Quality: The Race Without a Finish Line 1 Conflict of Interest Disclosure Speaker Conflict of Interest. Melanie Simpson is on the Speakers Bureau for Pacira Pharmaceutical, Inc. A conflict of interest is a particular financial or non financial circumstance that might compromise, or appear to compromise, professional judgment. Anything that fits this should be included. Examples are owning stock in a company whose product is being evaluated, being a consultant or employee of a company whose product is being evaluated, etc. Taken in part from On Being a Scientist: Responsible Conduct in Research. National Academies Press. 1995. 2 Additional Disclosures I do not have the formula for quality pain management I do not have all the answers I will tell you how I do pain management at KU (however it is not perfect) I do own pain management at my institution 3 1
What is quality? Health care quality is generally defined in terms of the attributes and outcomes of care provided by practitioners and received by patients. The Institute of Medicine: quality is the degree to which health services increase desired health outcomes and are consistent with professional knowledge. Patient satisfaction is a recommended measure in most evaluations of quality. National Committee for Quality Assurance 4 Definition of Quality Harm Reduction Reporting Quality Culture of Accountability Continuous Improvement 5 What is quality? Quality is a measure of how well we provide care, save lives and prevent harm. Quality is measured through mortality data and patient satisfaction 6 2
Mortality Index (Actual Deaths/Expected Deaths Based on Severity of Illness) Good 312 Fewer Deaths Than Expected Based on Patient Acuity FY13 78 consecutive months with Mortality Index <1.0 7 7 Patient Satisfaction Press Ganey Percentile Rank 100 90 80 70 60 50 40 30 20 19 25 62 36 48 29 3133 46 49 71 68 60 58 40 51 47 48 71 67 67 69 82 79 79 80 96 94 97 96 88 89 90 91 92 92 86 87 88 90 93 92 89 90 90 88 86 86 84 82 78 77 77 79 73 10 10 0 3Q99 4Q99 1Q00 2Q00 3Q00 4Q00 1Q01 2Q01 3Q01 4Q01 1Q02 2Q02 3Q02 3Q02 1Q03 2Q03 3Q03 4Q03 1Q04 2Q04 3Q04 4Q04 1Q05 2Q05 3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 3Q07 4Q07 1Q08 2Q08 3Q08 4Q08 1Q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10 4Q10 1Q11 2Q11 3Q11 4Q11 1Q12 2Q12 3Q12 4Q12 1Q13 2Q13 Quarter 8 Patient Satisfaction and Pain Patient satisfaction is based on patient expectations Responses can be skewed and difficult to interpret Paradoxical, yet consistent findings that despite high pain ratings, satisfaction scores may be high Likely more appropriate to evaluate the patient s perception of involvement in his own pain control 9 3
HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems Center for Medicare and Medicaid Services (CMS) included questions to measure patients perceptions of pain management. It emphasized the importance of pain management to patient satisfaction Hospitals need to be more transparent about what they are doing to improve pain management and what patients should expect as a result. Press Ganey, 2012 10 HCAHPS Questions During this hospital stay, did you need medicine for your pain? During this hospital stay, how often was your pain well controlled? During this hospital stay, how often did the hospital staff do everything they could to help you with your pain? 11 Domain KU HCAHPS September 2013 Body text goes here FY14YTD All DB FY14YTD Large DB Top Box Answer Rate Hospital (0-10) 98 99 9-10 Recommend 98 99 Definitely Yes RN Communication 92 98 Always MD Communication 78 88 Always Responsiveness 86 96 Always Hospital Environment 48 61 Always Pain Management 90 96 Always Med. Communication 96 99 Always Discharge Information 92 96 Yes Care Transitions 93 97 12 4
Relevant conclusions from patient satisfaction study 3 main themes: Lack of provider knowledge Lack of patient education Perceived lack of caring Sherwood et al. (2000). Qualitative assessment of hospitalized patients satisfaction with pain management. Research in Nursing & Health, 23 (6), 486-95. 13 US News & World Report ranks The University of Kansas Hospital, 7 th nationwide in patient satisfaction for Pain Management of the top 3000 hospitals, 2009 15 5
Quality Our Guiding Formula World Class Patient Outcomes World Class Patient Satisfaction Service Delivered by Competent, Committed and Engaged Staff People Growth Strong, Sustainable Growth Strong, Sustainable Financial Performance Cost 16 Expanding the Definition of Quality Efficiency Harm Reduction Culture of Accountability Quality Reporting Effectiveness Continuous Improvement 17 Including Efficiency and Effectiveness Efficiency includes managing throughput and length of stay Effectiveness ensures our care meets all identified standards such as core measures and that our processes help reduce unnecessary readmissions 18 6
Quality improvement: guidelines and evidence based practice Guidelines are systematically developed statements based on evidence designed to help practitioners and patients make appropriate health care decisions for specific clinical conditions Pub Med, Up to date, Cochrane Collaboration, Lippincott many evidence related sites Ask yourself 1. Is there scientific evidence 2. If there is no evidence, is it useless? 19 APS QI guidelines for the treatment of acute and cancer pain Recognize and treat pain promptly comprehensive assessment and importance of preventive and prompt treatment based on evidence Involve patients in the pain management plan customization of care and participation in treatment plan; patients need to know their options and responsibilities for participation Gordon et al. (2005). APS Recommendations for Improving the Quality of Acute and Cancer Pain Management, Archives of Internal Medicine, (165), 1574-1580 20 APS QI guidelines for the treatment of acute and cancer pain Improve treatment patterns multimodal approach, ensuring treatments are safe, evidence based advancements, move from old routines Reassess and adjust pain management plan as needed respond not only to pain intensity but to functional status and side effects, establish realistic goals, consider the burden of treatment on quality of life and resources Gordon et al. (2005). APS Recommendations for Improving the Quality of Acute and Cancer Pain Management, Archives of Internal Medicine, (165), 1574-1580 21 7
APS QI guidelines for the treatment of acute and cancer pain Monitor process and outcomes of pain management with the goal of continuous improvement Why do we do what we do? How do we know it works? How can we do it better? Pain Management performance measurement used for external accountability and transparency and facilitate QI priorities Gordon et al. (2005). APS Recommendations for Improving the Quality of Acute and Cancer Pain Management, Archives of Internal Medicine, (165), 1574-1580 22 Opportunities for quality improvement for pain management Explicit policies and procedures to guide the use of specialized techniques for analgesic administration Clearly defined accountability for pain management An ongoing process that evaluates the outcomes and works to improve the quality of pain management 23 Opportunities for quality improvement for pain management Information about pharm and nonpharmacologic interventions for clinicians to facilitate writing, interpreting and implementing of orders Orientation and continuing education opportunities Lack of provider knowledge Patient and family education programs and materials Lack of patient education Change perception of caring Lack of caring 24 8
Some of our interventions Lack of provider knowledge Pocket Analgesia guides Education presentations, grand rounds, PRN, staff mtgs LMS required yearly (range order policy, opioid dilution, etc.) Lack of patient education Preanesthesia testing clinic video Opioid teaching sheet White boards for communication 25 Some of our interventions Lack of caring Comfort video required is there anything else I can do to make you more comfortable? 5 minutes of caring Teaching providers to never say there is nothing I can do 26 Summary Guiding principles of quality remain knowledgebased, patient centered and system minded care Outcomes research has resulted in new measures of quality example, improved function as an outcome of quality pain management Quality improvement is ongoing process: Or in other words: the race without a finish line 27 9