Transcript Clinician-led quality and safety improvement Converting

Clinician-led quality and safety
improvement
Converting the vision into reality
Ian Scott
Director of Internal Medicine and Clinical Epidemiology
Princess Alexandra Hospital
Associate Professor of Medicine
University of Queensland
Brisbane
Hunter New England Quality Exposition
Tamworth 16/9/10
Quality and safety improvement
• Aims
– To provide safe, effective, efficient, appropriate, responsive, timely,
patient-centred care
– To provide care at the right time to the right person in the right
manner
– To maximise the comfort, dignity and health of a patient’s journey
through the healthcare system
• Which is more successful?
– Clinician-led vs managerially-led Q+S improvement
• 3 elements of Q+S improvement
– Capacity: workforce, infrastructure, skill set
– Processes: models of care
– Outcomes: clinical and non-clinical
• In-hospital care
• Ambulatory care
• Generic principles
In-hospital care
Acute
Initial evaluation
Diagnostic work-up
Clinical stabilisation
Formulation of care
plans
Disposition decisions
Diagnosis and
treatment of acute
problem(s)
In-patient
Execution of care plans
Completion of comprehensive
assessments
Management of background
medical problems
Avoidance of complications
Patient/carer education
Recovery/rehabilitation
Disposition decisions
Optimisation of
function and
physiology
Peri-discharge
Transition to community
care
Preparation for
discharge
Post-discharge
follow-up
Community-based care
services and support
Communication to care
providers
Enabling smooth transition
to community care +
preventing readmission
Proposed service principles
QH Statewide General Medicine Clinical Network 2010
Patient
perspective
Principles
Practices
What is wrong
with me?
Prompt evaluation and
diagnosis
Access to diagnostic investigations
Early senior clinician review
Early risk assessment
Interdisciplinary communication
Who is looking
after me?
Continuity of care
Consistent interdisciplinary team throughout acute
admission
Systems for clinical handover
Can you make me
better?
(Am I in good
hands??)
Effective management
of symptoms, primary
pathology and comorbidities impacting
on health
Early senior clinician review
Care guidelines and pathways
Systems for continuing education
Systems for audit of processes and outcomes
Will it hurt?
Minimising adverse
effects of
hospitalisation
Early risk assessment for common complications
linked to care plan
Regular interdisciplinary communication
Safe medication practices
Systems to reduce functional, nutritional,
cognitive decline
Proposed service principles
QH Statewide General Medicine Clinical Network 2010
Patient
perspective
Principles
Practices
Will I get back
on my feet?
Early functional
rehabilitation
Consistent interdisciplinary team with a team
focus on early mobility and independence
What are my
(our) options?
Involve patients (and
family/carers) in
decision making
Patient-carer counselling and education
When will I be
able to go home?
Define discharge
expectations
Effective discharge planning
What should I do
now? What will I
do if things go
wrong again?
Effective handover
Appropriate follow-up
Patient education and
self-management
Effective transitional care (eg discharge
communication; patient-held information;
medication reconciliation; red flags)
Systems for following up high risk patients
with interventions as required
Acute
In-hospital care
Initial evaluation
Diagnostic work-up
Clinical stabilisation
Formulation of care
plans
Disposition decisions
Diagnosis and
treatment of acute
problem(s)
In-patient
Peri-discharge
Medical assessment and planning units
Transferring patients from ED to more suitable
medical environment, reducing ED overcrowding
Higher level monitoring for more acutely ill patients
Cohorting of acute medical patients after-hours
Early multidisciplinary assessment
Identification and discharge of short-stay patients
Evidence for acute medical units
Peer review literature
No controlled trials
Nine before-after analyses of 7 units in UK and Ireland
• Two studies, one prospective, reported significant reductions in
in-patient mortality of between 0.6 and 5.6 percentage points
• Four studies reported significant reductions in LOS: 1.5 to 2.5 d
• One study reported 30% decrease in waiting times for patient
transfer from ED to medical beds
• Two studies described significant improvements in patient and
staff satisfaction with care
• Three studies saw the proportion of medical patients discharged
directly home from AMU increase by 8 to 25 percentage points
• Three studies noted no increase in 30-day readmission rates
following unit commencement
Grey literature
• Eight non-peer-reviewed reports relating to 48 units confirmed
reductions in length of stay.
