-
This conference was organized by Hacettepe University School of
Health Administration for the 35th anniversary of the establishment
of Hacettepe University Time: May 6, 2003 Place: Hacettepe
niversitesi Kltr Merkezi, Yeil Salon Hour: 10.00 - 12.30
-
Quality of Health Care in the United States: Practice and
PromiseProfessor Joseph D. Restuccia
Boston University School of Management
-
Quality of Health CareDegree to which health services for
individuals and populations increase the likelihood of desired
health outcomes and are consistent with professional knowledge. -
Institute of Medicine (IOM)
-
Strengths of the United States Health Care SystemModern,
well-equipped hospitals and ambulatory facilitiesHighly trained
physicians, nurses and other medical personnelAvailability of high
technology diagnostic and therapeutic procedures
-
Weaknesses of the United States Health Care SystemOveruse and
inappropriate careUnderuse of effective careMisuse and error in
medical care Inefficiency and waste
-
Assessment of US Health Care System to Achieve 6 Aims In its
current form, habits, and environment, American health care system
is incapable of providing the public with the quality of health
care it expects and deserves.- IOM Committee on Health Care in
America
-
Every Defect is a TreasureJapanese saying: every defect is a
treasure because identifying a defect enables us to find the root
cause and to eliminate it and, thus, to make improvements in the
futureIf defects are jewels, recent investigations to identify and
quantify defects in US health care have discovered a treasure chest
(or Pandoras box)
-
Weaknesses of the United States Health Care SystemOveruse and
inappropriate careUnderuse of effective careMisuse and error in
medical care Inefficiency and waste
-
Overuse(Rate of Inappropriate Use)
Advanced Antibiotics for Otitis Media 30%Antibiotics Used for
the Common Cold 60%Heart Revascularization 10-20%Hysterectomies
16-80%Hospital Admissions: 5-15%Hospital Days of Care: 10-30%
-
Overuse(Rate of Inappropriate Use)Other procedures commonly
overused:Bed Rest for Low Back PainProstate Specific Antigen
TestingUltrasound in Uncomplicated PregnancySedation of elderly
patients
-
Weaknesses of the United States Health Care SystemOveruse and
inappropriate careUnderuse of effective careMisuse and error in
medical care Inefficiency and waste
-
Underuse (Financial Access)Over 40 million people are uninsured
at any point in timeOver 75 million are uninsured as some time
during the yearAbout an equal number are severely underinsuredThe
majority of the uninsured and underinsured are the working poor and
their dependents
-
Underuse(Rate of Use of Effective Care)Beta-blockers in Elderly
Heart Attack Victims 21% Pneumococcal Vaccine in Elderly:
28%Appropriate Dx and Tx of Hypertension: 30%Physician Advice to
Quit Smoking: 37%Eye Examination in Diabetics: 46%Pharmacotherapy
of Depression: 45%
-
Weaknesses of the United States Health Care SystemOveruse and
inappropriate careUnderuse of effective careMisuse and error in
medical care Inefficiency and waste
-
MisuseAdverse drug events (ADEs) caused by medication errors
occur in 1.8/100 hospital admissionsADEs add $4,700 per
admission20% of ADEs are life threateningThere are an estimated
500,000 preventable medication errors per year causing 7,000
deaths
-
MisuseAn estimated 2.9% 3.7% of hospital admissions have an
adverse event (from all causes)Over 1 million adverse events per
yearEstimated national cost of adverse events is $38-50 billion per
year almost half preventable (2-4% of total health costs)
-
MisuseAn estimated 180,000 deaths per year due to adverse events
