Quality in Healthcare Organizations

Nawanan Theera-Ampornpunt, MD, PhDHealth Informatics Division

Faculty of Medicine Ramathibodi HospitalMahidol University, Thailand

January 9, 2013

Parts of this material were based on materials developed by Johns Hopkins University, funded by the Office of the National Coordinator for Health Information Technology, U.S. Department of Health and Human Services under Award

Number IU24OC000013 (Health IT Workforce Curriculum v.3.0, Component 12/Units 1-12).

TMHG 541: Fundamentals of Health Care and Medical Terminology

Introduction to Quality Improvement Principles of Quality and Safety The Culture of Safety Learning From Mistakes: Error Reporting and

Analysis and HIT

Introduction to Quality Improvement

This material (Comp12_Unit1a) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.

First, Do No Harm

Primum non nocere

(IOM, 2001)(IOM, 2000) (IOM, 2011)

To Err is Human (Institute of Medicine, 1999) Reported that:

• 44,000 to 98,000 people die in hospitals each year as a result of preventable medical mistakes

• Mistakes cost hospitals $17 billion to $29 billion yearly

• Individual errors are not the main problem• Faulty systems, processes, and other conditions

lead to preventable errors

6Health IT Workforce Curriculum Version 3.0/Spring 2012

Introduction to Healthcare and Public Health in the US Regulating Healthcare

Lecture d

Affected 1 in 3 hospital patients in one study In 2008, harms to patients from medical

errors cost $17.1 billionErrors can result in medical malpractice

lawsuits• 42% of doctors are sued at some point• Hospital malpractice suits alone could top $8.6

billion in 2011Suffering from medical errors: not

measurable

7Health IT Workforce Curriculum

Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US

Regulating Healthcare Lecture d

Humans are not perfect and are bound to make errors

Highlight problems in the U.S. health care system that systematically contributes to medical errors and poor quality

Recommends reform that would change how health care works and how technology innovations can help improve quality/safety

Health IT plays a role in improving patient safety (but it may also carry risks to safety in certain ways)

“Healthcare reform without attention to the nature and nurture of healthcare as a system is doomed …It will at best simply feed the beast, pouring precious resources into the overdevelopment of parts and never attending to the whole — that is care as our patients, their families and their communities experience it.” (Berwick, 2009)

“The performance of a system — its achievement of its aims —depends as much on the interactions among elements as on the elements themselves. (Berwick, 2009)

“The improvement of health and healthcare depends on systems thinking and systems redesign… ‘Reform’ without systems thinking isn’t reform at all.” (Berwick, 2009)


Quality Improvement Introduction to QI and HIT

Lecture a

MEANINGFUL USEProviders show they're using certified EHR technology in ways that can be measured significantly in quality and in quantity.

PATIENT-CENTERED MEDICAL HOMEProviders organize care around patients, working in teams,coordinating care, and tracking over time.

ACCOUNTABLE CARE ORGANIZATIONProvider reimbursements are tied to quality metrics and reductions in the total cost of care for assigned population of patients.



Lecture a

The American Recovery and Reinvestment Act of 2009“…authorizes the Centers for Medicare & Medicaid Services (CMS) to provide reimbursement incentives for eligible professionals and hospitals who are successful in becoming ‘meaningful users’ of certified electronic health record technology …” (The American Reinvestment and Recovery Act of 2009)

• The HITECH (Health Information Technology for Economic and Clinical Health) Act establishes programs under CMS in coordination with the Office of the National Coordinator to accomplish this charge.



Lecture a

Improve quality, safety, & efficiencyEngage patients & their families Improve care coordination Improve population & public health;

reduce disparitiesEnsure privacy & security protections



Lecture a



Lecture a

The quality of care received needs improvement.

In the current healthcare environment there are a number of initiatives that aim to improve the care in the U.S. context through the use of HIT.• Meaningful Use

• Patient Centered Medical Home

• Accountable Care Organization



Lecture a

“Quality”

“Quality of care is the degree to which health services for individuals and

populations increase the likelihood of desired outcomes and are consistent with

current professional knowledge.” (IOM, 2001)



Lecture b

Better patient outcomes (patient health)Better system performance (patient care)Better professional development

(clinician learning)Scientific evidence + particular context =

measured performance improvement


Introduction to Healthcare and Public Health in the US The Evolution and Reform of Healthcare in the US

Lecture c



Lecture b

National Quality Forum (NQF) www.qualityforum.org National Committee for Quality Assurance (NCQA) www.ncqa.org Provider organizations

