Quality Improvement In Health Care

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Quality Improvement In Health Care

• S. Strongwater, MD
• Director of Clinical Operations, Associate Dean
  Clinical Affairs

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Outline

• Background
• Challenge of improving quality
• Strategies to improve quality
• Tools to improve quality
• Conclusions

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Tonsillectomies in NYC

• Study design
• 1,000 eleven year old children
• 61 tonsillectomy _at_ 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

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Conclusion Tonsillectomy

• Variation in treatment decisions was due to the
  viewpoint and standards of the medical examiner
• American Child Health Association, p 82, 1934

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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

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Tympanoplasties

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

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Variation in Medical Practice

• Surgical rates vary by community
• Appendectomy Prostatectomy
• Tonsillectomy Mastectomy
• Hysterectomy Hemorrhoidectomy
• John Wennberg 1969

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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

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• 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

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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

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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

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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

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• 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)

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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

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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

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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

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Language/Acronyms of Quality

• CQI Continuous quality improvement
• QA Quality assurance
• TQM Total quality management
• PI Performance improvement
• QC Quality control

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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)

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Basic Quality Tenets

• Customer satisfaction
• Respect for people
• Management by fact
• Continuous improvement

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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

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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

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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)

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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

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Customer Supplier Chain

• Customer Process Supplier
• Inputs Process Services
• (orders) (med adminis) (cure)

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Customers

• Nurses
• Technicians
• Other MDs
• Therapists
• Labs

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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,

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Dimensions of Performance

• Efficacy
• Appropriateness
• Availability
• Timeliness
• Effectiveness
• Continuity
• Safety
• Efficiency
• Respect Caring

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Variation

• Normal and Abnormal variation
• Common cause and special cause
• Reducing variability improves outcomes

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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

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Internists 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

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Internists 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

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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

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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

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PROs 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

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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)

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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

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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

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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

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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

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Leapfrog Initiative

• Business labor consortium seeking to force
  improvements in medical outcomes
• Three targets
• Minimum of procedures
• Physician Order Entry
• Trained full time intensivist

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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

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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

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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

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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

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Targeted Conditions

• Cancer
• Diabetes
• Emphysema
• High cholesterol
• HIV/AIDs
• Hypertension
• Ischemic Heart Disease
• Stroke

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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.