Transcript Are you a quality improvement advocate?

Quality
Improvement for
MDs
The Good Hospital Practice
Training Series 2009
The Medical City
The quality improvement movement is
affecting our practices in unprecedented
ways. Our reputation, earnings, and
credentialing are beginning to depend on
quality improvement.
Though we were not taught quality
improvement in medical school, the wellbeing and the lives of the patients we care
for everyday depends on it.
Outline of presentation
So as physicians, we need to explore:
•What is quality and why quality improvement?
•Why should we work for quality improvement?
•How is quality improvement measured? How can
we tell if we've achieved the improvements we
desire?
•What tools do we need to improve care in our
offices, hospitals and clinics?
What is quality?
Quality is the extent to which health services
increase the likelihood of desired health
outcomes and are consistent with current
professional knowledge (evidence based
medicine). (IOM)
Healthcare Quality Improvement is the body of
knowledge, attitudes, and skills necessary to
efficiently influence and continuously improve
the multiple elements of care delivery within a
medical practice. (AAFP)
Why quality improvement?
Improving the quality of care is the right
thing to do. Improvement is a core aspect
of all professionalism, and our patients
trust us and depend on us to deliver
quality care every time they sit in the
examination room, rest on the hospital
bed, or lie on the operating table. This is
why we went to medical school, and this
is what satisfies us at the end of a long
hard day.
Why quality improvement?
Our reputation depends on quality performance.
We become known to our medical colleagues
and patients by the good (and bad!) work that we
do.
Our income depends on referrals from patients and
from the doctors, nurses and staff who know
about our expertise and ethics. PhilHealth is
moving towards a preferred provider payment
scheme that will reward hospitals and physicians
based on the quality of care delivered.
Why quality improvement?
Our re-credentialing and privileging depends on the
quality of our performance. In The Medical City,
pursuant to Joint Commission International
standards, each physician must be evaluated
at least once a year on the following bases:
1.
Quality and safety of patient care
2.
Practice adherence to evidence-based
medicine
3.
Professionalism
4.
Communication with team and patients
5.
Continuing education
The right care for every patient
every time
The goal of quality improvement in healthcare is
to provide the right care for every patient, every
time.
What is right care? Right care is putting evidencebased medicine into practice with judgment,
experience and adaptation to the patient’s
needs. Often bench research knowledge takes
decades to become bedside practice. For
example, studies in the 1980s showed the
benefit of administering beta-blockers after AMI,
yet in 2001 only 69% of patients received a
beta blocker at discharge. (8) Knowing what is
The right care for every patient
every time
Who is every patient? We must strive to provide
the right care for every patient without regard
for age, gender, education or capacity to pay.
What is every time? We must work to incorporate
evidence-based knowledge into our daily
practice. Unfortunately, it is difficult to do this on
a consistent basis. For example, only a small
per cent of TMC staff practice hand hygiene. In
the hustle of a busy clinic or the complexities of
a long surgical case, we sometimes overlook
routine, yet important, interventions, such as
the Universal Protocol or timely antibiotics.
Quality improvement needs us
At the core of quality improvement are healthcare
workers, patients, and systems.
Doctors, nurses, administrators, and other healthcare
workers are the agents who create, modify, or
refine the delivery of healthcare. As agents we
need to lead in quality improvement.
Patients and families must take responsibility for their
care and be empowered to manage their health.
Doctors, administrators and patients must collaborate
within the hospital system to achieve quality
outcomes.
Quality improvement is
system-based
System improvement is the main focus of the
quality improvement philosophy. A system will
only perform as well as it is built. Medical
systems currently perform at an error rate of 1
error (injury) per hundred hospitalized patients.
The better the system we build, like a car
engine, the better will be the performance we
experience.
In order to improve care we must improve the
systems we employ. Clinical pathways and
checklists for common diagnoses and
procedures improve the likelihood that the
Know your quality indicators
As doctors we are usually only concerned with
outcome indicators, such as reduction in
infection rate, because it relates to our daily
practice. However, outcome indicators can be
easily skewed by case mix, environment, data
collection, etc. Thus, evaluations of our
performance are often based on process
indicators.
Process indicators measure the steps in a
process, not the result or outcome of a process.
Hand hygiene and antibiotic prophlaxis rates
are process indicators. When process
Help measure quality
If we wish to improve quality then we must
measure quality. Measurement provides
objective and repeatable values to our
subjective experiences. For example, it is
difficult for a surgeon to estimate and act upon
his surgical infection rate at his facility without a
standardized data gathering and reporting
system.
Relevant data need to be measured in small
samples over time if we wish to improve. To be
able to influence indicators we need to modify
our practice and re-measure our performance
Help measure quality
Data need to be used for providing feedback to
doctors and nurses who affect the indicators.
Feedback has to be done in a collaborative and
non-punitive manner, so as to build trust, which
is essential for further change.