Scott, Vaughan, Bell Int J Qual Health Care 2009
Plethora of variants
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Acute medical assessment unit (AMAU)
Medical assessment and planning units (MAPU)
Acute assessment unit (AAU)
Acute medical wards (AMW)
Acute planning units (APU)
Rapid assessment medical units (RAMU)
Rapid assessment and planning units (RAPU)
Early assessment medical units (EMU)
Observation medicine units (OMU)
Short stay medicine units (SSMU)
• Surgical assessment and planning units (SAPU)
Integrated hospital emergency care
•
Reconfiguration of EDs into several different functional areas
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Co-location of medical assessment and planning units (MAPUs) with EDs
•
Admission avoidance and rapid response community teams within EDs
•
Multi-purpose short stay wards adjacent to ED
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Dedicated emergency surgical teams
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Patient pull strategies by receiving units
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Streamlined assessment and admission processes
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Optimal use of transit and discharge lounges
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high acuity/high complexity (or critical care areas)
low acuity/low complexity patients (observation bays)
low to medium acuity/high complexity patients
low to medium acuity/high complexity patients
Aim to discharge or transfer patients with 24 to 48 hours
Daily, consultant-led ward rounds, early multidisciplinary assessment, and prioritised access to ancillary
services
Screen, identify and provide community care for patients who do not need inpatient care
For fully assessed and medically stable patients undergoing treatments or procedures prior to discharge
within 24 hours.
Exclusively on call to assess and organise emergency surgery for ED patients
Integrated hospital emergency care
• Results of redesigned
emergency care
systems:
– 16% decrease in acute
medical admissions
– 4% decrease in acute
surgical admissions1
• Australian experiments
involving 60 acute
hospitals in NSW and
Flinders Medical Centre
in Adelaide: decreases
in ED access block2
1. Boyle et al. Emerg Med J 2008; 25: 78-82.
2. O’Connell et al. Med J Aust 2008; 188 (5 Suppl): S9-S13.
Integrated hospital emergency care
9000 10000
.6
Jul 08
Jul 05
Jan 06
Jan 07 Jul 07
...
8000
7000
6000
4000
Jan 08
Jul 08
3000
.3
8000
6000
5000
.2
.1
7000
ED presentations
Jan 09
7000
1000
.6
.5
Jul 08
.4
Jan 08
8000
Jan 07 Jul 07
...
6000
Jul 06
ED presentations
ED presentations
Jan 06
Jul 06
Jan 07
Jul 07
...
Jan 08
Jul 08
Jan 09
4000
ED presentations
Jul 05
Jan 09
Townsville Hospital
5000
Proportion access block
ED presentations
Jan 06
.2
.3
.4
Jul 05
9000 10000 11000
.2
.1
.6
Royal Brisbane & Women's Hospital
.5
Jul 06
5000
9000
Jan 09
ED presentations
5000
Jan 08
ED presentations
Jan 07 Jul 07
...
.4
Jul 06
.3
Jan 06
.1
3000
.1
Jul 05
7000
.5
.2
.3
4000
ED presentations
.4
5000
Proportion access block
ED presentations
.6
.4
.2
.3
Mater Hospital
ED presentations
.1
Proportion access block
Gold Coast Hospital
.5
.5
.6
6000
Princess Alexandra Hospital
Jul 05
Jan 06
Jul 06
Jan 07
Jul 07
...
