scal rtcc qi program gill cryer md. measurement of quality virtually absent in medicine compared to...
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SCAL RTCC QI Program
Gill Cryer MD
Measurement of Quality
• Virtually absent in medicine compared to industry and service organizations
• Needs redesign• Donabedian Model
– Structure– Process– Outcomes
DonabedianDonabedian
IOMIOM
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Crossing the Quality ChasmCrossing the Quality Chasm
• Redesign care processes on best practicesRedesign care processes on best practices
• Use information technology to support clinical Use information technology to support clinical decision makingdecision making
• Improve knowledge and skills managementImprove knowledge and skills management
• Develop effective teamsDevelop effective teams
• Coordinate careCoordinate care
• Incorporate performance and outcome Incorporate performance and outcome measures for quality improvement and measures for quality improvement and accountabilityaccountability
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NQF Accountability ModelNQF Accountability Model
Develop “Systems of Care” and Hold Develop “Systems of Care” and Hold Accountable for Longitudinal PerformanceAccountable for Longitudinal Performance
• Quality health care is a team sportQuality health care is a team sport• Patients’ needs cross settings and Patients’ needs cross settings and
professionals professionals • Organizational supports are criticalOrganizational supports are critical• Greater system integration needed Greater system integration needed
Standardization of care processes Standardization of care processes Shared accountability & shared rewardsShared accountability & shared rewards
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Components of ideal PIPS planComponents of ideal PIPS plan
• Accurate regional/ national clinical database Accurate regional/ national clinical database
• Identification of risk factors Identification of risk factors
• Accurate measurement of complications Accurate measurement of complications
• Risk adjusted outcomes measurement Risk adjusted outcomes measurement
• Identification of best practices/ evidence Identification of best practices/ evidence based guidelines based guidelines
• Benchmarking Benchmarking • National and regional monitoring and National and regional monitoring and
feedbackfeedback
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ACS COT PIPS Program: ACS COT PIPS Program: HistoryHistory
• Optimal resources Optimal resources document 1979-2006document 1979-2006
• ATLS 1980-2008ATLS 1980-2008• Benchmarking (TRISS) 1982 Benchmarking (TRISS) 1982 • Verification Committee 1987 Verification Committee 1987 • NTDB 1989NTDB 1989• PIPS Web manual 2002-2008PIPS Web manual 2002-2008• Good PIPS= good outcomesGood PIPS= good outcomes• TQIP 2010TQIP 2010
The National Study on Costs and Outcomes
of Trauma Center Care
NSCOTNSCOT
25% - Mortality Reduction <55
The Evidencefor trauma systems
• All measurement techniques:
8-10% mortality reduction
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• Professional society led national trauma quality improvement program (TQIP) to decrease variability in care and outcomes nation wide
• National risk adjusted clinical data-base with verified data accuracy and 100% participation
• Take benchmarking, feed-back, and identification, dissemination and monitoring of best practices to the next level
• Raise outcomes of all trauma centers to an ever increasing higher level
COT PIPS Program: FutureCOT PIPS Program: Future
Why do we need benchmarking?
• If we do take responsibility for being accountable ourselves somebody else will do it to us!
• LA Times 1-22-09: California measures quality of hospitals
• We all think we are above average• What do you do if somebody tells you are
below average?• What do you do if you find that you are below
average by risk adjusted criteria that you believe to be true?
