Quality in Healthcare If you wanted to get a sense of the quality of healthcare delivery, How would you go about it? You could ask each of the providers if they were following the guidelines for a specific disease You could ask providers to keep track of their errors or “near misses” Can you imagine any reason these methods may not work ?
Contrasting QI and QA Many people are familiar with the term Quality Assurance (QA), as it was a common term for many years. Quality Assurance – QA was reactive, retrospective, policing, and in many ways punitive. It often involved determining who was at fault after something went wrong. This term is older and not as likely to be used today. Quality Improvement – QI involves both prospective and retrospective reviews. It is aimed at improvement -- measuring where you are, and figuring out ways to make things better. It specifically attempts to avoid attributing blame, and to create systems to prevent errors from happening.
QA QI Which staff member failed to transfer the call to the correct extension? Are we creating an environment encouraging clinicians to report errors? Patient had a bad outcome; were the doctors or nurses at fault? What could we do to increase the efficiency of chart filing? Contrasting QI and QA
Providers: Tend to view quality in a technical sense – accuracy of diagnosis, appropriateness of therapy, resulting health outcome Payers: Focus on cost-effectiveness . Employers: Want both to keep their costs down, and to get their employees back to work quickly. Patients: Want compassion as well as skill with clear communication . DIFFERENT POINT OF VIEW
What actually needs to be assessed? <ul><li>Quality of treatment </li></ul><ul><li>Doctor </li></ul><ul><li>Whole organization </li></ul><ul><li>Practice </li></ul>
<ul><li>The concept of category forming </li></ul><ul><li>Quality of structure </li></ul><ul><li>Quality of process </li></ul><ul><li>Quality of outcome </li></ul>
Quality of structure Staffing . Quality and quantity. Basic and program For further training of the staff Premises Equipping the building and rooms Organization Principle and rules of organization, code of conduct Medicine and medicine technolog Diagnostic and therapeutic concepts and equipment
<ul><li>Quality of process </li></ul><ul><li>Reception ,talking, information to patients </li></ul><ul><li>History </li></ul><ul><li>Implementation of diagnostic measures </li></ul><ul><li>Guidelines or standards </li></ul><ul><li>Patient education </li></ul>
Quality of outcome Changes caused by medical care in the present or future state of health of the patient
Accreditation What is accreditation and what are the benefits? is a process in which an entity, separate and distinct from the health care organization, usually non-governmental, assess the health care organization to determine if it meets a set of standards requirements designed to improve quality of care. Accreditation is usually voluntary. Accreditation standards are usually regarded as optimal and achievable. Accreditation provides a visible commitment by an organization to improve the quality of patient care , to ensure a safe environment and to continually work to reduce risks to patients and staff. Accreditation has gained worldwide attention as an effective quality evaluation and management tool.
<ul><ul><ul><ul><ul><li>Method for evaluating health quality </li></ul></ul></ul></ul></ul>
Balanced Scorecard http:// healthcare.isixsigma.com/ca/baldridge / Benchmarking Business Process Reengineering (BPR) http:// healthcare.isixsigma.com/ca/deming / Document Control DMADV / New Product & Service Introduction DMAIC / Existing Product or Service Financial Analysis / Cost of Quality http://healthcare.isixsigma.com/ca/iso9000/ Lean, Lean Six Sigma and Lean Manufacturing Management Metrics Plan, Do, Check, Act - PDCA Process Management Project Selection Simulation Six Sigma Taguchi Methods http://healthcare.isixsigma.com/ca/tl9000/ Total Quality Management (TQM) TRIZ, Theory of Inventive Problem Solving Work-Out
(International Organization for Standardization) Is the world's largest developer and publisher of I International Standards.
ISO is a network of the national standards institutes of 157 countries, one member per country, with a Central Secretariat in Geneva, Switzerland, that coordinates the system. ISO is a non-governmental organization that forms a bridge between the public and private sectors. On the one hand, many of its member institutes are part of the governmental structure of their countries, or are mandated by their government. On the other hand, other members have their roots uniquely in the private sector, having been set up by national partnerships of industry associations. Therefore, ISO enables a consensus to be reached on solutions that meet both the requirements of business and the broader needs of society. ISO forms a bridge between the public and private sectors.
What is JCI Accreditation? In response to growing interest in accreditation and quality improvement worldwide, the Joint Commission launched its international accreditation program in 1999. Joint Commission International accreditation standards are based on international consensus standards and set uniform, achievable expectations for structures, processes and outcomes for hospitals. The accreditation process is designed to accommodate specific legal, religious and cultural factors within a country. Joint Commission International (JCI) accreditation can help international health care organizations, public health agencies, health ministries and others to evaluate, improve and demonstrate the quality of patient care in their nations.
