph M. Juran Statistical quality control at Western Electric Quality Control Handbook Provided assistance to Japanese after WWII
Edward Deming (trained physicist, statistician) Quality important issue for the US Army during WWII Sampling inspection began Sent to Japan in 1946 by Economic and Scientific Section of
War Department to study agriculture production and related problems
Successfully influenced Japanese business with statistical theory and confidence.
Quality History cont’d.
20th century Edward Deming
Trained as physicist Statistician for USDA and Census Bureau Quality important issue for the US Army during WWII Sampling inspection began Sent to Japan in 1946 by Economic and Scientific Section of
War Department to study agriculture production and related problems
Successfully influenced Japanese business with statistical theory and confidence.
Quality History cont’d.
Total Quality approach in Japan Japanese manufacturers focused on improving
all organizational processes through people who used them.
Higher quality exports at lower prices. Total Quality Management
American response in 1970’s emphasizing not only statistics but approaches that embraced entire organization.
Malcolm Baldridge National Quality Awards
Big Whigs in Pioneering Quality
Florence Nightingale The Crimean War The Charge of the Light Brigade Birth of the Modern Hospital
Ernest Amory Codman, MD The End-Result Idea
Don Berwick, MD IHI
Eye of the Beholder…Differing Perceptions on Quality
Patient - typically judges healthcare encounter from outcome and personal views of such things as physician attention, clear communication, and compassionate, skilled delivery of care
Provider - more technical views such as whether accurate diagnosis was made, surgical procedure was performed proficiently, and whether patient’s health status improved; more concerned with gap between what is scientifically sound and possible vs. actual practice and delivery of care
HC manager/payer/purchaser - want to know if services are cost effective; looking to see if desired
outcome was most efficient and effective
Public health official - seek whether healthcare resources are used appropriately to optimize population health,
as well as provided equitably w/in population
Six Fundamental Dimensions for Quality
1. Safe - care should be as safe for pts in HC facilities as in their homes
2. Effective - our science/evidence should serve as standard for HC delivery
3. Efficient - care/service should be cost effective, and waste should be removed
4. Timely - pts should experience no waits/delays in receiving care & services
5. Patient Centered - should revolve around pt preferences, who should have
control6. Equitable - unequal treatment and disparities
should be long since eliminatedSource: Ransom, Scott, Maulik, Joshi, Nash, David. The Healthcare Quality Book. Health Administration Press. 2004.
What is Six Sigma? a disciplined, data-driven approach and methodology for
eliminating defects (driving towards six standard deviations between the mean and the nearest specification limit) in any process -- from manufacturing to transactional and from product to service.
Better put, a methodology for implementing a measurement-based strategy that focuses on process improvement and variation reduction in any industry
Measures HC performance in various measures: Needle stick incidents, room turnover, throughput, etc.
Universal Standards:Six Sigma
Source: Six Sigma at url: http://www.isixsigma.com/sixsigma/six_sigma.asp
1
10
100
1,000
10,000
100,000
1,000,000
Defectsper
million
level (% defects)
U.S. IndustryBest-in-Class
Anesthesia-relatedfatality rate
Airline baggage handling
Outpatient ABX for colds
Post-MI-blockers
Breast cancerscreening (65-69)
Detection &treatment ofdepression
Adverse drugevents
Hospital acquired infections
Hospitalized patientsinjured through negligence
1(69%)
2(31%)
3(7%)
4(.6%)
5(.002%)
6(.00003%)
Source: modified from C. Buck, GE
“Measurements Drive Performance”
Overall Health Care in U.S. (Rand)
Six Sigma
Six SigmaStrategy Map for HC Performance
SOURCE: Six Sigma, url: http://healthcare.isixsigma.com/library/content/c061122a.asp
A Step toward QI: Leapfrog Group
Voluntary program Aimed at mobilizing employer purchasing
power to alert the health industry that big leaps in health care safety, quality and customer value will be recognized and rewarded
Comprehensive programs covering hospital administrators, doctors, employers, and health plans
SOURCE: http://www.leapfroggroup.org/about_us
Leapfrog Initiatives
Encourages employers to practice transparency and allow easy access to health care information
Rewards hospitals that have a proven record of high quality care
Leapfrog Expectations
If all hospitals perform as well as the best 25% of hospitals for key Leapfrog Hospital Insights, they estimate the nation will benefit from the following every year:
66,000 lives saved; $18.5 billion saved; 145,000 readmissions avoided; and 187,000 medication errors avoided.
