HSAD 8325 PBHL 8093

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HSAD 8325/ PBHL 8093

• HEALTH CARE
• QUALITY MANAGEMENT
• (INTRODUCTION)

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COURSE FRAMEWORK
DEFINITIONS HEALTH SYSTEM CLINICAL CARE
SERVICE
QUALITY ASSESSMENT
QUALITY ASSURANCE/IMPROVEMENT
LAWS, REGULATIONS, ACCREDITATION STANDARDS,
PROFESSIONAL STANDARDS
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HSAD 8325 COURSE FRAMEWORK

• DEFINITIONS OF QUALITY AT THE HEALTH SYSTEM LEVEL
• (NATIONAL, STATE AND LOCAL SOCIAL POLITICAL
  DEFINITION)
• ACCESS
• AVAILABILITY
• AFFORDABILITY
• ACCEPTABLE
• COORDINATED
• CONTINUITY
• EFFICIENCY
• SAFE
• EFFECTIVE
• PATIENT CENTERED
• TIMELY
• EFFICIENT
• EQUITABLE

HEALTH PLANNING PUBLIC HEALTH
INSTITUTE OF MEDICINE
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HSAD 8325 FRAMEWORK

• DEFINITION OF QUALITY AT THE
• CLINICAL CARE LEVEL (PROFESSIONAL DEFINITION)
• IATROGENIC
• PROCESS
• OUTCOMES
• SAFETY
• ERRORS
• EVIDENCE BASED

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HSAD 8325 FRAMEWORK

• DEFINITION OF QUALITY BASED ON
• SERVICE ( CUSTOMER DEFINED
• DEFINITION)
• SATISFACTION
• TIME
• INFORMATION
• COURTESY
• COST

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HSAD 8325 FRAMEWORK

• QUALITY ASSESSMENT TOOLS AND TECHNIQUES
• STRUCTURE-PROCESS-OUTCOMES
• OBSERVATIONAL STUDIES
• CLINICAL TRIALS
• SURVEYS
• ADMINISTRATIVE DATA BASES

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HSAD 8325 FRAMEWORK

• QUALITY ASSURANCE/IMPROVEMENT TOOLS AND
  TECHNIQUES
• BALDRIGE AWARD
• TQM/CQI
• SIX SIGMA
• LEAN
• FAILURE MODES AND EFFECTS
• DISEASE MANAGEMENT
• GUIDELINES AND PATHWAYS

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HSAD 8325 FRAMEWORK

• REGULATION OF QUALITY
• LAWS
• REGULATIONS
• ACCREDITATION STANDARDS
• PROFESSIONAL STANDARDS

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QUALITY LEADERSHIP(REINERTSEN)

• ROUTE 1 REVOLUTION
• LEADERSHIP FROM BELOW
• HEALTHCARE PROFESSIONAL DEMAND DRAMATIC CHANGES
• ROUTE 2 FRIENDLY TAKEOVER
• LEADERSHIP FROM OUTSIDE
• POWER SHIFT TO PATIENTS AND FAMILY

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QUALITY LEADERSHIP

• ROUTE 3 INTENTIONAL ORGANIZATIONAL
• TRANSFORMATION
• LEADERSHIP FROM ABOVE
• STRATEGIC ORGANIZATIONAL ADAPTATION
• ROUTE 4 INTENTIONAL MACROSYSTEM
• TRANSFORMATION
• LEADERSHIP FROM HIGH ABOVE
• ACTS OF POLICYMAKERS, REGULATORS AND OTHERS IN
  POSITIONS OF AUTHORITY OUTSIDE THE HEALTHCARE
  DELIVERY SYSTEM

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MAJOR HISTORICAL REPORTS

• FLEXNOR REPORT (1910)
• SURPLUS OF UNDERTRAINED MD's
• MEDICAL EDUCATION INADEQUATE
• SCIENTIFIC BASE LIMITED
• PROPRIETARY MEDICAL SCHOOLS
• COMMITTEE ON THE COST OF MEDICAL CARE (1933)
• REVISE ORGANIZATION OF MEDICAL CARE DELIVERY TO
  GROUP PRACTICE
• DEFINED GOOD MEDICAL PRACTICE

