1 A new indicator now in use Sample Patient suddenly collapses in - - PDF document

SLIDE 1

1

Do we ‘Measure’ up to Quality!

• Dr. Arati Verma

Chief - Medical Excellence Programs, Max Healthcare Quality Improvement

Real World Practice Q lit Why Measure?

What we don’t measure, we don’t know……. ……And we can

• nly improve

what we know

Quality Measurement

Optimal Practice Quality Gap

• access to care
• process of care

– outcome of care – patient experience

• f care

what we know

Uses

• To provide evidence of the quality of care.
• To make comparisons (benchmarking) over time

between places (e.g. hospitals).

• To support accountability regulation and
• To support accountability, regulation, and

accreditation.

• Planning
• To identify opportunity for improvement
• To provide a way to measure improvements

Measurement Levels

• Hospital
• Department specific
• Department specific
• Individual specific

Hospital Level

• Volume Indicators

– Volume of procedures – Bed Occupancy – ALOS

• Gross Mortality
• Patient Satisfaction
• Infection surveillance

S f t

• Safety

– Medication Errors – Sentinel events – Bed Sores – Patient Falls – Needlestick Injuries – Other Adverse Events

Department Specific- e.g. Cardiology

• Volume Indicators

– Procedure specific: CABG, PTCA – Procedure specific ALOS

• Procedure specific Mortality

Procedure specific Mortality

• Disease specific care indicators: e.g. Chest pain

protocol

• ICU infection rates

Types Rate Based provide a quantitative basis Incident Based Identify incidents

• f care that trigger

further q for quality improvement further investigation

(represent poor performance and they are generally used for risk management)

Examples of rate-based and incident indicators

• Rate-based indicators

– Clean and contaminated wound infection – (1) Numerator: the number of patients who develop wound infection from the fifth post-operative day after clean surgery – (2) Denominator: the total number of patients undergoing (2) Denominator: the total number of patients undergoing clean surgery within the time period under study who have a post-operative length of stay of 5 days.

• Incident indicators

– Numbers of needlestick injuries – Number of patient falls

Quality Building Blocks

Patient & staff satisfaction, Low infection rates, good clinical

• utcomes

Outcomes Availability of Beds, OPDs, Staff, Building, Space Equipment, Supplies, Resources, Basic Monitoring of patients Protocols, Procedures, Treatments, Policies, Training, Efficiency, low waste, Appropriate use Structure (Good foundation is critical) Processes

SLIDE 2

2

Patient suddenly collapses in Corridor

I Responder Alerts Code Blue BLS Started by 1 R d BLS Continued till Code Blue Team Reach Designated L i d Patient Transferred to

Sample

Responder Continued till Code Blue Team arrives Location and Take over Treatment Emergency Dept/ICU

Structure

• Availability of

medication in crash cart

• % of Doctors in

Process

• Response time

within 3 minutes

• Algorithm

followed Outcome

• % Failure to

Resuscitate

• Length of stay

post Survival % of Doctors in Emergency Dept who are ACLS qualified followed

• Documentation

compliance post Survival

• % Discharged to

Home

• Total Code Blue

Mortality

A new indicator now in use

• Appropriateness of Care

– Antibiotic use – Overuse of Investigations – Overstay in hospitals – Underuse of Specialists – Number of MRIs ordered for particular condition vs number showing positive findings – Number of appendicectomies done vs number showing positive histopathology

Risk adjustment

• Risk adjustment may be most important for
• utcome indicators.
• In most cases, multiple factors contribute to a

patient’s survival and health outcomes. Factors determining Outcome of Care

• The patient:

– Demographics: Age, Sex, Height – Lifestyle: Smoking, dietary habits, alcohol, physical activity, weight

• The Illness

– Severity – Prognosis – Co morbidity activity, weight – Psychosocial Factors: Social Status, Living conditions, Education – Compliance

Factors determining Outcome of Care

• The Treatment

(prevention, diagnostics, care, rehab, therapy): – Competence T h i l i t

• The Organization

– Quality Management and review – Use of Clinical Guidelines – Technical equipment – Evidence based Clinical practice – Accuracy – Effective – Safe Practices – Efficiency

Defining Thresholds: Standards

• 4 Parts:
• Component: Measurable aspect of care: e.g.

timeliness

• Yardstick: Desired quality level: 1 minute
• Target: Degree to which criterion should be met:

100%

• Exceptions: Valid reasons for non compliance?

