measuring for quality in healthcare · 2017. 7. 24. · big data: a revolution that will transform...

2017©

Measuring for Quality in Healthcare

Dr Thomas WK Lew

Chairman, Medical Board

Tan Tock Seng Hospital,

National Healthcare Group

SINGAPORE

2017©

NHG: Integrated Health Cluster for 2.2M (~40%) population

TTSH

2017 ©

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

2017©

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

2017©

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

2017©

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

2017©

Patient

Provider Payer

Access & Outcome

Costs & Access

Outcome & Costs

Parameters as applied to different stakeholders

2017©

Patient

Provider Payer

Access & Outcome &Cost

Costs & Access

Outcome & Costs

Parameters as applied to different stakeholders

Singapore System:Co-payment &Out-of-pocket expenses

2017©

Singapore Govt Health Expenditure (GHE) S$9.3b or 11.6% of Total Budget in 2015.

80% healthcare provided by public sector

2017©

Transparency of Hospital Bills - Ministry of Heath Singapore Website

2017©

Ministry of Heath Singapore Public Website

2017©

Ministry of Heath Singapore Public Website

Healthcare: “Information Asymmetry 0r Information Absence”

2017©

Disability Adjusted Life-Years – cumulative number of years lost due to ill-health, disability or early deaths

2017©

National Priority Areas Measurements(Against OECD Benchmarks)

2017©

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

2017©

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

2017©

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

2017©

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

2017©

2017©

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

2017 ©

TTSH PACH Svc Nurse

The Samsui Women

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?

2017 ©

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’

2017 ©Venice Beach, Santa Monica, CA

Discriminalization of Drugs : A Health Menace or Human Right?

2017©

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

2017©

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

2017©

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

2017 ©

NHG: Regional Health System RoadmapVision “Adding Years of Healthy Life”

2017©

NHG: Regional Health System RoadmapVision “Adding Years of Healthy Life”

2017©

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

2017©

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

2017©

Changi Airport vs Aircraft Carrier

HRO - Acute Care Unpredictable outcomeHigh Risk – gets higher w demandFlat Hierarchy, Broad-based team

Deliberation, Safety and Consistency

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

2017©

Department Level Measurements

2017©

• 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

2017©

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)

2017©

Tier 3

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




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


2017©

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


2017©


• Measuring Quality Improvement • Process• Outcome• Service

2017©

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

2017©

Developing A Just Safety Culture

2017©

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.

2017©

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

2017©

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

2017©

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

Presenting Hospital wide data of MRSA Bacteremia cases on Intranet

Return to CP Table130 Copyright CSI TTSH Mar 2017

2017©

[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)

2017©

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

2017©

• 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)

2017©

• 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

HEALTHCARE SYSTEM

What Is Important to our Staff

Operating Theatre Party 2016 – No Donations needed

2017©

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

2017©


• 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

2017©

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

2017 ©

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

2017 ©

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

2017©

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

2017©

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

measuring for quality in healthcare · 2017. 7. 24. · big data: a revolution that will transform...

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