(= 3 jumbo jet crashes every two days)Between 44,000 - 98,000 due
to preventable adverse eventsMore deaths than due to motor vehicle
accidents (43,438), breast cancer (43,297) or AIDS (16,516)
-
Weaknesses of the United States Health Care SystemOveruse and
inappropriate careUnderuse of effective careMisuse and error in
medical care Inefficiency and waste
-
Inefficiency and WasteWaits and DelaysOperating Room
ThroughputEmergency Department DiversionsTime to Treatment of
Coronary ConditionsMedical Records AvailabilityMismatch Between
Capacity and Demand
-
Assessment of US Health Care System to Achieve 6 Aims In its
current form, habits, and environment, American health car is
incapable of providing the public with the quality of health care
it expects and deserves. - IOM Committee on Health Care in
America
-
IOMs Six Aims for
ImprovementSafetyEffectivenessPatient-centerednessTimelinessEfficiencyEquity
-
Safe CareA patient receiving medical care should be as safe as
he is in his own homeExample: Computerized physician order entry
system to prevent medication errorsExample: Surgeons sign your site
of the body part that will be operated upon
-
Effective CareAvoid overuse and underuse of servicesExample:
Redesign processes based on best practices such as ensuring that
patients at risk for heart disease take appropriate medications
Example: Implement utilization management to reduce inappropriate
hospital use
-
Patient Centered CareRespect patient needs, preferences, and
cultureExample: Give patient access to his own medical
recordExample: Give patients information on alternative treatments
and decision-making in treatment choice
-
Timely CareReduce waits for those who receive and who give
careExample: Availability of appointments after work hours and on
weekendsExample: Email and telephone access to physicians and nurse
practitionersExample: Open access to physicians and nurse
practitioners
-
Efficient CareReduce waste of facilities, equipment, supplies,
and peopleExample: implement inventory management systems to reduce
amount of drugs and other suppliesExample: Use flexible staffing
systems based on patient numbers and needs to adjust number of
nurses per patient care unit
-
Equitable CareReduce racial, ethnic, geographic and
socio-economic differencesExample: Provide interpreters for
non-English speaking patientsExample: Train more physicians from
minority racial and ethnic groupsExample: Establish universal
health insurance coverage
-
Purpose of Health Care System To reduce continually the burden
of illness, injury, and disability, and to improve the health
status and function of the people of the United States - Presidents
Advisory Commission on Consumer Protection and Quality
-
Focus of QualityQuality must be defined in terms of experience
and outcomes of the patient and the population that generates
patients
-
Levels of Needed Health Care System ChangeOrganization
(hospitals, medical groups) Patient
Microsystem (patient units, physician offices)Environment
(insurers, purchasers, government)
-
Levels of Needed ChangeThe patients experienceThe functioning of
small units (microsystems) that provide patient careThe functioning
of organizations that contain microsystemsThe environment of
policy, payment, accreditation and regulation
-
Levels of Needed Health Care System ChangeAll levels of the
system must work together to meet the patients needsThe patient
must be at center, the first priority of the health care systemThe
major question to ask in changing the system or in treating the
patient must be, Is this the best thing we can do for the
patient?
