this conference was organized by hacettepe university school of health administration for the 35th...

This conference was organized by

Hacettepe UniversitySchool of Health Administration

for the 35th anniversary of the establishment of

Hacettepe University

Time: May 6, 2003 Time: May 6, 2003

Place: Place: Hacettepe Üniversitesi Kültür Merkezi, Yeşil SalonHacettepe Üniversitesi Kültür Merkezi, Yeşil Salon

Hour: 10.00 - 12.30Hour: 10.00 - 12.30

Quality of Health Care in the United States: Practice and

PromiseProfessor Joseph D. RestucciaProfessor Joseph D. Restuccia

Boston University School of Management

Quality of Health Care

““Degree to which health services Degree to which health services for individuals and populations for individuals and populations increase the likelihood of desired increase the likelihood of desired health outcomes and are consistent health outcomes and are consistent with professional knowledge.”with professional knowledge.”

- Institute of Medicine (IOM)- Institute of Medicine (IOM)

Strengths of the United States Health Care System Modern, well-equipped hospitals and Modern, well-equipped hospitals and

ambulatory facilitiesambulatory facilities Highly trained physicians, nurses and other Highly trained physicians, nurses and other

medical personnelmedical personnel Availability of high technology diagnostic Availability of high technology diagnostic

and therapeutic proceduresand therapeutic procedures

Weaknesses of the United States Health Care System

Overuse and inappropriate careOveruse and inappropriate care Underuse of effective careUnderuse of effective care Misuse and error in medical care Misuse and error in medical care Inefficiency and wasteInefficiency and waste

Assessment of US Health Care System to Achieve 6 Aims

“In its current form, habits, and environment, American health care system is incapable of providing the public with the quality of health care it expects and deserves.”

- IOM Committee on Health Care in America

“Every Defect is a Treasure”

Japanese saying: every defect is a treasure Japanese saying: every defect is a treasure because identifying a defect enables us to because identifying a defect enables us to find the root cause and to eliminate it and, find the root cause and to eliminate it and, thus, to make improvements in the futurethus, to make improvements in the future

If defects are jewels, recent investigations If defects are jewels, recent investigations to identify and quantify defects in US health to identify and quantify defects in US health care have discovered a treasure chest (or care have discovered a treasure chest (or Pandora’s box)Pandora’s box)

Overuse(Rate of Inappropriate Use)

Advanced Antibiotics for Otitis Media 30%Advanced Antibiotics for Otitis Media 30% Antibiotics Used for the Common Cold 60%Antibiotics Used for the Common Cold 60% Heart Revascularization 10-20%Heart Revascularization 10-20% HysterectomiesHysterectomies 16-80% 16-80% Hospital Admissions: 5-15%Hospital Admissions: 5-15% Hospital Days of Care: 10-30%Hospital Days of Care: 10-30%

Overuse(Rate of Inappropriate Use)

Other procedures commonly overused:Other procedures commonly overused: Bed Rest for Low Back PainBed Rest for Low Back Pain Prostate Specific Antigen TestingProstate Specific Antigen Testing Ultrasound in Uncomplicated PregnancyUltrasound in Uncomplicated Pregnancy Sedation of elderly patientsSedation of elderly patients

Underuse (Financial Access)

Over 40 million people are uninsured at any point Over 40 million people are uninsured at any point in timein time

Over 75 million are uninsured as some time Over 75 million are uninsured as some time during the yearduring the year

About an equal number are severely underinsuredAbout an equal number are severely underinsured The majority of the uninsured and underinsured The majority of the uninsured and underinsured

are the working poor and their dependents are the working poor and their dependents

Underuse(Rate of Use of Effective Care)

Beta-blockers in Elderly Heart Attack Victims 21% Beta-blockers in Elderly Heart Attack Victims 21% Pneumococcal Vaccine in Elderly: 28%Pneumococcal Vaccine in Elderly: 28% Appropriate Dx and Tx of Hypertension: 30%Appropriate Dx and Tx of Hypertension: 30% Physician Advice to Quit Smoking: 37%Physician Advice to Quit Smoking: 37% Eye Examination in Diabetics: 46%Eye Examination in Diabetics: 46% Pharmacotherapy of Depression: 45%Pharmacotherapy of Depression: 45%