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GOOD MEDICAL CARELEE JONES, 1933

• GOOD MEDICAL CARE IS THE KIND OF MEDICINE
  PRACTICED AND TAUGHT BY THE RECOGNIZED LEADERS OF
  THE MEDICAL PROFESSION AT A GIVEN TIME OR PERIOD
  OF SOCIAL, CULTURAL AND PROFESSIONAL DEVELOPMENT
  IN A COMMUNITY OR POPULATION GROUPTHE CONCEPT OF
  GOOD MEDICAL CARE THAT HAS BEEN EMPLOYED IN THIS
  STUDY IS BASED UPON CERTAIN ARTICLES OF FAITH
  WHICH CAN BE BRIEFLY STATED.
• 1. GOOD MEDICAL CARE IS LIMITED TO THE PRACTICE
  OF RATIONAL MEDICINE BASED ON THE MEDICAL
  SCIENCES
• 2. GOOD MEDICAL CARE EMPHASIZES PREVENTION
• 3. GOOD MEDICAL CARE REQUIRES INTELLIGENT
  COOPERATION BETWEEN THE LAY PUBLIC AND THE
  PRACTITIONERS OF SCIENTIFIC MEDICINE
• 4. GOOD MEDICAL CARE TREATS THE INDIVIDUAL AS A
  WHOLE.
• 5. GOOD MEDICAL CARE MAINTAINS A CLOSE AND
  CONTINUING PERSONAL RELATIONSHIP BETWEEN
  PHYSICIAN AND PATIENT.
• 6. GOOD MEDICAL CARE IS COORDINATED WITH SOCIAL
  WELFARE WORK.
• 7. GOOD MEDICAL CARE COORDINATES ALL TYPES OF
  MEDICAL SERVICES
• 8. GOOD MEDICAL CARE IMPLIES THE APPLICATION OF
  ALL NECESSAY SERVICES OF MODERN SCIENTIFIC
  MEDICINE TO THE NEEDS OF ALL THE PEOPLE.

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PRESIDENTS ADVISORY COMMISSION ON CONSUMER
PROTECTION AND QUALITY IN THE HEALTH CARE INDUSTRY

• Final report, March 1998 Quality First Better
  Health Care for All Americans
• KEY FINDINGS
• AVOIDABLE ERRORS
• UNDERUTILIZATION OF SERVICES
• OVERUTILIZATION OF SERVICES
• VARIATIONS IN SERVICES
• PRESENTED 50 RECOMMENDATIONS

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PRESIDENTS ADVISORY COMMISSION RECOMMENDATIONS

• CATEGORIES OF RECOMMENDATIONS
• SET OF NATIONAL AIMS FOR QUALITY
• DEVELOPMENT OF A CORE SET OF MEASURES FOR EACH
  SECTOR OF HEALTH CARE
• GROUP PURCHASERS SHOULD PROVIDE CHOICE OF HEALTH
  PLANS AND QUALITY INFORMATION
• LARGE GROUP PURCHASERS SHOULD STIMULATE QUALITY
• INCREASE CONSUMER EDUCATION
• FOCUS ON VULNERABLE POPULATIONS
• PROMOTE PUBLIC ACCOUNTABILITY
• REDUCE ERRORS AND INCREASE SAFETY
• FOSTER EVIDENCE BASED PRACTICE INNOVATION
• CHANGE LEADERSHIP FROM HEALTHCARE ORGANIZATIONS
• EDUCATION OF HEALTHCARE WORKFORCE
• ENHANCE INFORMATION SYSTEMS

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INSTITUTE OF MEDICINE NATIONAL ROUNDTABLE ON
HEALTH CARE QUALITY(1998)