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Using Surgical Outcomes Using Surgical Outcomes to Improve Care & Lower to Improve Care & Lower
CostsCosts
ACS - NSQIPACS - NSQIP
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*: Statistically significant high outlier (inferior performance)
#: Statistically significant low outlier (superior performance)
1
0
2
3
NSQIP Annual Report: Risk AdjustedMortality O/E Ratios for All Operations
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VAH Improved Mortality
2.572.75
2.552.33
2.14 2.08 1.99
1.70
3.163.16
2.38 2.28
0
1
2
3
4
Phase I 10/91-12/93
Phase II1/94-8/95
FY 96 FY 97 FY 98 FY 99 FY 00 FY01 FY02 FY03 FY04 FY05
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VAH Reduction in Complications
Reduction of morbidity (45%) in VA hospitals since the introduction of the NSQIP
0
2
4
6
8
10
12
14
16
18
20
Phase 1 Phase 2 1996 1997 1998 1999 2000
Mo
rbid
ity
Ra
te (
%)
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Lessons from NSQIP: Assurance of Data Quality/Reliability
• Dedicated surgical clinical nurse reviewer (SCNR)
• Centralized nurse training• Standardized protocol• Definitions Committee• Mandatory web-based competency tests• Hotline to address nurse questions • IRR assessed periodically by traveling SCNRs• Site visits on request
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NSQIP: Centers of concern: problems NSQIP: Centers of concern: problems accounting for higher mortalityaccounting for higher mortality
• Poor coordination of care • Gradual cutbacks in fiscal support• Service lines that fragment care• Poor monitoring of quality• Lack of surgeon led team with
administrative support• An issue of systems not providers
NSQIP ReportsNSQIP Reports
• Ability to view your data onlineAbility to view your data online• Comparisons with national dataComparisons with national data• Selection of time frameSelection of time frame• Can drill down on individual patientsCan drill down on individual patients• O/E’s are equivalent to “dashboard warning light”O/E’s are equivalent to “dashboard warning light”• Online report allows you to “look under the hood”Online report allows you to “look under the hood”• NTDB exploring online report capability for TQIPNTDB exploring online report capability for TQIP
ACS Committee on Trauma
COT NSQIP Retreat• Risk factor and outcomes data in trauma
registries much different than NSQIP
• Adding a NSQIP trauma module to trauma centers would duplicate infrastructure
• COT already has fixed much of what NSQIP found to be concerning problems
• COT and NSQIP to collaborate to add NSQIP principles to trauma PIPS program
• TQIP task force
Sept. 2005Sept. 2005
TQIP task force questions
• Have we already picked the low hanging fruit?– Variation in outcome in verified centers?
• Is NSQIP methodology workable in trauma?• Is NTDB data accurate enough ?• What complications are important?• What outcomes other than mortality should
we keep track of?• What modifications to our current process
will be required?
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Decreased mortality
Increased mortality
-50
510
W u
sing
AC
SIS
6
Hospitals with >250 cases, 80% complete data, n=487,776
Index ACS 1 ACS 2 Other
Do you want to know who you are?
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• Build upon existing trauma center infrastructure
• Standardized data collection and validation• Risk adjusted benchmarking• Performance feedback• Identification and sharing of best practices• Ongoing performance monitoring• Raise the performance of all trauma centers
and trauma systems to a higher level
Trauma Quality Improvement Project
What should a state trauma system PI plan look like?
• Trauma center ACS COT verified PIPS program
• LEMSA trauma system program
• Regional state LEMSA program
• State program
• Just how we have to decide
• Why do we need to do this?
Multicasualties In Southern Calif.Year Injured Deaths
ZOOT SUIT RIOTS 1943 > 150
BEL AIR FIRE 1961 > 50 0
WATTS RIOTS 1965 > 1000 34
SYLMAR QUAKE 1971 14
WESTWOOD DISASTER 1984 51 1
RODNEY KING RIOT 1992 > 1200 38
NORTHRIDGE QUAKE 1994 138 33
SANTA MONICA CRASH 2003 73 10
GLENDALE TRAIN 2005 106 11
CHATSWORTH TRAIN 2008 133 26
Systems PI and disaster managementSystems PI and disaster managementSystems PI and disaster managementSystems PI and disaster management
Glendale train crash 2005
Glendale metrolink train crash 2005
• 106 injured patients, 25 critical• Only 2 patients transported by air to
a trauma center• Only 11/25 (44%) of critical patients
were transported to trauma centers• 13 critical and 75 total patients were
taken to 4 local community hospitals and overwhelmed them
QI Debriefing • 5 level I trauma centers agreed to take 12
“immediate”patients between them• 8 level II trauma centers agreed to take 17
immediates• Local area hospitals agreed to take 75!• Patients were sent to local community
hospitals >15 miles away when 8 closer hospitals received none!
