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Quality health care

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Quality health care

  1. 1. Quality Health Care Practice Dr PS Deb
  2. 2. What is Quality? Product Services Good Perfect Satisfactory Punctual Robust Beautiful Error free
  3. 3. Quality Tea <ul><li>Product – Tea </li></ul><ul><li>Process – Making tea </li></ul><ul><li>Customer – Patient </li></ul><ul><li>Service – FNB </li></ul><ul><li>Manufacturer – Zesta </li></ul>
  4. 4. Quality? Producer or Provider User or Customer The totality of features and characteristics of a product or service that bear on its ability to satisfy stated or implied needs (ISO)
  5. 5. “ the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” Quality of care
  6. 6. Process <ul><li>Step of action intended to achieve a results </li></ul>History Exam Lab Diagnosis Treatment
  7. 7. Process variation – Error (Sigma) 3.4 6 230 5 6210 4 66800 3 308,000 2 690,000 1 DPMO S
  8. 8. 1. Error of execution - the failure of a planned action to be completed as intended 2. Error of planning - the use of a wrong plan to achieve an aim Medical error
  9. 9. Medical Error <ul><li>Harvard Medical Practice Study 84 </li></ul><ul><ul><li>3.7% of hospitalization resulted in some form of iatrogenic event – of these: 50% preventable, 13.6% fatal </li></ul></ul><ul><ul><li>1300.000 disability annually </li></ul></ul><ul><ul><li>180,000 death annually </li></ul></ul><ul><li>Australian Study 95 </li></ul><ul><ul><li>16.6% admission adverse event </li></ul></ul><ul><ul><ul><li>permanent disability 13.7% </li></ul></ul></ul><ul><ul><ul><li>Death 4.9% </li></ul></ul></ul><ul><ul><li>51% events were preventable </li></ul></ul><ul><li>Institute of Medicine Report 99 </li></ul><ul><ul><li>44,000 to 98,000 deaths annually due to medical errors </li></ul></ul>
  10. 10. Nature of Adverse Events <ul><li>Operative (47.7%) </li></ul><ul><li>Non-operative (52.3%) </li></ul><ul><ul><li>medication-related (19.4%) </li></ul></ul><ul><ul><li>diagnostic mishap (8.1%) </li></ul></ul><ul><ul><li>therapeutic mishap (7.5%) </li></ul></ul><ul><li>Patient suicide (16.7%), </li></ul><ul><li>Operative and post-operative complications (12.1%), </li></ul><ul><li>Medication errors (11.6%), </li></ul><ul><li>Wrong-site surgeries (11%), </li></ul><ul><li>Patient falls (5.1%) </li></ul><ul><ul><ul><li>Leape et al., NEJM 1991 </li></ul></ul></ul>JCAHO 2002
  11. 11. Medical error – extent of problem <ul><li>Less than one death per 100 000 encounters </li></ul><ul><ul><li>Nuclear power </li></ul></ul><ul><ul><li>European railroads </li></ul></ul><ul><ul><li>Scheduled airlines </li></ul></ul><ul><li>One death in less than 100 000 but more than 1000 encounters </li></ul><ul><ul><li>Driving </li></ul></ul><ul><ul><li>Chemical manufacturing </li></ul></ul><ul><li>More than one death per 1000 encounters </li></ul><ul><ul><li>Bungee jumping </li></ul></ul><ul><ul><li>Mountain climbing </li></ul></ul><ul><ul><li>Health care </li></ul></ul>
  12. 12. Medication Errors – Commonest Cause of Injury <ul><li>Med errors </li></ul><ul><ul><li>56% at stage of ordering </li></ul></ul><ul><ul><li>6% from transcribing order </li></ul></ul><ul><ul><li>34% at administration </li></ul></ul><ul><li>770,000 drug-related injuries yearly </li></ul><ul><ul><li>Many result in death or other serious outcome </li></ul></ul><ul><li>2-7 adverse drug events/100 admissions </li></ul>
  13. 13. Why do people make mistakes? <ul><li>Cognitive models of performance </li></ul><ul><ul><li>Skill-based (unconscious, rapid, effortless) </li></ul></ul><ul><ul><li>Rule-based (if X, then Y) </li></ul></ul><ul><ul><li>Knowledge-based (novel problem solving) </li></ul></ul><ul><li>Errors </li></ul><ul><ul><li>Skill-based leads to “slips” </li></ul></ul><ul><ul><li>Rule and knowledge-based lead to “mistakes” </li></ul></ul>
