8/10/2015. Module 1. A Fundamental Understanding of Quality. Management and its Application to Health Care

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1 Module 1 A Fundamental Understanding of Quality Management and its Application to Health Care Addressing Physician Uncertainty about Payment Reform: Skills for Success in Value-Based Delivery Systems The First of a Six Part Series to prepare Practitioners for the future when: Reimbursement is based on Outcomes Data and Analysis are Paramount Population Health is the Focus A Fundamental Understanding of Quality Management and its Application to Health Care Course Objectives Analyze basic quality theory Study the basics of healthcare quality management Apply this understanding to your practice of medicine Prepare your practice or delivery network for success in a value based system 1

2 Morbidity & Mortality Conference Early Dys-Quality Assessment In the early 1900s with Dr. Ernest Codman at Mass General Hospital in Boston. Lost privileges after suggesting the evaluation of individual surgeon s outcomes Codman attributed was the standardization of hospital practices including a case report system that ascribed responsibility for adverse outcomes Physician training includes discussion of errors at mortality conferences, where autopsy findings were presented, and in published case reports. In 1983, the Accreditation Council of Graduate Medical Education required accredited residency programs to conduct a weekly review of all complications and deaths. Breeds Fear Has Minimal Impact in Overall Quality Improvement Early Quality Assurance Dys-quality Assessment Rehabilitate Remove DYS-QUALITY ASSESSMENT Eliminate Bad Apples Breeding Fear Morbidity & Mortality Conference Today Moving Beyond Blame-storming The objectives of a well run M&M conference are to learn from complications and errors, to modify behavior and judgment based on previous experiences, and to prevent repetition of errors leading to complications. Conferences are non punitive, legally protected and focus on the goal of improved patient care. Most important for identifying systems issues which affect patient care NOT THE PEOPLE RESPONSIBLE FOR AN ERROR Remove Fear Find System Improvement Opportunities 2

3 Applying Dys-Quality Assessment Focus on Prevention of Errors ERROR Create standard care pathways that make deviation difficult Study errors in care and service to modify these pathways Track and evaluate near misses situations where something bad almost happened to modify these pathways further Always look for ways to improve the system to set yourself and colleagues up for success not failure MAKE YOUR CARE DELIVERY FOOL PROOF Removes Fear When Systems are Fool Proof Continuous Quality Improvement The PUSH Approach POOR FAIR GOOD VERY GOOD EXCELLENT TOTAL QUALITY MANAGEMENT Moving all performance toward excellence making everyone better Applying Continuous Quality Improvement Framework for the Continual Improvement of Health Care AIM: What are we trying to accomplish? MEASURES: How will we know that a change is an improvement? IMPROVEMENT TRIAL: What changes can we make that we predict will lead to improvement? ACT PLAN CHECK & STUDY DO Planning, Measurement, Piloting, Re Measurement, Improvement 3

4 Benchmarking Redefining Excellence The PULL Approach RESOURCES NEW BENCHMARK BENCHMARKING Invest Limited Resources Into The Best Results, Make Them Even Better And Share Their Process With All Others Gurus in Quality Management Learning From the Masters Donabedian Deming Juran Chassin Wennberg Berwick Gowande Structure, Process, Outcome Processes Vs. People Statistical Process Control; VOC Usage Errors Unexplained Variations In Care Triple Aim Checklists By Understanding These Leaders in Quality You Will Become a Quality Leader Yourself Donabedian Framework of Quality Assessment Structure, Process & Outcomes STRUCTURE / Systems PROCESS / Operations OUTCOME / Results This Is A Helpful Way To Approach Quality Problems 4