-
Examples of Efforts by Provider Organizations to Achieve the
IOMs Six Aims
-
Cincinnati Children Hospital Medical CenterIncludes families of
hospitalized children in morning physician roundsPermits adolescent
patients with chronic diseases (e.g., juvenile diabetes) to set
their own schedule of treatments and activities and to make entries
into their medical recordsPays physicians for involvement in major
quality management activities
-
Cambridge Health AllianceDeveloped registries for chronic
patients to identify needed diagnostic and therapeutic
interventions, help teach patient self-management, and track
patient outcomesProvides translators for over 30 languagesWorks
with governmental agencies to establish coverage programs for the
uninsured
-
Tallahassee Medical CenterConducts surveys of satisfaction on
every inpatient and outpatient and shares results
broadlyImplemented palliative care project to ensure that terminal
patient receive comfort care instead of intensive carePut
communication devices in ambulances, moved EKG lab, and changed
cardiologist schedule to enable PTCA within 90 minutes
-
Hackensack Medical CenterHired physician intensivists to care of
hospitalized medical patientsDeveloped nursing career ladder to
help hire, retain and further train nursing staffImplemented
advanced practice nurses to work with physicians and patients to
coordinate careImplemented daily multidisciplinary patient rounds
(physician, nurses, ancillary therapists, etc.) to improve
communication and teamwork
-
Brigham and Womens HospitalDeveloped computerized physician
order entry system (CPOE)Physician orders entered via terminalsTest
results and treatment summaries transmitted to electronic patient
recordOrders screened against knowledge base of rules to detect
medication errors Reduced serious medication errors over 80%
-
CareGroupDeveloped internet-based electronic medical record
Allows physicians password protected internet access to patient
recordsAllows patients password protected internet access to their
own recordsAllows patients to write in their own record and to
request appointments with physicians
-
Rosemont Medical CenterDeveloped open access program for patient
appointmentsProduced same day access for most patient visitsReduced
average wait time for routine visits from over 2 months to 1
day
-
Massachusetts General HospitalImplemented utilization management
to reduce inappropriate hospital daysCase managers apply MCAP
(derivative of the AEP) to facilitate day to day decision making
and data collection to change systemOver 10 years, inappropriate
days have been reduced by more than 50%
-
SSM Health CareContinuous Quality Improvement (CQI) - 13 year
sustained effortAlignment of goals and measures of performance
throughout the organizationUse team work to solve problems and
motivate employeesHuman resources are part of strategic planOnly
health care organization to win Malcolm Baldridge National Quality
Award
-
Continuous Quality ImprovementTop Management CommitmentWorker
EmpowermentTeam WorkCustomer focusApplication of Scientific Method
(Measurement and Reporting)Recognition of success
-
1. AIM: What are we trying to accomplish?2. MEASURES: How will
we know that a change is an improvement?3. CHANGES: What changes
can we make that we predict will lead to an improvement?AIM/PDSA
Model for Internal Quality Improvement
-
Examples of Efforts by Government Agencies to Achieve the IOMs
Six Aims
-
Department of Veterans Affairs Health SystemSystem of 171
hospital medical centers, 350 outpatient centersImplemented
electronic patient record & CPOEImplemented open access
(reducing wait time by 90% in Region 1)Implemented Quality
Enhancement Research Initiative (QUERI) to give providers
evidence-based care on 8 priority conditionsRecognized by IOM for
these efforts
-
Agency for Health Care Research and Quality (AHRQ)Supports
research on patient outcomesPrevention, diagnosis and
treatmentQuality measurement and improvementMedical errors and
public safetyExamplesDiagnosis of heart attackScreening for
pregnant womenConsumer Assessment of Health Plans Survey
(CAHPS)
-
Agency for Health Care Quality and Research (AHRQ)National
Guidelines Clearinghouse of evidence-based clinical practice
guidelinesNational Quality Measures ClearinghouseCAHPS
surveyCONQUEST quality measuresHealth Care Cost and Utilization
Project (HCUP) Quality Indicators
-
AHRQ HCUP Quality IndicatorsPrevention - ambulatory sensitive
conditionsBacterial pneumoniaDehydrationInpatient CareAcute
myocardial infarction mortality rateCABG volumePatient SafetyBirth
TraumaComplications of anesthesia
-
Center for Medicare and Medicaid Studies (CMS)Quality
Improvement Organizations monitor Medicare qualityNursing Home
Public Reporting Quality InitiativeHome Health Public Reporting
Quality InitiativeHospital Quality Information Initiative
-
CMS Hospital Quality InitiativeIn collaboration with JCAHO, NQF,
AHA and other national hospital associationsVoluntary reporting of
quality measuresExamplesAMI: aspirin and beta blocker at hospital
arrival and dischargePneumonia: initial antibiotic timing,
vaccination, oxygenation assessment Considering paying providers on
the basis of quality instead of just fee for service
-
CMS/AHRQ CAHPS SurveysNational survey of Medicare
beneficiariesAlso used for Medicaid and commercial beneficiary
surveysAdministered by CMS for MedicareComparative Medicare Medical
Care Plan Reports are publicly available on internetComparative
Hospital Reports Scheduled for internet availability in
2003-2004
-
HCAHPS - Example QuestionsHow often did nurses/doctors listen to
you carefully?How often did nurses/doctors spend enough time with
you?How often was your pain well controlled?Before you left the
hospital, did you get information in writing about activities you
could and could not do?Would you recommend this hospital to your
friends and family?
