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Measuring for Quality in Healthcare
Dr Thomas WK Lew
Chairman, Medical Board
Tan Tock Seng Hospital,
National Healthcare Group
SINGAPORE
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NHG: Integrated Health Cluster for 2.2M (~40%) population
TTSH
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Singapore Healthcare – Heading into uncharted Territories
Timeline Perspectives
❖Post-Independence: Public Health – water, sanitation, nutrition; vaccination; Maternal Health; Child Health; Primary Care
❖Development of treatment capabilities and health facilities for a young population & growing nation
❖Expertise, Deep specialisation; National Centres; Health-financing policies; Corporatization, privatization, Financial Management
❖Repurposing to public health mission; public health as part of the national social services agenda
❖Burning platforms for 21st Century with Demographic Shift – Water, Nutrition, Elderly health and Primary Care
❖Reorganising and bridging the Medical: Social Continuum
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Measuring Quality
(Einstein), “Not everything that counts can be counted, and not everything that can be counted counts.”
Edwards Deming, "It is not enough to just do your best or work hard. You must know what to work on.”
Measurement serves the provider in designing, optimizing or changing a system
Mindful that it must be the servant and not the leader
Many organisations have reached a saturation – they have plenty of data and not enough knowledge
Facts but no insights
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Measurement serves the system we seek to design, optimize or change
• Defining Quality
• Measuring How Society Pays for Healthcare
• Measuring outcomes based on healthcare priorities
• Measuring Change• New Models of Care; New Payment Models
• Measuring Improvement • Process, Outcome, Service Quality
• Measuring Satisfaction: Patient & Staff
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2008
Health Aff (Millwood). 2008 27(3):759-69.The triple aim: care, health, and cost. Berwick DM1, Nolan TW, Whittington J.
Three Important Elements
Health Affairs 27, no. 3 (2008): 759–769
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Patient
Provider Payer
Access & Outcome
Costs & Access
Outcome & Costs
Parameters as applied to different stakeholders
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Patient
Provider Payer
Access & Outcome &Cost
Costs & Access
Outcome & Costs
Parameters as applied to different stakeholders
Singapore System:Co-payment &Out-of-pocket expenses
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Singapore Govt Health Expenditure (GHE) S$9.3b or 11.6% of Total Budget in 2015.
80% healthcare provided by public sector
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Transparency of Hospital Bills - Ministry of Heath Singapore Website
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Ministry of Heath Singapore Public Website
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Ministry of Heath Singapore Public Website
Healthcare: “Information Asymmetry 0r Information Absence”
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Disability Adjusted Life-Years – cumulative number of years lost due to ill-health, disability or early deaths
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National Priority Areas Measurements(Against OECD Benchmarks)
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Hospital Performance Scorecard
• Measure outcomes from priority areas of health concerns • Contextualised benchmarking for performance and comparison.• Outcome Priority Areas : Heart Disease, Stroke, Diabetes Mellitus & its
complications• Services Process / Access indicators: ED. Inpatient, OT, Specialist Out-patient clinics
• Hospital Performance Scorecard• 3 categories – Performance, Measurements, Development
• Performance Standards: • Agreed standards under the Service Level Agreements between MOH and
hospitals using indicators monitored annually under a MOH-Healthcare Cluster’s “Statement of Priorities” • Health Performance Office – Definition & Measurement
• Senior Management performance review annually - Compared across all public-sector Restructured Hospitals
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4 Major Challenges
Ageing Population
Emerging Infectious Diseases
Burden of Chronic Diseases
Financing Future Healthcare
PM, Global Health Leadership Summit,
Singapore, 2013
SINGAPORE HEALTHCARE: CONTEXT
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MOH is Planning forBeyond Healthcare 2020
1. Providing appropriate care closer to community & home
2. Increase value & be sustainable
3. Support Singaporeans to lead Healthier lives
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The “Ecology of Medical Care: model revisited (Green LA, NEJM 2001; White, 1961)
Since its publication in the Journal in 1961, “The Ecology of Medical Care,” by White et al.,1 has provided a framework for thinking about the organization of health care, medical education, and research
in a population of 1000 adults, in an average month, 750 reported an illness, 250 consulted a physician, 9 were hospitalized, 5 were referred to another physician, and 1 was referred to a university medical center.
