The document discusses the history and evolution of quality improvement in US healthcare delivery systems from the 19th century to present day. It notes that Florence Nightingale was an early pioneer in recognizing the importance of sanitation and hospital conditions. Formal quality measurement began in 1913 with standards developed by the American College of Surgeons. Over time, various organizations took on roles to improve quality and several key reports drew national attention to issues like medical errors. The document outlines the shift from measuring structures to processes to outcomes over decades as the healthcare system incorporated concepts like continuous quality improvement and transparency.

1. US Healthcare Delivery Systems
Quality Outcome Measures
Donna Wilson, RN MPH MSJ CPHQ
Director, Quality Improvement/Patient Safety
Mount Sinai Beth Israel
History Pre- 1913
The godmother of quality was Florence Nightingale. She was a
wealthy woman who went to work in the nurse corp during the
Crimean war. She studied illness – the dysentery that the
soldiers were getting.
She was the first one credited with thinking about washing
hands, how close the beds were to one another and sharing
needles.
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2. EMERGENCE OF Continue
Quality Improvement in Health Care
1913 - American College of Surgeons (ACS)- started to measure
what we are doing and what difference it makes.
1918 - Hospital Standardization Program
1951 - Joint Commission on Accreditation of
Hospitals Organizations (JCAHO)-certifies 99% of
hospitals
1963 – Corporate Liability introduced to Hospitals 1st lawsuit
1986 - Corporatization of medicine (HMO’s started, PPO’s)
1988 - Harvard Health Care Demo Project
Need for objective information on physician performance
Data on cost/ outcomes of medical care used by CMS
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1913
First step toward improving quality care in American hospital.
Developed minimal essential standards of care for hospital.
Became the Hospital’s Standardization Program (HSP).
1951

3. HSP became JCAH - assumed responsibility for accreditation
Shift focus from structure to process
Increasing demand for availability of data on quality outcomes,
and cost
1963
Hospital can be held accountable for failing to establish system
of safe practices as defined by the industry.
EMERGENCE OF CQI IN HEALTH CARE
1990 - Introduction of TQM/CQI principles to hospital
management by industry people
1999:Institute of Medicine (IOM) Report said that over 100,000
patients died from medical errors
Started Patient Safety
Transparency in Healthcare
Creation of Institute for Healthcare Quality (IHI)
2000 - CMS Core Measures
2006 – Pay for Performance
2009 – Present on Admission & Readmissions
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70’s-80’s
Organization demanded data on cost, use patterns and practice
patterns because such information was crucial in managing care

4. in these systems. Essential to evaluating costs and quality of
care.
TQM
Growing focus on using scientific methods. TQM was
introduced to hospitals to change the way certain hospitals
approached quality.
Physician Performance
For appointment and reappointment process
Cost and Out come
Medicare Prospective Payment System - Center for Medicare
and Medicaid (CMS)
Continuous Quality Improvement
This term started in 1990s and started to look at quality on a
continuum
We would say “ this is the problem” then we would collect data
to see where we were weak and then come up with a solution
Then we would measure it ( the outcome) to see if what I put in
place actually helped.
If it worked we move onto a different problem. If not, we tried a
new solution
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5. CQI came from Japan’s car industry
Toyota would look for the problems
Decide a solution
Measure it
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1990
Everyone was blown away with the report that stated over
100,000 patient a year died unnecessarily from medical errors.
And that reall started the focus on patient safety.
It was not just about falling out of bed.
It looked at how do we make sure patients don’t get infections
or how do we make make sure that a diabetic is getting the right
diet.
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Measuring quality on a broad basis
Dr. Berwick in Boston created the Institute for Health Care
Quality & Harvard University
They looked at what people had been measuring in 1990s and
came up with Core Measures. It started out voluntary and is now

6. what is known as Pay for Performance
No longer are hospitals paid if the person got worse.
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Affordable Healthcare Act (2010)
Strengthen Medicare
Extend the Program through Cost Cuts
Reduce Payment for Errors, Waste, Fraud & Abuse
Improve Drug Coverage
Improve Patient Safety/Decrease Readmissions
Incentives for Improved Quality of Care
Affordable Healthcare Act (2010)
Decrease Health Disparities
Increase Preventive Care
Increased Coordination of Care
Diversity & Cultural Competency
Increase Access to Underserved Groups
Insurance Affordability/End Insurance Discrimination
Health Insurance Premium Hikes
States to Receive Federal Grants (NYS)
Expand Scope/Improve Review Process

7. Increase Transparency & Accessibility
Develop & Upgrade Technology
The New World Order
Transparency Plus Payment Changes
Value Based Purchasing (VBP)
Hospital Acquired Conditions (HACs)
Readmission Penalties
Meaningful Use for IT Implementation
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What is QUALITY?
Doing the right thing & doing it well
meeting or exceeding customer expectations
Minimizing adverse outcomes and medical errors
Good business
we can measure this by evaluating outcomes- through patient

8. satisfaction surveys, benchmarking, etc
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Definition of PI
Example: right patient, right test, done timely, meeting the
needs of the patient
(patient c/o are valid, even though as staff we consider the
patient to have had a good outcome)
How do we measure care?
What do we look at when we look at outcome?
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WHY QUALITY?
Improve Patient Safety
Improve Patient Outcomes
Regulatory Requirements
Increase Customer Satisfaction
Increase Organizational Effectiveness
Lower Costs

