Clinical Quality
-
Upload
madeson-taylor -
Category
Documents
-
view
59 -
download
1
description
Transcript of Clinical Quality
Clinical QualityClinical Quality
פרופ' מאיר ברזיספרופ' מאיר ברזיסהמרכז לאיכות ובטיחות קליניתהמרכז לאיכות ובטיחות קליניתהדסה והאוניברסיטה העבריתהדסה והאוניברסיטה העברית
ירושליםירושליםwww.hadassah.org.il/departments/quality
איכות קליניתאיכות קליניתבעולם ובהדסהבעולם ובהדסה
Definitions of Quality (Institute of Definitions of Quality (Institute of Medicine)Medicine)
Degree to which care increases likelihood of desired Degree to which care increases likelihood of desired health outcomes & consistent with current professional health outcomes & consistent with current professional
knowledgeknowledgeSafeSafeTimelyTimelyEffective Effective Patient centeredPatient centeredEquitableEquitableEfficientEfficient
Overuse Overuse (antibiotics, imaging)(antibiotics, imaging)
Underuse Underuse (prevention)(prevention)
MisuseMisuse (errors & complications) (errors & complications)
Evidence-based Patient-centered System-minded
Performance Performance Evaluation Evaluation • Voluntary Quality IndicatorsVoluntary Quality Indicators• Mandatory Performance EvaluationMandatory Performance Evaluation• Public Data Including Individual SurgeonPublic Data Including Individual Surgeon• Pay for PerformancePay for Performance• Non-payment for Preventable Non-payment for Preventable Complications Complications Challenges: measurement error, Challenges: measurement error, socioeconomic confounders, manipulation, socioeconomic confounders, manipulation,
denial, gamingdenial, gaming
* Harvard Professor Don Berwick, Institute for Health Improvement
Stages of Facing Reality*
Ego bias: “I’m above the average”(Kahneman & Tversky. Heuristics and Biases. The Psychology of Intuitive Judgment)
Stage 1. “The data are wrong”
Stage 2. “The data are right, but it’s not a problem”
Stage 3. “The data are right; it is a problem; but it is not my problem.”
Stage 4. “I accept the burden of improvement”
““In short, academic medical centers should not just have best In short, academic medical centers should not just have best knowledge, they should model the best execution…knowledge, they should model the best execution…They do notThey do not. .
Unreliability, waiting, lack of focus on patient’s needs and Unreliability, waiting, lack of focus on patient’s needs and safety are every bit of characteristic of academic medical safety are every bit of characteristic of academic medical centers…and centers…and that needs not be the casethat needs not be the case. .
The same intellectual fervor and talent that allow places like the The same intellectual fervor and talent that allow places like the Brigham to raise the bar in technical clinical care can equally be Brigham to raise the bar in technical clinical care can equally be used to raise the bar in the quality of medical care. used to raise the bar in the quality of medical care.
……it’s going to take much more acute self-awareness among it’s going to take much more acute self-awareness among academicians and academic medical centers….academicians and academic medical centers….
……a duty to encourage healthcare leaders and clinicians a duty to encourage healthcare leaders and clinicians everywhere to become involved in improvement."everywhere to become involved in improvement."
