HOSPITAL INFORMATION

7/29/2019 HOSPITAL INFORMATION

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Health information technologyFrom Wikipedia, the free encyclopedia

Health information technology (HIT) provides the umbrella framework to describe the comprehensive

management of health information across computerized systems and its secure exchange between consumers,

providers, government and quality entities, and insurers. Health information technology (HIT) is in general

increasingly viewed as the most promising tool for improving the overall quality, safety and efficiency of the health

delivery system (Chaudhry et al., 2006). Broad and consistent utilization of HIT will:

Improve health care quality;

Prevent medical errors;

Reduce health care costs;

Increase administrative efficiencies

Decrease paperwork; and

Expand access to affordable care.

Interoperable HIT will improve individual patient care, but it will also bring many public health benefits including:

Early detection of infectious disease outbreaks around the country;

Improved tracking of chronic disease management; and

Evaluation of health care based on value enabled by the collection of de-identified price and quality

information that can be compared.

Concepts and Definitions

Health information technology (HIT) is the application of information processing involving both computer hard-

ware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and

knowledge for communication and decision making (Brailer, & Thompson, 2004). Technology is a broad concept

that deals with a species' usage and knowledge of tools and crafts, and how it affects a species' ability to control and

adapt to its environment. However, a strict definition is elusive; "technology" can refer to material objects of use to

humanity, such as machines, hardware or utensils, but can also encompass broader themes, including systems,

methods of organization, and techniques. For HIT, technology represents computers and communications attributes

that can be networked to build systems for moving health information. Informatics is yet another integral aspect of

HIT.

Informaticsrefers to the science ofinformation, the practice ofinformation processing, and the engineering

ofinformation systems. Informatics underlies the academic investigation and practitioner application of computing

and communications technology to healthcare, health education, and biomedical research. Health informatics refers

to the intersection of information science, computer science, and health care. Health informatics describes the use

and sharing of information within the healthcare industry with contributions from computer science, mathematics,

and psychology. It deals with the resources, devices, and methods required for optimizing the acquisition, storage,

retrieval, and use of information in health and biomedicine. Health informatics tools include not only computers but

also clinical guidelines, formal medical terminologies, and information and communication systems. Medical

informatics,nursing informatics,public health informatics, andpharmacy informaticsare subdisciplines that informhealth informatics from different disciplinary perspectives. The processes and people of concern or study are the

main variables.
http://en.wikipedia.org/wiki/Technologyhttp://en.wikipedia.org/wiki/Informatics_(academic_field)http://en.wikipedia.org/wiki/Informatics_(academic_field)http://en.wikipedia.org/wiki/Informationhttp://en.wikipedia.org/wiki/Informationhttp://en.wikipedia.org/wiki/Information_processinghttp://en.wikipedia.org/wiki/Information_processinghttp://en.wikipedia.org/wiki/Information_processinghttp://en.wikipedia.org/wiki/Information_systemshttp://en.wikipedia.org/wiki/Information_systemshttp://en.wikipedia.org/wiki/Information_systemshttp://en.wikipedia.org/wiki/Health_informaticshttp://en.wikipedia.org/wiki/Health_informatics_toolshttp://en.wikipedia.org/wiki/Medical_informaticshttp://en.wikipedia.org/wiki/Medical_informaticshttp://en.wikipedia.org/wiki/Nursing_informaticshttp://en.wikipedia.org/wiki/Nursing_informaticshttp://en.wikipedia.org/wiki/Nursing_informaticshttp://en.wikipedia.org/wiki/Public_health_informaticshttp://en.wikipedia.org/wiki/Public_health_informaticshttp://en.wikipedia.org/wiki/Pharmacy_informaticshttp://en.wikipedia.org/wiki/Pharmacy_informaticshttp://en.wikipedia.org/wiki/Pharmacy_informaticshttp://en.wikipedia.org/wiki/Technologyhttp://en.wikipedia.org/wiki/Informatics_(academic_field)http://en.wikipedia.org/wiki/Informationhttp://en.wikipedia.org/wiki/Information_processinghttp://en.wikipedia.org/wiki/Information_systemshttp://en.wikipedia.org/wiki/Health_informaticshttp://en.wikipedia.org/wiki/Health_informatics_toolshttp://en.wikipedia.org/wiki/Medical_informaticshttp://en.wikipedia.org/wiki/Medical_informaticshttp://en.wikipedia.org/wiki/Nursing_informaticshttp://en.wikipedia.org/wiki/Public_health_informaticshttp://en.wikipedia.org/wiki/Pharmacy_informatics


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Physician Homer Warner (seated) consults with colleagues AlanPryor (center) and Reed Gardner in 1970 in the early days of hospital information technology. (Photo courtesy ofLDS Hospital)Eventhough information technology is now common in a number of hospitals and biomedical laboratories, in the

1950s only a small number of scientists imagined its enormous potential. In 1967, supported by NCRR, doctorHomer Warner led a seminal effort that created one of the first bioinformatics systems. This work has influencedpatient care, increased safety, and produced cost-effective service in hospitals around the nation. Today, NCRRcontinues its support of clinical bioinformatics as an integral component of the new Clinical and Translational Science

Awards.

