Quality

Improvement for

MDsThe 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 well-being 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

6. Practice adherence to Philippine health care goals

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 evidence-based 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 right care is not enough; we need to put evidence - based medicine into practice.

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 critical treatments are delivered consistently and in a timely manner.

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 indicators improve, outcomes usually improve as well.

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 to see if our actions have altered the indicator.

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 you.

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, and interpretation of the data.

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.

0

5

10

15

20

25

30

35

40

1 2 3 4 5 6 7 8 9 10 11 12

Months in 2008

0

0.1

0.2

0.3

0.4

0.5

0.6

Average Pred Mort

Actual Mort

SMR

Linear (SMR)

The PDCA cycle is our tool for delivering The PDCA cycle is our tool for delivering service of greater worthservice of greater worth

through continuous quality improvementthrough continuous quality improvement

Plan

Act Do

Check

P e r f o rman c e

Plan Stage1. 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 Stage3. 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 Stage1. Confirm effectiveness of solutions

2. Monitor implementation of solutions

3. 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 patient-desired 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 needs.

Create a quality culture

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 decision-making lessens the burden and shares the responsibility of complex and critically ill patients. Quality improvement creates patient-centered care. Quality improvement is the right thing to do!

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

4. ACDE

5. ABCDE

6. ABCDE

7. C

8. BCE

9. ABCD

10. A

Are you a quality improvement advocate?

10 out of 10 – you are a QI icon!

8 or 9 out of 10 – QI champion.

6 or 7 out of 10 – we look forward to more participation from you!

4 or 5 out of 8 – you can still improve the quality of your care*

<3 out of 10 – let us try again*

* 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 (Sgd) Dr Jose AcuinPresident and CEO Director, Medical Quality Improvement