Quality In Heath Sector

Prof Dr. Moh. BADR

Transfer corresponding concepts and methods from industry to health needs of some considerations.

1988 1999

Congress created the Agency for Health Care Policy and Research (AHCPR).

WHO DEFINITION OF HEATH

All are ill

Cost and policy makers

How much is a society prepared to pay for health?

Quality in Healthcare If you wanted to get a sense of the quality of healthcare delivery, How would you go about it?

You could ask each of the providers if they were following the guidelines for a specific disease

You could ask providers to keep track of their errors or “near misses” Can you imagine any reason these methods may not work?

Contrasting QI and QA Many people are familiar with the term Quality Assurance (QA), as it was a common term for many years.

Quality Assurance – QA was reactive, retrospective,

policing, and in many ways punitive. It often involved determining who was at fault after something went wrong. This term is older and not as likely to be used today.

Quality Improvement – QI involves both prospective and retrospective reviews. It is aimed at improvement -- measuring where you are, and figuring out ways to make things better. It specifically attempts to avoid attributing blame, and to create systems to prevent errors from happening.

QA QIWhich staff member failed to transfer the call to the correct extension?

Are we creating an environment encouraging clinicians to report errors?

Patient had a bad outcome; were the doctors or nurses at fault?

What could we do to increase the efficiency of chart filing?

Contrasting QI and QA

Providers:Tend to view quality in a technical sense – accuracy of diagnosis, appropriateness of therapy, resulting health outcome

Payers:Focus on cost-effectiveness.

Employers:Want both to keep their costs down, and to get their employees back to work quickly.

Patients:Want compassion as well as skill with clear communication.

DIFFERENT POINT OF VIEW

What actually needs to be assessed?

• Quality of treatment• Doctor• Whole organization• Practice

The concept of category forming 1. Quality of structure2. Quality of process3. Quality of outcome

Quality of structureQuality of structure Staffing. Quality and quantity. Basic and program For further training of the staff

PremisesEquipping the building and rooms

OrganizationPrinciple and rules of organization, code of conduct

Medicine and medicine technologDiagnostic and therapeutic concepts and equipment

Quality of process

• Reception ,talking, information to patients

• History

• Implementation of diagnostic measures

• Guidelines or standards

•Patient education

Quality of outcome

Changes caused by medical care in the present or future state of health of the patient

Accreditation

What is accreditation and what are the benefits?

is a process in which an entity, separate and distinct from the health care organization, usually non-governmental, assess the health care organization to determine if it meets a set of standards requirements designed to improve quality of care. Accreditation is usually voluntary. Accreditation standards are usually regarded as optimal and achievable. Accreditation provides a visible commitment by an organization to improve the quality of patient care, to ensure a safe environment and to continually work to reduce risks to patients and staff. Accreditation has gained worldwide attention as an effective quality evaluation and management tool.

Method for evaluating health quality

Method for evaluating health quality

Balanced Scorecard http://healthcare.isixsigma.com/ca/baldridge/ Benchmarking Business Process Reengineering (BPR) http://healthcare.isixsigma.com/ca/deming/ Document Control DMADV / New Product & Service Introduction DMAIC / Existing Product or Service Financial Analysis / Cost of Quality http://healthcare.isixsigma.com/ca/iso9000/ Lean, Lean Six Sigma and Lean Manufacturing Management Metrics Plan, Do, Check, Act - PDCA Process Management Project Selection Simulation Six Sigma Taguchi Methods http://healthcare.isixsigma.com/ca/tl9000/ Total Quality Management (TQM) TRIZ, Theory of Inventive Problem Solving Work-Out

(International Organization for Standardization)

Is

the world's largest developer and publisher of I International Standards.

ISO is a network of the national standards institutes of 157 countries, one member per country, with a Central Secretariat in Geneva, Switzerland, that coordinates the system. ISO is a non-governmental organization that forms a bridge between the public and private sectors. On the one hand, many of its member institutes are part of the governmental structure of their countries, or are mandated by their government. On the other hand, other members have their roots uniquely in the private sector, having been set up by national partnerships of industry associations. Therefore, ISO enables a consensus to be reached on solutions that meet both the requirements of business and the broader needs of society.ISO forms a bridge between the public and private sectors.

