quality improvement in the hospital - ucsf medical · pdf filevalue=a x quality / cost...
TRANSCRIPT
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Quality Improvement in the Hospital
Scott A. Flanders, M.D.
Professor of Medicine
Associate Chair, Quality and Innovation
Director, Hospital Medicine Program
Director, Hospital Medicine Safety Consortium
University of Michigan
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The Focus on Value
Value=A x Quality / Cost
Multiplier
A=APPROPRIATENESS
Overview
• Need to Improve-External Forces
• Common Pitfalls in hospital QI / Case studies– Leaders and champions
– Data
– Infrastructure
– Culture / Socioadaptive elements
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CMS Framework 2016 2018
1. FFS w/no link to quality
2. FFS w/link to quality
3. Alternative payment built on FFS
4. Population based payment
Goal 1: 30% of Medicare FFS payments are tied to value through alternative payment models by the end of 2016, and 50% by the end of 2018
Goal 2: 85% of all Medicare FFS payments are tied to quality metrics by the end of 2016, and 90% by the end of 2018
90%
50%
85%
30%
FFS linked to qualityAll Medicare FFS Alternative payment models
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Proportion of Value‐Based Payments is Increasing Rapidly
Confidential: not for distribution
Physician Payment
• Move away from all fee-for-service
• Strong focus on measuring and improving quality
• Cost control– More risk placed on physicians
– But also potential for reward
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Hospital Payment
• Value Based Purchasing Program– Carrot and Stick; 2% of DRG payments
• Readmissions Reduction Program– Stick only; 3% of DRG payments for excess readmits
• Hospital-Acquired Conditions Reduction Program– Stick only; 1% of all Medicare payments (not just DRG)
Value Based Purchasing
$ Millions of Dollars at Stake for Hospitals $
Clinical process (AMI, CHF, Pneumonia, SCIP, healthcare associated infections)
Patient experience (HCAHPS)
Clinical outcomes (Mortality rates for AMI, CHF, Pneumonia; CLABSI; Patient Safety Indicator 90)
Efficiency (Risk-Adjusted spending from 3 days PTA to 30 days post-discharge)
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Hospital Payment
• Value Based Purchasing Program– $3 million
• Readmissions Reduction Program– <$1 million
• Hospital-Acquired Conditions Reduction Program– $2 million
• Bundled payments / population based payments
• Narrow networks
– Low premiums are most important to consumers
• Increased transparency
– Consumer Reports
• Delivering high value (appropriate) care: necessary
QI V3.0: Sink or Swim (the burning platform)
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• Target high volume / high cost / high variability
– COPD, CHF, afib, CAP, Biliary dz, VTE, Sepsis, THR
• Measure your outcomes (cost and quality)
• Create guidelines and pathways (key processes)
• Integrate into IT systems / identify gaps
• Data feedback to providers
• Same process for complex / tertiary care
– Melanoma, bladder CA / cystectomy, colectomy (IBD)
Optimizing Performance
• Hand-offs
• Discharges
– Home
– Skilled nursing facilities
• Bedside rounds
• Patient communication
Standardizing Common Processes
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• Over-testing
– Troponin, iCa, viral panels
– PE CT for low pre-test probability / neg d-dimer
– “Repeat ECHO”
– MRI use
• Over-treatment
– UTI, CAP, HCAP, Cellulitis
• Under-treatment
– EP for afib, PCT
Target Cost and Appropriateness
“The hospital is the most complex human
organization ever devised…”
-Peter Drucker
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Overview
• Need to Improve-External Forces
• Common Pitfalls in hospital QI / Case studies– Leaders and champions
– Data
– Infrastructure
– Culture / Socioadaptive elements
A National Priority• First attempt to
characterize the annual human toll of antibiotic resistance.
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Local InterventionsThe Big 3 Infectious Diagnoses in U.S. Hospitals
Ranking at UMHS
Urinary Tract Infections #1
Pneumonia #2
Skin and Soft Tissue Infections #3
Gandhi T, et al. ICHE 2009
Improving Antibiotics for UTI
• Large AMC, community teaching hospital
• Goals:
– Evaluate antibiotic use for UTI
– Identify inappropriate treatment
– Design strategies to improve antibiotic use
– Target hospitalists
Hartley S, et al. ICHE, 2013
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Testing and Treatment for UTI
• 60% of patients lack guideline indications for urine culture
• Positive urine culture
– 40% have UTIs by adjudicated review
– 25% of UTIs had inappropriate treatment duration
– 65% of asymptomatic bacteriuria was treated
– 385 excess antibiotic days at UMHS alone
Hartley S, et al. ICHE, 2013
Improving Antibiotic Use
• Standardize recommendations for testing
• Standardize treatment algorithms
• Educate hospitalists
• Pharmacist-hospitalist review of urine cultures
• Measure the impact
IHI Forum, 2013
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The UMHS Approach
• Multidisciplinary team led by Sarah
• Asked hospitalists what might work
• Developed tools based on their input– Pocket Cards
– Posters in conference room
– Abx app
– Pharmacist timeout
• Education sessions– Dinner for night docs
• Shared data, identified and resolved barriers
Sarah Hartley, M.D.
