Clinical QualityClinical Quality

פרופ' מאיר ברזיספרופ' מאיר ברזיסהמרכז לאיכות ובטיחות קליניתהמרכז לאיכות ובטיחות קליניתהדסה והאוניברסיטה העבריתהדסה והאוניברסיטה העברית

ירושליםירושליםwww.hadassah.org.il/departments/quality

איכות קליניתאיכות קליניתבעולם ובהדסהבעולם ובהדסה

Definitions of Quality (Institute of Definitions of Quality (Institute of Medicine)Medicine)

Degree to which care increases likelihood of desired Degree to which care increases likelihood of desired health outcomes & consistent with current professional health outcomes & consistent with current professional

knowledgeknowledgeSafeSafeTimelyTimelyEffective Effective Patient centeredPatient centeredEquitableEquitableEfficientEfficient

Overuse Overuse (antibiotics, imaging)(antibiotics, imaging)

Underuse Underuse (prevention)(prevention)

MisuseMisuse (errors & complications) (errors & complications)

Evidence-based Patient-centered System-minded

Performance Performance Evaluation Evaluation • Voluntary Quality IndicatorsVoluntary Quality Indicators• Mandatory Performance EvaluationMandatory Performance Evaluation• Public Data Including Individual SurgeonPublic Data Including Individual Surgeon• Pay for PerformancePay for Performance• Non-payment for Preventable Non-payment for Preventable Complications Complications Challenges: measurement error, Challenges: measurement error, socioeconomic confounders, manipulation, socioeconomic confounders, manipulation,

denial, gamingdenial, gaming

* Harvard Professor Don Berwick, Institute for Health Improvement

Stages of Facing Reality*

Ego bias: “I’m above the average”(Kahneman & Tversky. Heuristics and Biases. The Psychology of Intuitive Judgment)

Stage 1. “The data are wrong”

Stage 2. “The data are right, but it’s not a problem”

Stage 3. “The data are right; it is a problem; but it is not my problem.”

Stage 4. “I accept the burden of improvement”

““In short, academic medical centers should not just have best In short, academic medical centers should not just have best knowledge, they should model the best execution…knowledge, they should model the best execution…They do notThey do not. .

Unreliability, waiting, lack of focus on patient’s needs and Unreliability, waiting, lack of focus on patient’s needs and safety are every bit of characteristic of academic medical safety are every bit of characteristic of academic medical centers…and centers…and that needs not be the casethat needs not be the case. .

The same intellectual fervor and talent that allow places like the The same intellectual fervor and talent that allow places like the Brigham to raise the bar in technical clinical care can equally be Brigham to raise the bar in technical clinical care can equally be used to raise the bar in the quality of medical care. used to raise the bar in the quality of medical care.

……it’s going to take much more acute self-awareness among it’s going to take much more acute self-awareness among academicians and academic medical centers….academicians and academic medical centers….

……a duty to encourage healthcare leaders and clinicians a duty to encourage healthcare leaders and clinicians everywhere to become involved in improvement."everywhere to become involved in improvement."

Donald M. Berwick, MD, MPP, FRCPDonald M. Berwick, MD, MPP, FRCPProfessor at Harvard School of Public HealthProfessor at Harvard School of Public HealthPresident, Institute for Health Improvement, President, Institute for Health Improvement, Boston, Massachusetts, USABoston, Massachusetts, USA

Cycles of Improvement (Industry Model)

PDSA

Example: monitoring of surgical infection rate is Example: monitoring of surgical infection rate is now recognized as important tool to preventionnow recognized as important tool to prevention

Statistical Process Control

Quality of General Intensive CareQuality of General Intensive Care

Survival at Hadassah vs. Israel AverageSurvival at Hadassah vs. Israel Average

Prof. Prof. Elisheva Simchen, Ministry of HealthElisheva Simchen, Ministry of Health

p<0.001

Despite higher severity score, Despite higher severity score, patients had better survival at patients had better survival at

HadassahHadassah

Quality of Neonatal Intensive CareQuality of Neonatal Intensive Care Survival at Hadassah vs. Israel Survival at Hadassah vs. Israel

AverageAverage Dr. Zivanit ErgazDr. Zivanit Ergaz, , Prof. Ilan AradProf. Ilan Arad & Gertner Institute & Gertner Institute

