Quality & Safety at Quality & Safety at

HadassahHadassahA Progress ReportA Progress Report

September 12, 2006September 12, 2006 Mayer Brezis, MD MPH, Professor of MedicineMayer Brezis, MD MPH, Professor of Medicine

Center of Clinical Quality & SafetyCenter of Clinical Quality & SafetyChairman, Quality & Safety CommitteeChairman, Quality & Safety Committee

Quality at Hadassah: some Quality at Hadassah: some statisticsstatistics

2004200420020055

20020066

Total number of projectsTotal number of projects414140403636Completed projectsCompleted projects8814141818Cross-institutional projectsCross-institutional projects9914141212Number of physicians Number of physicians involvedinvolved282840403636Presentations at annual Presentations at annual meeting of Society for meeting of Society for Quality in MedicineQuality in Medicine

232336*36*33*33** Best poster presentation award* Best poster presentation award 3636 projects completed as MD or MPH projects completed as MD or MPH

theses; 20 peer-reviewed publicationstheses; 20 peer-reviewed publications

• Appropriateness of Coronary Appropriateness of Coronary RevascularizationRevascularization• Quality of Elective Surgery for Quality of Elective Surgery for Inguinal Hernia RepairInguinal Hernia Repair• Reduction of Neurosurgical Shunt Reduction of Neurosurgical Shunt InfectionsInfections• Quality of Reconstruction Surgery Quality of Reconstruction Surgery After MastectomyAfter Mastectomy• Hand-washing by Medical StaffHand-washing by Medical Staff• Progress on Previous ProjectsProgress on Previous Projects• Evaluation of Specific Patient CareEvaluation of Specific Patient Care

OutlineOutline of presentation of presentation

Dr. Dalit Cayam-Rand, Dr. Ronny Alcalai, Prof. Amir Elami & Prof. Mayer BrezisDr. Dalit Cayam-Rand, Dr. Ronny Alcalai, Prof. Amir Elami & Prof. Mayer Brezis

Heart Institute, Department of Cardiothoracic Heart Institute, Department of Cardiothoracic Surgery & Center for Quality & Safety, HadassahSurgery & Center for Quality & Safety, Hadassah

PercutaneouPercutaneous Coronary s Coronary

InterventionIntervention

Coronary Artery Coronary Artery Bypass Graft (CABG) Bypass Graft (CABG)

surgerysurgery

Appropriateness of Coronary Appropriateness of Coronary Revascularization Procedures Revascularization Procedures

at Hadassah Hospital: at Hadassah Hospital: Adherence to Clinical Practice Adherence to Clinical Practice

GuidelinesGuidelines

Development of Development of guidelinesguidelines

• Institutional guidelines were developed by Institutional guidelines were developed by senior cardiologists and cardiac surgeons at senior cardiologists and cardiac surgeons at Hadassah, in collaboration with the Center Hadassah, in collaboration with the Center for Clinical Quality & Safety. The guidelines for Clinical Quality & Safety. The guidelines were derived from those of the American were derived from those of the American College of Cardiology and Heart Association, College of Cardiology and Heart Association, adapted on basis of most recent literature. adapted on basis of most recent literature.

• The guidelines were approved by staffs of The guidelines were approved by staffs of both the Heart Institute and Department of both the Heart Institute and Department of Cardiothoracic Surgery at Hadassah. Cardiothoracic Surgery at Hadassah.

• Six months after approval, implementation Six months after approval, implementation of guidelines was examined. of guidelines was examined.

Sample from guidelinesSample from guidelinesCABG is the first option for:CABG is the first option for:                        1. Left main coronary artery stenosis 1. Left main coronary artery stenosis

((level of evidence Alevel of evidence A))                        2. Obstruction of origin of 2. Obstruction of origin of

left anterior descending (LAD) artery left anterior descending (LAD) artery and of circumflex artery and of circumflex artery ((level of evidence Alevel of evidence A))

                        3. Triple vessel disease, with diabetes or 3. Triple vessel disease, with diabetes or renal failure (renal failure (level of evidence Alevel of evidence A))

                        4. Proximal LAD with 4. Proximal LAD with high risk for high risk for angiographic treatmentangiographic treatment ( (level of evidence Blevel of evidence B))

                        5. Triple vessel or proximal LAD and 5. Triple vessel or proximal LAD and failure of angiographic treatmentfailure of angiographic treatment ( (level of level of evidence Cevidence C))

Overall rate of inappropriateness: Overall rate of inappropriateness: 6%6%

Corrected rate (out of referrals): Corrected rate (out of referrals): 8%8%

RatingRatingNN%%

(1) Complete adherence to (1) Complete adherence to guidelinesguidelines27127185%85%

