Physician Quality Improvement Summit November 19, 2018 disclosures - - PowerPoint PPT Presentation

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Physician Quality Improvement Summit November 19, 2018 disclosures - - PowerPoint PPT Presentation

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Physician Quality Improvement Summit November 19, 2018 disclosures Carolyn Canfield and Dr Hector Baillie have declared that they have no commercial interests to disclose Hector Baillie MD Specialist in Complex Adult Medicine Nanaimo BC 19

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Physician Quality Improvement Summit November 19, 2018

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disclosures

Carolyn Canfield and Dr Hector Baillie have declared that they have no commercial interests to disclose

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Hector Baillie MD

Specialist in Complex Adult Medicine Nanaimo BC

19 November 2018

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Changes in 100 years

  • Nutrition
  • Sanitation
  • Housing
  • Education
  • Vaccination
  • Health Service
  • Diagnostics
  • Medication/Surgery
  • Peace

War Obesity-Diabetes Hepatitis/HIV Smoking illnesses Travel Cancer Degenerative disease Costs

Situational Lifestyle

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COLLABORATION

  • DOCTORS AND

NURSES ARE BURNT OUT – WHY?

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COMMUNICATION

Communication: 9/10ths of Medicine 9/10ths of Life What’s Missing Here?

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COMMUNICATION

Communication: 9/10ths of Medicine 9/10ths of Life This is my Aunt Jenny!

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FAST MEDICINE

  • BLOOD TEST
  • DRUG
  • OPERATION
  • DEVICE
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SLOW MEDICINE

  • TALK WITH PATIENT
  • TALK WITH FAMILY
  • ACKNOWLEDGE FEAR
  • END OF LIFE CARE
  • COMFORT & RESPECT
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Physician Nurse/ Allied HC Administration

PATIENT

COMMUNICATION

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SPECIALST SUPPORT COMMITTEE PHYSICIAN QI INITIATIVE

  • FUNDED BY MINISTRY OF HEALTH, DIRECTED BY DOBC
  • caregiver re-engagement
  • better patient outcomes
  • INDIVIDUAL HEALTH AUTHORITIES
  • 12 PHYSICIAN LED TEAMS (QI consultant & co-ordinators, data analyst)
  • 1 YEAR PROJECT
  • WORKSHOPS
  • POSTER PRESENTATIONS
  • LEARNING FROM QUALITY FORUM VANCOUVER/IHI ORLANDO
  • NOW IN ITS THIRD YEAR
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Plan Do Study Act Patient identified as SDB

  • CPAP/MAD therapy
  • Improvement in EF

and NT-proBNP

  • Improvement in

quality of life (subjective)

  • Prospective consecutive patient enrolment

from referral cohort to NRGH HF Clinic

  • Age, sex, BMI, HR/BP, AHI, LVEF, BNP noted
  • Epworth score on all patients
  • Level III sleep study
  • Follow-up visits to assess OSA+Rx: with

measurement of LVEF/BNP/QoL The PQI Initiative provides training and support to physicians, through technical resources and expertise, to lead quality improvement (QI) projects, which build QI capacity. This investment increases physician involvement in quality improvement and enhances the delivery of patient care. Please see our website for more details: sscbc.ca

CONCLUSION

Heart failure (HF) either with reduced or preserved ejection fraction, is becoming more common as our population ages, and as the obesity epidemic evolves. Common causes of HF include hypertension, ischemic heart disease and valvular

  • dysfunction. Obstructive sleep apnoea is a well recognised cause of refractory hypertension, arrhythmia and oxidative
  • stress. It is more common in men, and is linked to obesity. Our study shows that it must be considered in all patients

with HF, who should be screened and offered appropriate therapy. Quality of life improves, LV function improves, and survival improves. We would like to see the STOP-BANG questionnaire become standard in HF Clinics.

  • Hector M Baillie MD (Physician Lead)
  • Honeylette Abesamis RN (HF Clinic Nurse)
  • Suzanne Beyrodt-Blyt RN (QI Co-ordinator)
  • Curtis Bilson (Data Management)

Obstructive Sleep Apnoea (OSA) leads to intermittent hypoxia, increased RV volumes and SNS activation, leading to hypertension, arrhythmia, atherosclerosis, and heart failure. Prevalence in the general population 2-7%, but 30-50% in HF patients. Treatment with CPAP or mandibular advancement device can improve health and increase survival (ACC/AHA class IIa recommendation). Central Sleep Apnoea (CSA) often a consequence of advanced HF/low cardiac output: CPAP can improve Sa02 but no survival advantage.