-
Examples of Efforts by Private Organizations to Achieve the IOMs
Six Aims
-
Joint Commission on Accreditation of Healthcare Organizations
(JCAHO)Develops standards for optimal healthcareApplies
accreditation process to 17,000 healthcare organizationsProvides
information to health care organizations, professionals, and the
public on strategies to improve safetyPlans to make public
comparative performance reports on provider organizations (in
2004)
-
Examples of JCAHO InitiativesQuality Performance MeasurementCore
(required) measuresProvider selected measuresPain Management
StandardsStaffing Effectiveness StandardsPatient Safety
StandardsSentinel Event Policy and Alert
-
Foundation for Accountability (FACCT) Advocates an accountable
and accessible health care system responsive to consumersMembers:
consumer organizations and purchasersCollaborates with government
and private health care organizationsReports on federal and state
health policyProvides consumers with information to help assess
quality of care and select providers and tools to help manage their
own health, e.g. CompareYourCare)
-
National Committee for Quality Assurance (NCQA)Accreditation and
certification of health plans and utilization review
organizationsAdministers Health Plan Employer Data and Information
Set (HEDIS)HEDIS is used to compare health plans and choose quality
- results released to public as Quality Compass
-
HEDIS 3.0 Reporting Set MeasuresEffectiveness of CareChildhood
Immunization Status Low Birth Weight Babies Adolescent Immunization
Status Check-ups After DeliveryAdvising Smokers to Quit Treating
Child Ear InfectionsFlu Shots for Older Adults Beta Blockers after
MIEye Exams for Diabetics Breast Cancer Screening1st Trimester
Prenatal Care Cervical Cancer Screening Follow-up after
Hospitalization Medicare Health Outcome Survey for Mental
Illness
-
Leapfrog GroupGroup of very large US companiesMission is to
stimulate improvement in quality, customer service and
affordabilityRecognizes and rewards health care organizations that
implement evidence-based patient safety measuresEncourages members
to buy health care from these organizations
-
Leapfrog Group Patient Safety MeasuresReferral of specific
complex procedures to hospitals with high volume (estimated to
reduce deaths > 30%)Intensive care unit staffing with physicians
certified to practice critical care medicine (estimated to reduce
ICU deaths > 10%)Computer physician order entry (estimated to
prevent > 500,000 fewer serious medication errors per year)
-
Institute for Healthcare Improvement (IHI)Mission: is driving
the improvement in health by advancing the quality and value of
health careConferencesCollaborationsCoursesTraining Material
-
Institute for Healthcare Improvement (IHI)National Director of
Robert Wood Johnson Foundation Pursuing Perfection ProgramPublishes
QualityHealthcare.org (with British Medical Journal)Website:
www.ihi.com
-
Institute for Healthcare Improvement (IHI)Examples of Topics for
Collaboratives:Achieving Workforce ExcellenceAdult Intensive
CareAdverse Drug EventsCare for Chronic ConditionsDelays and
Waiting TimesEnd of Life CarePatient FlowPatient Safety
-
Major Quality Improvement Will Require Fundamental
ChangesEvidence-based medicineEvidence-based management
(CQI)Electronic patient record with CPOERecognition of system
interdependence between microsystem, organization, environment
Alignment of incentives and strategy at all levelsPayment based on
quality, not just servicesPublic reporting of comparative provider
qualityUniversal health coverage
********