PFD402: Quality Improvement

quality

the standard of something as measured against other things of a similar kind; the degree of excellence of something

quality healthcare

the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge

quality measurement (QM)

collection of data about structure, process or outcomes of health care activities

quality assurance (QA)

using data to compare results from health care activities against a pre-defined set of standards or quality indicators

quality improvement (QI)

cyclical set of activities designed to make continuous improvement in health care structure, processes or outcomes. method for continuously finding better ways to provide better patient care and service

combined and unceasing efforts of everyone to make changes that will lead to better patient outcomes (health), system performance (care) and professional development (learning)

formal approach using data measurement to test, implement, and spread changes and ideas

dental quality alliance

established by the ADA to develop performance measures for oral health care. formed in 2010. measures address prevention and disease management to promote oral health for both children and adults

safe, effective, timely, efficient, equitable, patient-centered

IOM (institute of medicine) 6 aims for improving health care quality

quality in dentistry

an iterative process involving dental professionals, patients, and other stakeholders to develop and maintain goals and measures to achieve optimal health outcomes

continuous quality improvement cycle

recurrent planning, executing, measuring, interpreting, evaluating and then acting on results

1. what are we trying to accomplish?

2. how will we know that a change is an improvement?

3. what change can we make that will result in improvement?

what are the three questions associated with the model for improvement?

plan, do, study, act

what are the steps of the cycle associated with the model for improvement?

incident

an event that almost causes harm to a patient and that is avoided by luck or by an act at the last moment

accident

a random event that is unforeseen and unexpected, and causes damage to the patient or to materials or to health care staff

negligence

mistake that occurs through lack of knowledge or basic skills, the omission of minimal precautions, or neglect

adverse event

harm from medical care rather than an underlying disease. patient safety events that resulted in harm to a patient. event may occur by omission or commission of medical care

error

mistake by omission or commission in health care practice

1 in 10

how many patients develops a health care acquired condition during hospitalization?

powerful drugs, highly technical equipment, need for communication among many caregivers, constantly evolving recommendations, every patient is unique, limited time and resources, gray areas in medicine/dentistry

what are the major reasons why health care is dangerous?

patient safety

prevention of errors and adverse effects to patients associated with health care

to err is human

published in 1999, IOM report reporting that health care system causes as many deaths as 3 fully loaded jumbo jets crashing and killing everyone on board every other day

health risk management

trying to identify, evaluate, and treat problems that can cause harm to patients, lead to malpractice claims, and cause unnecessary economic losses to health care providers

learning system

the ability to self-reflect, and identify strengths and defects both in real time and in periodic review intervals

culture

the product of individual and group values, attitudes, competencies, and behaviors that form a strong foundation on which to build a learning system

50% (25% untreated, 20% extensive)

percentage of CA children who have caries experience by kindergarden

60%

percentage of CA children who have caries experience by third grade

health care quality

the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge

mother (and other caregivers)

who is usually the primary source of transmission of dental caries?

before teeth erupts (colonize teeth shortly after they erupt)

when are cariogenic bacteria generally transmitted?

host and teeth, microflora, substrate

OLD perspective of concept of caries looked at these three categories

child-level, family level, community level

the multi-level contemporary conceptual model of childhood dental caries looks at these three levels

genetic, biological, social, physical, dental and medical care

what are the key domains/determinants in the contemporary concept of childhood caries

• family income <200% FPL

• not living in a 2 parent household

• uninsured

• black/hispanic

• family conflict

• low maternal mental health

• unsafe neighborhood

social risk factors on children's health

up to 50%

how much do social determinants (where and how people live) impact their health status?

10%

about how much influence does genetics have on people's health status?

20-25%

abut how much impact does health care have on chronic disease

outcomes

goals

primary drivers

what it takes to achieve goals/contribute directly to achieving the aim; often requires protocols

secondary drivers

things that are needed to achieve primary drivers

changes

what is needed for secondary drivers

high reliability organization

organizations that operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures

• preoccupation with failure

• deference to expertise

• sensitivity to operations

• commitment to resilience

• respect for people

• fostering a culture of safety

• constancy of purpose

what are the features of a high reliability organization (8)

patient safety event

an incident or condition that could have resulted or did result in harm to a patient. can be but is not necessarily the results of a defective system or process design, a system or process breakdown, equipment failure or malfunction, or human error

no-harm event

patient safety events that reached the patient but did not cause harm (ex broken instrument in the mouth)