Misuse Adverse drug events (ADEs) caused Adverse drug events (ADEs) caused

by medication errors occur in 1.8/100 by medication errors occur in 1.8/100 hospital admissionshospital admissions

ADEs add $4,700 per admissionADEs add $4,700 per admission 20% of ADEs are life threatening20% of ADEs are life threatening There are an estimated 500,000 There are an estimated 500,000

preventable medication errors per preventable medication errors per year causing 7,000 deathsyear causing 7,000 deaths

Misuse

An estimated 2.9% – 3.7% of hospital An estimated 2.9% – 3.7% of hospital admissions have an adverse event (from admissions have an adverse event (from all causes)all causes)

Over 1 million adverse events per yearOver 1 million adverse events per year Estimated national cost of adverse events Estimated national cost of adverse events

is $38-50 billion per year – almost half is $38-50 billion per year – almost half preventable (2-4% of total health costs)preventable (2-4% of total health costs)

Misuse

An estimated 180,000 deaths per year An estimated 180,000 deaths per year due to adverse events (= 3 jumbo jet due to adverse events (= 3 jumbo jet crashes every two days)crashes every two days)

Between 44,000 - 98,000 due to Between 44,000 - 98,000 due to preventable adverse eventspreventable adverse events

More deaths than due to motor vehicle More deaths than due to motor vehicle accidents (43,438), breast cancer accidents (43,438), breast cancer (43,297) or AIDS (16,516)(43,297) or AIDS (16,516)

Inefficiency and Waste

Waits and DelaysWaits and Delays

Operating Room ThroughputOperating Room Throughput

Emergency Department DiversionsEmergency Department Diversions

Time to Treatment of Coronary ConditionsTime to Treatment of Coronary Conditions

Medical Records AvailabilityMedical Records Availability

Mismatch Between Capacity and DemandMismatch Between Capacity and Demand

Assessment of US Health Care System to Achieve 6 Aims

“In its current form, habits, and environment, American health car is incapable of providing the public with the quality of health care it expects and deserves.”

- IOM Committee on Health Care in America

IOM’s Six Aims for Improvement

• Safety

• Effectiveness

• Patient-centeredness

• Timeliness

• Efficiency

• Equity

Safe Care

A patient receiving medical care should be A patient receiving medical care should be as safe as he is in his own homeas safe as he is in his own home

Example: Computerized physician order Example: Computerized physician order entry system to prevent medication errorsentry system to prevent medication errors

Example: Surgeons “sign your site” of the Example: Surgeons “sign your site” of the body part that will be operated uponbody part that will be operated upon

Effective Care

Avoid overuse and underuse of servicesAvoid overuse and underuse of services Example: Redesign processes based on best Example: Redesign processes based on best

practices such as ensuring that patients at practices such as ensuring that patients at risk for heart disease take appropriate risk for heart disease take appropriate medications medications

Example: Implement utilization Example: Implement utilization management to reduce inappropriate management to reduce inappropriate hospital usehospital use

Patient Centered Care

Respect patient needs, preferences, and Respect patient needs, preferences, and cultureculture

Example: Give patient access to his own Example: Give patient access to his own medical recordmedical record

Example: Give patients information on Example: Give patients information on alternative treatments and decision-making alternative treatments and decision-making in treatment choicein treatment choice

Timely Care

Reduce waits for those who receive and Reduce waits for those who receive and who give carewho give care

Example: Availability of appointments after Example: Availability of appointments after work hours and on weekendswork hours and on weekends

Example: Email and telephone access to Example: Email and telephone access to physicians and nurse practitionersphysicians and nurse practitioners

Example: “Open access” to physicians and Example: “Open access” to physicians and nurse practitionersnurse practitioners

Efficient Care

Reduce waste of facilities, equipment, Reduce waste of facilities, equipment, supplies, and peoplesupplies, and people

Example: implement inventory Example: implement inventory management systems to reduce amount of management systems to reduce amount of drugs and other suppliesdrugs and other supplies

Example: Use flexible staffing systems Example: Use flexible staffing systems based on patient numbers and needs to based on patient numbers and needs to adjust number of nurses per patient care adjust number of nurses per patient care unitunit

Equitable Care

Reduce racial, ethnic, geographic and socio-Reduce racial, ethnic, geographic and socio-economic differenceseconomic differences