Jan 08
Jul 08
Jan 09
Scott IA, Wills R, Watson M, et al Qual Saf Health Care 2010 (under review)
In-hospital care
Acute
In-patient
Peri-discharge
Older patients with complex needs
Optimisation of
function and
physiology
High prevalence of cognitive impairment,
physical dependency, social isolation
At risk for hospital-acquired
complications (delirium, falls,
polypharmacy, immobilisation)
Need for high functioning
multidisciplinary teams
Need for patient/carer/family education
and support
In-hospital quality and safety issues
16 hospitals
Issues raised on reviewing deaths 2002-2007
Behal & Finn Acad Med 2009; 84: 1657-1662
Failure to rescue
•
Strong consistent
correlation between riskadjusted failure to rescue
rates and risk-adjusted inhospital mortality rates
for all 6 conditions
– AMI, CHF, pneumonia,
stroke, GI haemorrhage,
hip fracture
R = 0.20-0.38; p<0.01
•
Hospitals with best failure
to rescue rates had
between 22% and 31%
lower relative mortality
rates across all 6
conditions compared to
hospitals with worse rates
4504 US hospitals 2003 PSI data
Isaac et al JGIM 2008; 23: 1373-8
Clinical care processes
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Track and trigger systems and rescue responses for deteriorating
patients
Hand hygiene/barrier nursing/infection control systems
Clinical handover systems/continuity of care
Interdisciplinary communication and teamwork
Evidence-based process of care packages (‘care bundles’) for
specific diagnoses
– AMI, CHF, COPD, stroke, sepsis
– Hip surgery, PCI, CABG, vascular surgery
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Prophylactic measures
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Medication reconciliation/medication safety practices
WHO surgery checklist
Infection control systems
Palliative care service
Post-operative care
Family/carer communication
Post-death debriefing
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Catheter-associated bacteraemias
Surgical site infections
Ventilator-associated pneumonia
Falls and pressure areas
DVT/PTE
Clinical care processes
• Comprehensive assessment of patient risks and proactive
prophylactic intervention
• High-risk patient care areas
– Patients at high risk of falls, pressure sores, delirium, behavioural
problems
• Regular MDT meetings using patient journey boards
• Daily morning ward rounds by medical teams
• Team-based nursing care at the bedside
• Fast-track access to comprehensive geriatric assessment teams,
ACAT teams, other gate-keepers
• Same day consultant responses for inter-specialty requests for
advice on acute management
Effects of diagnosis-specific care
bundles on HSMR
• Implementation
of eight
diagnosisspecific care
bundles
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Central venous
catheter/line asepsis
Diarrhoea and vomiting
Stroke
Ventilator acquired
pneumonia
MRSA infection
Heart failure
Surgical site infections
COPD
HSMR of 13 diagnoses reflecting care bundles
Effects on mortality
Physician led improvement teams
Early goal-directed treatment of sepsis
Central line and ventilator bundles to prevent infections
Rapid response teams
Standardised care protocols for cardiac surgery, stroke, etc
Patient safety programs including clinical handover
Feedback to transferring hospitals
Improved clinical documentation and coding
Increased resourcing: nurse levels ICU, defibrillators, intensivists
Hospice-in-the-hospital program
Senior managerial work rounds
Behal & Finn Acad Med 2009; 84: 1657-1662
Greater than average decrease
seen for all US hospitals
Observed total mortality dropped as well
as risk-adjusted index
In-hospital general medicine services
Acute
In-patient
Peri-discharge
Transition to community care
Preparation for discharge
Post-discharge follow-up
Community-based care services and support
Communication to care providers
Enabling smooth transition to
community care + preventing
early readmission
Readmissions a common problem
• 3% to 11% all discharges readmitted within 30 days1
– 90% unplanned
– 80% relate to an acute medical complication
– 60% occur in patients >65 years age
• Highest readmission rates in US2
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Heart failure
Pneumonia
PTCA
COPD
Other vascular
CABG
AMI
12.5%
9.5%
10.0%
10.7%
11.7%
13.5%
13.4%
1.Jencks et al N Engl J Med 2009
2. MedPAC, “Report to Congress: Promoting Greater Effi ciency in Medicare,” June 2007; U.S. Department of Health
and Human Services, “Hospital Compare,” available at: http://www.hospitalcompare.hhs.gov, accessed September 5,
2009; MedPAC June 2007; Cardiovascular Roundtable interviews and analysis.