Clinical application of bioinformatics began in earnest when the University of Utah installed a state-of-the-artcomputer in the early part of 1960s. Back then, Warner became intrigued by the possibility of using this newtechnology with patients at the Latter-day Saints (LDS) Hospital. It wasn't long before he gained access to the giantmachine and began writing programs to study coronary blood flow. Because the computer was only available atnight, he set a cot beside it to sleep on while the computer slowly crunched numbers.

One of the central questions in his mind was how to obtain around-the-clock physiological information from post-operative cardiac patients. Warner resolved this problem by inserting catheters into patients' arteries. Whenconnected through a computer, the apparatus calculated stroke volume, heart rate, cardiac output, and bloodpressure on demand. Resulting data were displayed on the screen of an oscilloscope, and three small lights alertednurses of abnormal vital signs that could lead to complications. This was one of the first uses of computers forpreemptive patient monitoring, a concept now propagated through nearly every intensive care unit.

By the late 1960s, Warner obtained an NCRR grant to develop a computer facility for the medical community.Through this award, he acquired one of the first Control Data 3200 computers. "The CD 3200 was an amazingmachine for its time," says Warner. "There was a total of 64K in the whole machine and it filled a 20-by-20-footroom, which mandatory under-floor air conditioning." Nonetheless, it was lightning fast for its time, with an ability toperform 800 calculations every second. The system placed LDS Hospital ahead of the curve. "We had visitors comingfrom all over the world to see our system," adds Warner.

As computer systems advanced, so did Warner's ideas. In the 1970s, using the CD 3200 computer, he developed ahospital information system named HELP (Health Evaluation through Logical Processing), which collected extensivepatient data. The system eventually grew to incorporate information from various parts of the hospital-laboratoryresults, pharmacy prescriptions, nursing care plans, surgery schedules, and accounting-thus creating one of the firstintegrated clinical systems. This integrative approach to organizing and storing patient information gave healthprofessionals access to the totality of records in one system, which supported their decision making.

In the late 1980s, HELP benefited thousands of patients. At LDS Hospital, automated prescription of antibiotics tosurgical patients decreased the rate of adverse drug events by 30 percent and halved the cost of antibiotics perpatient. In addition, in-hospital mortality dropped significantly. Almost 40 years later, Warner's initial technologygamble paid off handsomely by demonstrating how it could not only improve lives, but also save them.


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QUALITY IN HEALTH CARE DELIVERYVIKRAM ANAND HOSMAC INDIA PVT.LTD

Contents :Quality in Health Care Delivery

Quality in Health Care Sector-Key Principles

Infrastructure for Quality Assurance in Health Care

Decision Making in Health Care Improvement

Audit Key Tool in Q.A

Conclusion

Quality in Health Care Sector :

Key Principles

HEALTH CARE

The system that a Nation has built up and continuously maintains in order to combat (unnecessary)

Death,Disease,Disability,Dissatisfaction and (social) Disruption

A collection of curative,preventive,rehabilitative and promotive services

Health care is a social and economical endeavor encompassing activities by

providers,consumers,financiers and government within their respective value systems

Whats wrong in todays Health Care? Avoidable errors

Underutilization of services

Overuse of services

Variation in services

Communication problems

Lack of Evidence

Dissatisfied clients

What can we do about it?

Do nothing

Better education and training

Policing,Inspection,Punishment Change,Improve,Reward

Comprehensive Approach:Quality Assurance

Definition of Quality

Why define quality of care?

Reach consensus among employees

Avoid confusion and in-house fighting

Allow for sound evaluation

Allow consumers to make a choice

From the beginning there was

chaos

quality assessment

quality assurance

quality improvement

continuous quality improvement

Information technology

values

Quality :Terminology

Quality Assurance: the overall philosophy on Quality and its Assurance

Total Quality Management:one of the newest organizational and managerial approaches to

Quality Assurance in the (not) for profit industry Continuous Quality Improvement:an important organizational and managerial mechanism for

quality assurance in the health sector

Development in Phases


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In industrialized countries:

Before 1970: the Individual Phase

1970-1980: the Professional Phase

1980-1990: the Bureaucratic Phase

1990-2000: the Industrial Phase

2000- : the Information Technology Phase

Continuous Quality Improvement

Important elements: External and internal customer satisfaction

Management leadership

Involves all personnel

Uses statistical methods

Focuses on improvements

Definition of healthcare quality

Quality is working according to specifications

Quality is providing effective services with a minimum of unnecessary use of resources

Quality is to satisfy customers

The Core PrinciplesThe essentials are:

Assuring(I.e assessing and improving) quality is the responsibility of the provider

