Quality and Performance in Healthcare

1
Quality and Performance in Healthcare

• Chapter 1
• Defining a Performance Improvement Model

2
Key Terms

• Continuous Monitoring
• Opportunities for Improvement
• Performance Improvement Team
• Process redesign
• QI toolbox techniques

3
Process Improvement Model

• Define the Problem
• Identify and document process
• Measure performance
• Understand why (Analyze results)
• Develop and test ideas
• Implement solutions and evaluate

4
Establishment of a PI Program

• Define and implement the organization-wide PI
  model.
• Establish a staff education plan to train
  employees in performance improvement.
• Prioritize and define PI measures.
• Define data collection and reporting
  responsibilities.
• Appoint PI teams when process variation exceeds
  established benchmarks.
• Maintain a process of reporting significant
  findings and corrective actions to the board of
  directors and other stakeholders.

5
Team Based PI Processes

• Create a flow-chart of the current process.
• Brainstorm problem areas within the current
  process.
• Research any regulatory requirements related to
  the current process.
• Compare the organizations current process to
  performance standards and/or nationally
  recognized standards.
• Conduct a survey to gather customer input on
  their needs and expectations.
• Prioritize problem areas for focused improvement.

6
Performance Improvement as a Cyclical Process
7
Team-based performance improvement process
8
Performance Improvement Model
9
Performance Measure Example
of incomplete medical records that exceed the
medical staffestablished timeframe for chart
completion _______________________________________
__________________________________________________
_________ Average monthly
discharges
10
Benchmark Example

• Community Hospital of the West Employee Turnover
  Rate

11
Community Hospital of the West Performance
Improvement Model
12
Performance Improvement Models

• Supplement to Chapter 1

13
Demings 14 Principles

• Create constancy of purpose toward improvement of
  service
• Adopt the new philosophy
• Cease dependence on mass inspection to achieve
  quality
• End the practice of awarding business on the
  basis of price tag
• Improve constantly and forever the system of
  service delivery
• Institute training on the job
• Institute leadership
• Drive out fear
• Break down barriers between business units and
  departments
• Eliminate slogans, exhortations, and targets for
  the workforce
• Eliminate work standards and quotas for the work
  force. Eliminate management by objectives and
  management by numerical goals
• Remove barriers to pride in workmanship
• Institute a vigorous program of education and
  improvement
• Put everyone to work to accomplish the
  transformation

14
Crosbys 14 Points to Improving Quality

• Appoint a management committee
• Establish a quality improvement team
• Set up measurements
• Identify the cost of poor quality
• Develop quality awareness
• Undertake corrective action programs
• Zero defects planning
• Employee education
• Implement a zero defects kickoff day
• Begin quality goal setting
• Practice error-cause removal
• Give recognition to accomplishments
• Develop a quality council
• Do it over again

15
7 Steps to Problem Solving

• Identify and define the problem
• Measure impact on customers
• Prioritize possible causes
• Research and analyze root causes
• Outline alternative solutions
• Validate that the solutions work
• Execute solutions and standardize

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JCAHO 10 STEP PROCESS

• Assign Responsibility
• Delineate scope of care and service
• Identify important aspects of care/service
• Identify indicators
• Establish thresholds for evaluation
• Collect and organize data
• Initiate Evaluation
• Take actions to improve care and service
• Assess the effectiveness of actions and maintain
  the gain
• Communicate results to affected individuals and
  groups

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12 Step QI Process

• List and prioritize problems
• Define project and team or individual
• Analyze symptoms
• Formulate theories of causes
• Test theories
• Identify room cause
• Consider alternative solutions
• Design solutions and controls
• Address resistance to change
• Implement solutions and controls
• Check performance
• Monitor control system

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12 Step Strategy

• Top management commitment
• Internal evaluation
• Determining customer requirements
• Goals and performance measures
• Customer driven management
• Becoming a customer champion
• Employee motivation and self-esteem
• Empowerment and training
• Empowering employees to solve and prevent
  problems
• Communicating feedback
• Recognition, rewards, celebrations
• Rapid continuous improvement

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FOCUS

• F Find an opportunity
• O Organize a team
• C Clarify knowledge of the process
• and measure impact on
• customers
• U Undercover the root cause of
• process variation
• S Select the process improvement