SOURCE: https://leapfrog.medstat.com/insights/references/OpportunityAnalysis.pdf
Another Step Towards QI: SCRIPT “Model for Medication Management”
Medication Management Score Any three of the six denominator conditions or diseases
One or more measures in at least three of the four functional categories (rx, monitoring, achieving goals, compliance)
Why Script? There are increasing morbidity, mortality, costs
associated with medication use and misuse Potential drug benefit Interest in measurement at the practice/physician level
Source: Performance Measurement: Recent Developments and a Look to the Future. CMS.
SCRIPT: How did it happen?
Meeting in 1997 with United Health Care, AMA, CMS , others on regional diabetes project. Discussion of common interests in medication management led to SCRIPT.
Funded by CMS in 1998 Built on lessons learned from DQIP
Source: Performance Measurement: Recent Developments and a Look to the Future. CMS.
SCRIPT goals
Improve quality of medication use
Develop core set of quality measures that are nationally standardized and would be widely used for QI and accountability
Begin by focus on elderly ambulatory populations and most important conditions
Source: Performance Measurement: Recent Developments and a Look to the Future. CMS.
Other Policy-Based Improvement Avenues
Mass implementation of information technology, such as hand-held bedside computers, to eliminate reliance on handwriting for ordering medications and other tx needs
FDA regulation against similar-sounding/ look-alike names and packages of medication
Standardization of treatment policies and protocols to avoid confusion and reliance on memory
known to be fallible and responsible for many errors
Source: http://www.ahrq.gov/qual/errback.htm
Health Industry Standards for QI
Reward providers and employers who emphasize prevention and wellness prevention
Reward providers who are delivering cost-effective quality health care – “Pay for Performance”
Make information available to the public on who is delivering quality health care and who is not
Emphasize paperless administration and reward providers who utilize such technology
Implement a comprehensive database on all patients Focus on health, not health care
Source: Washington Mutual Presentation on Health and Quality
Berwick’s Critique of “Pay for Performance” Concerned for individual Doctors and Nurses
Training Problems with Capacity v. Capability
Members of medical community have the capacity, but not the capability because of lack of training
Leadership – hospital boards care about the organizations, but do not understand that they have the duty to create change in the workplace.
Mistake to focus only on Doctors when looking at Quality, a fuller picture must be examined
Changes can come from outside of the Defined System
Berwick cont’d
Mistake to focus only on Doctors when looking at Quality, a fuller picture must be examined
Changes can come from outside of the Defined System
Political Implications of QualityParty Issues, Model Legislation, and
Our GOP Policy Proposal
Key Issues - Democrats
Increased access to health care Increasing the quality of services provided by
healthcare providers
Previous Legislative Efforts
Senators Clinton and Obama introduced a bill in 2005 to amend the Public Health Service Act
National Medical Error Disclosure and Compensation (MEDIC) Bill
MEDIC Bill
Key points in MEDIC proposal:
Promotion of open communication between health care providers and patients;
Reduction of preventable medical errors; Ensuring patient access to fair compensation for
medical errors; Reducing the cost of medical liability insurance; Will also create an Office of Patient Safety and
Health Care Quality within the Department of Health and Human Services which will establish a National Patient Safety Database.
MEDIC Bill cont’d.
The National Patient Safety Database will conduct data analyses to assist and provide information for policy and practice recommendations; establish and administer the MEDIC program, and support studies related to MEDIC and the medical liability system.
There are no Congressional Budget Office (CBO) costs estimates for the MEDIC proposal.
However, experts state that adherence by healthcare providers will be difficult unless providers are given immunity from possible subsequent litigation.
British Efforts
Pay for Performance (P4P)
Compensates physicians based on high quality performance. The British use financial incentives to improve physician’s performance.
Key Issues - Republicans
Linking of information to provide quality care such as electronic medical records
Increasing quality of care through compensation
Previous Legislation
The Medicare Modernization Act of 2003 (MMA)
The act was introduced as an overhaul to one of the United States largest entitlements programs—Medicare. On June 16, 2003, it was introduced in the House of Representatives by Rep. William M. Thomas, (R-CA.). Subsequently, it was redesignated as another house bill and was then sponsored by Representative J. Dennis Hastert (R-IL).
Source: Ryan Dougherty, Executive Summary: The Implications of Pay for
Performance, Extended care Product News
MMA cont’d.
Best known for providing prescription drug coverage for Medicare beneficiaries, however, the Act also included Pay for Performance provisions.
