Quality Improvement in the Hospital Scott A. Flanders, M.D. - - PDF document
10/14/2016 Quality Improvement in the Hospital Scott A. Flanders, M.D. Professor of Medicine Associate Chair, Quality and Innovation Director, Hospital Medicine Program Director, Hospital Medicine Safety Consortium University of Michigan 1
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Quality Improvement in the Hospital
Scott A. Flanders, M.D. Professor of Medicine Associate Chair, Quality and Innovation Director, Hospital Medicine Program Director, Hospital Medicine Safety Consortium University of Michigan
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The Focus on Value
Value=A x Quality / Cost
Multiplier A=APPROPRIATENESS
Overview
– Leaders and champions – Data – Infrastructure – Culture / Socioadaptive elements
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CMS Framework 2016 2018
end of 2018 90% 50% 85% 30% FFS linked to quality All Medicare FFS Alternative payment models
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Proportion of Value‐Based Payments is Increasing Rapidly
Confidential: not for distribution
Physician Payment
– More risk placed on physicians – But also potential for reward
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Hospital Payment
– Carrot and Stick; 2% of DRG payments
– Stick only; 3% of DRG payments for excess readmits
– Stick only; 1% of all Medicare payments (not just DRG)
Value Based Purchasing
$ Millions of Dollars at Stake for Hospitals $
Clinical process (AMI, CHF, Pneumonia, SCIP, healthcare associated infections) Patient experience (HCAHPS) Clinical outcomes (Mortality rates for AMI, CHF, Pneumonia; CLABSI; Patient Safety Indicator 90) Efficiency (Risk-Adjusted spending from 3 days PTA to 30 days post- discharge)
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Hospital Payment
– $3 million
– <$1 million
– $2 million
– Low premiums are most important to consumers
– Consumer Reports
QI V3.0: Sink or Swim (the burning platform)
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– COPD, CHF, afib, CAP, Biliary dz, VTE, Sepsis, THR
– Melanoma, bladder CA / cystectomy, colectomy (IBD)
Optimizing Performance
– Home – Skilled nursing facilities
Standardizing Common Processes
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– Troponin, iCa, viral panels – PE CT for low pre-test probability / neg d-dimer – “Repeat ECHO” – MRI use
– UTI, CAP, HCAP, Cellulitis
– EP for afib, PCT
Target Cost and Appropriateness
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Overview
– Leaders and champions – Data – Infrastructure – Culture / Socioadaptive elements
characterize the annual human toll of antibiotic resistance.
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Local Interventions
The Big 3 Infectious Diagnoses in U.S. Hospitals
Ranking at UMHS Urinary Tract Infections #1 Pneumonia #2 Skin and Soft Tissue Infections #3
Gandhi T, et al. ICHE 2009
Improving Antibiotics for UTI
– Evaluate antibiotic use for UTI – Identify inappropriate treatment – Design strategies to improve antibiotic use – Target hospitalists
Hartley S, et al. ICHE, 2013
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Testing and Treatment for UTI
– 40% have UTIs by adjudicated review – 25% of UTIs had inappropriate treatment duration – 65% of asymptomatic bacteriuria was treated – 385 excess antibiotic days at UMHS alone
Hartley S, et al. ICHE, 2013
Improving Antibiotic Use
IHI Forum, 2013
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The UMHS Approach
– Pocket Cards – Posters in conference room – Abx app – Pharmacist timeout
– Dinner for night docs
Sarah Hartley, M.D.
Does the patient have any of the following without alternate explanation? 1. Urgency, frequency, dysuria 2. Suprapubic pain/tenderness 3. Flank pain or tenderness 4. New onset delirium 5. Fever >100.4 F/Rigors 6. Acute hematuria 7. Increased spasticity or dysreflexia in a spinal cord injury patient 8. > 2 SIRS criteria (T > 38.5 C or < 35 C, HR > 90, RR >20 or PaCO2< 32 mmHg, WBC >12 K/mm3 or <4 K/mm3 or > 10% bands)
Do NOT send urine culture Send U/A & urine culture Document indication for sending urine culture Start empiric therapy (see reverse side)
YES NO
*Symptom based screening is not reliable in the following cases: pregnancy, prior to urologic procedures, patients with complex urinary anatomy
(i.e., nephrostomy tubes, urinary tract stents, h/o urinary diversion surgery in the past, or renal transplant), patients admitted to the ICU, or
SHOULD THIS PATIENT BE EVALUATED FOR A URINARY TRACT INFECTION*?
