Reflections on Defining and Measuring Quality of Emergency

Care in Denmark

Philip D. Anderson, MDAssistant Professor, Harvard Medical School

Department of Emergency Medicine Beth Israel Deaconess Medical Center

Boston, Massachusetts USA

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Overview

• EM-specific quality and performance measurement

• The Balanced Scorecard approach

• Categories and Examples of Indicators

3

Progress towards a new model of emergency care delivery in Denmark

• Specific plans from all Regions describing implementation of recommendations from Sundhedsstyrelsen

• Fagomraadsbeskrivelsen for akutmedicin by DMS – education based on this has started

• Many FAME enheder established at regional hospitals

• Agreements with primary sector and psychiatry for cooperation with FAME enheder

• New national model for klinisk basisuddannelse – all nye læger spend some time in FAM

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Defining and Measuring Quality:A Significant Challenge Worldwide

• Multi-dimensional nature of Quality

– Safe, Effective, Patient-centered, Timely, Efficient, Equitable

– Meaningful understanding requires multiple measures

• Complexity of emergency care delivery

– Wide range of patients, providers, processes

• Outcomes alone inadequate measures of quality

– Variability due to many factors

– Isolating effect of EM care from subsequent care

– Difficult to interpret in terms of what to fix

– Infrequent occurrence of bad outcomes = low statistical power

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International Experience with Defining and Measuring EM Quality

• EM quality measurement literature– current concepts, strategies

• EM quality measurement strategies in 4 countries– Canada, UK, Australia, USA

– Wide range of EM specific indicators

– “no one has a perfect strategy”

• Existing emergency healthcare data gathering in Denmark– Klinisk Epidemiologisk Afd.

Aarhus Universitet

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Why is there an urgent need for EM specific quality measurement tools?

• Historic national quality improvement initiative– General goals, model for emergency care is clearly defined – Many details of how to implement not clearly defined

• Individualized regional, local hospital strategies– Increase potential for variability in implementation – Some variability unavoidable to accommodate local circumstances– Too much variability threatens larger quality goals

• Success depends on uniform standards – What structure / process elements don’t want to compromise on? – Incorporate these into quality standards

• Regions will be judged on success / failure of implementation– Better to define own success criteria, rather than use someone else’s

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What challenges do Healthcare Leaders face?

• Clearly articulate a specific quality agenda for hospital-based emergency care:– What do we want to improve / change? (indicators)

– How will we measure success? (standards)

• Promote uniform development of FAM system:– Organizational structures

– Clinical practice model

– FAM staffing, education and training

• Successfully balance multiple (competing) agendas:– Organizational / Operational

– Innovation / Sustainability

– Quality / Safety / Satisfaction

– Financial

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Unique Opportunities for Emergency Medicine in Denmark

• Implement a world-class model of emergency care delivery– Strengths of Danish healthcare

system

– Build on international EM experience

• Create a “best-practices” framework for measuring quality, impact of care– Existing national quality tools

– National healthcare databases

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Existing National Quality Tools:

• Den Danske Kvalitetsmodel (DKM): – General accreditation model for all healthcare institutions

– Leadership and quality improvement tool

– Framework for developing standards

• Det Nationale Indikatorprojekt (NIP): – Development, testing and implementation of healthcare quality

indicators

– Evidence-based,

– Diagnosis / condition-specific

These seem to be perfect; why is there a need for anything else?

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Potential limitations for use in measuring emergency care quality?

• Early stages of development?– Much EM specific content yet to be developed– How long will it take to develop? When is a quality measurement tool needed?

• Too general?– Do they contain the necessary detail to provide useful guidance for development

of emergency care system?

• Political dimensions?– Committee-driven process w/ many stakeholders, many agendas– Tend towards least controversial standards, maintain status quo– Will they produce standards that push a necessary paradigm shift?

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Existing emergency healthcaredata sources offer great potential:

• ”Vores overordnede konklusion er, at LPR kan anvendes til en overordnet monitorering af akut området...”

• ”For at optimere monitorering af akutområdet bør den nuværende registrering ændres og udvides til at omfatte oplysning som tillader en bedre karakteristik af indlæggelsesforløbene...”

Christensen, et al. Akutte indlæggelsesforløb og skadestuebesøg på hospitaler i Region Midtjylland og Nordjylland 2003-2007, Klinisk Epidemiologisk Afd.,

Aarhus Universitet, 2009.

