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									HEALTH CARE QUALITY:
A Twenty Year Revolution
          Tri-Cities Quality Forum
              October 14, 2008




        A. BLANTON GODFREY, Ph.D.
      DEAN. COLLGE OF TEXTILES & JOSEPH D. MOORE
 DISTINGUISHED UNIVERSITY PROFESSOR, NORTH CAROLINA
                   STATE UNIVERSITY
MEDICAL TEXTILES




LaamScience
   BIOTEXTILES




Quill
      INTRODUCTION
U.S. Healthcare in the 1980s
For each problem, fix blame
Review problems months after they happen
No change in processes, belief it’s a people
problem
Industry Quality Management in 1980s
 Focus on prevention not problem fixing (TAT 8)
 Understanding that the system (process) is key to
quality, the people work in the system
 Providing support to people doing the real work
(education, tools, software)

                                      4
Institute of Medicine Conclusions
• There are serious problems in quality
   – Between the health care we have and the care
    we could have lies not just a gap but a chasm.
• The problems come from poor systems…not bad
  people
   – In its current form, habits, and environment,
    American health care is incapable of providing
    the public with the quality health care it expects
    and deserves.
• We can fix it… but it will require changes
           OUTLINE
• Accreditation & Standards
• Learning from Industry
• Emergence of the Institute for
  Healthcare Improvement
• Focus on Process
• Best Practices & Rapid Replication
ACCREDITATION & STANDARDS
   JCHAO (Joint Commission)
   ISO 9000 Series of Standards
   Other accrediting bodies in Canada,
   Australia, U.K., New Zealand,
   Malaysia, Philippines, India, Thailand,
   Taiwan, Mongolia, …



                                 7
       JCAHO Acute Myocardial Infarction (AMI)
          Quality Measures CardioCard # 1
ACUTE MYOCARDIAL INFARCTION NATIONAL QUALITY
  MEASURES (9 Primary measures 2 sub-measures)
• Measures—8 are time-sensitive

   – AMI-1 Aspirin at Arrival
   – AMI-2 Aspirin Prescribed at Discharge
   – AMI-3 ACEI or ARB for LVSD
   – AMI-4 Adult Smoking Cessation Advice/Counseling
   – AMI-5 Beta Blocker Prescribed at Discharge
   – AMI-6 Beta Blocker at Arrival
   – AMI-7 Median Time to Fibrinolysis
   – AMI-7a Fibrinolytic Therapy Received Within 30 Minutes of
     Hospital Arrival
   – AMI-8 Median Time to Primary PCI
   – AMI-8a Primary PCI Received Within 90 Minutes of
     Hospital Arrival
   – AMI-9 Inpatient Mortality
               SAS Institute, Inc. Health Metrics
                Dashboard Data Architecture
                        ETL              RAPID
 PATIENTS
   Patient#                           CARDIOCARD
  Birth Date
                        DATA                                         Data Marts
                        Quality       SAS BI Server
   Gender
Admission Data
 Discharge Data                                 Staging
                                                           Statistical
                        DATA                    Platform   Validation
 MEDICINES              Integration
   Patient#
    Medicine
                                             metadata                    OLAP
     Date
Order Information

DIAGNOSES
   ICD-9
  Patient#
  Diagnosis
     Date
Admit/Discharge

PROCEDURES
   ICD9
  Patient#
   Procedure
      Date
LEARNING FROM INDUSTRY
 National Demonstration Project
 Error-proofing healthcare
 Quality Systems extended to healthcare
 organizations
 Malcolm Baldrige National Quality Award
 Toyoto Production System
 Lean Six Sigma
 Simulation



                                     10
NATIONAL DEMONSTRATION PROJECT

   21 leading healthcare providers
   partnered with 21 leading companies
   to share methods
   Eight-month experiment proved that
   industrial methods work in healthcare
   Experiment extended three years
   then…