Data need to be profiled by individual units such
as hospital floor or physician, in order to be
meaningful to individuals, and to motivate
change.
You can help by contributing your patient data and
acting upon the quality measures specific to
Be a team player
In the past, all it takes to be a good MD was to
listen to a patient, make a decision and dictate
orders to residents and nurses. This model no
longer works.
Today, a good physician has to work as part of a
team by providing technical leadership. A
technical leader has in depth clinical knowledge
and knows the process of care. He guides the
frontliners (residents and nurses), making sure
treatments are given and data are collected.
She guides in the formation of quality
indicators, measurement tools, data collection,
Why be a team player?
When teamwork was promoted in the ICU by our
intensivists, our ICU mortality rates fell below
predicted rates (see red line below). This is proof
that when doctors and nurses work as teams, lives
are saved.
40
0.6
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30
0.4
25
20
0.3
15
0.2
10
0.1
5
0
0
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Months in 2008
9 10 11 12
Average Pred Mort
Actual Mort
SMR
Linear (SMR)
The PDCA cycle is our tool for delivering
service of greater worth
through continuous quality improvement
Plan
Act
Do
Check
P
e
r
f
o
r
m
a
n
c
e
Plan Stage
1. Identify a theme or problem
• Evaluate and narrow down the problem or issue
• Clarify the reasons why a problem or issue must be
addressed
2. Understand the current situation
• Clarify process and sources of variations from standards
• Set targets and decide on what the situation should be if
the problem were solved
• Identify indicators
• Collect relevant data
Plan Stage
3. Create a plan for action
4. Analyze the problem
•
Analyze the root causes
•
Enumerate as many causes of the problem as possible,
group them together to discover root causes and narrow
down the list to the vital few
Some of the tools used in the Plan Stage are:
1.
Brainstorming
2.
Flowchart
3.
Check sheet
4.
Pareto diagram
Do Stage
1.
Develop and implement countermeasures
2.
Propose as many solutions to the vital few root
causes
3.
Narrow down solutions to the most effective and
practical countermeasures
4.
Implement countermeasures
Some of the tools used in the Do Stage are:
–
Tree diagram
–
Gantt chart
–
Clinical pathways
Check Stage
1.
2.
3.
Confirm effectiveness of solutions
Monitor implementation of solutions
Document the effectiveness of solutions by collecting
data
4. Analyze data
5. Determine if the problem has been solved, targets
achieved, and standards reached
6. Reflect on the lessons learned from the problem solving
step
Some of the tools used in the Check Stage are:
– Graphs (bar, pie, histogram)
– Check sheet
Act Stage
1.
Standardize and institutionalize solutions
2.
Present the results to management, to a
hospital-wide forum and any other
appropriate venue
3.
Get top management’s approval to adopt
the solution throughout the organization
Some of the tools used in the Act Stage are:
–
Control chart
–
Clinical pathways
You can make PDCA your tool
for delivering high quality care
• Plan by participating in quality measurement
activities such as chart reviews, audits, sentinel
event analyses, etc.
• Do by implementing specific interventions to
address quality deficiencies;
• Check by assessing the effectiveness of your
interventions on your patients.
• Act by incorporating effective interventions into
routine patient care.
You can help The Medical City
implement these life saving
quality interventions
• Activate the Chest Pain Pathways to deliver
reliable, evidence-based care for acute myocardial
infarction and prevent deaths from heart attack
• Implement medication reconciliation to protect
your patients from Adverse Drug Events (ADEs)
from unwanted drug-drug interactions and drug
overdose
• Order the administration of the correct
prophylactic antibiotic at least 30 minutes before
cutting time to protect your patients from surgical
site infections
You can help The Medical City
implement these life saving
quality interventions
• Enforce strict hand hygiene and use of personal
protection equipment (PPEs) on all of your staff to protect
your patients from hospital acquired infections
• Activate clinical pathways to ensure your patient the benefit
of evidence-based interventions
• Implement the Universal Protocol on all your patients for
surgical or radiologic procedures
• Prevent harm from high-alert medications starting with a
focus on anticoagulants, sedatives, narcotics, and insulin
A focus on quality will lead to
a change in our culture. In a
quality culture, systems are
designed to reduce
unwarranted variations, yet
they permit clinically
necessary and patientdesired variations. For
example, clinical pathway
systems standardize
delivery of critical
interventions and yet allow
for justified variances so
that care can be suited to
our patients’ individual
Create a
quality
culture
In a quality culture, administrators
increase their focus on quality.
Transparency of all quality data is the
rule. For example, reports on quality
are given at least the same amount
of time and attention as the census
or the financial report. Also, quality
data are shared between
departments.
In a quality culture, doctors take
teamwork seriously. Team decisionmaking lessens the burden and
shares the responsibility of complex
and critically ill patients. Quality
improvement creates patientcentered care. Quality improvement
is the right thing to do!