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Electronic capture of administrative and process data at departmental level

• Electronic time stamps for actions of interest– Administrative data, demographics, patient

movements– Computerized Provider Order Entry– Test results, medications, interventions

• Automated reporting of benchmarking data– Start simple : add more data elements over

time

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Regional EM Data Reporting System

Landspatientregister

Regional administration

Local FAM administration

Health systems research

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National Ambulatory Care Reporting System (NACRS)

• The Canadian Institute for Health Information (CIHI)

– an independent, not-for-profit organization

– provides essential data and analysis on Canada’s health system and the health of Canadians.

• The National Ambulatory Care Reporting System (NACRS)

– contains data for all hospital-based and community-based ambulatory care:

– day surgery, outpatient clinics and emergency departments.

• Individual ED patient visit level data reporting

• 179 Emergency Departments reporting in Ontario

• 82 data elements in 2009 version:– Administrative – Demographics– Referral – Disposition**– Chief complaint – Acuity– Time-motion data– Therapeutic Interventions

**allows for accurate linking of “kontakter” to reconstruct overall “patientforløb”

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Charting the Course Forward

• Create EM specific quality measurement tools– Establish uniform standards– Drive uniform development

• Develop national databases and IT tools to meet emergency care data needs– Clinical care, administration, research– Input from relevant stakeholders is critical

• Balanced scorecard approach– Align organizational strategy with

performance measurement – Many perspectives and indicators to

consider

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The Balanced Scorecard: a performance measurement and strategic planning methodology

Financial

Customer

Internal

Learning and Growth Learning and Growth

Internal

Financial

Mission &Stakeholders

For-profit organizationsNot-for-profit (Healthcare)

organizations

Kaplan and Norton. Harv Bus Rev, 1992;70(1):71-79

Basic infrastructure to improve, create value and

achieve mission

Processes at which we need to excel in order to satisfy

our customers

Priority is to generate profit for

shareholders

Priority is to fulfill mission and satisfy

stakeholders

Healthy finances a necessary condition

rather than ultimate goal

How do our customers

perceive us?

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Applying the Balanced Scorecard in Healthcare Provider Organizations

Study of 9 Provider Organizations• Integrated healthcare delivery systems• Academic medical centers• Community hospitals

Benefit Themes:• Clarify and gain consensus on strategy• Increase credibility of management

with board members• Framework for executive decision

making• Set priorities by identifying,

rationalizing and aligning initiatives• Link strategy with resource allocation• Greater accountability• Enabled learning and continuous

improvement

Organizational Performance improvement = 64%

• Volume of provided services• Productivity• Patient satisfaction • Utilization management

Improved Financial Position = 76%

• Cost reduction• Revenue enhancement

Inamdar and Kaplan. J Healthc Manag. 2002;47(3):179-195

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Ontario Hospital Association Balanced Scorecard for ED Care

• Publically financed healthcare system

• 25 indicators across 4 performance areas

• 124 participating hospital emergency departments across Ontario

• Voluntary participation: 109 (88%) 1 quadrant; 85 (69%) 4 quadrants

• “High-Performing” Hospitals identified for each quadrant

Hospital Report 2007: Emergency Department Care

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Balanced Scorecard for the Dutch Health System ten Asbroek at al. Int J Qual Health Care. 2004;16 Suppl 1:i65-i71

Perspectives and indicator areas of balanced scorecard for Dutch Health System

Financial Perspective• Health system costs• Efficient use of resources• Financial viability

Consumer Perspective• Effectiveness• Patient safety• Patient satisfaction

Internal Process Perspective• Quality of healthcare delivery

processes• Concentration of care provision • Human resources (availability,

vacancies, satisfaction)

Innovation Perspective• Funds for learning and growth• Information infrastructure• Innovative working environments• Development and diffusion of

organizational innovations• “Anticipate need for new

professionals for healthcare delivery of tomorrow”

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What system perspectives would you prioritize?

?

? ?

?

Which indicators would you choose?

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System Elements Related to Quality

“the resources we use, and conditions under which, we deliver care”

“what happens to patients as a result of our delivering care to them”

“what we do to patients in the process of delivering care

Structure Process Outcome

Donabedian, JAMA, 1988

“Good structures increase the likelihood of good processes, and good processes increase the likelihood of good outcomes.”