11.5%

19.6%

2.1%2.9%2.6% 2.7%3.2%

6.7%5.8%5.5%5.8%5.3%

13.4%

18.4%

14.4%13.6%

20.2% 20.5%20.9%19.7%

0%

10%

20%

30%

1999 2000 2001 2002 2003

Hadassah - Total Mortality NTDB - Total Mortality

Hadassah - ISS 16+ Mortality NTDB - ISS 16+ Mortality

Quality of Treatment in TraumaQuality of Treatment in Trauma Mortality at Hadassah vs. US level I centersMortality at Hadassah vs. US level I centers

Dr. Yoav Mintz, Dr. Yoav Mintz, Ms. Irina GertcenchteinMs. Irina Gertcenchtein & & Prof. Avraham Prof. Avraham RivkindRivkind

Hadassah data Hadassah data Israeli National Israeli National

Trauma Registry Trauma Registry n=7,391n=7,391

US National US National Trauma Data Bank Trauma Data Bank

from 51 level-I from 51 level-I trauma centers, trauma centers,

n= 263,524n= 263,524

Quality indicators for myocardial Quality indicators for myocardial infarction, Hadassah vs. US datainfarction, Hadassah vs. US data

HadassahHadassah ((%%) 89 90 50 83 69 44’ 102’Referral to cardiac rehabilitation only 21% Referral to cardiac rehabilitation only 21%

Percent of patients receiving adequate anticoagulation

%%

Surgery A

Surgery A

Surgery B

Surgery B

Surgery C

Surgery C

Gynecology

Gynecology

AA Gynecology

Gynecology

BB

p<0.00p<0.0011

p<0.00p<0.0011

p<0.00p<0.0011

p<0.02p<0.02

Catheter-related Bloodstream Catheter-related Bloodstream InfectionsInfections

Intervention in 108 ICU’s resulted in 66% reduction Intervention in 108 ICU’s resulted in 66% reduction in rates of catheter-related bloodstream infectionin rates of catheter-related bloodstream infection

Catheter-related Bloodstream Catheter-related Bloodstream InfectionsInfections

At Hadassah, baseline observations over five months revealed a rate of infection of 13.2% (42/318 catheters), on the high side of reported ranges.

Observations in ICU’s and OR: aseptic conditions not always strictly kept during catheter insertion.

Intervention included discussion of results with staff, training for correct aseptic technique, use of a checklist, and authorization to nurses to feedback and stop physicians breaching asepsis.

I. Gross, S. Benenson, M. Cohen, C. BlochI. Gross, S. Benenson, M. Cohen, C. Bloch

Catheter-related Bloodstream Catheter-related Bloodstream InfectionsInfections

Following intervention, improvement in technique was observed; rate of infection declined by 62%, from 13.2% to 5.0% (17/337 catheters, p<0.001).

100.0080.0060.0040.0020.000.00

1.0

0.9

0.8

0.7

0.6

0.5

0.4

0.3

Cu

m S

urv

ival

1.00.00

NewGroup

Survival Function for patterns 1 - 2

100.0080.0060.0040.0020.000.00

1.0

0.9

0.8

0.7

0.6

0.5

0.4

0.3

Cu

m S

urv

iva

l

1.00.00

NewGroup

Days of catheter

Proportion of catheters remaining

without infection

(Cox regression)Before the

intervention

After the intervention

100.0080.0060.0040.0020.000.00

1.0

0.9

0.8

0.7

0.6

0.5

0.4

0.3

1.00.00

NewGroup

100.00

80.00

60.00

40.00

20.00

0.00

1.0

0.9

0.8

0.7

0.6

0.5

0.4

0.3

1.00

.00

NewGroup

100.0080.0060.0040.0020.000.00

1.0

0.9

0.8

0.7

0.6

0.5

0.4

0.3

1.00.00

NewGroup

p<0.001

Catheter-related Bloodstream Catheter-related Bloodstream InfectionsInfections

UnitBefore InterventionAfter InterventionRate

Reduction (%)

Catheter days

N infected

Rate*Catheter

daysN

infectedRate*

ICU-A117665.1129632.355

ICU-B124075.687922.360

ICU Medicine9951616.1171563.578

Neuro-surgery225417.817315.867

Cardiac surgery56258.955147.318

ICCU150426.763115.940

Total4348429.664677173.6362.4**

* Rate of infection per 1000 catheter-days ** p<0.001

Catheter-related Bloodstream Catheter-related Bloodstream InfectionsInfections

Pronovost P. et al. An intervention to decrease Pronovost P. et al. An intervention to decrease catheter-related bloodstream infections in the ICU. catheter-related bloodstream infections in the ICU.