Quality assurance is an evaluation and improvement process

Of all the necessary attributes(knowledge,skills,attitudes,values) values and attitudes are the most

important

TOTAL QUALITY

The end point of a development in phases:

Focus on professional quality

Focus on client satisfaction

Focus on system effectiveness

Focus on interconnections

Organizational and societal unification

Why improve my quality

Because I know it is needed

because I am told to do so

because I must survive

Because I need to follow the rules

Todays choice:SURVIVAL

Mission Statement

Rationale:programme SURVIVALMy programme is dedicated to

Provide high-quality service to the members of the community

Employ well-trained professionals

Maintain a high safety record

Provide a customer friendly environment

Plan high quality services

Identify priorities,goals and customers

Set up working groups

Describe service according to:

-consumer and client needs- structure,process,outcome

Make plans for evaluation

Quality Planning


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Establish Quality project: goals and team

Identify customers

Determine client needs

Design services to be provided

Design delivery process

Determine information need

Use and evaluate

Train professionals Select key professionals

Design appropriate training

Organize continuous training sessions

Evaluate results of training including satisfaction

Reward participants

Repeat training regularly

Evaluation

Includes assessment and improvement

Orientation:what are the possibilities?

Selection:What is most appropriate?

Implement: who is doing what? Collect and discuss the results

Disseminate the results inside and outside

Prepare for the next round

Improvement of care

Focus:Structure,Process and Outcome

Structure:better equipment

Process:doing the right things better!

Outcome:obtain better results in

- effective services

-costs

- client and employee satisfaction

Improvement of structure

Includes building,equipment,personnel,manuals,

information systems,rules and regulations

Includes new provisions,and updating and

refurbishing of old provisions

Need to include recording of inputs and costs

Improvement of Process

Principle:Doing the right things better!

Doing the right things more effective!

Doing the right things more efficient!Includes:

Appropriate use of technology

Appropriate use of personnel

Client/provider relationship

Improvement of outcome

Focus:

Programme effectiveness

Programme efficiency

Consumer and employee satisfaction

Consumer and employee education

Building and technology safety Community relations

Information and communication needs

Tools for Improvement


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Motivation

Insight

Evaluation methods

Communication tools

Dedicated personnel

Dedicated Management

Money

That implies: Quality improvement is essential for survival

Customer satisfaction is important for survival

Monetary support will come only after well-executed quality assurance studies

Infrastructure for Quality

Assurance in Health Care

Quality Assurance Universe Big including small

Small Concepts

Methods

Application

Effectiveness

Efficiency

Criteria for good care

Improvement activities

Infrastructural Needs

Assessment of actual situation:

Structural analysis

Rapid need assessment

SWOT analysis

Programme evaluation

Part of certification

Essentials

A Policy Document for Quality Assurance

A Blue Print for Quality Assurance

Quality Assurance Policy Document Directed to Quality Assurance,not to quality

Based on National Needs for Improvement of health services

Items:definitions,principles,locus,focus,actors,

costs,strategies

Contd..

Size:less than 32 pages

Production Time: less than 9 months

Easy to understand ,no jargon

Support by main parties(participants) Distributed widely

Updated once in five years


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Listing the Infrastructure

The Body

The Engine

The Petrol

Assembly line and Maintenance

The Route Map

The Driver

And then On the road!

The Engine

Policies

Planning Mechanisms

Implementation strategies

Organization

Resources

Knowledge,skills,attitudes

Value systemsThe Body

The system for quality assurance

Information systems

Conformity between healthcare system and QA system

The Driver

Roles and Functions

Education and Training

License

Rewards

Remuneration

Accountability

Value Systems

The Petrol

Epidemiology of Health and disease

Epidemiology of quality(ABNA)

Willingness to evaluate/be evaluated

Willingness to Change and Improve

Legislation

Value Systems

Epidemiology of Quality

Rumours and Hearsay Surveys:Opinions,Dissatisfaction

Registration of Facts:Incidents

Registration of Facts: Trends

ABNA:Achievable Benefit Not Achieved

Maintenance

Support mechanisms

Research and Development

Internal Quality Assurance System

Value Systems

Assembling Quality Assurance

A Laboratory (be in control) Real Life situations(hope the best)

Value Systems


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Whatever you do , you still need a Manual and a Road Map!

Decision Making in Healthcare

Improvement

Key Concerns: To find the decision makers:

Who decides about quality?

Who decides about quality improvement?

