Quality Improvement Quality Improvement in Ambulatory Carein Ambulatory Care

Daniel P. Dunham MD, MPHDaniel P. Dunham MD, MPH

Assistant Professor of MedicineAssistant Professor of Medicine

Northwestern University Northwestern University

Feinberg School of MedicineFeinberg School of Medicine

What is Quality?What is Quality?

““Doing the right things right” Doing the right things right” W. Edwards Deming W. Edwards Deming (Pioneer of the quality movement in (Pioneer of the quality movement in industry)industry)

Institute of Medicine in the USInstitute of Medicine in the US

Health care quality is the degree to Health care quality is the degree to which health services for individuals which health services for individuals and populations increase the and populations increase the likelihood of desired health outcomes likelihood of desired health outcomes and are consistent with current and are consistent with current professional knowledge.professional knowledge.

Patients/Client’s PerspectivePatients/Client’s Perspective

Choice of methodsChoice of methods Information given to clientsInformation given to clients Technical competenceTechnical competence Interpersonal relationsInterpersonal relations Mechanisms to encourage continuityMechanisms to encourage continuity Appropriate constellation of servicesAppropriate constellation of services

Institute of Medicine in the USInstitute of Medicine in the US

EffectiveEffective SafeSafe Patient centeredPatient centered TimelyTimely EfficientEfficient EquitableEquitable

Earliest Quality MetricsEarliest Quality Metrics

In ancient China, physicians were In ancient China, physicians were paid only when their patients were paid only when their patients were kept well and often not paid if the kept well and often not paid if the patient got sick. If a patient died, a patient got sick. If a patient died, a special lantern was hung outside the special lantern was hung outside the doctor’s house. Upon each death doctor’s house. Upon each death another lantern was added. another lantern was added.

History of Quality Movement History of Quality Movement in Health Carein Health Care

Practice Standards governing who could Practice Standards governing who could practice medicine to the first century C.E. practice medicine to the first century C.E. in India and China.in India and China.

1140 Medical Licenses were awarded in 1140 Medical Licenses were awarded in Italy.Italy.

1917-US, American College of Surgeons 1917-US, American College of Surgeons compiled the first set of minimum compiled the first set of minimum standards for US hospitals to find and standards for US hospitals to find and eliminate poor care. This evolved into the eliminate poor care. This evolved into the Joint Commision on Accredition of Joint Commision on Accredition of Healthcare Organizations.(JCAHO)Healthcare Organizations.(JCAHO)

Hx(cont.)Hx(cont.)

1951-JCAHO has developed 1951-JCAHO has developed standards and evaluated the standards and evaluated the compliance of health care compliance of health care organizations.organizations.

1960’s-Awareness of Injury Control 1960’s-Awareness of Injury Control due to lessons from Viet Namdue to lessons from Viet Nam

Hx(cont.)Hx(cont.) 1980’s weakness in the JCAHO inspection 1980’s weakness in the JCAHO inspection

process, new management techniques, process, new management techniques, and rising costs lead to reassessment of and rising costs lead to reassessment of accreditation.accreditation.

1984 Luciane Leape MD,pediatric surgeon, 1984 Luciane Leape MD,pediatric surgeon, investigated cardiac surgery. Chart-review investigated cardiac surgery. Chart-review study in NY created a data base to study in NY created a data base to understand incidence and prevalance of understand incidence and prevalance of preventability, negligence, and preventability, negligence, and malpractice.malpractice.

Hx(cont.)Hx(cont.)

1991 Harvard Medical Practice Study 1991 Harvard Medical Practice Study revealed adverse events in 3.7% of revealed adverse events in 3.7% of all hospitalizations in review of all hospitalizations in review of 30,121 charts and 28% of these were 30,121 charts and 28% of these were labeled negligent. Nearly 20% of all labeled negligent. Nearly 20% of all events occurring in hospitals were events occurring in hospitals were due to medication problems.due to medication problems.

Center for Medicare and Center for Medicare and Medicaid Services(CMS)Medicaid Services(CMS)

Began releasing mortality rates for Began releasing mortality rates for hospitals in 1980’shospitals in 1980’s

Some State Governments provide Some State Governments provide risk-adjusted mortality rates for risk-adjusted mortality rates for cardiac surgery by hospital and cardiac surgery by hospital and surgeon.surgeon.

Sentinel EventSentinel Event

1994 Betsy Lehman, health 1994 Betsy Lehman, health columnist for the Boston Globe, died columnist for the Boston Globe, died of overdose of Cisplatin, she was of overdose of Cisplatin, she was taking for Breast CA at the Dana-taking for Breast CA at the Dana-Farber Cancer Institute in Botston.Farber Cancer Institute in Botston.

Federal PolicyFederal Policy 1999 the Institute of Medicine 1999 the Institute of Medicine

published “To Err is Human: Building published “To Err is Human: Building a Safer Health System”a Safer Health System”

Estimated 44-98,000 patients die Estimated 44-98,000 patients die preventable deaths annually in preventable deaths annually in hospitals in the US with a cost of hospitals in the US with a cost of $38-50 billion. $38-50 billion.