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Patient Safety - IOM Report 1999 - preventable errors; new
patient safety standards 7/01
Patient Outcomes -e ffective Treatment - d/c status, re-
admission, infection control
Regulatory - NYPORTS, JCAHO, Hospital report cards
Customer Satisfaction - patient centered customer more aware
Organizational Effectiveness - systems that work - rapid TAT
lab and diagnostic testing
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Meeting the Changes in Our Healthcare Environment
Why provide the best quality possible?
Value = Quality
Cost
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Cost of quality falls into 4 categories:
1. Cost of prevention (training, team activities, community)
2. Cost if appraised (testing and inspection)

10. 3. Cost of internal failure (waste, rework downtime, disruption)
4. Cost of external failure (patient goes elsewhere, litigation,
ill will)
Car example
If the cost of the car is low but is not reliable and it doesn’t
have good gas mileage, it might not be a good value
If you can get a good solid car – something that is safe,
inexpensive and reliable – that’s value
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Hospital example
If you can get a test done at hospital x and they do thousands of
those and it cost more than hospital y and hospital y has more
errors, it’s not value.
In the end we want the cost as low as we can get and then the
determining factor is quality. If you can pay the lowest and get
the best reputation and the best docs and workers and best
equipment – you have gotten value
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11. 17
How do you achieve QUALITY?
Outcomes are achieved and customer requirements are met
through processes
Quality can be ascertained by evaluating processes and/ or
measuring outcomes
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Process is a series of actions
Outcome - change in patient’s condition following treatment
What is Continuous Quality Improvement (CQI)?
The creation of organization-wide participation in examining,
planning and implementing continuous improvements in the
quality of care and services as defined by the customer
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12. 18
Evolution of Measurement
Structure
Policies & Procedures
Process
How to Achieve Workflow
Were You Efficient
Outcomes
What was the result
Were Your Policies Effective
Did Your Workflow Follow Policy
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What is the Definition of Process?
A sequential series of actions that seek a desired outcome
Set of activities that occur daily within organizations
Includes all facets and people involved in a health care delivery
system

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Illustrate patient movement through system
� � � �
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What is the Definition of Outcome?
Clinical response to treatment
Desired result
Undesirable result
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Change in patient’s condition following treatment
Desirable
Undesirable

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How do we choose indicators?
According to high volume, high risk, problem prone procedures.
Required indicators set forth by regulatory agencies
Review of acceptable professional standards
Review of reliable benchmarking data that is available to us.
Overuse, under-use and misuse
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High Volume Examples:
Cardiac Cath, Colonoscopy, CAP, CHF
Problem Prone Example:
Medication administration process
High Risk Procedures Example:
Brain Embolizations
Required indicators - immunizations, Care CAP, AMI patient,
conscious sedation, use of restraints
Overuse, under-use and misuse Example
Use of Heparin/Coumadin
QI Program Annual Appraisal/ Assessment

15. Areas of Evaluation
Adverse Occurrence/SE Trends
External Requirements (TJC,CMS,IPRO,DOH)
Current Performance Based on High Volume/High Risk/
Problem Prone
Publicly Reported Indicators/Core Measures/Value Based
Purchasing
Benchmarking Data/ Best Practices
HCAHPS – Patient Satisfaction
Infection Prevention Initiatives
Joint Commission Required Data Collection
PI Priorities
Operative & Other Procedures
Tissue Review
Adverse Events Related To Moderate Sedation & Anesthesia
Use of Blood & Blood Products
Transfusion Reactions
Results of Resuscitation
Significant Medication Errors & Adverse Drug Reactions
Patient Perceptions of Care, Quality & Safety (HCAHPS)

16. Falls and Fall Reduction
RRT
Core (ORYX) Measures
Why standardize indicators?
Common Indicators
Internal
Ambulatory Network
Across Hospital Systems
External
CMS, DOH
, TJC, AHRQ, Q-HIP (Payers)
Outcome Data Example - NSQIP

17. CAUTI Prevention
Privileged and Confidential: Prepared in accordance with New
York State Public Health Law 2805 j through m; New York
State Education Law 6527; & Federal Law 109-4.
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Improvement Achieved with:
Hand hygiene before and after patient contact
Use of PPE when handling Foley
Keeping drainage bag below bladder level
Improvement Still Needed with:
Securing Foley tubing to patient leg as per protocol
Valid orders in PRISM
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CAUTI

18. Privileged and Confidential: Prepared in accordance with New
York State Public Health Law 2805 j through m; New York
State Education Law 6527; & Federal Law 109-4.
28
2013 National Prevention Target
25% reduction in CAUTI rate compared to 2009
SIR < 0.75
10% reduction in device utilization
100% adherence to indications for Foley catheter
SIR BIP = 0.3
SIR BIB = 0.3
THANK YOU !!!
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19. Chart1JulAugSepOctNovDec
Series 1
Time
% Compliance
Foley Catheter Maintenance Bundle Compliance
68
75
55
80
100
99
Sheet1Series 1Jul68Aug75Sep55Oct80Nov100Dec99
Chart1200920092009201220122012201320132013
BIP
BIB
NHSN
Rate per 1,000 Catheter Days
2.8
1.8
1.1
0.4
0.9
0.6
2.4
Sheet1BIPBIBNHSN20092.81.820121.10.420130.90.62.4To
resize chart data range, drag lower right corner of range.