• AMA’s Physician Consortium for Performance Improvement (PCPI) www.ama-assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinical-quality/physician-consortium-performance-improvement

Joint Commission (JC) www.jointcommission.org Institute for Healthcare Improvement (IHI)



Lecture b

Joint Commission certifies medical care facilities• Oldest and largest healthcare accrediting body• Independent nonprofit organization• Evaluates more than 18,000 US healthcare

organizations and programs of all types Goal is to improve effectiveness, safety, and value

of healthcare Organizations must undergo periodic site visits to

identify and resolve problems


Introduction to Healthcare and Public Health in the US Delivering Healthcare (part 1)

Lecture c

1910: The forerunner of JC is called the “end-result” system

1951: Joint Commission on Accreditation of Hospitals (JCAH) is created and starts accrediting and certifying healthcare organizations

1987: Name changed to Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

2007: Name simplified to Joint Commission (JC); currently accredits and certifies more than 18,000 organizations and programs in the US



Lecture a

“To continuously improve healthcare for the public, in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.”(The Joint Commission, 2011)



Lecture a

Earned by an entire healthcare organization (hospital, nursing home, office-based surgery practice, etc.)

Tools the JC uses to measure performance• Integrated Survey Process (ISP): Evaluates

performance across organization• ORYX: System for healthcare organizations to report

to the JC about patients with certain conditions (core measure sets) The core measure sets reported depend on the type and size

of the organization



Lecture a

Examples• Heart attack• Pneumonia• Inpatient psychiatric care• Children’s asthma• Stroke

Each core set has performance measures• For example, the JC looks at whether children

with asthma received certain drugs in the hospital and were sent home with a management plan



Lecture a

JC-accredited organizations and providers of healthcare staffing services can also earn certification for specific programs or services• For chronic diseases and conditions Examples: asthma, diabetes, heart failure programs

• Programs can be within the medical center or in the community



Lecture a

National Patient Safety GoalsUniversal ProtocolOffice of Quality MonitoringSpeak Up™ programSentinel Event Policy



Lecture a

Sentinel Event Policy• Unexpected death, unexpected serious physical

or psychological injury, or the risk of such an event

Patient Safety Advisory Group• Panel of experts who recommend National

Patient Safety Goals• Also address newly developing safety issues



Lecture d

• Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery– Pre-surgery verification– Site marking– “Time out” before an incision is made

• The Speak Up Initiative– Encourages patients to participate in their care– Free patient education materials



Lecture d


Introduction to Healthcare and Public Health in the US The Evolution and Reform of Healthcare in the US

Lecture c

Part of Department of Health and Human Services

Mission: “to improve quality, safety, efficiency, and effectiveness of healthcare for all Americans”• Safety and quality: Reduce risk of harm• Effectiveness: Improve healthcare outcomes• Efficiency: Transform research into practice

The Healthcare Accreditation Institute (Public Organization) www.ha.or.th Joint Commission (JC) www.jointcommission.org International Organization for Standardization (ISO) www.iso.org Provider & professional organizations

• University Hospital Network (UHOSNET) www.uhosnet.com

• The Medical Council of Thailand www.tmc.or.th

• Thai Medical Informatics Association (TMI) www.tmi.or.th

• Other professional councils and organizations Regulatory organizations

• Ministry of Public Health

• Ministry of Education Thai Qualifications Framework for Higher Education (TQF:HEd)

Payer organizations

• National Health Security Office (NHSO) www.nhso.go.th

• Social Security Office (SSO)

• Comptroller-General Department Other quality frameworks

• Thai Quality Award (TQA) www.tqa.or.th30

Needs to be improved, especially for the uninsured

Patient safety & healthcare-associated infections warrant urgent attention

Quality is improving, but pace is slow, especially in preventive care & chronic disease management

Disparities are common and lack of insurance is a contributor

Many disparities are not decreasing; those that warrant increased attention include care for cancer, heart failure, and pneumonia



Lecture b

National study of physician performance for 30 medical conditions plus preventive care: physicians provided only 55% of recommended care.

(McGlynn et al. NEJM 2003; 348:2635)

66% of people with hypertension are inadequately treated. (JNC 7, JAMA 2003;289: 2560)

63% of people with diabetes have HbA1c levels greater than 7.0%. (Saydah, et al. JAMA 2004;291:335)

62% of people with elevated LDL cholesterol have not reached lipid goals.

(Afonso, Am J Man Care 2006;12:589)

50-70% of healthcare-associated infections are preventable.(Umscheid et al. Infect Control Hosp Epidemiol. 2011 Feb;32(2):101-14.)