Donald M. Berwick, MD, MPP, FRCPDonald M. Berwick, MD, MPP, FRCPProfessor at Harvard School of Public HealthProfessor at Harvard School of Public HealthPresident, Institute for Health Improvement, President, Institute for Health Improvement, Boston, Massachusetts, USABoston, Massachusetts, USA
Cycles of Improvement (Industry Model)
PDSA
Example: monitoring of surgical infection rate is Example: monitoring of surgical infection rate is now recognized as important tool to preventionnow recognized as important tool to prevention
Statistical Process Control
Quality of General Intensive CareQuality of General Intensive Care
Survival at Hadassah vs. Israel AverageSurvival at Hadassah vs. Israel Average
Prof. Prof. Elisheva Simchen, Ministry of HealthElisheva Simchen, Ministry of Health
p<0.001
Despite higher severity score, Despite higher severity score, patients had better survival at patients had better survival at
HadassahHadassah
Quality of Neonatal Intensive CareQuality of Neonatal Intensive Care Survival at Hadassah vs. Israel Survival at Hadassah vs. Israel
AverageAverage Dr. Zivanit ErgazDr. Zivanit Ergaz, , Prof. Ilan AradProf. Ilan Arad & Gertner Institute & Gertner Institute
11.5%
19.6%
2.1%2.9%2.6% 2.7%3.2%
6.7%5.8%5.5%5.8%5.3%
13.4%
18.4%
14.4%13.6%
20.2% 20.5%20.9%19.7%
0%
10%
20%
30%
1999 2000 2001 2002 2003
Hadassah - Total Mortality NTDB - Total Mortality
Hadassah - ISS 16+ Mortality NTDB - ISS 16+ Mortality
Quality of Treatment in TraumaQuality of Treatment in Trauma Mortality at Hadassah vs. US level I centersMortality at Hadassah vs. US level I centers
Dr. Yoav Mintz, Dr. Yoav Mintz, Ms. Irina GertcenchteinMs. Irina Gertcenchtein & & Prof. Avraham Prof. Avraham RivkindRivkind
Hadassah data Hadassah data Israeli National Israeli National
Trauma Registry Trauma Registry n=7,391n=7,391
US National US National Trauma Data Bank Trauma Data Bank
from 51 level-I from 51 level-I trauma centers, trauma centers,
n= 263,524n= 263,524
Quality indicators for myocardial Quality indicators for myocardial infarction, Hadassah vs. US datainfarction, Hadassah vs. US data
HadassahHadassah ((%%) 89 90 50 83 69 44’ 102’Referral to cardiac rehabilitation only 21% Referral to cardiac rehabilitation only 21%
Percent of patients receiving adequate anticoagulation
%%
Surgery A
Surgery A
Surgery B
Surgery B
Surgery C
Surgery C
Gynecology
Gynecology
AA Gynecology
Gynecology
BB
p<0.00p<0.0011
p<0.00p<0.0011
p<0.00p<0.0011
p<0.02p<0.02
Catheter-related Bloodstream Catheter-related Bloodstream InfectionsInfections
Intervention in 108 ICU’s resulted in 66% reduction Intervention in 108 ICU’s resulted in 66% reduction in rates of catheter-related bloodstream infectionin rates of catheter-related bloodstream infection
Catheter-related Bloodstream Catheter-related Bloodstream InfectionsInfections
At Hadassah, baseline observations over five months revealed a rate of infection of 13.2% (42/318 catheters), on the high side of reported ranges.
Observations in ICU’s and OR: aseptic conditions not always strictly kept during catheter insertion.
Intervention included discussion of results with staff, training for correct aseptic technique, use of a checklist, and authorization to nurses to feedback and stop physicians breaching asepsis.
I. Gross, S. Benenson, M. Cohen, C. BlochI. Gross, S. Benenson, M. Cohen, C. Bloch
Catheter-related Bloodstream Catheter-related Bloodstream InfectionsInfections
Following intervention, improvement in technique was observed; rate of infection declined by 62%, from 13.2% to 5.0% (17/337 catheters, p<0.001).
100.0080.0060.0040.0020.000.00
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
Cu
m S
urv
ival
1.00.00
NewGroup
Survival Function for patterns 1 - 2
100.0080.0060.0040.0020.000.00
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
Cu
m S
urv
iva
l
1.00.00
NewGroup
Days of catheter
Proportion of catheters remaining
without infection
(Cox regression)Before the
intervention
After the intervention
100.0080.0060.0040.0020.000.00
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
1.00.00
NewGroup
100.00
80.00
60.00
40.00
20.00
0.00
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
1.00
.00
NewGroup
100.0080.0060.0040.0020.000.00
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
1.00.00
NewGroup
p<0.001
Catheter-related Bloodstream Catheter-related Bloodstream InfectionsInfections
UnitBefore InterventionAfter InterventionRate
Reduction (%)
Catheter days
N infected
Rate*Catheter
daysN
infectedRate*
ICU-A117665.1129632.355
ICU-B124075.687922.360
ICU Medicine9951616.1171563.578
Neuro-surgery225417.817315.867
Cardiac surgery56258.955147.318
ICCU150426.763115.940
Total4348429.664677173.6362.4**
* Rate of infection per 1000 catheter-days ** p<0.001
Catheter-related Bloodstream Catheter-related Bloodstream InfectionsInfections
Pronovost P. et al. An intervention to decrease Pronovost P. et al. An intervention to decrease catheter-related bloodstream infections in the ICU. catheter-related bloodstream infections in the ICU.
