My Practice is Perfect So Why Are Some Of My Patients Unhappy and Unhealthy
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Transcript of My Practice is Perfect So Why Are Some Of My Patients Unhappy and Unhealthy
Developing a Provider Culture of Dynamic Quality Improvement
My Practice is Perfect So Why Are Some Of My Patients Unhappy and
Unhealthy
Quality Health Care
“Problems in health care quality are serious and extensive; they occur in all delivery
systems and financing mechanisms. Americans bear a great burden of harm
because of these problems, a burden that is measured in lost lives, reduced functioning, and wasted resources. Collectively, these
problems call for urgent action.”Institute of Medicine, Committee on Quality of Health Care in America.
Crossing the Quality Chasm. A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001
Quality Health Care
“The Institute of Medicine outlines 6 aims for improving our nation’s health care system by stating that all health care
should be
safe,
effective,
patient-centered,
efficient,
equitable, and
timely. “Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm. A New Health System for the 21st Century. Washington, DC: National
Academy Press; 2001
Quality Health Care
The quality of health care is defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with
current professional knowledge.
Donald Berwick
How Do We Define Health Care
Three Domains of Health Care
1. Structural
2. Processes3. Outcomes
How Do We Define Health Care
Three Domains of Health Care
1. Structural – tools available for care
2. Processes – activities we do
3. Outcomes - results
IndicatorsIndicators are the metrics we use to
measure the element of the three domains.
As medical professionals, we are used to working with these. Vital
signs are a outcome metric we use all the time.
How Do We Define Health Care
Types of Quality Problems
1. Overuse – risk of potential harm exceeds the possible benefit
2. Underuse – opportunity for likely favorable outcome missed
3. Misuse - appropriate service causes a preventable complication and full potential benefit not acheived
Six Health Care Improvement Dimensions
1. Safe - Avoiding injuries to patients from the care
2. Effective - Providing services based on scientific knowledge
3. Patient-centered - respectful of and responsive to individual
4. Timely - reducing delays
5. Efficient - avoiding waste
6. Equitable – patient doesn’t impact the quality of service offered
Institute of Medicine, Committee on Quality Health Care in America. Crossing the Quality Chasm. A New Health System for the 21st
Century. Washington, DC: National Academy Press; 2001.
I Wish My Practice Was This Simple
A Better Model of My Practice
Direct Effects of Practice Variables on Patient Outcome
Age
Gender
Family
Health Status
Care Coordination
Communication
A Better Model of My Practice
Numerous Direct and Indirect Effects of Practice Variables on Patient Outcome
Age
Family
Health Status
Care Coordination
Communication
R=Residual Error
RF
RA
RHS
RC
RCC
RP
Blalock HM, Causal Models in the Social Sciences, Aldine Publishing Co., 1999.
Building Blocks of Quality Improvement
Focus on PROCESS
Both internal and external CUSTOMER driven
Use objective DATA to make
decisions
Building a Team for Quality Improvement
• Multidisciplinary TeamMD NursingLab ITBilling Office StaffMedical RecordsManagement
• Clear involvement of leadershipVariable sponsorship
Efficient communication• Meet regularly• Foster “No Bad Suggestion”
culture
Quality Improvement Model
The Model for Improvement, as seen on the Institute for Healthcare Improvement’s website (IHI.org), was developed by Associates in Process Improvement [Langley, Nolan, Nolan, Norman, Provost. The Improvement Guide. San Francisco: Jossey-Bass Publishers; 1996].
Quality Improvement Model
The Model for Improvement, as seen on the Institute for Healthcare Improvement’s website (IHI.org), was developed by Associates in Process Improvement [Langley, Nolan, Nolan, Norman, Provost. The Improvement Guide. San Francisco: Jossey-Bass Publishers; 1996].
What Are We Trying To Accomplish?
AIMUse quality indicators to make a list of
problems faced by your practice or opportunities for change.
Prioritize the problems or opportunities for change
Make goal improvement unambiguous and achievable
Be clear on boundaries
What Change Can We Make That Will Result in Improvement?
Change ConceptsEliminate wasteImprove work flowOptimize inventory – VaccinesChange the work environmentImprove provider/customer experienceImprove time efficienciesDecrease variation in the processMistake proofingImprove product or service
Langley G et al. The Improvement Guide. Josey-Bass Publishers, San Francisco, 1996; xxi,
p295.
What Are We Trying To Accomplish?
AIMUse quality indicators to make a list of
problems faced by your practice or opportunities for change.