BACKGROUND PROBLEM

  • To determine prevalence SDB in 42

consecutive HF patients over a 6 month period.

  • To identify an effective screening tool for

OSA’

  • To determine if SDB intervention, combined

with standard medical therapy, improves HF

  • utcome measures (LV-EF, NT-proBNP):

predicted 40% improvement.

AIM OF PROJECT PDSA Cycle DATA ANALYSIS

“Most nights I spent in the Lazy-Boy…I was sleepy with HF, I

  • ften felt I was

drowning”.

Image 3: Description / summary of the above data diagram

Sleep disordered breathing is poorly recognised as a cause (and effect) of heart failure. Diagnosis is simple, treatment effective. Patient compliance with both seem variable, despite proven benefit in terms of

  • utcomes, and quality measures. By using screening

questionnaire, and intervening with CPAP or a mandibular advancement device, heart function improves.

1. OSA is under-recognised by referral physicians 2. Prevalence of SDB in HF Clinic: % 3. Epworth Score not a good screening tool: we will use STOP-BANG questionnaire in future 4. CPAP and MAD treatment had positive benefit in terms of HF outcomes (Echo, BNP)

FINDINGS PATIENT VOICE

Sleep Disordered Breathing in CHF

a common finding in HF - not commonly recognised.

TEAM PLAYERS

“With CPAP, the difference was immediate... I slept like a baby for the first time in 3 years.... yes there is some frustration with the mask if the fit isn’t perfect, but I feel wonderful now”

  • C.O.
Range Age 36-40 45-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85 85+ 1 2 3 4 5 6 7 8 9 10 11 N umberof Rec ords 4 1 1 1 1 1 1 8 3 3 3 7 2 2 2 2 Island Health: NRGH Heart Func tion Clinic Sleep Apnea Patients November 2016 - J uly 2017 Number of Records by Pati ent Age Ranges and Gender S ex F emal e Mal e Range AHI / Pre Post AHI Under 10 10-19 20-29 40-49 Nul l PRE P OST PRE POST P RE POS T PRE P OST PRE POST 2 4 6 8 10 12 14 16 18 20 Number of Records 19 9 8 5 2 5 2 5 11 18 Island Health: NR GH Heart Function C linic Sleep A pnea Pat ients November 2016 - July 2017 Number of R ecords by Pre and Post Apnea-Hypopnea Index (AHI) Pre Post AHI P RE P OS T Range BMI / P reP
  • st BMI
Under 20 20-24 25-29 30-34 35+ Null PRE PRE P OST PRE POST P RE POST P RE POS T PRE P OS T 2 4 6 8 10 12 14 16 18 Number of Records 1 8 7 13 17 12 5 3 3 14 1 Island Health: NRGH Heart Function Clinic Sleep Apnea Patient s November 2016 - July 2017 Number of Records by Pr e and Post Body/Mass Index (BMI) PrePost BMI PRE POST Range HR / P rePost HR 40-59 60-79 80-99 100+ Nul l PRE POST PRE POST PRE POST PRE POST 2 4 6 8 10 12 14 16 18 20 Num ber of Records 11 13 15 19 8 3 2 13 Island Healt h: NRGH Heart Funct ion Clinic S leep Apnea Patient s November 2016 - July 2017 Number of Records by P r e and P
  • st Heart Rates
PrePost HR PRE POST
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Physician Nurse/ Allied HC Admin PATIENT COMMUNICATION

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Patients are taxpayers Patients deserve to know what’s working well, what isn’t Patients are unrepresented in almost all committees I’ve ever been on Patients have important perspectives we should respect: we are all patients- in-waiting

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Patient leadership in healthcare Patient focus – safety Patient direction – quality means..? Re-engagement Patients should be an integral part of our PQI teams

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Michael E Porter Thomas H Lee

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Porter, Michael E. "What is value in health care?." Lee, Thomas H. "Putting the value framework to work.” New England Journal of Medicine 363.26 (2010): 2477-2483.