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FORCE

• F Focus on the opportunity
• O Outline the opportunity
• R Research the opportunity
• C Create and implement an action
• plan
• E Execute the plan and evaluate
• the effectiveness of the actions

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FOCUS PDCA / PDSA

• P Plan the project definition and
  organization
• D Do data collection and analysis
• C Check on recommendations
• A Act on recommendations
• P Plan the project definition
• and organization
• D Do data collection and
• analysis
• S Study the data
• A Act on Recommendations

PLAN
DO
ACT
CHECK
22
Quality Indicators

• Items which will automatically trigger review
• A defined measurable dimension of the quality and
  appropriateness of an important aspect of care or
  service that will be monitored for compliance
  with agreed upon standards and criteria.

23
Quality Indicator

• Address the degree of adherence to
• generally recognized
• contemporary standards of good practice and
• achievement of expected outcomes of a particular
• problem,
• procedure and diagnosis
• or service.

24
Appropriateness Indicator

• Addresses the extent to which a particular
• diagnostic or therapeutic procedure or
• service is clearly
• indicated,
• effective,
• not excessive or
• inadequate in quantity and
• is provided in the setting best suited to the
  patients needs.

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Indicators of Performance

• Efficacy the degree to which the
  care/intervention used for the patient has been
  shown to accomplish the desired/projected
  outcomes. (If something does what it is intended
  to do)
• Appropriateness the degree to which the
  care/intervention provided is relevant to the
  patients clinical needs, given the current
  technological state of the art.
• Availability the degree to which appropriate
  care/interventions are available to meet the
  needs of the patients served.

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Indicators of performance

• Timeliness the degree to which the
  care/interventions is provided to the patient at
  the time it is most beneficial or necessary.
• Effectiveness the degree to which the
  care/intervention is provided in the correct
  manner, given by the correct state of the art
  methodology, in order to achieve the
  desired/projected outcome for the patient. (How
  successful the end results are)
• Continuity the degree to which the risk of an
  intervention risk in the care environment are
  reduced for the patient and the healthcare
  provided.

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Indicators of Performance

• Safety the degree to which the risk of an
  intervention risk in the care environment are
  reduced for the patient the healthcare
  provider.
• Efficiency of services the ratio of the
  outcomes or results of care for a patient to the
  resources used to deliver the care. (How well
  something is done)
• Respect caring the degree to which a patient,
  or designee, is involved in his/her own care
  decisions, that those providing services do so
  with sensitivity respect for his/her needs
  expectations individual performance.

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Criterion

• A yardstick or gauge of what is acceptable
  quality and appropriateness of an aspect of care
  defined by the indicator.
• Criteria may be related to
• structure (physical facilities/resources)
• process, (procedures)
• or outcome of care or service

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Hospital Wide

• Death
• Unexpected transfer to ICU
• Acute MI during hospital stay
• Pneumonia developed post-admission
• Readmission within 30 days
• Development of decubitus ulcer

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Examples of Indicators

• SURGERY
• Elective Aneurysmectomy
• discharged with persistent 100 or more increase
  in BUN/Creatinine or need for dialysis
• with cross clamp time gt 1 hour or complications
  such as amputation
• Craniotomy patient
• discharged by death
• with prolonged coma gt2 hours post craniotomy when
  patient was not comatose prior to surgery
• discharged with hemiplegia

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Surgical Case Review

• Preop and postop diagnosis disagree with
  pathology
• Indications for procedure not met
• Trauma to organs during surgery
• Unplanned removal of body part during surgery
• Admission after OP procedure (post-anesthesia)
• Surgical wound infection
• Postop pulmonary embolus

32
OB

• Excessive maternal blood loss
• Infant weighing lt2500 grams after induction of
  C-section
• Significant birth trauma
• Term infant with hypoxic encephalopathy or
  seizure
• Infant death

33
Anesthesia

• CNS complication within 2 post procedure days
• Peripheral neurologic deficit within 2 post
  procedure days
• Acute MI within 2 post procedure days
• Cardiac arrest within one post procedure days
• Death within 2 post procedure days
• Unplanned admission within one post procedure day
  following OP procedure
• Admission to ICU within one post procedure day
  with ICU stay gt one day