Prioritize the problems or opportunities for change
Make goal improvement unambiguous and achievable
Be clear on boundaries
What Are We Trying To Accomplish?
AIM
FOCUS on
what is important to your organization
not what is sexy
STEAL shamelessly
What Are We Trying To Accomplish?
AIMAvoid AIM drift
Be ready to refocus – always learn from current data set
Pilot, try a panel of strategy and spread
What Are We Trying To Accomplish?
AIMHOW GOOD?
BY WHEN?
What Are We Trying To Accomplish?
AIMHOW GOOD?
BY WHEN?
Highland Pediatrics will decrease mean registration to physician time by 20% in 18 months.
What Are We Trying To Accomplish?
AIMHOW GOOD?
BY WHEN?
Highland Pediatrics will offer 3 possible well care visits times
within 48 hours of parental request within the next 6 months.
What Are We Trying To Accomplish?
AIMHOW GOOD?
BY WHEN?
Highland Patients will decrease ER or hospital admissions in known Asthma patients by 15% in 12
months.
What Are We Trying To Accomplish?
AIMHOW GOOD?
BY WHEN?
Highland Pediatrics babies will have completed maternal
Edinburgh screens on the chart for the one and four months visits for 90% of patients in 12 months.
Quality Improvement Model
The Model for Improvement, as seen on the Institute for Healthcare Improvement’s website (IHI.org), was developed by Associates in Process Improvement [Langley, Nolan, Nolan, Norman, Provost. The Improvement Guide. San Francisco: Jossey-Bass Publishers; 1996].
How will we know a change is an improvement?
Know that progression is vital
BUT can be painful
How will we know a change is an improvement?
ChallengesAdds work
Threatening – I plead the 5th
Difficultly with accuracy and consistency
Using the data to take action
Manual vs Automated
Management’s reality conflicts with data
Measured elements chosen inappropriately
Lack of training in data collection and analysis
How will we know a change is an improvement?
OpportunityHealthier and more effective decision
making processProgress (or lack of) can be followedBuild a defined platform for improvement and areas of opportunity
Build confidence in understanding of operationsEveryone is talking a similar language
Easier to see trends – move to proactive instead of reactive
Focus on important items
Data sells ideas and limits the power of dramatic anecdote
How will we know a change is an improvement?
RulesQI is for learning how well what you do correlates with what you want to do
QI is not to build a case to punish someone
“All measures have limits, but limitations do not negate value.”
Use a “balanced set of measures”
Focus on a VITAL FEW forget the common many
Data plotted over time
How will we know a change is an improvement?
StepsAIM Statement
Concept
Measures
Operational Definition
Data Collection
Analysis
Test Change
How will we know a change is an improvement?
Operational DefinitionClear and not ambiguous
Measurement methods
Measurement equipment
Identifies criteria
Specific measures
Ends with numerator/
denominator
How will we know a change is an improvement?
Run ChartMeasure over time
Common and Special Causes
Dr Coffman - Edinburgh Screening
0.00
0.20
0.40
0.60
0.80
1.00
1.20
Q2/11 Q3/11 Q4/11 Q1/12 Q2/12 Q3/12 Q4/12 Q1/13
one month
four month
Balance
Quality Improvement Model
The Model for Improvement, as seen on the Institute for Healthcare Improvement’s website (IHI.org), was developed by Associates in Process Improvement [Langley, Nolan, Nolan, Norman, Provost. The Improvement Guide. San Francisco: Jossey-Bass Publishers; 1996].
What Change Can We Make That Will Result in Improvement?
“All improvement will result in change. All change will not result in improvement”
“Every system is perfectly designed to get the precise results that it gets”
What Change Can We Make That Will Result in Improvement?
Do a detailed analysis of your area of concern
Review the current Evidence-Based Medicine
Review Benchmarks (ie, learning from superior performers in the area chosen for improvement)
Advice from experts or others who have attempted improvement in similar topics
Brainstorming, critical thinking, and hunches about the current system of care
Don’t reinvent the wheel
What Change Can We Make That Will Result in Improvement?
Change ConceptsEliminate wasteImprove work flowOptimize inventory – VaccinesChange the work environmentImprove provider/customer experienceImprove time efficienciesDecrease variation in the processMistake proofingImprove product or service
Langley G et al. The Improvement Guide. Josey-Bass Publishers, San Francisco, 1996; xxi,
p295.
Quality Improvement Model
The Model for Improvement, as seen on the Institute for Healthcare Improvement’s website (IHI.org), was developed by Associates in Process Improvement [Langley, Nolan, Nolan, Norman, Provost. The Improvement Guide. San Francisco: Jossey-Bass Publishers; 1996].