(2) Both procedures appropriate (2) Both procedures appropriate 19196%6%

(3) Deviation for medical reasons (3) Deviation for medical reasons 662%2%

(4) Deviation for patient’s (4) Deviation for patient’s preferencepreference441%1%

(5) Deviation with no notable reason (5) Deviation with no notable reason 18186%6%

Rate of adherence to Rate of adherence to guidelinesguidelines

Rates of appropriateness Rates of appropriateness according to angiogram according to angiogram

resultsresultsAngiogram resultAngiogram resultNNAppropriateAppropriate

Normal coronaries or Normal coronaries or insignificant diseaseinsignificant disease868686 (100%)86 (100%)

Single-vessel coronary diseaseSingle-vessel coronary disease999995 (96%)95 (96%)

Double-vessel coronary diseaseDouble-vessel coronary disease717170 (99%)70 (99%)

Triple-vessel disease (TVD)Triple-vessel disease (TVD)626249 (79%)49 (79%)

TVD & diabetes or renal failure TVD & diabetes or renal failure 20207 (35%)7 (35%)

Proximal LAD disease with high Proximal LAD disease with high risk for angiographic treatment risk for angiographic treatment 171710 (59%)10 (59%)

““For patients with two or more For patients with two or more diseased coronary arteries, diseased coronary arteries,

CABG is associated with higher CABG is associated with higher adjusted rates of long-term adjusted rates of long-term

survival than stenting.”survival than stenting.” Hannan, Hannan, E. et al.E. et al.

N Engl J Med 2005 352: 2174-N Engl J Med 2005 352: 2174-21832183

BMJ, April 2, 2005

““CABG is still the best treatment CABG is still the best treatment for multivessel and left main disease”for multivessel and left main disease”

Professor David P TaggartProfessor David P TaggartCardiovascular Surgery, OxfordCardiovascular Surgery, Oxford

ConclusionConclusionOverall adherence to guidelines Overall adherence to guidelines

satisfactory (over 90%)satisfactory (over 90%)Adherence is suboptimal among Adherence is suboptimal among

specific subgroups of patients:specific subgroups of patients:with proximal LAD, triple vessel disease & diabetes or with proximal LAD, triple vessel disease & diabetes or renal failure renal failure

Results discussed with staffResults discussed with staffAre patients sufficiently informed?Are patients sufficiently informed?

Dr. Tal Yemini, Dr. Mahmid Badriah, Dr. Dr. Tal Yemini, Dr. Mahmid Badriah, Dr. Yoav Mintz, Prof. Raphael Udassin, Prof. Yoav Mintz, Prof. Raphael Udassin, Prof.

Avraham Rivkind and Prof. Mayer Avraham Rivkind and Prof. Mayer BrezisBrezis

Evaluation of Quality of Evaluation of Quality of Elective Surgery for Inguinal Elective Surgery for Inguinal Hernia Repair in Adults and Hernia Repair in Adults and

in Children at Hadassahin Children at Hadassah

Departments of General and Pediatric Departments of General and Pediatric Surgery, Ein Kerem and Mt Scopus & Surgery, Ein Kerem and Mt Scopus &

Center for Quality & Safety, Hadassah Center for Quality & Safety, Hadassah Hebrew University Medical CenterHebrew University Medical Center

Goal & MethodsGoal & MethodsEvaluation of quality of care for Evaluation of quality of care for unilateral hernia repair by unilateral hernia repair by following criteria:following criteria: Overall satisfactionOverall satisfaction PainPain Return to activityReturn to activity ComplicationsComplicationsComparison to literatureComparison to literatureProspective phone survey ofProspective phone survey of 114 adults (age 14-87) 114 adults (age 14-87) 102 children (age 2-6) 102 children (age 2-6)

Satisfaction was high to very Satisfaction was high to very high in 94% of both adults and high in 94% of both adults and children; children; 88% of adult patients and 88% of adult patients and 95% of parents would 95% of parents would recommend having such recommend having such operation at Hadassahoperation at HadassahProblems reported: waiting Problems reported: waiting and relation with staffand relation with staff

SatisfactionSatisfaction

Pain & return to activityPain & return to activity

AnalgesicAnalgesicss

Return to Return to activityactivity

ChildreChildrenn

1 day 1 day 3-4 days3-4 days

AdultsAdults5 days5 days10-15 days10-15 daysResults concord with reports in Results concord with reports in

literatureliteratureAbout 10% of adults had still more pain after About 10% of adults had still more pain after

surgery than before and not returned to work after surgery than before and not returned to work after 4-6 weeks. 4-6 weeks.

These results are consistent with the notion that patients These results are consistent with the notion that patients with minimally symptomatic hernia may not need surgical with minimally symptomatic hernia may not need surgical

repair JAMA 2006;295:285.repair JAMA 2006;295:285.