  14. 14. Why do Medication Errors Occur? <ul><li>“ Sound alikes, look alikes” </li></ul><ul><ul><ul><ul><ul><li>Lasix/Losec Accupril/Accutane Zocor/Zoloft Doxepin/Loxepine Xanax/Zantac </li></ul></ul></ul></ul></ul><ul><li>Failure to recognize Allergies </li></ul><ul><li>Failure to recognize drug interactions </li></ul><ul><ul><li>Not searching for interaction </li></ul></ul><ul><ul><li>Not knowing patient on a drug - or herbal </li></ul></ul><ul><li>Decimal point errors (or mg. Vs. mcg.) </li></ul><ul><li>Handwriting </li></ul><ul><li>Verbal orders (though at least one study shows verbal orders less likely to result in errors!) </li></ul>
  15. 15. Conditions that Create Errors <ul><li>Reliance on memory </li></ul><ul><li>Reliance on vigilance </li></ul><ul><li>Non-standard processes </li></ul><ul><li>Excess number of handoffs </li></ul><ul><li>Variable information available </li></ul><ul><li>Excessive work load </li></ul><ul><li>Spotty feedback </li></ul>
  16. 16. Examples of Design Flaws <ul><li>Naming, packaging, labeling </li></ul><ul><li>Metric vs. English system </li></ul><ul><li>Handwriting </li></ul><ul><li>Matching staffing with demand </li></ul><ul><li>Medication delivery </li></ul><ul><li>Accepting mediocre performance </li></ul><ul><li>“Sort and shoot” approaches to error </li></ul>
  17. 17. Look & sound-alike medications <ul><li>mellaril elavil </li></ul><ul><li>paxil taxol </li></ul><ul><li>prilosec prozac </li></ul><ul><li>cerebyx celebrex celexa </li></ul><ul><li>oxycontin oxycodone </li></ul><ul><li>hydroxyzine hydralazine </li></ul><ul><li>alprostadil alprazolam </li></ul>
  18. 18. Evolution of Health Care Quality Regulatory Learning Management Punish Academic Quality practice Hammurabi  (2100 B.C.) Standardization (1917) ACS – HSP (JCAHO: 1951 – 1980s) Hippocrates (300 B.C.) Controlled Trials  (1840s) Industrial Revolution (1800 AD) Sigma, ISO, TQM
  19. 19. Quality control - Standard <ul><li>An acknowledged measure of comparison for quantitative or qualitative value </li></ul><ul><li>A basis for comparison; a reference point against which other things can be evaluated; they set the measure for all subsequent work </li></ul>
  20. 20. Quality Control TQM ISO Accreditation Six Sigma
  21. 21. Standardization - ISO <ul><li>International Standard Organization - European manufacturing industry 1946 </li></ul><ul><li>Provide standards for the development, implementation and management of a quality management system </li></ul><ul><li>ISO 9000 - a management tool to promote &quot;quality control&quot; in a manufacturing and service sector business to health care providers </li></ul>
  22. 22. The ISO 9000 Core Standards <ul><li>ISO 9000:2000 - quality management principles and fundamentals. </li></ul><ul><li>ISO 9001:2000 - customer and regulatory requirements, such as JCAHO, NCQA, URAC or state and federal requirements. </li></ul><ul><li>ISO 9004:2000 - beyond ISO 9001 requirements to meet and exceed customer expectations efficiently. </li></ul><ul><li>ISO 19011 - planning and conducting quality audits. </li></ul>
  23. 23. ISO 9000 <ul><li>Document what you do and do what you document </li></ul><ul><ul><li>control of documents, </li></ul></ul><ul><ul><li>control of records, </li></ul></ul><ul><ul><li>internal audits, </li></ul></ul><ul><ul><li>control of non-conformances, </li></ul></ul><ul><ul><li>corrective actions, and </li></ul></ul><ul><ul><li>preventive actions </li></ul></ul>
  24. 24. ISO 9001-2000 <ul><li>Specific for health care industry </li></ul><ul><li>It describe what must be done to make up a quality system, not how to set it. </li></ul><ul><li>a process based system rather than a compliance/standards requirement based system </li></ul><ul><li>It insure for continued quality improvement </li></ul><ul><li>Problems and process variation are dealt with quickly </li></ul>
  25. 25. Clauses in the ISO 9001 <ul><li>Quality Management System </li></ul><ul><li>Management Responsibility </li></ul><ul><li>Resource Management </li></ul><ul><li>Product Realization </li></ul><ul><li>Measurement, Analysis and improvement </li></ul>
  26. 26. The act of the granting recognition that maintains suitable standards  Accreditation
