CCTS 46003/01 Advanced Healthcare Quality …€¦ · The Donabedian Model ... -Avedis Donabedian...
Transcript of CCTS 46003/01 Advanced Healthcare Quality …€¦ · The Donabedian Model ... -Avedis Donabedian...
5/12/2015
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NPUAP Mission
The National Pressure Ulcer Advisory Panel (NPUAP) serves as the authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment through public policy, education and research.
International Guideline
NPUAP – in collaboration with the
European Pressure Ulcer Advisory
Panel (EPUAP) and the Pan Pacific
Pressure Injury Alliance (PPPIA) –
has worked to develop a NEW
pressure ulcer prevention and
treatment Clinical Practice
Guideline and a companion Quick
Reference Guide.
Purchase your copy today at
www.npuap.orgnpuap.org
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NPUAP Monograph
Released in November 2012, the 254-page,
24 chapter monograph, Pressure Ulcers:
Prevalence, Incidence and Implications for the
Future was authored by 27 experts from NPUAP
and invited authorities and edited by NPUAP
Alumna Dr. Barbara Pieper.
The monograph focuses on pressure ulcer rates
from all clinical settings and populations; rates in
special populations; a review of pressure ulcer
prevention programs; and a discussion of the state
of pressure ulcers in America over the last decade.
Purchase the monograph today at www.npuap.org
• Hard Copy $75
• E-version $49
• Individual Chapters $19 npuap.org
Save the date
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Reducing Pressure Ulcers
from Medical Devices
Dr. Peggy Kalowes, RN PhD CNS FAHA
Dr. Joyce M. Black, PhD RN
5/12/2015
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Save the date
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25 – 29 September
www.wuwhs2016.com
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Quality Improvement Frameworks to Implement Evidence-based Practices for
Pressure Ulcer Prevention
William Padula, PhD, MS
University of Chicago
May 12, 2015
The Donabedian Model
Donabedian, JAMA 1988
The secret of quality is love. -Avedis Donabedian
Structure
ProcessOutcomes
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Hazards of Hospitalization in the Elderly
Creditor, Ann Intern Med 1993
Framework of Implementation and Dissemination
Gonzalez et al (2012). A Framework for Training Health Professionals in Implementation and Dissemination Science, Academic Med.
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Evidence-based Practices (EBPs) for Pressure Ulcer Prevention
a. Risk-assessment with Braden Scale
b. Patient repositioning
c. Managing moisture and incontinence
d. Monitoring nutrition
e. Modern support surfaces (beds, overlays)
f. Continual nursing education about EBPs
• It’s a Checklist
Braden, Res Nurs Hlth 1994; Ratliff, NPUAP 2004
Economic Burden
Berwick: Eliminating Waste in U.S. Health Care
Financial Impact of Pressure Ulcers
• Most costly hospital-acquired condition– Treatment: $500-130,000
– Malpractice settlements: $Millions
• $11 billion/year in U.S.– Direct
– Indirect
• Pressure Ulcers represent 0.3% of all healthcare
• $36-45 Billion spent on “failures of care delivery”
Berwick, JAMA 2012; Kuhn, Nurs Econ, 1992; Padula, Med Care 2011
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• Main comparators
– Do-Nothing: Inconsistent
EBPs implementation
– Prevention with EBPs
• Evidence-based practices for
pressure ulcer prevention are
cost-effective
– Invest $55/patient/day in EBPs
– Cost-saving
• *If practiced consistently*
Inpatient
Deep Tissue
Injury
Discharge
Pressure
Ulcer
Stage I/II
Death
Pressure
Ulcer
Stage III/IV
No
Complication
Nurse &
Monitor
Acute &
Chronic
Care
Surgery
Standard Care
Prevention
M
Markov Model
Stakeholders of QI
• Government– National Institutes of Health (NIH)– Agency for Healthcare Research and Quality (AHRQ)– Dept Health and Human Services (HHS)
• Payers– Centers for Medicare and Medicaid Services (CMS)– Commercial Payers
• Advocacy– Institute of Medicine (IOM)– Institute for Healthcare Improvement (IHI)– The Joint Commission (TJC), formerly the Joint Commission
on Accreditation of Healthcare Organizations (JCAHO)
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IOM Reports
• To Err is Human
– Human error is a natural occurrence and can lead to adverse events
– However, systematic flaws within the healthcare environment are what lead to medical error
– Systematic Improvement could reduce likelihood of compound human error that exposes patients to harm
IOM Reports
• First, Do No Harm
– Evidence-based directives
• Failure to employ indicated tests
• Error in performance of operation, procedure or test
• Inadequate monitoring of follow-up of preventive treatments
• “other” system failures
– Motivate health care stakeholders
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IOM Reports
• Crossing the Quality Chasm
– Calls for complete system redesign of U.S. Health Care
– Concept that medical errors cannot be “patched” up with straightforward recommendations
– Adjusting not only how EBPs reach the patient, but how clinical teams reorganize to ensure that EBPs are implemented consistently [without harmful variation]
Fallout of IOM Reports
• Create Center for Patient Safety within AHRQ
• A national system of mandatory and voluntary reporting of medical error within hospitals to create provider transparency
• Regulators need to raise standards– FDA
– The Joint Commission
• Healthcare organizations should create safety systems of safe, evidence-based practices
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IHI Campaigns
• 100,000 Lives– Encourage hospital adoption of…
• preset goals
• preset timeframe
– Garner a personal [hospital] sense of responsibility towards improving quality and patient safety
– Prevention of several hospital-acquired conditions (HACs)
• Surgical Site Infections (SSIs)
• Central Line Infections (CLABSI)
• Adverse Drug Events (ADEs)
IHI Campaigns
– Continue mission of 100,000 Lives
– Add 5 more preventable conditions• CAUTI, pressure ulcers, falls, etc.
