Transcript Practice-Based Learning and Designing a Quality

Practice-Based Learning and
Designing a Quality
Improvement Project
Richard Schifeling, MD
EBM Working Group
November 15, 2007
Quality Improvement (QI)
Experiment
You are the hospital administrator at
your institution in charge of QI
You’ve just learned that CMS will no
longer reimburse hospitals for care
related to preventable cathetherassociated urinary tract infections
What do you do?
Administrator reaction
Join the writers’ strike
Look for a job in ambulatory care
Form a committee to study the impact
on your institution
Check with infection control
Check with nursing education &
providers
Beginning Oct. 2008,
CMS to withhold payments:
Catheter-associated UTI’s
Vascular catheter-associated infections
Mediastinitis post- CABG
Pressure sores
Falls
Objects left in patients’ bodies
Air embolism, incompatible blood tx’s
CMS Methodology
No reimbursement for select conditions:
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High cost or high volume or both
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Would result in higher payment as 2nd Dx
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Reasonably prevent by using evidencebased guidelines
Volume/ Cost of Cath UTI’s
1 million cases per year in US- most
common nosocomial infection
Each infection adds ~ 1 hospital day
Cost is ~ $ 500 million per year
~ 40% Medicare pts have urinary cath
~ 20% pts w/ cath get infection
< 1% develop urosepsis
Prevention of UTI’s
Use catheters only when necessary and
only as long as necessary- not for
convenience of staff
Staff training for aseptic management,
proper irrigation and urine flow
Handwashing
Practice-Based Learning &
Improvement
Residents expected to:
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analyze practice experience & perform
practice-based improvement activities
locate, appraise, use “best practices”
related to their patients’ health problems
appraise clinical studies
use information technology to manage
info, support clinical care, pt education &
own education
Need for quality improvement
Institute of Medicine (www.iom.edu)
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Quality of Health Care in America
“To Err Is Human: Building a Safer
Health Sytem” 1999
“Crossing the Quality Chasm: A New
Health System for the 21st Century”
2000
Need for quality improvement
Quality of healthcare can be measured
Serious, widespread problems in quality
throughout U.S. healthcare
All systems affected: managed care,
fee-for-service, big/ small communities
Must change system of healthcare
delivery to improve quality
Chassin MR,JAMA1998;280:10005.
Need for quality improvement
U.S. healthcare at its best is superb
Often it is not at its best resulting in
population burden measured in:
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lost lives (IOM estimates 98K iatrogenic
deaths each year in US hospitals)
reduced functioning
wasted resources
Chassin MR,JAMA1998;280:10005.
Definition of Quality
Degree to which health services for
individuals and populations:
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increase likelihood of desired outcomes
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are c/w current professional knowledge
Systems of care/ critical factors
Healthcare professionals practice in
groups & systems of care
Systems need to prevent/ minimize
errors and harm
Coordinate care for settings & providers
Relevant/ accurate healthcare info must
be available when needed
Classification of quality of care
issues/ opportunities
Overuse, Underuse, Misuse
Overuse: give service for which
potential risk outweighs benefit
Underuse: fail to give service for which
potential benefit outweighs risk
Misuse: appropriate service given in
manner leading to avoidable risks
Examples
Overuse: Rx of antibiotic for URI,
use urine catheter for convenience
Underuse: lack beta-blocker post-MI,
lack immunization, lack prenatal care,
lack medication reconciliation
Misuse: preventable complications like
wrong-side surgery
The 100,000 Lives
Campaign:
Getting Started
Institute for Healthcare
Improvement
www.ihi.org/IHI/Programs/Campaign/
Six Changes That
Save Lives
Deployment of Rapid Response Teams…at the first sign of
patient decline
Delivery of Reliable, Evidence-Based Care for Acute
Myocardial Infarction…to prevent deaths from heart attack
Prevention of Adverse Drug Events (ADEs)…by
implementing medication reconciliation
Prevention of Central Line Infections…by implementing a
series of interdependent, scientifically grounded steps called the
“Central Line Bundle”
Prevention of Surgical Site Infections…by reliably delivering
the correct perioperative antibiotics at the proper time
Prevention of Ventilator-Associated Pneumonia…by
implementing a series of interdependent, scientifically grounded
steps called the “Ventilator Bundle”
Prevent Adverse Drug Events
by Implementing Medication Reconciliation
Reconciliation: A process of identifying the most
accurate list of all medications a patient is
taking—including name, dosage, frequency, and
route—and using this list to provide correct
medications for patients anywhere within the
health care system
Requires comparing the patient’s list of current
medications against the physician’s admission,
transfer, and/or discharge orders
Medication Reconciliation
IOM estimates 7000 deaths annually
due to medication errors
About 50% these errors occur at
transition points (hosp admit, D/C,
transfer to another unit)
JCAHO makes medication reconciliation
a National Patient Safety Goal
Medication Reconciliation
Requires change in system
Emphasizes teamwork/ efficiency
Improves patient safety
Can improve medication errors at
transition points
? Impact on adverse drug events and
deaths- limited evidence thus far
Institute of Medicine Vision
of Future Quality Healthcare
U.S. healthcare will be:
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Safe (avoiding patient injury)
Effective (EBM & avoid overuse/underuse)
Patient-centered (patient values)
Timely (reducing waits and delays)
Efficient (avoid waste)
Equitable (no practice variability based on
socioeconomics, race, gender, geography)
Crossing the Quality Chasm
2000:5-6
Institute of Medicine Vision
Current care systems can’t do the job
They rely on outmoded systems of work
Need redesigned systems of care for
safer, high-quality care
Need better use of information tech. to
support clinical and administ. processes
Institute of Medicine Vision
Majority of healthcare services address
~ 15 to 25 conditions
Focus attention on chronic care
processes for these common conditions
Evidence-based processes, supported
by automated clinical info & decision
support systems promise best outcomes
QI project using EBM
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Consider common chronic care problem
that needs improvement and has EBM best
practice(s)
Consider changes in system of healthcare
needed to improve quality
Consider how to measure performance
pre-/ post-intervention & complete cycle
QI Project Steps
Choose specific area of care or provider
education to improve
Check project idea meets criteria
Define best practice
Measure current practice
Change system to improve practice
Measure post-intervention practice
•Question(Hypothesis)
*To know where to look, you need a
hypothesis to guide you.
*This is the key to any successful
research(QI project)
•Confronting Quality Problems
*Underuse of Services
*Overuse of Services
*Misuse of Services
*Variation of Services
AHRQ: http://www.ahrq.gov/
IOM: http://www.nap.edu/catalog/10027.html?se_side
• Evidence
- review of the literature
- finding similar questions
and study designs
- shows that EBM is fun
http://hubnet.buffalo.edu/loginiphome.html
Time Allocation
•Decide your direction
•Limit the scope
•Schedule the time
•Dedicate the time
•Delegate the tasks
•Start now!
Attitude
QI requires a positive
attitude and the mindset
to continue to ask
questions.