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Categories & Characteristics of Indicators

• Material resources• Human resources • Organizational

structures

• Health status• Patient satisfaction

• Representative tasks• Representative

conditions

Structure Process Outcome

• Indicators should be:

– Relevant (matter to stakeholders)

– Meaningful (can be influenced by healthcare system, room for improvement)

– Scientifically sound (validity, reliability)

– Evidence-based (causal linkage to desired outcomes)

– Measurable (clearly defined numerator, denominator, technically feasible to collect data)

• Indicators can change over time to reflect evolving quality agenda

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Structural Indicators of Emergency Care Quality

• Material Resources– Facilities– Equipment– Financing

• Human Resources– Type, number of staff– Staff qualifications

• Organizational Structures– FAM level– Hospital level– Regional level

Structure Process Outcome

What characteristics of the emergency care system affect the system’s ability to provide the desired emergency care?

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Examples:

FAM configuration: Contiguous clinical areas in FAM Admin/educ space adjacent to FAM Proximity to vagtlaege konsultation

Access to other hospital functions: x-ray, laboratory ICU, OR, cath lab

Hospital inpatient resources: Access to inpatient floor beds Access to inpatient ICU beds

Indicators Related to Material Resources

Structure Process Outcome

Material Resources:

Features of the FAM facilities that describe how well suited it is to provide efficient and effective emergency care

Does our FAM have the space / beds that we need to care for our patients?

Do we have the access we need to key functions to provide care effectively

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Indicators Related to Material Resources

Structure Process Outcome

Examples of Access related indicators:

• Access Block for ED patient, wait > 8 hours

– Percent of patients admitted, planned for admission but discharged, transferred to another hospital or died in ED, whose total ED time exceeded 8 hours

• Access Block for ED patients, wait > 4 hours

– Percent of mental health or critical care patients who wait greater than 4 hrs in the ED after the time of decision to admit them

Australasian Clinical Indicator Report: 2001-2007. ACHS, 2008.

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Examples:

Adequate number of physicians for:

24/7 clinical coverage?

Administrative functions?

Education (self, junior physicians)

Staff Qualifications:

Percent of FAM physician staff with recommended training in EM

Percent of FAM nursing staff with recommended training in EM

Indicators Related to Human Resources

Structure Process Outcome

Human Resources:

Characteristics of the FAM staffing that describe how well suited it is to provide efficient and effective emergency care

Do we have sufficient numbers of staff to provide adequate clinical coverage?

Do our staff have the necessary education and training to provide the desired scope of care?

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Organizational Structures:

• Characteristics of the organization, policies and practices that:

– encourage delivery of cost effective, high quality care

– support growth and development of robust, sustainable FAM organization

• Attractive work environment

• Desirable career choice

• Professional recognition

Indicators Related to Organizational Structures

Structure Process Outcome

Examples:

System Integration: Use of Standardized Protocols Internal coordination of care External partnerships

Medical Informatics: Clinical data collection Use of clinical information technology

FAM Department Leadership: reports directly to hospital leadership able to hire own physician staff

Strategic Alignment of Incentives: appropriateness of inpatient admission employment, compensation models

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Organizational Structures:

• Characteristics of the organization, policies and practices that:

– encourage delivery of cost effective, high quality care

– support growth and development of robust, sustainable FAM organization

• Attractive work environment

• Desirable career choice

• Professional recognition

Indicators Related to Organizational Structures

Structure Process Outcome

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Process Indicators of Emergency Care Quality

Structure Process Outcome

What did we do to the patient? How well was it done?

Process measures ideally need compelling evidence linking them to desired outcomes to be valid

When hard evidence doesn’t exist, process measures can be based on expert consensus

• Representative tasks performed in the FAM

– Diagnostics – Therapeutics– Others

• Representative conditions seen in the FAM

– Common problems– Across spectrum of acuity

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Process Indicators of Emergency Care Quality

Structure Process Outcome

Representative tasks performed in the FAM:

• Triage

• Focused history and physical exam

• Determine diagnosis

• Pharmacotherapy

• Consultation and disposition

• Documentation

Thomas et al. Acad Emerg Med. 2008:15(8);776-779

• Emergency stabilization

• Diagnostic studies

• Therapeutic interventions

• Observation and reassessment

• Prevention and education

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Process Indicators of Emergency Care Quality

Representative conditions encountered in FAM:

• Treated in most FAM

• Wide spectrum of age groups

• Represent different degrees of patient acuity

• Common reasons for seeking emergency care

• Evidence that “best practice clinical care” in FAM may have impact on patient outcome or lead to enhanced clinical efficiency

• Rare conditions or where improving FAM care unlikely to change patient outcomes should be excluded

Structure Process Outcome

Lindsay et al. Acad Emerg Med, 2002, 9(11):1131-1139.