Majority of Care is Delivered Outside of Hospitals
• Changing Models of Care
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Well Prevent Disease
@Risk Delay Onset
Controlled Detect Early
Complicated Control Progression
Serious Minimize Complication
Frail Sustain Health
End of Life Comfort
“Fall Prevention” – Changing Models of Healthcare
Co
ord
inat
ed
Car
eD
isea
se
Bu
rden
From Dr Eric Wong, CMIO NHG
Challenge of presenting new paradigms shift: from patient to population; from treatment to prevention
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TTSH PACH Svc Nurse
The Samsui Women
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MOH to wage war on diabetes
In the US, portion sizes have expanded so much that a restaurant meal today is about four times larger than in the 1950’s
Build one new Dialysis Centre Centreevery year?
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Cleveland Clinic’s Medical Innovation Summit: Top 10 Innovations 2016
1. Using the microbiome to prevent, diagnose and treat disease
2. Diabetes drugs that reduce cardiovascular disease and death
3. Cellular immunotherapy to treat leukemia and lymphomas
4. Liquid biopsies to find circulating tumor DNA
5. Automated car safety features and driverless capabilities
6. Fast Healthcare Interoperability Resources (FHIR)
7. Ketamine for treatment-resistant depression
8. 3-D visualization and augmented reality for surgery
9. Self-administered HPV test
10. Bioabsorbable stents
Technology will not go away:Managing High-cost or potentially ‘Exponential Technologies is a given’
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2017 ©Venice Beach, Santa Monica, CA
Discriminalization of Drugs : A Health Menace or Human Right?
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N = AllBig Data
Personalized MedicineN = 1
Big Data: A Revolution That Will Transform How We Live, Work, and ThinkViktor Mayer-Schönberger and Kenneth Cukier
Multi- Centre Randomized Control Trial
Single-Centre Trial
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0%
20%
40%
60%
80%
100%
120%
0
500
1000
1500
2000
2500
3000
35000 6
12
18
24
30
36
42
48
54
60
66
72
78
84
90
96
10
2
10
8
11
4
% R
ate
of
Ad
mis
sio
n A
gain
st
ED
A
tten
dan
ce A
cco
rdin
g t
o A
ge
No
of
ED
Att
en
dan
ce A
cco
rdin
g t
o A
ge
Age of Patients
ED Attendance
Rate of Admission & ED Attendance by Age (Year 2015)
Average Length of Stay and Admission rate by Age
Source: Ministry of Health Workplan Seminar 2015
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Measuring for Changing Models of Care
• Defining the Population Health Agenda within a Cluster of healthcare institutions
• Defining a patient’s journey within these broad segments
• Address the patients’ needs and services requirements using Clinical and Medical-Social Complexity Matrices.
• Measuring for Improvement - key strategic improvement projects
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NHG: Regional Health System RoadmapVision “Adding Years of Healthy Life”
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NHG: Regional Health System RoadmapVision “Adding Years of Healthy Life”
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Better
Care
(Mission-focused)
1. Deliver Excellent Hospital Care
Outreach &
Population
Health
NCID/
Outbreaks
3. Enable Community
Partnered Care
2. Manage Public Health
& Emergencies
Partnering Primary
Care & Community
Services
Structuring
Transitional
CareNational &
Civil
Emergenci
es
Establishing Intermediate Care
3. Standard
Care
1. Complex
Care
2. Acute Care
TTSH’s Mental Model for Complex & Crisis Care Delivery
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Integrated Care HubStatus Update:
Undergoing Gateway Process (TOP 2021)
Demolition Work has started (Q1-Q3 2016)
Features:
• Enable early return to daily functions
in life and active ageing;
• Empower active participation in self-
management;
• Partner the community in providing
sustainable healthcare services;
• Provide holistic end-of-life care.