• Data presented to LA EMS THAC
ACS Triage Inclusive Trauma System
Mackersie, Prehosp Emergency Care ’06
Disaster ManagementDisaster ManagementDisaster ManagementDisaster Management
Revised LA County disaster plan
• LA City Fire is asked to respond to a multicasualty event
• LA City fire notifies Medical Alert Center (MAC)• MAC sends multicasualty incident poll via
reddinet to area hospitals reg bed availability• MAC relays bed availability to paramedics who
organize transfer• Trauma centers automatically are responsible for
6 beds at each level 1 and 3 beds at each level 2 (48 total)
• Critical patients distributed to trauma centers
Metrolink train crash 9-12-08
Chatsworth 9-12-08
Freight engine inside metrolink
Extrication
Field triage
Transport by ground
Transport by air
Cooperation of different agencies
2008 Metrolilnk crash
Think about how it would turn out if this Think about how it would turn out if this Crash occurred near your hospitalCrash occurred near your hospital
Metrolink train crash 2008
• 133 victims• 25 dead at the scene• 98 patients transported to hospitals
– 25 by air to 4 level 1 trauma centers– 39 by air and ground to 4 level 2 trauma
centers– 34 by ground to 8 local community hospitals
• Only 1 transported patient died (Massive TBI)
Metrolink train crash 2008
• 33 patients critical– 27/33 (82%) went to level 1 and 2 trauma
centers
• 45 patients seriously injured– 22/45 (49%) went to level 1 and 2 trauma
centers
• 13 patients minor injuries– 9/13 (69%) went to level 1 and 2 trauma
centers
Train disaster comparison
• Glendale- 2005– 13/25 (56%) critical and 75/106 (71%) total
patients to 4 local community hospitals– 11/25 (44%) critical and 31/106 (29%) total
patients to 3 level I and II trauma centers
• Chatsworth-2008– 6/33 (18%) critical and 34/98 (34%) total
patients to 8 local community hospitals– 27/33 (82%) critical and 64/98 (66%) total
patients to 8 level I and II trauma centers
Patients to OR within 1 hour
• Pancreatic/duodenal, liver, vascular• Pancreatic transection• Perforated viscus, mesenteric vascular• Craniotomy• Exploratory laparotomy• Bilateral tension pneumothorax• Scalp avulsion• 11 open fracture/peripheral vascular• If you needed to do all these operations in your
hospital in 1 hour could you do it?
8 level I and II trauma centers8 level I and II trauma centers
Emerging Concepts• Bombings / shootings most common
• Triage: 20 – 25% require urgent care
• Coord. interaction of all area hospitals
• Most severely injured to trauma center
• They do it all the time!
• Utilize trauma systems
• They do it all the time!
• Regionalize planning and practice
Disaster ManagementDisaster ManagementDisaster ManagementDisaster Management
USGS Shakeout scenario
USGS Shakeout scenario
• 7.8 magnitude
• Shaking in downtown LA 55 sec
• 1800 deaths
• 50,000 seek help in Ers
• 67% of hospital bed nonfunctional
• Are we ready? We better be
• Disasters are Unpredictable but not unexpected• Analysis and planning essential
• Building around a trauma system: critical
Disaster ManagementDisaster ManagementDisaster ManagementDisaster Management
Look familiar?
State regional trauma systems
• Develop state and national trauma systems as foundation for disaster preparedness
• Combine with a regional, state and national QI plan
• Care of the injured will improve markedly as will other emergencies
disaster preparedness priority
Thank youThank you