What is JCI Accreditation?In response to growing interest in accreditation and quality improvement worldwide, the Joint Commission launched its international accreditation program in 1999. Joint Commission International accreditation standards are based on international consensus standards and set uniform, achievable expectations for structures, processes and outcomes for hospitals. The accreditation process is designed to accommodate specific legal, religious and cultural factors within a country.

Joint Commission International (JCI) accreditation can help international health care organizations, public health agencies, health ministries and others to evaluate, improve and demonstrate the quality of patient care in their nations.

What is QI?Quality Improvement is a formal approach to the analysis of performance and systematic efforts to improve it. There are numerous models used.

Some commonly discussed include:

FADE

PDSA

Six Sigma (DMAIC) CQI: Continuous Quality Improvement - http://deming.eng.clemson.edu/pub/tutorials/

TQM: Total Quality Management – http://www.mapnp.org/library/quality/tqm/tqm.htm

startaction

disruption

Divergence =Quality fault

correction

goal

yes

no

Quality management cycle

Planning & implementation Assessment &

observation

Removing obstacles

analysis

Methods of Quality Improvement The FADE Model There are 4 broad steps to the FADE QI model:

FOCUS: Define and verify the process to be improved

ANALYZE: Collect and analyze data to establish baselines, identify root causes and point toward possible solutions

DEVELOP: Based on the data, develop action plans for improvement, including implementation, communication, and measuring/monitoring

EXECUTE: Implement the action plans, on a pilot basis as indicated, and EVALUATE: Install an ongoing measuring/monitoring (process control) system to ensure success.

FADE Model in Action

You Evaluate the impact of your change You Focus down further You Analyze the problem to find the root cause(s) Then Develop methods for further improvement And Execute and Evaluate again! Repeat the process until the goal is achieved.

Another commonly used QI model is the PDSA cycle: PLAN: Plan a change or test of how something works. DO: Carry out the plan. STUDY: Look at the results. What did you find out? ACT: Decide what actions should be taken to improve. Repeat as needed until the desired goal is achieved

PDSA

PDSA

Six Sigma Six Sigma is another model for improvement. The term comes from the use in statistics of the Greek Letter (sigma) to denote Standard Deviation from the mean. 6 sigma is equivalent to 3.4 defects or errors per million.levels

Six Sigma

Six Sigma is a measurement-based strategy for process improvement and problem reduction completed through the application of improvement projects. This is accomplished through the use of two Six Sigma models: DMAIC and DMADV. DMAIC (define, measure, analyze, improve, control) is an improvement system for existing processes falling below specification and looking for incremental improvement. DMADV (define, measure, analyze, design, verify) is an improvement system used to develop new processor products at Six Sigma quality levels

Cardiac catherization labs represent a significant capital investment for many hospitals. Realizing a return on this investment is increasingly challenging, given the introduction of advanced technologies and limitations in reimbursement. To meet the challenges and maintain fiscal health, hospitals are pursuing strategies such as Six Sigma, lean and change management techniques to improve throughput, maximize equipment utilization and increase efficiency.

Six sigma

Quality-Adjusted Life Years (QALYs)

Reduce the value of a year of life associated with concurrent illness

1.0 When free of major illness

0.69 for blindness

0.61 for End Stage Renal Disease (ESRD)

0.80 for lower extremity amputation (LEA)

0.0 for death

DCCT

Lifetime Benefits and Costs of DCCT Intensive Therapy

Lifetime Benefits and Costs of DCCT Intensive Therapy

DCCT

References:

Diabetes Care, 1995 18:1468-78.

JAMA, 1996 276: 1409-15.

References:

Diabetes Care, 1995 18:1468-78.

JAMA, 1996 276: 1409-15.

