This conference was organized by Hacettepe University School of Health Administration for the 35th anniversary of the establishment of Hacettepe University Time: May 6, 2003 Place: Hacettepe niversitesi Kltr Merkezi, Yeil Salon Hour: 10.00 - 12.30

Quality of Health Care in the United States: Practice and PromiseProfessor Joseph D. Restuccia

Boston University School of Management

Quality of Health CareDegree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with professional knowledge. - Institute of Medicine (IOM)

Strengths of the United States Health Care SystemModern, well-equipped hospitals and ambulatory facilitiesHighly trained physicians, nurses and other medical personnelAvailability of high technology diagnostic and therapeutic procedures

Weaknesses of the United States Health Care SystemOveruse and inappropriate careUnderuse of effective careMisuse and error in medical care Inefficiency and waste

Assessment of US Health Care System to Achieve 6 Aims In its current form, habits, and environment, American health care system is incapable of providing the public with the quality of health care it expects and deserves.- IOM Committee on Health Care in America

Every Defect is a TreasureJapanese saying: every defect is a treasure because identifying a defect enables us to find the root cause and to eliminate it and, thus, to make improvements in the futureIf defects are jewels, recent investigations to identify and quantify defects in US health care have discovered a treasure chest (or Pandoras box)

Weaknesses of the United States Health Care SystemOveruse and inappropriate careUnderuse of effective careMisuse and error in medical care Inefficiency and waste

Overuse(Rate of Inappropriate Use)

Advanced Antibiotics for Otitis Media 30%Antibiotics Used for the Common Cold 60%Heart Revascularization 10-20%Hysterectomies 16-80%Hospital Admissions: 5-15%Hospital Days of Care: 10-30%

Overuse(Rate of Inappropriate Use)Other procedures commonly overused:Bed Rest for Low Back PainProstate Specific Antigen TestingUltrasound in Uncomplicated PregnancySedation of elderly patients

Weaknesses of the United States Health Care SystemOveruse and inappropriate careUnderuse of effective careMisuse and error in medical care Inefficiency and waste

Underuse (Financial Access)Over 40 million people are uninsured at any point in timeOver 75 million are uninsured as some time during the yearAbout an equal number are severely underinsuredThe majority of the uninsured and underinsured are the working poor and their dependents

Underuse(Rate of Use of Effective Care)Beta-blockers in Elderly Heart Attack Victims 21% Pneumococcal Vaccine in Elderly: 28%Appropriate Dx and Tx of Hypertension: 30%Physician Advice to Quit Smoking: 37%Eye Examination in Diabetics: 46%Pharmacotherapy of Depression: 45%

Weaknesses of the United States Health Care SystemOveruse and inappropriate careUnderuse of effective careMisuse and error in medical care Inefficiency and waste

MisuseAdverse drug events (ADEs) caused by medication errors occur in 1.8/100 hospital admissionsADEs add $4,700 per admission20% of ADEs are life threateningThere are an estimated 500,000 preventable medication errors per year causing 7,000 deaths

MisuseAn estimated 2.9% 3.7% of hospital admissions have an adverse event (from all causes)Over 1 million adverse events per yearEstimated national cost of adverse events is $38-50 billion per year almost half preventable (2-4% of total health costs)

MisuseAn estimated 180,000 deaths per year due to adverse events (= 3 jumbo jet crashes every two days)Between 44,000 - 98,000 due to preventable adverse eventsMore deaths than due to motor vehicle accidents (43,438), breast cancer (43,297) or AIDS (16,516)

Weaknesses of the United States Health Care SystemOveruse and inappropriate careUnderuse of effective careMisuse and error in medical care Inefficiency and waste

Inefficiency and WasteWaits and DelaysOperating Room ThroughputEmergency Department DiversionsTime to Treatment of Coronary ConditionsMedical Records AvailabilityMismatch Between Capacity and Demand

Assessment of US Health Care System to Achieve 6 Aims In its current form, habits, and environment, American health car is incapable of providing the public with the quality of health care it expects and deserves. - IOM Committee on Health Care in America

IOMs Six Aims for ImprovementSafetyEffectivenessPatient-centerednessTimelinessEfficiencyEquity

Safe CareA patient receiving medical care should be as safe as he is in his own homeExample: Computerized physician order entry system to prevent medication errorsExample: Surgeons sign your site of the body part that will be operated upon

Effective CareAvoid overuse and underuse of servicesExample: Redesign processes based on best practices such as ensuring that patients at risk for heart disease take appropriate medications Example: Implement utilization management to reduce inappropriate hospital use

Patient Centered CareRespect patient needs, preferences, and cultureExample: Give patient access to his own medical recordExample: Give patients information on alternative treatments and decision-making in treatment choice

Timely CareReduce waits for those who receive and who give careExample: Availability of appointments after work hours and on weekendsExample: Email and telephone access to physicians and nurse practitionersExample: Open access to physicians and nurse practitioners

