Group FQuality

Willie Jackson, IIILisa KanarekJennifer KimVatrice Perrin

So Why Care About Quality Anyway?

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

At least 44,000 Americans die each year as result of medical errors.

Deaths due to medical errors exceed the number attributable to 8th leading cause of death.

More people die in given year as result of medical errors than from MVA’s, breast cancer or AIDS.

Medication errors alone estimated to account for over 7,000 deaths annually.

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

Adults receive recommended and appropriate health care approximately ½ of the time Overall care – 55% Acute care – 54% Preventive care – 55% Chronic care – 56%

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

There are as many as 7,000 deaths annually in the United States from incorrect prescriptions (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… That’s 150 MILLION WRONG

prescriptions!Source: http://www.consumeraffairs.com/news/pharmacy_errors.html

Why We Care…Medical Mishaps

Indianapolis -- two premature infants died and a third was in critical condition after being given adult-size 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

© 2004 Express Scripts, Inc. All Rights Reserved.

Betsy LehmanBoston Globe Health Reporter

Died December, 1994 after

receiving an accidental four-

fold overdose of

chemotherapy.

“Celebrity illness can help

change public attitudes.

There is no shortage of

precedents.”

Boston Globe, May 23, 1994

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

Guilds responsible for product service and quality (1200-1800)

Evolution of US practices in 1800’s (Industrial Revolution)

Craftsmanship Factory system Taylor system (Frederick W. Taylor)

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.

20th century: Process-oriented and WWII Emergence of Quality Improvement Leaders

Joseph M. Juran Statistical quality control at Western Electric Quality Control Handbook Provided assistance to Japanese after WWII

Edward 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.

20th century Edward 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.

Total Quality approach in Japan Japanese manufacturers focused on improving

all organizational processes through people who used them.

Higher quality exports at lower prices. Total Quality Management

American response in 1970’s emphasizing not only statistics but approaches that embraced entire organization.

Malcolm Baldridge National Quality Awards

Big Whigs in Pioneering Quality

Florence Nightingale The Crimean War The Charge of the Light Brigade Birth of the Modern Hospital

Ernest Amory Codman, MD The End-Result Idea

Don Berwick, MD 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 facilities as in their homes

2. Effective - our science/evidence should serve as standard for HC delivery

3. Efficient - care/service should be cost effective, and waste should be removed

4. Timely - pts should experience no waits/delays in receiving care & services

5. Patient Centered - should revolve around pt preferences, who should have

control6. Equitable - unequal treatment and disparities

should be long since eliminatedSource: Ransom, Scott, Maulik, Joshi, Nash, David. The Healthcare Quality Book. Health Administration Press. 2004.

What is Six Sigma? 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.

Universal Standards:Six Sigma

Source: Six Sigma at url: http://www.isixsigma.com/sixsigma/six_sigma.asp

1

10

100

1,000

10,000

100,000

1,000,000

Defectsper

million

level (% defects)

U.S. IndustryBest-in-Class

Anesthesia-relatedfatality rate

Airline baggage handling

Outpatient ABX for colds

Post-MI-blockers

Breast cancerscreening (65-69)

Detection &treatment ofdepression

Adverse drugevents

Hospital acquired infections

Hospitalized patientsinjured through negligence

1(69%)

2(31%)

3(7%)

4(.6%)

5(.002%)

6(.00003%)

Source: modified from C. Buck, GE

“Measurements Drive Performance”

Overall Health Care in U.S. (Rand)

Six Sigma

Six SigmaStrategy 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

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

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.

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

One or more measures in at least three of the four functional categories (rx, monitoring, achieving goals, compliance)

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?

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

Improve quality of medication use

Develop core set of quality measures that are nationally standardized and would be widely used for QI and accountability

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/ look-alike names and packages of medication

Standardization of treatment policies and protocols to avoid confusion and reliance on memory

known to be fallible and responsible for many errors

Source: http://www.ahrq.gov/qual/errback.htm

Health Industry Standards for QI

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” Concerned for individual Doctors and Nurses

Training Problems with Capacity v. Capability

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

Political Implications of QualityParty 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

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

MEDIC Bill

Key points in MEDIC proposal:

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.

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)

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

Previous Legislation

The Medicare Modernization Act of 2003 (MMA)

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.

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.

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

Goals

Designate “patient safety work product” as privileged and not subject to:

(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

DHHS Secretary Michael Leavitt

Requires DHHS Secretary to:

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

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…

“..the prices of care, not the amount of care delivered, are the primary difference between the U.S. and other countries…the more-costly 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

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.

Patient Safety and Quality Improvement Act of 2007

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

PSQIA 2007: Target Groups

Health Care Providers Hospitals Clinics Physicians

PSQIA 2007: Mechanism

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

PSQIA 2007: Outcomes

PSQIA 2007: Fiscal Implications

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).