Quality

Health care seen as a Rubic cube

Quality

The Russian Doll of Health Care

Quality

Just something for health care in developed economies???

“Concern about the quality of care is as old as medicine. But honest concern about quality, however genuine, is not the same as methodical assessment based on reliable evidence”.

(Robert Maxwell BMJ 1984)

All health systems have problems

• 12% patients suffer from errors caused by health system

• International comparisons show deficits in all health systems

• Variations within systems• Attention grabbed by head line catastrophic

failures of care• Institute of Medicine “Crossing the Chasm”

Challenge …….should you decide to accept it…...

• Is to reverse “Institutional Blindness” to problems of quality and safety.

Five themes from 30 enquiries into care disasters in the UK.

• Poor communication

• Disempowerment of staff and patients

• Ineffective systems and processes

• Isolation

• Inadequate leadership/management

Terminology

Quality:

• Agenda

• Management

• Benchmarking

• Total Quality Management

• Industry

• Audit

Quality:

• Assessment• Assurance• Control

• Improvement

• Quality vs. Safety • Clinical governance

What else is “quality”

• Performance indicators (54)

• Standards

• Report cards

• Public access to performance data

• League tables

• Comparative health status data

Quality improvement in UK

• Confidential enquiry into maternal deaths

• Laboratory quality assurance

• External inspection residential care homes

• CEPOD

• Pre 1989 “Doctor knows best”

• 1989 Medical audit

• 1991 Clinical audit

• 1999 Clinical governance

Quality improvement in UK

Quality improvement in the UK

• 1996 Calman Hine Cancer report

• 1997 Clinical Governance

• 1998 NICE and CHI

• 1998 National Service Frameworks

• 1999 Cancer Care Collaboratives

• 2000 An Organisation with a Memory

• 2000 NHS 10 year plan much CQI

The Rubric Cube – dimensions of quality : (Maxwell BMJ 1984)

• Effectiveness

• Efficiency

• Equity

• Appropriateness

• Acceptability

• Access

More dimensions - for 2006

• Choice

• Respect

• Provision of “real information”

• Safety

Frameworks for assessing quality of care-(Donabedian)

• Structure

• Process

• Outcome

• Medical technical

• Interpersonal

Everyone talks about it: but no one does anything about it

Mark Twain on English weather

Who cares about “quality”?

•Politicians

•Purchasers of health care

•Provider institutions

•Professionals

•Public - media

•Patients

Checking where we are?

• Health care system

• Interface between organisations

• Provider organisation

• Interface between clinical services

• Clinical teams

• Patient - practitioner interface

• Or…responding to headlines???

Quality in terms of the system or service:

• National/regional waiting lists

• Health outcomes

• Or …?health outcomes of health care

• Provision of specialist services

In terms of hospital or practice:

• Access/equity

• Process of care for groups of patients

• % appropriate use of effective treatments

• Efficiency - or costs- or value for money?

In terms of Patient - practitioner interface:

• Choice

• Access: no waits

• Effective treatment/relief

• Involvement in decision making

• Medico-technical skills of clinicians

• Communication skills of clinicians

Quality:

• Link between organisational behaviour and clinical practice and health care outcomes

• Any improvement in clinical care requires an organisational change.

Quality

• Improving the quality of care within current resources.• Making changes that can be shown to improve care

for patients• Practical approach to closing gaps between the ideal,

what is wanted, what is expected and what is actually happening

• Making sure more winners than losers and more winning than losing

• Being smart, thinking out of the box and taking others with you

Quality: Balancing needs of populations and individuals

• Giving patients a better deal

• Always giving THE patient very good care

• Some professionals sometimes find this tough

Quality: is about change management

• Defining the gaps in care

• Understanding the causal problems

• Working out a solution

• Managing the change

• Reassessing the affects of that change

Health leader and quality of care. • Needs to be able to describe the quality of care• Needs mechanisms for further improvement• Needs early warning response mechanisms.• Articulates expectations to employees • Exerts proper role as “employer” • Carries a sense of “ Chronic Anxiety” about the

quality and safety of care that is being delivered

Health leader’s role in quality?

• Philosopher: having the ideas

• Politician: getting the ideas across

• Plumber: putting the ideas into action

Philosopher

• Set out values

• Understand the complexities of the issues

• Works out priorities

• Relate concerns to practice

• Connect between worlds

• Reflective part of role

Six worlds: (after Dawson 1997)

• Pure science

• Clinical trials

• Meta analysis

• Guidelines and protocols

• Organisation

• Clinical practitioner

Politician

• Translating the philosophy into strategy • Linking external drivers to internal mechanisms • Picking up and responding to concerns• Communicating to many groups • Ensure relevance to everyone involved in change• Understanding the impact on different groups • Ensure local ownership of problem and solutions

• Working under constant pressure

Plumber

• Managing change

• Working through ambiguities

• Understanding incentives

• Measure results

• Working under constant pressure

Plumber’s role: unblocking the system

• If you go on doing what you are doing – you go on getting what you’ve got.

