quality improvement justine strand, mph, pa-c patricia castillo, ms, pa-c victoria kaprielian, md
TRANSCRIPT
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Quality Improvement
Justine Strand, MPH, PA-C
Patricia Castillo, MS, PA-C
Victoria Kaprielian, MD
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Goal:
Apply principles and practices of Quality Improvement.
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What is QI?
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QI Opportunities and Benefits
QI can give you the opportunity to …..
• Look at things differently• Come up with new options and solutions• Eliminate things that make you crazy
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QI: A Historical Perspective
• based on the theories of Deming and Juran
• 1980s – Japanese auto industry
• 1990s – American manufacturers and health care industry
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Health Care: Cost and Access
• Improvements in technology
• Higher prices
• Greater demand
• Integrated medical delivery systems
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Perspectives on Quality
• Providers
• Payers
• Employers
• Consumers
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QI is a “Hot Topic”
• “…The quality of health care received by the people of the United States falls short of what it should be.”
IOM, 2001
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US Health System Rankings
• 37th place overall (out of 191) because of significant health disparities
• Tied for 82nd place (out of 171) on polio vaccination rate
• Number 1 on both dollars spent per capita, and proportion of GDP spend on health care
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Medical Errors
• How extensive is the problem of medical errors?
• More people die in a year from medical errors than from motor vehicle accidents, breast cancer, or AIDS
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“Crossing the Quality Chasm” IOM 2001
• Under use – helpful services not delivered
• Overuse – useless interventions
• Mistakes – inevitable human error
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Medical Errors
• Not the fault of individuals
• Lessons from industry
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QI in Health Care
• How can you measure quality in health care?
• What do you want to measure?• How can you do it?• What are the challenges?
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Issues in Measurement
• Structure
• Process
• Outcome
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Process vs. Outcome
• Process:– How health care is provided– How the system works
• Outcome:– Health status– Does it make a difference?
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Proxy Measures
• Used when you can’t exactly measure what you want or need
• Measure something that is close enough to reflect similarly
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Information Systems
• Can be a valuable tool
• Can facilitate quality efforts
• Examples:– Databases– Disease registries
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Convenience Samples
• Takes a limited number
• Extrapolates to the whole population
• Not necessarily randomized
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QI: Issues in Measurement
• Process vs. Outcome
• Proxy measures
• Information systems
• Convenience samples
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“FADE” Methodology
u FOCUSu ANALYZEu DEVELOPu EXECUTE/EVALUATE
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The FADE model
GenerateGeneratea list ofa list of
problemsproblems
SelectSelectoneone
problemproblemVerify/Verify/definedefine
problemproblem
FOCUSFOCUS
Written statement of problemWritten statement of problem
DecideDecidewhat youwhat youneed toneed toknowknow
List ofList ofmostmost
influentialinfluentialfactorsfactors
BaselineBaselinedatadata
CollectCollectdatadata
baselines/baselines/patternspatterns
AANNAALLYYZZEE
DEVELOPDEVELOP
Solution forSolution forproblemproblem
DevelopDevelopimplementationimplementation
planplan SelectSelectsolutionsolution
GenerateGeneratepromisingpromisingsolutionssolutions
A plan forA plan forimplementationimplementation
EXECUTE
Organizationalcommitment
Gaincommitment
Executeplan
Executeplan
Monitorimpact
Recordof
impact
F A D E
DetermineDetermineinfluentialinfluential
factorsfactors
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Example 1
The state child health report indicates no well child care is being done in your primary care clinic.
What do you do?
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Quality Improvement vs. Performance Improvement
• Quality Improvement focuses on quality of care
• Performance Improvement focuses on administrative systems
• The goal is improvement in quality
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The Diagnostic Process
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Example 2
An audit shows your immunization rate for well children to be 45%
What do you do?
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Evaluation results
About 18 months later, your immunization rate is now 82%
What would you do now?
Is 82% good enough?
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QI: Rapid Cycle Improvement
• EVALUATE• FOCUS• ANALYZE• DEVELOP• EXECUTE• EVALUATE
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“PDSA” Methodology
• PLAN
• DO
• STUDY
• ACT
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“PDSA” Methodology
• PLAN
• DO
• STUDY
• ACT
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Example 3
Improving a phone message system
PLAN
DO
STUDY
ACT
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QI vs. Research
QI:• Confidential• Existing standard of
care• Improving care
• No IRB approval needed
Research:• Publish/present• Tests new methods• Creating new
generalizable knowledge
• Needs IRB approval
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Summary
• Improving health care quality is our responsibility
• Identify the cause before making changes
• Be creative in developing solutions
THINK OUTSIDE THE BOX!