Does the patient have any of the following without alternate explanation?
1. Urgency, frequency, dysuria2. Suprapubic pain/tenderness3. Flank pain or tenderness4. New onset delirium 5. Fever >100.4 F/Rigors6. Acute hematuria7. Increased spasticity or dysreflexia in a spinal cord injury patient8. > 2 SIRS criteria (T > 38.5 C or < 35 C, HR > 90, RR >20 or PaCO2< 32
mmHg, WBC >12 K/mm3 or <4 K/mm3 or > 10% bands)
Do NOT send urine culture
Send U/A & urine culture
Document indication for sending urine culture
Start empiric therapy (see reverse side)
YES NO
*Symptom based screening is not reliable in the following cases: pregnancy, prior to urologic procedures, patients with complex urinary anatomy (i.e., nephrostomy tubes, urinary tract stents, h/o urinary diversion surgery in the past, or renal transplant), patients admitted to the ICU, or neutropenia. Use your clinical judgment for this population.
SHOULD THIS PATIENT BE EVALUATED FOR A URINARY TRACT INFECTION*?
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The Community Teaching Hospital
• ID doc who had done research previously led work
• Asked hospitalists to watch video of Dr Hartley’s talks
• Gave them UMHS pocket cards
• Offered “authorship on a paper” for the hospitalist lead who would help make sure everyone watched the video
Treatment of Asymptomatic Bacteriuria
73.8 79
6557
5362
0102030405060708090
100
Overall Hospital #1 Hospital #2% A
SB
Rec
eivi
ng
An
tib
ioti
cs
Pre
Post
**
* p<0.05
Data modified from original: to make a point!
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Key Characteristics of the Champion
• Role model for the change– Respected / passionate
• Collaborating, commit resources and attention
• Communicate throughout work
• Have a clear process
• Be consistent in behaviors
Identifying the Champion / Leader
• Passion: ideally they bring the project forward
• Subject matter expert
• Outstanding clinician / teacher / role model
• Effective communicator
• Prior improvement experience a plus, but not required
• Time for the work
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Overview
• Need to Improve-External Forces
• Common Pitfalls in hospital QI / Case studies– Leaders and champions
– Data
– Infrastructure
– Culture / Socioadaptive elements
Total Inpatient HH compliance
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MFH Specific Data
Barriers and solutions
• Closely partnered with IPE personnel to enhance monitoring of HHH
Barrier Solution
Paucity of Data 2 observers dedicated to hospitalist service
Non-specific Data
• Unable to ID Hospitalist Shared schedule and pictures of hospitalists
• Unit Based observers Covert observers shadowed hospitalists
Lack of Awareness Educational sessions, Audit/Feedback, Physician champions
Unknown Modes of failure Identified clinical situations with higher failure rates
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Hospital Medicine Focused HH Interventions
• Educational sessions:– Importance of HH in preventing infections
– Review of incidence of MRSA, VRE, CDI rates
• Audit/Feedback– Service level-target problem areas
– Physician level-target problem areas
• Physician Champions
• $$$$ (QI Incentive)
Overall Hospitalist Hand Hygiene Compliance
51 45
90
0
10
20
30
40
50
60
70
80
90
100
Jan - March 2015 Apr-15 Feb- May 2016
Overall HHH Compliance
% (190/211)
% (14/27) % (28/62)
Increased HMData collection
HM focused Intervention
System Wide HH Intervention (Clean/Remind/Thank, etc.)
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Facilitating Data Collection • Use Data Already Being Collected
– Hand hygiene
– HCAPS
– CAUTI / CLABSI / C.Diff
– ED wait times
– Readmission rates
– Any existing EMR data field
• Capture during the new process– 72 hour antibiotic timeout
– (challenge is “pre-” data)
Facilitating Data Collection • Manual medical record review (if all else fails)
– Use standard data audit forms
– Make it easy , no judgment; ideally non-healthcare providers can collect data
– Samples vs. Consecutive pts
• Useful for change over time
• High volume conditions / data elements
• Group level metrics rather than MD-specific
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Overview
• Need to Improve-External Forces
• Common Pitfalls in hospital QI / Case studies– Leaders and champions
– Data
– Infrastructure
– Culture / Socioadaptive elements
UMHS Large Scale QI: Problems• Are we providing high value care?