N Engl J MedN Engl J Med 2006;355:2725 2006;355:2725
Physicians’ Hand Physicians’ Hand Hygiene at HadassahHygiene at Hadassah
Ein KeremMt. Scopus
Medicine65%55%
Pediatrics55%62%
Surgery 35%66%
Ob-Gyn25%
Rate of hand-washing out of contacts with patients
Summary of surveys in recent Summary of surveys in recent yearsyears
Use of Hadassol has been widely Use of Hadassol has been widely adopted but rate of hand hygiene adopted but rate of hand hygiene unchanged unchanged
Surgical Infections in General Surgical Infections in General SurgerySurgery
Rate of post-operative wound infection is 8-12%, within the range reported in the literature.
Pre-operative antibiotic administration is documented as given on time in 59% of cases.
A significant proportion of infections are
diagnosed after discharge from the hospital.
Infection monitoring is recognized as an important tool to keep rates low.
N. Minster, M. Zarhia, G. Almogy, A. Rivkind, S. Benenson, M. Cohen N. Minster, M. Zarhia, G. Almogy, A. Rivkind, S. Benenson, M. Cohen
ComplicationsRate of infection (95% CI)
Children 6% (2-13)0.7-14%*
Adults12% (7-20)
Rate of hematoma (95% CI) Children10% (5-18)
11-15%*Adults13% (8-21)
*Range in literature varies by motive (voluntary or mandatory)
Satisfaction high to very high in 94% of adults and children; problems: waiting & relation with staff
Quality of Inguinal Hernia Repair in Quality of Inguinal Hernia Repair in Adults and in Children at HadassahAdults and in Children at Hadassah
T. Yemini, M. Badriah, Y. Mintz, R. Udassin, A. Rivkind
Quality of Special SurgeriesQuality of Special Surgeries
Outcomes of special surgery in the Departments of Ear, Nose & Throat (ENT), Ophthalmology,
Plastic and Neurosurgery
ENTSnoring, tonsillectomies
OphthalmologyCorneal transplant, Lasik
Plastic surgeryBreast reconstruction
NeurosurgeryPrevention of shunt infection
Management of Snoring Disorders with Management of Snoring Disorders with Radiofrequency at Hadassah Optimal Radiofrequency at Hadassah Optimal
%
p<0.01 p≤0.05p<0.005
L. GordonL. Gordon,, S. Catinari, R. EliasharS. Catinari, R. Eliashar
Lasik (Myopic Corneal Refractive Surgery) at Lasik (Myopic Corneal Refractive Surgery) at Hadassah Optimal (N=109) Hadassah Optimal (N=109)
%
N. Orwa, A. Solomon, Y. Frucht-PeriN. Orwa, A. Solomon, Y. Frucht-Peri
Evaluation of Outcomes for Evaluation of Outcomes for Tonsillectomies at Hadassah (2008)Tonsillectomies at Hadassah (2008)
Hadassah(N=106)
Literature UK audit &
others (N>30,000)
% with any bleeding28?
% needed readmission203-10
% needed reoperation4.70.5-2.0
O. Frenkel, R. EliasharO. Frenkel, R. Eliashar
Quality of Reconstruction Surgery Quality of Reconstruction Surgery After MastectomyAfter Mastectomy
R. Yanko-Arzi, M. J. Cohen, R. Braunstein, E. Kaliner, R. Neuman R. Yanko-Arzi, M. J. Cohen, R. Braunstein, E. Kaliner, R. Neuman Dept of Plastic Surgery & Center for Clinical Quality & SafetyDept of Plastic Surgery & Center for Clinical Quality & Safety
A survey of 140 A survey of 140 women after women after reconstructive reconstructive breast surgery breast surgery for cancer for cancer showed showed satisfaction satisfaction related mostly related mostly to expectations to expectations before surgery.before surgery.