5 Donabedian Framework Health System Quality Assessment Here Are Examples Of Elements Within Structure, Process and Outcome Deming's 14 points Creating a Quality Culture - Purpose 1. Create constancy of purpose 2. Adopt the new philosophy. 3. Cease dependence on inspection. 4. Use a single supplier based on a longterm relationship of loyalty and trust. 5. Improve constantly 6. Institute training. 7. Institute leadership to help people and machines and gadgets to do a better job. 8. Drive out fear of supervision / evaluation 9. Break down barriers between departments - work as a team, 10. Eliminate slogans, exhortations, and targets they create adversarial relationships 11. The responsibility of organizations must be changed from sheer numbers to quality. 12. Establish pride of workmanship. 13. Institute a vigorous program of education and self-improvement. 14. Put everybody in the company to work to accomplish the transformation. The transformation is everybody's job Key Words: Purpose, Trust, Loyalty, Constancy, Training, Leadership, Teaming, System Focus, Pride of Workmanship, Education, Self Improvement, Quality is Everyone s Job Application of Deming s 14 Points (PCMH) NO FEAR - A Patient Gateway NOT a Gate Keeper 7 Tenets Resonate Personal Physician Trusted Relationship Physician- Directed Medical Practice Leadership > Management Whole Person Orientation Pride of Workmanship Income for outcome Coordinated Integrated Care Team based care New Modes of Payment Enhanced Access to Care Constancy of purpose Quality and Safety Systems Emphasis is on the system 15 5

6 Summary of Deming's Teachings Application to Your Practice Standard Approach Quality is expensive Inspection is the key to Quality Defects are caused by workers Deming s Approach Quality leads to lower costs Inspection is too late. If workers can produce defect-free goods, eliminate inspection Most defects are caused by the system Quality is an investment Prevention medical errors Don t just study them Focus on the system Rewarding the best performers and punishing the worst will lead to greater productivity and creativity Most variation is caused by the systems that judge, punish, destroy teamwork and the company Reward everyone for improvements in the system Profits are made by keeping revenue high and costs down Profits are generated by loyal customers Success is based on satisfied patients "Fitness for Use" Juran's Beliefs Meets Needs & Error Free Juran s two definitions of quality Definition of Quality 1 Definition of Quality 2 Product features that meet customer needs Higher quality enables company to: Increase customer satisfaction Make products salable Meet competition Increase market share Provide sales income Secure premium prices The major effect is on sales. Usually, higher quality costs more. Freedom from deficiencies Higher quality enables companies to: Reduce error rates Reduce rework, waste Reduce field failures, warranty charges Reduce customer dissatisfaction Reduce inspection, test Shorten time to put new products on the market Increase yields, capacity Improve delivery performance Major effect is on costs. Usually, higher quality costs less "Fitness for Use" Juran's Beliefs Application to Your Practice Juran s two definitions of quality Definition of Quality 1 Definition of Quality 2 Be responsive to the needs of the patient Higher quality practices will: Increase patient satisfaction Increase provider satisfaction more rewarding Make the practice more popular Excel among peers Increase market share Maximize your payment for services & income Generate profit to invest into practice Spend more on your practice than others to make it a benchmark Eliminate patient errors in care & service Higher quality practices will Get the diagnosis and care plan right the first time Create trust & loyalty Reduce liabilities Build quality into the process rather than periodic episodic inspection afterwards Shorten time to adopt new treatments and services Grow by adding practitioners and locations Improve delivery performance Be more efficient & effective 6

7 The Juran Trilogy Planning, Control, Improvement Quality Planning: Determine who the customers are. Determine the needs of the customers. Develop product features that respond to customer s needs. Develop processes that are able to produce those product features. Quality Control: Evaluate actual Quality Performance. Compare actual performance to quality goals. Act on differences Quality Improvement: Establish the infrastructure needed to secure annual quality improvement. Optimize the process in all possible ways. Identify specific needs for improvement the improvement projects. Provide the resources, motivation, and training to teams. The Juran Trilogy Applied to Medical Practice Quality Planning: Understand your patient population & the community Determine the needs of your patient population & the community Design your practice and care delivery to meet their needs. Develop processes to deliver the needed care and services Quality Control: Evaluate your practice s performance Compare actual performance to quality goals Act on differences Quality Improvement: Build quality into your practice to secure annual quality improvement Optimize the process in all possible ways care & service Identify specific needs for improvement assign improvement projects Provide the resources, motivation, and training to everyone in your practice Juran Key Contribution Voice of the Customer (VOC) The Voice of the Customer (VOC) describes the spoken and unspoken true needs of the recipient of one s goods or services. The customer can be both internal and external, and its voice cannot be overlooked. Constantly listen to your co workers, colleagues and patients. They will tell you how to improve the practice 7

