Studying Quality

1
Studying Quality

• James G. Adams, MD
• Professor and Chair
• Dept of Emergency Medicine
• Feinberg School of Medicine Northwestern
  University
• Chicago, Illinois

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Definition of Quality

• Agency for Healthcare Research Quality (AHRQ)
• "Doing the right thing, at the right time, for
  the right person, and having the best possible
  result"

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Quality is not a process but achievement of a
goal

• Quality itself is defined not as consisting of
  the properties of an object but rather as the
  capacity of these properties to achieve goals.
• Accordingly, quality medical care is the capacity
  of the elements of that care to achieve
  legitimate medical and nonmedical goals.
• G. E. Steffen Department of Philosophy,
  University of Colorado, Boulder. JAMA 1988260(1)

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• Quality is the customers' perception of the value
  of the suppliers' work output. 
•   Winder, Richard E. and Judd, Daniel K., 1996,
  ORGANIZATIONAL ORIENTEERING  Linking Deming,
  Covey, and Senge in an Integrated Five Dimension
  Quality Model, In ASQC Seventh National Quality
  Management Conference Transactions. American
  Society for Quality.

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Unjustified Conclusions are possible

• The aim of medical research is to advance
  scientific knowledge and hencedirectly or
  indirectlylead to improvements in the treatment
  and prevention of disease.
• Each research project should continue
  systematically from previous research and feed
  into future research. Each project should
  contribute beneficially to a slowly evolving body
  of research.
• A study should not mislead otherwise it could
  adversely affect clinical practice and future
  research.
• In 1994 I observed that research papers commonly
  contain methodological errors, report results
  selectively, and draw unjustified conclusions.
• Altman DG. Poor Quality Medical Research What
  Can Journals Do? JAMA. 20022872765-67.

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IOM Definition of Quality

• "The degree to which health services for
  individuals and populations increase the
  likelihood of desired health outcomes and are
  consistent with current professional knowledge.
• Safe. Treatment helps patients and does not cause
  harm.
• Effective. Research shows that treatments have
  positive (good) results.
• Patient-centered. Healthcare providers (doctors,
  nurses, and others) treat all patients with
  respect. This means taking into account each
  patient's values about health and quality of
  life.
• Timely. Patients get the care they need at a time
  when it will do the most good.
• Efficient. Treatment does not waste doctors' or
  patients' money or time.
• Equitable. Everyone is entitled to high quality
  healthcare. This includes men and women of all
  cultures, income, level of education, and social
  status.
• Hurtado MP, Swift EK, Corrigan JM, eds. Crossing
  the Quality Chasm A New Health System for the
  21st Century. Washington DC. National Acad Press.
  2001
• Kohn LT, Corrigan JM, Donaldson MS, eds. To Err
  is Human Building a Safer Health System.
  Washington DC. National Academies Press. 1999

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• Quality has many dimensions
• Focusing on one dimension is important for
  science
• Focusing on one dimension may lead to incomplete
  conclusions.
• e.g. Electronic medical records improve quality
• Specific attributes may be assessed, but not full
  impact.
• Data are true, misleading, and understate overall
  impact
• Full impact cannot be assessed with
  oversimplified methods
• It is worth recognizing that Quality and Safety
  are not the same thing.

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Quality vs Safety

• Quality
• Attribute of a normally functioning system.
• Quality improvements attempt to understand,
  control, and optimize processes in a normally
  functioning system to achieve measurable
  outcomes.
• Safety
• A proactive attribute to mitigate or prevent
  harm.
• Variability, unpredictability are hazardous.
• A hazard is an condition in which harm, error, or
  quality violation may occur.

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Fundamental Work Hazards

• Schull MJ, Vermeulen MJ, Stukeel TA. The risk of
  missed diagnosis of acute myocardial infarction
  associated with emergency department volume.
  Annals of Emerg Med. 200648647-55.
• Lower volume EDs have up to a 2 fold higher odds
  of missed MI

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Fundamental work

• Fee C, Weber EJ. Identification of 90 of
  patients ultimately diagnosed with pneumonia
  within 4 hoursmay not be feasible. Ann Emerg Med
  200749553-59.
• Pines J. Measuring Antibiotic Timing for
  Pneumonia in the Emergency Department Another
  Nail in the Coffin. Annals of Emergency Medicine
  2007, Volume 49, Issue 5, Pages 561 - 563
• Fee C, Weber EJ, Maak CA, Bacchetti P. Effect of
  emergency department crowding on time to
  antibiotics in patients admitted with
  community-acquired pneumonia. Ann Emerg Med. 2007
  Nov50(5)501-9, 509.e1
• Pines JM, Hollander JE. Emergency Department
  crowding is associated with poor care for
  patients with severe pain. Ann Emerg Med
  2008511-5.