Example: Provide interpreters for non-Example: Provide interpreters for non-English speaking patientsEnglish speaking patients

Example: Train more physicians from Example: Train more physicians from minority racial and ethnic groupsminority racial and ethnic groups

Example: Establish universal health Example: Establish universal health insurance coverageinsurance coverage

Purpose of Health Care System

“To reduce continually the burden of illness, injury, and disability, and to improve the health status and function of the people of the United States”

- President’s Advisory Commission on Consumer Protection and Quality

Focus of Quality

Quality must be defined in terms Quality must be defined in terms of experience and outcomes of of experience and outcomes of the patient and the population the patient and the population that generates patientsthat generates patients

Levels of Needed Health Care System Change

Organization (hospitals, medical groups)Organization (hospitals, medical groups)

PatientPatient

Microsystem (patient units, physician offices)

Environment (insurers, purchasers, government)

Levels of Needed Change

The patient’s experienceThe patient’s experience The functioning of small units The functioning of small units

(“microsystems”) that provide patient care(“microsystems”) that provide patient care The functioning of organizations that The functioning of organizations that

contain microsystemscontain microsystems The environment of policy, payment, The environment of policy, payment,

accreditation and regulation accreditation and regulation

Levels of Needed Health Care System Change

All levels of the system must work together All levels of the system must work together to meet the patient’s needsto meet the patient’s needs

The patient must be at center, the first The patient must be at center, the first priority of the health care systempriority of the health care system

The major question to ask in changing the The major question to ask in changing the system or in treating the patient must be, system or in treating the patient must be, “Is this the best thing we can do for the “Is this the best thing we can do for the patient?”patient?”

Examples of Efforts by Provider Organizations to Achieve the IOM’s Six Aims

Cincinnati Children Hospital Medical Center Includes families of hospitalized children in Includes families of hospitalized children in

morning physician roundsmorning physician rounds Permits adolescent patients with chronic Permits adolescent patients with chronic

diseases (e.g., juvenile diabetes) to set their diseases (e.g., juvenile diabetes) to set their own schedule of treatments and activities and own schedule of treatments and activities and to make entries into their medical recordsto make entries into their medical records

Pays physicians for involvement in major Pays physicians for involvement in major quality management activitiesquality management activities

Cambridge Health Alliance

Developed registries for chronic patients to Developed registries for chronic patients to identify needed diagnostic and therapeutic identify needed diagnostic and therapeutic interventions, help teach patient self-interventions, help teach patient self-management, and track patient outcomesmanagement, and track patient outcomes

Provides translators for over 30 languagesProvides translators for over 30 languages Works with governmental agencies to Works with governmental agencies to

establish coverage programs for the establish coverage programs for the uninsureduninsured

Tallahassee Medical Center

Conducts surveys of satisfaction on every Conducts surveys of satisfaction on every inpatient and outpatient and shares results inpatient and outpatient and shares results broadlybroadly

Implemented palliative care project to Implemented palliative care project to ensure that terminal patient receive comfort ensure that terminal patient receive comfort care instead of intensive carecare instead of intensive care

Put communication devices in ambulances, Put communication devices in ambulances, moved EKG lab, and changed cardiologist moved EKG lab, and changed cardiologist schedule to enable PTCA within 90 minutesschedule to enable PTCA within 90 minutes

Hackensack Medical Center

Hired physician “intensivists” to care of Hired physician “intensivists” to care of hospitalized medical patientshospitalized medical patients

Developed nursing career ladder to help hire, Developed nursing career ladder to help hire, retain and further train nursing staffretain and further train nursing staff

Implemented advanced practice nurses to work Implemented advanced practice nurses to work with physicians and patients to coordinate carewith physicians and patients to coordinate care

Implemented daily multidisciplinary patient Implemented daily multidisciplinary patient rounds (physician, nurses, ancillary therapists, rounds (physician, nurses, ancillary therapists, etc.) to improve communication and teamworketc.) to improve communication and teamwork

Brigham and Women’s Hospital Developed computerized physician order entry Developed computerized physician order entry

system (CPOE)system (CPOE) Physician orders entered via terminalsPhysician orders entered via terminals

Test results and treatment summaries Test results and treatment summaries transmitted to electronic patient recordtransmitted to electronic patient record