8 Mark Chassin, MD Types of Errors in Care Overuse wide variations in access and utilization Under use evidence based medicine, preventive services Misuse preventable errors in diagnosis and treatment Types of Errors in Care Applied to Your Practice Overuse wide variations in access and utilization Study your practice patterns against norms Eliminate unnecessary care Under use evidence based medicine, preventive services Seek to deliver evidence based care without gaps Approach 100% application of preventive services Misuse preventable errors in diagnosis and treatment Eliminate preventable medical errors Guard patients from fraudulent, wasteful and abusive care Jack Wennberg, MD Unexplained Variation Refers to differences that cannot be explained by illness, medical need, or the dictates of evidence based medicine. It can be caused by shortfalls in three areas: Effective care and patient safety, which includes services of proven clinical effectiveness, evidence based guidelines such as using lipid lowering agents in patients with coronary artery disease. Preference sensitive care, treatment for conditions that have significant trade offs in terms of risks and benefits for the patient. But the choice of care is, or should be, driven by the patient s own preferences. Supply sensitive care, care which is strongly correlated with healthcare system resource capacity and is generally provided in the absence of medical evidence and clinical theory. 8

9 Jack Wennberg, MD Unexplained Variation of Use The Dartmouth Atlas Cancer & Hospice Care Hospital Readmission Jack Wennberg, MD Unexplained Variation of Cost The Dartmouth Atlas Resolve Unexplained Variation Applied to Your Practice Establish pathways for care based on conditions and patient preferences Standardize office visit structure and process Apply evidence based medicine Deploy shared decision making whenever there are treatment options 9

10 Resolve Unexplained Variation Shared Decision Making 1. Invite patient to participate 2. Present options 3. Provide information on benefits and risks 4. Assist patient in evaluating options based on their goals and concerns 5. Facilitate deliberation and decision making 6. Assist with implementation Invite Options Benefits and Risks Patient Preferences Deliberate and Decide Implementation Resolve Unexplained Variation Shared Decision Making Impact Increase patient knowledge and compliance Increase understanding of risk (patients have more realistic expectations) Reduce the proportion of patients who remain undecided Will more often opt for the conservative therapy (less over utilization) Increase the consistency between patient decisions & patient values Reduce decisional conflict related to feeling uninformed Reduced medical liability Invite Options Benefits and Risks Patient Preferences Deliberate and Decide Implementation Don Berwick, MD Basic Principals of Medical Quality Management 1. Productive Work Is Accomplished Through Processes 2. Sound Customer Supplier Relationships Are Absolutely Necessary for Sound Quality Management 3. The Main Source of Quality Defects Is Problems in the Process 4. Poor Quality Is Costly 5. Understanding The Variability of Processes Is Key to Improving Quality 6. Quality Control Should Focus on the Most Vital Processes 7. The Modern Approach to Quality Is Thoroughly Grounded in Scientific and Statistical Thinking 8. Total Employee Involvement Is Critical 9. New Organizational Structures Can Help Achieve Quality Improvement 10. Quality Management Employs Three Basic, Closely Interrelated Activities: Quality Planning, Quality Control, and Quality Improvement. 10

11 Don Berwick, MD Institute for Health Improvement IHI s vision for health care is an adaptation from the Institute of Medicine's six improvement aims for the health care system: care that is safe, effective, patient centered, timely, efficient, and equitable: [ No Needless Deaths No Needless Pain or Suffering No Helplessness in Those Served or Serving No Unwanted Waiting No Waste No One Left Out Don Berwick MD Institute for Health Improvement TRIPLE AIM HEALTH STATUS OF THE POPULATION PERCEIVED VAUE / SATISFACTION COST PER CAPITA FOR PROVIDING CARE In Your Practice Focus on the 3E s of Clinical Practice Efficiency E Effectiveness Experience E 3 3 Atul Gawande, MD Improve Surgical Outcomes - Checklists 11

12 Atul Gawande, MD Checklist for Checklist Development Development Capture critical safety steps with needed actions Foster communication between stakeholders Drafting Used during breaks in workflow One page Validation Detecting errors in time to fix them Modified over time with feedback & use Atul Gawande, MD Checklist for Checklist Development Identify Opportunities for Improvement Utilization Trends Certification Process Provider Input Identify Opportunities Demographics Staff Input Patient Input 12

13 Follow the Effectiveness Pathway Your Great Journey Going Forward Converting Concern to Demonstration Concern for Quality????? Demonstration of Quality 13