Quality Improvement In Health Care: Quality Improvement In Health Care S. Strongwater, MD Director of Clinical Operations, Associate Dean Clinical Affairs


Outline: Outline Background Challenge of improving quality Strategies to improve quality Tools to improve quality Conclusions


Tonsillectomies in NYC: Tonsillectomies in NYC Study design: 1,000 eleven year old children 61% tonsillectomy @ start Remaining 39% referred for evaluation Of these, 45% felt to need surgery 55% of remaining group referred for another opinion. 44% felt to need surgery


Conclusion: Tonsillectomy : Conclusion: Tonsillectomy “Variation in treatment decisions was due to the viewpoint and standards of the medical examiner” American Child Health Association, p 82, 1934


Tonsillectomy: Tonsillectomy 1950 50-50 chance of a child undergoing a tonsillectomy 1970 50-80% surgeries unnecessary 1991 25% of surgeries unnecessary nb. From 1950-55 there were 2-300 annual deaths due to surgical complications


Tympanoplasties: Tympanoplasties Surgical treatment for otitis media 700,000 procedures annually 27% of surgeries unnecessary JAMA, 1994


Variation in Medical Practice: Variation in Medical Practice Surgical rates vary by community Appendectomy Prostatectomy Tonsillectomy Mastectomy Hysterectomy Hemorrhoidectomy John Wennberg 1969


Small Area Analysis: Small Area Analysis Study of variation within small geographic areas (Vermont, Maine, Iowa) Hysterectomy rates: 20 to 70% (to age 70) Prostatectomy rates: 15 to 60% Tonsillectomy rates: 8 to 70 %


Slide9: “An average of 17 years is required for new knowledge generated by randomized controlled trials to be incorporated into practice. Even then, application is highly uneven…” Balas E, SA Borens. Yearbook of Informatics. 2000


Conclusions: Conclusions 1. Evidence based medical practice is variably practiced 2. New discoveries diffuse slowly into common usage 3. Variation in care can be associated with excess morbidity, mortality and cost


Quality Opportunities: Quality Opportunities Reduce unnecessary procedures/hospitalizations Utilize appropriate therapies (medications, treatments, etc.) Reduce mistakes (medical errors) Implement preventive healthcare measures Measure outcomes to identify new opportunities to improve care


State of Health 1998: State of Health 1998 IOM Roundtable on Healthcare Quality Reports: overuse, underuse and misuse of care in USA Committee on the Quality of Health Care in America forms subcommittee: Technical Advisory Panel on the State of Quality. In collaboration w Rand Institute, review literature and conclude: “…there is abundant evidence that serious and extensive quality problems exist through American Medicine resulting in harm to many Americans”


Slide13: Excess Mortality: IOM Report To Err is Human. Reports there are approximately 100,000 excess deaths in American hospitals due to medical errors “These quality problems occur typically not because of a failure of good will, knowledge, effort, or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized” (Crossing the Quality Chasm p. 25, 2001)


So I am called eccentric for saying in public:: So I am called eccentric for saying in public: That hospitals, if they wish to be sure of improvement… Must find out what their results are Must analyze their results, to find their strong and weak points Must compare their results with those of other hospitals Must care for what cases they can care for well, and avoid attempting to care for cases which they are not qualified to care for well


Continued...: Continued... Must assign the cases to members of the staff (for treatment) for better reasons than seniority, the calendar, or temporary convenience Must promote members of the staff on a basis which gives due consideration to what they can and do accomplish for their patients Such opinions will not be eccentric a few years hence. Ernest A Codman. 1914


Industrial Quality Principles Applied to Medicine: Industrial Quality Principles Applied to Medicine W. Edward Deming: introduced a series of management principles and tools in post World War II that led to economic recovery in Japan. These techniques were reintroduced to the recession torn American economy in the1980s which led to our economic revival. National Demonstration Project applies these principles to Medicine in 1990. Conclusively proved these concepts are effective in improving quality in Medicine


Language/Acronyms of Quality: Language/Acronyms of Quality CQI Continuous quality improvement QA Quality assurance TQM Total quality management PI Performance improvement QC Quality control


Strategies to Improve Quality : Strategies to Improve Quality Performance Improvement Regulation (Hospitals: JCAHO; Plans: NCQA; MDs: credentialing/licensure requirements) Financial Penalties Litigation (the stick) Public Pressure (Disclosure, Foundation for Accountability-FACT)


Basic Quality Tenets : Basic Quality Tenets Customer satisfaction Respect for people Management by fact Continuous improvement


Important Principles : Important Principles 1. Productive work is accomplished through processes 2. Sound customer supplier relationships are absolutely necessary for sound quality management 3. The main source of quality defects is problems in the process 4. Poor quality is costly 5. Understanding variability of process is key to improving quality


Important Principles, continued: Important Principles, continued 6. Quality control should focus on the most vital processes 7. The modern approach to quality is thoroughly grounded in scientific & statistical thinking 8. Total employee involvement is critical 9. New organizational structure can help achieve improvement 10. Quality management employs three basic, closely interrelated activities: quality planning, quality control, and quality improvement National Demonstration Project, 1990


Applying these principles has led to…. : Applying these principles has led to…. Reduced post operative infection rates (administration of antibiotics within 30 minutes of incision) Reduced myocardial infarct size (aspirin at presentation, angioplasty, ACE inhibitors) Improved pneumonia survival rates (ER administration of antibiotics)


How does it really work?: How does it really work? Mindset: change is possible Stop looking for the bad apples and redesign the work flow Understand where the hand-offs occur Reduce the number of hand offs Reduce variation by standardizing as many processes as possible Measure results Keep looking for improvement