SUBACUTE
CARE
ACUTE
REHAB
INTERMEDIATE
REHAB
HOSPICE CARE
(with DPH)
Key Project Information:GFA: 60,800 sqmBeds: 607
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Changi Airport vs Aircraft Carrier
HRO - Acute Care Unpredictable outcomeHigh Risk – gets higher w demandFlat Hierarchy, Broad-based team
Deliberation, Safety and Consistency
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1
Community Partners: Home-based
Professional Intervention
Patient Activation during
Discharge Planning and At Home
Collaboration with Partners
2Inpatient Clinical Excellence:
Perioperative Enhancement
Safe Inpatient Care
3
SOC & Ambulatory Care
Excellence: Quality and Safe Care
Coordinated Care
Timely and Accessible Care
4
Elderly Care Initiatives:
Inpatient Senior Friendly Care and
Palliative Management
Geriatric and Palliative Care
Integration with Community and
Partners
5IT Enablement of Care
Transformation
6 Diabetes + End-stage Renal Failure
7 Emergency Care Excellence
8 Service and New Capability
Development
9 Patient Education Excellence
10Comprehensive Cancer Care
(JOINT)
11National Centre for Infectious
Diseases (NCID)
12Integrated Intermediate Care Hub
(IICH) Comprehensive Capability
Development
13 Outreach
14 Neuro-Musculo-Skeletal (NMSK)
Ranked Strategic Themes
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Department Level Measurements
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• These Outcomes are subject to several layers of competing interests, demands and priorities by different stakeholders
• ACO; capitation; bundled payments, activity-based costing, etc are instruments that serve to measure value for money in healthcare delivery and satisfy all stakeholders
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8
Transitional Care
• Medical & functional stabilization & optimization
• Case management• Medication management• Home environment review• Patient education• Palliative/EOL etc
CommunityHospital
In-patient
SOC
ED
Patients at risk of readmission and/or unable to discharge in
a timely manner
Care assessment to
identify appropriate
patientsHome healthCentre-based
Community supportEg. Singhealth linkup with Kreta Ayer C2H
Social support
Co-management & handover
Co-management & escalation
Identified Common Processes across Clusters
SHS Integrated Clinical Care
Services
AHS Ageing In Place
NHG Virtual Hospital NUHS Care
Connect
EHA Neighbours
Hospital to Home Project (Courtesy of Dr John Abishiganaden)
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Tier 3
Unresolved medical conditions or geriatric syndrome(s) that need to be optimised
Complex nursing needs
High functional needs requiring multi-disciplinary inputs
+
Unresolved medical conditions or geriatric syndrome(s) that need to be optimised
+
Unresolved medical conditions or geriatric syndrome(s) that need to be optimised
Complex nursing needs
High functional needs requiring multi-disciplinary inputs
End of Life
Inability to manage continuing care plan:
1. Inability to manage own care (housing, financial, confused, mental health, dementia)
AND/OR
2. No caregiver/caregiver challenged
*We note that H2H team may not be able to close psychosocial needs during H2H intervention. Need for MSWs to work closely with social workers from ILTC/social care providers
Psychosocial
Stratification of patients based on needs
Unresolved medical conditions or geriatric syndrome(s) that need to be optimised
Complex nursing needs
High functional needs requiring multi-disciplinary inputs
Tier 2
+
Stable multiple co-morbid
Basic nursing and functional needsTier 1 +
OR
(a)
(b)
(c) + +
(d)
OR
OR
OR
(a)
(b)
Med
ical
Lev
elTo guide resource allocation
Hospital to Home Project (Courtesy of Dr John Abishiganaden)
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System Goals
39
• Regular review sessions with workgroup to update on progress, observations and learning points post implementation
Healthcare Utilisation Indicators At ED, Inpatient, SOC, CH, NH settings • ALOS of subsequent
admissions while under H2H care
• Non-elective readmissions post discharge
• ED attendance rates post discharge (15D, 30D, 60D up to 12 mths)
No. of deaths at home/NH
Process Indicators • Actual no. of home visits
and phone reviews completed
• Length of actual monitoring period
• Manpower resourcing (No. of staff)
• Staff mix (Types of staff, team composition)
Predictive tool• Total flagged cases vis-à-
vis assessed and recruited
• Reasons for rejection
Clinical Indicators • Clinical Indicator
Charlson Comorbidity Index (CCI)
• Functional Indicator Clinical Frailty Scale (to pilot)
• Social Indicator Caregiver Stress: ZaritBurden Scale
Hospital to Home Project (Courtesy of Dr John Abishiganaden)
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Measurement serves the system we seek to design, optimize or change
• Measuring Quality Improvement • Process• Outcome• Service