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OUTCOMES** (QUALITY + SAFETY + SATISFACTION)

COST VALUE EQUATION =

** “As is often true in medicine itself, the critical first step is

  • measurement. Provider organizations need to capture data
  • n the outcomes that matter to patients, as well as the costs

for a patient over meaningful episodes of care.” T.H.Lee 2010

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⋅ OUTCOMES THAT MATTER TO PATIENTS ⋅ COMPREHENSIVE COSTS TO CARE FOR A PATIENT ⋅ MEANINGFUL [to the patient] EPISODES OF CARE

Lee, Thomas H. "Putting the value framework to work.” New England Journal of Medicine 363.26 (2010): 2481-2483.

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QUALITY SAFETY

managing risk

Vincent, C., & Amalberti, R. (2016). Safer healthcare: Strategies for the real world.

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Vincent, C., & Amalberti, R. (2016) Safer healthcare: Strategies for the real world

“Management of RISK over time in order to MAXIMIZE benefit and MINIMIZE harm to patients in the healthcare system”

Patient Safety: a Definition

X

^

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studio Mile

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Six Levers to Help Organizations to Accelerate Healthcare Improvement

https://www.cfhi-fcass.ca/PublicationsAndResources/ResourcesAndTools/six-levers

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“the citizen-patient”

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Working definition of “citizen-patient”

a person who has health services experience (patient, family or community) AND has an interest in supporting system level improvement

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patientvoicesbc.ca

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We’re all patients, Carolyn!

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Work As Imagined*

Why is work-as-imagined different from work-as-done? / Hollnagel, Erik. in Resilient Health Care: The resilience

  • f everyday clinical work. ed. / Robert L Wears; Erik Hollnagel; Jeffrey Braithwaite. Vol. 2 Ashgate, 2015. p. 249-264.

*

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http://resilienthealthcare.net/onewebmedia/WhitePaperFinal.pdf

Work As Imagined*

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image credit: BMC Systems Biology 2011, 5:168

Work As Done* - care networks

Why is work-as-imagined different from work-as-done? / Hollnagel, Erik. in Resilient Health Care: The resilience

  • f everyday clinical work. ed. / Robert L Wears; Erik Hollnagel; Jeffrey Braithwaite. Vol. 2 Ashgate, 2015. p. 249-264.

*

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image credit: Mednick SC, Christakis NA, Fowler JH (2010). PLoS ONE 5(3): e9775. doi:10.1371/journal.pone.0009775

Work As Done* - patienthood

Why is work-as-imagined different from work-as-done? / Hollnagel, Erik. in Resilient Health Care: The resilience

  • f everyday clinical work. ed. / Robert L Wears; Erik Hollnagel; Jeffrey Braithwaite. Vol. 2 Ashgate, 2015. p. 249-264.

*

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Healthcare as a Complex Adaptive System Patient-hood as a Complex Adaptive System

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Bodenheimer, Thomas, and Christine Sinsky. "From triple to quadruple aim: care of the patient requires care of the provider." The Annals

  • f Family Medicine 12.6 (2014): 573-576.
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  • Aligning goals
  • Clarifying expectations
  • Understanding and embracing risk
  • Co-creating risk mitigation
  • Preparing physically, mentally, practically
  • Connection to respond to needs and concerns
  • Role in my own care, backed by mentor (peer?)

WHAT MAKES US (all) FEEL SAFER?

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  • What can I do to improve your care today? needs
  • What’s the best you think you can be? goals
  • What’s one thing you wish you’d known? gaps
  • What’s one thing that made a difference? assets
  • What’s one thing I should know about you? values
  • What’s one thing that….. ?

LEARNING WHAT MAKES US (all) FEEL SAFER?

  • C. Canfield, A. Carson-Steven, N. Cork (2016)
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 skills  respect  awareness  competence  trust  calmness  accountability  intuition  communications  interdependence  and more!

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The patient always leads …but we travel together Who leads better health care?

RISK REWARD UNKNOWABLE

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Questions?

hbaillie@telus.net carolyn.canfield@ubc.ca