  27. 27. Organizational Structure ACS 1913 HSP - 1917 JCAHO - 1951 JCR - 1997 JCI - 1997
  28. 28. International Accreditation <ul><li>October 1997 JCAHO Board decision to provide international accreditation </li></ul><ul><li>Decision based on work in over 30 countries and consistent requests form health care organizations to be evaluated against JCAHO standards, viewed as the “benchmark” for hospitals </li></ul>
  29. 29. P ATIENT- C ENTERED S TANDARDS <ul><li>Access to Care and Continuity of Care (ACC) </li></ul><ul><li>Patient and Family Rights (PFR) </li></ul><ul><li>Assessment of Patient (AOP) </li></ul><ul><li>Care of Patients (COP) </li></ul><ul><li>Patient and Family Education (PFE) </li></ul>
  30. 30. H EALTH C ARE O RGANIZATION M ANAGEMENT S TANDARDS (HCO) <ul><li>Quality Management & Improvement (QMI) </li></ul><ul><li>Governance, Leadership & Direction (GLD) </li></ul><ul><li>Facility Management & Safety (FMS) </li></ul><ul><li>Staff Qualifications & Management (SQE) </li></ul><ul><li>Management of Information (MOI) </li></ul><ul><li>Prevention and Control of Infection (PCI) </li></ul>
  31. 31. A CCESS TO C ARE/ C ONTINUITY OF C ARE (ACC) <ul><li>Goals: </li></ul><ul><li>Correctly match the patient’s health care needs with the services available from health care organization. </li></ul><ul><li>Integrate and coordinate the services provided to the patient in the organization. </li></ul><ul><li>Plan for discharge and follow-up. </li></ul><ul><li>Primary Processes: </li></ul><ul><li>Patient entry to organization </li></ul><ul><li>Determination and prioritize patient need </li></ul><ul><li>Connecting patient care inside organization </li></ul><ul><li>Reconnecting patient with community resources </li></ul>
  32. 32. P ATIENT AND F AMILY R IGHTS (PFR) <ul><li>Goals: </li></ul><ul><li>Improve patient outcomes by: </li></ul><ul><ul><li>Respecting patient rights </li></ul></ul><ul><ul><li>Understanding and safeguarding the cultural, psychosocial and spiritual values of each patient. </li></ul></ul><ul><li>Primary Process: </li></ul><ul><li>Identify patient and family expectations </li></ul><ul><li>Inform patients and family of rights </li></ul><ul><li>Obtain informed consent </li></ul><ul><li>Involve in care process </li></ul><ul><li>Provide ethical business framework </li></ul>
  33. 33. A SSESSMENT OF P ATIENTS (AOP) <ul><li>Goals: </li></ul><ul><li>Determine care needs based on assessment </li></ul><ul><li>Assessment by qualified individual </li></ul><ul><li>Primary Processes: </li></ul><ul><li>Assess physical, psychological, social needs of patients - financial factors </li></ul><ul><li>Provide timely laboratory and radiology services </li></ul><ul><li>Reassess patients appropriately </li></ul>
  34. 34. C ARE OF P ATIENTS (COP) <ul><li>Goal: </li></ul><ul><li>Care is planned, coordinated and provided in a setting that is supportive and responsive to the unique needs of each patient. </li></ul><ul><li>Primary Processes: </li></ul><ul><li>Plan and deliver uniform care to all patients - especially frail and vulnerable </li></ul><ul><li>Make care seamless through effective communication </li></ul><ul><li>Provide safe anesthesia care </li></ul><ul><li>Provide safe surgical care </li></ul><ul><li>Use medications safely </li></ul><ul><li>Support patient nutrition need </li></ul>
  35. 35. P ATIENT AND F AMILY E DUCATION (PFE) <ul><li>Goal: </li></ul><ul><li>Improve patient health outcomes by promoting healthy behaviors and involving the patient in care and care decisions. </li></ul><ul><li>Primary Processes: </li></ul><ul><li>Support Patient and family participation in care process </li></ul><ul><li>Provide effective education </li></ul><ul><li>Use education resources efficiently </li></ul>
  36. 36. Q UALITY M ANAGEMENT AND I MPROVEMENT (QMI) <ul><li>Goal: </li></ul><ul><li>Continuously improve patient health outcomes: </li></ul><ul><ul><li>Design </li></ul></ul><ul><ul><li>Measure </li></ul></ul><ul><ul><li>Assess </li></ul></ul><ul><ul><li>Improve </li></ul></ul><ul><li>Primary Processes: </li></ul><ul><li>Provide leadership for quality </li></ul><ul><li>Monitor clinical and managerial processes and outcomes </li></ul><ul><li>Plan, implement, and sustain improvements </li></ul>