Patient predictors
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Age ≥ 80 yrs
Previous admission <30 dys
≥5 co-morbidities
History of depression
OR
1.8
2.3
2.6
3.2
Marcantonio et al Am J Med 1999
Older patient cohort ≥60 yrs
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Living alone
Cognitive impairment
Functional status
Nutritional status
Disease severity
Longer index LOS
Lack of health insurance
Residential care
Previous readmissions
Non-adherence
Thomas & Holloway Med Care 1991
Sullivan J Am Geriatr Soc 1992
Librero et al J Clin Epidemiol 1999
Fethke et al Med Care 1986
Corrigan & Martin Health Serv Res 1992
Smith et al J Clin Epidemiol 2000
Au et al Ann Acad Med Singapore 2002
Silverstein et al Proc (Bayl Univ Med Cent) 2008
Predicting patients most at risk of
readmission
• Several attempts at risk prediction models in general acute
medical patients
• Most are not very discriminatory
– AUROC 0.61-0.70
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Smith et al J Clin Epidemiol 2000
Billings et al BMJ 2006
Bottle et al J R Soc Med 2006
Howell et al BMC Health Serv Res 2009
Hasan et al JGIM 2009
Novotny et al Nurs Res 2008
• Disease-specific risk prediction models
– Congestive heart failure: AUROC 0.60
– Ross et al Arch Intern Med 2008
• Accurate model (AUROC 0.83)
– requires detailed data on co-morbidities and functional capacity - 20
variables
Coleman et al Health Serv Res 2004
How preventable are readmissions?
• 9% to 48% in 7 studies published to 1998
– Median 16%
» Benbasset et al Arch Intern Med 2000
• 5.5% of 437 readmissions JHH
» Miles, Lowe J Qual Clin Pract 1999
• 19% of 363 to one Spanish hospital
» Jimenez-Puente et al Int J Technol Assess Health Care 2004
• 27% of 390 to 12 US hospitals
» Halforn et al Med Care 2006
• 34% of 204 to PAH
» Scott et al 2001 (unpublished)
• 33% of 271 to Israeli hospital
» Balla et al Medicine 2008
How preventable are readmissions?
• In one study of general medicine patients 33%
readmissions vs 6% controls had quality of care
problems
– Age and sex adjusted only
– Main errors
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incomplete evaluation (33%)
too short hospital stay (31%)
inappropriate medication (44%)
diagnostic error (16%)
– Most preventable readmissions involved CV event or
CHF
– Mean time to readmission: 10 days
– Inpatient mortality 6.7% vs 1.7% among readmissions
with no QOC problems (p=0.05)
Balla et al Medicine 2008; 87: 294-300
How preventable are readmissions?