• CONSENSUS STATEMENT
• QUALITY OF CARE CAN BE PRECISELY DEFINED AND
  MEASURED WITH A DEGREE OF SCIENTIFIC ACCURACY
• SERIOUS AND WIDESPREAD QUALITY PROBLEMS EXIST
• UNDERUSE, OVERUSE, MISUSE
• EQUAL FREQUENCY IN MANAGED CARE AND FEE FOR
  SERVICE
• LARGE NUMBER OF AMERICANS ARE HARMED
• QUALITY OF CARE IS THE PROBLEM NOT MANAGED CARE
• CURRENT EFFORTS TO IMPROVE WILL NOT SUCCEED UNLES
  WE UNDERTAKE A MAJOR, SYSTEMATIC EFFORT TO
  OVERHALL HOW WE DELIVER HEALTH CARE SERVICES,
  EDUCATE AND TRAIN CLINICIANS, AND ASSESS AND
  IMPROVE QUALITY.

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INSTITUTE OF MEDICINE

• DEFINITION OF QUALITY OF CARE
• Quality is the degree to which health services
  for individuals and populations increases the
  likelihood of desires health outcomes and are
  consistent with professional knowledge.

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INSTITUTE OF MEDICINE

• PRESIDENTS COMMISSION ON THE QUALITY OF HEALTH
  CARE (1998)
• QUALITY ISSUES GENERATED BY MANAGED CARE
• INSTITUTE OF MEDICINE STUDY PRODUCED REPORT IN
  1999
• TO ERR IS HUMAN BUILDING A SAFER HEALTH SYSTEM

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TO ERR IS HUMANKEY FINDINGS

• MEDICAL ERRORS ACCOUNT FOR 44,00-98,000 DEATHS
  EACH YEAR
• MEDICAL ERRORS ACCOUNT FOR MORE DEATHS THAN MOTOR
  VEHICLE ACCIDENTS, BREAST CANCER OR AIDS
• ANNUAL COST 17-29 BILLION
• MEDICAL ERRORS ACCOUNT FOR 7,000 DEATHS ANNUALLY

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TO ERR IS HUMAN BUILDING A SAFER HEALTH SYSTEM

• ERROR
• FAILURE OF A PLANNED ACTION TO BE COMPLETED AS
  INTENDED
• ERROR OF EXECUTION
• ERROR OF PLANNING
• ADVERSE EVENT
• INJURY CAUSED BY MEDICAL MANAGEMENT RATHER THAN
  THE UNDERLYING CONDITION OF THE PATIENT
• PREVENTABLE ADVERSE EVENT
• ADVERSE EVENT ATTRIBUTABLE TO AN ERROR
• NEGLIGENT ADVERSE EVENT
• ADVERSE EVENT ATTRIBUTABLE TO NEGLIGENCE (LEGAL
  DEFINITION)

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ADVERSE EVENTS

• MEDICATION ERRORS/ COMPLICATIONS
• WOUND INFECTIONS
• DEATH
• IATROGENIC RELATED
• ANESTHESIA
• WRONG SITE SURGERY
• WRONG SURGERY
• WRONG PATIENT
• TRANSFUSION ERRORS
• PREVENTABLE SUICIDES
• RESTRAINTS
• PRESSURE ULCERS

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COMMON TYPES OF MEDICAL ERRORS(LUCIAN LEAPE, et
al.)