  37. 37. G OVERNANCE, L EADERSHIP AND D IRECTION (GLD) <ul><li>Goal: </li></ul><ul><li>Effective leadership supports excellent patient care. </li></ul><ul><li>Primary Processes: </li></ul><ul><li>Identify governance structure and responsibility </li></ul><ul><li>Provide collaborative leadership of the organization </li></ul><ul><li>Provide responsible leadership at department and service level </li></ul>
  38. 38. F ACILITY M ANAGEMENT & S AFETY (FMS) <ul><li>Goal: </li></ul><ul><li>Provide a safe, functional and supportive facility for patients, families, staff members and visitors to: </li></ul><ul><ul><li>Reduce and control hazards and risks </li></ul></ul><ul><ul><li>Prevent accidents and injuries </li></ul></ul><ul><ul><li>Maintain safe conditions </li></ul></ul><ul><li>Primary Processes: </li></ul><ul><li>Understand facility risks and plan to reduce the risks </li></ul><ul><li>Inspect, test, and maintain medical equipment </li></ul><ul><li>Inspect, test, and maintain utility systems </li></ul><ul><li>Educate staff to participate in risks reduction </li></ul>
  39. 39. S TAFF Q UALIFICATIONS & E DUCATION (SQE) <ul><li>Goal: </li></ul><ul><li>An appropriate number of qualified people are available to fulfill the health care organization’s mission and meet the needs of the patients it serves. </li></ul><ul><li>Primary Processes: </li></ul><ul><li>Plan the number and types of staff </li></ul><ul><li>Orient and educate everyone to their responsibilities </li></ul><ul><li>Gather, verify, evaluate, and use medical/dental credentials </li></ul><ul><li>Gather, verify, evaluate, and use nursing credentials </li></ul><ul><li>Gather, verify, evaluate, and use other professional credentials </li></ul>
  40. 40. M ANAGEMENT OF I NFORMATION (MOI) <ul><li>Goal: </li></ul><ul><li>To obtain, manage and use information to improve: </li></ul><ul><ul><li>Patient outcomes </li></ul></ul><ul><ul><li>Individual and overall organization performance </li></ul></ul><ul><li>Primary Processes: </li></ul><ul><li>Identify information needs </li></ul><ul><li>Plan system to meet those needs </li></ul><ul><li>Create and use an effective patient clinical record </li></ul><ul><li>Combine and compare data and information </li></ul>
  41. 41. P REVENTION AND C ONTROL OF I NFECTIONS (PCI) <ul><li>Goal: </li></ul><ul><li>To identify and reduce the risks of acquiring and transmitting infections among patients, employees, doctors, contract workers, volunteers, students and visitors. </li></ul><ul><li>Primary Processes: </li></ul><ul><li>Understand infection risks in entire organization </li></ul><ul><li>Plan and implement surveillance and prevention strategies </li></ul><ul><li>Provide effective leadership and support </li></ul>
  42. 42. WHAT HOW ACCREDITATION ISO
  43. 43. Capability Maturity Model (CMM) 1- Initial – Ad hoc, chaotic 2- Repeatable – tack cost, schedule, function 3 – Defined – Documented, standardized 4 – Managed 5 - Optimized
  44. 44. Hippocratic oath <ul><li>I swear to practice Quality Medicine to fulfill, to the best of my ability and judgment, this covenant: </li></ul><ul><li>I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow. I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism. I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug. I will not be ashamed to say &quot;I know not,&quot; nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery. I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God. I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick. I will prevent disease whenever I can, for prevention is preferable to cure. I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm. If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help. </li></ul>
  45. 45. Ayubouwan

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