near miss event

patient safety events that did not reach the patient (ex. reviewing wrong record for patient, reversed radiograph)

unsafe (hazardous) condition

a condition or a circumstance (other than a patient's own disease process or condition) that increases the probability of an adverse event (ex. wet floors, faulty equipment)

department of defense reportable event (DoD RE)

adverse events that meet the following definitions: any patient safety event resulting in death, permanent harm, or severe temporary harm (ex. wrong site surgeries, retained foreign objects)

sentinel event

an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof; debilitating to both patients and health care providers involved in the event; system issue that may result in similar events in the future; preventable, serious, and unambiguous adverse events that should never occur; aka "never events"

wrong site surgery

what is the major dental PSR

clear goal, (with number) and time window

what two things are usually required for setting a clear aim?

measurement

critical part of testing and implementing changes; tells a team whether the changes they are making actually lead to improvement

measurement of research

purpose is to discover new knowledge/information. tested using a blind test with controls. gather as much data as posisble

measurement for learning and process improvement

purpose is to bring new knowledge into daily practice (to change a standard). uses many sequential, observable tests and stabilizes the biases from test to test. gathers just enough data to learn and complete another cycle. uses small tests of significant changes to accelerate the rate of improvement

process measures

the procedures and formal processes that go into delivering care. data that can be looked at. ex. number of encounters for oral health services per month or year, number of preventative procedures provided, number of referrals to other providers

outcome measures

data describing the results of healthcare services - how does the system impact the values of patients, their health, and wellbeing?

ex. frequency of toothbrushing, reasons for not brushing teeth, time since last dental visit, oral health improvements

(final goal)

• significant lack of standardized set of measures between public and private sectors and across communities, state, and national levels

• measures that are routinely used are duplicative across different organizations

what are the challenges for measurement in dentistry

run chart

Tool for tracking results over a period of time. Can help identify trends or other patterns that may be occurring and whether or not the changes you are making are leading to improvement

improvement tracker

run chart

driver diagram

• a visual display of a team's theory of what "drives" or contributes to, the achievement of a project aim

• useful tool for communicating to a range of stakeholders where a team is testing and working

• depicts relationship between aim, primary drivers, secondary drivers, and change ideas

• theory of change which represents a practice's current hypothesis of cause and effect in the system

• most useful in planning a quality improvement initiative and also helps in defining which aspect of the system should be measured and monitored to see if the changes/interventions are effective and if the underlying causal theories are correct

triple aim

improving patient care experience, improving health of populations and reducing cost of health care

• improve patient care experience

• improve health of populations

• reduce cost of health care

what are the triple aims of the national strategy for quality improvement in health care?

lack of quality measures (ex. diagnostic codes for dental insurance)

what is a major barrier to adopting quality improvement activities in dentistry?

chronic disease management

system of coordinated health care interventions in which patient self-management efforts are significant. relies on close collaboration between an informed and engaged patient and/or parent and a proactive health care provider/team.

Early Childhood Caries Collaborative

has been supported since 2008 by DentaQuest Institute. learning collaborative which trains dental and oral health care teams across the US to use quality improvement strategies to test and implement a chronic disease management approach to address ECC

• caries risk assessment

• effective communication

• self-management goal setting

• caries charting

• fluorides and other remineralizing strategies

• restorative treatment as needed/desired by patient/family

• recare interval based on risk

what are the 7 components included in the most recent ECC chronic disease management clinical protocol?

• identify and address major barriers limiting oral health care for young children and pregnant women

• increase capacity for community clinics

• increase awareness of importance of oral health in young children

what were the over all goals of the UCLA-First 5 LA Oral Health Program?

• struggle achieving and sustaining reliable and efficient care processes

• lack of training and confidence in providing oral health care services to target populations

• lack of awareness about important of oral health in young children and pregnant women

• lack of systems-based population health approaches to delivering integrated, patient-centered, evidence-based care within clinical setting and through collaborations with community partners

• lack of commitment of improving oral health care within programs

what were the major barriers/challenges that the UCLA-First 5 LA Oral Health Care Program faced?

change package

an evidence-based set of changes that are critical to the improvement of an identified care process

fishbone diagram

cause and effect diagram visually displaying potential causes of an effect/problem. causes are broken up into sub categories

people, methods, materials, equipment (space), environment

what are the typical categories used for fishbone diagrams?

balancing measure

determine whether changes designed to improve one part of the system are causing new problems in other parts of the system