ECMH Grand Rounds, December 14th, 2012Moderators: Donna Woods, Kris Gleason, Dan Evans

HEALTHCARE QUALITY

INSTITUTE OF MEDICINESIX AIMS FOR IMPROVEMENT

Safe Timely Effective Efficient Equitable Patient-

centered

S T E E E P

Safe Healthcare should not cause unnecessary harm Make planned actions occur as intended Avoid incorrect or more dangerous plans

Timely Avoid long delays Improve flow of care with patients’ interest in mind

Effective Care based on best scientific knowledge Maximize use of services likely to produce benefits Avoid services unlikely to result in benefits

Efficient Avoid waste Reduce administrative and production costs of care Use lower-cost choices if efficacy is comparable

Equitable Secure the benefits of healthcare for all people Improve access and care delivery based on need Reduce disparities between groups Treat all individuals fairly

Patient-Centered Deliver care responsive to patients’ values,

preferences and expressed needs

IS HEALTHCARE IN THE U.S. SAFE?

An Epidemic of Medical Error

0 100 200 300 400 500 600 700 800

AIDS

Diabetes

Pneumonia

Accidental Injury

Medical Errors

Lung Disease

Stroke

Cancer

Heart Disease

Deaths in Thousands

Source: US Mortality Data 1997 / CDC / IOM

IS HEALTHCARE IN THE U.S. EFFECTIVE?

COMPARATIVE RELIABILITY BETWEEN INDUSTRIES

01

10100

1,00010,000

100,0001,000,000

50% 31% 7% 1% 0.02% 0.0003%1 2 3 4 5 6

DefectsSigma

Sigma Scale of Measure

PPM

Low Back TX

Difficulty with Referral

Post Heart Attack Medications

Mammography Screening

IRS - Tax Advice (phone-in) (140,000 PPM)

Airline Baggage Handling

U.S. Anesthesia Deaths

Domestic Airline Flight Fatality Rate(0.43 PPM)

Inpatient Medication

Safety

CASE #1: 49 yo with sarcoidosis, congenital colonic

malrotation with chronic abd pain, major depression, and uncontrolled diabetes…

Had been hospitalized in Oct for glc of 1,100 ! Presents (after multiple team outreach calls) to

discuss her severe depression, passive suicidal thoughts, her glucose of 450 last week, and her continuing abd & back pain…

ROS: + cough (sarcoid?) + burning hands/feet

WHICH QUALITY INDICATORS DID WE SATISFY?

BP control for DM LDL control for DM Cervical Ca screening Breast Ca screening DM foot exam DM eye exam DM – attn to nephropathy DM a1c measurement BMI documentation, counseling Influenza vaccination PNA vaccination

WHICH QUALITY INDICATORS DID WE SATISFY?

BP control for DM LDL control for DM Cervical Ca screening Breast Ca screening DM foot exam DM eye exam DM – attn nephropathy DM a1c measurement BMI & counseling Influenza vaccination PNA vaccination

No (140/89) No (149 in Oct ‘12) No (last pap ’06) Yes (Oct ‘12) No No No Yes (11, down from 16) No Yes Yes

CASE #2: 84 yo had not seen MD for 20+ yrs until

slurred speech while at Treasure Island in ‘11 Next 12 mths: CVA (HTN, HL), colon cancer

(found when she bled on heparin), pneumonia, DVT/PE, c.diff, deconditioning, SNF, more c.diff, hemi-colectomy with ostomy, more SNF, another CVA, depression, recovers – goes home! 3 mths later dx with B breast cancer (on femara)

Comes to see us for a planned visit, check-up

WHICH QUALITY INDICATORS DID WE SATISFY?

BP control LDL control for IVD Statin for CVA Depression med

mgmt BMI & counseling Influenza vaccination PNA vaccination ASA for hx of CVA

Yes (120/74) No (108 in ‘11) Yes Yes Yes Yes Yes No !!!!!!!!!!!!!!!

QUESTIONS FOR THE AUDIENCE…

Are your patients receiving QUALITY CARE?

How would you MEASURE their quality of care?

DECEMBER ‘12 STUDENT CHART AUDITS:FIRST 100 ECMH PATIENTS LOGGED

ANALYSIS OF THE FIRST 100 CHARTS LOGGED:

66% female, 33% male 60% minorities, 40% white 66% of ECMH patients have HTN 20% have CAD 8% with afib, 6% with prior MI, 6% with CHF 8% with asthma 60% on meds that require monitoring 33% diabetes 63% have a BMI > 30

CONTROLLED BLOOD PRESSURE

2010 2011 20120%10%20%30%40%50%60%70%80%90%

100%

67% 62% 62%

BP <140/90 on last visit

ANTI-PLATELET DRUG & STATINS FOR ISCHEMIC VASCULAR DISEASE

2010 2011 20120%10%20%30%40%50%60%70%80%90%

100%

53%63%

84%

53%66%

79%

Documentation of active Rx

Anti-pltStatin

VACCINATION: PNEUMOCOCCAL

2010 2011 20120%10%20%30%40%50%60%70%80%90%

100%

44% 48%62%

Received PNA-vax

WOMEN’S HEALTH: CERVICAL CA, BREAST CA, & CHLAMYDIA SCREENING

2010 2011 201220%

30%

40%

50%

60%

70%

80%

42%

60% 58%50%

60%65%

43%

57% 57%

Documentation of active Rx

Cervical CaBreast CaChlamydia

DIABETES A1C CONTROL

2010 2011 20120%10%20%30%40%50%60%70%80%90%

100%

44%52% 50%

DIABETIC FOOT & EYE EXAMS

2010 2011 20120%10%20%30%40%50%60%70%80%90%

100%

6% 9% 9%15% 18%

52%

BMI & COUNSELING

2010 2011 20120%10%20%30%40%50%60%70%80%90%

100%

55%

68%

92%

57% 60% 62%BMI measuredDocumented counseling (if obese)

COLON CA SCREENING

2010 2011 20120%10%20%30%40%50%60%70%80%90%

100%

47% 47% 47%

71% 71% 71%

Chart Title

BlacksWhites

QUALITY METRIC Q & A

GOING FORWARD… Over the next month… We need to establish our baseline performance We need your help to track the quality of care We need a team captain for each ECMH clinic Compile your “official panel” list Make sure 1 person “owns” each patient Fill out the QI survey for each patient that you

OWN Due date = mid January (before next GR)

NEXT GRAND ROUNDS: We will focus on best practices across each

ECMH clinic, use the hour for students to present ideas for improvement

Remember – you can’t improve things unless you have baseline data!

Please keep logging your patients! https://

www.surveymonkey.com/s/ECMH_QI_chart_audit_scorecard