Quality Management-Improving Patient Outcomes the Smart Way_Dlugacz

8/6/2019 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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Copyright 2009, Krasnoff Quality Management Institute slide # 2


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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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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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Copyright 2009, Krasnoff Quality Management Institute slide # 21Copyright 2009, Krasnoff Quality Management Institute slide # 21Copyright 2009, Krasnoff Quality Management Institute slide # 21


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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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Copyright 2009, Krasnoff Quality Management Institute slide # 30Copyright 2009, Krasnoff Quality Management Institute slide # 30


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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


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

[email protected]

Thank you!

Quality Management-Improving Patient Outcomes the Smart Way_Dlugacz

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