These are errors of comission, These are errors of comission, omission might be higher.omission might be higher.

AccreditationAccreditation 1996, JCAHO was stung by medical 1996, JCAHO was stung by medical

reports of its triennial surveys. reports of its triennial surveys. Several hospitals who won top Several hospitals who won top accreditation status, were found to accreditation status, were found to have experienced tragic sentinel have experienced tragic sentinel events involving preventable death events involving preventable death or injury to patients.or injury to patients.

JCAHO instituted a sentinel-event JCAHO instituted a sentinel-event policy.policy.

Role of Large PayorsRole of Large Payors Leapfrog group(1999) is an effort Leapfrog group(1999) is an effort

sponsored by business roundtable to sponsored by business roundtable to leverage purchasing power and improve leverage purchasing power and improve patient safety.patient safety.

Composed of more than 140 public and Composed of more than 140 public and private organizations that provide health private organizations that provide health benefits.benefits.

Represent more than 34 million health Represent more than 34 million health care consumers in all 50 statescare consumers in all 50 states

Leapfrog GroupLeapfrog Group

They directed patients to hospitals They directed patients to hospitals that show compliance with practices.that show compliance with practices.

1) Computerized physician order-1) Computerized physician order-entry systems 2) Board-certified or entry systems 2) Board-certified or elibigle Intensivists in ICU 3) Hospital elibigle Intensivists in ICU 3) Hospital referrals for complex treatments referrals for complex treatments based on hospital volumesbased on hospital volumes

CPOE Cost SavingsCPOE Cost Savings

Brigham and Women researchers found Brigham and Women researchers found that CPOE could reduce serious that CPOE could reduce serious medications errors by at least 55%, medications errors by at least 55%, resulting in cost savings at that hospital resulting in cost savings at that hospital between $5-10 million annually.between $5-10 million annually.

32% of hospitals have CPOE system wholly 32% of hospitals have CPOE system wholly or partially in place.or partially in place.

2% of hospitals require physicians to use 2% of hospitals require physicians to use CPOE system.CPOE system.

Cost of Adverse Drug EventCost of Adverse Drug Event

Brigham and Women’s study showed Brigham and Women’s study showed 10.7 non intercepted Serious 10.7 non intercepted Serious medication errors per 1000 patient-medication errors per 1000 patient-days.days.

The cost per adverse drug event is The cost per adverse drug event is estimated to exceed $2,000estimated to exceed $2,000

The cost of CPOE is $1,000,000 to The cost of CPOE is $1,000,000 to start, and $500,000 to maintain start, and $500,000 to maintain annually.annually.

Leapfrong Safety MeasuresLeapfrong Safety Measures

John Birkmeyer, M.D., did research John Birkmeyer, M.D., did research suggesting these three patient safety suggesting these three patient safety practices could save over 50,000 lives a practices could save over 50,000 lives a years and prevent over 500,000 years and prevent over 500,000 medication errors, if implemented by all medication errors, if implemented by all non-rural hospitals.non-rural hospitals.

$10 billion could be saved each year solely $10 billion could be saved each year solely from the benefits of increased life from the benefits of increased life expectancy for patients.expectancy for patients.

Quality ProblemsQuality Problems

UnderuseUnderuse Overuse Overuse MisuseMisuse

UnderuseUnderuse

Variation by insurance type, and lack Variation by insurance type, and lack of insuranceof insurance

MammogramsMammograms Beta Blockers in patients with MIBeta Blockers in patients with MI VaccinationVaccination HTN controlHTN control

OveruseOveruse

21% of all antibiotics given to treat 21% of all antibiotics given to treat coldscolds

17% of coronary angiographies, 32% 17% of coronary angiographies, 32% of Carotid endarterectomies, 17% of of Carotid endarterectomies, 17% of EGD are unnecessaryEGD are unnecessary

10-27% of hysterectomies10-27% of hysterectomies

MisuseMisuse

Preventable complications of Preventable complications of treatmenttreatment

22% error in diagnosis22% error in diagnosis 21% non-invasive non drug related 21% non-invasive non drug related

treatmenttreatment 12% mistakes in medication use12% mistakes in medication use 8% technical complications of 8% technical complications of

surgerysurgery 6% surgical wound complications6% surgical wound complications

First Law of ImprovementFirst Law of Improvement

““Almost all quality improvement Almost all quality improvement comes via simplification of design, …comes via simplification of design, …layout, processes, and procedures.”layout, processes, and procedures.”

Tom PetersTom Peters

Quality Improvement ProgramQuality Improvement Program

Goal is to raise the level of care-no Goal is to raise the level of care-no matter how good it may already be matter how good it may already be through a continuous search for through a continuous search for improvement.improvement.

QI asks physicians, managers, and QI asks physicians, managers, and other providers to raise the other providers to raise the standards.standards.

