EAHM - Düsseldorf Ir Laurens Touwen Reinier de Graaf Hospital, Delft 16 november 2007 Düsseldorf
Where are we talking about? from the patient point of view "The way we deliver care : profession overuse, underuse, misuse (patient safety) "The way we organize care : organisation health care is an archipelago access-problems, waiting times, delays coordination problems communication gap "The way we take care : relationship information co-decision making empathy "The level of recovery : results L.Touwen, 16 nov 07 2
Where are we talking about? from the organization point of view Striving for quality For the individual patient For the general practitioner/ referral For the specialist For the employees For the government/inspection For And how to put your quality in concrete L.Touwen, 16 nov 07 3
L.Touwen, 16 nov 07 4 What we don t like to happen. Basically miscommunication!
Accreditation? and or Quality Improvement? paradigm good-bad emphasize the status quo organis./profess. in the centre measurement - control part of quality-system minimal-quality static fast costs energy dangers: bureaucracy window-dressing alibi-function paradigm good-better emphasis on better results patient in the centre measurem. improv. contr. is quality-system innovation and improvement dynamic slow, time-consuming gives new energy dangers: religion/jargon failure leadership dependant L.Touwen, 16 nov 07 5
Quality defined IOM 1999 Care must be: Safe Effective Patient-centered Timely Efficient Equal for all L.Touwen, 16 nov 07 6
Changing Health Care Four Levels of Intervention Patient-level 6 aims, patient-involvement, patient-experiences Level of the care-process: work floor professional x organization results Institutional level leadership with courage, strategy integration, collaboration supported by: flow-management, IT, HRM, MD internal incentives (reinforcing intrinsic motivation) System-level structure, law, financing, bureaucracy, external incentives L.Touwen, 16 nov 07 7
Dr Deming influenced quality-improvement very strongly L.Touwen, 16 nov 07 8
L.Touwen, 16 nov 07 9
NIAZ- Dutch institute for accreditation of hospitals CCKL - Coordination Commission for enhancement of Quality assurance in the realm of Laboratory research GLP Good Laboratory Practice HACCP-Hazard Analysis Critical Control Points ISO Etc. L.Touwen, 16 nov 07 10
What does not do NIAZ? Niaz is fixing the organizational processes Defines Norms per department Niaz does not define or assure the Medical treatment or Medical results L.Touwen, 16 nov 07 11
Indicators Dutch inspection started to ask yearly indicators: - results: f.i. bedsore, - process indicators: IT-application Total over 100 indicators, also having NIAZ-accreditation is a point L.Touwen, 16 nov 07 12
Hospital Standardised Mortality Ratios (HSMRs) and SMRs HSMR gives an overview of the hospital performance as judged by death rates adjusted for main influences HSMR covers 50 diagnoses leading to 80% all deaths Adjust for age, sex, admission method, admission source, (LOS), primary diagnosis, +/- social deprivation, Charlson Index, readmission rate, season, palliative care, year L.Touwen, 16 nov 07 13
Hospital age, sex, race, payer, admission source, admission type standardized death rate vs age, diagnosis standardized charge per admission, AHRQ 1997 data Standardised death rate 180 160 140 120 100 80 60 40 20 0 0 5,000 10,000 15,000 20,000 25,000 Standardised charge $ per admission L.Touwen, 16 nov 07 14
Dutch hospital HSMRs (15 Jan 2007 model, 2003-5 lmr data, 7 hospitals with inadequate or noncomparable data removed) 160 140 HSMR(with 95% confidence inter 120 100 80 60 40 20 0 99 68 89 18 14 75 58 10 27 35 83 66 60 5 43 79 62 63 81 38 103 55 59 29 85 28 49 106 50 25 44 94 51 20 3 22 90 96 53 39 70 13 101 9 47 52 8 33 69 86 56 107 87 23 100 82 11 34 104 36 72 97 74 30 16 84 95 61 73 31 54 64 40 6 2 19 12 71 21 78 67 102 93 98 65 41 45 1 17 37 32 7 48 4 All Brian Jarman hospital number L.Touwen, 16 nov 07 15
Dutch HSMRs vs year (using year 2003 as the standard) 125 120 115 HSMRs (95% CIs) 110 105 100 95 90 85 80 1998 1999 2000 2001 2002 2003 2004 2005 L.Touwen, 16 nov 07 16
Move Your Dot: status analyses A way to learn from your experiences L.Touwen, 16 nov 07 17
Real Time Monitoring (RTM), a way to Continuously check your results, based on LMR- National medical records L.Touwen, 16 nov 07 18
Clinical Pathways KU Leuven Method to organize optimal care for specific group of patients Gives overview of care-activities - of all disciplines - from preparation of admittance till follow up - So: everybody knows: who does what when Possibility to evaluate the care process and to improve L.Touwen, 16 nov 07 19
Clinical Pathways L.Touwen, 16 nov 07 20
Dutch Health inspection: Avoid harm, work safe Goal of national safety program: In 2012 reduction of 50% of avoidable harm in Dutch hospitals by realizing 10 interventions, f.i.: Avoid Surgical site infections Avoid harm Central line infections Avoid adverse drug events Discern patients at risk: SIT Rapid Response Team L.Touwen, 16 nov 07 21
Reinier de Graaf-experience Start in 2000 with NIAZ So much rules and paperwork It threatened instead inspired We emphasize improvement and innovation We are weak in quality assurance L.Touwen, 16 nov 07 22
Dutch future accreditation? Niaz accreditation Professional quality visitations for medical groups Outcome indicators Safety management system HSMR Then we have the ultimate safe healthcare? L.Touwen, 16 nov 07 23
External audit Integrated Quality System financial management system Public accountability Norming: guidelines, best practices Measurement: indicators internal/external Intrinsic motivation Measurement: indicators, complaints, errors Improvement Redesign Spread: internal/external Holding the gains External incentives L.Touwen, 16 nov 07 24
What is our motive Improvement of patient care Better care for the living!! For every patient: No needless pain No needless deaths No needless helplessness L.Touwen, 16 nov 07 25