Physician Quality Improvement SummitNovember 19, 2018

disclosuresCarolyn Canfield and Dr Hector Bailliehave declared that they have nocommercial interests to disclose

Hector Baillie MDSpecialist in Complex Adult Medicine

Nanaimo BC

19 November 2018

Changes in 100 years• Nutrition• Sanitation• Housing• Education• Vaccination• Health Service• Diagnostics• Medication/Surgery• Peace

WarObesity-DiabetesHepatitis/HIVSmoking illnessesTravelCancerDegenerative diseaseCosts

Situational Lifestyle

COLLABORATION• DOCTORS AND

NURSES ARE BURNTOUT – WHY?

COMMUNICATION Communication:9/10ths of Medicine

9/10ths of Life

What’sMissingHere?

COMMUNICATIONCommunication:

9/10ths of Medicine9/10ths of Life

This ismy

AuntJenny!

FAST MEDICINE

- BLOOD TEST- DRUG- OPERATION- DEVICE

SLOW MEDICINE

- TALK WITH PATIENT- TALK WITH FAMILY- ACKNOWLEDGE FEAR- END OF LIFE CARE- COMFORT & RESPECT

Physician

Nurse/Allied HC

Administration

PATIENT

COMMUNICATION

SPECIALST SUPPORT COMMITTEEPHYSICIAN QI INITIATIVE

• FUNDED BY MINISTRY OF HEALTH, DIRECTED BY DOBC- caregiver re-engagement- better patient outcomes

• INDIVIDUAL HEALTH AUTHORITIES• 12 PHYSICIAN LED TEAMS (QI consultant & co-ordinators, data analyst)• 1 YEAR PROJECT• WORKSHOPS• POSTER PRESENTATIONS• LEARNING FROM QUALITY FORUM VANCOUVER/IHI ORLANDO• NOW IN ITS THIRD YEAR

Plan

DoStudy

Act

Patient identified as SDB- CPAP/MAD therapy- Improvement in EF

and NT-proBNP- Improvement in

quality of life(subjective)

- Prospective consecutive patient enrolmentfrom referral cohort to NRGH HF Clinic

- Age, sex, BMI, HR/BP, AHI, LVEF, BNP noted- Epworth score on all patients- Level III sleep study- Follow-up visits to assess OSA+Rx: with

measurement of LVEF/BNP/QoL

The PQI Initiative provides training and support to physicians, through technical resources and expertise, to lead quality improvement (QI) projects, whichbuild QI capacity. This investment increases physician involvement in quality improvement and enhances the delivery of patient care.

Please see our website for more details: sscbc.ca

CONCLUSIONHeart failure (HF) either with reduced or preserved ejection fraction, is becoming more common as our population ages,and as the obesity epidemic evolves. Common causes of HF include hypertension, ischemic heart disease and valvulardysfunction. Obstructive sleep apnoea is a well recognised cause of refractory hypertension, arrhythmia and oxidativestress. It is more common in men, and is linked to obesity. Our study shows that it must be considered in all patientswith HF, who should be screened and offered appropriate therapy. Quality of life improves, LV function improves, andsurvival improves. We would like to see the STOP-BANG questionnaire become standard in HF Clinics.

• Hector M Baillie MD (Physician Lead)• Honeylette Abesamis RN (HF Clinic Nurse)• Suzanne Beyrodt-Blyt RN (QI Co-ordinator)• Curtis Bilson (Data Management)

Obstructive Sleep Apnoea (OSA) leads to intermittenthypoxia, increased RV volumes and SNS activation,leading to hypertension, arrhythmia, atherosclerosis,and heart failure. Prevalence in the general population2-7%, but 30-50% in HF patients. Treatment withCPAP or mandibular advancement device can improvehealth and increase survival (ACC/AHA class IIarecommendation).Central Sleep Apnoea (CSA) often a consequence ofadvanced HF/low cardiac output: CPAP can improveSa02 but no survival advantage.

BACKGROUND PROBLEM

- To determine prevalence SDB in 42consecutive HF patients over a 6 monthperiod.

