EAHM - Düsseldorf

Ir Laurens TouwenReinier de Graaf Hospital, Delft

16 november 2007 Düsseldorf

L.Touwen, 16 nov 07 2

Where are we talking about?

from the patient point of view

• "The way we deliver care“: professionoveruse, underuse, misuse (patient safety)

• "The way we organize care“: organisationhealth care is an archipelagoaccess-problems, waiting times, delayscoordination problemscommunication gap

• "The way we take care“ : relationshipinformationco-decision makingempathy

• "The level of recovery“ : results

L.Touwen, 16 nov 07 3

Where are we talking about? from the organization point of view

Striving for quality• For the individual patient• For the general practitioner/ referral• For the specialist• For the employees• For the government/inspection• For……

And how to put your quality in concrete

L.Touwen, 16 nov 07 4What we don’t like to happen….Basically miscommunication!

L.Touwen, 16 nov 07 5

Accreditation? Quality Improvement?

• paradigm “good-bad”• emphasize the status quo• organis./profess. in the centre• measurement - control• part of quality-system• minimal-quality• static• fast• costs energy• dangers: bureaucracy

window-dressing alibi-function

• paradigm “good-better”• emphasis on better results• patient in the centre• measurem.→improv.→contr.• is quality-system• innovation and improvement• dynamic• slow, time-consuming• gives new energy• dangers: religion/jargon

failure leadership dependant

and or

L.Touwen, 16 nov 07 6

Quality defined IOM 1999

• Safe• Effective• Patient-centered• Timely• Efficient• Equal for all

Care must be:

L.Touwen, 16 nov 07 7

Changing Health Care Four Levels of Intervention

• Patient-level 6 aims, patient-involvement, patient-experiences

• Level of the care-process: work floor professional x organization → results

• Institutional level leadership with courage, strategyintegration, collaborationsupported by: flow-management, IT, HRM, MDinternal incentives (reinforcing intrinsic motivation)

• System-level structure, law, financing,bureaucracy, external incentives

L.Touwen, 16 nov 07 8

Dr Deming influenced quality-improvement very strongly

L.Touwen, 16 nov 07 9

L.Touwen, 16 nov 07 10

NIAZ- Dutch institute for accreditation of hospitals

• CCKL - Coordination Commission for enhancement of Quality assurance in the realm of Laboratory research

• GLP –Good Laboratory Practice • HACCP-Hazard Analysis Critical Control

Points• ISO• Etc….

L.Touwen, 16 nov 07 11

What does not do NIAZ?• Niaz is fixing the organizational processes• Defines ‘’Norms’’ per department• Niaz does not define or assure the

Medical treatment or Medical results

L.Touwen, 16 nov 07 12

Indicators• Dutch inspection started to ask yearly

indicators:- results: f.i. bedsore, - process indicators: IT-application

• Total over 100 indicators, also having NIAZ-accreditation is a point

L.Touwen, 16 nov 07 13

Hospital Standardised Mortality Ratios (HSMRs) and SMRs

• HSMR gives an overview of the hospital performance as judged by death rates adjusted for main influences

• HSMR covers 50 diagnoses leading to 80% all deaths

• Adjust for age, sex, admission method, admission source, (LOS), primary diagnosis, +/- social deprivation, Charlson Index, readmission rate, season, palliative care, year

L.Touwen, 16 nov 07 14

Hospital age, sex, race, payer, admission source, admission type standardized death rate vs age, diagnosis

standardized charge per admission, AHRQ 1997 data

0

20

40

60

80100

120

140

160

180

0 5,000 10,000 15,000 20,000 25,000

Standardised charge $ per admission

Stan

dard

ised

dea

th ra

te

L.Touwen, 16 nov 07 15

Dutch hospital HSMRs(15 Jan 2007 model, 2003-5 lmr data, 7 hospitals with inadequate or non-

comparable data removed)

0

20

40

60

80

100

120

140

160

99 68 89 18 14 75 58 10 27 35 83 66 60 5 43 79 62 63 81 38 103

55 59 29 85 28 49 106

50 25 44 94 51 20 3 22 90 96 53 39 70 13 101 9 47 52 8 33 69 86 56 107

87 23 100

82 11 34 104

36 72 97 74 30 16 84 95 61 73 31 54 64 40 6 2 19 12 71 21 78 67 102

93 98 65 41 45 1 17 37 32 7 48 4 All

Brian Jarman hospital number

HSM

R (w

ith

95%

con

fide

nce

inte

rval

s)

L.Touwen, 16 nov 07 16

Dutch HSMRs vs year (using year 2003 as the standard)

80

85

90

95

100

105

110

115

120

125

1998 1999 2000 2001 2002 2003 2004 2005

HSM

Rs (

95%

CIs

)

L.Touwen, 16 nov 07 17

Move Your Dot: Move Your Dot: status analysesstatus analysesA way to learn from your experiencesA way to learn from your experiences

L.Touwen, 16 nov 07 18

Real Time Monitoring (RTM), a way to Continuously check your results,

based on LMR- National medical records

L.Touwen, 16 nov 07 19

Clinical Pathways – KU Leuven

• Method to organize optimal care for specific group of patients

• Gives overview of care-activities - of all disciplines - from preparation of admittance till follow up - So: everybody knows: who does what when

• Possibility to evaluate the care process and to improve

L.Touwen, 16 nov 07 20Clinical Pathways

L.Touwen, 16 nov 07 21

Dutch Health inspection: ”Avoid harm, work safe”

Goal of national safety program: In 2012 reduction of 50% of avoidable harm in Dutch

hospitals by realizing 10 interventions, f.i.:Avoid Surgical site infections Avoid harm Central line infections Avoid adverse drug eventsDiscern patients at risk: SIT – Rapid Response Team

L.Touwen, 16 nov 07 22

Reinier de Graaf-experience• Start in 2000 with NIAZ• So much rules and paperwork• It threatened instead inspired• We emphasize improvement and

innovation• We are weak in quality assurance

L.Touwen, 16 nov 07 23

Dutch future accreditation?• Niaz accreditation• Professional quality visitations for medical

groups• Outcome indicators• Safety management system• HSMRThen we have the ultimate safe healthcare?

L.Touwen, 16 nov 07 24

Integrated Quality System ≈ financial management system

Norming: guidelines, best practices

Measurement: indicators, complaints, errors

ImprovementRedesign

Holding the gainsSpread:internal/external

Publicaccountability Measurement:

indicatorsinternal/external

External audit

External incentives

Intrinsic motivation

L.Touwen, 16 nov 07 25

What is our motive Improvement of patient care

Better care for the living!!

For every patient: No needless pain No needless deaths No needless helplessness