Orders screened against knowledge base of Orders screened against knowledge base of rules to detect medication errors rules to detect medication errors

Reduced serious medication errors over 80%Reduced serious medication errors over 80%

CareGroup

Developed internet-based electronic Developed internet-based electronic medical record medical record

Allows physicians password protected Allows physicians password protected internet access to patient recordsinternet access to patient records

Allows patients password protected internet Allows patients password protected internet access to their own recordsaccess to their own records

Allows patients to write in their own record Allows patients to write in their own record and to request appointments with physiciansand to request appointments with physicians

Rosemont Medical Center

Developed “open access” program for Developed “open access” program for patient appointmentspatient appointments

Produced same day access for most patient Produced same day access for most patient visitsvisits

Reduced average wait time for routine visits Reduced average wait time for routine visits from over 2 months to 1 dayfrom over 2 months to 1 day

Massachusetts General Hospital

Implemented utilization management to Implemented utilization management to reduce inappropriate hospital daysreduce inappropriate hospital days

Case managers apply MCAP (derivative of Case managers apply MCAP (derivative of the AEP) to facilitate day to day decision the AEP) to facilitate day to day decision making and data collection to change systemmaking and data collection to change system

Over 10 years, inappropriate days have been Over 10 years, inappropriate days have been reduced by more than 50%reduced by more than 50%

SSM Health Care

Continuous Quality Improvement (CQI) - 13 Continuous Quality Improvement (CQI) - 13 year sustained effortyear sustained effort

Alignment of goals and measures of Alignment of goals and measures of performance throughout the organizationperformance throughout the organization

Use team work to solve problems and motivate Use team work to solve problems and motivate employeesemployees

Human resources are part of strategic planHuman resources are part of strategic plan Only health care organization to win Malcolm Only health care organization to win Malcolm

Baldridge National Quality AwardBaldridge National Quality Award

Continuous Quality Improvement

Top Management CommitmentTop Management Commitment Worker EmpowermentWorker Empowerment Team WorkTeam Work Customer focusCustomer focus Application of Scientific Method Application of Scientific Method

(Measurement and Reporting)(Measurement and Reporting) Recognition of successRecognition of success

7. ACT 4. PLAN

6. STUDY 5. DO

1. AIM: What are we trying to accomplish?

2. MEASURES: How will we know that a change is an improvement?

3. CHANGES: What changes can we make that we predict will lead to an improvement?

AIM/PDSA Model for Internal Quality Improvement

Examples of Efforts by Government Agencies to Achieve the IOM’s Six Aims

Department of Veterans Affairs Health System

System of 171 hospital medical centers, 350 System of 171 hospital medical centers, 350 outpatient centersoutpatient centers

Implemented electronic patient record & CPOEImplemented electronic patient record & CPOE Implemented open access (reducing wait time Implemented open access (reducing wait time

by 90% in Region 1)by 90% in Region 1) Implemented Quality Enhancement Research Implemented Quality Enhancement Research

Initiative (QUERI) to give providers evidence-Initiative (QUERI) to give providers evidence-based care on 8 priority conditionsbased care on 8 priority conditions

Recognized by IOM for these effortsRecognized by IOM for these efforts

Agency for Health Care Research and Quality (AHRQ) Supports research on patient outcomesSupports research on patient outcomes

Prevention, diagnosis and treatmentPrevention, diagnosis and treatmentQuality measurement and improvementQuality measurement and improvementMedical errors and public safetyMedical errors and public safety

ExamplesExamplesDiagnosis of heart attackDiagnosis of heart attackScreening for pregnant womenScreening for pregnant womenConsumer Assessment of Health Plans Survey Consumer Assessment of Health Plans Survey

(CAHPS)(CAHPS)

Agency for Health Care Quality and Research (AHRQ)

National Guidelines Clearinghouse of National Guidelines Clearinghouse of evidence-based clinical practice guidelinesevidence-based clinical practice guidelines

National Quality Measures ClearinghouseNational Quality Measures Clearinghouse CAHPS surveyCAHPS survey CONQUEST quality measuresCONQUEST quality measures Health Care Cost and Utilization Project Health Care Cost and Utilization Project

