Healthcare Quality Improvement: A Primer Nancy Davis, PhD

Drivers of Healthcare Quality Improvement •

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IOM reports: 98,000 deaths due to medical errors1 Rising healthcare costs: one-third of healthcare dollars spent on waste and annual cost of poor quality per covered employee is $2,0002 Rand report: only 55% of recommended care delivered3

1) IOM 2001. Available at: http://www.iom.edu/. Accessed on September 24, 2008. 2) Midwest Business Group on Health 2001. Available at: http://www.mbgh.org/. Accessed on September 24, 2008. 3) McGlynn EA, Asch SM, Adams J, et al. N Engl J Med. 2003;348:2635-2645.

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IOM “Six Aims for Improvement” in Healthcare •

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Safe: Avoid injuries to patients from the care that is intended to help them Effective: Match care to science; avoid overuse of ineffective care and underuse of effective care Patient-Centered: Honor the individual and respect choice Timely: Reduce waiting for both patients and those who give care Efficient: Reduce waste Equitable: Close racial and ethnic gaps in health status

Crossing the Quality Chasm: A New Health System for the 21st Century

A Definition of Quality •

Quality of care is the degree to which health services for individuals and populations increase the likelihood off desired health outcomes and are consistent with the current professional knowledge…..

Lohr KN. IOM Committee to Design a Strategy for Quality Review and Assurance in Medicare. 1990.

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Healthcare Quality Improvement •

W. Edwards Deming –

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Developed theory for improvement which revolutionized l i i d Japanese J i d industry f ll i WWII following Building on Walter Shewhart’s work to develop ‘Plan, Do, Study, Act’ cycle: for learning and improvement

Deming’s Plan-Do-Study-Act (PDSA)

Plan

Act

PDSA

Do Do

Study

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Systems and Processes •

Baldrige Criteria and Related Systems –

Malcolm Baldrige National Quality Award - 1987

Baldrige Award Criteria Categories 1. Leadership 2. Strategic planning 3. Focus on patients, other customers and markets 4. Measurement, analysis, and knowledge management 5 Staff focus 5. 6. Process management 7. Organizational performance results

Baldrige National Quality Program. NIST. http://www.quality.nist.gov/HealthCare_Criteria.htm. Accessed on September 24, 2008.

Systems and Processes •

IHI Breakthrough Series Model –

Institute for Healthcare Quality Improvement (IHI) model d l •

Collaborative approach – – –

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Short term Team-based Focus area

Guidance of national experts Study test implement Study,

A resource from the institute of Healthcare Improvement. Available at: http://www.ihi.org/IHI/Results/WhitePapers/TheBreakthroughSeriesIHIsCollaborativeModelforAchieving%20B reakthroughImprovement.htm. Accessed on September 24, 2008.

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Systems and Processes •

Lean Thinking –

Toyota Production Systems Identify which features create value Identify the sequence of activities--the value stream Make the activities flow Let the consumer pull the ‘product’ through the process Perfect the process

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Systems and Processes •

Six Sigma – – –

Hewlett Packard, Motorola, GE Key: reduce variation Five step approach: DMAIC • • • • •

Define Measure Analyze Improve p Control

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Quality Measurement •

Measuring overall compliance with a clinical guideline or standard – –

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Adherence to clinical guidelines Process Measures: is the clinician/practice in compliance? Outcomes Measures: are patient outcomes in compliance?

Performance Measures •

Process measures - clinician’s control –

Ordering CD4 cell count test every four months to monitor i HIV HIV-positive i i patients i •

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Assume process will have eventual effect on outcomes

Outcomes measures - actual patient outcomes that depend on action outside the clinician’s control –

Maintaining CD4 cell count in normal limits

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Where do Performance Measures Come From? • • • •

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CMS Specialty societies Health plans AMA Physician Consortium for Performance Improvement NCQA AQA Alliance

National Quality Measures Clearinghouse. Available at: www.qualitymeasures.ahrq.gov. Accessed on September 24, 2008.