                                11
NDP RESULTS REPUBLISHED




                 12
  LESSONS LEARNED (2002)
1. Spending too much time analyzing processes can slow
   the pace of change.
2. Getting action is more important than getting buy-in.
   Improvement is a matter of changing the process, not
   blaming the people. The shift of blame from individuals
   to processes is not 100%
3. Measurement is very difficult for health care, and health
   care is far behind. (BSC, SPC, IT, MR)
4. There need to be consequences for not being involved in
   improvement.
5. Waste is pervasive in health care; improvement is the
   best way to save money.
     LESSONS LEARNED (2002)
6. Balance is important.
7. Health care lacks a training infrastructure.
8. Clinical outcomes are critical.
9. Definitions of quality in health care must include
   the entire patient experience – not just clinical
   outcomes and cost.
10.The executive leader doesn’t always have to be
   the driver of change.
BASIC TOOLS
     Box Plots
     Brainstorming
     Cause-and-effect Diagrams
     Graphs and Charts
     Histograms
     Mistake Proofing
     Pareto Analysis
     Process Control Plans
     Process Flow Diagrams
     Scatter Diagrams
     Statistical Process Control
     Stratification
ADVANCED TOOLS
       Value Stream Analysis
       Analysis of Variance (ANOVA)
       Correlation & Regression
       Design Of Experiments
            Full Factorial Designs
            Fractional Factorial Designs
            2k Designs
       Evolutionary Operation (EVOP)
       FMECA
       Hypothesis Testing
       Statistical Process Control
       Measurement System Analysis
       Process Capability Studies
       Quality Function Deployment
       Response Surface Methods
               CREATIVITY TOOLS
        (See The Creativity Tools Memory Jogger™)

•   Brainwriting
•   Brainstorming
•   Imaginary Brainstorming
•   Knowledge mapping
•   Morphological Box
•   Picture Associations
•   Biotechniques
•   Purpose Hierarchy
•   TILMAG
•   Word Associations
•   Problem Reformation
•   Heuristic Redefinition
          DESIGN FOR SIX SIGMA TOOLS
•   VOC
•   QFD
•   NPD Process
•   FDM
•   FMEA
•   High-level design
•   Concept selection
•   Hypothesis testing
•   Tolerance design
•   Reliability prediction
•   Robust Design
•   Prototyping
•   DFA/DFM
•   Pugh Chart
•   C & E Matrix
•   Simulation
     “To Err is Human”
• Cost of preventable errors in the U.S. is
  between $17-29 billion per year
• > 2 % of admissions experience an
  Adverse Drug Event (ADE)
• Medication-related errors ~$4,700 per
  admission
• Estimate is that 98,000 preventable
  deaths occur each year due to medical
  errors

   Kohn, Linda, et al. To Err is Human: Building a Safer Health
       System. Washington, DC. National Academy Press, 2000.
           Error Proofing
• Improvement of work operations, including
  materials, machines and methods, with the
  aim of preventing problems due to human
  error.


   Improve                   Improve
Human Beings              Work Operations
     Fit to                    Fit to
Work Operations            Human Beings
         Principles of Error Proofing
                                                Operations
                                           Memory
   Tasks             Functions                                                    Abnorma-
                                          Perceptio              Error                                     Effects
   Risks             Required               Motion
                                                                                    lities


        7%                    26%                         48%                              14%                5%

Elimination       Replacement                  Facilitation                  Detection               Mitigation

             Prevention of Occurrence                                           Minimization of Effects
         Prevent the occurrence of human errors                             Minimize the effects of human errors.
               which may cause troubles.


                                         Error Proofing
Small                                             Losses                                                    Large

              The percentage indicates the ratio of examples corresponding to each principle.
              Principles of Error Proofing
                          Elimination        Task Elimination

                                             Risk Elimination
           Prevention
               of         Replacement          Automation
           Occurrence
                                             Support System

                          Facilitation        Simplification

                                               Distinction
 Error
                                               Adjustment
Proofing
                           Detection     Record & Verify Motions

           Minimizatio                      Restrict Motions
           n of Effects
                                              Verify Results

                           Mitigation         Redundancy

                                                 Failsafe

                                                Protector
                                             Error-Proofing Results
                              Number of Actual and Potential Errors Associated with Allergy ID
                                                    Jan '05 - Jun '06
Number of Medication Errors
 Associated with Allergy ID




