Healthcare Quality and Improvement

A Primer

Our current medical world

• Issues about the quality of healthcare are daily news items

• Medical profession is in a “fishbowl”

I

Healthcare SafetyMedicine vs.. Airline Industry

• Headline: “Can you be as safe in a hospital as you are in a jet?”

• Medical mistakes in hospitalized patients account for a minimum of 120 deaths annually

• This equates to a crash of a Boeing 747 every week killing all on board.

Healthcare CostsErrors

• Headline: “Medication errors in 2006 added $3.5 billion to the cost of healthcare”

• Headline: “80,000 catheter-related bloodstream infections occur in intensive care units in the US each year”

Healthcare EffectivenessAcute URIvisits/10,000 with antibiotic prescription

Healthcare BacklashBoston Globe

• Headline: “We pay for medical errors”

• By Richard Lord and Dr. Marylou Buyse. 9/12/ 2007

• “WHAT IF your mechanic forgot to replace the lug nuts after changing one of your tires and you got into a serious accident when the wheel came off? You wouldn't expect your mechanic to send you a bill for the repairs, would you?”

• “Unfortunately, that's what happens in healthcare; we pay a high price for mistakes.”

Boston Globe

• “Healthcare entities should not be rewarded financially when such preventable errors occur. Hospital-acquired infections offer one example.”

• “No other industry generates revenue from mistakes. Preventable errors should not be part of the usual cost of healthcare.”

Can we fix this?

• The train is out of the station and it’s heading towards YOU

• Hop on…….or prepare to be trampled

National Healthcare Quality Organizations

Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov

Health Care Quality www.consumer.gov/qualityhealth/index.html

Joint Commission on Accreditation of Healthcare Organizations (JCAHO) www.jcaho.org. National Committee for Quality Assurance

www.ncqa.org. Quality Interagency Coordination (QuIC) Task Force

www.quic.gov. URAC (also known as the American Accreditation Healthcare Commission) www.urac.org

U.S. Consumer Gateway: Health www.consumer.gov/health.htm

U.S. News Online www.usnews.com/usnews/nycu/health/hehome.htm

Quality Improvement Basic ingredients

• Clinical knowledge and experience

+

• QI basic concepts+

• Systems approach

Objectives

• Quality problems in health care• Define quality• Who, what, why and how of quality improvement• Key elements of a good QI project• Quality improvement vs.. research• Joint Commission• National Patient Safety Goals

Our current medical worldContributing factors

• Knowledge and technology explosion

• Barriers to translation of scientific knowledge into clinical practice

• Increasing complexity of healthcare needs

• Outdated processes and systems for complex multidisciplinary healthcare delivery

Our medical worldPast and future

• Cottage industry– Individual patient focus– “I know it when I see

it”

• Integrated healthcare system– System focus– Evidence based

Our current medical worldAccelerating factors

• Multiple studies and reports– widespread and frequent incidence of medical errors– lack of consistency in the care received in different facilities

and from different providers

• Explosion of healthcare quality interest and organizations

• Institute of Medicine Reports– To Err is Human: Building a Safer Health System(1999)– Crossing the Quality Chasm(2001)

Quality Chasm/Gap

• Defined by the IOM

• The difference between what is scientifically sound and possible and the actual practice and delivery of health services

• Illustrates the need for healthcare quality improvement efforts

Quality problemsHealthcare services

• Underuse

• Overuse

• Misuse

• Variation

• Fragmentation

Institute of MedicineQuality Aims

• Name the 6 quality aims identified by the IOM

Institute of MedicineQuality Aims

• Safe

• Effective

• Patient centered

• Timely

• Efficient

• Effective

Institute of MedicineQuality Aims

• Safe– Avoid injury to patients from the care that is

intended to help them

• Examples– Prescription of medication that patient is allergic

to– Failure to address an abnormal lab or Xray result– Failure to perform the correct procedure

Institute of MedicineQuality Aims

• Effective– Avoid overuse of ineffective care and

underuse of effective care

• Examples– Obtaining lab or Xray tests that don’t alter

treatment plan

Healthcare EffectivenessAcute URIvisits/10,000 with antibiotic prescription

Institute of MedicineQuality Aims

• Patient centered– Provide care that is respectful of and

responsive to individual patient preferences, needs and values

• Examples– Shared decision making for treatment options

Institute of MedicineQuality Aims

• Timely– Reduce waits and harmful delays for both

those who receive care and those who give care

• Examples

Institute of MedicineQuality Aims

• Efficient– Avoid waste including waste of supplies,

equipment, ideas and energy

• Example– Necessary supplies, personnel, and

medications in room for patient procedure

Institute of MedicineQuality Aims

• Equitable– Provide care that does not vary in quality due

to gender, ethnicity, geographic location or socioeconomic status

• Example

Our current medical world

• Issues about the quality of healthcare are daily news items

• Medical profession is in a “fishbowl”