Compliance Calculation Performance Calculation % of DM pts >40 y/o Rx ASA

Number of patients meeting measure criteria (number of patients prescribed ASA)

_________________________________ Number of p patients meeting g study y criteria minus number patients with valid exclusions (number of patients > 40 y/o with diabetes minus those who have adverse reactions to ASA)

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Sources of Healthcare Quality Data • • • • • •

Medical Records Review (retrospective—after care) Medical Records Review (prospective—during care) Administrative Databases Patient Surveys Health Plan Databases Patient Registries

Data for Performance Measurement •

Practice profile--Denominator – –

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Process data--Numerator – – –

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Patient Registries Medical Records Administrative data--lab, Rx Health plan data--claims Medical records

Outcomes data--Numerator – –

Medical Records Patient surveys

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Performance Reporting • •

Scorecards Dashboards

From Performance Reporting to Performance Improvement

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Interventions for improvement – – – –

Education Systems-based process improvements Decision Support Disease management

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Practice-Based Quality Improvement

PDSA Cycle

Practice-based Actions

Six Sigma

Plan

Identify area to improve Collect data to assess current state

Define Measure Analyze

Do

Implement improvement interventions

Improve

Study

R Reassess d data t for f change/improvement

Measure M Analyze

Act

Change practice based on improvement

Control

Using the Chronic Care Model

Community Resources and Policies

Health System Health Care Organization g

SelfManagement Support

Informed, Activated Patient

Delivery System Design

Clinical Information Systems Decision Support

Productive Interactions

Prepared, P Proactive ti Practice Team

Improved Outcomes McColl Institute. Available at: http://www.centerforhealthstudies.org/research/maccoll.html. Accessed on September 24, 2008.

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Getting Started •

Assess Current Condition - Based on measures – – –

First-hand data Root cause analysis: five whys Problem • • •

Why? First immediate cause Why? Cause for the first immediate cause Etc.

Getting Started • • •

Decide on interventions for improvement Develop an action plan Determine goals: measures of success

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Getting Started • • •

Re-measure / re-assess Follow up / reflect Spread change

Resources: Performance Measures •

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AMA Physician Consortium for Performance Improvement. Available at: www.amaassn.org/go/quality. Accessed on September 24, 2008. Joint Commission. Available at: www.jointcommission.org. Accessed on September 24, 2008. National Committee for Quality Assurance. Available at: www.ncqa.org. Accessed on September 24 24, 2008 2008. National Quality Forum. Available at: www.qualityforum.org. Accessed on September 24, 2008. AQA (previously Ambulatory Quality Alliance), Available at: www.aqaalliance.org. Accessed on September 24, 2008. HQA—Hospital Quality Alliance. Available at: http://www.cms.hhs.gov/HospitalQualityInits/15_HospitalQualityAlliance.asp. Accessed on September 24, 2008. Center for Medicare and Medicaid Services Quality Improvement Organizations. A il bl at: http://www.cms.hhs.gov/QualityImprovementOrgs/. Available h // hh /Q li I O / Accessed A d on September 24, 2008. Physician Quality Reporting Initiative. Available at: http://www.cms.hhs.gov/pqri/. Accessed on September 24, 2008. Bridges to Excellence. Available at: www.bridgestoexcellence.org. Accessed on September 24, 2008. National Quality Measures Clearinghouse (NQMC). Available at: www.qualitymeasures.ahrq.gov. Accessed on September 24, 2008.

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Resources: Education and Materials •

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Pittsburgh Regional Health Initiative. Available at: http://www.prhi.org/. Accessed on September 24, 2008. Institute for Healthcare Quality Improvement. Available at: www.ihi.org. Accessed on September 24, 2008. Baldrige Healthcare Criteria for Performance Excellence. Available at: http://www quality nist gov/HealthCare Criteria htm http://www.quality.nist.gov/HealthCare_Criteria.htm. Accessed on September 24, 2008. Wagner Chronic Care Model. Available at: http://www.improvingchroniccare.org/. Accessed on September 24, 2008.

Resources: Education and Materials •

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Going Lean in Health Care. IHI Innovation Series white paper. Cambridge, MA: Institute for f Healthcare Improvement; 2005. 200 Available at: www.IHI.org. Accessed on September 24, 2008. Six Sigma for Healthcare. Available at: http://www.asq.org/healthcaresixsigma/. Accessed on September 24 24, 2008 2008.

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