24.7% of Medicare patients admitted to the hospital for heart failure are readmitted within 30 days.

(CMS, 2009)



Lecture b

Only 27% of adults with a regular primary care physician (PCP) could easily contact their physician over the telephone, obtain care or medical advice after hours, or experience timely office visits.

Only 57% of adults rate the information they get about their health issues as very good; only 43% find it easy to get an appointment; and only 56% find the physician’s office to be well-organized and feel their time is not wasted.



Lecture b

Given the current sub-optimal quality of care received by patients, the introduction of QI initiatives is imperative.

HIT has an important role to play in QI initiatives.



Lecture b

“Every system is perfectly designed to achieve the results it achieves.”

(Paul Batalden, M.D, 2008)

So, the answer must lay in the system redesign.



Lecture b



Lecture b

Make it specific• Assign it a number if possible

Assign it a timelineMake it measurableMake sure it is challenging but doable



Lecture b

PROCESS MEASURE: Are we doing what we must to get the improvement we seek?

OUTCOME MEASURE: Are we getting what we expect?

BALANCING MEASURE: Are we causing new problems in other parts of the system?



Lecture b

Hospital• AIM: we will reduce the number of

ventilator-associated pneumonias (VAP) in the ICU from the current 23% to under 10% in 4 months

• MEASURES: Process measure: Ventilator days Over-sedation hours Oral care performed

Outcome measure: Number of VAP

Balancing Measure: Cost of care Re-intubation rates

Ambulatory• AIM: we will reduce the amount

of time it takes our patients to get an appointment (request to appointment) from 23 days to 0 days in 6 months

• MEASURES: Process measure: Supply Demand No-show rate

Outcome measure: third next available appointment

Balancing Measure: Patient satisfaction



Lecture b

Concepts and strategies: decide on the overall changes that will lead to the desired improvement.

Specific changes: • Make them small• Make them fast• Make them frequent

You may need to include additional measures specifically to decide if a change you have tested is worth keeping or did not lead to improvement.

Consider using pre-existing change packages.



Lecture b

• One of the most important aspects of QI is to understand how your systems actually perform, under a range of conditions.

• Deming’s theory of profound knowledge is based on the principle that each organization is composed of a system of interrelated processes and people.

• The improvement of the system depends on the capability to organize the balance of each component to enhance the entire system.

• Understanding and learning about your system is essential to improve it.



Lecture b

• PDCA (Deming Cycle)

42

Plan

Do

Check

Act

http://en.wikipedia.org/wiki/Shewhart_cycle

• Continuous Quality Improvement (CQI)http://en.wikipedia.org/wiki/Continual_improvement_process

Quality improvement is an ongoing, continuous effort

• Total Quality Management (TQM)http://en.wikipedia.org/wiki/Total_quality_management

Quality of products and processes is the responsibility of everyone involved in the products or services

• Six Sigmahttp://en.wikipedia.org/wiki/Six_Sigma

Seeks to improve quality by removing causes of defects and minimizing variability in manufacturing and business processes

43

• Leanhttp://en.wikipedia.org/wiki/Lean_manufacturing

Considers expenditure of resources that does not create value a waste -> “Preserving value with less work”

Including tools such as Value Stream Mapping, 5S, Kanban (pull systems), Just in time (JIT), etc.

• Routine to Research (R2R)http://home.kku.ac.th/kitsir/research/html/download/news/r2r.pdf

Improves the routine work processes through research

• Risk Managementhttp://en.wikipedia.org/wiki/Risk_management

Identification, assessment, prioritization , prevention, mitigation, monitoring, and control of risks

44

Image source: Senoo et al. (2007) http://dx.doi.org/10.1108/14601060710776725

Nonaka SECI Model

The quality of care received needs improvement.

Quality improvement is an ongoing process that includes the setting of an aim and a progressive measurement, change test, and understanding of the system.

There are various complementary approaches to quality improvement



Lecture b



Lecture c

Principles of Quality and Safety for HIT



Quality Improvement Principles of Quality and Safety for HIT

Lecture a

In U.S. Healthcare system7% of patients suffer a medication error44,000- 98,000 deaths100,0000 death from hospital-acquired

infectionsPatients receive half of recommend

therapies $50 billion in total costs

Similar results in UK and Australia



Lecture a

How can this happen?

We need to view the delivery of health care as a science



Lecture a

1. Accept we are fallible—assume things will go wrong rather than right.

2. Every system is perfectly designed to achieve the results it gets.

3. Understand principles of safe design. • Standardize• Create checklists• Learn when things go wrong

4. Recognize these principles apply to technical and team work.

5. Teams make wise decision when there is diverse and independent input.

Caregivers are not to blame



Lecture a



Lecture a



Lecture a

Standardize. • Eliminate steps if possible.