– An effort to move past EBPs and into patient-centered care (PCC) to improve prevention
• Over 4,000 hospitals adopted this QI campaign
• HACs dropped as much as 72%
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Issue with EBP -> PCC in 2006
• Providers, especially nurses at the interface of change, not adhering to EBPs
– 64% of nurses read 1 or more specialty journals
– 53% read a nursing journal
– 20% did not read any professional journals
– 0% read a journal dedicated to publication of original research
The Joint Commission
• The regulatory body of hospital quality and performance
• Accredit payer reimbursements (e.g. CMS)
• Mandate adherence to EBPs
• Errors and preventable harms that occur are recorded and noted and associated to EBP implementation failures
• Misreporting quality/performance measures can jeorpardize accreditation
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CMS
• Largest single-payer in the U.S.– 46 million Medicare beneficiaries
– 50 million Medicaid eligible
• Powerful stance on reimbursement policy
• Has used reimbursement to influence QI– Nonpayment for harms
– Pay for performance
• Monitors quality/performance measures of health systems to deduct reimbursements
CMS Nonpayment Policy
• Spring, 2007: CMS announces nonpayment policy for hospital-acquired conditions
• October, 2008: Implementation of nonpayment policy for hospital-acquired conditions
• Present: Hospitals absorb costs for all hospital-acquired conditions– e.g. Pressure Ulcers; Falls; Ventilator-associated
Pneumonia; Catheter-associated UTI; Surgical-site Infections; MRSA; Central-line Infections; etc.2
– Theoretical redistribution of estimated $40+ billion per year3
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CMS Policy Updates: P4P
• 1% payment reduction to hospitals ranking in the lowest quartile of HAC prevention
• HAC including: PSI-03 Pressure Ulcer; PSI-06 Iatrogenic Pneumothorax; PSI-07 CLABSI; PSI-08 Hip Fracture; PSI-12 Pulmonary embolism and DVT; PSI-13 Sepsis; PSI-14 Wound Dehiscence: PSI-15 Accidental puncture/laceration
• Affects all hospitals reimbursed through the inpatient prospective payment system (IPPS)
Timeline of Culture of Improving Quality
7%
(Whittingon, 2004)
4.6%
(Bergquist-Beringer,
2009)
4.5%
(Lyder, 2012)
2-3% (Padula,
2013)
?
Significant Reductions in Pressure Ulcer Incidence since mid-2000s (Stotts, 2013)
Goal is 0%(The Joint
Commission)
$5436
$6721
$8905
$1285
$3469
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$9,000
$10,000
AMI AMI + UTI AMI +Urosepsis
Reimbursement for AMI at University of Colorado Hospital, 2007
Wald, JAMA 2007
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Health care has developed EBPs for many patient safety issues
UHC Hospital Rates of HAPUsAHRQ PSI-3
CMS Policy Interruption
Padula, Jt Comm J Qual Pat Saf 2015
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Pressure Ulcer Prevention Protocol
Quality ImprovementDefinition
The combined and unceasing efforts of everyone – health care professionals, patients and their families, planners, administrators, educators – to make changes that lead to better patient outcomes, better systematic performance, and better professional services.