I

Defining Quality

• “Quality is a way of thinking about work; quality is about achieving excellence-nothing less”

• IOM definition of quality– The degree to which health services for

individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge

Defining Quality• Quality is…

– A system-wide issue– An individual performance issue rarely

Quality is a major team sport

Quality Improvement

• A process of innovation and adaptation designed to bring about immediate positive changes in the delivery of health care in particular settings– systematic – data-guided– multidisciplinary

Quality ImprovementKey elements

• Systematic• Data-guided and knowledge informed• Experiential• Innovative• Employs formal explicit methodology• Continuous • Core responsibility of healthcare

professionals

QI vs. Informal Improvement

• Systematic• Data-guided and

knowledge informed• Experiential• Innovative• Employs formal explicit

methodology• Continuous • Core responsibility of all

healthcare professionals• Systems change

• Individual or group• May be knowledge

informed; rarely data• Experiential, anecdotal• Innovative• Informal process

• Episodic• No explicit responsibility.

Usually hierarchical• Individual change

Quality Improvement Work

• Team oriented

• Requires team skills– Collaboration– Meeting skills– Value all perspectives

• Develop local new useful knowledge to inform health care processes

QI vs. Informal Improvement

• Systematic• Data-guided and

knowledge informed• Experiential• Innovative• Employs formal explicit

methodology• Continuous • Core responsibility of all

healthcare professionals• Systems change

• Individual or group• May be knowledge

informed; rarely data• Experiential, anecdotal• Innovative• Informal process

• Episodic• No explicit responsibility.

Usually hierarchical• Individual change

Quality Improvement Methods and Terms

• What is Root Cause Analysis?

• What does PDSA stand for?

• What are Sentinel Events?

Quality Improvement Methods and Terms

• Terms• Sentinel events• Never events• Practice standardization• Adverse events• Harm• Incident reports• Balanced scorecard

• Methods• PDSA• LEAN• Six sigma• Root Cause analysis• Fishbone diagram• FMEA • Tracers• Trigger tools• Action plans

Improvement MethodsA brief overview

• Model for Improvement

• Lean

• Six Sigma

• Trigger tools

Model for Improvement

• Flexible improvement framework

• IHI

• PDSA methodology

• Emphasizes– Aims and measures– Initial small tests of change– Widespread testing– Implementation and spread

Model for ImprovementSetting Aims

• Improvement requires setting aims. The aim should be time-specific, measurable and define the specific population of patients that will be affected.

SIP CollaborativeProject Aim

SSI Rate 50% reduction

ED Wait Collaborative Project Aim

– 25% reduction in ED length of stay by 6/30/07

Model for ImprovementSetting Aims

• What are you trying to accomplish?

Model for ImprovementEstablishing Measures

• Teams use quantitative measures to determine if a specific change actually leads to an improvement.

SIP Collaborative Establishing Measures

Measurement Collaborative Goal

SSI Rate 50% reduction

Antibiotic use rate

Skin anti-sepsis rate

Model for ImprovementSelecting Changes

• All improvement requires changes, but not all changes result in improvement.

• Identify the changes that are most likely to result in improvement.

SIP Collaborative Establishing Measures

Measurement Collaborative Goal

Antibiotic use rate

Timing

Re-dosing

Skin anti-sepsis rate

Chlorhexidine

Hair removal

Our “Dizzying Complexity”Communication to Admit One ED Patient

ED Wait CollaborativeChanges Selected

• Aim: 25% reduction in ED LOS• Measures

– ED total LOS– Time from provider to decision re: disposition– Time from decision to discharge/admit

• Asthma/wheezing patients– Initiation of Albuterol by RT/RN if emergent

• Practice change

– Asthma CPG revision• Evidence based practice and process standardization

– Floor admission-selected patients receiving continuous Albuterol• Practice and process change

Model for ImprovementTesting Change

• The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change in the real work setting — by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method used for action-oriented learning.

O4. Decision to Discharge TimeAverage total minutes from clinical decision to child leaving the ED

                                                                                                                                                                                                                            

Model for ImprovementImplementing Changes

• After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the team can implement the change on a broader scale

Model for ImprovementSpreading Change

• After successful implementation of a change or package of changes for a pilot population or an entire unit, the team can spread the changes.

 

QI Projects?

• Are you doing any?

• How is it going?

• Lessons learned?

