Medical Quality: a Brief Primer and History Keith Marton, MD Chief Medical Quality Officer Providence Health & Services.

Medical Quality: a Brief Medical Quality: a Brief Primer and History Primer and History Keith Marton, MD Chief Medical Quality Officer Providence Health & Services

Today’s Goals Today’s Goals To retrace the history of quality

efforts in the USTo describe the present day

status of healthcare quality work in the US

Who said this? ◦ “ So I am called eccentric for saying in

public: that hospitals, if they wish to be sure of improvement, (1) must find out what their results are, (2) must analyze their results, to find out their strong and weak points; (3) must compare their results with those of other hopsitals…and (8) must welcome publicity not only for their successes but for their errors”

◦ Ernest A Codman, MD 1916

The real Beginning The real Beginning Florence Nightingale

◦Statistical analysis of surgical outcomes in the 1850’s

The Flexner report on Medical Education-1909

Other noteworthy Events Other noteworthy Events 1952—Joint Commission on

Accreditation of Hospitals—JCAH---is created (1987—JCAHO, 2009—JC)

1961—Kerr White, MD publishes seminal articles on health services research◦“the objective of medical care research

is reduction of the time lag between advances in the laboratory and measurable improvement in the health of society’s members”

1980’s: things pick up1980’s: things pick upEdward Deming—the father of

modern manufacturing ◦1982: “Out of the Crisis”◦Focus on the Toyota method

(“Lean”) Avedis Donabedian

◦1982: “Quality, cost and health: an integrative Model “

◦Focus on structure, process, outcome

1990’s: we rock and roll 1990’s: we rock and roll 1990: National Clinical Quality

Association (NCQA)1991: Institute for Healthcare

Improvement (IHI)1999: National Quality Forum

(NQF)2000: the Leapfrog Group 2000: Institute of medicine (IOM)

—To err is human

2121stst Century—it starts to Century—it starts to come together come together The advent of quality strategic

plans Plus, many new tools/incentives:

◦Quality dashboards ◦Public reporting ◦Six sigma/Lean ◦Culture of safety/high reliability

organizations

Some present day Some present day principles principles Reduce variation (six sigma) Reduce waste (Lean) Create cultures that nourish

widespread collaboration, teamwork, accountability (high reliability)

Measure both processes and outcomes and do it in real time.

STEEEPThe Triple Aim

Expert Opinion:Profile of Market Leaders

• Superior safety / quality / operational efficiency as non-negotiable

• Transparency of performance and process• Leadership engagement and accountability• Cultural work - just, fair, flexible• Reliable processes / robust improvement methodologies• Philosophy of learning organization• Measurement and feedback

Leonard, M. Benchmarking Market Leaders in Quality & Safety, Kaiser Permanente, 2008

Five innovations identified to hold great promisePromoting an organizational culture of safety Improving teamwork and communication to

promote patient safetyEnhancing rapid response to prevent heart

attacks and other crises in the hospitalPreventing health care-associated infectionsPreventing adverse drug events throughout the

hospital

Committed to Safety: Ten Case Studies on Reducing Harm to Patients, Douglas McCarthy and David Blumenthal, The Commonwealth Fund, April 2006

Case StudiesCase Studieson Patient Safetyon Patient Safety

Dana-FarberDana-FarberCancer InstituteCancer Institute

Total commitment to a culture of safety

150 patients involved in every committee in the hospital, including peer review

4-fold increase in revenue over the last 10 years

Nursing turnover = 0.4 % ◦ U.S Average is 10-12 % with cost

per RN turnover $86K◦ Estimate 1 million short in 10

years

Leonard, M. Benchmarking Market Leaders in Quality & Safety, Kaiser Permanente, 2008

From Dana-Farber Cancer Institute• Create a learning environment and workplace that supports core

values of impact, excellence, respect, compassion, & discovery in every aspect of work

• Support the efforts of every individual to deliver the best work possible

• Commit to holding individuals accountable for their own performance

• Promote an interdisciplinary discussion of untoward events

• Improve all areas of the workplace by implementing changes based on analysis of problems & potential or actual harm

• Commit to a culture of inclusion & education

• Assess success in promoting a learning environment by evaluating our willingness to communicate openly & by the improvements we achieve

Principles of a Fair & Just Culture

Principles adapted from Allan Frankel, M.D. and the Patient Safety Leaders at Partners Healthcare Systemwww.macoalition.org/Initiatives/docs/Dana-Farber_PrinciplesJustCulture.pdfhttps://www.justculture.org

Effect on Claim Effect on Claim FrequencyFrequency& Loss Cost& Loss Cost

Source: ASHRM Hospital Professional Liability & Physician Liability 2006 Benchmark Analysis

$4,100 $4,200$4,700

$5,100

$5,800

$4,800

$2,609

$2,389

$3,367

$2,073 $1,807 $1,808

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

2001 2002 2003 2004 2005 2006

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Losses Nat'l Losses Frequency

Sentara HealthcareSentara HealthcareSelected Hospital IndicatorsSelected Hospital Indicators

 200

3200

4200

5200

6200

7Improvem

ent

Falls with InjuryPer 1,000 adjusted patient days

0.63 0.48 0.43 0.42 0.37 41.3% ↓

Ventilator Associated pneumonia Per 1,000 ventilator days

4.55 2.23 1.57 0.97 0.42 90.8% ↓

Blood Stream Infections

Per 1000 device days3.46 2.35 1.78 2.23 1.05 69.7% ↓

Surgical Care Infection PreventionOverall Antibiotic Prophylaxis Compliance

90.8 91.0 90.3 93.8 94.8 4.4% ↑

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Sentara HealthcareSentara HealthcareCreating a Safe DayCreating a Safe Day

SSE Free for7 months

Serious SafetyEventRate

SSER

SM

17

PROVIDENCE CORE STRATEGY: One Ministry Committed to Excellence: Inspired by our heritage, we work together to deliver excellent health care in the communities we serve. We realize the value of being a system through our common strategic directions, systems & structures, tools & resources, knowledge transfer and operational execution and results.