%% 0 20 40 60 80
Severe
moderate high
Complications
Success
Satisfaction
WouldRecommendHadassah
10 17 21 24
05
10152025303540
% of shunts infected
2001 2002 2003 2004-5Number of shunts inserted
InterventionIntervention
Neurosurgical shunt infections
Mortality in infected cases dropped from 50% to 0%Mortality in infected cases dropped from 50% to 0%
I. Paldor, Z. Israel, C. Block with the dept of NeurosurgeryI. Paldor, Z. Israel, C. Block with the dept of Neurosurgery
Is the X-ray interpretation by the junior staff on duty correct?
Dr. Y. Mintz, Dr. D. Kisselgoff, Y. Gronowitz, A. Shaham, R. Hefez, Dr. D. Shaham - Departments of Surgery,
Radiology, and Center for Clinical Quality & Safety
Pulmonary Pulmonary EmbolismEmbolismSurgerySurgeryTraumTraum
aa % %
agreementagreement resident vs. resident vs. specialistspecialist
95%95%77%77%94%94%
Effect of Translators on Effect of Translators on Understanding & Satisfaction of Understanding & Satisfaction of
Arab Parents Arab Parents
Department of Pediatrics & ER, Mt Scopus & Center for Clinical Quality & Safety,
Hadassah Hebrew University Medical Center
The Presence of a Translator Significantly Improved Parental Understanding Regarding
Diagnosis, Treatment and Follow-up96
86
72 7478
3438
23
0
20
40
60
80
100
Understanding ofdiagnosis
Necessary follow-up When return visit to ERnecessary
Dosage & duration ofmedication
%
translator no translatorp<0.001, n=194
Will patient’s empowerment improve Will patient’s empowerment improve efficacy & safety of oral efficacy & safety of oral
anticoagulation? anticoagulation? Self-management for CoumadinSelf-management for CoumadinH. Goldberg, Y.Ben David, U. Izhar, L. Gordon, T. Baevsky, M.Burzstyn H. Goldberg, Y.Ben David, U. Izhar, L. Gordon, T. Baevsky, M.Burzstyn
& M.Brezis with the Departments of Cardiothoracic Surgery and & M.Brezis with the Departments of Cardiothoracic Surgery and MedicineMedicine
0
10
20
30
40
50
60
% %of of tests tests within within target target INRINR
6600%% * *p<0.001p<0.001
3838%%
ControlControl InterventionIntervention
Patient’s knowledge & satisfaction significantly improvedPatient’s knowledge & satisfaction significantly improved
Patient’s empowerment improves Patient’s empowerment improves efficacy & safety of oral efficacy & safety of oral
anticoagulationanticoagulation
Communicating with Families & Communicating with Families & Satisfaction with End-of-Life Satisfaction with End-of-Life
DecisionsDecisionsDepartments of Medicine & Center for Clinical Quality & Safety
% of relatives agreeing with statement:ControlIntervention
“I felt the team didn’t care about my opinion”3513*
“It upset me I didn’t know what was going on”4310*
“Patient’s problems weren’t explained to me” 443*
“Management options were not explained”4617*
“I was afraid to ask questions”3810*
“I felt excluded in the decision-making”5217*
Communication with families of patients near end of life improves perceived quality of care
*p<0.005 in favor of the intervention group
Rate of patient’s recall for explanations Rate of patient’s recall for explanations on risks & alternatives: informed on risks & alternatives: informed
consent?consent?
WardWardType of Type of procedureprocedureNNExplanationsExplanations
about risksabout risksDiscussion ofDiscussion ofalternativesalternatives
SurgerySurgeryOperationOperation17817860%60%20%20%
ObGynObGynOperationOperation19819857%57%19%19%
MedicineMedicineDiagnostic or Diagnostic or therapeutictherapeuticprocedureprocedure
11711742%42%40%40%
CardiologyCardiologyAngiographyAngiography12012039%39%8%8%
TotalTotal61361351%51%21%21%
International Journal for Quality in Health Care 2008
ConclusionConclusion
Projects help make healthcare at Projects help make healthcare at Hadassah more evidence-based, patient-Hadassah more evidence-based, patient-centered & system-minded. centered & system-minded.
Over 100 projects presented at National Over 100 projects presented at National Meetings of Israeli Society for Quality in Meetings of Israeli Society for Quality in Healthcare; over 48 theses and 19 peer-Healthcare; over 48 theses and 19 peer-reviewed publications.reviewed publications.
Center for Clinical Quality & SafetyCenter for Clinical Quality & Safety