module 1 understanding quality applying it to your ... · analyze basic quality theory study the...

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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”

Pennsylvania Medical Society

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

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

A Fundamental Understanding of Quality Management and its Application to Health Care


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Morbidity & Mortality Conference Early Dys-Quality Assessment


Breeds Fear – Has Minimal Impact in Overall Quality Improvement

• 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.

Early Quality Assurance“Dys-quality” Assessment


Eliminate Bad Apples Breeding Fear

DYS-QUALITY ASSESSMENT

Rehabilitate Remove

Morbidity & Mortality Conference Today Moving Beyond “Blame-storming”


Remove Fear – Find System Improvement Opportunities

• 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

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Applying Dys-Quality Assessment Focus on Prevention of Errors


Removes Fear – When Systems are Fool Proof

• 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

ERROR

Continuous Quality ImprovementThe PUSH Approach


Moving all performance toward excellence making everyone better

TOTAL QUALITY MANAGEMENT

POOR FAIR GOODVERYGOOD EXCELLENT


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

DOCHECK &

STUDY

Planning, Measurement, Piloting, Re‐Measurement, Improvement

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Benchmarking – Redefining ExcellenceThe PULL Approach


BENCHMARKING

RESOURCESNEW BENCHMARK

Invest Limited Resources Into The Best Results, Make Them Even Better And Share Their Process With All Others


“Gurus” in Quality ManagementLearning From the Masters

Donabedian Structure, Process, Outcome

Deming Processes Vs. People

Juran Statistical Process Control; VOC

Chassin Usage Errors

Wennberg Unexplained Variations In Care

Berwick Triple Aim

Gowande Checklists

By Understanding These Leaders in Quality You Will Become a Quality Leader Yourself


Donabedian Framework of Quality AssessmentStructure, Process & Outcomes

This Is A Helpful Way To Approach Quality Problems

STRUCTURE / Systems

PROCESS / Operations

OUTCOME / Results

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Donabedian Framework Health System Quality Assessment

Here Are Examples Of Elements Within Structure, Process and Outcome

1. Create constancy of purpose

2. Adopt the new philosophy.

3. Cease dependence on inspection.

4. Use a single supplier based on a long-term 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

Deming's 14 points…Creating a Quality Culture - Purpose


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 Keeper7 Tenets Resonate

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Personal Physician

Physician-Directed Medical Practice

Whole Person

Orientation

CoordinatedIntegrated

Care

Quality and Safety

Systems

Enhanced Access to

Care

New Modes of Payment

Trusted Relationship

Pride of Workmanship

Team based care

Emphasis is on the system

Constancy of purpose

Income for outcome

Leadership > Management

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Summary of Deming's TeachingsApplication to Your Practice

Standard Approach Deming’s Approach

Quality is expensive Quality leads to lower costs

Inspection is the key to Quality Inspection is too late. If workers can produce defect-free goods, eliminate inspection

Defects are caused by workers Most defects are caused by 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

Profits are made by keeping revenue high and costs down

Profits are generated by loyal customers

Quality is an investment

Prevention medical errorsDon’t just study them

Focus on the system

Reward everyone for improvements in the system

Success is based on satisfied patients


"Fitness for Use"– Juran's BeliefsMeets Needs & Error Free

Juran’s two definitions of quality

Definition of Quality 1 Definition of Quality 2

Product features that meet customer needsHigher quality enables company to:Increase customer satisfactionMake products salableMeet competitionIncrease market shareProvide sales incomeSecure premium pricesThe major effect is on sales.Usually, higher quality costs more.

Freedom from deficienciesHigher quality enables companies to:Reduce error ratesReduce rework, wasteReduce field failures, warranty chargesReduce customer dissatisfactionReduce inspection, testShorten time to put new products on the marketIncrease yields, capacityImprove delivery performanceMajor effect is on costs.Usually, higher quality costs less


"Fitness for Use"– Juran's BeliefsApplication 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

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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 communityDetermine the needs of your patient population & the communityDesign your practice and care delivery to meet their needs.Develop processes to deliver the needed care and services

Quality Control:Evaluate your practice’s performanceCompare actual performance to quality goalsAct on differences

Quality Improvement:Build quality into your practice to secure annual quality improvementOptimize the process in all possible ways – care & service Identify specific needs for improvement –assign improvement projectsProvide 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

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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 CareApplied to Your Practice

Overuse – wide variations in access and utilizationStudy your practice patterns against norms Eliminate unnecessary care Under use – evidence based medicine, preventive servicesSeek to deliver evidence based care without gaps Approach 100% application of preventive services Misuse – preventable errors in diagnosis and treatmentEliminate preventable medical errors Guard patients from fraudulent, wasteful and abusive care


Jack Wennberg, MDUnexplained 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.

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Jack Wennberg, MDUnexplained Variation of Use“The Dartmouth Atlas”

Cancer & Hospice Care Hospital Readmission


Jack Wennberg, MDUnexplained Variation of Cost“The Dartmouth Atlas”


Resolve Unexplained VariationApplied 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

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Resolve Unexplained VariationShared 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

DecideImplementation


Resolve Unexplained VariationShared 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

DecideImplementation


Don Berwick, MD Basic Principals of Medical Quality Management

1. Productive Work Is Accomplished Through Processes2. Sound Customer‐Supplier Relationships Are Absolutely Necessary for Sound Quality Management3. The Main Source of Quality Defects Is Problems in the Process4. Poor Quality Is Costly5. Understanding The Variability of Processes Is Key to Improving Quality6. Quality Control Should Focus on the Most Vital Processes7. The Modern Approach to Quality Is Thoroughly Grounded in Scientific and Statistical Thinking8. Total Employee Involvement Is Critical9. New Organizational Structures Can Help Achieve Quality Improvement10. Quality Management Employs Three Basic, Closely Interrelated Activities:

Quality Planning, Quality Control, and Quality Improvement.

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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

• Effectiveness • Experience E3E3


Atul Gawande, MD Improve Surgical Outcomes - Checklists

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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

Identify Opportunities

UtilizationTrends

Certification Process Provider Input

Patient InputStaff Input

Demographics

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Follow the Effectiveness Pathway


Your Great Journey Going Forward Converting Concern to Demonstration

Concernfor

Quality

Demonstrationof

Quality?????

module 1 understanding quality applying it to your ... · analyze basic quality theory study the...

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