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The Community Teaching Hospital
who would help make sure everyone watched the video
Treatment of Asymptomatic Bacteriuria
73.8 79 65 57 53 62 10 20 30 40 50 60 70 80 90 100 Overall Hospital #1 Hospital #2 % ASB Receiving Antibiotics Pre Post
* * * p<0.05
Data modified from original: to make a point!
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Key Characteristics of the Champion
– Respected / passionate
Identifying the Champion / Leader
required
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Overview
– Leaders and champions – Data – Infrastructure – Culture / Socioadaptive elements
Total Inpatient HH compliance
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MFH Specific Data Barriers and solutions
enhance monitoring of HHH
Barrier Solution Paucity of Data 2 observers dedicated to hospitalist service Non-specific Data
Shared schedule and pictures of hospitalists
Covert observers shadowed hospitalists Lack of Awareness
Educational sessions, Audit/Feedback, Physician champions
Unknown Modes of failure Identified clinical situations with higher failure rates
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Hospital Medicine Focused HH Interventions
– Importance of HH in preventing infections – Review of incidence of MRSA, VRE, CDI rates
– Service level-target problem areas – Physician level-target problem areas
Overall Hospitalist Hand Hygiene Compliance
51 45 90 10 20 30 40 50 60 70 80 90 100 Jan - March 2015 Apr-15 Feb- May 2016
Overall HHH Compliance
% (190/211) % (14/27) % (28/62) Increased HM Data collection
HM focused Intervention
System Wide HH Intervention (Clean/Remind/Thank, etc.)
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Facilitating Data Collection
– Hand hygiene – HCAPS – CAUTI / CLABSI / C.Diff – ED wait times – Readmission rates – Any existing EMR data field
– 72 hour antibiotic timeout – (challenge is “pre-” data)
Facilitating Data Collection
– Use standard data audit forms – Make it easy , no judgment; ideally non-healthcare providers can collect data – Samples vs. Consecutive pts
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Overview
– Leaders and champions – Data – Infrastructure – Culture / Socioadaptive elements
UMHS Large Scale QI: Problems
– Outcomes, cost, appropriateness – Often not measured or reported
– More than one group “owns” the condition – Multiple care pathways exist – Everyone is busy, competing priorities – Projects fail without frontline provider engagement
– Data, improvement experts
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– Implement a program/process w/resource support – Engage physicians /care team to own program PDCA
development and analytics for each program
cost and quality
*Adapted from Advisory Board 37
UMMG Goal: Demonstrate and Improve Value
Clinical Design Resource Framework
Clinical Design
Central Support 1.0 FTE Admin Mgr 2.0 FTE Proj. Mgr
Program and Operations Analysis
1.0 FTE
Finance
1.0 FTE
Analytics PACE, Pop. Health Analytics Others
manager support and a contracted model with SME areas, e.g., Finance, Program & Operations Analysis, others
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Program Selection Criteria
‒ Cost ‒ Process ‒ Clinical Outcomes
‒ Provided to a large number of patients ‒ Tertiary/quaternary service within ACO ‒ Bundled payments
‒ Engaged Physician Lead ‒ Integrated Process owner
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10/14/2016 21 Scoping / Pre‐work
– Define problem – SIPOC – Customer requirements – Gemba Waste Walk
Current State map
– Review/refine map – Review baseline data, gemba
Analysis of Current State Future State map Implementation Planning Project Implementation
Prior to Workshop Workshop 1 (Review/ Update) Workshop 2 Workshop 4 Workshop 3 Post‐ Workshop
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What isn’t working well Impact
OR efficiency Fewer cases done OR scheduling Uneven scheduling, resource utilization IP bed availability PACU delays Outpatient Pharmacy delay Discharge delay Clinic scheduling/yield See more patients to fill OR schedule Clinic delays Patient and staff dissatisfaction IP coordination Delays in patient progression to d/c ready Discharge delays Bed utilization Discharge destination High SNF utilization and cost Pre‐op screening Cancellations Referrer satisfaction Fewer referrals
Led to ~ 8 to 10 Projects/Teams
