Quality Management: Improving Patient Outcomes the Smart Way

REGIONAL FAMILY MEDICINE CONFERENCE Sponsored by New York State Academy of Family Physicians and Albany County NYSAFP

Yosef D. Dlugacz, PhD Senior Vice President and Chief of Clinical Quality, Education & Research Saturday, September 12, 2009
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What We Do To Sustain Change

Implement post assessment improvements Establish/Reestablish Quality Management infrastructure Develop Centers for Excellence Define leadership responsibilities Design objective evaluation tools Refine medical staff structure Reinforce the team approach Develop databases and web tools Evaluate clinical care Interpret and analyze data Report to key stakeholders for action Provide clients with local support to monitor and maintain improvement Create a data-driven system to provide evidence to clinicians
DECISION SUPPORT

PROGRAM
EVALUATION

M.D. FOCUSED Q.M.

EDUCATION

Build a culture of quality through education Develop curricula for clinical and nonclinical professionals Tailor workshops to clients specifications Collaborate with academic institutions Minimizing the art of medicine and maximizing the science through data
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Understanding the Role of QM in Todays Health Care Environment

Quality Management is much more than meeting regulatory requirements
Administrative rather than medical concerns

Quality Management is much more than embracing transparency

Somewhat medical concerns such as cardiac surgery

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Transparency Is Not A New Concept

Ernest Amory Codman, MD (1869-1940) set standards for open, honest, and public evaluation of the end results of medical and hospital care that will probably never be met again.

What is the end-result idea? It is that every hospital should trace each patient with the object of ascertaining where the maximum benefit has been obtained and to find out if not, why not? The end-result idea merely demands that the results shallbe constantly analyzed and possible methods of improvement constantly considered.

Source: Codman, E.A. A Study in Hospital Efficiency, 1917.

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Understanding the Role of QM in Todays Health Care Environment

Quality Management links quality of care and organizational financial success to help caregivers and organizations survive in todays competitive marketplace
Medical concerns change from how much (utilization) to what and how care is provided (efficacy and efficiency)

Using evidence-based protocols, measuring outcomes against benchmarks, sharing data to improve negotiations with insurers
Medical concerns: still cook book medicine
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The Challenge Evidence-Based Medicine

Physicians clinical decisions should be based on scientific, aggregated data related to known clinical outcomes, not on cumulative and anecdotal clinical experiences of individual practitioners.

Source: Timmermans, Stefan and Kolker, Emily. 2004. Evidence-Based Medicine and the Reconfiguration of Medical Knowledge Journal of Health and Social Behavior 45:177-193

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The Challenge Team Approach

Autonomy is often overvalued by physicians. At times they would rather do the wrong thing than have someone else tell them what they must do. The culture of physician autonomy in American health care is at times the enemy of quality.
Jordan Cohen, M.D., President, AAMC

Communication

Teamwork

Error Acknowledgment
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The Challenge Integrating Quality into the Delivery of Care

Quality is the result of a carefully constructed culture: it has to be the fabric of the organization not part of the fabric, but the actual fabric. It is not hard for a modern management team to produce quality if they are willing to learn how to change and implement.
Philip B. Crosby

Quality means do the right thing right the first time

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The Challenge - Quantifying the Definition

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The Challenge - Reeducation

Unless everyone who works in health care recognizes that they have 2 jobs when they come to work every day, i.e., doing the work and improving it, medicine is likely to have difficulty meeting Houles second criterion for judging a profession: continuous movement towards new levels of performance.

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MBA in Quality Management

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Three Aspects of Quality in Health Care

Measurable Exceeds minimum standards and criteria Judged by the recipient or observer of care rather than by the provider of care

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The Axioms of Quality

PDCA Methodology

Risk Adjusted Models

t en em fin of ses Re es e oc ar Pr f C o

Reduction of Waste Appropriate Care

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O Pr utc ed om ic e tio s n

What Can Be Applied from Article 28 Clinics to the Private Office?

Data Definitions for Clinical Indicators Comprehensive Diabetes Care (ages 18-75) Yearly Screening for the following:
HbA1c testing HbA1c result >9.0 = poor control HbA1c result <7.0 = good control LDL-C, LDL-C result < 100 Nephropathy
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What Can Be Applied from Article 28 Clinics to the Private Office?

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What Can Be Applied from Article 28 Clinics to the Private Office?

TABLE OF MEASURES FOR AMBULATORY CARE Family Practice Ambulatory Care Center
Advance Directives Discussion Documentation Rate Breast Cancer Screening Completed Rate Breast Cancer Screening Offered Rate Cervical Cancer Screening Completed Rate Cervical Cancer Screening Offered Rate Colorectal Cancer Screening Completed Rate Colorectal Cancer Screening Offered Rate BMI Documentation Compliance Rate (ages 2-19) Immunization of Two-Year Olds Completed Rate Pneumonia Vaccination Completed Rate Pneumonia Vaccination Offered Rate Smoking Cessation Screening Educated/Referred Rate Smoking Cessation Screening Screened Rate Summary Completed Rate

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What Can Be Applied from Article 28 Clinics to the Private Office?

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What Can Be Applied from Article 28 Clinics to the Private Office?