QI project developmentEssential steps

• Identify a project aim

• Develop a plan to achieve the aim– Responsibilities and roles– Improvement methods– Data sources– Timelines

• Identify outcome and balancing measures

• Use data to identify improvement

Part 2

• Review key concepts

• Move on to other QI methods

• Discuss project development

• Research vs. QI

• National patient safety goals

• Joint commission

Objectives

• Quality problems in health care• Define quality• Who, what, why and how of quality improvement

– Tools and methods

• Key elements of a good QI project• Quality improvement vs.. research• National Patient Safety Goals• Joint Commission

Defining Quality• Quality is…

– A systems-wide issue– An individual performance issue rarely

Quality is a team sport

Quality Improvement

• A process of innovation and adaptation designed to bring about immediate positive changes in the delivery of health care in particular settings– systematic – data-guided– multidisciplinary

Quality Improvementand Data

• Use data for learning, not judging– “Generate light, not heat”

• Use data to report system attributes

• Use aggregate not individual data

• Do not report data on individual performance

Improvement MethodsA brief overview

• Model for Improvement

• Lean

• Six Sigma

• Trigger tools

Model for Improvement

• Flexible improvement framework

• IHI• PDSA methodology• Emphasizes

– Aims and measures– Initial small tests of change– Widespread testing– Implementation and spread

Improvement Methods

• What is LEAN?

• What is Six Sigma?

• Identify a trigger tool

Lean

• Management philosophy based on 2 key themes– Continuous elimination of waste– Respect for people and society

• Key principles– Value is in the eyes of the customer– Make value flow without interuptions

• Improve work flow• Standardize work processes

– Pursue perfection

Lean

• Culture– Stop and fix the problem as soon as it is

identified– Toyota manufacturing culture

• Process– Measure– Change– Measure– Change…..

Lean Project“Improve ED Patient Flow”

• Project aim-reduce ED LOS by 50%• Process improvements(reduce waste)

– Work standards and evidence-based clinical practice guidelines for all ED staff defined

– Batching of orders eliminated– Right supplies and equipment in the right place;

eliminated unnecessary S&E– Admission process streamlined

• Results– Reduced ED LOS for discharges by 23%– Reduced ED LOS for admissions by 20%

Lean What is waste in medicine?

• Surgical infection• Preventable adverse drug events• Ventilator assisted pneumonia• Equipment failure• Waiting and lack of flow• Inadequate training or orientation• Unnecessary or poorly designed processes• Not following evidence based practices

Six Sigma

• Focus is to eliminate defects– Nonconformity of a product or service to its

specifications

• Six sigma processes have variation that result in <3.4 parts/million defects

Why Zero Defects is the Only Acceptable Quality Standard

• At 99.9% quality levels in a 250 bed hospital

– 12 inpatients per year would die due to errors– 6 day surgery patients would die– 9,742 wrong medications would be delivered– 4,923 incorrect laboratory tests would be

reported– 502 incorrect radiographs would be completed

Six Sigma

• Systematic and scientific management approach to reduce sources of process variation and improve reliability– Customer and financially focused– Strategic– Uses project management concepts– Strong statistical focus– Focus on “mistake-proofing”

• Requires rigorous professional training

Six Sigma Project“Reducing Hospital-Acquired Pressure Ulcers”

• 5 structured project phases– Define– Measure– Analyze– Improve– Control

Trigger tools

• Method for identifying adverse events (harm) and measuring the rate of adverse events over time

• Method options – Retrospective review of a random sample of patient

records using triggers (clues)– Prospective surveillance of electronic patient records

• Goal-to identify areas for improvement and prevent harm

Trigger Tools Your medical world

• Are there triggers that could be used in your specialty to identify areas of potential patient harm?

Root Cause Analysis

• Process to identify causal factors for variation in performance; “learning from consequences”

• Systems and processes focus• Individual performance not a focus• Identifies potential improvements to

reduce likelihood of future event• Used in M&M process, sentinel event

investigations

Patient FactorsCondition (complexity and seriousness)Language and communicationPersonality and social factors

Individual (staff) factorsKnowledge and skillsCompetencePhysical and mental health

Work Environmental FactorsStaffing levels and skills mixWorkload and shift patternsDesign, availability and maintenance of equipmentAdministrative and managerial supportEnvironmentPhysical

Task FactorsTask design and clarity of structureAvailability and use of protocolsAvailability and accuracy of test resultsDecision-making aids

Team FactorsVerbal communicationWritten communicationSupervision and seeking helpTeam structure (congruence, consistency, leadership, etc)

Organizational and Management FactorsFinancial resources and constraintsOrganizational structurePolicy, standards and goalsSafety culture and priorities

C D P DDDDPPP

Care Delivery problems (CDPs)Care deviated beyond safe limits of practiceThe deviation had at least a potential direct or indirect effect for an adverse outcome for the patient, staff or general publicExamples: Failure to monitor, observe or actIncorrect (with hindsight) decisionNot seeking help when necessary