Rates of ComplicationsRates of ComplicationsRateRate

95%95%Range in Range in literatureliterature

InfectionInfectionChildrenChildren6%6%2-132-13

0.7-14%0.7-14%AdultsAdults12%12%7-207-20

HematomaHematomaChildrenChildren10%10%5-185-18

11-15%11-15%AdultsAdults13%13%8-218-21

confidence interval

Reported range varies by site of study & Reported range varies by site of study & methodology & motive (is it voluntary or methodology & motive (is it voluntary or

mandatory?)mandatory?)

ConclusionConclusionPerformance of surgical repair at Performance of surgical repair at

Hadassah is consistent with standards Hadassah is consistent with standards reported in literature reported in literature

We could not find similar reports from We could not find similar reports from other Israeli hospitals other Israeli hospitals

Importantly, measurement of rate of Importantly, measurement of rate of infection and feedback to surgeons has infection and feedback to surgeons has recently been shown to be an efficient recently been shown to be an efficient tool to improve performance and reduce tool to improve performance and reduce infection rates*infection rates*

* Reduction in infection rates by surveillance with follow-* Reduction in infection rates by surveillance with follow-up and feedback. up and feedback. British J of Surgery 2006;93:630-638British J of Surgery 2006;93:630-638

Dr. Ido Paldor, Dr. Zvi Israel, Prof. Colin Dr. Ido Paldor, Dr. Zvi Israel, Prof. Colin Block and Prof. Mayer BrezisBlock and Prof. Mayer Brezis

Can We Reduce Can We Reduce Neurosurgical Neurosurgical

Shunt Shunt Infections?Infections?

Departments of Neurosurgery and Departments of Neurosurgery and Infectious Diseases & Center for Quality & Infectious Diseases & Center for Quality &

Safety, Hadassah Hebrew University Safety, Hadassah Hebrew University Medical CenterMedical Center

Hydrocephalus Hydrocephalus (accumulation of (accumulation of

cerebrospinal fluid due cerebrospinal fluid due drainage obstruction) is a drainage obstruction) is a neurosurgical condition neurosurgical condition treated by insertion of a treated by insertion of a shunt draining fluid from shunt draining fluid from

the ventricles. the ventricles.

Infection is a serious Infection is a serious complication of shunt complication of shunt insertion, with a high insertion, with a high

mortality rate.mortality rate.

Shunts coated with Shunts coated with antibiotics may reduce rate antibiotics may reduce rate

of infection.of infection.

BackgroundBackground

10 17 21 24

05

10152025303540

% of shunts infected

2001 2002 2003 2004-5Number of shunts inserted

InterventioInterventionn

Results: rate of shunt infection

Mortality dropped from 50% (in Mortality dropped from 50% (in infected cases) to none after infected cases) to none after

interventionintervention

ConclusionConclusionIntervention reduced rate of infection Intervention reduced rate of infection

from average of 25% to less than 5%, from average of 25% to less than 5%, and abolished mortality from and abolished mortality from infectioninfection

This may derive from antibiotic-coated This may derive from antibiotic-coated shunts and also from shunts and also from surveillance surveillance itselfitself, shown to reduce surgical site , shown to reduce surgical site infections*infections* * Reduced risk of surgical site infections through * Reduced risk of surgical site infections through

surveillance in a network. surveillance in a network. Int J Qual Health Care 2006;18: Int J Qual Health Care 2006;18: 127-133127-133

Dr. Ravit Yanco, Dr. Matan Cohen, Dr. Dr. Ravit Yanco, Dr. Matan Cohen, Dr. Ehud Kleiner, Dr. Helen Green & Dr. Ehud Kleiner, Dr. Helen Green & Dr.

Avraham NeumanAvraham Neuman

Quality of Reconstruction Quality of Reconstruction Surgery after MastectomySurgery after Mastectomy

Department of Plastic Surgery & Center for Department of Plastic Surgery & Center for Quality & Safety, Hadassah Hebrew Quality & Safety, Hadassah Hebrew

University Medical CenterUniversity Medical Center

These results are similar to outcomes These results are similar to outcomes reported in the U.S.* and will help reported in the U.S.* and will help

make better choice of implantmake better choice of implant* Reconstructive breast implantation after mastectomy for * Reconstructive breast implantation after mastectomy for

breast cancer: clinical outcomes in a nationwide breast cancer: clinical outcomes in a nationwide prospective cohort study. prospective cohort study. Arch Surg. 2005;140:1152-Arch Surg. 2005;140:1152-

11591159. .