To identify the client in health care quality improvement

Roles and Functions in Decision making in Quality Improvement

The Consumers

The Professionals

The Managers

The Government,Policy Makers

The Seven Roles of the Consumer

Definers of Quality

Evaluators of Quality

Informants of Care

Co-producers of care

Targets of Quality Assurance

Controllers of Practitioner Behavior

Reformers of Health Services

The Seven Roles of the Provider

To be accountable

To provide quality care(plan,implement)

To safeguard the quality of care services

To be evaluated by colleagues

To evaluate his colleagues

To continue learning

To collaborate with colleagues and management

Seven Roles and Functions of Management

Do their job(Quality Management)

Exert leadership

Participate in Quality Management Communicate on Quality matters

Be accountable re: quality

Evaluation of Quality Management

Provide resources

Role of Government

Still open:

Active role with responsibilities

Support role with limited responsibilities

No role at all

AUDIT

Key Tool for QA Implementation

History of Audit


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Global Development:

Until 1980s : the only mechanism available

since 1985: superseded by CQI

Since 1995: rebirth ofaudit as tool for professionals in CQI programmes

Historical definition: audit is retrospective review of medical care as laid down in the medical record

Audit: a modern definition

Is a criterion referenced review of health care delivery to establish quality followed by, if

necessary, specific activities to improve care delivery

The method is used by professionals to assess and, if needed, improve the quality of their work

Audit :Applied with little more discipline

Practical Solutions:

Focusing on relevant health care delivery

Focusing on multidisciplinary professional work

Retrospective and concurrent in orientation

Focus on assessment and improvement

Based on reliable and valid data Not more time consuming than others

Audits Building Stones

A well selected topic

A limited number of relevant criteria

Well selected reliable and valid data

A functioningjudgmentprocedure

A willto change when needed

Relevant changes leading to improvements

What are benefits in health care?

Improvement in health status

Increase in satisfaction

Elimination of impairment

Elimination of disability

Elimination of risks

Elimination of malfunctioning

all due to present health care

What is ABNA?

ABNA

Maximum conceivable benefit

Achievable benefit Benefit not achievable

Achievable benefit achieved Achievable benefit not achieved

Errors of commission Errors of omission

Well chosen priorities

Priorities for Quality Improvement:

Are formulated in a clear mode

Identify targets with high ABNA

Identify all players in the field including patients Provide insight into attainable improvements

Put the responsibility for quality improvement where it should be

Conclusion


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We should:

Focus on generalities,later on specifics!

Focus on gaps and weaknesses!

Each country gets the quality assurance

system it deserves!

Thank You

CCCCCCCCCCCCCCCCCC

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 fishbowlHealthcare Safety

Medicine 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 Costs

Errors

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 theUS each year

Healthcare Effectiveness

Acute URIvisits/10,000 with antibiotic prescription

Healthcare Backlash

Boston 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 yougot 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 theusual cost of healthcare.

Can we fix this?

The train is out of the station and its heading towards YOU Hop on.or prepare to be trampled


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It is clear the public is demanding change and you have to agree that our healthcare systems need major

improvement. Physicians are being challenged to participate in and lead many of these efforts. In fact

physicians and nurses who are providing the bedside care are the people most likely and most needed to

figure out how to make the healthcare system work better. So, to answer the question about why fellows

are sitting in a classroom listening to a presentation on QI, you are here to gain new knowledge and insight

about how you can change our healthcare system. You are the future of healthcare. And, oh by the way, if

you dont want to do this, there are plenty of others willing to do the work.

Quality Improvement

Basic ingredients

Clinical knowledge and experience

+

QI basic concepts+

Systems approach

Well, its pretty basic. You need to take your clinical knowledge and experience and combine it with some

basic QI knowledge. Then adjust your perspective to a systems perspective. Then you will be ready to be

part of the movement to produce positive systems changes in healthcare. Sound easy?

Well, its simple. You need to have a little QI knowledge and use your experience and clinical knowledge

to help produce positive change. And my hope is that, after this and the December presentation that you

will have greater knowledge and skill to do so.

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


Contributing 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

Lets talk a little about what got us to our current medical world. As fellows you are well aware of the

amount of knowledge you have been expected to acquire. Its overwhelming! And technology applications

in healthcare are also accelerating rapidly. For many reasons the scientific knowledge that is available is

not always translated to the bedside. This is a complex problem with solutions being studied. Im confident

that you in his group could probably identify some of the many reasons why knowledge does not translate

in to timely practice changes. Our patients are far more complex today than they were 20 years ago.

Combine that with the fact that very little attention has been given to HOW we deliver this complex health

care and we are behind the 8 ball. It's time to change


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Our medical world

Past and future

Cottage industry Individual patient focus I know it when I see it

Integrated healthcare system System focus Evidence based

Small change has been occurring but we need to accelerate the pace. We have been dinosaurs in the way

we provide healthcare and we are gradually moving from the cottage industry model to integrated health

systems of healthcare


Accelerating 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)

Our current medical world with the focus on healthcare deficiencies and the need to improve healthcare

quality has been accelerated by 3 major factors. In the last decade multiple studies and reports have

pointed out the..These are not new facts; this has been known for a while. However the problem was notacknowledged until multiple studies and reports began to examine the issues about healthcare delivery and

chronicle the misadventures and errors. This fueled the explosion of organizations and interest in HC

quality. The biggest accelerant has been the IOM reports; in 1999 the IOM published the sentinel report

on errors followed by the report crossing the quality chasm. (There is a 3rd report which will not be

discussed today)

