Quality Management in Your Practice:A Nuts and Bolts Primer

Richard P. Dutton, MD MBAExecutive DirectorAnesthesia Quality Institute

04/11/23

Some people need feedback on their work performance

Introduction

• I am an anesthesiologist.

• I have led QM programs at the department and hospital levels

• Now I get to try it at the national level!

Introducing Yourself

Please send us a message (in the system or by email to j.mlodoch@asahq.org):

– Who are you? What is your title?– Why are you listening?– Do you have any specific questions or topic

areas?

Why Have Quality Management?

• To improve patient outcomes

• To improve business efficiency

• To meet regulatory requirements

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The Challenge

The government wants to know that Ma and Pa are getting the healthcare they deserve … and that our taxes pay for.

The Eight Step Program: One

Who’s in charge here?

An effective QM program often depends on the initiative of a single person

What the leader does …

• Promotion of open dialogue

• Timely feedback

• Getting "buy in" from providers

• Support after a bad outcome– Accurate analysis by experts– A forum for discussion– Prevention of future events

The Eight Step Program: Two

What do we need to know?

Sometimes, knowing your destination makes it easier to find the best route

Typical QM Questions

• How many cases did we do last year?

• How many deaths?– Anesthesia related?– Preventable?

• How many complications?

• How satisfied are our patients?

• How do our results compare with others?

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Data: Indicators

• Business (numbers, times, dollars)

• Outcomes (deaths, complications)

• Processes – Steps that lead to outcomes … – Often problematic

• Focused reviews

• Sentinel events

The Quality Triangle

RiskFactors

Outcomes

Process

The Eight Step Program: Three

Gather the data!

•First, steal as much as you can

•Only then consider making your own

He who has the data controls the futureHe who has the data controls the future

What to Collect?

• “Administrative” data

• AIMS data

• Hospital EHR data

• Quality and outcome data– Your group– Other specialties

• Patient satisfaction information

• Anecdotes

How to Make Your Own Data

http://aqihq.org/AQIVendors.aspx

The Eight Step Program: Four

Share with your friends

•Produce a regular QM report

•Publish it internally

•Excerpt it externally

“We have lots of information technology, we just don’t have any information”

Who has your data already?

• The federal government

• CMS – Medicare Data

• AHRQ – CAHPS Data

• Private insurance companies

• The Joint Commission

• The ABA

• Your IT vendors

Data “Safety”

• You cannot hide your data

• You can see yourself as others will see you

• You can pre-empt illegitimate use

The Eight Step Program: Five

Capture the interesting cases

One of your goals should be to learn from the mistakes of others -- this is more fun than making the mistakes yourself.

Lessons From Aviation

The US National Civil Aviation Review Commission Chaired by Senator Norman Mineta“Avoiding Aviation Gridlock & Reducing the Accident Rate,” December 1997.

•FOQA and other safety risk management programs are based on trust.

• Keeping this data confidential is the key to acquiring it in the first place.

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Focus on Systems

• Not about weeding out "bad apples”

• W. Edwards Deming: 94% of the potential for improvement resides in system performance, only 6% is individual

• Dutton’s corollary: “system performance” usually equals “communication”

Management BY Anecdote

• Over-reaction to isolated events

• Layered bureaucracy

• Failure to discover root causes

• Failure to assess both benefits and risks

• Frequent disposal of both baby and bathwater!

Management OF Anecdotes

• Have a process for addressing sentinel events– Discovery– Reporting– Disclosure– Fact finding: who?– Analysis– Discussion and System Changes

The Eight Step Program: Six

Change things.

Don’t be afraid to tinker with your systems and processes.

PACU Reintubation Rate

Provider Education

andRocuronium

Removed

Rocuronium Introduced

The Eight Step Program: Seven

Lather, rinse, repeat

QM becomes easier over time, and more effective. You want to embed this

process in the fabric of your

practice.

Control Chart AnalysisAnesthesiology

The Eight Step Program: Eight

Report your data externally. Collect benchmarks you can use.

Participate in the AQI!

Where is the Improvement?

0

1000

2000

3000

4000

5000

6000

7000

0

1

2

3

4

5

6

7

8

9

10

Admissions

Deaths

z-score

“The unexamined life is not worth living.”

-- Socrates, Apology 38a

Contact Us!

www.aqihq.org

or

r.dutton@asahq.org