– Outcomes, cost, appropriateness
– Often not measured or reported
• Responsibility for work– More than one group “owns” the condition
– Multiple care pathways exist
– Everyone is busy, competing priorities
– Projects fail without frontline provider engagement
• Resources / Infrastructure– Data, improvement experts
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• Develop capacity to improve Value for all Programs
– Implement a program/process w/resource support
– Engage physicians /care team to own program PDCA
• Manage clinical variation through care pathway development and analytics for each program
• Create and improve value for our patients while balancing cost and quality
*Adapted from Advisory Board37
UMMG Goal: Demonstrate and Improve Value of Clinical Services – Clinical Design Program
Clinical Design Resource Framework
Clinical Design Central Support
1.0 FTE Admin Mgr
2.0 FTE Proj. Mgr
Program and Operations Analysis
1.0 FTE
Finance1.0 FTE
Analytics
PACE, Pop. Health Analytics
Others
• ClinicalDesignwillhavecentraladministrativeandprojectmanagersupportandacontractedmodelwithSMEareas,e.g.,Finance,Program&OperationsAnalysis,others 38
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Program Selection Criteria1. Clinical Program has variation in value
‒ Cost ‒ Process
‒ Clinical Outcomes
2. Program is high volume/impact:‒ Provided to a large number of patients
‒ Tertiary/quaternary service within ACO
‒ Bundled payments
3. Clinical Program Readiness‒ Engaged Physician Lead
‒ Integrated Process owner
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Orthopaedics Joint ReplacementValue Streams
Clinical Design + Orthopaedics
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Scoping / Pre‐work– Define problem– SIPOC– Customer requirements– Gemba Waste Walk
Current State map – Review/refine map– Review baseline data, gemba
Analysis of Current State
Future State map
Implementation Planning
Project Implementation
Prior to W
orkshop
Workshop 1(Review/ Update)
Workshop 2
Workshop 4
Workshop 3
Post‐Workshop
Structure of a Lean Project
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High Level VSM & Opportunities
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Colectomy
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Orthopaedics Opportunities
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What isn’t working well Impact
OR efficiency Fewer cases done
OR scheduling Uneven scheduling, resource utilization
IP bed availability PACU delays
Outpatient Pharmacy delay Discharge delay
Clinic scheduling/yield See more patients to fill OR schedule
Clinic delays Patient and staff dissatisfaction
IP coordination Delays in patient progression to d/c ready
Discharge delays Bed utilization
Discharge destination High SNF utilization and cost
Pre‐op screening Cancellations
Referrer satisfaction Fewer referrals
Led to ~ 8 to 10 Projects/Teams
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Orthopaedics Countermeasures
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• MARCQI data shared w/ dept (Jul, 2014)• Pre‐op class:
– “Your surgeon wants you to go home” @ pre‐op classes (Aug 2014)
– Collect prescription insurance information (July 2015)
• New Pain protocol (Nov 2014)• Surgeons sharing expectations w/ patients (Nov 2014) • ePrescribe pain meds @ d/c (Sep 2015)• More cases getting PT/OT on day 0 (Aug 2015)• Post discharge pathway (Sep 2015)• Call Center improvements (scheduling algorithm/triage tool)• Updated MiChart referral
Inpatient Pathway
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Post Discharge Pathway
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Orthopaedics ‐ Results
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Orthopaedics ‐ Results
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Afib – ED Program
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• Partnership with Internal Medicine Quality and Innovation Program
• Completed scoping and current state analysis– Focus on patients in the ED
– Understand variation to existing guideline
• Implemented ED Pathway
• Developed MiChart “disposition” report– Completed “vapor test” and “fake back end” to build and test Rapid Follow up Electrophysiology Clinic
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Afib Project – Stole Good Ideas
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Afib – ED Pathway and Rapid Follow up EP Clinic Pilot
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• Appointment slots available on select Mondays and Thursdays (Feb – Aug)
• ED doctors have sent 16 patients to clinic with positive feedback from patients, EP attending and ED physicians
• Anecdotal feedback from ED, more DC Cardioversions
• Developing referral process using EMCRS (Emergency Medicine Consult Referral Process)
• EP Clinic launch 9/1/16
EP Rapid Follow Up Clinic
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Afib – ED “Fake Back End”
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Afib – ED MiChart Dashboard
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• Physician/nurse leadership
– Engagement and alignment around care variation management
– Use of evidence‐based medicine (EBM)
• Clinical Performance Improvement Infrastructure
– Performance improvement support to engage clinicians
– High functioning quality governance and management
• Clinical Informatics and Analysis
– Robust clinical informatics and analytic capabilities that allow “drill‐down” into actionable improvement areas
– Provide quality outcome, cost, process data that is quantifiable, reliable evidence of opportunities.
