Transcript to patient care

Need for Quality, Introduction to Quality
Improvement and PCMH
Thanks to Migrant Clinics Network , Institute for Health Care Improvement, Marc
Williams- Intermountain Healthcare & Mike Hindmarsh
MacColl Institute for Health Care Innovation
Institute For Healthcare Improvement
Paul Bray, MA, LMFT
Assistant Research Professor, Dept. of Family Medicine, ECU
Work e-mail [email protected]
Why are we discussing improving
quality in health care?
 It is the center of discussion with health care reform: All reform
emphasis quality
 It’s on your certification exams: Specialty board certification &
JCAHO (Joint Commission on Accreditation of Health Care Organizations)
accreditation
 It can increase your pay: Incentive pay, managed care pay, patient
centered medical home and Pay for performance
 It can keep you competitive: Learn about quality improvement
because it is a world wide movement
 Most important, for your patients: Learn about the methods to help
your patients
Do we have a quality
Problem in US health
care?
Consensus: We do not
have a problem we have
a CRISIS!
The IOM Quality Report- To Err Is
Human: Building a Safer Health System
To Err is Human Medical
Injuries IOM November 1999 Report
 44,000-98,000 deaths per year through
medical errors
 More people die from medical
errors than from breast cancer or
AIDS or motor vehicle accidents
 100,000 deaths per year from
procedures/surgery complications, exceeding
motor vchicle deaths
 Direct health care costs $9-15
billion/year
 It’s a conservative estimate!!
March 1, 2001
“Between the health
care we have and the
care we could have
lies not just a gap,
but a chasm.”
The IOM Quality Report- Update 2001
How Good Are We?
 Only 50% of Americans receive recommended preventive
care
Patients with acute illness
70% received recommended treatments
30% received contraindicated treatments
 Patients with chronic illness
60% received recommended treatments
20% received contraindicated treatments
Schuster et al. How good is the quality of healthcare in
the United States? Milbank Quarterly 76:517-63, 1998
The toll on patients is high: US Data
Source: Elizabeth McGlynn, et al. “The Quality of Health Care Delivered to Adults in the
US.” NEJM 2003; 348:2635-45
SHORTFALL IN CARE
AVOIDABLE TOLL
CONDITION
 Diabetes
 Average blood sugar not measured
 Hypertension

 Heart attack


 Pneumonia
 Colorectal cancer

for 24% 29,000 kidney failures 2,600 blind
Less than 65% received indicated
care - 68,000 deaths
39% to 55% didn't receive needed
medications - 37,000 deaths
36% of elderly didn't receive
vaccine - 10,000 deaths
62% not screened - 9,600 deaths
Source: World Bank’s World Development Indicators, UC Atlas
"THIS WEEK I CONVEYED TO
CONGRESS MY BELIEF THAT ANY
HEALTH CARE REFORM MUST BE BUILT
AROUND FUNDAMENTAL REFORMS
THAT LOWER COSTS, IMPROVE QUALITY
AND COVERAGE, AND ALSO PROTECT
CONSUMER CHOICE," BARACK OBAMA
JUNE 6, 2009
The IOM Quality report: A New Health
System for the 21st Century
 Institute of Medicine
 “The current care systems
cannot do the job.”
 “Trying harder will not
work.”
 “Changing care
systems will.”
http://www.iom.edu/CMS/8089.aspx
Chronic Care Model or Planned Care Model
Community
Health System
Health Care Organization
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
Primary Care as the key to Quality:
Patient-Centered Medical Home
(PCMH)
The patient‐centered medical home is a model for care provided by
physicians practices that seeks to strengthen the physician‐patient
relationship by replacing episodic care based on illnesses and
patient complaints with coordinated care and a long‐term healing
relationship.
Reimbursement is central
to PCMH and Quality Improvement
Reform Proposal: fees + PCMH pay-per-patient + performance from system of quality
Characteristics of PCMH
(National Center for Quality Assurance)
1. Team based care
2. Whole person orientation
3. Care coordination
4. Enhanced access
5. Systems for quality
6. Systems for safety
How do we know a clinic is a
PCMH
• 24/7 Access and Communication
• Test Tracking
• Patient Tracking and Registry
Functions
• Referral Tracking
• Care Management from a nurse
or other non-physician
• Patient Self‐Management Support
• Electronic Prescribing
• Performance Reporting and
Improvement, team reviews results
• Advanced Electronic Communications
How do we have “systems of
quality”?
(One of the 6 requirements of a PCMH)
Set a goal (if you do not have a
target, that is what you will hit)
 Form a team
Take Small steps
Measure your progress- collect data
CORE STEPS IN CONTINUOUS
IMPROVEMENT (i.e. diabetes)
 Define a clear aim (reduced morbidity from diabetes)
 Identify and define measures of success. (>40% < 7 A1c)
 Form a team that has knowledge of the system needing
improvement (physician, dia. Ed, scheduler)
 Brainstorm potential change strategies for producing
improvement. (add 20 min ed visit to >7)
 Plan, collect, and use data for facilitating effective decision
making. (measure A1c for ed vs. non ed)
 Apply the scientific method to test and refine changes (id best
curriculum & self-management)
What is the PDSA Cycle?
Act
Plan
• What changes
are to be
made?
• Objective
• Questions and
predictions (why)
• Plan to carry out
• Next cycle?
the cycle (who,
•maintain modify
what, where, when)
add to the plan
Study
• Complete the
analysis of the data
•Compare data to
predictions
•Summarize what
was learned
Do
• Carry out the plan
• Document problems
and unexpected
observations
• Begin analysis
of the data
How do we get there?
Define a Problem
2. Set a Goal
3. Form a Team
4. Plan for a change using “small scale steps”
5. Do the change
6. Study- collect data & analyze change/outcome
7. Act – correct, repeat, spread, install
1.
Achievements
 In the first Diabetes Collaborative applying the
CCM; enrolling 16,000 people with diabetes.
 The national shared performance measure of
“two Hemoglobin A1c (HbA1c) tests done
within a year” increased by almost 300%.
 Diabetes pilot patients had significantly reduced
CVD risk (pilot>control), resulting in a reduced
risk of 1 cardiovascular disease event for every
48 patients exposed(RAND Corp. Study
www.improvingchroniccare.org).
Reading List for Residence First QI
Application Session
 ECU Getting Started Powerpoint Presentation
 CQI Family Medicine CQI Introduction
 Mike Hindmarsh chronic care model intro
 IHI Improvement Methods Intro Web Site
http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/
 Tools: Cause-effect “Fish-bone” exercise
http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/Cause+an
d+Effect+Diagram.htm
 Tools: Pareto Diagram Exercise
http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/Pareto+Dia
gram.htm
Resources
http://www.ihi.org: Institute for Healthcare Improvement,
tools to print , “how to” manuals
http://www.healthdisparities.net: collaboratives done at
HRSA clinics, Handbook for many chronic conditions
(diabetes, asthma, CHF etc)
http://betterdiabetescare.org: info for practitioners
Resources
 http://www.Improvingchroniccare.org
 Educational materials for patients
http://www.ncdiabetes.org/
 http://www.aace.com
 http://ndep.nih/gov
 http://www/cdc/gov/team-ndep
 http://www.diabetesatwork.org