Type of Health Care Costs by Treatment Group

Intensive Conventional

Treatment Side Effects Complications

DCCT

Cumulative Incidence of Proliferative Retinopathy by

Treatment Group

Age

Per

cent

19 29 39 49 59 69 79 89 99

0

20

40

60

80

100

ConventionalConventional

IntensiveIntensive

Cumulative Incidence of Clinical Nephropathy (Albuminuria) by Treatment

Group

Cumulative Incidence of Clinical Nephropathy (Albuminuria) by Treatment

Group

0

20

40

60

80

100

19 29 39 49 59 69

Age (years)Age (years)

Per

cent

Per

cent

IntensiveIntensive

ConventionalConventional

DCCT

Average Number of Years Living Without ...

Average Number of Years Living Without ...

Conventional Intensive Difference

Proliferative Retin. 39.1 53.9 14.8

Macular Edema 44.7 52.9 8.2

Visual Acuity Loss 49.1 56.8 7.7

Overt Nephrop. 49.7 59.5 9.8

ESRD 55.6 61.3 5.8

LE Amputation 55.2 60.9 5.7

1st major comp. 37.0 52.2 15.2

DCCT

Quality Management and total quality management Assessment representation are the basis of quality management. Whatever the results indicate the way of Improvements. But how can quality improvement or quality development can be achieved ? This is the problem

Not just a leadership, quality management means all the executives from the administrative manager ,senior consultants, senior physicians ,senior nurses owners of practices are included in the system

Quality of process

•Reception ,talking, information to patients

•History

•Implementation of diagnotic measuresGuidelines or standards

•Patient education

BASIS OF PATIENT EDUCATION

Components of the Diabetes Components of the Diabetes TeamTeam

The Ideal ScenarioThe Ideal Scenario

DietitianDietitian

EndocrinologisEndocrinologistt

Nurse EducatorNurse Educator

Exercise TherapistExercise TherapistCase ManagerCase Manager

PCPPCP

Patient Education

Change of the Attitude and Behavior towards common health problems for better control or reduce its complications

Goal of Health Education

1. Knowledge2. Improvement , development and corrects skills3. Change attitudes and believes

LIFE STYLE MODIFICATION

STAGES OF PATIENT HEATH EDUCATION

1.Explanation of details2.Convinced by the knowledge given 3.Change believe4.Application attitude5.Transformation of recipient to donor health educator

WHO PERFORM THE HEATH EDUCATION

1.Physicians2.Nurses3.Dieteticien4.Social support5.Volunteers6.Patients themselves

Characteristics of Health educator

•Good Knowledge & experience•Good listener•Good observer•Simplicity•Repetition & Concentration•Speech tone and expression•Verbal & visual communication•Avoid scientific terms•Respect •Accepting errors

Factors in The recipient

1. Interest 2.Concentration3.The capability to change the attitude

Factors Affecting the Process of Learning

1.Time2.Place3.Intellectual ability4.Motive

The Subject must be :

short

ClearComplete

Plan For health education program

What are the goal

Who will do it

Content of knowledge & skills

When & to who

Duration &cost

THE WAY USED

• Person to person• Small groups• Large group lecture• Media: Newspaper Radio T V Pamphlets

Person to person education

Influence and effective

Friendship environment

Convenient to newly discovered

Disadvantage : Time consuming

Success depend on Welcoming & friendship environmentExpression and voice pitch changesSelection of subjectSimplicity, clarity, local accentGood occasion to ask questions

Person to person

Small group health education

No from 8 to 12

Done on short interval Once weekly on 6 sessionsNot more than 60-90 minutes

Selection of the groupType of diseaseAge & sexSpecial situation pregnancyIntellectual levelPrevious attendance

Encourage DiscussionSelf experience

Some beneficial notes in group education

Stop and ask questionsSummarize before transition from point to pointNo blame for wrong answerUse verbal and visual expressionTell small story to increase attentionSkills explained on vivid examples and tools

Education of large group

Communication with audience weakerLow degree of retention

PrerequisitesClear goalGood LecturerGood comfortable placeGood preparationSelection of the groupDuration 20 to 25 minutesAllow enough time for discussionUse audio visual aidsSimple language Summarize the lecture