Efficient CareReduce waste of facilities, equipment, supplies, and peopleExample: implement inventory management systems to reduce amount of drugs and other suppliesExample: Use flexible staffing systems based on patient numbers and needs to adjust number of nurses per patient care unit

Equitable CareReduce racial, ethnic, geographic and socio-economic differencesExample: Provide interpreters for non-English speaking patientsExample: Train more physicians from minority racial and ethnic groupsExample: Establish universal health insurance coverage

Purpose of Health Care System To reduce continually the burden of illness, injury, and disability, and to improve the health status and function of the people of the United States - Presidents Advisory Commission on Consumer Protection and Quality

Focus of QualityQuality must be defined in terms of experience and outcomes of the patient and the population that generates patients

Levels of Needed Health Care System ChangeOrganization (hospitals, medical groups) Patient

Microsystem (patient units, physician offices)Environment (insurers, purchasers, government)

Levels of Needed ChangeThe patients experienceThe functioning of small units (microsystems) that provide patient careThe functioning of organizations that contain microsystemsThe environment of policy, payment, accreditation and regulation

Levels of Needed Health Care System ChangeAll levels of the system must work together to meet the patients needsThe patient must be at center, the first priority of the health care systemThe major question to ask in changing the system or in treating the patient must be, Is this the best thing we can do for the patient?

Examples of Efforts by Provider Organizations to Achieve the IOMs Six Aims

Cincinnati Children Hospital Medical CenterIncludes families of hospitalized children in morning physician roundsPermits adolescent patients with chronic diseases (e.g., juvenile diabetes) to set their own schedule of treatments and activities and to make entries into their medical recordsPays physicians for involvement in major quality management activities

Cambridge Health AllianceDeveloped registries for chronic patients to identify needed diagnostic and therapeutic interventions, help teach patient self-management, and track patient outcomesProvides translators for over 30 languagesWorks with governmental agencies to establish coverage programs for the uninsured

Tallahassee Medical CenterConducts surveys of satisfaction on every inpatient and outpatient and shares results broadlyImplemented palliative care project to ensure that terminal patient receive comfort care instead of intensive carePut communication devices in ambulances, moved EKG lab, and changed cardiologist schedule to enable PTCA within 90 minutes

Hackensack Medical CenterHired physician intensivists to care of hospitalized medical patientsDeveloped nursing career ladder to help hire, retain and further train nursing staffImplemented advanced practice nurses to work with physicians and patients to coordinate careImplemented daily multidisciplinary patient rounds (physician, nurses, ancillary therapists, etc.) to improve communication and teamwork

Brigham and Womens HospitalDeveloped computerized physician order entry system (CPOE)Physician orders entered via terminalsTest results and treatment summaries transmitted to electronic patient recordOrders screened against knowledge base of rules to detect medication errors Reduced serious medication errors over 80%

CareGroupDeveloped internet-based electronic medical record Allows physicians password protected internet access to patient recordsAllows patients password protected internet access to their own recordsAllows patients to write in their own record and to request appointments with physicians

Rosemont Medical CenterDeveloped open access program for patient appointmentsProduced same day access for most patient visitsReduced average wait time for routine visits from over 2 months to 1 day

Massachusetts General HospitalImplemented utilization management to reduce inappropriate hospital daysCase managers apply MCAP (derivative of the AEP) to facilitate day to day decision making and data collection to change systemOver 10 years, inappropriate days have been reduced by more than 50%

SSM Health CareContinuous Quality Improvement (CQI) - 13 year sustained effortAlignment of goals and measures of performance throughout the organizationUse team work to solve problems and motivate employeesHuman resources are part of strategic planOnly health care organization to win Malcolm Baldridge National Quality Award

Continuous Quality ImprovementTop Management CommitmentWorker EmpowermentTeam WorkCustomer focusApplication of Scientific Method (Measurement and Reporting)Recognition of success

1. AIM: What are we trying to accomplish?2. MEASURES: How will we know that a change is an improvement?3. CHANGES: What changes can we make that we predict will lead to an improvement?AIM/PDSA Model for Internal Quality Improvement

Examples of Efforts by Government Agencies to Achieve the IOMs Six Aims

Department of Veterans Affairs Health SystemSystem of 171 hospital medical centers, 350 outpatient centersImplemented electronic patient record & CPOEImplemented open access (reducing wait time by 90% in Region 1)Implemented Quality Enhancement Research Initiative (QUERI) to give providers evidence-based care on 8 priority conditionsRecognized by IOM for these efforts

Agency for Health Care Research and Quality (AHRQ)Supports research on patient outcomesPrevention, diagnosis and treatmentQuality measurement and improvementMedical errors and public safetyExamplesDiagnosis of heart attackScreening for pregnant womenConsumer Assessment of Health Plans Survey (CAHPS)