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Medicine

• Admission DX of diabetes mellitus with acidosis
  discharged by death
• Admission DX of DM with acidosis without fasting
  blood sugar controlled between 250-280 within 72
  hours of admission
• Admission DX of back/neck pain with myelogram
  revealing herniated nucleus pulposus without a
  request for neurosurgical consult
• Admission DX of back/neck pain maintained on
  narcotics gt 24 hours without use of other
  conservative measure or without myelogram

35
Family Practice

• Death related to ketoacidosis of DM
• New discharge DX of DM without documentation of
  diabetic education
• DX of pyelonephritis without antibiotic coverage
  consistent with urine culture and sensitivity
• Discharge DX of pyelonephritis with positive
  urine screen/culture and without documentation of
  scheduled follow-up

36
Core MeasuresJCAHO Mandated Data Sets

• Acute Myocardial Infarction
• Heart Failure
• Pneumonia
• Pregnancy and Related Conditions
• Surgical Infection Preventions
• Effective with October 1, 06 Discharges
• Cardiac Beta Blocker Therapy
• Venous Thromboembolism Prophylaxis

37
Acute Myocardial Infarction

• AMI-1 Aspirin at Arrival Acute myocardial
  infarction (AMI) patients without aspirin
  contraindications who received aspirin within 24
  hours before or after hospital arrival.
• AMI-2  Aspirin Prescribed at Discharge - Acute
  myocardial infarction (AMI) patients without
  aspirin contraindications who are prescribed
  aspirin at hospital discharge.

38
Acute Myocardial Infarction

• AMI-3 ACEI or ARB for LVSD-Acute myocardial
  infarction (AMI) patients with left ventricular
  systolic dysfunction (LVSD) and without both
  angiotensin converting enzyme inhibitor (ACEI)
  and angiotensin receptor blocker (ARB)
  contraindications who are prescribed an ACEI or
  ARB at hospital discharge. For purposes of this
  measure, LVSD is defined as chart documentation
  of a left ventricular ejection fraction (LVEF)
  less than 40 or a narrative description of left
  ventricular function (LVF) consistent with
  moderate or severe systolic dysfunction.

39
Acute Myocardial Infarction, Continued

• AMI-4 Adult Smoking Cessation Advice/Counseling-
  Acute myocardial infarction (AMI) patients with a
  history of smoking cigarettes who are given
  smoking cessation advice or counseling during
  hospital stay.  For purposes of this measure, a
  smoker is defined as someone who has smoked
  cigarettes anytime during the year prior to
  hospital arrival.
• AMI-5 Beta Blocker Prescribed at Discharge-Acute
  myocardial infarction (AMI) patients without beta
  blocker contraindications who are prescribed a
  beta blocker at hospital discharge.

40
Acute Myocardial Infarction, Continued

• AMI-6 Beta Blocker at Arrival- Acute myocardial
  infarction (AMI) patients without beta blocker
  contraindications who received a beta blocker
  within 24 hours after hospital arrival.

41
Acute Myocardial Infarction, Continued

• AMI-7 Median Time to Thrombolysis- Median time
  from arrival to administration of a thrombolytic
  agent in patients with ST segment elevation or
  left bundle branch block (LBBB) on the
  electrocardiogram (ECG) performed closest to
  hospital arrival time.
• AMI-7a  Thrombolytic Agent Received Within 30
  Minutes of Hospital Arrival - Acute myocardial
  infarction (AMI) patients receiving thrombolytic
  therapy during the hospital stay and having a
  time from hospital arrival to thrombolysis of 30
  minutes or less.

42
Acute Myocardial Infarction, Continued

• AMI-8 Median Time to PTCA- Median time from
  arrival to percutaneous transluminal coronary
  angioplasty (PTCA) in patients with ST segment
  elevation or left bundle branch block (LBBB) on
  the electrocardiogram (ECG) performed closest to
  hospital arrival time.
• AMI-8a PCI received within 90 minutes of hospital
  arrival - Acute myocardial infarction (AMI)
  patients receiving primary percutaneous coronary
  intervention (PCI) during the hospital stay with
  a time from hospital arrival to PCI of 90 minutes
  or less.

