Transcript Group F Quality - University of Florida

Group F
Quality
Willie Jackson, III
Lisa Kanarek
Jennifer Kim
Vatrice Perrin
So Why Care About Quality Anyway?
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Accessibility to, actual provision of, and outcomes
of health services are consistently substandard
Gap between current practices and realistic,
optimistic practice possible today (considering
technology, medical advancements, etc.)
Highest spender (US) on health expenditures (50%
of global HC spending) has 16% uninsured…why?
Why We Care…The Reality
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At least 44,000 Americans die each year as result of
medical errors.
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Deaths due to medical errors exceed the number
attributable to 8th leading cause of death.
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More people die in given year as result of medical errors
than from MVA’s, breast cancer or AIDS.
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Medication errors alone estimated to account for over
7,000 deaths annually.
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Total national costs of preventable adverse events are
estimated to be between $17 billion and $29 billion.
To Err is Human, IOM, 1999
Why We Care…Adult Care Standards
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Adults receive recommended and
appropriate health care approximately ½ of
the time
Overall care – 55%
 Acute care – 54%
 Preventive care – 55%
 Chronic care – 56%
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Source: McGlynn, EA, et al, “The Quality of Health Care Delivered to Adults in the
US,” NEJM, Vol. 348, No. 26.
Why We Care…Pharmacy Pholeys
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There are as many as 7,000
deaths annually in the United
States from incorrect
prescriptions
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(Carmen Catizone, National Association
of Boards of Pharmacy)
Told The Washington Post as
many as 5% of the 3 billion
prescriptions filled annually are
incorrect…
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That’s 150 MILLION WRONG
prescriptions!
Source: http://www.consumeraffairs.com/news/pharmacy_errors.html
Why We Care…Medical Mishaps
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Indianapolis -- two premature infants died and a
third was in critical condition after being given adultsize doses of medication, prompting hospital
officials to review drug-handling procedures.
Adult doses of the blood-thinner Heparin were
somehow placed in a drug cabinet at the Newborn
Intensive Care Unit of Methodist Hospital, said Sam
Odle, chief executive of Methodist and Indiana
University Hospitals. The hospital said human error
was to blame.
Source: http://www.msnbc.msn.com/id/14883323/
Why We Care…Media Martyr
Betsy Lehman
Boston Globe Health Reporter
Died December, 1994 after
receiving an accidental fourfold overdose of
chemotherapy.
“Celebrity illness can help
change public attitudes.
There is no shortage of
precedents.”
Boston Globe, May 23, 1994
© 2004 Express Scripts, Inc.
All Rights Reserved.
Defining the Issue
So what IS quality?
“Quality of care is the degree to which health services for
individuals and populations increase the likelihood of desired
health outcomes and are consistent with current professional
knowledge…How care is provided should reflect appropriate use
of the most current knowledge abut scientific, clinical, technical,
interpersonal, manual, cognitive, and organization and
management elements of health care.”
Source: Lohr, 1990 - by Committee to Design a Strategy for Quality Review
and Assurance in Medicare
Quality History
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Guilds responsible for product service and quality
(1200-1800)
Evolution of US practices in 1800’s (Industrial
Revolution)
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Craftsmanship
Factory system
Taylor system (Frederick W. Taylor)
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Increase productivity by assigning factory planning to specialized
engineers.
New emphasis on productivity had negative effect on quality.
Inspection departments created to detect defective products.
Quality History cont’d.
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20th century: Process-oriented and WWII
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Emergence of Quality Improvement Leaders
 Joseph
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Statistical quality control at Western Electric
Quality Control Handbook
Provided assistance to Japanese after WWII
 Edward
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M. Juran
Deming (trained physicist, statistician)
Quality important issue for the US Army during WWII
Sampling inspection began
Sent to Japan in 1946 by Economic and Scientific Section of
War Department to study agriculture production and related
problems
Successfully influenced Japanese business with statistical
theory and confidence.
Quality History cont’d.
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20th century
 Edward
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Deming
Trained as physicist
Statistician for USDA and Census Bureau
Quality important issue for the US Army during WWII
Sampling inspection began
Sent to Japan in 1946 by Economic and Scientific Section of
War Department to study agriculture production and related
problems
Successfully influenced Japanese business with statistical
theory and confidence.
Quality History cont’d.
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Total Quality approach in Japan
Japanese manufacturers focused on improving
all organizational processes through people who
used them.