What is QI? Quality Improvement is a formal approach to the analysis of performance and systematic efforts to improve it. There are numerous models used. Some commonly discussed include: FADE PDSA Six Sigma (DMAIC) CQI: Continuous Quality Improvement - http:// deming.eng.clemson.edu /pub/tutorials/ TQM: Total Quality Management – http:// www.mapnp.org/library/quality/tqm/tqm.htm
Methods of Quality Improvement The FADE Model There are 4 broad steps to the FADE QI model: FOCUS: Define and verify the process to be improved ANALYZE : Collect and analyze data to establish baselines, identify root causes and point toward possible solutions DEVELOP : Based on the data, develop action plans for improvement, including implementation, communication, and measuring/monitoring EXECUTE : Implement the action plans, on a pilot basis as indicated, and EVALUATE : Install an ongoing measuring/monitoring (process control) system to ensure success.
FADE Model in Action You Evaluate the impact of your change You Focus down further You Analyze the problem to find the root cause(s) Then Develop methods for further improvement And Execute and Evaluate again! Repeat the process until the goal is achieved.
Another commonly used QI model is the PDSA cycle: PLAN : Plan a change or test of how something works. DO: Carry out the plan. STUDY : Look at the results. What did you find out? ACT : Decide what actions should be taken to improve . Repeat as needed until the desired goal is achieved PDSA
Six Sigma Six Sigma is another model for improvement. The term comes from the use in statistics of the Greek Letter (sigma) to denote Standard Deviation from the mean. 6 sigma is equivalent to 3.4 defects or errors per million. levels
Six Sigma Six Sigma is a measurement-based strategy for process improvement and problem reduction completed through the application of improvement projects. This is accomplished through the use of two Six Sigma models: DMAIC and DMADV. DMAIC (define, measure, analyze, improve, control) is an improvement system for existing processes falling below specification and looking for incremental improvement. DMADV (define, measure, analyze, design, verify) is an improvement system used to develop new processor products at Six Sigma quality levels
Cardiac catherization labs represent a significant capital investment for many hospitals. Realizing a return on this investment is increasingly challenging, given the introduction of advanced technologies and limitations in reimbursement. To meet the challenges and maintain fiscal health, hospitals are pursuing strategies such as Six Sigma, lean and change management techniques to improve throughput, maximize equipment utilization and increase efficiency. Six sigma
Quality-Adjusted Life Years (QALYs) <ul><li>Reduce the value of a year of life associated with concurrent illness </li></ul><ul><li>1.0 When free of major illness </li></ul><ul><li>0.69 for blindness </li></ul><ul><li>0.61 for End Stage Renal Disease (ESRD) </li></ul><ul><li>0.80 for lower extremity amputation (LEA) </li></ul><ul><li>0.0 for death </li></ul>DCCT
Lifetime Benefits and Costs of DCCT Intensive Therapy DCCT References: Diabetes Care , 1995 18 :1468-78. JAMA , 1996 276 : 1409-15.
Type of Health Care Costs by Treatment Group Intensive Conventional Treatment Side Effects Complications DCCT
Cumulative Incidence of Proliferative Retinopathy by Treatment Group Age Percent 19 29 39 49 59 69 79 89 99 0 20 40 60 80 100 Conventional Intensive
Cumulative Incidence of Clinical Nephropathy (Albuminuria) by Treatment Group 0 20 40 60 80 100 19 29 39 49 59 69 Age (years) Percent Intensive Conventional DCCT
Average Number of Years Living Without ... DCCT
Quality Management and total quality management Assessment representation are the basis of quality management. Whatever the results indicate the way of Improvements. But how can quality improvement or quality development can be achieved ? This is the problem
Not just a leadership, quality management means all the executives from the administrative manager ,senior consultants, senior physicians ,senior nurses owners of practices are included in the system
<ul><li>Quality of process </li></ul><ul><li>Reception ,talking, information to patients </li></ul><ul><li>History </li></ul><ul><li>Implementation of diagnotic measures </li></ul><ul><li>Guidelines or standards </li></ul><ul><li>Patient education </li></ul>
Components of the Diabetes Team The Ideal Scenario Dietitian Endocrinologis t Nurse Educator Exercise Therapist Case Manager PCP
Patient Education Change of the Attitude and Behavior towards common health problems for better control or reduce its complications
Goal of Health Education <ul><li>Knowledge </li></ul><ul><li>Improvement , development and corrects skills </li></ul><ul><li>Change attitudes and believes </li></ul>LIFE STYLE MODIFICATION
STAGES OF PATIENT HEATH EDUCATION <ul><li>Explanation of details </li></ul><ul><li>Convinced by the knowledge given </li></ul><ul><li>Change believe </li></ul><ul><li>Application attitude </li></ul><ul><li>Transformation of recipient to donor </li></ul><ul><li>health educator </li></ul>