-Quality by Design
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Key Terms in QI
• Evidence-based Practices vs. Quality Improvement– Evidence-based Practices
• Must be implemented in order to achieve better outcomes
• Guidelines that should be followed
– Quality Improvement• Tools designed to increase effective implementation of EBPs
• A theoretical framework of tools and resources
• Lead to systematic change for improved adherence to evidence-based practice
• Implement vs. Adopt– Implement = evidence-based practices
• Institutionalized by CMS and The Joint Commission
• Measured quality indicators
– Adopt = quality improvement interventions• Establishing a culture of better care
• Up to individual practitioners to develop
QI Best-practice Framework
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QI Adoption in 53 UHC Hospitals
Overall Between domains
Trends in Scope of QI strategies
(N=55)
0
0.2
0.4
0.6
0.8
1
1 6 11 16 21
Quarter (January, 2007 - June, 2012)
Pro
po
rtio
n o
f H
osp
itals
Hospitals with 0 domains
Hospitals with 1 domain
Hospitals with 2 domains
Hospitals with 3 domains
Hospitals with 4 domains
Padula, Wordviews Evid Based Nurs (In Press)
Longitudinal Data Analysis
• Effect Size Analysis– Changes in HAPU rates associated with QI adoption– Unadjusted comparison of clinically meaningful QI interventions
according to CMS reduction threshold: 1 HAPU case per 1,000
• Mixed-effects Poisson Regression– Counts of HAPU rates over time, nested in Hospitals– Random intercept– Random effect: CMS nonpayment policy– Adjusted comparison of statistically significant QI interventions– Outcome Measures:
• Associations between QI interventions and HAPU counts• Empirical Bayes estimates of hospital-level rates
Padula, BMJ Qual Saf 2012
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Unadjusted Effect Size Analysis
Padula, Jt CommJ Qual Pat Saf2015
Combinations of QI Interventions
QI Intervention
Leadership
Initiatives
Visual Tools HAPU
Staging
Skin Care Nutrition
Leadership Initiatives x x x x x
Visual Tools 0.0011 x x x x
HAPU Staging 0.0013 0.0011 x x x
Skin Care 0.0013 0.0012 0.0014 x x
Nutrition 0.0013 0.0012 0.0012 0.0013 x
BOLDED effect sizes indicate statistical significance at the 95% confidence-level. HAPU
indicates Hospital-acquired Pressure Ulcer; QI, Quality Improvement.
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Unadjusted Effect Size Analysis
• 5 QI interventions found to have clinically meaningful impact on prevention
– Leadership Initiatives to present data in clinics
– Visual Tools (e.g. checklists, posters)
– Updates to HAPU staging protocol
– Use of new skin care products or creams
– Emphasis on patient nutrition
Padula, Jt Comm J Qual Pat Saf 2015
Mixed-effects Poisson Regression
• Adjusting for QI interventions
• Relative treatment effects of effective QI interventions over time
Poisson[E(Yij)] = (β0 + ui0) + β1quarterj + β2QIij + (β3 + ui1) × policyj + …+ Ζij
Poisson[E(Yij)] = (β0 + ui0) + β1quarterj + β2QIij + (β3 + ui1) × policyj + …
+ β5quarterj × QIij + β6policyj × QIij + Ζij
Hedeker & Gibbons, Longitudinal Data Analysis 2006
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ME Results – all QI interventions
Padula, Hospital Med 2015
ME Results - Updates to EBPs
Mixed-effects Poisson Regression Model
Hospital-level empirical Bayes estimates
Padula, Hospital Med 2015
EBP Updates associated with 1 HAPU case Reduction per Year = $130,000
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Limitations
• Fair response rate (30.5%; 55 / 180 hospitals)
• Reporting bias from survey responses
• Recall bias for QI interventions dating back 4-5 years
• Difficult to imply all HAPU outcomes on adoption of QI interventions
• Results of QI adoption are co-linear to CMS policy
Conclusions
• Hospital Implications
– Updates to EBPs leads to improve patient outcomes
– Identifies the best QI interventions to explore for HAPU prevention
– Effective QI strategy to bundle with EBPs:
• Leadership: Leadership Initiatives
• P&I: Visual Tools; HAPU Staging; Nutrition; Skin Care
• CMS nonpayment policy provided incentive for hospitals to prevent HAPUs
• Model framework for CER of QI and HACs– Utilize the best-practice framework: Leadership, Staff, IT, Perform &
Improve
– Reapply to other areas: Falls; CAUTI; Pain management; C. Difficile
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Final Thoughts
• Every system is perfectly designed to get the results it gets.– Paul Batalden, MD
Co-founder of IHI
• Any indication of a forced concept or practice upon clinicians receives pushback…– Peter Pronovost, MD, PhD
Director of Armstrong Inst.
CEU Information
To earn the 1.0 continuing education credit from
today’s webinar please visit the link below.
This information will also be emailed out to
participants at the conclusion of the webinar.
https://www.blueq-
surveys.creighton.edu/se.ashx?s=46BEEE7F640F
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