 Higher quality exports at lower prices.
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Total Quality Management
American response in 1970’s emphasizing not
only statistics but approaches that embraced
entire organization.
 Malcolm Baldridge National Quality Awards
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Big Whigs in Pioneering Quality
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Florence Nightingale
The Crimean War
 The Charge of the Light Brigade
 Birth of the Modern Hospital
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Ernest Amory Codman, MD
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The End-Result Idea
Don Berwick, MD
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IHI
Eye of the Beholder…
Differing Perceptions on Quality
Patient - typically judges healthcare encounter from outcome and personal
views of such things as physician attention, clear communication,
and compassionate, skilled delivery of care
Provider - more technical views such as whether accurate diagnosis was
made, surgical procedure was performed proficiently, and whether
patient’s health status improved; more concerned with gap between
what is scientifically sound and possible vs. actual practice and
delivery of care
HC manager/payer/purchaser - want to know if services are cost
effective; looking to see if desired outcome
was most efficient and effective
Public health official - seek whether healthcare resources are used
appropriately to optimize population health,
as well as provided equitably w/in population
Six Fundamental Dimensions for Quality
1. Safe - care should be as safe for pts in HC
2.
3.
4.
5.
6.
facilities as in their homes
Effective - our science/evidence should serve as
standard for HC delivery
Efficient - care/service should be cost effective,
and waste should be removed
Timely - pts should experience no waits/delays in
receiving care & services
Patient Centered - should revolve around pt
preferences, who should have
control
Equitable - unequal treatment and disparities
should be long since eliminated
Source: Ransom, Scott, Maulik, Joshi, Nash, David. The Healthcare Quality Book.
Health Administration Press. 2004.
Universal Standards:
Six Sigma
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What is Six Sigma?
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a disciplined, data-driven approach and methodology for
eliminating defects (driving towards six standard
deviations between the mean and the nearest
specification limit) in any process -- from manufacturing
to transactional and from product to service.
Better put, a methodology for implementing a
measurement-based strategy that focuses on process
improvement and variation reduction in any industry
Measures HC performance in various measures:
 Needle
stick incidents, room turnover, throughput, etc.
Source: Six Sigma at url: http://www.isixsigma.com/sixsigma/six_sigma.asp
Six Sigma
“Measurements Drive Performance”
Overall Health Care in U.S. (Rand)
Breast cancer
Outpatient ABX for colds
screening (65-69)
1,000,000
Hospital acquired infections
Hospitalized patients
injured through negligence
100,000
Defects
per
million
Post-MI
10,000 -blockers
1,000
100
Airline baggage handling
Detection & Adverse drug
treatment of
events
depression
Anesthesia-related
fatality rate
10
1
U.S. Industry
Best-in-Class
1
2
(69%) (31%)
3
(7%)
4
5
6
(.6%) (.002%) (.00003%)
 level (% defects)
Source: modified from C. Buck, GE
Six Sigma
Strategy Map for HC Performance
SOURCE: Six Sigma, url: http://healthcare.isixsigma.com/library/content/c061122a.asp
A Step toward QI: Leapfrog Group
Voluntary program
 Aimed at mobilizing employer purchasing
power to alert the health industry that big
leaps in health care safety, quality and
customer value will be recognized and
rewarded
 Comprehensive programs covering hospital
administrators, doctors, employers, and
health plans
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SOURCE: http://www.leapfroggroup.org/about_us
Leapfrog Initiatives
Encourages employers to practice
transparency and allow easy access
to health care information
 Rewards hospitals that have a proven record
of high quality care
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Leapfrog Expectations
If all hospitals perform as well as the best
25% of hospitals for key Leapfrog Hospital
Insights, they estimate the nation will benefit
from the following every year:
 66,000 lives saved;
 $18.5 billion saved;
 145,000 readmissions avoided; and
 187,000 medication errors avoided.
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SOURCE: https://leapfrog.medstat.com/insights/references/OpportunityAnalysis.pdf
Another Step Towards QI: SCRIPT
“Model for Medication Management”
Medication Management Score
 Any three of the six denominator conditions or diseases
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One or more measures in at least three of the four functional
categories (rx, monitoring, achieving goals, compliance)
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Why Script?
 There are increasing morbidity, mortality, costs
associated with medication use and misuse
 Potential drug benefit
 Interest in measurement at the practice/physician level
Source: Performance Measurement: Recent Developments and a Look to the Future. CMS.