43
Acute Myocardial Infarction, Continued

• AMI-9 JCAHO Only Inpatient mortality-AMI patients
  who expire during hospital stay.

44
Heart Failure

• HF-1 Discharge Instructions -Heart failure
  patients discharged home with written discharge
  instructions or educational material given to
  patient or caregiver at discharge or during the
  hospital stay addressing all of the following
• activity level
• diet
• discharge medications
• follow-up appointment
• weight monitoring
• what to do if symptoms worsen.

45
Heart Failure, continued

• HF-2 LVF Assessment-Heart failure patients with
  documentation in the hospital record that left
  ventricular function (LVF) was assessed before
  arrival, during hospitalization, or is planned
  for after discharge.

46
Heart Failure, continued

• HF-3 ACEI or ARB for LVSD -Heart failure patients
  with left ventricular systolic dysfunction (LVSD)
  and without both angiotensin converting enzyme
  inhibitor (ACEI) and angiotensin receptor blocker
  (ARB) contraindications who are prescribed an
  ACEI or ARB at hospital discharge. For purposes
  of this measure, LVSD is defined as chart
  documentation of a left ventricular ejection
  fraction (LVEF) less than 40 or a narrative
  description of left ventricular function (LVF)
  consistent with moderate or severe systolic
  dysfunction.

47
Heart Failure, continued

• HF-4 Adult Smoking Cessation Advice/Counseling-Hea
  rt failure patients with a history of smoking
  cigarettes who are given smoking cessation advice
  or counseling during hospital stay.  For purposes
  of this measure, a smoker is defined as someone
  who has smoked cigarettes anytime during the year
  prior to hospital arrival.

48
Pneumonia

• PN-1 Oxygenation assessment-Pneumonia patients
  who had an assessment of arterial oxygenation by
  arterial blood gas measurement or pulse oximetry
  within 24 hours prior to or after arrival at the
  hospital.
• PN-2 Pneumococcal screening and/or
  vaccination-Pneumonia patients age 65 and older
  who were screened for pneumococcal vaccine status
  and were administered the vaccine prior to
  discharge, if indicated.

49
Pneumonia, continued

• PN-3a Blood Cultures Performed Within 24 Hours
  Prior to or 24 Hours After Hospital Arrival for
  Patients Who Were Transferred or Admitted to the
  ICU Within 24 Hours of Hospital Arrival -
  Pneumonia patients transferred or admitted to the
  ICU within 24 hours of hospital arrival, who had
  blood cultures performed within 24 hours prior to
  or 24 hours after hospital arrival.
• PN-3b Blood Cultures Performed in the Emergency
  Department Prior to Initial Antibiotic Received
  in Hospital - Pneumonia patients whose initial
  emergency room blood culture specimen was
  collected prior to first hospital dose of
  antibiotics

50
Pneumonia, continued

• PN-4 Adult smoking cessation advice/counseling-Pne
  umonia patients with a history of smoking
  cigarettes who are given smoking cessation advice
  or counseling during hospital stay.

51
Pneumonia, continued

• PN-5 Antibiotic timing-The time, in minutes, from
  hospital arrival to administration of first
  antibiotic for inpatients with pneumonia.
• PN-5a Initial antibiotic received within 8 hours
  of hospital arrival and
• PN-5b Initial antibiotic received within 4 hours
  of hospital arrival - PN-5a Pneumonia patients
  who receive their first dose of antibiotics
  within 8 hours after arrival at the hospital PN
  5b Pneumonia patients who receive their first
  dose of antibiotics within 4 hours after arrival
  at the hospital.

52
Pneumonia, continued

• PN-6) Immunocompetent patients with
  Community-Acquired Pneumonia who receive an
  initial antibiotic regimen during the first 24
  hours that is consistent with current guidelines
• (PN-6a) Immunocompetent ICU patients with
  Community-Acquired Pneumonia who receive an
  initial antibiotic regimen during the first 24
  hours that is consistent with current guidelines.
  

53
Pneumonia, continued

• (PN-6b) Immunocompetent non-Intensive Care Unit
  (ICU) patients with Community-Acquired Pneumonia
  who receive an initial antibiotic regimen during
  the first 24 hours that is consistent with
  current guidelines. -Immunocompetent patients for
  both ICU (PN-6a) and non-ICU (PN-6b) with
  pneumonia who receive an initial antibiotic
  regimen during the first 24 hours that is
  consistent with current guidelines.
• PN-7 Influenza vaccination-Pneumonia patients age
  50 years and older, hospitalized during October,
  November, December, January, or February who were
  screened for influenza vaccine status and were
  vaccinated prior to discharge, if indicated.