Results and ConclusionResults and Conclusion

Hand-washing Hand-washing by Medical Staffby Medical Staff

Department of Clinical Department of Clinical Microbiology & Center Microbiology & Center for Quality & Safety, for Quality & Safety, Hadassah Hebrew Hadassah Hebrew University Medical University Medical

CenterCenter

Dr. Dror Cantrell, Dr. Dror Cantrell, Prof. Zvi Stern, Prof. Prof. Zvi Stern, Prof. Colin Block & Prof. Colin Block & Prof.

Mayer BrezisMayer Brezis

Increase in physicians hand-Increase in physicians hand-washing by alcohol gelwashing by alcohol gel

Alcohol Gel Available in WardAlcohol Gel Available in Ward

% of physicians

washing hands

between patient

contacts

* * p<0.001

*

Alcohol-chlorhexidine replaced the gel during 1 week

ConclusionConclusion A committee for Infection Prevention at A committee for Infection Prevention at Hadassah is now designing a system-wide Hadassah is now designing a system-wide intervention including: alcohol gel, intervention including: alcohol gel, education and feedback with periodic education and feedback with periodic monitoring of adherence. monitoring of adherence.

Alcohol gel is more expensive that water & Alcohol gel is more expensive that water & soap but if effective, this may have soap but if effective, this may have considerable impact on the difficult and considerable impact on the difficult and costly problem of cross-infections by bugs costly problem of cross-infections by bugs increasingly resistant to multiple antibiotics.increasingly resistant to multiple antibiotics.

Evaluation of performance by a Evaluation of performance by a specific surgeon being specific surgeon being

considered for tenure at considered for tenure at HadassahHadassah

Physician A performs high-risk, complex operations 2.5 Physician A performs high-risk, complex operations 2.5 more frequently than other surgeons. Post-surgical length more frequently than other surgeons. Post-surgical length

of stay for physician A’s patients is shorter by 3-4 days of stay for physician A’s patients is shorter by 3-4 days compared to other high complexity patients (p= 0.01). compared to other high complexity patients (p= 0.01). Patients managed by physician A showed a first-month Patients managed by physician A showed a first-month mortality rate of 1 out of 339 (0.28%) not different from mortality rate of 1 out of 339 (0.28%) not different from the rate of the rest of the urological team over the same the rate of the rest of the urological team over the same

period: 7 out of 2164 (0.32%). period: 7 out of 2164 (0.32%).

The bottom line was that physician A performs at The bottom line was that physician A performs at least as well as, and probably even better than least as well as, and probably even better than the other surgeons of the Urology department. the other surgeons of the Urology department.

Progress on Previous ProjectsProgress on Previous Projects • Improved glucose control for hospitalized patients with diabetes

• Improvement of palliative care

• Patient’s empowerment to improve effectiveness and safety of oral anticoagulation

• Perioperative prevention of clots

• Improved patient instructions at discharge after hip or forearm fractures

www.hadassah.org.il/departments/quality

Summary & Conclusion Summary & Conclusion

• Diverse projects attempt to make Diverse projects attempt to make healthcare at Hadassah more healthcare at Hadassah more patient-centered, more evidence-patient-centered, more evidence-based and more system-minded.based and more system-minded.

• While in some areas, noticeable While in some areas, noticeable improvements have been improvements have been achieved, it is increasingly achieved, it is increasingly apparent that further successes apparent that further successes require a systematic mode of require a systematic mode of monitoring and feedback.monitoring and feedback.

AcknowledgmentsAcknowledgmentsProf. Yoel Donchin, Ms. Nurit Porat, Prof. Prof. Yoel Donchin, Ms. Nurit Porat, Prof.

Amir Elami, Dr. Ronny Alcalai, Dr. Mahmid Amir Elami, Dr. Ronny Alcalai, Dr. Mahmid Badriah, Dr. Yoav Mintz, Prof. Raphael Badriah, Dr. Yoav Mintz, Prof. Raphael Udassin, Prof. Avraham Rivkind, Udassin, Prof. Avraham Rivkind, Dr. Zvi Dr. Zvi

Israel, Prof. Colin Block, Israel, Prof. Colin Block, Dr. Ravit Yanco, Dr. Dr. Ravit Yanco, Dr. Matan Cohen, Dr. Ehud Kleiner, Dr. Helen Matan Cohen, Dr. Ehud Kleiner, Dr. Helen

Green, Dr. Avraham Neuman, Prof. Zvi Green, Dr. Avraham Neuman, Prof. Zvi Stern, Dr. Rony Braunstein, Dr. Rami Oren, Stern, Dr. Rony Braunstein, Dr. Rami Oren, Ms. Lois Gordon, & many other physicians, Ms. Lois Gordon, & many other physicians,

nurses, pharmacists & students greatly nurses, pharmacists & students greatly contributed to projects described in this contributed to projects described in this

report.report.