SCRIPT: How did it happen?
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Meeting in 1997 with United Health Care, AMA,
CMS , others on regional diabetes project.
Discussion of common interests in medication
management led to SCRIPT.
Funded by CMS in 1998
Built on lessons learned from DQIP
Source: Performance Measurement: Recent Developments and a Look to
the Future. CMS.
SCRIPT goals
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Improve quality of medication use
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Develop core set of quality measures that
are nationally standardized and would be
widely used for QI and accountability
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Begin by focus on elderly ambulatory
populations and most important conditions
Source: Performance Measurement: Recent Developments and a Look to the
Future. CMS.
Other Policy-Based Improvement
Avenues
Mass implementation of information technology,
such as hand-held bedside computers, to
eliminate reliance on handwriting for ordering
medications and other tx needs
 FDA regulation against similar-sounding/ lookalike names and packages of medication
 Standardization of treatment policies and
protocols to avoid confusion and reliance on
memory
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 known
to be fallible and responsible for many errors
Source: http://www.ahrq.gov/qual/errback.htm
Health Industry Standards for QI
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Reward providers and employers who emphasize
prevention and wellness prevention
Reward providers who are delivering cost-effective quality
health care – “Pay for Performance”
Make information available to the public on who is delivering
quality health care and who is not
Emphasize paperless administration and reward providers
who utilize such technology
Implement a comprehensive database on all patients
Focus on health, not health care
Source: Washington Mutual Presentation on Health and Quality
Berwick’s Critique of “Pay for
Performance”
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Concerned for individual Doctors and Nurses
Training
Problems with Capacity v. Capability
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Members of medical community have the capacity, but
not the capability because of lack of training
Leadership – hospital boards care about the
organizations, but do not understand that they have the
duty to create change in the workplace.
Mistake to focus only on Doctors when looking at Quality,
a fuller picture must be examined
Changes can come from outside of the Defined
System
Berwick cont’d
Mistake to focus only on Doctors when
looking at Quality, a fuller picture must be
examined
 Changes can come from outside of the
Defined System
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Political Implications of Quality
Party Issues, Model Legislation, and
Our GOP Policy Proposal
Key Issues - Democrats
Increased access to health care
 Increasing the quality of services provided by
healthcare providers
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Previous Legislative Efforts
Senators Clinton and Obama introduced a
bill in 2005 to amend the Public Health
Service Act
 National Medical Error Disclosure and
Compensation (MEDIC) Bill
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MEDIC Bill
Key points in MEDIC proposal:
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Promotion of open communication between health
care providers and patients;
Reduction of preventable medical errors;
Ensuring patient access to fair compensation for
medical errors;
Reducing the cost of medical liability insurance;
Will also create an Office of Patient Safety and
Health Care Quality within the Department of
Health and Human Services which will establish a
National Patient Safety Database.
MEDIC Bill cont’d.
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The National Patient Safety Database will conduct
data analyses to assist and provide information for
policy and practice recommendations; establish
and administer the MEDIC program, and support
studies related to MEDIC and the medical liability
system.
There are no Congressional Budget Office (CBO)
costs estimates for the MEDIC proposal.
However, experts state that adherence by
healthcare providers will be difficult unless
providers are given immunity from possible
subsequent litigation.
British Efforts
Pay for Performance (P4P)
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Compensates physicians based on high
quality performance. The British use
financial incentives to improve physician’s
performance.
Key Issues - Republicans
Linking of information to provide quality care
such as electronic medical records
 Increasing quality of care through
compensation
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Previous Legislation
The Medicare Modernization Act of 2003 (MMA)
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The act was introduced as an overhaul to one of the United
States largest entitlements programs—Medicare. On June
16, 2003, it was introduced in the House of Representatives
by Rep. William M. Thomas, (R-CA.). Subsequently, it was
redesignated as another house bill and was then sponsored
by Representative J. Dennis Hastert (R-IL).
Source: Ryan Dougherty, Executive Summary: The Implications of Pay for
Performance, Extended care Product News
MMA cont’d.
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Best known for providing prescription drug
coverage for Medicare beneficiaries, however, the
Act also included Pay for Performance provisions.
To improve quality of care provided to Medicare
beneficiaries and avoid unnecessary medical costs,
in 2003, Centers for Medicare and Medicaid
Service (CMS) implemented measures to
compensate health care providers who comply with
certain health care outcomes.