54
Pregnancy and Related Conditions

• PRC-1 VBAC -- Rate of patients who have had a
  vaginal delivery after a cesarean section."
• PRC-2 Neonatal Mortality -- Live-born neonates
  who expire within 28 days after birth.

55
Pregnancy and Related Conditions

• PRC-3 Third or Fourth Degree Laceration --
  Patients who have vaginal deliveries with third
  or fourth degree laceration (tear).

56
Surgical Infection Prevention

• SCIP- Inf-1 Prophylactic Antibiotic Received
  Within 1 Hour Prior to Surgical Incision-Surgical
  patients who received prophylactic antibiotics
  within one hour prior to surgical incision.
  Patients who received vancomycin or a
  fluoroquinolone for prophylactic antibiotics
  should have the antibiotics administered within
  two hours prior to surgical incision. Due to the
  longer infusion time required for vancomycin or a
  fluoroquinolone, it is acceptable to start these
  antibiotics within two hours prior to incision
  time.

57
Surgical Infection Prevention, continued

• SCIP- Inf-2 Prophylactic Antibiotic Selection for
  Surgical Patients- Surgical patients who received
  prophylactic antibiotics consistent with current
  guidelines (specific to each type of surgical
  procedure).
• SCIP- Inf-3 Prophylactic Antibiotics Discontinued
  Within 24 Hours After Surgery End Time-Surgical
  patients whose prophylactic antibiotics were
  discontinued within 24 hours after surgery end
  time.

58
Surgical Infection Prevention - Each indicator is
stratified in the following manner
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Surgical Infection Prevention, continued

• SCIP- Inf-4 Cardiac Surgery Patients With
  Controlled 6 A.M. Postoperative Serum Glucose -
  Cardiac surgery patients with controlled 6 A.M.
  serum glucose ( 200 mg/dL) on postoperative day
  one (POD 1) and postoperative day two (POD 2)
  with Surgery End Date being postoperative day
  zero (POD 0).

60
Surgical Infection Prevention, continued

• SCIP- Inf-6 Surgery Patients with Appropriate
  Hair Removal- Surgery patients with appropriate
  surgical site hair removal. No hair removal, or
  hair removal with clippers or depilatory is
  considered appropriate. Shaving is considered
  inappropriate.
• SCIP- Inf-7 Colorectal Surgery Patients with
  Immediate Postoperative Normothermia- Colorectal
  surgery patients with immediate normothermia
  (96.8-100.4 F) within the first hour after
  leaving the operating room.

61
Cardiac

• SCIP-Card-2  Surgery Patients on Beta Blocker
  Therapy Prior to Admission Who Received a Beta
  Blocker During the Perioperative Period - Surgery
  patients on beta blocker therapy prior to
  admission who received a beta blocker during the
  perioperative period.  The perioperative period
  for the SCIP Cardiac measures is defined as 24
  hours prior to surgical incision through
  discharge from post-anesthesia care/recovery
  area.

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Venous Thromboembolism Prophylaxis

• SCIP-VTE-1   Surgery Patients with Recommended
  Venous Thromboembolism Prophylaxis Ordered -
  Surgery patients with recommended venous
  thromboembolism (VTE) prophylaxis ordered during
  the admission.

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Venous Thromboembolism Prophylaxis, continued

• SCIP-VTE-2   Surgery Patients Who Received
  Appropriate Venous Thromboembolism Prophylaxis
  Within 24 Hours Prior to Surgery to 24 Hours
  After Surgery - Surgery patients who received
  appropriate venous thromboembolism (VTE)
  prophylaxis within 24 hours prior to Surgical
  Incision Time to 24 hours after Surgery End Time.
  

64
CMS Core Measures

• Acute Myocardial Infarction
• Heart Failure
• Community Acquired Pneumonia
• Pregnancy and Related Conditions

65

• http//www.jointcommission.org/
• Performance Measurement
• Core Measures