How To Use a PDSA Cycle
PlanDescribe the change to be tested.What do you predict will happen?When will you conduct the test?Who will be involved?Who needs to know about the test?How will you conduct the test?
DoConduct the test.Document what happened.
StudyDiscuss the results of the test.How do your results compare with
your predictions?What did you learn?
ActBased on the results of the test
adopt, adapt, or abort the change.
Overview on Testing Change
Must have a THEORY and a PREDICTION
Test on small scale and collect data over time
Build on your understanding with multiple PDSA cycles for each change idea
Look at change over a wide range on circumstances as you sequence through your PDSA cycles
How will we know a change is an improvement?
Change Concept
Testing Change Concept
Applying Change Concept
Universalization
Theory and Prediction
Test over a spectrum of conditions
Become routine operation
How will we know a change is an improvement?
AIM: Improve infant care of depressed mothers by better screening mothers at one and four month visits
Cycle 1: MD gives mom Edinburgh Screening Tool to complete during exam to 3 moms
Cycle 2: MD gives screen to all moms for a month
Cycle 3: RN introduces screen during rooming, MD grades
Cycle 4: All staff oriented to use of Edinburgh Screen Tool
Having moms fill out Edinburgh Screening Tool will help identify mothers at risk for severe post partum depression
Data
15% have EST
90% have EST
How will we know a change is an improvement?
Change Concept
Testing Change Concept
Applying Change Concept
Universalization
Theory and Prediction
Test over a spectrum of conditions
Become routine operation
PDSA Cycle
Why did you succeed?
Why did you fail?
What further changes do you now need to make in order to succeed?
Were there unintended consequences or harm created by your change attempts?
Concept Triangle
Change Concept-I want to minimize my vaccine inventory
Concept Triangle
Idea-
Only order to replace what we have used that month
Change Concept-I want to minimize my vaccine inventory
Concept Triangle
Idea-
Only order to replace what we have used that month
Idea Concept-
Not overstock by over ordering
Change Concept-I want to minimize my vaccine inventory
Concept Triangle
Idea-
Only order to replace what we have used that month
Idea Concept-
Not overstock by over ordering
Another way to do that idea concept-
Track our use from last year and purchase potential deficient compared to current stock
Change Concept-I want to minimize my vaccine inventory
Concept Triangle
Idea-
Only order to replace what we have used that month
Idea Concept-
Not overstock by over ordering
Another way to do that idea concept-
Track our use from last year and purchase potential deficient compared to current stock
Change Concept-I want to minimize my vaccine inventory
Summary
My Mind SetThink like your customer for the problem at hand
Focus on processes – How you do what you do
Use DATA
My Map and CompassMy AIM – What am I trying to accomplish
How do I know a change is an improvement?
What change can I make that will result in improvement?
My TransportationStart SMALL and end with ALL
Build your understanding of your processes through sequential testing
Test, Implement, Spread
ReferencesBerwick DM. Developing and testing changes in delivery of care. Ann Intern Med1998;128(8):651-656.
Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA. 1998;280(11): 1000-1005.
Clemmer TP, Spuhler VJ, Berwick DM, Nolan TW. Cooperation: the foundation of improvement.Ann Intern Med. 1998;128(12):1004-1009.
Council on Medical Service. Quality of care. JAMA.1986;256(8):1032-1034.
Donabedian A. The Definition of Quality and Approaches to its Assessment. Ann Arbor, MI: Health Administration Press, 1980. Explorations in Quality Assessment and Monitoring; vol 1.
Horbar JD. The Vermont Oxford Network: evidence-based quality improvement for neonatology.Pediatrics. 1999;103(1)(suppl E):350-359.
Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm. A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
Langley GJ, Nolan KM, Nolan TW, Normal CL, Provost LP. The Improvement Guide. A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass Publishers; 1996. E):203-214.
Lloyd R. An Introduction to the Model for Improvement. The Institute for Healthcare Improvement . 2007-06-29
Mangione-Smith R, DeCristofaro AH, Setodji CM, et al. The quality of ambulatory care delivered to children in the United States. N Engl J Med. 2007;357(15):1515-1523.
Perla RJ, Provost LP, Murray SK. Sampling considerations in health care improvement. Quality Management in Health Care. 2013 Jan/Mar;22(1):36-47.
Plsek PE. Quality improvement methods in clinical medicine. Pediatrics. 1999;103(1)(suppl