Thanks to Migrant Clinics Network , Institute for Health Care Improvement, Marc Williams- Intermountain Healthcare &
Mike Hindmarsh
MacColl Institute for Health Care Innovation
Institute For Healthcare Improvement
Paul Bray, MA, LMFT
Assistant Research Professor, Dept. of Family Medicine, ECU
Work e-mail [email protected]
Need for Quality, Introduction to Quality Improvement and PCMH
Why are we discussing improving quality in health
care? It is the center of discussion with health
care reform: All reform emphasis quality
It’s on your certification exams: Specialty board certification & JCAHO (Joint Commission on Accreditation of Health Care Organizations) accreditation
It can increase your pay: Incentive pay, managed care pay, patient centered medical home and Pay for performance
It can keep you competitive: Learn about quality improvement because it is a world wide movement
Most important, for your patients: Learn about the methods to help your patients
The IOM Quality Report- To Err Is Human: Building a Safer Health System
Do we have a qualityProblem in US health care?
Consensus: We do nothave a problem we have a CRISIS!
To Err is Human Medical Injuries IOM November 1999 Report
44,000-98,000 deaths per year through medical errors More people die from medicalerrors than from breast cancer orAIDS or motor vehicle accidents 100,000 deaths per year from procedures/surgery complications, exceeding motor vchicle deaths Direct health care costs $9-15billion/year It’s a conservative estimate!!
March 1, 2001
“Between the healthcare we have and thecare we could havelies not just a gap,but a chasm.”
The IOM Quality Report- Update 2001
How Good Are We? Only 50% of Americans receive recommended preventive care
Patients with acute illness 70% received recommended treatments 30% received contraindicated treatments
Patients with chronic illness 60% received recommended treatments 20% received contraindicated treatments
Schuster et al. How good is the quality of healthcare inthe United States? Milbank Quarterly 76:517-63, 1998
The toll on patients is high: US Data
Source: Elizabeth McGlynn, et al. “The Quality of Health Care Delivered to Adults in the US.” NEJM 2003; 348:2635-45
CONDITIONSHORTFALL IN CARE
AVOIDABLE TOLL
Diabetes
Hypertension
Heart attack
Pneumonia
Colorectal cancer
Average blood sugar not measured for 24% 29,000 kidney failures - 2,600 blind
Less than 65% received indicated care - 68,000 deaths
39% to 55% didn't receive needed medications - 37,000 deaths
36% of elderly didn't receive vaccine - 10,000 deaths
62% not screened - 9,600 deaths
Source: World Bank’s World Development Indicators, UC Atlas
"THIS WEEK I CONVEYED TO CONGRESS MY BELIEF THAT ANY HEALTH CARE REFORM MUST BE BUILT AROUND FUNDAMENTAL REFORMS THAT LOWER COSTS, IMPROVE QUALITY AND COVERAGE, AND ALSO PROTECT CONSUMER CHOICE," BARACK OBAMA JUNE 6, 2009
The IOM Quality report: A New Health System for the 21st Century
Institute of Medicine
“The current care
systems cannot do the job.”
“Trying harder will not work.”
“Changing care systems will.”
http://www.iom.edu/CMS/8089.aspx
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Improved Outcomes
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Resources and Policies
Community
Health Care Organization
Chronic Care Model or Planned Care Model
The patient‐centered medical home is a model for care provided by physicians practices that seeks to strengthen the physician‐patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care and a long‐term healing relationship.
Primary Care as the key to Quality:Patient-Centered Medical Home
(PCMH)
Reimbursement is central to PCMH and Quality ImprovementReform Proposal: fees + PCMH pay-per-patient + performance from system of quality
1. Team based care2. Whole person orientation3. Care coordination4. Enhanced access5. Systems for quality6. Systems for safety
Characteristics of PCMH(National Center for Quality Assurance)
• 24/7 Access and Communication
• Patient Tracking and Registry Functions
• Care Management from a nurse or other non-physician
• Patient Self‐Management Support • Electronic Prescribing
• Test Tracking
• Referral Tracking
• Performance Reporting and Improvement, team reviews results
• Advanced Electronic Communications
How do we know a clinic is a PCMH
How do we have “systems of quality”?
(One of the 6 requirements of a PCMH)
Set a goal (if you do not have a target, that is what you will hit)
Form a teamTake Small stepsMeasure your progress- collect data
CORE STEPS IN CONTINUOUS IMPROVEMENT (i.e. diabetes)
Define a clear aim (reduced morbidity from diabetes)
Identify and define measures of success. (>40% < 7 A1c)
Form a team that has knowledge of the system needing improvement (physician, dia. Ed, scheduler)
Brainstorm potential change strategies for producing improvement. (add 20 min ed visit to >7)
Plan, collect, and use data for facilitating effective decision making. (measure A1c for ed vs. non ed)
Apply the scientific method to test and refine changes (id best curriculum & self-management)
What is the PDSA Cycle?
Act• What changes are to be made?
• Next cycle?•maintain modify add to the plan
Plan• Objective• Questions and predictions (why)• Plan to carry out the cycle (who, what, where, when)
Study• Complete the
analysis of the data•Compare data to
predictions•Summarize
what was learned
Do• Carry out the plan• Document problems and unexpected observations• Begin analysis of the data
How do we get there?
1. Define a Problem2. Set a Goal
3. Form a Team4. Plan for a change using “small scale
steps”5. Do the change
6. Study- collect data & analyze change/outcome
7. Act – correct, repeat, spread, install
Achievements In the first Diabetes Collaborative
applying the CCM; enrolling 16,000 people with diabetes.
The national shared performance measure of “two Hemoglobin A1c (HbA1c) tests done within a year” increased by almost 300%.
Diabetes pilot patients had significantly reduced CVD risk (pilot>control), resulting in a reduced risk of 1 cardiovascular disease event for every 48 patients exposed(RAND Corp. Study www.improvingchroniccare.org).
Reading List for Residence First QI Application Session
ECU Getting Started Powerpoint Presentation CQI Family Medicine CQI Introduction Mike Hindmarsh chronic care model intro IHI Improvement Methods Intro Web Sitehttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/ Tools: Cause-effect “Fish-bone” exercisehttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/Cause+and+Effect+Diagram.htm Tools: Pareto Diagram Exercisehttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/Pareto+Diagram.htm
Resourceshttp://www.ihi.org: Institute for Healthcare
Improvement, tools to print , “how to” manuals
http://www.healthdisparities.net: collaboratives done at HRSA clinics, Handbook for many chronic conditions (diabetes, asthma, CHF etc)
http://betterdiabetescare.org: info for practitioners
Resourceshttp://www.Improvingchroniccare.orgEducational materials for patientshttp://www.ncdiabetes.org/http://www.aace.comhttp://ndep.nih/govhttp://www/cdc/gov/team-ndephttp://www.diabetesatwork.org