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– “Your surgeon wants you to go home” @ pre‐op classes (Aug 2014) – Collect prescription insurance information (July 2015)
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and Innovation Program
– Focus on patients in the ED – Understand variation to existing guideline
– Completed “vapor test” and “fake back end” to build and test Rapid Follow up Electrophysiology Clinic
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Afib – ED Pathway and Rapid Follow up EP Clinic Pilot
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Mondays and Thursdays (Feb – Aug)
clinic with positive feedback from patients, EP attending and ED physicians
DC Cardioversions
EMCRS (Emergency Medicine Consult Referral Process)
EP Rapid Follow Up Clinic
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– Engagement and alignment around care variation management – Use of evidence‐based medicine (EBM)
– Performance improvement support to engage clinicians – High functioning quality governance and management
– Robust clinical informatics and analytic capabilities that allow “drill‐down” into actionable improvement areas – Provide quality outcome, cost, process data that is quantifiable, reliable evidence of opportunities.
* Karpook, J. Smalto, G, van Pelt R, Bailey C. Transforming care delivery: The power of clinical variation management, Chartis Whitepaper, April 2015
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Overview
– Leaders and champions – Data – Infrastructure – Culture / Socioadaptive elements
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It’s Culture Stupid….
good technical solution
good technical solution
GE Healthcare Consulting
Michigan’s CAUTI Journey
– Hospitalists – CAUTI researchers – Nurse leader-head of QI – Hospital quality leader – Data Support
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Disrupting the Lifecycle of the Urinary Catheter
1 4 3 2
2. Maintaining Awareness & Proper Care
Catheter Replacement
(Meddings & Saint. Clin Infect Dis 2011)
The Technical: Timely Removal of Indwelling Catheters
reminders and stop-orders – Significant reduction in catheter-associated urinary tract infection (53%) – No evidence of harm (ie, re-insertion) – Will also address the non-infectious harms of the Foley
Meddings J et al. BMJ Qual Saf 2013
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Michigan’s CAUTI Journey
– New CPOE order requires indication for catheter – Nurses assess daily for indication – Nurse can d/c catheter when no indication
– Solution presented at several hospital committees – 4 units targeted initially – Unit nurse managers educated – Launched – Track catheter use, indications selected, CAUTI
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Project Start
Michigan’s CAUTI Journey
– No definition of “critically ill” – “Other” box included (and often used) – Patient request not considered – Alternatives to indwelling catheter not always clear
– Physicians did not buy in – Nurses “uncomfortable and unwilling” to d/c catheter – Physicians critical of nurse discontinuation
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Preventing CAUTI: 50 State (+) Project
rates
– University of Michigan (SS, SK, MTG, KF) – St. John Hospital – Johns Hopkins University – MHA Keystone Center for Patient Safety & Quality
– Association for Professionals in Infection Control and Epidemiology – Society for Healthcare Epidemiology of America – Society of Hospital Medicine – Emergency Nurses Association
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Scott A. Flanders, MD University of Michigan Sarah Hartley, MD University of Michigan Eugene Chu, MD, FHM University of Colorado Christin Ko, MD, MBA, SFHM, FACP Emory University Ian Jenkins, MD University of California, San Diego
Disrupting the Lifecycle of the Urinary Catheter
1 4 3 2
2. Maintaining Awareness & Proper Care
Catheter Replacement
(Meddings & Saint. Clin Infect Dis 2011)
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Emphasizing the Socioadaptive: I-ACT
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decrease in catheter use)
Preventing CAUTI in Acute Care
(Saint et al. N Engl J Med 2016)
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Getting Results
Results = Effective Solution X Change Management
Six Sigma Lean PDSA Cycles Socioadaptive elements Champions Engagement
Change Acceleration Recipe
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Quality Improvement in the Hospital
– Leaders / champions – Data – Infrastructure – Culture / socioadaptive