N Engl J MedN Engl J Med 2006;355:2725 2006;355:2725

Physicians’ Hand Physicians’ Hand Hygiene at HadassahHygiene at Hadassah

Ein KeremMt. Scopus

Medicine65%55%

Pediatrics55%62%

Surgery 35%66%

Ob-Gyn25%

Rate of hand-washing out of contacts with patients

Summary of surveys in recent Summary of surveys in recent yearsyears

Use of Hadassol has been widely Use of Hadassol has been widely adopted but rate of hand hygiene adopted but rate of hand hygiene unchanged unchanged

Surgical Infections in General Surgical Infections in General SurgerySurgery

Rate of post-operative wound infection is 8-12%, within the range reported in the literature.

Pre-operative antibiotic administration is documented as given on time in 59% of cases.

A significant proportion of infections are

diagnosed after discharge from the hospital.

Infection monitoring is recognized as an important tool to keep rates low.

N. Minster, M. Zarhia, G. Almogy, A. Rivkind, S. Benenson, M. Cohen N. Minster, M. Zarhia, G. Almogy, A. Rivkind, S. Benenson, M. Cohen

ComplicationsRate of infection (95% CI)

Children 6% (2-13)0.7-14%*

Adults12% (7-20)

Rate of hematoma (95% CI) Children10% (5-18)

11-15%*Adults13% (8-21)

*Range in literature varies by motive (voluntary or mandatory)

Satisfaction high to very high in 94% of adults and children; problems: waiting & relation with staff

Quality of Inguinal Hernia Repair in Quality of Inguinal Hernia Repair in Adults and in Children at HadassahAdults and in Children at Hadassah

T. Yemini, M. Badriah, Y. Mintz, R. Udassin, A. Rivkind

Quality of Special SurgeriesQuality of Special Surgeries

Outcomes of special surgery in the Departments of Ear, Nose & Throat (ENT), Ophthalmology,

Plastic and Neurosurgery

ENTSnoring, tonsillectomies

OphthalmologyCorneal transplant, Lasik

Plastic surgeryBreast reconstruction

NeurosurgeryPrevention of shunt infection

Management of Snoring Disorders with Management of Snoring Disorders with Radiofrequency at Hadassah Optimal Radiofrequency at Hadassah Optimal

%

p<0.01 p≤0.05p<0.005

L. GordonL. Gordon,, S. Catinari, R. EliasharS. Catinari, R. Eliashar

Lasik (Myopic Corneal Refractive Surgery) at Lasik (Myopic Corneal Refractive Surgery) at Hadassah Optimal (N=109) Hadassah Optimal (N=109)

%

N. Orwa, A. Solomon, Y. Frucht-PeriN. Orwa, A. Solomon, Y. Frucht-Peri

Evaluation of Outcomes for Evaluation of Outcomes for Tonsillectomies at Hadassah (2008)Tonsillectomies at Hadassah (2008)

Hadassah(N=106)

Literature UK audit &

others (N>30,000)

% with any bleeding28?

% needed readmission203-10

% needed reoperation4.70.5-2.0

O. Frenkel, R. EliasharO. Frenkel, R. Eliashar

Quality of Reconstruction Surgery Quality of Reconstruction Surgery After MastectomyAfter Mastectomy

R. Yanko-Arzi, M. J. Cohen, R. Braunstein, E. Kaliner, R. Neuman R. Yanko-Arzi, M. J. Cohen, R. Braunstein, E. Kaliner, R. Neuman Dept of Plastic Surgery & Center for Clinical Quality & SafetyDept of Plastic Surgery & Center for Clinical Quality & Safety

A survey of 140 A survey of 140 women after women after reconstructive reconstructive breast surgery breast surgery for cancer for cancer showed showed satisfaction satisfaction related mostly related mostly to expectations to expectations before surgery.before surgery.