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Centred on what the Patient Value 1) Three Improvement Programs: Process, Service & Clinical 2) A robust training & orientation program for Patient Safety &
Communications3) Clinical Standards, Sensing, Audit & Improvement Agency
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Developing A Just Safety Culture
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1 i. MRSA Bacteraemia
CONFIDENTIAL
2012 2013 2014 20152016(Jan-Jun)
Jan'16 Feb'16 Mar'16 Apr'16 May'16 Jun'16
No. of Patient Days 465,818 472,139 482,388 493,652 257,665 43,473 39,536 43,871 42,546 44,977 43,262
No. of Discharges and Deaths 55,766 56,341 57,006 56,850 30,516 5,185 4,821 5,317 4,961 5,100 5,132
No. of Cases 65 56 52 57 16 4 5 1 2 2 2
Rate (per 10,000 pt days), % 1.4 1.2 1.1 1.2 0.6 0.9 1.3 0.2 0.5 0.4 0.5
Target, % 0.92 0.92 0.92 0.92 0.92 0.92 0.92
0.0
1.0
2.0
3.0
4.0
5.0
0
10
20
30
40
50
60
70
Rat
e (
pe
r 1
0,0
00
pat
ien
t d
ays,
%
No
. of
Cas
es
[43]
Initiatives (1st Half 2016) - 100% RCA for all positive bacteraemia cases to determine root causes- Intensify efforts on meticulous peripheral and central venous line care
in patients - Intensify focus on skin cleansing before procedures involving breach of
skin (e.g. insertion of intra-venous lines)- Improved wound care for patients who are MRSA carriers- Conduct case control study to identify risk factors for MRSA
bacteraemia and ensure that targeted interventions are in place- Explore role of decolonisation of MRSA-colonised patients to reduce
their risk of developing MRSA bacteraemia. - On-going Hand Hygiene compliance campaign
Target: 0.92%
2015 and earlier New Criteria (w.e.f. January 2016)
Numerator Total number of MRSA Bacteraemia; Positive MRSA blood cultures after (>) 48 hours of admission
Number of Healthcare Facility Onset-MRSA Bacteraemia after 3rd calendar day of admission per admission episode (hospital-wide) and >14 days from the last positive result.
Any multiple positive MRSA blood cultures within 14 days will be counted as one
Any multiple positive MRSA blood cultures within 14 days will be counted as one event, counting from the last positive MRSA blood cultures.
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Quarterly Strategic Assembly
CONFIDENTIAL
QUARTERLY STRATEGIC ASSEMBLY (Chaired by CMB Since April 2013) ▪ Infection Control Committee▪ Hospital Acquired Infection Elimination (HAIE) Collaborative ▪ Antimicrobial Stewardship Programme (ASP)
▪ Objectives are :o Integrated & Coordinated Whole-of-Hospital Control Strategic Initiatives and Efforts:o Strategies -
[44]
Confront with Transparent & Authentic Data Create Rules – where evidence is strongUse Psychology - Facilitate Nudges Use Technology -Force-in-functions Create a Positive Campaign for a Worthy Cause
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MRSA Bacteraemia Improvement Project:Detailed Measurement of Improvement over Time, Locations, Root Causes, and Actions taken to prevent recurrence at the individual, or systems level
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1 i. MRSA Bacteraemia Initiatives
CONFIDENTIAL
[46]
MRSA PCR implementation at ED
Hand Hygiene (HH) Campaign
HH focus group discussions &
survey
Improved cohorting of
MRSA patients
Appt of IPC for greater ownership to
improving HH compliance in wards
HH sharingby CEO during
Townhall
HH sharing by CEO during Townhall
Started RCA for every MRSA
bacteremia & presentation in
Clinical HOD Meeting
HH sharingby CEO during
Townhall
Standardisation& training of
blood sampling/culture from PICC line & scrub the hub for
Nursing
Training of blood sampling/
culture from PICC line & scrub
the hub for Medical Team
• Blood sampling/ culture from PICC line & scrub the hub implemented hospital wide
• Hand gel evaluation
“HH Audit in Progress” poster put up in all wards
• Blood sampling/ culture from PICC line & scrub the hub poster put up in all wards
• “HH Audit in Progress” poster put up in wards with low hand hygiene compliance
• Monthly audit for scrub the hub
• Hand Hygiene Event
Completed trainings of blood sampling/ culture from PICC line for Clinical depts
IPCs started sharing HH initiatives in Clinical HOD Meeting &Nursing MtgReview
2012 2013 2014 2015 1H 2016
• 100% RCA for all positive bacteraemia cases to determine root causes
• Intensify efforts on meticulous peripheral and central venous line care in patients
• Intensify focus on skin cleansing before procedures involving breach of skin (e.g. insertion of intra-venous lines)
• Improved wound care for patients who are MRSA carriers
• Conduct case control study to identify risk factors for MRSA bacteraemia and ensure that targeted interventions are in place
• Explore role of decolonisation of MRSA-colonised patients to reduce their risk of developing MRSA bacteraemia.