QUALITY VISION: We will deliver the best care to every person every time in a safe, timely, efficient, effective, equitable, patient-centered and affordable manner.

VISION MEASURES OF SUCCESS

VISION GOAL• No Preventable Injuries or Deaths • Superior Clinical Practice and Outcomes• Evidence-based Care Delivery• No Preventable Readmissions

MEASURED BY:• O/E Mortality Ratio and Health Care-Associated Infections• Reduction of Variation in Practice and Outcomes • Adoption of Clinical Best Practices• Observed Readmission Rate

Quality Strategies

Advance a culture committed to excellence and safety

Build sustainable systems and structures for reliability and reduction of harm

Reduce unnecessary variation with evidence-based standardization

Optimize outcomes through coordinated and efficient models of care

2010 PH&S Quality Strategic Plan (QSP) Framework

1818

Governance Questions Governance Questions

Wise Strategic Thinking Question 1 – Are we clear

about our quality strategic aims and focused on the most important improvement opportunities to achieve those aims?

Question 2 – Is there a solid strategic rationale for the annual and long term improvement goals that management is recommending?

Focused & Effective Execution

Question 3 – Are we improving fast enough to meet our annual and long term improvement goals?

Question 4 – Do we have any systemic weaknesses that should be addressed to meet our internal improvement aims and/or to respond to external demands for data and accountability?

Question 5 – Are there any individual facilities or programs that have weak improvement capabilities or insufficient capacity to improve?

Question 6 – What are our experiences with improvement telling us about the changes that are necessary in our Quality Strategic Plan? (widespread learning)

Question 7 – Are we sparking innovation, finding and systematically spreading best outcome practices and great ideas?

Other key areas of focus Other key areas of focus Specific disease conditions

◦Sepsis, heart failure, pneumonia, heart attack, Healthcare associated infections, surgical complications

Specific processes◦Medication safety◦Coordination of care ◦Checklists!!

Mortality reduction

Why the emphasis on Why the emphasis on mortality? mortality? It’s the quality equivalent of Net operating

income ◦ A key indicator that is affected by multiple inputs ◦ It’s a “bottom line “ measure (i.e. we all care about

it) Data from several sources tell us that we

should (and can) be doing betterMany systems are aiming for “zero

preventable deaths”

20

O/E Trend ComparisonO/E Trend ComparisonRisk-Adjusted Mortality10 quarters (2006q3 -- 2008q4)

0.65

0.70

0.75

0.80

0.85

0.90

0.95

1.00

1.05

2006q3 2006q4 2007q1 2007q2 2007q3 2007q4 2008q1 2008q2 2008q3 2008q4

O/E

Mo

rtal

ity

Rat

io

Premier (481 hospitals - 13 MM dischg)

CCHC (132 hospitals - 4 MM dischg)

CCHC and other Premier trend together (-17% over 10 quarters)

CHCC about 5% below Premier.

Lives Saved by Qtr by SystemLives Saved by Qtr by System

2007q3 2007q4 2008q1 2008q2 2008q3 2008q4 TOTALASC 1158 504 510 368 616 748 3904Avera -11 -11 -11 -30 7 25 -31Bon Secours 20 109 117 218 250 208 922CHP -60 16 18 1 3 56 34Franciscan Serv -43 -14 -1 0 -29 31 -58PH&S 68 130 30 72 212 168 679Sis of Charity 3 -1 -39 -29 36 19 -11St. Joe - Orange 87 66 2 83 269 179 687TOTAL 1223 800 625 682 1364 1433 6127INCL non-partic 1328 813 617 701 1383 1573 6415NonCCHC Prem 2584 3261 881 2822 4530 5027 19104

LIVES SAVED BY QUARTER SINCE YEAR 1

Lives Saved Comparison

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

2007q3 2007q4 2008q1 2008q2 2008q3 2008q4 TOTAL

Quarter and Total

CCHC TOTAL

INCL non-partic

NonCCHC Prem

Clinical Priority: MortalityClinical Priority: MortalitySevere Sepsis and Septic Shock Mortality(Data includes all PH&S Premier Facilities, and transfers)

20.00%

23.00%

26.00%

29.00%

32.00%

35.00%

Mo

rtal

ity

Rat

e (#

Dea

ths

/ #

Pat

ien

ts w

/ S

epsi

s)Mortality Rate 2007 Annual Rate 2008 Annual Rate2009 YTD Mortality Rate Goal Mortality Rate Trend Line

Sepsis Observed vs. Expected Mortality

28 253 137 163 34 366 127 266 11 95 45 73581 793 2240.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

PH&S AK WA/MT OR CA PH&S AK WA/MT OR CA PH&S AK WA/MT OR CA

2007 2008 2009 YTD

Mortalities Mortality Rate Exp. Mortality Rate

Conclusions Conclusions Our focus on quality has

increased significantly in the last 10 years

Our ability to improve quality and safety has also improved

But, we are actually just beginning the real journey

Questions?