quality management-improving patient outcomes the smart way_dlugacz
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Copyright 2009, Krasnoff Quality Management Institute
Quality Management: Improving Patient Outcomes the Smart Way
REGIONAL FAMILY MEDICINE CONFERENCESponsored by New York State Academy of Family Physicians and Albany County NYSAFP
Yosef D. Dlugacz, PhDSenior Vice President and Chief of Clinical Quality, Education & Research
Saturday, September 12, 2009
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What We Do To Sustain Change
Build a culture of quality through education Develop curricula for clinical and non-
clinical professionals
Tailor workshops to clients specifications
Collaborate with academic institutions
Minimizing the art of medicine and
maximizing the science through data
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
PROGRAM
EVALUATION
DECISION
SUPPORTEDUCATION
M.D. FOCUSEDQ.M.
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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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Source: Codman, E.A. A Study in Hospital Efficiency, 1917.
Ernest Amory Codman, MD (1869-1940) set standards for open, honest,
and public evaluation of the end results of medical and hospital care that willprobably never be met again.
Transparency Is Not A New Concept
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.
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Understanding the Role of QM
in Todays Health Care Environment
Quality Management links quality of care andorganizational 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, measuringoutcomes against benchmarks, sharing data to
improve negotiations with insurers
Medical concerns: still cook book medicine
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The Challenge Evidence-Based Medicine
Source: Timmermans, Stefan and Kolker, Emily. 2004. Evidence-Based Medicine and the
Reconfiguration of Medical Knowledge Journal of Health and Social Behavior45:177-193
Physicians clinical decisions should be based on
scientific, aggregated data related to known clinicaloutcomes, not on cumulative and anecdotal clinical
experiences of individual practitioners.
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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
Error AcknowledgmentTeamwork
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The Challenge Integrating Quality
into the Delivery of Care
Quality means do the right thing right the first time
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 modernmanagement team to produce quality if they are willing to
learn how to change and implement.
Philip B. Crosby
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The Challenge - Quantifying the Definition
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The Challenge - Reeducation
Unless everyone who works in health care recognizesthat 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 ofperformance.
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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
Reduction of Waste Appropriate Care
Refin
ement
of
P
rocesse
s
ofC
are
PDCA Methodology
Outco
mes
Pre
dictio
n
Risk Adjusted Models
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Data Definitions for Clinical IndicatorsComprehensive Diabetes Care (ages 18-75)
Yearly Screening for the following:
HbA1c testing
HbA1c result >9.0 = poor control
HbA1c result
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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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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
32.826.420.1US Average
61.820.321.1Hosp I
54.924.528.5Hosp H
47.720.319.7Hosp G
59.418.929Hosp F
55.41721Hosp E
68.624.527.5Hosp D
60.412.628.8Hosp C
58.915.419Hosp B
69.51922Hosp A
% seeing 10> physicians
in last 6 months
% admitted to Hospice
in last 6 months
% Death with 1> stay
in ICU
Dartmouth Study Shows Quality Indicators Shape Financial Resources
Table 6: Quality Measures (part 1)
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Building Blocks for Quality Infrastructure
Database Development
Trustees Support
CEOs
Medical Leadership
Validation of Program
Community
Hofstra MBA
Methodology
Statistical Analysis
Education
Communication
ResearchPerformance Improvement
Database Development
Trustees Support
CEOs
Medical Leadership
Validation of Program
Community
Hofstra MBA
Methodology
Statistical Analysis
Education
Communication
ResearchPerformance Improvement
External Validation Internal Validation
Accreditation & Regulation
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The Skills - Decision Support
Data
Sources
Data AnalysisData Warehouse(store, organize data)
Technical
Analytical
Technology
- Oracle
- Crystal Enterprise
Structure Process Outcome Metrics
To Emphasize
New Priorities
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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)
Statistical Tools Used in Data Analysis
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Measures can be gauges not only of clinical processesbut 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 helpthe decision maker relate practices to goals and
understand guidelines for care.
Measuring Health Care (2006)
Yosef D. Dlugacz, PhD
The Role of Measurements
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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 ofCare Evidence-Based Practice
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Indicator
Numerator
Denominator
OutcomeEvent
OutcomeOutcome
EventEvent
Population Under Study/Defines Unit of AnalysisTotal Number that have the Opportunity for the Outcome or EventPopulation Under Study/Defines Unit of AnalysisPopulation Under Study/Defines Unit of AnalysisTotal Number that have the Opportunity for the Outcome or EventTotal Number that have the Opportunity for the Outcome or Event
Specifies the criteria for selection toensure an appropriate definition
(Validity) and appropriate interpretationof the definition (Reliability)
Specifies the criteria for selection toSpecifies the criteria for selection to
ensure an appropriate definitionensure an appropriate definition
(Validity) and appropriate interpretation(Validity) and appropriate interpretation
of the definition (Reliability)of the definition (Reliability)
Inclusions:
Exclusions:
The definition of Quality is aboutquantifying experiences (clinical)
as it is related to evidence
= Improvement,Best Practice
It is not about the singular patient
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administ ra t i on o ff i c i a ls say tha t Med ica re w i l l no
longer pay t he ex t ra cos t s o f t rea t ing preventab le
errors , in jur ies and in fec t ions that oc c ur in hospi t a ls , am ove t hey say c ould save l i ves and mi l l ions of do l lars.
The new pol i cy is send ing
r ipp les through t he heal th indust ry .Copyright 2009, Krasnoff Quality Management Institute slide # 31
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Readmission Analysis: 2008Readmission Analysis: 2008
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Observed Rate = Numerator_ X 1000
Denominator
Risk Adjusted Color-based Trend
Risk Adjusted Rate
Risk Adjusted Confidence Interval
Since the
confidence interval
does not contain the
New York State
Rate (33.34%), thishospital has a
significantly higher
rate than the New
York State
Decubitus Ulcer
Rate.
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Pressure Injury Reduction - Spreading the Word
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.
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.
N A h t I C
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New Approach to Improve Care
HOSPITAL
A
I i Ph i i Ed ti b t QM
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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
S ifi C I t ti i l d
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Specific Course Instruction includes
Developing Research Skills and Techniques
from Hypothesis to Publication
Prioritizing an issue for analysisand 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 aboutappropriate 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
Formulate null Create data
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Copyright 2009, Krasnoff Quality Management Institute slide # 42slide # 42
AA CCC
DDPPSelect topic
Implement
intervention or
data collection
plan
Implement
statistical analysis
Discover
conclusion
Define study population
(data definition)
Build case(Literature Review)
Formulate null
hypothesis
Create data
plan
Select
sample size
& statistical
technique
Implementchanges
Publish &
communicate
study
Decide toimplement PDCA
phase II
Copyright 2009, Krasnoff Quality Management Institute slide # 42
Q lit R f
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Quality References
Questions?
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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
Thank you!