• On-going hand hygiene compliance campaign
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Presenting Hospital wide data of MRSA Bacteremia cases on Intranet
Return to CP Table130 Copyright CSI TTSH Mar 2017
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[48]
People - Building a culture of Hand Hygiene
CONFIDENTIAL
In the wards: Ms Lily Lim, a veteran volunteer at TTSH, shining a UV torchlight on a staff-participant’s hands after using handrub with illuminating agent to show her how well the 7 Steps of Hand Hygiene cleaned her hands.
Doctors, nurses and administrative staff alike, took part in the handwashing exercise during our Campaign Outreach.
Total Volunteers: 490Number of volunteer hours:1,165
Total Participants: 77073,326 (43%) staff, 4,381 (57%) patients, caregivers and visitors.
Post-Campaign Survey:99% found campaign effective98% now more aware of the importance of Hand Hygiene
Hand Hygiene Campaign 2016
(6 May – 23 June)
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What Patients Really Want & Value
1. Cure Me
2. Heal Me
3. Don’t Hurt Me
4. Don’t Make Me Waste my Money
5. Respect Me as a Person
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• Carried out by an independent survey company, using a structured questionnaire over face-to-face or phone interviews with patients or their caregivers.
• 12,469 responses (2015)
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• Opportunities to drill down on root causes for dissatisfaction: institutions, locations, service, family groups
• Focus areas (e.g., Emergency Department, long wait-times for hospital beds)
National Public Hospital Patient Satisfaction Survey
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Qualitative Studies: Defining Patients’ Needs through Design Thinking & Personas
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HEALTHCARE SYSTEM
What Is Important to our Staff
Operating Theatre Party 2016 – No Donations needed
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Ebola: Waste Management Process
Step 1
Housekeeping don on
PPE as per TTSH IC
guidelines
Step 2
User place waste into
double bag liners
Step 3
Housekeeping lines the
3rd bag in the Ebola
labeled transportation bin
Step 4
Housekeeping will collect
and transport the waste in
a buckled bin
Step 5
The bio hazard bins are
placed in the designated
locked bio-hazard room
Step 6
Twice daily waste
collection by licensed
vendor and e-filing to
NEA by Housekeeping
and vendor
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PIA: Excellence in Action Awards 2015
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Hypoglycaemia in Orthopaedics Ward 12A CPIP Project
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Measurement serves the system we seek to design, optimize or change
• Defining Quality
• Measuring How Society Pays for Healthcare
• Measuring outcomes based on healthcare priorities
• Measuring Change• New Models of Care; New Payment Models
• Measuring Improvement • Process, Outcome, Service Quality
• Measuring Satisfaction: Patient & Staff
• Caution
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Click here to add or delete a section
Consumer Satisfaction
Clinical outcomes
$$$
Measurable Outcomes
“Not everything that counts can be counted, and not everything that can be counted counts.”
Measure to design, optimize or change
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National Health System, Funding & Policies
Regional Health System, Svc Scope & Retrieval Response
Acute Tertiary Hospital ICU & Acute Care Services
ICU Providers & Patient
Levels of Organisational Perspectives
Optimizing at one level may sub-optimise at the next
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Daniel Kim. Pegasus Communications Article Volume 3 No 5 (June/July 1993) Levels of Perspectives: “Firefighting” at Multiple Levels.
Difficult to Find Measurements for Disruption / Radical Change
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Measuring Safety
R Amalbarti, Ann Int Med 2005
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On Measuring Safety
“Management Use Safety. Top management views safety in terms of mitigating the consequences of a crisis, so as to avoid jeopardizing the total organization. To them, patient safety is just another source of risk, among other sources that have similar consequences to the organization, such as troubled industrial relations or inadequate cash flow.”
“Perverse effect of excellence. It is generated by the accumulation of layers that are intended to improve safety but make the system overly complex, burdensome, and ultra-protected.”
“When risks to patients become less observable, the best move is to simplify the system, eliminate non-productive regulations, and give clinicians more latitude in decision making.”
R Amalbarti, Ann Int Med 2005
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Pride of PurposePublic Service EthosHospital-of-ChoicePractice - Education- Research
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Conclusion
• Measurement is the Slave, not the Master
• Commonest measures within a system tend to inhibit radical changes to the system if large scale changes are needed
• Lends to micromanagement
• Overzealous Measurements may hamper the successful implementation of a new model of care. • Cost
• Resources
• Returns on Investments
• Leap of Faith