WHO PERFORM THE HEATH EDUCATION <ul><li>Physicians </li></ul><ul><li>Nurses </li></ul><ul><li>Dieteticien </li></ul><ul><li>Social support </li></ul><ul><li>Volunteers </li></ul><ul><li>Patients themselves </li></ul>
Characteristics of Health educator <ul><li>Good Knowledge & experience </li></ul><ul><li>Good listener </li></ul><ul><li>Good observer </li></ul><ul><li>Simplicity </li></ul><ul><li>Repetition & Concentration </li></ul><ul><li>Speech tone and expression </li></ul><ul><li>Verbal & visual communication </li></ul><ul><li>Avoid scientific terms </li></ul><ul><li>Respect </li></ul><ul><li>Accepting errors </li></ul>
Factors in The recipient <ul><li>Interest </li></ul><ul><li>Concentration </li></ul><ul><li>The capability to change the attitude </li></ul>
Factors Affecting the Process of Learning <ul><li>Time </li></ul><ul><li>Place </li></ul><ul><li>Intellectual ability </li></ul><ul><li>Motive </li></ul>
The Subject must be : short <ul><ul><li>Clear </li></ul></ul>Complete
Plan For health education program What are the goal Who will do it Content of knowledge & skills When & to who Duration &cost
THE WAY USED <ul><li>Person to person </li></ul><ul><li>Small groups </li></ul><ul><li>Large group lecture </li></ul><ul><li>Media: </li></ul><ul><li>Newspaper </li></ul><ul><li>Radio </li></ul><ul><li>T V </li></ul><ul><li>Pamphlets </li></ul>
Person to person education Influence and effective Friendship environment Convenient to newly discovered Disadvantage : Time consuming
Success depend on Welcoming & friendship environment Expression and voice pitch changes Selection of subject Simplicity, clarity, local accent Good occasion to ask questions Person to person
Small group health education No from 8 to 12 Done on short interval Once weekly on 6 sessions Not more than 60-90 minutes Selection of the group Type of disease Age & sex Special situation pregnancy Intellectual level Previous attendance Encourage Discussion Self experience
Some beneficial notes in group education Stop and ask questions Summarize before transition from point to point No blame for wrong answer Use verbal and visual expression Tell small story to increase attention Skills explained on vivid examples and tools
Education of large group Communication with audience weaker Low degree of retention Prerequisites Clear goal Good Lecturer Good comfortable place Good preparation Selection of the group Duration 20 to 25 minutes Allow enough time for discussion Use audio visual aids Simple language Summarize the lecture
Patient Education through the Media TV, Videocassette…… Easy to large no in short time and attractive Can be repeated Disadvantages Increase knowledge but not the attitude Misunderstanding Not free from marketing influence
Evaluation of educational program Degree of disease control Bld sugar, Wt,Glycated Hb, Lipids, Bld pressure Prevalence of acute and chronic complication Evaluation of the degree of retention Pre and post program questionnaire Skills direct observation Continuous health education and repetition
Interventions to Improve Quality of Care Luigi Meneghini, MD, MBA Diabetes Research Institute (DRI) University of Miami School of Medicine II PAHO-DOTA Workshop on Quality of Diabetes Care DRI, 14–16 May 2003
Mastering Your Diabetes Metabolic & Psychosocial Outcomes Diabetes Empowerment Scale (DES) The DES is a valid and reliable survey of patient empowerment which yields an overall empowerment score based on all 28 items and three subscale scores (range for all scales: 1.0-5.0). Improvement was evident on all DES scales for participants in the MYD pilot study, despite high baseline values. Diabetes Empowerment Scale Pretest Posttest 3mF/U Overall empowerment 4.1 4.2 4.3* Managing psychosocial aspects 3.9 4.2 4.2 Dissatisfaction/readiness to change 4.3 4.5 4.6* Setting/ achieving diabetes goals 4.0 4.0 4.1 (*P<0.05 v. baseline) Quality of Life & Self-Efficacy Measures of both Quality of Life (QOL) and Self-Efficacy showed statistically significant improvement following the intervention. At the three month follow-up the most significant improvement in QOL sub-scales was for Satisfaction (p=0.0113). 8.84 8.01 7.65 8.10 7.50 6.80 7.00 7.20 7.40 7.60 7.80 8.00 8.20 8.40 8.60 8.80 Mean HbA1c % Mo 1-3 Pre-MYD * p<0.05 v. pre-MYD Mo 4-6 Mo 7-9 Mo 10-12 * * *
Impact of Comprehensive Diabetes Management Program Source: Rubin RJ, et al. J Clin Endocrinol Metab 1998; 83: 2635. * Total costs decreased by $44 per member/month (10.9%) which would translate into savings of $528,000 in the first year for a plan with 1000 members with diabetes. Break-even at 1,265 members with diabetes as per DTCA. $406 $362 $182 $135 $84 $76 $44 $45 $66 $76 $29 $30 $0 $50 $100 $150 $200 $250 $300 $350 $400 $450 Average Cost per member/month Total Inpatient Outpatient MD Drugs Other Baseline (54,186 member months) Follow-up (55,879 member months)
ARE INVOLVED IN THE PROCESS OF HEALTHCARE IMPROVEMENT