• DIAGNOSTIC
• ERROR OR DELAY IN DIAGNOSIS
• FAILURE TO EMPLOY INDICATED TESTS
• USE OF OUTMODED TEST/THERAPY
• FAILURE TO ACT ON TEST RESULTS
• TREATMENT
• ERROR IN PERFORMANCE OF AN OPERATION, PROCEDURE
  OR TEST
• ERROR IN ADINISTERING THE TREATMENT
• ERROR IN DOSE OR METHOD OF USING A DRUG
• AVOIDABLE DELAY IN TREATMENT OR RESPONDIG TO AN
  ABNORMAL TEST
• PREVENTIVE
• FAILURE TO PROVIDE PROPHYLACTIC TREATMENT
• INADEQUATE MONITORING OR FOLLOW-UP OF TREATMENT
• OTHER
• FAILURE TO COMMUNICATE
• EQUIPMENT FAILURE
• OTHER SYSTEM FAILURE

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COMMON MEDICATION ERRORS(DEBORAH NADZAM)

• PRESCRIBING
• ASSESSING THE NEED FOR AND SELECTING THE CORRECT
  DRUG
• INDIVIDUALIZING THE THERAPEUTIC REGIMEN
• DESIGNATING THE DESIRED THERAPEUTIC RESPONSE
• DISPENSING
• REVIEWING THE ORDER
• PROCESSING THE ORDER
• COMPOUNDING AND PREPARING THE DRUG
• DISPENSING THE DRUG IN A TIMELY MANNER
• ADMINISTERING
• RIGHT MEDICATION TO RIGHT PATIENT
• ADMINISTERING WHEN INDICATED
• INFORMING PATIENT ABOUT MEDICATION
• INCLUDING PATIENT IN ADMINISTRATION
• MONITORING
• MONITORING AND DOCUMENTING PATIENT RESPONSE
• IDENTIFYING AND REPORTING ADVERSE DRUG EVENTS
• REEVALUATING DRUG SELECTION, REGIMEN, FREQUENCY
  AND DURATION
• SYSTEMS AND MANAGEMENT CONTROL

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TO ERR IS HUMAN

• CAUSES OF ERRORS
• COMPLEXITY OF SYSTEMS
• SYSTEM FAILURE DUE TO MULTIPLE FAULTS THAT OCCUR
  TOGETHER
• HUMAN ERROR
• LATENT ERRORS BUILT INTO A SYSTEM AND PRESENT
  LONG BEFORE AN ACTIVE ERROR

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RECOMMENDATIONS OF TO ERR IS HUMAN

• ESTABLISH A NATIONAL FOCUS TO CREATE LEADERSHIP,
  RESEARCH, TOOLS AND PROTOCOLS TO ENHANCE THE
  KNOWLEDGE BASE ABOUT SAFETY
• IDENTIFYING AND LEARNING FROM ERRORS THROUGH
  IMMEDIATE AND STRONG MANDATORY REPORTING EFFORTS,
  AS WELL AS THE ENCOURAGEMENT OF VOLUNTARY
  EFFORTS
• RAISING STANDARDS AND EXPECTATIONS FOR
  IMPROVEMENTS IN SAFETY THROUGH THE ACTIONS OF
  OVERSIGHT ORGANIZATIONS, GROUP PURCHASERS, AND
  PROFESSIONAL GROUPS
• CREATE SAFETY SYSTEMS INSIDE HEALTH CARE
  ORGANIZATIONS

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OTHER RECOMMENDATIONTO ERR IS HUMAN

• CREATE A CENTER FOR PATIENT SAFETY
• NATIONWIDE MANDATORY REPORTING SYSTEM
• ENCOURAGE VOLUNTARY REPORTING
• PEER REVIEW PROTECTIONS TO SAFETY DATA
• REGULATORS/ACCREDIATION SHOULD REQUIRE SAFETY
  PROGRAMS
• HEALTH PROFESSIONAL STANDARDS SHOULD INCLUDE
  PATIENT SAFETY
• FDA SHOULD REVIEW SAFE USE OF DRUGS PRE AND POST
  MARKETING
• HCOs SHOULD CONTINUALLY IMPROVE PATIENT SAFETY
• HCOs SHOULD IMPROVE MEDICATION SAFETY

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CROSSING THE QUALITY CHASM (2001)