Create independent checks.Learn when things go wrong.

• What happened?• Why did it happen?• What did you do to reduce risk?• How do you know it worked?



Lecture b



Lecture b



Lecture b



Lecture b

Assume things will go wrong Develop lenses to see systems Work to Mitigate Technical and Teamwork

Hazards• Standardize work• Create independent checks• Learn from mistakes

Make wise decisions by getting input from others

Keep the patient the north star



Lecture b

In this unit we’ve learned about the ways that teams make wise decisions with diverse and independent input. We’ve also explored the importance of communication and especially the place of critical listening.



Lecture b

The Culture of Safety

This material (Comp12_Unit4) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.

Video 1


Quality Improvement Reliability, Culture of Safety, & HIT

Pointing the finger at people rather than systems.





Limits learning Increases likelihood of repeat errorsDrives self-reporting underground











In this unit we explored the characteristics of high reliability organizations and learned more about establishing an organizational culture of safety.



Learning From Mistakes: Error Reporting and

Analysis and HIT: Part 1


“A new delivery system must be built to achieve substantial improvements in patient safety – a system that is capable of preventing errors from occurring in the first place, while at the same time incorporating lessons learned from any errors that do occur.”(IOM,2004)


Quality Improvement Learning From Mistakes: Error Reporting and Analysis

and HIT─Lecture a



and HIT─Lecture a



and HIT─Lecture a

Admit that providing health care is potentially hazardous

Take responsibility for reducing risks Encourage error reporting without blame Learn from mistakes Communicate across traditional hierarchies and

boundaries; encourage open discussion of errors Use a systems (not individual) approach to analyze

errors Advocate for multidisciplinary teamwork Establish structures for accountability to patient safety



and HIT─Lecture a



and HIT─Lecture a

Near Miss Harm



and HIT─Lecture a

Swiss cheese model of errorA culture of safetyThree HIT mechanisms to help control

error• surveillance systems, on-line event reporting,

and predictive analytics/data modelingRisk assessment model (near-miss VS

harm)



This material (Comp12_Unit12b) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.


Quality Improvement Learning From Mistakes: Error Reporting and Analysis and

HIT─Lecture b



HIT─Lecture b



HIT─Lecture b



This material (Comp12_Unit12c) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.



HIT─Lecture c

Structured problem-solving process

Considers all potential causal or contributing factors Human factors System factors

Detailed chronological list of events surrounding incident

Premise: one can learn from one’s mistakes



HIT─Lecture c



HIT─Lecture c

Healthcare Example: Mrs. A. received blood in the Emergency Department. Within 15 minutes, she experienced a bad reaction. Her nurse realized that she had received blood intended for another patient. She was transferred to the intensive care unit to be stabilized. The ED staff wanted to know how this could have happened so they assembled a team to identify possible causes.



HIT─Lecture c

Briefly describe event Identify affected areas/servicesAssemble a team Diagram the process (flow chart) Identify potential root causes Prioritize root causes Develop action plan Evaluate results!



HIT─Lecture c



HIT─Lecture c

Story: Before I had children, I invited one of my high school friends and her family, including a toddler, to dinner. I was worried that her toddler would somehow manage to hurt himself in my house, which was designed for a childless couple.



HIT─Lecture c

Select a high risk process, one that is

known to have problems, and assemble a

team.



HIT─Lecture c



HIT─Lecture c



HIT─Lecture c

The higher the number, the more urgent the need to prevent a failure.

Event: After reading several articles about laboratory specimen errors that result in lab tests being done on the wrong patients, doctors at a community office practice decide to examine the potential for this problem to happen in their office laboratory.



HIT─Lecture c

Select a high risk process (patient identification):• Affects a large number of patients• Carries a high risk for patients• Has known process problems identified by other

organizations (e.g., Joint Commission Sentinel Event Alert!) Assemble a team

• People closest to issue involved• People critical to implementation of potential changes• Respected, credible team leader• Someone with decision-making authority• People with diverse knowledge bases



HIT─Lecture c



HIT─Lecture c

The higher the number, the more urgent the need to prevent a failure.



HIT─Lecture c



HIT─Lecture c



HIT─Lecture c

Tools• Root Cause Analysis (RCA)• Failure Mode Effect Analysis (FMEA)• Hazard Analysis• Flow Charting

Health & Medicine

Quality in Healthcare Organizations