Patient Education through the Media TV, Videocassette……

Easy to large no in short time and attractiveCan be repeated

DisadvantagesIncrease knowledge but not the attitudeMisunderstandingNot free from marketing influence

Evaluation of educational program

Degree of disease controlBld sugar, Wt,Glycated Hb, Lipids, Bld pressure

Prevalence of acute and chronic complication

Evaluation of the degree of retentionPre and post program questionnaireSkills direct observation

Continuous health education and repetition

Interventions to Improve Quality of Care

Luigi Meneghini, MD, MBADiabetes Research Institute (DRI)

University of Miami School of MedicineII PAHO-DOTA Workshop on Quality of Diabetes Care

DRI, 14–16 May 2003

Mastering Your Diabetes Metabolic & Psychosocial Outcomes

Diabetes Empowerment Scale (DES)Diabetes Empowerment Scale (DES)The DES is a valid and reliable survey of patient The DES is a valid and reliable survey of patient empowerment which yields an overall empowerment empowerment which yields an overall empowerment score based on all 28 items and three subscale scores score based on all 28 items and three subscale scores (range for all scales: 1.0-5.0). Improvement was evident (range for all scales: 1.0-5.0). Improvement was evident on all DES scales for participants in the MYD pilot on all DES scales for participants in the MYD pilot study, despite high baseline values.study, despite high baseline values.

Diabetes Empowerment ScaleDiabetes Empowerment Scale PretestPretest PosttestPosttest 3mF/U3mF/UOverall empowermentOverall empowerment 4.1 4.24.1 4.2 4.3* 4.3*Managing psychosocial aspects Managing psychosocial aspects 3.9 4.23.9 4.2 4.2 4.2Dissatisfaction/readiness to changeDissatisfaction/readiness to change 4.3 4.54.3 4.5 4.6* 4.6*Setting/ achieving diabetes goalsSetting/ achieving diabetes goals 4.0 4.04.0 4.0 4.1 4.1(*P<0.05 v. baseline)(*P<0.05 v. baseline)

Quality of Life & Self-EfficacyQuality of Life & Self-EfficacyMeasures of both Quality of Life (QOL) and Self-Measures of both Quality of Life (QOL) and Self-Efficacy showed statistically significant improvement Efficacy showed statistically significant improvement following the intervention. At the three month follow-up following the intervention. At the three month follow-up the most significant improvement in QOL sub-scales the most significant improvement in QOL sub-scales was for Satisfaction (p=0.0113).was for Satisfaction (p=0.0113).

8.848.84

8.018.01

7.657.65

8.108.10

7.507.50

6.806.80

7.007.00

7.207.20

7.407.40

7.607.60

7.807.80

8.008.00

8.208.20

8.408.40

8.608.60

8.808.80

Mea

n H

bA

1c %

Mea

n H

bA

1c %

Mo 1-3Mo 1-3Pre-Pre-MYDMYD

* p<0.05 v. pre-* p<0.05 v. pre-MYDMYD

Mo 4-6Mo 4-6 Mo 7-9Mo 7-9 Mo 10-12Mo 10-12

**

**

**

Impact of Comprehensive Impact of Comprehensive Diabetes Management ProgramDiabetes Management Program

Source: Rubin RJ, et al. J Clin Endocrinol Metab 1998; 83: 2635.

$406

$362

$182

$135

$84$76$44$45

$66$76

$29$30

$0

$50

$100

$150

$200

$250

$300

$350

$400

$450

Avera

ge C

ost

per

mem

ber/

mon

th

Total Inpatient Outpatient MD Drugs Other

Baseline (54,186 member months)Follow-up (55,879 member months)

* Total costs decreased by $44 per member/month (10.9%) which would translate into savings of $528,000 in the first year for a plan with 1000 members with diabetes. Break-even at 1,265 members with diabetes as per DTCA.

ARE INVOLVED IN THE PROCESS OF HEALTHCARE IMPROVEMENT

Designed by RACHA BADR