- To identify an effective screening tool forOSA’

- To determine if SDB intervention, combinedwith standard medical therapy, improves HFoutcome measures (LV-EF, NT-proBNP):predicted 40% improvement.

AIM OF PROJECT

PDSA Cycle

DATA ANALYSIS

“Most nights Ispent in theLazy-Boy…Iwas sleepywith HF, Ioften felt I wasdrowning”.

Image 3: Description / summary of the abovedata diagram

Sleep disordered breathing is poorly recognised as acause (and effect) of heart failure. Diagnosis is simple,treatment effective. Patient compliance with bothseem variable, despite proven benefit in terms ofoutcomes, and quality measures. By using screeningquestionnaire, and intervening with CPAP or amandibular advancement device, heart functionimproves.

1. OSA is under-recognised by referralphysicians

2. Prevalence of SDB in HF Clinic: %3. Epworth Score not a good screening tool: we

will use STOP-BANG questionnaire in future4. CPAP and MAD treatment had positive

benefit in terms of HF outcomes (Echo, BNP)

FINDINGS

PATIENT VOICE

Sleep Disordered Breathing in CHFa common finding in HF - not commonly recognised.

TEAM PLAYERS

“With CPAP, the difference was immediate... I sleptlike a baby for the first time in 3 years.... yes there issome frustration with the mask if the fit isn’t perfect,but I feel wonderful now” - C.O.

Range Age

36-40 45-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85 85+

0

1

2

3

4

5

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8

9

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11

Num

bero

fRec

ords

4

1

1

1

1

1 1

8

3

3 3

7

2

2

2 2

Island Health: NRGH Hear t Function Clinic Sleep Apnea PatientsNovember 2016 - July 2017Number of Records by Pat i ent Age Ranges and Gender

SexFemal eMal e

Range AHI / Pre Post AHIUnder 10 10 -19 20 -29 40-49 Nul l

PRE POST PRE POST PRE POST PRE POST PRE POST0

2

4

6

8

10

12

14

16

18

20

Nu

mb

ero

fRe

cord

s

1 9

9

8

5

2

5

2

5

11

18

Island Health: NRGH Heart Function Clinic Sleep Apnea Pat ientsNovember 2016 - July 2017Number of Records by Pre and Post Apnea-Hypopnea Index (AHI)

Pre Post AHIPRE

PO ST

Range BMI / PrePost BMIUnde r 20 20-24 25-29 30 -34 35+ Nu ll

PRE PRE POST PRE POST PRE POST PRE POST PRE PO ST0

2

4

6

8

10

12

14

16

18

Nu

mb

ero

fRe

cord

s

1

8

7

13

17

12

5

3 3

14

1

Island Health: NRGH Heart Function Clinic Sleep Apnea Patient sNovember 2016 - July 2017Number of Records by Pr e and Post Body/Mass Index (BMI )

PrePost BMIPRE

POST

Range HR / PrePost HR40-59 60-79 80-99 100+ Nul l

PRE POST PRE POST PRE POST PRE POST0

2

4

6

8

10

12

14

16

18

20

Num

bero

fRec

ords

11

13

15

19

8

3

2

13

Island Healt h: NRGH Heart Funct ion Clinic Sleep Apnea Patient sNovember 2016 - July 2017Number of Records by Pr e and Post Heart Rates

PrePost HRPREPOST

Physician

Nurse/Allied HC

Admin

PATIENT

COMMUNICATION

Patients are taxpayers

Patients deserve to knowwhat’s working well, whatisn’t

Patients are unrepresented inalmost all committees I’veever been on

Patients have importantperspectives we shouldrespect: we are all patients-in-waiting

Patient leadership in healthcare

Patient focus – safety

Patient direction – quality means..?

Re-engagement

Patients should be an integral part of our PQI teams

Michael E Porter Thomas H Lee

Porter, Michael E. "What is value in health care?."Lee, Thomas H. "Putting the value framework to work.”New England Journal of Medicine 363.26 (2010): 2477-2483.