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Fundamental work

• Graff LG, Wang Y, Borkowski B, et al. Delay in
  the diagnosis of acute myocardial infarction
  effect on quality of care and its assessment.
  Acad Emerg Med 200613931-938.
• Pines JM. Morton MJ, Datner EM, Hollander JE.
  Systematic delays in antibiotic administration in
  the emergency department for adult patients
  admitted with pneumonia. Acad Emerg Med
  200613939-45.

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Assessing impact, driving importance

• Cuong J, Kelen GD, Pronovost PJ. National study
  on the quality of emergency department care in
  the treatment of acute myocardial infarction and
  pneumonia. Acad Emerg Med. 200714856-63.
• 22,000 excess deaths per year

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Quality Attributes

• Timely
• Safe
• Effective
• Patient-Centered
• Efficient
• Equitable

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Calls for traditional and optimal science are
well intentioned but misguided

• Where is the randomized trial? is, for many
  purposes the right question, but for many others
  it is the wrong question, a myopic one. A better
  one is broader What is everyone learning?
  Asking the question that way will help clinicians
  and researchers see further
• Berwick DM JAMA 2008299(10)1182-84.

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• Descriptive
• Describe the magnitude of the problem
• Pitfalls in identifying the numerator and
  denominator
• Qualitative
• Identify causal factors, what is the root cause?
• Host, agent, environment (Haddons matrix)
• Analytic
• Evaluate interventions to improve quality
• Predictor variable, outcome variable, study
  design
• Kyriacou DN, Coben JH. Errors in emergency
  medicine research strategies. Acad Emerg Med.
  200071201-3
• Brasel KJ, Layde PM, Hargarten S. Evaluation of
  error in medicine application of a public health
  model. Acad Emerg Med 200071298-302
• Bizovi KE, Wears R, Lowe RA. Researching Quality
  in Emergency Medicine. Acad Emerg Med
  200291116-23.

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National Quality Forum Mission Standardize
measurement and reporting

• Criteria for quality measures
• Important, reflecting variation in quality or low
  performance
• Scientifically acceptable, producing consistent
  and credible results when implemented
• Useable, understandable by intended audiences
• Feasible, enabling the data to be obtained
• www.qualityforum.org
• Pronovost PJ, Berenholtz SM, Needham DM. A
  framework for health care organizations to
  develop and evaluate a safety scorecard. JAMA
  2007298(17)2063-6.

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Quality Attributes

• Timely
• Arrival to Doctor
• Arrival to Discharge
• Arrival to Admission
• Safe
• Understand and minimize impacts of
• adverse conditions, situations
• Effective
• Right treatment, timing, sequence
• Improve outcomes through compliance with best
  practices
• Patient-Centered
• Satisfying
• Efficient
• Minimize wasted time and money
• Equitable
• Fair

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Improving Quality through Operations Research

• Determining the optimum action given limited
  resources
• Across a department
• Across a hospital or large organization
• Developed during WWII by the British to allocate
  resources
• Credited with helping win the Battle of the North
  Atlantic and a Campaign in the Pacific
• Put the resources in the best place to get the
  highest impact
• Mathematical techniques of modeling
• Includes human behaviors and organizational
  dynamics

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Solutions are optimized by using mathematical
analyses in addition to operational logic and
insight

• How to decrease waiting time
• How to get patients with STEMI to the cath lab
• How to deliver antibiotics within a given time
  period
• How to improve hospital profitability
• How to minimize bottlenecks and delays

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Elements of a Decision Model

• Summarizes a decision problem
• Systematically identifies and evaluates
  alternatives
• Addresses problem constraints and objective
  criteria
• Identifies an optimum solution

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SimulationShould a hospital build a bigger
emergency department?

• Which is Better Adding More Beds to Your ED or
  Reducing Inpatient Holding Times?
• Rahul K Khare, MD1
• Emilie S Powell, MD, MBA1
• Gilles Reinhardt, PhD2
• Martin Lucenti, MD, PhD1
• 1 Northwestern University, Department of
  Emergency Medicine, Feinberg School of Medicine,
  Chicago, IL
• 2 DePaul University

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Operations Research

• Essential to the future of healthcare delivery
• Healthcare delivery is messy but important
• Requires alliance with partnersnobody can have
  all the skills
• OR scientists are typically at business and
  engineering schools.