Agency for Health Care Quality and Research (AHRQ)National Guidelines Clearinghouse of evidence-based clinical practice guidelinesNational Quality Measures ClearinghouseCAHPS surveyCONQUEST quality measuresHealth Care Cost and Utilization Project (HCUP) Quality Indicators

AHRQ HCUP Quality IndicatorsPrevention - ambulatory sensitive conditionsBacterial pneumoniaDehydrationInpatient CareAcute myocardial infarction mortality rateCABG volumePatient SafetyBirth TraumaComplications of anesthesia

Center for Medicare and Medicaid Studies (CMS)Quality Improvement Organizations monitor Medicare qualityNursing Home Public Reporting Quality InitiativeHome Health Public Reporting Quality InitiativeHospital Quality Information Initiative

CMS Hospital Quality InitiativeIn collaboration with JCAHO, NQF, AHA and other national hospital associationsVoluntary reporting of quality measuresExamplesAMI: aspirin and beta blocker at hospital arrival and dischargePneumonia: initial antibiotic timing, vaccination, oxygenation assessment Considering paying providers on the basis of quality instead of just fee for service

CMS/AHRQ CAHPS SurveysNational survey of Medicare beneficiariesAlso used for Medicaid and commercial beneficiary surveysAdministered by CMS for MedicareComparative Medicare Medical Care Plan Reports are publicly available on internetComparative Hospital Reports Scheduled for internet availability in 2003-2004

HCAHPS - Example QuestionsHow often did nurses/doctors listen to you carefully?How often did nurses/doctors spend enough time with you?How often was your pain well controlled?Before you left the hospital, did you get information in writing about activities you could and could not do?Would you recommend this hospital to your friends and family?

Examples of Efforts by Private Organizations to Achieve the IOMs Six Aims

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)Develops standards for optimal healthcareApplies accreditation process to 17,000 healthcare organizationsProvides information to health care organizations, professionals, and the public on strategies to improve safetyPlans to make public comparative performance reports on provider organizations (in 2004)

Examples of JCAHO InitiativesQuality Performance MeasurementCore (required) measuresProvider selected measuresPain Management StandardsStaffing Effectiveness StandardsPatient Safety StandardsSentinel Event Policy and Alert

Foundation for Accountability (FACCT) Advocates an accountable and accessible health care system responsive to consumersMembers: consumer organizations and purchasersCollaborates with government and private health care organizationsReports on federal and state health policyProvides consumers with information to help assess quality of care and select providers and tools to help manage their own health, e.g. CompareYourCare)

National Committee for Quality Assurance (NCQA)Accreditation and certification of health plans and utilization review organizationsAdministers Health Plan Employer Data and Information Set (HEDIS)HEDIS is used to compare health plans and choose quality - results released to public as Quality Compass

HEDIS 3.0 Reporting Set MeasuresEffectiveness of CareChildhood Immunization Status Low Birth Weight Babies Adolescent Immunization Status Check-ups After DeliveryAdvising Smokers to Quit Treating Child Ear InfectionsFlu Shots for Older Adults Beta Blockers after MIEye Exams for Diabetics Breast Cancer Screening1st Trimester Prenatal Care Cervical Cancer Screening Follow-up after Hospitalization Medicare Health Outcome Survey for Mental Illness

Leapfrog GroupGroup of very large US companiesMission is to stimulate improvement in quality, customer service and affordabilityRecognizes and rewards health care organizations that implement evidence-based patient safety measuresEncourages members to buy health care from these organizations

Leapfrog Group Patient Safety MeasuresReferral of specific complex procedures to hospitals with high volume (estimated to reduce deaths > 30%)Intensive care unit staffing with physicians certified to practice critical care medicine (estimated to reduce ICU deaths > 10%)Computer physician order entry (estimated to prevent > 500,000 fewer serious medication errors per year)

Institute for Healthcare Improvement (IHI)Mission: is driving the improvement in health by advancing the quality and value of health careConferencesCollaborationsCoursesTraining Material

Institute for Healthcare Improvement (IHI)National Director of Robert Wood Johnson Foundation Pursuing Perfection ProgramPublishes QualityHealthcare.org (with British Medical Journal)Website: www.ihi.com

Institute for Healthcare Improvement (IHI)Examples of Topics for Collaboratives:Achieving Workforce ExcellenceAdult Intensive CareAdverse Drug EventsCare for Chronic ConditionsDelays and Waiting TimesEnd of Life CarePatient FlowPatient Safety

Major Quality Improvement Will Require Fundamental ChangesEvidence-based medicineEvidence-based management (CQI)Electronic patient record with CPOERecognition of system interdependence between microsystem, organization, environment Alignment of incentives and strategy at all levelsPayment based on quality, not just servicesPublic reporting of comparative provider qualityUniversal health coverage

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