Can We Build a Culture of Patient Safety & Quality Improvement in Health Care?
Wendy Levinson, MD Chair of Medicine University of Toronto
Medicine
UNIVERSITY OF TORONTO
Goals
1. Pose a problem – we spend 50% of our tax dollars on health care but quality is not consistent 2. Describe elements of transformational change in quality improvement 3. Some reflection on change process
• “Reporter Dies from Chemotherapy Overdose” – Boston Globe, 1995 • “Prominent Neurosurgeon Removes Wrong Side of Brain – Twice!” – New York Times, 2000 • “Canadian Woman Had Surgical Tool in Stomach for 4 Months ” – CNN, 2000
Performance of Quality Indicators in US
Condition Breast cancer Prenatal care Hypertension Asthma Hyperlipidemia Diabetes UTI STD/vaginitis No. of Indicators 9 39 27 25 7 13 13 26 % of Recommended Care Received
(95% CI)
75.5 (69.9-81.4) 73.0 (69.5-76.6) 64.7 (62.6-66.7) 53.5 (50.0-57.0) 48.6 (44.1-53.2) 45.4 (42.7-48.3) 40.7 (37.3-44.1) 36.7 (33.8-39.6)
A fib Alcohol dependence
McGLynn, EA. N Engl J Med 2003
10 5
24.7 (18.4-30.9) 10.5 (6.8-14.6)
Coordinating Care: How are we doing?
• Information transfer between hospital-based and primary care physician - PCP involved in discussions about discharge plan: 3% - PCP notified that patient had been discharged: 17-20%
- Discharge summary did not include lab reports: 38%
- Discharge summary did not include discharge meds: 21% - PCP cared for post-hospital patient before receiving discharge summary: 66%
Kripalani et. al. JAMA 2007; 297:831
Variations in spending across academic medical centers
Inpatient + Part B spending per decedent 120,000
Spending per Medicare beneficiary with severe chronic disease
Cedars-Sinai UCLA Medical Center New York-Presbyterian Johns Hopkins UCSF Medical Center Univ. of Washington Mass. General Barnes-Jewish Duke University Hosp. Mayo Clinic (St. Mary's) Cleveland Clinic 76,934 72,793 69,962 60,653 56,859 50,716 47,880 44,463 37,765 37,271 35,455
100,000
80,000 60,000 40,000
20,000
How can the best medical care in the world cost twice as much as the best medical care in the world?
Uwe Reinhardt
The Paradox of Plenty: Spending, Quality and the Challenge of Clinical Judgment Elliott S. Fisher, MDMPH
Association between spending and quality
Baicker and Chandra, Health Affairs, web exclusives
Summary
1. We spend a lot 2. There are big gaps in quality 3. Quality and cost don’t always correlate
Driving Change
1. Show doctors their own data against benchmarks 2. Cross-institutional programs 3. Reward 4. Leaders must own this – CEOs, Board of Directors 5. Pay for Performance – US 6. Recertification – US
Practice Improvement Module
New Process to Deliver Care Chart Audit Ideas to Change System Performance Report Guided Reflection Patient Survey
Practice Survey
Plan
Outcomes of Care Clinical outcomes Systolic BP <130 mm Hg Diastolic BP <85 mm Hg LDL cholesterol at goal Chart Review (n= 20) N 9 19 7 % 45 95 35 Patient Survey (n= 31) N %
HDL Cholesterol >40 mg dL
Triglycerides <150 mg dL Functional outcomes and behaviors Good fitness level Physical activity >4 days/week Patient satisfaction Patients rate practice of preventive care excellent
10
12 N
50
60 % N 2 4 % 6 12 % 19
N
%
N 5
Patient Survey (CAHPS)
• Appointment access
• Phone access—during and after hours
• Wait times in office
• Communication: explanation, listening, instruction clarity, knows your history, respect, enough time • Test follow-up
Departmental Strategies
• Quality RFP
• Educational program for learning teams
•Awards
Payment Reform
Payment Reform
Pay for performance experiments in the U.S. • Bridges to Excellence • Medicare payment a) Stop payments for ―never events‖ b) 1% increase • Medicare seeking measures for individual physicians. • In Ontario Family physicians paid extra for prevention targets.
Recertification in the U.S.
1. License
2. Knowledge self-assessed
3. Secure exam 4. Practice improvement
Key elements for change
1. 2. 3. 4. 5. Need ―burning platform‖ Clear and concise message Passionate leaders Buy-in of senior leaders Patience