To improve quality of care provided to Medicare beneficiaries and avoid unnecessary medical costs, in 2003, Centers for Medicare and Medicaid Service (CMS) implemented measures to compensate health care providers who comply with certain health care outcomes.
Source: Ryan Dougherty, Executive Summary: The Implications of Pay for Performance, Extended care
Product News
MMA cont’d.
The initiative pays providers such as physicians, hospitals, physician groups and nursing homes.
According to prior estimates, health care providers will receive anywhere 2% to less than a 1% increase in payments (ECPN, 2007).
The CBO has no exact estimates regarding the costs of P4P, but it estimates that the MMA will cost $405 billion over a nine year period.
Source: Ryan Dougherty, Executive Summary: The Implications of Pay for Performance, Extended care Product News
Policy Model for Proposal:Patient Safety and Quality Improvement Act of 2005
Senator Jim Jeffords (I-Vt)
S.544 (109th), H.R. 3205
Public Law109-41
Political View
Bipartisan support Senate Supporters: Jeffords (I-VT), Kennedy
(D-MA), Frist (R-TN), Collins (R-ME), Bingaman (D-NM)
House Supporters: Bilirakis (R-FL), Emanuel (D-IL), Waxman (D-CA), Bono (R-CA), Norwood (R-GA)
Introduced in Senate on March 8, 2005 Signed by President July 29, 2005
Goals
Designate “patient safety work product” as privileged and not subject to:
(1) a subpoena or discovery in a civil, criminal, or administrative disciplinary proceeding against a provider;
(2) disclosure under the Freedom of Information Act (FOIA) or a similar law;
(3) admission as evidence in any civil, criminal, or administrative proceeding; or
(4) admission in a professional disciplinary proceeding
DHHS Secretary Michael Leavitt
Requires DHHS Secretary to:
Report to Congress on effective strategies for reducing medical errors and increasing patient safety.
Create and maintain a network of patient safety databases that: provide an interactive evidence-based management resource for
providers, PSOs, and other entities; and have the capacity to accept, aggregate across the network, and
analyze voluntarily reported nonidentifiable work product. Assess the feasibility of providing for a single point of access to the
network for qualified researchers for information aggregated across the network and, if feasible, provide for implementation.
Allows the Secretary to determine common formats for reporting to the databases that are consistent with the Social Security Act.
Requires that information reported to the databases be used to analyze national and regional statistics and be made available to the public.
Costs
CBO estimates that implementing S. 544 would cost $5 million in 2006 and $58 million over the 2006-2010 period, assuming the appropriation of the necessary amounts. CBO estimates that receipts from fines for violation of the privacy protections, which are recorded as federal revenues, would amount to less than $500,000 a year
Less than 1 dollar to every American in 2006
Foreshadowing our Policy…
“..the prices of care, not the amount of care delivered, are the primary difference between the U.S. and other countries…the more-costly U.S. healthcare has not resulted in demonstrably better technical quality of care or better patient satisfaction with care.”
Source: Anderson, GA, et al, “Health Spending in the US and the Rest of the Industrialized World,” Health Affairs, 2005, Vol. 24, No. 4.
GOP Proposed Legislation
Patient Safety and
Quality Improvement Act of 2007
PSOs implement the Act by: Analyzing medical error data; Determining the causes of the errors and; Disseminating evidence-based information to
hospitals and healthcare providers.
Patient Safety and Quality Improvement Act of 2007
PSQIA 2007: Rationale
Improve Patient Care through transparent reporting of hospital errors
Provide hospitals with incentives to report, using a pay for performance model
Financing scheme similar to Medicare Modernization Act
Governing body: Department of Health and Human Services, Agency for Healthcare Research and Quality
PSQIA 2007: Target Groups
Health Care Providers Hospitals Clinics Physicians
PSQIA 2007: Mechanism
Fund a program within the Agency for Healthcare Research and Quality which is housed in the Dept. of Health and Human Services.
PSQIA 2007: Financing
Give hospital’s tax breaks based on a sliding scales of costs necessary to gather reporting information
There will be a tax break for up to $500,000 of spending
PSQIA 2007: Outcomes
PSQIA 2007: Fiscal Implications
In 2005, the Congressional Budget Office estimated that implementing the Patient Safety and Quality Improvement Act of 2005 would cost $5 million in 2006 and $58 million over the 2006-2010 period.
Additionally, the agency estimated that receipts from fines for violation of the privacy protections would amount to less than $500,000 a year (CBO, 2005).