• Avoidable complications of care
47%
• Drug-related adverse events
13%
• Erroneous diagnosis/inappropriate care
11%
• Premature discharge
20%
• Poor discharge preparation
9%
Halforn et al Med Care 2006
Reducing readmissions
Discharge planning/preparation
• Screening for high-risk patients in need of more post-discharge support
• Multidisciplinary discharge rounds, case conferences
• Discharge planning protocols and checklists
• Discharge care plans
• Patient-carer educational interventions
• Liaison nurses, discharge co-ordinators, case managers
• Pharmacist-facilitated discharge program
• GP input into discharge planning
• Nurse-led intermediate care units
• Patient/carer self-management
• Advanced care plans
Discharge support/aftercare
• Augmented hospital-primary care communication
• Post-discharge home visits
• Post-discharge telephonic contact
• Post-discharge community support
Hospital avoidance programs
• Hospital in the home
• Chronic disease management programs
Scott Aust Health Rev 2010 (in press)
Discharge planning
• Cochrane review updated Jan 2010
• Discharge planning defined as:
– Inpatient assessment and preparation of discharge plan
based on individual needs
• Multidisciplinary assessment involving patient and family
• Communication between relevant professionals within hospital
– Implementation of discharge plan
– Monitoring
• For elderly patients with medical condition
(usually heart failure) readmission rate at 4
weeks reduced by 15%
OR = 0.85 (0.74-0.97)
Shepperd et al 2010
Comprehensive discharge planning
and post-discharge support
• RCT; 363 patients ≥65 years (mean age 75 years)
• Specialist nurse-led assessment, discharge planning,
patient-carer education; written care plans and
medication lists; discharge summaries; co-ordination of
post-discharge services; home visits (24 hrs and 7-10
days), telephonic follow-up
• Results at 6 months:
– Readmissions: 20% vs 37%
p<0.001
– Health costs:
$0.6m vs $1.2m
p<0.001
– No effects on mortality, functional status, patient/carer
satisfaction
Naylor et al JAMA 1999
Comprehensive discharge planning and
post-discharge support
• Meta-analysis of 18 RCT; 3304 patients with CHF; mean age ≥70
yrs
• Intervention components
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Specialist nurse or clinical pharmacist-led review
Patient education and self-management strategies
Discharge planning
Written care plans and medication lists
Home visits, telephonic follow-up, early clinic review
Enhanced communication between providers
• Results at 8 months:
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Readmissions:
All-cause mortality:
% increase QOL score:
Health care costs:
35% vs 43%
14% vs 17%
26% vs 14%
No difference
RR=0.75 (0.64-0.88)
RR=0.87 (0.73-1.03)
p=0.01
Phillips et al JAMA 2004
Comprehensive discharge planning and
post-discharge support
• Transition coaching
• Self-management tuition in medication use,
relapse recognition, personal health record,
timely follow with GPs and specialists
– Lower readmission rates
• at 30 days - 8% vs 12%; p=0.05
• at 90 days - 17% vs 23%, p=0.04
– Coleman et al Arch Intern Med 2006
Comprehensive discharge planning and
post-discharge support
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Comprehensive nursing and physiotherapy assessment
Nurse-led education and self-management strategies
Individualised program of exercise strategies
Written guidelines for post-discharge care
Arrangement of community services and social support
Nurse-conducted home visit and telephone follow-up
commencing in hospital and continuing for 24 weeks after
discharge
• High risk elderly cohort
At 6 months:
– Fewer readmissions - 22% vs 47%; p=0.007
Courtney et al J Am Geriatr Soc 2009; 57: 395-402.
Improving peri-discharge processes
A nurse discharge advocate worked with patients
during their hospital stay to:
• arrange follow-up appointments
• confirm medication reconciliation
• conduct patient education with individualized
instruction booklet that was sent to their primary
care doctor
Clinical pharmacist called patients 2 to 4 days after
discharge to reinforce the discharge plan and review
medications
Jack et al Ann Intern Med 2009; 150: 178-187
Improving peri-discharge processes
Jack et al Ann Intern Med 2009; 150: 178-187
Improved peri-discharge processes
Transition from hospital to home
Ambulatory care
Hospital-based
clinics
Review of recently
discharged patients
Assessment of priority
new patient referrals
Timely access to
specialist review
Chronic disease management
Secondary and tertiary
prevention
Optimisation of disease control,
symptom relief, functional
capacity
Avoidance of hospitalisation
Holistic care for multi-system
disease
Primary/secondary care
collaboration
Optimisation of
function and
physiology
End-of-life care
Palliative care
Advanced care planning
Acute care in RACF
Avoidance of
hospitalisation
Compassionate and
appropriate care at
end of life
Proposed service principles
QH Statewide General Medicine Clinical Network 2010
Patient perspective
Principles
Practices
What do I need to
do to stay well?
How will I know if
my health is
deteriorating?
Selfmanagement
Education in disease patterns and early
warning signs and symptoms of disease
relapse or loss of control
Education in how to self-manage disease
Patient-held diaries, self-management
tools
Who is responsible
for my continuing
care?