Customer Supplier Chain: Customer Supplier Chain Customer Process Supplier Inputs Process Services (orders) (med adminis) (cure)


Customers : Customers Nurses Technicians Other MDs Therapists Labs


Quality: Quality Shewart Cycle: Plan, Do, Check, Act (Find faults and fix them) Pareto Principle (80% problems, due to 20% process) Tools: flow diagrams, cause and effect diagrams, run charts, control charts,


Dimensions of Performance: Dimensions of Performance Efficacy Appropriateness Availability Timeliness Effectiveness Continuity Safety Efficiency Respect & Caring


Variation: Variation Normal and Abnormal variation Common cause and special cause Reducing variability improves outcomes


Practice Guidelines/Carepaths: Practice Guidelines/Carepaths “...systematically developed statements to assist practitioners and patient decisions about appropriate health care for specific clinical circumstances.” IOM Carepaths define and order the processes that lead to specific outcomes


Internist’s Attitudes About Practice Guidelines: Internist’s Attitudes About Practice Guidelines Sample size: 2,513 Respondents: 1,513 Challenge to MD autonomy Reduce MD satisfaction Likely to be used for MD discipline Too rigid for individual patients Over simplified Cookbook medicine


Internist’s Attitude, continued: Internist’s Attitude, continued Good educational tools Convenient source of advice Intended to improve quality of care Likely to be used for QA Likely to reduce costs Likely to reduce malpractice suits Likely to reduce defensive practices Tunis SR, et.al. Ann Int Med, 1994


Regulation: Regulation CMS: Center for Medicare and Medicaid Services Ensure that institutions providing care to beneficiaries meet standards of quality Quality Improvement System for Managed Care (QISMC, 1996) JCAHO (Sentinel Alerts) AHA & AMA; authority to terminate hospital participation in Medicare Oryx Program: Hospital based outcomes reporting Mortality, MI, DM mgmt, pneumonia, A Fib, CHF, Cancer care


Performance Improvement CMS Mandates: Performance Improvement CMS Mandates Data Submission: Four Conditions Heart Failure, AMI, Pneumonia, TIA/Afib/CVA 85 Medical Records abstracted per condition Data analysis (discharges, 14d readmit rate, 30 d mortality, ALOS, peer group comparison) Action plan (quarterly PI plan per condition, quarterly telephone contact


PRO’s: Performance Review Organizations: PRO’s: Performance Review Organizations CMS contracted review organization: Qualidigm in Connecticut Authorized to monitor quality and some billing practices (fraud and abuse investigation) 1992-shift to PI, pattern of care analysis: MI, CHF, Stroke, Pneumonia Patient complaint review


Hedis 3.0 : Hedis 3.0 Approximately 50 measures Focus on underuse/prevention Chronic disease focus 51% HMOs allowed data to be published in 1996; 45% in 1997 (NEJM 430 (6) 1999)


HEDIS 3.0: HEDIS 3.0 Healthplan Employer Data Information Set Childhood immunization rates Adult immunization rates Breast Cancer screening Cervical Cancer screening Pre/post natal care Advice to stop smoking Beta blocker Rx post MI Comprehensive DM care (eye exam rate) Cholesterol management Antidepressant medication management Getting care quickly Customer satisfaction


New England HEDIS Coalition Diabetic Eye Exam Rate 1998: New England HEDIS Coalition Diabetic Eye Exam Rate 1998 Average Score US 40.86% New England 50.75 Anthem CT 60.1 Anthem New Hamp 54.8 BC/BS Maine 60.6 Cigna Mass 54.5 Benchmark 90th percentile 57%


Benchmarking: Benchmarking Identification of best practice Introduced by Robert Camp--Xerox Corp Break down process and find best practice for each step or equipment Use of best practice will improve overall outcomes


Credentialing: Credentialing JCAHO, NCQA requirement Mandated for hospital and health plans Query of NPDB, AMA data bank Peer review protection Quality improvement participation mandated by JCHAO


Leapfrog Initiative: Leapfrog Initiative Business & labor consortium seeking to force improvements in medical outcomes Three targets: Minimum # of procedures Physician Order Entry Trained full time intensivist


Crossing the Quality Chasm: Crossing the Quality Chasm “Health care has safety and quality problems because it relies on outmoded systems of work. Poor designs set the workforce up to fail, regardless of how hard they try.” IOM National Academy Press. 2001


Six Aims for the 21st Century: Six Aims for the 21st Century Safe . Avoid injuries to patients Effective. Provide services based on scientific knowledge to all who could benefit (avoid over and under use) Patient Centered. Providing care that is respectful of and responsive to individual preferences, needs and values, and ensuring that patient values guide all clinical decisions


21st Century, continued: 21st Century, continued Timely. Reduce waits and sometimes harmful delays for both those who receive and those who give care Efficient. Avoid waste, including waste of equipment, supplies, ideas and energy Equitable. Provide care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status


Challenges in Improving Quality of Care: Challenges in Improving Quality of Care Cultural shift Information technology Regulation: HIPAA (privacy), peer review protections, litigation Payment policies (prevention vs. fee for service) Training Commitment


Targeted Conditions: Targeted Conditions Cancer Diabetes Emphysema High cholesterol HIV/AIDs Hypertension Ischemic Heart Disease Stroke


Quality: Quality “Perfect care may be a long way off, but much better care is within our grasp” (IOM, Crossing the Quality Chasm) We will need to commit to: Measurement, performance improvement, regulatory and malpractice reform, political transformation and system redesign.