• WE HAVE A QUALITY GAP BETWEEN THE CURRENT
  SYSTEM AND THE DESIRED SYSTEM
• FOUR REASONS FOR THE GAP
• 1. INCREASED COMPLEXITY OF SCIENCE AND TECHNOLOGY
• 2. INCREASE IN CHRONIC CONDITIONS
• 3. A POORLY ORGANIZED DELIVERY SYSTEM
• 4. CONSTRAINTS ON EXPLOITING THE REVOLUTION IN
  INFORMATION TECHNOLOGY

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CROSSING THE QUALITY CHASM(2001)

• SIX AIMS OF NEW HEALTH SYSTEM FOR
• THE 21ST CENTURY
• 1. SAFE
• AVOIDING INJURIES TO PATIENTS FROM THE CARE
  INTENDED TO HELP THEM
• 2. EFFECTIVE
• PROVIDING SERVICES BASED ON SCIENTIFIC KNOWLEDGE
  TO ALL WHO COULD BENEFIT AND REFRAINING FROM
  PROVIDING SERVICES TO THOSE NOT LIKELY TO BENEFIT
  (AVOID UNDERUSE AND OVERUSE)

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CROSSING THE QUALITY CHASM(2001)

• 3. PATIENT-CENTERED CARE
• PROVIDING CARE THAT IS RESPECTFUL OF AND
  RESPONSIVE TO INDIVIDUAL PATIENT PREFERENCES,
  NEEDS, AND VALUES AND ENSURING THAT PATIENT
  VALUES GUIDE ALL CLINICAL DECISIONS

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CROSSING THE QUALITY CHASM(2001)

• 4. TIMELY
• REDUCING WAITS AND SOMETIMES HARMFUL DELAYS FOR
  BOTH THOSE WHO RECEIVE AND THOSE WHO GIVE CARE
• 5. EFFICIENT
• AVOIDING WASTE, INCLUDING WASTE OF EQUIPMENT,
  SUPPLIES, IDEAS, AND ENERGY

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CROSSING THE QUALITY CHASM(2001)

• 6. EQUITABLE
• PROVIDING CARE THAT DOES NOT VARY IN QUALITY
  BECAUSE OF PERSONAL CHARACTERISTICS SUCH AS
  GENDER, ETHNICITY, GEOGRAPHIC LOCATION, AND SOCIO
  ECONOMIC STATUS

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CROSSING THE QUALITY CHASM(2001)10 NEW RULES
FOR 21ST CENTURY HEALTH SYSTEM

• CURRENT SYSTEM
• CARE IS BASED PRIMARILY ON VISITS
• NEW SYSTEM
• CARE IS BASED ON CONTINUOUS
• HEALING RELATIONSHIPS

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CROSSING THE QUALITY CHASM(2001)10 NEW RULES
FOR 21ST CENTURY HEALTH SYSTEM

• CURRENT SYSTEM
• PROFESSIONAL AUTONOMY DRIVES
• VARIABILITY
• NEW SYSTEM
• CARE IS CUSTOMIZED ACCORDING TO
• PATIENT NEEDS AND VALUES

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CROSSING THE QUALITY CHASM(2001)10 NEW RULES
FOR 21ST CENTURY HEALTH SYSTEM

• CURRENT SYSTEM
• PROFESSIONALS CONTROL CARE
• NEW SYSTEM
• THE PATIENT IS THE SOURCE OF
• CONTROL

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CROSSING THE QUALITY CHASM(2001)10 NEW RULES
FOR 21ST CENTURY HEALTH SYSTEM

• CURRENT SYSTEM
• INFORMATION IS A RECORD
• NEW SYSTEM
• KNOWLEDGE IS SHARED AND
• INFORMATION FLOWS FREELY

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CROSSING THE QUALITY CHASM(2001)10 NEW RULES
FOR 21ST CENTURY HEALTH SYSTEM

• CURRENT SYSTEM
• DECISION MAKING IS BASED ON
• TRAINING AND EXPERIENCE
• NEW SYSTEM
• DECISION MAKING IS EVIDENCE
• BASED