Quality Chasm/Gap

Defined by the IOM The difference between what is scientifically sound and possible and the actual practice anddelivery of health services

Illustratesthe need for healthcare quality improvement efforts

Quality problems

Healthcare services

Underuse Overuse Misuse Variation

FragmentationInstitute of Medicine

Quality Aims


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Name the 6 quality aims identified by the IOMInstitute of Medicine

Quality Aims

Safe Effective Patient centered

Timely Efficient Effective

Institute of Medicine

Quality 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


Quality Aims

Effective Avoid overuse of ineffective care and underuse of effective care

Examples

Obtaining lab or Xray tests that dont alter treatment plan

Healthcare Effectiveness

Acute URIvisits/10,000 with antibiotic prescription


Quality 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


Quality Aims

Timely Reduce waits and harmful delays for both those who receive care and those who give care

Examples


Quality Aims

Efficient


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Avoid waste including waste of supplies, equipment, ideas and energy

Example Necessary supplies, personnel, and medications in room for patient procedure


Quality Aims Equitable Provide care that does not vary in quality due to gender, ethnicity, geographic location orsocioeconomic status

Example


Issues about the quality of healthcare are daily news items Medical profession is in a fishbowl

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 ofdesired health outcomes and are consistent with current professional knowledge

Defining quality is not easy to do. There are many definitions of quality and not everyone agrees. What I

think we would all agree with is that the provision of quality work is a basic value for physicians. I think

most of us would agree with the 1st definition of quality. The IOM definition looks beyond individual

healthcare provider quality to a systems perspective and defines quality asthe quality of your care is

impacted by the care provided by other members of your team and the systems and processes in place.Healthcare quality is more than just the quality of care you provide as a physician.

Defining Quality

Quality is A system-wide issue An individual performance issue rarelyQuality is a major team sport

Here is a more basic view of quality. Simply stated quality is an attribute of a system. It requires team

work among healthcare providers to achieve. Id like to state that again; quality is a system issue thatrequires a team effort and commitment. It is rarely an individual performance issue. However we will

see that individual accountability IS a key component of a well functioning system. So, weve talkedabout how to define quality. Now lets move on to what quality improvement involves

Quality Improvement

A process of innovation and adaptation designed to bring about immediate positive changes in thedelivery of health care in particular settings

systematic

data-guided multidisciplinary

Quality Improvement


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Key elements

Systematic Data-guided and knowledge informed Experiential Innovative

Employs formal explicit methodology

Continuous Core responsibility of healthcare professionals

These are key elements. To expound a bit on some of them. Again systems and a systematic and deliberate

approach is a critical concept-the focus is on improving systems. These activities generally are guided by

data and prevailing knowledge. Experience of the caregivers is important in identifying opportunities for

improvement and suggesting innovations. Innovation is key-try new things. Formal explicit methodology

requires team skills effort and commitment. And it is a core responsibility of all healthcare providers. HCP

must be accountable for disregarding identified safe practices or engaging in unjustified hazardous

conduct. So, Im sure many of you are thinking, whats so new about that? We do that!

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

Yes, some of this work has been done in the past. Generally it was informal, came from the top, often

anecdotal and rarely evaluated. A good example is the physician who changes their practice after seeing

the report on antibiotics prescribed for URIs that I showed earlier. This physician decides to stop

prescribing the Abx. Now his patients, who are use to getting the antibiotics are not getting them And they

realize that, hey, maybe the other docs in the practice are still giving antibiotics. So, instead of scheduling

an appointment for their sick child with this doctor they wait until 8PM and call the on call doctor who

prescribes amoxicillin for the cold. In a QI mode the entire practice would read the report, have a

discussion about practice change, all implement the practice and improve the care for the entire practice,

not just one individual. Andthe on call doctor would not have to take that 8PM phone call. Key

differences between QI and informal improvement are systematic, data guided, formal, continuous and an

expectation of all from the front line to the boardroom

Quality Improvement Work


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Team oriented Requires team skills Collaboration Meeting skills Value all perspectives

Develop local new useful knowledge to inform health care processes

I really want to re-emphasize that qi work is team oriented and requires team skills. The product of QI

work is to develop local.It is proactive not reactive; the focus is in improving systems not blaming

individuals

QI vs. Informal Improvement


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 changeWe are now going to focus on the explicit methodology associated with QI. Many of these methods

have been borrowed from other disciplines. These methods are used to structure cooperation of

participants, change the process or system, monitor what happens and evaluate changes.

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


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PDSA LEAN Six sigma Root Cause analysis Fishbone diagram FMEA Tracers

Trigger tools Action plans

Improvement Methods

A brief overview

Model for Improvement Lean Six Sigma Trigger toolsModel for Improvement

Flexible improvement framework IHI PDSA methodology Emphasizes Aims and measures Initial small tests of change Widespread testing Implementation and spread

Model for Improvement

Setting Aims

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

SIP Collaborative

Project Aim

ED Wait Collaborative

Project Aim

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


Setting Aims

What are you trying to accomplish?Model for Improvement

Establishing Measures

Teams use quantitative measures to determine if a specific change actually leads to animprovement.