Source: Ryan Dougherty, Executive Summary: The Implications of Pay for Performance, Extended care
Product News
MMA cont’d.
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The initiative pays providers such as physicians,
hospitals, physician groups and nursing homes.
According to prior estimates, health care providers
will receive anywhere 2% to less than a 1%
increase in payments (ECPN, 2007).
The CBO has no exact estimates regarding the
costs of P4P, but it estimates that the MMA will cost
$405 billion over a nine year period.
Source: Ryan Dougherty, Executive Summary: The Implications of Pay for Performance, Extended care Product
News
Policy Model for Proposal:
Patient Safety and Quality
Improvement Act of 2005
Senator Jim Jeffords (I-Vt)
S.544 (109th), H.R. 3205
Public Law109-41
Political View
Bipartisan support
 Senate Supporters: Jeffords (I-VT), Kennedy
(D-MA), Frist (R-TN), Collins (R-ME),
Bingaman (D-NM)
 House Supporters: Bilirakis (R-FL), Emanuel
(D-IL), Waxman (D-CA), Bono (R-CA),
Norwood (R-GA)
 Introduced in Senate on March 8, 2005
 Signed by President July 29, 2005
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Goals
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Designate “patient safety work product” as
privileged and not subject to:
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(1) a subpoena or discovery in a civil, criminal, or
administrative disciplinary proceeding against a provider;
(2) disclosure under the Freedom of Information Act
(FOIA) or a similar law;
(3) admission as evidence in any civil, criminal, or
administrative proceeding; or
(4) admission in a professional disciplinary proceeding
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DHHS Secretary Michael Leavitt
Requires DHHS Secretary to:
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Report to Congress on effective strategies for reducing medical errors
and increasing patient safety.
Create and maintain a network of patient safety databases that:
 provide an interactive evidence-based management resource for
providers, PSOs, and other entities; and
 have the capacity to accept, aggregate across the network, and
analyze voluntarily reported nonidentifiable work product.
Assess the feasibility of providing for a single point of access to the
network for qualified researchers for information aggregated across the
network and, if feasible, provide for implementation.
Allows the Secretary to determine common formats for reporting to the
databases that are consistent with the Social Security Act.
Requires that information reported to the databases be used to analyze
national and regional statistics and be made available to the public.
Costs
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CBO estimates that implementing S. 544 would
cost $5 million in 2006 and $58 million over the
2006-2010 period, assuming the appropriation of
the necessary amounts. CBO estimates that
receipts from fines for violation of the privacy
protections, which are recorded as federal
revenues, would amount to less than $500,000 a
year
Less than 1 dollar to every American in 2006
Foreshadowing our Policy…
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“..the prices of care, not the amount of care
delivered, are the primary difference between
the U.S. and other countries…the morecostly U.S. healthcare has not resulted in
demonstrably better technical quality of care
or better patient satisfaction with care.”
Source: Anderson, GA, et al, “Health Spending in the US and the Rest of
the Industrialized World,” Health Affairs, 2005, Vol. 24, No. 4.
GOP Proposed Legislation
Patient Safety and
Quality Improvement Act
of 2007
Patient Safety and
Quality Improvement Act of 2007
PSOs implement the Act by:
 Analyzing medical error data;
 Determining the causes of the errors and;
 Disseminating evidence-based information to
hospitals and healthcare providers.
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PSQIA 2007: Rationale
Improve Patient Care through transparent
reporting of hospital errors
 Provide hospitals with incentives to report,
using a pay for performance model
 Financing scheme similar to Medicare
Modernization Act
 Governing body: Department of Health and
Human Services, Agency for Healthcare
Research and Quality
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PSQIA 2007: Target Groups
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Health Care Providers
Hospitals
 Clinics
 Physicians
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PSQIA 2007: Mechanism
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Fund a program within the Agency for
Healthcare Research and Quality which is
housed in the Dept. of Health and Human
Services.
PSQIA 2007: Financing
Give hospital’s tax breaks based on a sliding
scales of costs necessary to gather reporting
information
 There will be a tax break for up to $500,000
of spending
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PSQIA 2007: Outcomes
PSQIA 2007: Fiscal Implications
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In 2005, the Congressional Budget Office estimated
that implementing the Patient Safety and Quality
Improvement Act of 2005 would cost $5 million in
2006 and $58 million over the 2006-2010 period.
Additionally, the agency
estimated that receipts from fines for violation of the
privacy protections
would amount to less than $500,000 a year (CBO,
2005).