• Everyone wants to improve – but there are many blocks

• Someone is going to have to change how they work

Block 1- demonstrating problem

• Evidence of problem or need for change

• Acceptance of problem

• Ownership of problem

• Availability of data

• Timeliness of change

Nature of evidence

• Often contended/challenged

• Plural of anecdotes = data

• Has not been reliable or complete or relevant

• Need to understand clinical data in the context of organisational practice

Nature of “evidence” of problem

• Beyond reasonable doubt:clinical trials

• On the balance of probabilities: quality improvement

Block 2 - understanding systems

• Complexity of care

• Improving the quality of care always involves changing the system of care

• Clinical education focussed almost solely on the care of individuals

• Little emphasis in education on care of systems

Three central laws of improvement

• Results are the properties of systems

• Every system is perfectly designed to get exactly the results that it gets.

• For every complex problem there is a simple solution: and it is wrong

“Swiss cheese model”

Three bucket model of error likelihood

Blocks 3 - global

• Time

• Territory

• Tradition

• Trust

• Training

“New clinical skills” - ability to:

• Perceive and work in interdependencies

• Work in teams

• Understand work as a process

• Collect and analyse outcome data

• Collaborative exchange with patients

• Collaborative exchange with lay managers

Quality

• Puts values into practice?

• Describes clinical practice in organisational terms?

• Balances best deals for populations with excellence for individuals?

Quality

Workforce + education+ training

=

Improved quality of clinical care

Assumptions are things that you don’t know you are making.

Douglas Adams

History of Quality Improvement in the UK

Quality improvement in UK

• Confidential enquiry into maternal deaths

• Laboratory quality assurance

• External inspection residential care homes

• CEPOD

• Pre 1989 “Doctor knows best”

• 1989 Medical audit

• 1991 Clinical audit

• 1999 Clinical governance

Quality improvement in UK

Moving on from audit

• Evidence for intervention• Evidence for deficiency in care - audit• Link problem to organisational context • Define the processes of care • Define the organisational problem • Make organisational change

Quality improvement in the UK

• 1996 Calman Hine Cancer report

• 1997 Clinical Governance

• 1998 NICE and CHI

• 1998 National Service Frameworks

• 1999 Cancer Care Collaboratives

• 2000 An Organisation with a Memory

• 2000 NHS 10 year plan much CQI

• Quality in terms of customers needs

• Customers needs priority for everyone

• Existence of internal and external customers

• Measurement as basis for change

• Remove barriers between staff

• Promote effective team working

• Training for everyone

Improving Care:

• Change

• Change is difficult - uncertainty

• Continuous process

• Involves every one

• Based on continuing training/development for all staff

Example of complexity

Quality: the whole picture6 months in the life of an engineer

• 3 months cough

• Chest x ray shadow

• Investigations lung cancer

• Further tests operable tumour

• Pneumonectomy“complete” excision

• Steady recovery back to work

Quality: the whole picturewho is involved?• Receptionist • Radiographer -3• Nurse practitioner-3• Physician - 2• Radiologist- 3• Pathologist - 1• Pathology technician

• ECG technician• Lung function tech• Phlebotomist• Day care receptionist• Day care nurse -2 • Secretary• Contracts manager

Which population?

• All people in clinic waiting room?

• All people with lung cancer?

• All people with cough?

• All people who smoke?

• All people who live in hospital catchment?

• All people in UK?

At what level improvement?

• Patient

• Practitioner

• Clinical teams

• Service

• Service interface

• Organisation

• Organisational interface

Levels of concern about the Quality of health care• Patient

• Institution (s)

• System

Some definitions

Effectiveness:

Is the extent to which a health care intervention, when used in routine practice, achieves the desired outcome.

Appropriate Health Care (1)

“... the selection, from the body of interventions that have been shown to be efficacious for a disorder, of the intervention that is most likely to produce the outcomes desired by the individual patient”

Appropriate Health Care (2)

• Availability of competent technical skills• Intervention to be performed in an acceptable way• Patient to have information about a range of

interventions• Discussion of possible adverse outcomes with

patient• Patient preferences to guide choice

   

STRUCTURE

 

PROCESS

 

OUTCOME

Effectiveness      

Efficiency      

Equity      

Appropriateness      

Acceptability      

Access