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CROSSING THE QUALITY CHASM(2001)10 NEW RULES
FOR 21ST CENTURY HEALTH SYSTEM

• CURRENT SYSTEM
• DO NO HARM IS AN INDIVIDUAL
• RESPONSIBILITY
• NEW SYSTEM
• SAFETY IS A SYSTEM PROPERTY

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CROSSING THE QUALITY CHASM(2001)10 NEW RULES
FOR 21ST CENTURY HEALTH SYSTEM

• CURRENT SYSTEM
• SECRECY IS NECESSARY
• NEW SYSTEM
• TRANSPARENCY IS NECESSARY

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CROSSING THE QUALITY CHASM(2001)10 NEW RULES
FOR 21ST CENTURY HEALTH SYSTEM

• CURRENT SYSTEM
• THE SYSTEM REACTS TO NEEDS
• NEW SYSTEM
• NEEDS ARE ANTICIPATED

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CROSSING THE QUALITY CHASM(2001)10 NEW RULES
FOR 21ST CENTURY HEALTH SYSTEM

• CURRENT SYSTEM
• COST REDUCTION IS SOUGHT
• NEW SYSTEM
• WASTE IS CONTINUOUSLY
• DECREASED

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CROSSING THE QUALITY CHASM(2001)10 NEW RULES
FOR 21ST CENTURY HEALTH SYSTEM

• CURRENT SYSTEM
• PREFERENCE IS GIVEN TO
• PROFESSIONAL ROLES OVER THE
• SYSTEM
• NEW SYSTEM
• COOPERATION AMONG CLINICIANS
• IS A PRIORITY

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GENERAL RECOMMENDATION CATEGORIESCROSSING THE
QUALITY CHASM

• APPLY CURRENT EVIDENCE TO HEALTH CARE DELIVERY
• USE INFORMATION TECHNOLOGY
• ALIGN PAYMENT POLICIES WITH QUALITY IMPROVEMENT
• EDUCATE WORKFORCE

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PRIORITY AREAS FOR NATIONAL ACTION TRANSFORMING
HEALTH CARE QUALITYIOM (2003)

• DEFINED 20 PRIORITY AREAS
• 1. CARE COORDINATION ( CROSS CUTTING)
• 2. SELF MANAGEMENT/HEALTH LITERACY (CC)
• 3. ASTHMA
• 4. EVIDENCE BASED CANCER SCREENING-COLORECTAL/CERV
  ICAL
• 5. CHILDREN WITH SPECIAL HEALTH NEEDS
• 6. DIABETES
• 7. END OF LIFE WITH ADVANCED ORGAN FAILURE
  CHF/COPD

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PRIORITY AREAS(CONTINUED)

• 8. FRAILITY WITH OLD AGE
• 9. HYPERTENSION
• 10. IMMUNIZATION
• 11. ISCHEMIC HEART DISEASE
• 12. MAJOR DEPRESSION
• 13. MEDICATION MANAGEMENT
• 14. NOSOCOMIAL INFECTIONS
• 15. PAIN CONTROL - CANCER
• 16. PREGNANCY AND CHILDBIRTH
• 17. SEVERE PERSISTENT MENTAL ILLNESS
• 18. STROKE
• 19. TOBACCO
• 20. OBESITY

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SUMMARY

• QUALITY OF CARE BECOMES A TOP POLICY ISSUES
  DURING THE LATE 1990S
• SAFE CARE IS THE STARTING POINT
• SIGNIFICANT MODIFICATION IN THE HEALTH CARE
  SYSTEM EMERGES AS THE QUALITY STRATEGY
• SIGNIFICANT FEDERAL, FOUNDATION AND PRIVATE FUNDS
  ARE DEVOTED TO IMPROVEMENTS IN QUALITY
• HEALTH CARE ORGANIZATIONS ENHANCE QUALITY EFFORTS