SIP Collaborative


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.


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SIP Collaborative


ED Wait Collaborative

Changes 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


Testing 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.


Implementing 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 scaleModel for Improvement

Spreading Change

After successful implementation of a change or package of changes for a pilot population or anentire 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 improvementPart 2

Review key concepts


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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

Just a reminder that quality is a system issue and requires a team effort to produce. Again quality work

focuses on system improvement however individuals are held accountable to engage in safe practices

Quality Improvement

A process of innovation and adaptation designed to bring about immediate positive changes in thedelivery of health care in particular settings

systematic data-guided multidisciplinary

QI is a deliberate process that is systematic, data informed and multidisciplinary It requires a great deal of

collaboration and cannot be done successfully in isolation

Quality Improvement

and 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 performanceImprovement Methods

A brief overview

Model for Improvement Lean Six Sigma


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Trigger toolsModel 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 toolLean

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 is a very specific methodology focused on eliminating defects by continuously focusing oneliminating waste. The focus is on the customer, who are our patients, needs and lean methods seek

to standardize and improve work flow and processes with the ultimate goal of pursuing perfection.

Many organizations use lean methods to inform their QI processes

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


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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 practicesSix Sigma

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

Six sigma processes have variation that result in


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Systems and processes focus Individual performance nota focus Identifies potential improvements to reduce likelihood of future event Used in M&M process, sentinel event investigationsFishbone 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 processesQI 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 standardizationCentral Line Infections

Defining 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 daysCentral Line Infections

Stating the project aim

Reduce central line infection rate to 0 in the ICU in 12 monthsCentral Line Infections

Practice 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 Infections

Practice StandardizationQuality at CMH

How informed are you?

Rate of compliance with hand washing?


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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 Improvement

2007

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

Systems approach Individual blame not the norm IndividualISaccountableQuality Improvement vs. Research

Its 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 18-39months

Joint Commission

Mission

To continuously improve the safety and quality of care provided to the public through the provisionof 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 safety2008 NPSG

Goal 1 Improve the accuracy of patient identification. 1A Use at least two patient identifiers when providing care, treatment or services.


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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 thecomplete 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 notto 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, andthe 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 toask 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 bythe 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 HealthOrganization (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 permanentloss 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 patients current medications with those ordered forthe patient while under the care of the organization.

8B A complete list of the patients medications is communicated to the next provider of servicewhen 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 concernsabout 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 patients condition.

16A The organization selects a suitable method that enables health care staff members todirectly request additional assistance from a specially trained individual(s) when the patients

condition appears to be worsening.

Quality Improvement
http://www.who.int/patientsafety/information_centre/ghhad_download/en/index.htmlhttp://www.who.int/patientsafety/information_centre/ghhad_download/en/index.htmlhttp://www.who.int/patientsafety/information_centre/ghhad_download/en/index.htmlhttp://www.who.int/patientsafety/information_centre/ghhad_download/en/index.html


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Key elements


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

The Disadvantages of Computers in HospitalsAdding computers or going electronic can make everything from billing to keeping track of patientrecords quicker in a hospital, but computers also bring disadvantages to the hospital environment.As technology and computers become more advanced, additional elements will appear in thehospital setting, but whether the advances are really improvements is open for some debate.

Cost

One of the biggest drawbacks of adding computers to hospitals is the cost. Computers costmoney, and a large hospital needs many computers to keep the system running smoothly. Creating anetwork to transfer medical records or keep track of billing is an additional initial cost. Unlike paperrecords, which simply require a few more copies, electronic record keeping requires constant upkeepof computers, computer software and other electronic elements, which can cost even more.

Security

If your doctor or hospital is switching to computers or electronic record keeping, you're proba-bly worried about the security of your medical records. Paper records are kept in a doctor's office or awarehouse, but once computers are added to a hospital, electronic record keeping typically follows.Once electronic record keeping is begun, medical information is usually added to a closed computernetwork, but as long as an Internet connection comes into the network, the system is vulnerable tooutside sources, opening the debate to questions about patient privacy and medical record security.

Lack of Standardization

From a hospital point of view, one of the biggest disadvantages of adding computers and elec-tronic records to a hospital is the lack of standardization through the medical field. Different hospitalsuse different shorthand abbreviations or symbols on medical records than others. Even the codes

called out during emergencies don't always mean the same thing in every hospital. If a medical recordis transferred from another hospital or the system becomes open so hospitals can share information,the lack of standardization in hospital notes and records could cause problems when it comes to amedical professional's understanding of the medical record.