(HCUP) Quality Indicators(HCUP) Quality Indicators

AHRQ HCUP Quality Indicators Prevention - ambulatory sensitive conditionsPrevention - ambulatory sensitive conditions

Bacterial pneumoniaBacterial pneumonia DehydrationDehydration

Inpatient CareInpatient Care Acute myocardial infarction mortality rateAcute myocardial infarction mortality rate CABG volumeCABG volume

Patient SafetyPatient Safety Birth TraumaBirth Trauma Complications of anesthesiaComplications of anesthesia

Center for Medicare and Medicaid Studies (CMS) Quality Improvement Organizations Quality Improvement Organizations

monitor Medicare qualitymonitor Medicare quality Nursing Home Public Reporting Quality Nursing Home Public Reporting Quality

InitiativeInitiative Home Health Public Reporting Quality Home Health Public Reporting Quality

InitiativeInitiative Hospital Quality Information InitiativeHospital Quality Information Initiative

CMS Hospital Quality Initiative In collaboration with JCAHO, NQF, AHA and other In collaboration with JCAHO, NQF, AHA and other

national hospital associationsnational hospital associations Voluntary reporting of quality measuresVoluntary reporting of quality measures ExamplesExamples

AMI: aspirin and beta blocker at hospital arrival AMI: aspirin and beta blocker at hospital arrival and dischargeand discharge

Pneumonia: initial antibiotic timing, vaccination, Pneumonia: initial antibiotic timing, vaccination, oxygenation assessment oxygenation assessment

Considering paying providers on the basis of quality Considering paying providers on the basis of quality instead of just fee for serviceinstead of just fee for service

CMS/AHRQ CAHPS Surveys

National survey of Medicare beneficiariesNational survey of Medicare beneficiaries Also used for Medicaid and commercial Also used for Medicaid and commercial

beneficiary surveysbeneficiary surveys Administered by CMS for MedicareAdministered by CMS for Medicare Comparative Medicare Medical Care Plan Comparative Medicare Medical Care Plan

Reports are publicly available on internetReports are publicly available on internet Comparative Hospital Reports Scheduled Comparative Hospital Reports Scheduled

for internet availability in 2003-2004for internet availability in 2003-2004

HCAHPS - Example Questions How often did nurses/doctors listen to you How often did nurses/doctors listen to you

carefully?carefully? How often did nurses/doctors spend enough How often did nurses/doctors spend enough

time with you?time with you? How often was your pain well controlled?How often was your pain well controlled? Before you left the hospital, did you get Before you left the hospital, did you get

information in writing about activities you could information in writing about activities you could and could not do?and could not do?

Would you recommend this hospital to your Would you recommend this hospital to your friends and family?friends and family?

Examples of Efforts by Private Organizations to Achieve the IOM’s Six Aims

Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Develops standards for optimal healthcareDevelops standards for optimal healthcare Applies accreditation process to 17,000 Applies accreditation process to 17,000

healthcare organizationshealthcare organizations Provides information to health care Provides information to health care

organizations, professionals, and the public organizations, professionals, and the public on strategies to improve safetyon strategies to improve safety

Plans to make public comparative Plans to make public comparative performance reports on provider performance reports on provider organizations (in 2004) organizations (in 2004)

Examples of JCAHO Initiatives

Quality Performance MeasurementQuality Performance Measurement Core (required) measuresCore (required) measures Provider selected measuresProvider selected measures

Pain Management StandardsPain Management Standards Staffing Effectiveness StandardsStaffing Effectiveness Standards Patient Safety StandardsPatient Safety Standards Sentinel Event Policy and AlertSentinel Event Policy and Alert

Foundation for Accountability (FACCT)

Advocates an accountable and accessible health Advocates an accountable and accessible health care system responsive to consumerscare system responsive to consumers

Members: consumer organizations and purchasersMembers: consumer organizations and purchasers Collaborates with government and private health Collaborates with government and private health

care organizationscare organizations Reports on federal and state health policyReports on federal and state health policy Provides consumers with information to help Provides consumers with information to help

assess quality of care and select providers and assess quality of care and select providers and tools to help manage their own health, e.g. tools to help manage their own health, e.g. CompareYourCare)CompareYourCare)

National Committee for Quality Assurance (NCQA)

Accreditation and certification of health Accreditation and certification of health plans and utilization review organizationsplans and utilization review organizations