Continuity of
care
Consistent team of GP, specialist, and
community multidisciplinary team
Systems for monitoring patient progress;
recall/reminder
Systems for ensuring interdisciplinary
communication
What should I do if
I get worse?
Effective early
intervention for
episodes of
disease relapse
or
decompensation
Timely access to specialist review (rapid
access clinics), intensified multidisciplinary
support, community health services
Systems for auditing processes and
outcomes
Proposed service principles
QH Statewide General Medicine Clinical Network 2010
Patient perspective
Principles
Practices
How much burden,
inconvenience and
potential harm will
the management of
my health problems
impose on me (and
my family)?
Minimising
Itemised care plans and linked services
adverse effects Education in financial and logistical
of chronic care assistance
Safe medication practices
Timely access to crisis and respite
support
What does the
Accurate
future hold for me? prognostication
Risk prediction tools
Patient education and reconciliation of
expectations
How do I best plan
for the future?
Chronic care plans
Advance care planning, advanced care
directives
Care planning
Ambulatory care
Hospital-based
clinics
Chronic disease management
End-of-life care
Improving referrals from GP to specialist
Review of recently
discharged patients
Assessment of priority
new patient referrals
Timely access to
specialist review
Generally effective strategies included
dissemination of guidelines with structured
referral sheets (four out of five studies) and
involvement of consultants in educational activities
(two out of three studies).
The effects of 'in-house' second opinion and
other intermediate primary care based
alternatives to outpatient referral appear
promising.
Akbari et al Cochrane Database Syst Rev 2008
Ambulatory care
Hospital-based
clinics
Chronic disease management
• Intervention designed to
manage or prevent a chronic
condition using a systematic,
evidence-based approach to care
and potentially employing multiple
treatment modalities
Weingarten et al 2002
Optimisation of
function and
physiology
End-of-life care
Chronic disease management
Chronic disease management
Gwadry-Sridhar FH, Archives of
Internal Medicine, 2004, 164:
2315-2320
Gonseth J, et al., European Heart
Journal, 2005, 26(3): 314-315
Holland R, et al., Heart,
2005, 91: 899-906
Roccaforte R, et al., European
Journal of Heart Failure, 2005
7(7): 1133-1144
Taylor SJ, et al., Cochrane
Database of Systematic Reviews,
2005, 2
Clark RA, et al., British Medical
Journal, 2007, 334(7600): 942
Chronic disease management
• Respiratory rehabilitation programs for patients with
recent exacerbations of COPD reduce admission rates
by up to 87%1
• Improve diabetes control; no evidence yet on
complications2
• CDM items and team care arrangements in primary
care have not been as effective as expected3
1. Puhan M, Scharplatz M, Troosters T, et al. Pulmonary rehabilitation following exacerbations of chronic
obstructive pulmonary disease. Cochrane Database Syst Rev 2009 Jan 21; (1): CD005305.
2. Renders CM, Valk GD, Griffin S, Wagner EH, et al. Interventions to improve the management of diabetes
mellitus in primary care, outpatient and community settings. Cochrane Database of Systematic Reviews
2000, Issue 4. Art. No.:CD001481.DOI: 10.1002/14651858.CD001481.
3. Hartigan et al. Do Team Care Arrangements address the real issues in the management of chronic diseases?
Med J Aust 2009; 191: 99-100.
Chronic disease management
Klersy et al. JACC 2009; 54: 1683-1694
•
Chronic disease management
Co-located specialists in primary care
Gruen et al. Cochrane Database Syst Rev 2004
Nine met the inclusion criteria (RCT, controlled B/A trials, ITS).
Most studies came from urban populations in developed countries
Simple 'shifted outpatients' styles of specialist outreach improved
access, but no evidence of impact on health outcomes.
Specialist outreach as part of more complex multifaceted
interventions involving collaboration with primary care,
education or other services associated with improved health
outcomes, more efficient and guideline-consistent care, and
less use of inpatient services.