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Process Indicators of Emergency Care Quality

Example of a set of Representative Conditions:

• Asthma

• Pneumonia

• Acute myocardial infarction

• Deep venous thrombosis / pulmonary embolus

• Chest pain

• Minor head trauma

• Ankle / foot trauma

Structure Process Outcome

Lindsay et al. Acad Emerg Med, 2002, 9(11):1131-1139.

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Process Indicators of Emergency Care Quality

Examples of disease specific process measures:

• Asthma

– Beta-agonist administration in all patients presenting to the ED with an exacerbation of asthma (within 15 minutes of arrival in ED)

– Corticosteroid administration in all ED patients with asthma with:

• 1) moderate to severe exacerbations,

• 2) failure to respond promptly to inhaled beta-agonists,

• 3) admitted to hospital,

• 4) already on steroids at time of ED arrival

– Oral corticosteroids at discharge in all asthmatic patients who meet criteria to receive steroids in the ED

Structure Process Outcome

Sullivan et al. Acad Emerg Med. 2007; 14:1182–1189

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Process Indicators of Emergency Care Quality

Examples of disease specific process measures:

• Acute myocardial infarction

– Timely ECG in all patients who present to ED with symptoms suggestive of ACS (door-ECG time < 15 minutes)

– Delivery of aspirin / anti-platelet agent to all patients without contraindication who present with symptoms suggestive of ACS

– Delivery of reperfusion therapy to all AMI patients who meet criteria for reperfusion therapy

• door-to-needle time < 45 minutes for iv thrombolytic therapy

• door-to balloon time < 60 minutes for primary angioplasty

Structure Process Outcome

Sullivan et al. Acad Emerg Med. 2007; 14:1182–1189

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Process Indicators of Emergency Care Quality

Structure Process Outcome

Examples of Laboratory Turnaround Time indicators:

• Urgent serum potassium

– result within 60 minutes, during normal working hours

– result within 60 minutes, out of hours

• Urgent haemoglobin

– result within 60 minutes, during normal working hours

– result within 60 minutes, out of hours

Australasian Clinical Indicator Report: 2001-2007. ACHS, 2008.

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Outcome Indicators of Emergency Care Quality

Structure Process Outcome

What happened to the patient as a result of the care that was provided?

To what extent can we expect changes in FAM care delivery to change the outcome?

Need for risk adjustment of outcomes?

• Health Status– Morbidity – Mortality (???)– Disability

• Patient Satisfaction – Overall Impressions– Communication – Consideration – Responsiveness

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Outcome Indicators of Emergency Care Quality

Examples of Outcome Indicators:

• Proportion of Pneumonia Patients with Inpatient LOS ≤ 2 days

• Return Visit Rate for Asthma (≤ 24 hrs, 24-72 hrs)

• X-ray Rate for Ankle or Foot Injury Patients

• Return X-ray Rate for Ankle of Foot Injury Patients (≤ 7 days)

Structure Process Outcome

Hospital Report 2007: Emergency Department Care. Ontario Hospital Assoc.

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Outcome Indicators of Emergency Care Quality

Examples of Outcome Indicators:

• Percentage of ED visits where Adverse Drug Event recorded

• Percentage of ED visits where Adverse Transfusion Event recorded

Structure Process Outcome

Australasian Clinical Indicator Report: 2001-2007. ACHS, 2008.

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Outcome Indicators of Emergency Care Quality

Examples of Patient Satisfaction Indicators: • Overall Impressions

– Patients’ assessments, overall, of their ED stay

• Communication – Patients’ assessments of how well information was communicated to them or their family

during their ED stay

• Consideration – Patients’ assessments of whether they were treated with respect and courtesy by doctors,

nurses and staff during their stays in the ED

• Responsiveness– Patients’ assessments of the amount of time they waited to see doctors and nurses and

receive test results, assessments of pain management; assessments of team work; and staff’s responsiveness to their needs

Structure Process Outcome

Hospital Report 2007: Emergency Department Care. Ontario Hospital Assoc.

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Putting it all together

• Excellent foundation with existing quality frameworks, metrics, data gathering

– Danske Kvalitetsmodel (DKM), National Indikator Project (NIP)– Patients Administrative Systemer (PAS)– Landspatientregistret (LPR)

• Simplified overview of key perspectives, indicators to drive uniform development

– Balanced scorecard

• Additional indicators to create a meaningful framework of measures:– Wide range of examples from international experience– Structural conditions that support development of effective FAM system– Focus on patients, processes seen in the FAM