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Background - Hospital Information TechnologyHospitals began investing in health IT during the 1960s. Information technology was

_rstused to support billing and _nancial services. Subsequently, the role of IT grew to

managepharmacy, laboratory, and radiology service lines (Collen, 1995). Although their pri-mary6purpose was to support billing and capture revenues (commonly referred to ascharge capture)these applications began to monitor and support basic clinical activities. These sys-temsfrequently provided services such as drug interaction controls, laboratory qualitycontrols,and documentation of patient's radiology histories. These systems were nearly ubiq-uitous by2000 (McCullough, 2008).

The development of electronic medical record (EMR) systems has greatly expandedtheautomation of clinical services. These systems replace a hospital's medical recordand inte-grate clinical information from ancillary services such as pharmacy, radiology, andlaboratory.More sophisticated systems allow physicians to directly access the electronic medicalrecord

and enter orders electronically. Computerized providers order entry (CPOE) is intend-ed toreduce communication errors and serve as a platform for treatment guideline auto-mation.While leading academic medical centers have been developing these technologiesfor manyyears, it is only during the past decade that this technology has begun to di_usewidely.Information technology can a_ect hospital productivity through a variety of mecha-nisms.While hospitals may gain the same bene_ts from IT as any other service _rm (e.g.,

improvedsupply chain management or enhanced labor productivity), three mechanisms areparticu-


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larly important for hospitals: billing management, provider monitoring, and clinicaldecisionsupport.Improved billing may be the most widespread e_ect of hospital IT investments. Hos-pitalsprovide a wide range of services and the prices of these services depend upon pa-tients' clinical

characteristics as well as contracts negotiated between payers and providers. For ex-ample,the reimbursement rate for cardiac surgery often depends upon whether a patient isa diabeticor has hypertension as these comorbidities a_ect hospital costs. Price schedules andclinicaldocumentation requirements depend on contracts with private insurers as well asgovernmentregulations. While hospitals have long used conventional IT for billing support, EMRsareincreasingly used to document care and facilitate charge capture.Clinical complexity also creates a di_cult monitoring problem. Although physicianscon-trol most hospital resources their actions are di_cult to document and evaluate. Fur-thermore,most physicians are employed by physician-owned practices rather than hospitals.Hospitals7use IT to monitor physician behavior. Relatively simple clinical information systemsmaybe used to generate periodic reports on physician behavior and resource utilization.

Thesereports may be used to support quality improvement initiatives or to identify theoveruseof laboratory and radiology resources. Comprehensive EMR systems allow for muchmoresophisticated provider monitoring and may lead to improved resource allocationwithin hos-pitals.Clinical decision support is the most ambitious objective of hospital IT. SophisticatedEMR systems with CPOE may be used as a platform to implement treatment guide-lines,

identify dangerous drug interactions, or coordinate care across provider team mem-bers. Thesereal-time decision support functions should standardize care and reduce errors, thusenhanc-ing both clinical quality and productivity.Decision support systems are more e_ective when they possess detailed informationre-garding patients' clinical characteristics and treatment histories. Thus, EMRs may ex-hibitnetwork externalities as their value could increase if neighboring providers adopted

inter-operable EMRs. Although EMRs with real-time clinical decision support among themost-


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discussed forms health IT, Jha et al. (2009) _nd that information sharing acrossproviders isquite rare.Most of these productivity-enhancing mechanisms should be captured by conven-tionalmeasures of value added. Quality changes may, however, be omitted from valueadded if

they do not lead to increases in prices or quantities. This may be important for hospi-tals asquality is di_cult to measure and the prices for many patients (i.e., Medicarebene_ciaries)are _xed by law. A number of recent economic studies provide evidence that al-though EMRsmay improve quality, the average e_ect is quite small (McCullough et al., 2010;Agha, 2011;McCullough et al., 2011; Tucker and Miller, 2011).

How to Strengthen the Hospital Management and Improve Quality of Medical Ser -vice (20061018)

In recent days, Kinmen Hospital has been more concerned by regional public representativeswho collectively expect that the service quality of Kinmen Hospital of Department of Health willbe better than that of Kinmen County Hospital. Therefore, we actively consider how to establish apartnership with the Kinmen Hospital of Department of Health to increase its medical servicequality by means of joint efforts.

Connotation of medical service quality consists of medical technology, medical art and medicalspace. Influenced by objective factors of insufficient specialists and medical equipments, there'sno way comparing medical technology in Kinmen with that in Taipei Medical Center, not to men-tion the less spacious medical space which cant keep up with that in large hospitals in Taipei.Nevertheless, the doctor-patient relationship and well-communicated administrative managementcovered by medical art are worthy of being improved by joint efforts of all supervisors and col-leagues. In order to improve in medical service quality, achieve permanent and sustainable oper-ation, deliver service for the common people in the region and win good reputation, supervisorsof various departments shall strengthen administrative management and promote executiveforce. In respect of strengthening administrative management of department supervisors, myopinions are as follows:

. To establish Patient-Focused Service Culture

Taking hospitalities of restaurants and airline companies as a learning object, we should have ourloyal patients who have confidence in the hospital be cultured as salesmen of Kinmen Hospital ofDepartment of Health. On the other hand, conflict behaviors between medical staffs and patientsor their relatives shall be avoided in emergency room or outpatient department.