* Karpook, J. Smalto, G, van Pelt R, Bailey C. Transforming care delivery: The power of clinical variation management, Chartis Whitepaper, April 2015
Keys to Success
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Overview
• Need to Improve-External Forces
• Common Pitfalls in hospital QI / Case studies– Leaders and champions
– Data
– Infrastructure
– Culture / Socioadaptive elements
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It’s Culture Stupid….
• 100% of changes evaluated as successful had a good technical solution
• 98% of changes evaluated as unsuccessful had a good technical solution
GE Healthcare Consulting
Michigan’s CAUTI Journey• CAUTI SIR >>> national / UHC / state rates
• Payment / public reporting
• Leadership desire to change
• Multidisciplinary team convened– Hospitalists
– CAUTI researchers
– Nurse leader-head of QI
– Hospital quality leader
– Data Support
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Disrupting the Lifecycle of the Urinary Catheter
1
4
3
2
1. Preventing Unnecessary and Improper Placement
2. Maintaining Awareness & Proper Care of Catheters
3. Prompting Catheter Removal
4. Preventing Catheter Replacement
(Meddings & Saint. Clin Infect Dis 2011)
The Technical: Timely Removal of Indwelling Catheters
• 30 studies have evaluated urinary catheter reminders and stop-orders
– Significant reduction in catheter-associated urinary tract infection (53%)
– No evidence of harm (ie, re-insertion)
– Will also address the non-infectious harms of the Foley
Meddings J et al. BMJ Qual Saf 2013
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The key intervention is having the bedside nurse assess daily whether the
catheter is necessary.
Michigan’s CAUTI Journey• Nurse-driven discontinuation of urinary catheters
– New CPOE order requires indication for catheter
– Nurses assess daily for indication
– Nurse can d/c catheter when no indication
• Roll-out– Solution presented at several hospital committees
– 4 units targeted initially
– Unit nurse managers educated
– Launched
– Track catheter use, indications selected, CAUTI
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Project Start
Michigan’s CAUTI Journey• Lots of little “technical” issues
– No definition of “critically ill”
– “Other” box included (and often used)
– Patient request not considered
– Alternatives to indwelling catheter not always clear
• The big “socioadaptive” issues– Physicians did not buy in
– Nurses “uncomfortable and unwilling” to d/c catheter
– Physicians critical of nurse discontinuation
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Preventing CAUTI: 50 State (+) Project
• AHRQ-funded collaborative that aims to reduce CAUTI rates
• 4-year project (Sept 2011 – Aug 2015); ~$20 million
• Project Leadership Team:
– University of Michigan (SS, SK, MTG, KF)
– St. John Hospital
– Johns Hopkins University
– MHA Keystone Center for Patient Safety & Quality
Extended Faculty
• Use the Expertise of Key Professional Societies:
– Association for Professionals in Infection Control and Epidemiology
– Society for Healthcare Epidemiology of America
– Society of Hospital Medicine
– Emergency Nurses Association
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SHM Extended Faculty
Scott A. Flanders, MDUniversity of Michigan
Sarah Hartley, MD University of Michigan
Eugene Chu, MD, FHMUniversity of Colorado
Christin Ko, MD, MBA, SFHM, FACPEmory University
Ian Jenkins, MD University of California, San Diego
Disrupting the Lifecycle of the Urinary Catheter
1
4
3
2
1. Preventing Unnecessary and Improper Placement
2. Maintaining Awareness & Proper Care of Catheters
3. Prompting Catheter Removal
4. Preventing Catheter Replacement
(Meddings & Saint. Clin Infect Dis 2011)
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Implementation
Technical Socioadaptive
Emphasizing the Socioadaptive:I-ACT
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• Federally-funded national program
• Total of 603 hospitals (926 units) in 32 states
• ~60% non-ICU; ~40% ICU
• Non-ICUs: CAUTI reduced by 32% (& decrease in catheter use)
• ICUs: no change in CAUTI or catheter use
Preventing CAUTI in Acute Care(Saint et al. N Engl J Med 2016)
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Getting Results
Results = Effective Solution X Change Management
Six Sigma
Lean
PDSA Cycles
Socioadaptive elements
Champions
Engagement
Change Acceleration Recipe• Leader
• Clear reason for change
• Shared vision for improvement
• Commitment from key constituents
• Make change last
• Monitor progress
• Systems / structure support change
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Quality Improvement in the Hospital• Improved value of care desperately needed
• Everyone is doing QI in the hospital
• Few are doing it well
• Avoid common pitfalls– Leaders / champions
– Data
– Infrastructure
– Culture / socioadaptive
Thank You!