11 quality: the race without a finish line. 2 conflict of interest disclosure speaker conflict of...
TRANSCRIPT
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Quality: The Race Without a Finish Line
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Conflict of Interest Disclosure
• Speaker Conflict of Interest.• Melanie Simpson is on the Speakers Bureau for Pacira
Pharmaceutical, Inc.
A conflict of interest is a particular financial or non-financial circumstance that might compromise, or appear to compromise, professional judgment. Anything that fits this should be included. Examples are owning stock in a company whose product is being evaluated, being a consultant or employee of a company whose product is being evaluated, etc.
– Taken in part from “On Being a Scientist: Responsible Conduct in Research”. National Academies Press. 1995.
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Additional Disclosures
• I do not have the formula for quality pain management
• I do not have all the answers• I will tell you how I do pain management at KU
(however it is not perfect)• I do own pain management at my institution
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Pain Management Resource Team
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Coalition for Comprehensive Pain Management
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What is quality?
• Health care quality is generally defined in terms of the attributes and outcomes of care provided by practitioners and received by patients.
• The Institute of Medicine: quality is the degree to which health services increase desired health outcomes and are consistent with professional knowledge.
• Patient satisfaction is a recommended measure in most evaluations of quality.
National Committee for Quality Assurance
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Definition of Quality
Quality
HarmReduction
Reporting Culture of Accountability
Continuous Improvement
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What is quality?
• The University of Kansas Hospital:– Quality is a measure of how well we provide care, save
lives and prevent harm. – Quality is measured through mortality data and patient
satisfaction
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Mortality Index(Actual Deaths/Expected Deaths Based on Severity of Illness)
0.7300.681
0.5850.642
0.699 0.737
0.614 0.586
0.738
0.465
0.624 0.649 0.647
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0.000
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Index Ranking
Good
312 Fewer Deaths Than Expected Based on Patient Acuity FY1378 consecutive months with Mortality Index <1.0
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Patient Satisfaction - Press Ganey3
Q9
94
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91
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US News & World Report ranks The University of Kansas Hospital , 7th nationwide in patient satisfaction for Pain
Management of the top 3000 hospitals, 2009
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Our Guiding FormulaWorld Class
Patient OutcomesWorld Class
Patient Satisfaction
Delivered by Competent, Committed and Engaged Staff
Strong, Sustainable
Growth
Strong, Sustainable
Financial Performance
Quality Service
People
Growth Cost
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Expanding the Definition of Quality
Quality
HarmReduction
Efficiency
EffectivenessReporting
Culture of Accountability
Continuous Improvement
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Quality Assurance vs Improvement
• Quality Assurance—broad based form of audit and feedback in which outcomes are compared; may be too late in the process to provide practical information
• Quality Improvement—Broader, more comprehensive descendant of QA; focused on systems improvement; collection of data “along the way”
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Quality improvement: guidelines and evidence based practice
• Guidelines are systematically developed statements based on evidence designed to help practitioners and patients make appropriate health care decisions for specific clinical conditions
• Pub Med, Up-to-date, Cochrane Collaboration, Lippincott—many “evidence” related sites
• Ask yourself—– 1. Is there scientific evidence– 2. If there is no evidence, is it useless?
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APS QI guidelines for the treatment of acute and cancer pain
• Recognize and treat pain promptly –comprehensive assessment and importance of preventive and prompt treatment based on evidence for neuroplasticity
• Involve patients in the pain management plan—customization of care and participation in treatment plan; patients need to know their options and responsibilities for participation
Gordon et al. (2005). APS Recommendations for Improving the Quality of Acute and Cancer Pain Management, Archives of Internal Medicine, (165), 1574-1580
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APS QI guidelines for the treatment of acute and cancer pain
• Improve treatment patterns—multimodal approach, ensuring treatments are safe, evidence based advancements, move from old routines
• Reassess and adjust pain management plan as needed—respond not only to pain intensity but to functional status and side effects, establish realistic goals, consider the burden of treatment on quality of life and resources
Gordon et al. (2005). APS Recommendations for Improving the Quality of Acute and Cancer Pain Management, Archives of Internal Medicine, (165), 1574-1580
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APS QI guidelines for the treatment of acute and cancer pain
• Monitor process and outcomes of pain management with the goal of continuous improvement– Why do we do what we do?– How do we know it works?– How can we do it better?
Gordon et al. (2005). APS Recommendations for Improving the Quality of Acute and Cancer Pain Management, Archives of Internal Medicine, (165), 1574-1580
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APS guideline implementation results
• Improvement in assessment of pain
• Improvement in prescribing practices
• Improvement in patient outcomes
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Key elements in an institutional QI program
• Patient comfort and satisfaction with pain management
• The range and appropriateness of options available within a particular institution
• How those options are best applied• Minimizing side effects and complications related to
pain control
Agency for Health Care Policy and Research QA Guidelines
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Patient Satisfaction and Pain
• Patient satisfaction is based on patient expectations
• Responses can be skewed and difficult to interpret
• Paradoxical, yet consistent findings that despite high
pain ratings, satisfaction scores may be high
• Likely more appropriate to evaluate the patient’s
perception of involvement in his own pain control
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HCAHPSHospital Consumer Assessment of Healthcare Providers and Systems
• Center for Medicare and Medicaid Services (CMS) included questions to measure patients’ perceptions of pain management.
• It emphasized the importance of pain management to patient satisfaction
• Hospitals need to be more transparent about what they are doing to improve pain management and what patients should expect as a result.
Press Ganey, 2012
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HCAHPS
• Body text goes here
Domain FY14YTDAll DB
FY13YTDLarge DB
Top Box Answer
Rate Hospital (0-10) 98 99 9-10
Recommend 98 99 Definitely Yes
RN Communication 92 98 Always
MD Communication 78 88 Always
Responsiveness 86 96 Always
Hospital Environment 48 61 Always
Pain Management 90 96 Always
Med. Communication 96 99 Always
Discharge Information 92 96 Yes
Care Transitions 93 97
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HCAHPS Questions
• During this hospital stay, did you need medicine for your pain?
• During this hospital stay, how often was your pain well-controlled?
• During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?
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Qualitative Assessment of Hospitalized Patients’ Satisfaction with Pain
Management
• 3 main themes:– Lack of provider knowledge– Lack of patient education– Lack of caring
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Opportunities for quality improvement for pain management
• Explicit policies and procedures to guide the use of specialized techniques for analgesic administration
• Clearly defined accountability for pain management• An ongoing process that evaluates the outcomes and
works to improve the quality of pain management
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Opportunities for quality improvement for pain management
• Information about pharm and nonpharmacologic interventions for clinicians to facilitate writing, interpreting and implementing of orders
• Orientation and continuing education opportunities
• Patient and family education programs and materials
• Change perception of caring
Lack of provider knowledge
Lack of patient education
Lack of caring
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Some of our interventions• Lack of provider knowledge
– Pocket Analgesia guides– Education presentations, grand rounds, PRN, staff mtgs– LMS – required yearly (range order policy, opioid dilution, etc.)
• Lack of patient education– Preanesthesia testing clinic video– Opioid teaching sheet– White boards
• Lack of caring– Comfort video – required– 5 minutes of caring
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Summary
• Guiding principles of quality remain knowledge-based, patient-centered and system-minded care
• Outcomes research has resulted in new measures of quality—example, improved function as an outcome of quality pain management
• Quality improvement is ongoing process:
Or in other words: the race without a finish line