Fishbone Diagram

Failure modes and Effects Analysis (FMEA)

• Prospective technique

• Systematic assessment to– Prevent problems before they occur– Reduce the chance of unintended adverse

harm if they occur

• Used for high risk procedures or error prone processes

QI projects

• Ideas/Aims

• Methods

• Data

• Challenges

Improvement project ideas

• Care process changes– Hand offs– Scheduling– Medication reconciliation

• Implementation of new clinical or administrative practices

• Practice standardization

Central Line InfectionsDefining the problem

• 15 million central venous catheter-days per year in ICUs

• Attributable mortality for these infections 4- 20%

• Bloodstream infections prolong hospitalization by a mean of 7 days 

Central Line InfectionsStating the project aim

• Reduce central line infection rate to 0 in the ICU in 12 months

Central Line InfectionsPractice Standardization

• Hand Hygiene • Maximal Barrier Precautions upon insertion • Chlorhexidine skin antisepsis • Optimal catheter site selection, with Subclavian

Vein as the preferred site for non-tunneled catheters

• Daily review of line necessity with prompt removal of unnecessary lines

Central Line InfectionsPractice Standardization

Quality at CMHHow informed are you?

• Rate of compliance with hand washing?– 90%

• Central line infection rate?– 1.2/1000 cath days-PICU

• % of codes outside the PICU?– 50%

• % of inpatients with medication reconciliation performed?– 70%

Healthcare Quality Improvement2007

• Move from cottage industry mode of care delivery to data driven system model of healthcare delivery

• Systems approach

• Individual blame not the norm

• Individual IS accountable

Quality Improvement vs. ResearchIt’s Complicated….

• QI– Systematic data-guided

activities designed to bring about immediate positive changes in healthcare delivery in local practice settings

– An integral part of the ongoing healthcare delivery system

– A form of clinical and managerial innovation and adaptation

– Combines discipline specific knowledge with experiential learning and discovery

• Research– A systematic investigation

designed to develop or contribute to generalizable new knowledge

– Implementation of research is a separate process and occurs later, if at all

– A knowledge seeking enterprise that is independent of routine medical care

Hastings Report

Questions?

Joint Commission

• Accrediting organization for healthcare institutions

• Sets administrative and practice standards and evaluates compliance

• Performs unannounced on-site surveys of accredited hospitals to assess compliance every 18-39 months

Joint CommissionMission

• To continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations

National Patient Safety Goals

• Key national safety goals for hospitals

• Set by Joint Commission

• Updated yearly

• Goal is to promote specific improvements in patient safety

2008 NPSG

• Goal 1 Improve the accuracy of patient identification. – 1A Use at least two patient identifiers when

providing care, treatment or services.

2008 NPSG

• Goal 2 Improve the effectiveness of communication among caregivers.– 2A For verbal or telephone orders or for

telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result.

– 2B Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.

2008 NPSG

• Goal 2 Improve the effectiveness of communication among caregivers.– 2C Measure and assess, and if appropriate,

take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.

– 2E Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.

2008 NPSG

• Goal 3 Improve the safety of using medications.– 3C Identify and, at a minimum, annually review a

list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs.

– 3D Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field.

– 3E Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.

2008 NPSG

• Goal 7 Reduce the risk of health care-associated infections.7AComply with current World Health Organization (WHO) Hand Hygiene Guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.– 7B Manage as sentinel events all identified cases

of unanticipated death or major permanent loss of function associated with a health care-associated infection

2008 NPSG

• Goal 8 Accurately and completely reconcile medications across the continuum of care.– 8A There is a process for comparing the patient’s

current medications with those ordered for the patient while under the care of the organization.

– 8B A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility.

2008 NPSG

• Goal 9 Reduce the risk of patient harm resulting from falls.– 9B Implement a fall reduction program

including an evaluation of the effectiveness of the program.

2008 NPSG

– Goal 13 Encourage patients’ active involvement in their own care as a patient safety strategy.

• 13A Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.

2008 NPSG

• Goal 15 The organization identifies safety risks inherent in its patient population.– 15A The organization identifies patients at risk

for suicide.

2008 NPSG

• Goal 16 Improve recognition and response to changes in a patient’s condition.– 16A The organization selects a suitable

method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening.

Quality ImprovementKey elements

• Systematic• Data-guided and knowledge informed• Experiential• Innovative• Employs formal explicit methodology• Continuous • Core responsibility of healthcare

professionals

Quality Improvement Work

• Focused on systems

• Team oriented

• Requires team skills– Collaboration– Meeting skills– Value all perspectives

• Develop local new useful knowledge to inform health care processes