                              80
                              70
                              60
                              50
                              40
                              30
                              20
                              10
                               0
                                   Jan '05




                                                                                      Jun '05

                                                                                                Jul '05




                                                                                                                                                            Jan '06




                                                                                                                                                                                                              Jun '06
                                                                                                                              Oct '05
                                             Feb '05

                                                        Mar '05




                                                                            May '05




                                                                                                                                                                      Feb '06

                                                                                                                                                                                Mar '06




                                                                                                                                                                                                    May '06
                                                                                                                                        Nov '05

                                                                                                                                                  Dec '05
                                                                                                                    Sep '05
                                                                  Apr '05




                                                                                                          Aug '05




                                                                                                                                                                                          Apr '06
                                                                     Source: Online Incident Reports, JNeff, Nsg Adm
                                                       Includes Raleigh, Zebulon, Clayton Medical Park, North Healthplex cam puses
QUALITY SYSTEMS EXPANDED
     TO HEALTHCARE
  Malcolm Baldrige National Quality
  Award was extended to healthcare.
  Hospitals began exploring how the
  Toyota Production System can be
  used to dramatically change care.
  Leading hospitals have discovered
  and are now using Lean Six Sigma.


                            24
                  SIMULATION
• Training of airline pilots
   – Experts create training
     plans
   – Simulators are used for
     training
   – Crises are built into training
   – No one is certified until they
     pass
• Apprentice programs also
   – Historic way to learn
   – Masters pass down skills
   Measuring Behavior--BEFORE

Scatter-Plot
rendering of Pre-
Simulation
Clinical Test
Performance
Measurement
Results --
Variance from
Best-Practices
Protocols
  Measuring Behavior--AFTER

Scatter-Plot
rendering of Post-
Simulation
Clinical Test
Performance
Measurement
Results --
Variance from
Best-Practices
Protocols
Healthcare Value-Based Analytics
                                                         Preventative
      Academic                                        Research Measures
    Medical Centers
V                                        Health Predictive
A                                       Research Indicators
L
U                              Clinical Outcomes      Researchers &
E                                                       Hospitals
                      Clinical Disease Registries

      Data Repositories

               ANALYTICAL COMPLEXITY
                                 Charles Coleman, SAS Institute
INSTITUTE FOR HEALTHCARE
       IMPROVEMENT
 Foundation was the National
 Demonstration Project for Improving
 the Quality of Healthcare.
 Expansion of project to become a
 permanent organization called IHI.
 Grown to become a leader in quality
 improvement thinking in health care.


                              29
INSTITUTE FOR HEALTHCARE
   IMPROVEMENT MISSION
“We are a reliable source of energy,
  knowledge, and support for a never-
  ending campaign to improve health
  care worldwide.”




                              30
IHI’s “No Needless” List
     No needless deaths
      No needless pain
      No helplessness
    No unwanted waiting
         No waste
       …for anyone


                      31
  FOCUS ON PROCESS
Robert Wood Johnson Foundation project
Leading hospitals focused on “flow.”
Hospitals rethinking cardiovascular surgery
“process”
Rethinking medication errors as a process
Emergency room redesign




                                 32
PURSUING PERFECTION
Robert Wood Johnson Foundation created a
special project to create role model
healthcare providers by focusing efforts on
first creating “two perfect processes.”
Seven U.S. organizations were selected out
of over 250 applicants.
Each received financial grant and support.




                                33
PURSUING PERFECTION
  Focus on Process
Original goal was to create small
number of role model hospitals
Sweden, U.K. and the Netherlands
joined project at beginning
Hospitals were to go from 2 “perfect
processes” to 5 then many, then
extend lessons learned to partners


                             34
     BEST PRACTICES AND
      RAPID REPLICATION
1. Far faster to get results starting from
   practices (processes) with documented
   results.
2. Most practices can not be copied exactly,
   modification is necessary for different
   cultures, different organizations.
3. But learning from others is extremely
   efficient way to get results quickly.
IHI’s 100,000 LIVES CAMPAIGN
  Bold Idea
  Sharing of known best practices
  Spreading internationally