Create a
quality
culture
Are you a quality advocate?
(there is more than one correct answer!)
1. How will Medical City measure the clinical
performance of its doctors?
a. Quality and safety of patient care
b. Practice adherence to evidence-based
medicine
c. Professionalism
d. Communication with team and patients
e. Patient volumes and revenues
Answer:
Are you a quality advocate?
(there is more than one correct answer!)
2. A quality culture is fostered by
a. Catching people doing the wrong thing and
sanctioning them
b. Reliable and transparent quality measurement
c. Dealing with errors privately or only with the
involved staff
d. Regular monitoring and feedback to frontliners
e. Relentless pursuit of improvement
Answer:
Are you a quality advocate?
(there is more than one correct answer!)
3. In the Plan stage of a quality improvement project
a. Quality problems are prioritized and selected
b. Performance measurements are made to measure
the quality gap
c. Root causes of quality problems are identified
d. Action plans to address the quality problem are
made
e. Potential solutions are prioritized and selected
Answer:
Are you a quality advocate?
(there is more than one correct answer!)
4. In the Do stage of a quality improvement project
a. As many potential solutions as possible are
proposed to address root causes
b. The effectiveness of countermeasures is checked.
c. Solutions are narrowed down to the most effective
and practical countermeasures
d. Countermeasures are tested on a limited scale.
e. Implementation is documented
Answer:
Are you a quality advocate?
(there is more than one correct answer!)
5. In the Check stage of a quality improvement project
a. Performance measurements are made to determine if
the quality gap has been narrowed
b. Implementation of solutions is monitored.
c. Data are collected to assess if the problem has been
solved, targets achieved, and standards reached
d. The team reflects on the lessons learned from the
problem solving step
e. The effectiveness of countermeasures is checked.
Answer:
Are you a quality advocate?
(there is more than one correct answer!)
6. In the Act stage of a quality improvement project
a. Quality solutions are integrated into routine care
b. Care processes are standardized to include the winning
quality solutions
c. Data are continuously collected to ensure that quality
gains are maintained.
d. Results of the Quality Improvement project are
presented to top management
e. Top management approves the adoption of the solution
throughout the organization.
Answer:
Are you a quality advocate?
(there is more than one correct answer!)
7. Which of the following interventions should be adopted
into routine care to prevent hospital acquired
infections?
a. Use of extended spectrum antibiotics in all patients
with sepsis
b. Prophylactic antibiotics on all surgical patients
c. Routine hand hygiene before and after patient contact.
d. Regular intermittent suctioning of patients on artificial
ventilation.
e. No white coats or neckties for all medical staff
Answer:
Are you a quality advocate?
(there is more than one correct answer!)
8. Which of the following interventions should be adopted into
routine care to assure patients of evidence-based care?
a. Use of high glucose diets for low birth weight infants
b. Universal Protocol for all patients undergoing surgical or
radiologic interventions
c. Use of Medical City clinical pathways for sepsis, acute
myocardial infarction, asthma, pneumonia and others.
d. Body hair shaving prior to surgery
e. Continuous subglottic suctioning for patients on artificial
ventilation
Answer:
Are you a quality advocate?
(there is more than one correct answer!)
9. Which of the following interventions should be adopted into
routine care to ensure patient safety?
a. Medication reconciliation to compare drugs taken at home
vs hospital drugs vs drugs to be taken after discharge
b. Regular reporting of near-misses and sentinel events
c. Standardized use of high alert medications, such as
insulin, narcotics, sedatives and anticoagulants
d. Consistent use of PPEs
e. No children below seven inside the hospital
Answer:
Are you a quality advocate?
(there is more than one correct answer!)
10. Quality means doing the right thing to every patient every
time. In practical terms this means that
a. Care should be based on scientific evidence, clinical
experience, patient values and the availability of
resources.
b. Care must be the same for every patient with the same
medical condition every time.
c. Care must conform primarily to physician’s preferences
and hunches.
d. Deviations from care should be generally avoided or
minimized.
e. Care must maximize the use of hospital resources.
Answer:
Now check your answers:
1.
ABCD
2.
BDE
3.
ABCD
10 out of 10 – you are a QI icon!
4.
ACDE
8 or 9 out of 10 – QI champion.
5.
ABCDE
6 or 7 out of 10 – we look forward to more
participation from you!
6. ABCDE
Are you a quality improvement
advocate?
7. C
4 or 5 out of 8 – you can still improve the
quality of your care*
8. BCE
<3 out of 10 – let us try again*
9. ABCD
10. A
* Please go over the slides again.
This SIM Card certifies that
______(please overwrite with your name, thank you)__,
MD
has successfully completed the
Self Instructional Module on Quality
Improvement for MDs.
(Sgd) Dr Alfredo Bengzon
President and CEO
(Sgd) Dr Jose Acuin
Director, Medical Quality Improvement