OUTCOMES** (QUALITY + SAFETY + SATISFACTION)

COST

VALUE EQUATION =

** “As is often true in medicine itself, the critical first step ismeasurement. Provider organizations need to capture dataon the outcomes that matter to patients, as well as the costsfor a patient over meaningful episodes of care.” T.H.Lee 2010

⋅ OUTCOMES THAT MATTER TO PATIENTS⋅ COMPREHENSIVE COSTS TO CARE FOR A PATIENT⋅ MEANINGFUL [to the patient] EPISODES OF CARE

Lee, Thomas H. "Putting the value framework to work.”New England Journal of Medicine 363.26 (2010): 2481-2483.

QUALITYSAFETY

managing risk

Vincent, C., & Amalberti, R. (2016). Safer healthcare: Strategies for the real world.

Vincent, C., & Amalberti, R. (2016)Safer healthcare: Strategies for the real world

“Management of RISK over time in order to

MAXIMIZE benefit and

MINIMIZE harm

to patients in the healthcare system”

Patient Safety: a Definition

X

^

studio Mile

Six Levers toHelp Organizationsto AccelerateHealthcareImprovement

https://www.cfhi-fcass.ca/PublicationsAndResources/ResourcesAndTools/six-levers

“the citizen-patient”

Working definition of“citizen-patient”

a person who has health services experience(patient, family or community) AND has aninterest in supporting system level improvement

patientvoicesbc.ca

We’re all patients, Carolyn!

Work As Imagined*

Why is work-as-imagined different from work-as-done? / Hollnagel, Erik. in Resilient Health Care: The resilienceof everyday clinical work. ed. / Robert L Wears; Erik Hollnagel; Jeffrey Braithwaite. Vol. 2 Ashgate, 2015. p. 249-264.*

http://resilienthealthcare.net/onewebmedia/WhitePaperFinal.pdf

Work As Imagined*

image credit: BMC Systems Biology 2011, 5:168

Work As Done* - care networks

Why is work-as-imagined different from work-as-done? / Hollnagel, Erik. in Resilient Health Care: The resilienceof everyday clinical work. ed. / Robert L Wears; Erik Hollnagel; Jeffrey Braithwaite. Vol. 2 Ashgate, 2015. p. 249-264.*

image credit: Mednick SC, Christakis NA, Fowler JH (2010).PLoS ONE 5(3): e9775. doi:10.1371/journal.pone.0009775

Work As Done* - patienthood

Why is work-as-imagined different from work-as-done? / Hollnagel, Erik. in Resilient Health Care: The resilienceof everyday clinical work. ed. / Robert L Wears; Erik Hollnagel; Jeffrey Braithwaite. Vol. 2 Ashgate, 2015. p. 249-264.*

Healthcare asa ComplexAdaptiveSystem

Patient-hoodas a ComplexAdaptiveSystem

Bodenheimer, Thomas, and Christine Sinsky."From triple to quadruple aim: care of thepatient requires care of the provider." The Annalsof Family Medicine 12.6 (2014): 573-576.

• Aligning goals

• Clarifying expectations

• Understanding and embracing risk

• Co-creating risk mitigation

• Preparing physically, mentally, practically

• Connection to respond to needs and concerns

• Role in my own care, backed by mentor (peer?)

WHAT MAKES US (all) FEEL SAFER?

• What can I do to improve your care today? needs

• What’s the best you think you can be? goals

• What’s one thing you wish you’d known? gaps

• What’s one thing that made a difference? assets

• What’s one thing I should know about you? values

• What’s one thing that….. ?

LEARNING WHAT MAKES US (all) FEEL SAFER?

C. Canfield, A. Carson-Steven, N. Cork (2016)

skills

respect

awareness

competence

trust

calmness

accountability

intuition

communications

interdependence

and more!

The patient always leads…but we travel together

Who leads better health care?

RISK

REWARDUNKNOWABLE

Questions?hbaillie@telus.net

carolyn.canfield@ubc.ca