%% 0 20 40 60 80

Severe

moderate high

Complications

Success

Satisfaction

WouldRecommendHadassah

10 17 21 24

05

10152025303540

% of shunts infected

2001 2002 2003 2004-5Number of shunts inserted

InterventionIntervention

Neurosurgical shunt infections

Mortality in infected cases dropped from 50% to 0%Mortality in infected cases dropped from 50% to 0%

I. Paldor, Z. Israel, C. Block with the dept of NeurosurgeryI. Paldor, Z. Israel, C. Block with the dept of Neurosurgery

Is the X-ray interpretation by the junior staff on duty correct?

Dr. Y. Mintz, Dr. D. Kisselgoff, Y. Gronowitz, A. Shaham, R. Hefez, Dr. D. Shaham - Departments of Surgery,

Radiology, and Center for Clinical Quality & Safety

Pulmonary Pulmonary EmbolismEmbolismSurgerySurgeryTraumTraum

aa % %

agreementagreement resident vs. resident vs. specialistspecialist

95%95%77%77%94%94%

Effect of Translators on Effect of Translators on Understanding & Satisfaction of Understanding & Satisfaction of

Arab Parents Arab Parents

Department of Pediatrics & ER, Mt Scopus & Center for Clinical Quality & Safety,

Hadassah Hebrew University Medical Center

The Presence of a Translator Significantly Improved Parental Understanding Regarding

Diagnosis, Treatment and Follow-up96

86

72 7478

3438

23

0

20

40

60

80

100

Understanding ofdiagnosis

Necessary follow-up When return visit to ERnecessary

Dosage & duration ofmedication

%

translator no translatorp<0.001, n=194

Will patient’s empowerment improve Will patient’s empowerment improve efficacy & safety of oral efficacy & safety of oral

anticoagulation? anticoagulation? Self-management for CoumadinSelf-management for CoumadinH. Goldberg, Y.Ben David, U. Izhar, L. Gordon, T. Baevsky, M.Burzstyn H. Goldberg, Y.Ben David, U. Izhar, L. Gordon, T. Baevsky, M.Burzstyn

& M.Brezis with the Departments of Cardiothoracic Surgery and & M.Brezis with the Departments of Cardiothoracic Surgery and MedicineMedicine

0

10

20

30

40

50

60

% %of of tests tests within within target target INRINR

6600%% * *p<0.001p<0.001

3838%%

ControlControl InterventionIntervention

Patient’s knowledge & satisfaction significantly improvedPatient’s knowledge & satisfaction significantly improved

Patient’s empowerment improves Patient’s empowerment improves efficacy & safety of oral efficacy & safety of oral

anticoagulationanticoagulation

Communicating with Families & Communicating with Families & Satisfaction with End-of-Life Satisfaction with End-of-Life

DecisionsDecisionsDepartments of Medicine & Center for Clinical Quality & Safety

% of relatives agreeing with statement:ControlIntervention

“I felt the team didn’t care about my opinion”3513*

“It upset me I didn’t know what was going on”4310*

“Patient’s problems weren’t explained to me” 443*

“Management options were not explained”4617*

“I was afraid to ask questions”3810*

“I felt excluded in the decision-making”5217*

Communication with families of patients near end of life improves perceived quality of care

*p<0.005 in favor of the intervention group

Rate of patient’s recall for explanations Rate of patient’s recall for explanations on risks & alternatives: informed on risks & alternatives: informed

consent?consent?

WardWardType of Type of procedureprocedureNNExplanationsExplanations

about risksabout risksDiscussion ofDiscussion ofalternativesalternatives

SurgerySurgeryOperationOperation17817860%60%20%20%

ObGynObGynOperationOperation19819857%57%19%19%

MedicineMedicineDiagnostic or Diagnostic or therapeutictherapeuticprocedureprocedure

11711742%42%40%40%

CardiologyCardiologyAngiographyAngiography12012039%39%8%8%

TotalTotal61361351%51%21%21%

International Journal for Quality in Health Care 2008

ConclusionConclusion

Projects help make healthcare at Projects help make healthcare at Hadassah more evidence-based, patient-Hadassah more evidence-based, patient-centered & system-minded. centered & system-minded.

Over 100 projects presented at National Over 100 projects presented at National Meetings of Israeli Society for Quality in Meetings of Israeli Society for Quality in Healthcare; over 48 theses and 19 peer-Healthcare; over 48 theses and 19 peer-reviewed publications.reviewed publications.

Center for Clinical Quality & SafetyCenter for Clinical Quality & Safety