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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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