Up to 30% reduction in future events
requiring hospitalisation
Additional costs of outreach balanced by improved health outcomes
Chronic disease management
• Co-located specialists in primary care
– Jackson C, Russell A, Spurling G, et al WCIM 2010
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Inala CDM Program for patients with complex type 2 diabetes mellitus
Community-based general practice with care delivered by a
multidisciplinary team of allied health professionals and up-skilled
general practitioners who undertook a structured education programme
delivered by an endocrinologist who provided ongoing on-site support
Evidence based protocols were adopted and individualised care plans
were developed for the patients incorporating principles of selfmanagement
Service evaluated and compared with a control group of similar patients
whose care was provided at the tertiary hospital
Significantly greater percentage of patients achieving all 3 targets
– HbA1c ≤7.0%
– BP ≤130/80
– LDL cholesterol ≤2.5 mmol/l
24% vs 10%; p<0.001
•
Sustained funding model needed to maintain new care model
Chronic disease management
• Telehealth
– Access to ‘live’ interactive specialist
consultation
• under-staffed regional and rural centres
• RCFs
– More efficient use of clinics
– Fewer unnecessary referrals for
hospitalisation
– Patient and referrer messaging
Ambulatory care
Hospital-based
clinics
Chronic disease management
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80
70
60
50
40
30
20
10
0
Access to palliative care expertise in
hospital care
Early aged care intervention programs
Need for more advance care planning
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More universal use of advance care
directives and palliative care programs in
RCFs
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Reduce hospitalisation rates by up to 40%
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Shift family/carer expectations towards
more conservative care for patients with
severe dementia
2008
cember
vember
ctober
tember
August
July
June
May
April
March
ebruary
2009
January
End-of-life care
»
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Molloy et al. JAMA 2000
Levy et al. J Palliat Med 2008
Badger et al. Palliat Med 2009
Mitchell et al Engl J Med 2009
Principles of Q+S improvement
At multiple levels
• unit
• department
• hospital
• network
Scott I, Phelps G
Intern Med J
2009; 39: 347-351
What distinguishes successful from
non-successful hospitals?
• Use of data and acceptance of data
• Different departments working together on common agenda
• Good physician-management relations
– Good connect between middle managers and senior executives
– Engagement of clinical departmental heads
• Engaged quality improvement staff (vs ‘learned helplessness’)
• Systematic establishment of infrastructure, processes and
performance review systems for continuous improvement
• Strategic alignment and integration of improvement efforts
with organisational priorities
• Active development of clinical champions, teams and staff
• Absence of an organisational ‘metabolic syndrome’
• Note: none of the interventions directly targeted hospital’s
‘culture’ or ‘leadership’
Behal & Finn Acad Med 2009; 84: 1657-1662
Wang et al Jt Comm J Qual Patient Saf 2006; 32: 599-611
Generic Q+S indicators
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Standardised mortality ratios
LOS – relative stay index
Unplanned readmissions
Complication rates
Critical incidents
Complaints
Unplanned transfers OT/ICU/CCU/HDU
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Pressure areas
DVT/PTE
Falls
Nosocomial infections
Medication errors
– Hospital-wide
– Diagnosis-specific
– Unit-specific
Unit- or condition-specific Q+S
indicators
• AMI
– Process
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•
Reperfusion
PCI
Discharge medications
Cardiac rehabilitation
– Outcome
• In-hospital death
• Readmissions
• 6 or 12-month mortality
• ……… for other high volume, high risk
conditions associated with evidence-based
indicators
Quality and safety scorecard
Dimension
Indicator
Target
Effectiveness/
appropriateness
Clinical audits for top 5 DRG
Screening procedures for risk
conditions
Risk-adjusted mortality (-DNR)
Readmissions
Discharge processes
>80% pts receive optimal care
Capacity
Staffing levels
Agreed benchmarks
Safety
SAC 1 + 2
Medication errors
VTE prophylaxis
Falls
Agreed benchmark
Access
Clinic waiting time new referral
<2 weeks
Efficiency
Median LOS
Agreed benchmark
Pt centredness
Patient satisfaction survey
>80% patients satisfied
>80% at risk patients screened
Agreed benchmark
Agreed benchmark
>80% discharge plans
Is all this data being used in the most
effective way to drive QSI?