Elements of a QI ProgramElements of a QI Program

Clinical Quality(Provider’s Agenda)Clinical Quality(Provider’s Agenda) Service Quality(Patients Agenda)Service Quality(Patients Agenda) Patient Safety Patient Safety Operational ImprovementOperational Improvement MeasurementMeasurement

Measurement of QualityMeasurement of Quality

Achieving results based on evidence Achieving results based on evidence based medicinebased medicine

Process versus outcome measuresProcess versus outcome measures

Process versus OutcomesProcess versus Outcomes

Process of care measures of quality Process of care measures of quality assess the degree to which providers assess the degree to which providers perform health care processes perform health care processes demonstrated to be successful by demonstrated to be successful by evidence based medicine.evidence based medicine.

National Committee on Quality National Committee on Quality Assurance Assurance

NCQA collects data on HEDIS quality NCQA collects data on HEDIS quality measures and includes evidence-measures and includes evidence-based measures of health plan based measures of health plan processes of care.processes of care.

These measures are part on NCQA’s These measures are part on NCQA’s health plan accreditation program health plan accreditation program and are used by some employers, and are used by some employers, insurers, and government payers to insurers, and government payers to choose health plans.choose health plans.

Process Measures for DMProcess Measures for DM

Lower HGB A1CLower HGB A1C Lower lipid LevelsLower lipid Levels Higher use of appropriate ACE Higher use of appropriate ACE

inhibitorsinhibitors Better screening for microalbuminBetter screening for microalbumin Better control of HTNBetter control of HTN

Process Measures for CADProcess Measures for CAD

Higher use of ASAHigher use of ASA Higher use of Better BlockerHigher use of Better Blocker Higher use of ACE inhibitorHigher use of ACE inhibitor Lower Lipid levelsLower Lipid levels Good BP controlGood BP control

Process Measures for CHFProcess Measures for CHF

Higher use of Beta BlockersHigher use of Beta Blockers Higher use of ACE inhibitorsHigher use of ACE inhibitors

Strategies to Improve Physician Strategies to Improve Physician PerformancePerformance

CME and Educational Material: minimally CME and Educational Material: minimally effectiveeffective

Opinion leaders and feedback: Opinion leaders and feedback: moderatively effectivemoderatively effective

Prompts: initially effective but Prompts: initially effective but effectiveness wanes over timeeffectiveness wanes over time

Computer systems: effectiveComputer systems: effective Aligning Incentives with CQI and Aligning Incentives with CQI and

multifaceted interventions: most effectivemultifaceted interventions: most effective

QI ResearchQI Research

Builds on previous work found to Builds on previous work found to improve the quality of Health Careimprove the quality of Health Care

Can measure process or outcomesCan measure process or outcomes Valid and relevant (high risk or high Valid and relevant (high risk or high

volume diseases).volume diseases). Evidence Based: Non-evidence-based Evidence Based: Non-evidence-based

CQI most often fails.CQI most often fails.

QI ResearchQI Research

Process measures are easier to study, take Process measures are easier to study, take less time, do not require the use of less time, do not require the use of extensive risk adjustment models, can use extensive risk adjustment models, can use a smaller sample size, and are easy to a smaller sample size, and are easy to benchmarkbenchmark

Outcome measures are more easily Outcome measures are more easily understood by lay people(survival, health, understood by lay people(survival, health, well being). Usually requires longitudinal well being). Usually requires longitudinal follow up. (prospective cohorts)follow up. (prospective cohorts)

QI at NMFF GIM using EMRQI at NMFF GIM using EMR

Process metrics related to HEDIS Process metrics related to HEDIS metrics:metrics:

DM Metrics(Lipids, HTN control, Hgb DM Metrics(Lipids, HTN control, Hgb A1C, UA)A1C, UA)

CAD Metrics (ASA use, Beta Blockers)CAD Metrics (ASA use, Beta Blockers) CHF (Ace Inhibitor usage)CHF (Ace Inhibitor usage) Influenza vaccinationInfluenza vaccination Mammogram and Pap smear rateMammogram and Pap smear rate

QI at GIMQI at GIM

Identifying patients at high risk of Identifying patients at high risk of ADE and contacting provider to ADE and contacting provider to assess for intervention.assess for intervention.

Identifying patients taking Metformin Identifying patients taking Metformin with elevated creatinine or none with elevated creatinine or none measured.measured.

Identifying patients taking statins Identifying patients taking statins without lft’s being checked.without lft’s being checked.

Physician Service MetricsPhysician Service Metrics

Percentage of bumped patientsPercentage of bumped patients Percentage of patients not seenPercentage of patients not seen Frequency of late cancellationsFrequency of late cancellations Time from patient appointment to Time from patient appointment to

dischargedischarge Patient SatisfactionPatient Satisfaction

Opportunity to Improve Opportunity to Improve Safety(OTIS)Safety(OTIS)

Operational improvementOperational improvement Web-based site to enter any Web-based site to enter any

incidents in which safety can be incidents in which safety can be improvedimproved

Confidential, accessible, non-Confidential, accessible, non-threateningthreatening