Administers Health Plan Employer Data Administers Health Plan Employer Data and Information Set (HEDIS)and Information Set (HEDIS)

HEDIS is used to compare health plans and HEDIS is used to compare health plans and choose quality - results released to public as choose quality - results released to public as Quality CompassQuality Compass

HEDIS 3.0 Reporting Set Measures

Effectiveness of CareEffectiveness of CareChildhood Immunization StatusChildhood Immunization Status Low Birth Weight Babies Low Birth Weight Babies

Adolescent Immunization StatusAdolescent Immunization Status Check-ups After DeliveryCheck-ups After Delivery

Advising Smokers to QuitAdvising Smokers to Quit Treating Child Ear InfectionsTreating Child Ear Infections

Flu Shots for Older AdultsFlu Shots for Older Adults Beta Blockers after MIBeta Blockers after MI

Eye Exams for Diabetics Eye Exams for Diabetics Breast Cancer Screening Breast Cancer Screening

1st Trimester1st Trimester Prenatal Care Cervical Cancer ScreeningPrenatal Care Cervical Cancer Screening

Follow-up after Hospitalization Medicare Health Outcome SurveyFollow-up after Hospitalization Medicare Health Outcome Survey

for Mental Illnessfor Mental Illness

Leapfrog Group

Group of very large US companiesGroup of very large US companies Mission is to stimulate improvement in Mission is to stimulate improvement in

quality, customer service and affordabilityquality, customer service and affordability Recognizes and rewards health care Recognizes and rewards health care

organizations that implement evidence-based organizations that implement evidence-based patient safety measurespatient safety measures

Encourages members to buy health care from Encourages members to buy health care from these organizationsthese organizations

Leapfrog Group Patient Safety Measures Referral of specific complex procedures to Referral of specific complex procedures to

hospitals with high volume (estimated to hospitals with high volume (estimated to reduce deaths > 30%)reduce deaths > 30%)

Intensive care unit staffing with physicians Intensive care unit staffing with physicians certified to practice critical care medicine certified to practice critical care medicine (estimated to reduce ICU deaths > 10%)(estimated to reduce ICU deaths > 10%)

Computer physician order entry (estimated to Computer physician order entry (estimated to prevent > 500,000 fewer serious medication prevent > 500,000 fewer serious medication errors per year)errors per year)

Institute for Healthcare Improvement (IHI) Mission: is “driving the improvement in Mission: is “driving the improvement in

health by advancing the quality and value health by advancing the quality and value of health care”of health care”

ConferencesConferences CollaborationsCollaborations CoursesCourses Training MaterialTraining Material

Institute for Healthcare Improvement (IHI) National Director of Robert Wood Johnson National Director of Robert Wood Johnson

Foundation Pursuing Perfection ProgramFoundation Pursuing Perfection Program Publishes QualityHealthcare.org (with Publishes QualityHealthcare.org (with

British Medical Journal)British Medical Journal) Website: www.ihi.comWebsite: www.ihi.com

Institute for Healthcare Improvement (IHI) Examples of Topics for Collaboratives:Examples of Topics for Collaboratives:

Achieving Workforce ExcellenceAchieving Workforce Excellence Adult Intensive CareAdult Intensive Care Adverse Drug EventsAdverse Drug Events Care for Chronic ConditionsCare for Chronic Conditions Delays and Waiting TimesDelays and Waiting Times End of Life CareEnd of Life Care Patient FlowPatient Flow Patient SafetyPatient Safety

Major Quality Improvement Will Require Fundamental Changes Evidence-based medicineEvidence-based medicine Evidence-based management (CQI)Evidence-based management (CQI) Electronic patient record with CPOEElectronic patient record with CPOE Recognition of system interdependence between Recognition of system interdependence between

microsystem, organization, environment microsystem, organization, environment Alignment of incentives and strategy at all levelsAlignment of incentives and strategy at all levels

Payment based on quality, not just servicesPayment based on quality, not just services Public reporting of comparative provider qualityPublic reporting of comparative provider quality

Universal health coverageUniversal health coverage

this conference was organized by hacettepe university school of health administration for the 35th...

Documents

inappropriate care overuse

medical care misuse

medical care inefficiency

american health care

quality of health care

hospital days of care

health services

waste slide