Getting started

• Get key functional persons together
• Brain storm :

– Identify which processes are important for patient care/both service and clinical in your hospital. – Research and benchmark from internet Create Your Own Quality Dashboard – Some are required for accreditation

• Focus on access, structure, process and
• utcome
• Selection: simple, valid, reliable, easily

measurable process points that impact quality/safety of patient care.

• The vital few rather than the desirable many

"Not everything that can be counted counts, and not everything that counts can be counted."

• Albert Einstein

(1879-1955)

How to get started?

• Decide on what is the

numerator/denominator, sample size, frequency of data, who will collect.

• List desirable targets:

Create Your Own Quality Dashboard

• List desirable targets:
• Create your own dashboard
• Review regularly and initiate QI projects

"Not everything that can be counted counts, and not everything that counts can be counted."

• Albert Einstein

(1879-1955)

SLIDE 3

3

– You want to measure mortality rate in surgical department. – What is the relevance? Can this be measured? – Can this be measured? – Define the numerator and denominator – How many times, how often and by whom should this be measured?

Relationship to Quality Institutes with lower mortality rates reflect good outcomes of care Definition Number

• f

patient deaths in the surgical units per 100 discharges. Numerator Total number of deaths in operated patients in a month X 100

Surgical Mortality Rate

Denominator Total number

• f
• perated

patients discharged per month (including deaths) Dimension Safety, Quality Data collection Incidental findings Data source MRD Responsibility MRD In charge Analysis frequency Monthly

Indicators Examples

Emergency:

• Ambulance Response Time
• Consultant Response Time
• Response To Code Blue
• Availability of drugs in Ambulance/Crash

carts carts OPD

• Time taken from registration

to Dr consult starting

• OPD protocols
• Appointments timing (clinic start time)
• Wearing White Coats
• Documentation

Indicators

Diagnostics

• Errors in information for Test preparation
• Timeliness of Reports Delivery

(OPD & IPD) (OPD & IPD)

• Number of Reporting errors
• Timeliness of post discharge pending

reports of patients IPD

• Nurse call bell response time
• Pre operative evaluation

completion

Indicators

• Timeliness of Consultant rounds
• Requisition Errors
• Prescription/transcription errors
• Discharge process timeliness

Indicators

Pharmacy

• Delivery to external

customers

• % of Times Substitutes delivered
• Time to deliver to Depts
• Errors in delivery to Depts

(wrong medicines)

• Waiting time at pharmacy

counter

Indicators

• Morbidity & Mortality
• Hospital Mortality Rate
• Readmissions 24 hours after discharge
• Post Operative Wound infection rate
• Infections in 72 hours (for Afebrile

Infections in 72 hours (for Afebrile patient admissions)

• Return to theatre rate
• Return to ICU rate
• Death within 24 hours of elective

surgery (upto ASA grade 2 patients) 87.50 100.00 95.65 91.67 100.00 95.45 86.36 73.91 70.00 80.00 90.00 100.00 % Compliance

Acute MI

0.00 10.00 20.00 30.00 40.00 50.00 60.00 Aspirin at Arvl Aspirin IPD Beta Blockers IPD ACE/ARBs IPD Risk Straification ASA at Discharge B-blockers at discharge ACE/ARBs at Discharge Series1

Critical success factors

• Transparency
• Mutual trust within clinicians and staff
• Unbiased
• Indicator should be: Reliable and valid
• Culture of continuous improvement
• Openness to change
• No Blame games
• Must show improvement over time
• Review indicators and targets for current relevance

SLIDE 4

4

Did this ppt have a similar effect on you!