                              36
  Some Is Not a Number…
    Soon Is Not a Time
      The Number:
   100,000 Lives
        The Time:
June 14, 2006 – 9 a.m. ET

                    37
1. Deploy Rapid Response Teams
2. Deliver Reliable, Evidence-Based Care for Acute
   Myocardial Infarction
3. Prevent Adverse Drug Events (ADEs)
4. Prevent Central Line Infections
5. Prevent Surgical Site Infections
6. Prevent Ventilator-Associated Pneumonia
39
         Campaign Results
•   Over 3,100 hospitals enrolled in all 50 states
•   Nearly 90% of U.S. hospital beds
•   Thousands on national calls
•   Unprecedented web activity and new tool
    development
•   Related campaigns formed in other countries
•   Hospitals reported results monthly
•   Best estimate was that over 122,000 lives were
    saved in 18 months
Examples of Campaign Hospital Success
• 26 Hospitals in the Catholic Healthcare West
  System achieved a 55% system wide reduction
  in Ventilator Associated Pneumonias (VAPs)
• 7 Hospitals have had no VAPs for 16 -27 months
• Sentara Healthcare reported no VAPs for the
  last 30 months
• Community Health Network headquartered in
  Indianapolis have maintained VAP-free ICU’s for
  32 months


                 Joint Commission Benchmark – September/October 2006
5 MILLION LIVES CAMPAIGN
1. Reduce Surgical Complications
2. Prevent Harm from High Alert Medications
3. Prevent MRSA Infections
4. Reduce Readmissions from Congestive
   Heart Failure
5. Prevent Pressure Ulcers
6. Get Boards on Board
       IHI in Malawi and
The Health Foundation Consortium

 Program Aim: To reduce Maternal and
 Neonatal Mortality by 30% in Kasungu,
 Salima, and Lilongwe districts by
 February 2010
THFC Program Phases
THFC Coverage

       By Feb. 2010:
       • 10 CEmOC Hospitals
       • 32 Health Facilities (health
         centres/posts, non-
         CEmOC)
       • 729 Communities

       March 2010 – 2012
       • Expand to additional 32
         Health Facilities
       • ? Scale up of communities
    Key Drivers to Reducing Delays in                                              Reducing Delays in
Seeking/Receiving Care to Improve Maternal                                      Seeking & Receiving Care
         and Neonatal Outcomes
                                                                                    DEMAND: Reduce
                                   Empowered Women                                 Delays in Deciding to
                                                                                        Seek Care
                                 Supportive Community                                  Community
                                                                                       Mobilisation
                                                                                                                       Intervention
                               Effective Communication &                                                              leads to 30%
                                      Transportation                               LINKAGE: Reduce                     reduction in
                                                                                  Delays in Identifying &             Maternal and
                                                                                  Reaching Appropriate                   Neonatal
Malawi MoH Standards of Care




                                  Family-Friendly Care                               Medical Facility
                                                                                  Community & Health
                                                                                                                       Mortality by
                                  Prompt Treatment at                              Facility Partnerships              Feb. 2010 in
                                  Appropriate Facility                                                                  Kasungu,
                                                                                                                       Salima, and
                                Effective Support Systems                                                                Lilongwe
                                                                                SUPPLY: Reduce Delays
                                                                                   in Receiving Quality
                                                                                  Routine & Emergency
                                 Clinically Excellent Care
                                                                                 Maternal/Neonatal Care
                                                                                  Quality Improvement
                               Information-Driven Decision-
                                          Making
                                           Adapted from “Three Delays Framework” on www.unfpa.org/mothers/obstetric.htm
      WHAT HAS WORKED
1. Strong Quality System: Accreditation &
   Standards
2. Center/Institute for Modern Quality
   Management, Improvement, and Sharing
   of Best Practices with Ability for Advanced
   Training & Support
3. National Awards to Recognize and
   Reward Best Practices
      THANKS
    A. Blanton Godfrey
blanton_godfrey@ncsu.edu
     www.tx.ncsu.edu

								
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