• No – why not?
– Front-line clinicians rarely see this data
• If they do they question its validity and usefulness
– Accuracy of the data is questioned
– Insufficient sample size
– Data is not timely or relevant
– Absence of agreed benchmarks
– Not used to direct investment in SQI
•
•
•
•
•
Accreditation
Credentialing
Marketing
Funding applications for more resources
Politics
– No closing of the loop
Clinical Governance Scorecard
Princess Alexandra Hospital, June 2010
KPI
Topic
Target
Score
1
Patient Satisfaction Rate
>95%
97%
2
Complaints resolved within 35 days
>80%
94%
3
Staff Satisfaction (engagement) Rates
>42%
46%
4
Hospital Standardised Mortality Rate
<90%
78%
5
AMI pts discharged with appropriate medications
>80%
95%
6
VLAD timeliness (LL3 reported on time)
100%
100%
7
Deaths reviewed as per PAH process.
100%
100%
8
Rapid Response Team utilisation rates per 1000 admissions
56 - 26
26.8
9
Cardiac Arrests per 1000 admissions
<1.3
2.3
10
Appropriate VTE prophylaxis for at risk patients (medical and
surgical)
>75%
79%
11
Low risk patients receiving inappropriate VTE prophylaxis.
<5%
13%
Note: Due to using existing data collection methods, not all data is from the same time periods. Results
shown is the most recent available for that indicator
Clinical Governance Scorecard
Princess Alexandra Hospital, June 2010
KPI
Topic
Target
Score
12
ACHS Indicators with a statistically significant worse rate than
peer group aggregate rate.
<50%
20%
13
Units fully compliant with the Clinical Governance Clinical
Audit and Review Implementation Standard
>90%
70%
14
Rejected blood tube rate for samples collected by nonphlebotomist.
<0.66
%
1.37%
15
INR >5 with subsequent dose adjustment
>90%
100%
16
Healthcare Associated Staphylococcus Aureus Blood Stream
Infections per 1000 bed days
< 0.18
0.13
17
Surgical Antibiotic Prophylaxis
>90%
86%
18
Med History taken within 24 hrs of admission (weekend &
midweek)
>80%
67%
19
Pressure Ulcer prevalence rate (post admission)
<11%
8%
20
Triage of SAC 1 events in relation to type of review required
>90%
100%
21
Falls resulting in significant harm per 6 months.
<8
10
Clinical Governance Scorecard
Princess Alexandra Hospital, June 2010
KPI
Topic
Target
Score
>80%
100%
22
Full or partial implementation of recommendations from
RCAs in past 12 months
23
Open Disclosure offered in SAC 1 events
-
.
24
Med Safety Self Assessment Score
-
.
25
WHO Surgical Safety Checklist Compliance
-
.
26
Patients admitted via ED within 8 hours (YTD performance)
>64%
57%
27
ED patients seen within triage times (YTD performance)
>64%
56%
28
ED time to AB's in pts with Systemic Inflammatory Response
Syndrome (SIRS)
>80%
66%
29
Psych pts with post discharge 7 day follow up
100%
97%
30
Episodes of seclusion
0
8
31
Medical Credentialing (% Drs Credentialed)
100%
100%
32
Medical Specialists with tri-annual SMPR
>90%
96%
33
Communication training undertaken by clinical staff since
2006 - 2009
>50%
29%
Closing comments
• Professor of Health Architecture Ian Forbes
– Hospitals (and perhaps all health care services)
traditionally have operated rather like a medieval
joust, with various groups standing under their
shields and operating entirely within their own
little worlds
– What we need is a greater focus on
multidisciplinary and multi-team care centred on
patient needs (not those of providers), better
connectivity between hospital and community
teams , and greater use of existing data for
facilitating and evaluating quality of care
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