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The Role of the Physician in Competing Environments

Geographical variation in tests, treatment options, procedures, and outcomes Equal access to care for various social, ethnic, financial strata Variations in pricing/cost across the country Adopting new technology to meet expectations (EMR) Demonstrate to insurers/purchasers that you are a high value provider
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Variations in End of Life Care

Dartmouth Study Shows Quality Indicators Shape Financial Resources
% Death with 1> stay in ICU Hosp A Hosp B Hosp C Hosp D Hosp E Hosp F Hosp G Hosp H Hosp I US Average % admitted to Hospice in last 6 months % seeing 10> physicians in last 6 months

22 19 28.8 27.5 21 29 19.7 28.5 21.1 20.1

19 15.4 12.6 24.5 17 18.9 20.3 24.5 20.3 26.4

69.5 58.9 60.4 68.6 55.4 59.4 47.7 54.9 61.8 32.8

Table 6: Quality Measures (part 1)

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Building Blocks for Quality Infrastructure

External Validation
Validation of Program Community
Accreditation & Regulation

Internal Validation
Trustees Support CEOs

Hofstra MBA

Research Performance Improvement Communication Education Statistical Analysis Methodology Database Development
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Medical Leadership

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The Skills - Decision Support

Structure
Data Sources

Process
Data Warehouse
(store, organize data)

Outcome
Data Analysis

Metrics
To Emphasize New Priorities

Technology - Oracle - Crystal Enterprise

Technical Analytical
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Statistical Tools Used in Data Analysis

Controlling for Severity/ Risk (Outcome e.g., mortality) Controlling Variation in process (Run/ Control Charts e.g., patient falls) Comparing Competitors (Percentile Ranking e.g., P4P, pneumonia)

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The Role of Measurements

Measures can be gauges not only of clinical processes but also of values; they are a way to examine the process of care, to look at methods and outcomes, and to learn from errors and events. Information and education help the decision maker relate practices to goals and understand guidelines for care.
Measuring Health Care (2006) Yosef D. Dlugacz, PhD

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Paradigm Shift
Reactive Compliance Regulation Quality addressed every three years with Joint Commission visit Analysis based on check list Accountability by QM department Leadership not involved Communication limited End product is accreditation Proactive Measurement Statistical models Databases Change in practice Assessment and analysis of practices Accountability by caregivers Leadership involved Communication productive End product recognized quality program

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Value of Measures in Defining Quality

Accountability and Transparency
Data publication on web sites (CMS, JC, DOH) and Report Cards

Transforming Processes and Delivery of Care

Real time measures Real time reaction

Assessing Performance
Mortality rates, hospital associated infections

Benchmarking
Highlighting/Sharing Best Practices

Understanding Variation Before Standardization of Care

Evidence-Based Practice
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Indicator
The definition of Quality is about quantifying experiences (clinical) as it is related to evidence

Numerator

Outcome Outcome Event Event

= Improvement, Best Practice

Denominator

Population Under Study/Defines Unit of Analysis Population Under Study/Defines Unit of Analysis Total Number that have the Opportunity for the Outcome or Event Total Number that have the Opportunity for the Outcome or Event
It is not about the singular patient

Inclusions: Exclusions:

Specifies the criteria for selection to Specifies the criteria for selection to ensure an appropriate definition ensure an appropriate definition (Validity) and appropriate interpretation (Validity) and appropriate interpretation of the definition (Reliability) of the definition (Reliability)
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 administration officials say that Medicare will no longer pay the extra costs of treating preventable errors, injuries and infections that occur in hospitals, a move they say could save lives and millions of dollars.

The new policy is sending ripples through the health industry.

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Readmission Analysis: 2008 Readmission Analysis: 2008

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Risk Adjusted Confidence Interval Risk Adjusted Rate

Risk Adjusted Colorbased Trend

Since the confidence interval does not contain the New York State Rate (33.34%), this hospital has a significantly higher rate than the New York State Decubitus Ulcer Rate.

Observed Rate =

Numerator_ X 1000 Denominator

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Pressure Injury Reduction - Spreading the Word

A standardized approach to patient assessment/ reassessment through the use of evidence-based guidelines, in addition to uniform treatment methodologies and skin care products, has led to a common understanding of skin care management and improved communication across the continuum of care.

Dlugacz, Y., Stier, L. and Greenwood, A. (2001) Changing the System: A Quality Management Approach to Pressure Injuries Journal for Healthcare Quality, Vol. 23, No. 5, Sept-Oct. Copyright 2009, Krasnoff Quality Management Institute slide # 38

New Approach to Improve Care

HO SP

ITA LA

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Improving Physician Education about QM

DOH & ACGME mandate an 80 hour residency work week and provide oversight GMEC must monitor compliance ACGME requirements for Practice-based Learning & Improvement Application of quality improvement skills & evidence-based medicine

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Specific Course Instruction includes

Developing Research Skills and Techniques from Hypothesis to Publication
Prioritizing an issue for analysis and improvement Understanding the role of the null hypothesis Using the medical record as a resource Developing assumptions for defined project Reviewing the relevant literature Defining a project Identifying variables Understanding issues about appropriate sample size Defining the appropriate numerator and denominator for the patient population being studied Defining appropriate measurements Collecting data Gaining familiarity with IRB approval requirements Communicating results effectively to peers via journal articles or professional presentations
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Formulate null hypothesis Build case

(Literature Review)

Create data plan Select sample size & statistical technique Implement intervention or data collection plan

Define study population (data definition) Select topic Decide to implement PDCA phase II Implement changes

PD AC
Publish & communicate study Discover conclusion Implement statistical analysis
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Quality References

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Questions?
For additional information, please visit our web site at www.theKQMI.org or Contact us directly:
Krasnoff Quality Management Institute 600 Northern Boulevard, Suite 220B Great Neck, New York, USA 11021-5200 516-465-8440 kqmi@nshs.edu

Thank you!

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