II. Systematical guidance

In addition to avoidance of individual heroism, department supervisors shall work with great en-

thusiasm and care for colleagues. Moreover, opportunities to receive education and to grow upshall be provided to create an environment for encouraging colleagues to make progress and forperforming their abilities and wisdoms. As regards to patients requirements of both transferringtreatment and transportation, euphemistic explanations shall be made to enable patients and


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their relatives to fully understand standpoint of the hospital and necessity. In the case that pa-tients require hospitalization, medical staffs shall explain in details based on patients conditionsto allow patients to achieve their purposes or to passably accept medical staffs suggestions,even with a little dissatisfaction.

III. Setting of an Example to Others by Department Supervisors

Knowing the principle that a good example is the best sermon, department supervisors shall turninto an example to other colleagues. Therefore, all department supervisors shall be willing toshoulder responsibilities and set themselves as an example to other colleagues. Consequently,the colleagues will follow the example. In the manner of establishing a typical model and goodexample being worthy of respects from colleagues, the department supervisors, at any time, shallremind their colleagues to learn hospitals culture, mission, vision and core value.

. Management by Walking Around

Department supervisors shall often appear at the work site to experience colleagues require-ments, which means department supervisors shall often communicate with colleagues face to

face, whereby various problems reflected by common people can be found in advance. To savenine with a stitch in time and to reduce complaints, department supervisors shall instruct col-leagues to respond correctly and in time.

. Questionnaires about Degree of Satisfaction of Common People

Structured questionnaire and open-ended questionnaire can be employed at regular intervals forsampling survey on patients and their relatives opinions on various services of the hospital. Fur-thermore, hospitals shall publicly respond to these opinions to improve communication channelsbetween the hospital and the common people monthly. With respect to the patients who are hos-pitalized in Taiwan by emergent or conventional transportation, telephone interviews shall be ar-ranged after treatment and attention shall be paid to their progression of disease, which helps tofollow up the subsequent return treatment and arrange refund of hospice care. Because afore-mentioned cares move common people with less expenses, they are worthy of implementing andpopularizing.

Finally, in my own view, Health Bureau and Kinmen Hospital shall establish a management cul-ture guided by a principle that focuses on patients, gives priority to common people and empha-sizes good service quality, which enables Kinmen Hospital to turn into a health care teamVvvvvvvvvvvvvvvvvv

How can YOU become one of Health Care's Most Wired?For the 14th year, H&HN has named the Most Wired Hospitals and Health Systems based on the Most Wired Sur-vey. The 2012 survey results build on the analytic structure that was implemented in 2010 after two years of re-design. The methodology sets specific requirements in each of four focus areas. If any of these requirements are notmet, the organization does not achieve the Most Wired designation. Thus, an organization may have many ad-vanced capabilities, yet not achieve Most Wired status. The four focus areas are:

1 | Infrastructure

Identity management, access controls and audit capabilities

Data recovery plan testing and disaster recovery restoration capabilities within 72 hours

Security technology safeguards, including encryption for laptops

Regular risk analysis, security assessments and penetration testing


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Wireless networks for clinical applications, accessible by clinicians and staff

2 | Business and Administrative Management

Expanded use of electronic payer transactions

Automation of revenue-cycle processes

Partially automated management systems for supply chain and use of bar code technology

Patient flow automation

Human resource management and training systems

Enterprise decision support and business intelligence

3 | Clinical Quality and Safety (inpatient/outpatient hospital)

Patient demographics, vital signs and status, and documentation recorded as structured data

Routine use of electronic health record and clinical information systems by nurses, pharmacists andphysicians

Physician access to clinical pathways/order sets and medical image review across care settings

Clinical decision support enabled for drug allergy alerts and drug interaction alerts

Digital clinical imaging/PACS in hospital and clinic

CPOE for medication orders

Point-of-care medication administration systems and automated medication management

Electronic recording of quality data

Electronic recording of infection control data

4 | Clinical Integration (ambulatory/physician/patient/community)

Physician-office EMR connectivity for clinical documentation and viewing results

Physician office e-prescribing

Online health information for patient education

Interoperability of applications within hospital

This year, 662 hospitals and health systems completed the survey, representing 1,570 hospitals, roughly 27 percentof all U.S. hospitals. Even with additional requirements, the number of hospitals and health systems designated asMost Wired increased to 215 organizations. H&HNuses the same criteria to name the 25 Most Improved and the 25Most Wired - Small and Rural.

From a set of separately submitted essays, a panel of hospital and information technology leaders identifies note-worthy IT projects and names the Innovator Award winners and finalists. IT projects are evaluated on achievement ofbusiness objective, creativity and uniqueness of concept, scope of solution and impact on the organization.

The 2012 Most Wired Survey was made possible by the generous support of McKesson, AT&T, CareTech Solutionsand in cooperation with CHIME, the AHA and H&HN.

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