Quality Assurance and Improvement

Olson

Quality

• no universally accepted definition in healthcare

• degree of excellence

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

• improved quality → increased productivity

Quality in pharmacy practice

• represents a degree of excellence

• increases probability of positive outcomes

• decreases probability of negative outcomes

• corresponds with current medical knowledge

• offers patient what they want

• provides patient with what they need

Donabedian model

• quality is measured based upon structure, process, outcomes

• structure: raw materials needed for production

• process: method/procedure used

• outcomes: end result

• historically based on structure/process but today’s focus is on outcomes

Driving force behind MTM

• outcomes

• pharmacist led improvement in patient care:

  • increase pt control of their condition

  • decreased use of healthcare resources

  • increase pt knowledge of their conditions, tx, meds

  • increased adherence to med regimen

  • increased pt satisfaction w care

  • saving payer money

  • improving quality of life

Measuring outcomes

• ECHO model (economic, clinical, humanistic outcomes)

• depicts value of pharmaceutical product or service as a combo of traditional clinical-based outcomes with more contemporary measures of economic efficiency and quality

Economic outcomes

• direct and indirect costs and consequences

• both medical and non-medical

• ex. prescription copays, gas used to pick up prescription, lost wages, incomplete assignment/test

Clinical outcomes

• morbidity, mortality, event rate, sign/symptom resolution

• may be difficult to measure as onset may be delayed following rx or intervention

• use indicators or markers

• condition, procedure or patient care specific

• ex. A1C (condition specific), post-op infection rate (procedure specific), BP used to assess risk for stroke (patient care issue)

Humanistic outcomes

• measures human aspect of care

• accounts for the effect of a treatment on other aspects of a pt’s life in conjunction with the therapeutic effect or discrete health outcome

• quality of life (QOL)

• patient satisfaction

• productivity

Quality of life

• how a pt’s percieved well-being is affected by a disease or condition over time

• assessed by surveys or questionnaires

Goal of quality in healthcare

• decrease unnecessary variation

• improve quality

• healthcare lags other industries in quality improvement

• follow airline industry

Systems engineering initiative for pt safety

• SEIPS model

• expands Donabedian’s process concept from direct pt care to processes that support pt care

• multidisciplinary initiative applying systems engineering, human factors engineering, and quality engineering approaches

Systems Theory

• used in engineering, medicine, and education to improve process efficiency and quality

• involves:

  • defining purpose and performance expectations of system

  • examining characteristics of the inputs

  • considering alt mechs for achieving stated goals

  • implementing system

  • adjusting system based on feedback

Systems thinkers must

• differentiate cause and effect algorithms and procedures with work designs that encompass an awareness of systems

• determine downstream and upstream influences and processes that give intention to decision making

• align human and material resource requirements for fit and appropriateness within the system

• identify and set boundaries around systems that are embedded within other interdependent systems

• incorporate clinical, social, and economic perspectives to address health care’s complexity when making decisions and assessing efficacy

Human Factors Principles

• systems view of quality improvement that focus on relationships between quality problems and the system in which they occur

• concepts about the design of work that take advantage of the strengths and weaknesses of the human mind and compensates for its limitations

• reduce reliance on memory (CDS)

• simplify and standardize (rules, pathways)

• use protocols and checklists (decrease confusion, reminders)

• use mechanisms to physically prevent error (constraints, forcing functions)

• improve access to info (integration of EHRs)

• decrease reliance on vigilance (integration of CDSS, DUR)

• differentiating

• implementing automation (barcoding, robotics)

Human factors engineering

• deals with computer and human systems and processes and provides a methodology for designing and evaluating systems as they interact with human beings

• focus on how systems work in actual practice with real and falliable human beings at the controls and attempts to design systems that optimize safety and minimize the risk of error in complex environments

Quality Control (CQ)

• the activity of checking goods as they are produced to make sure that the final products are good

• defect detection with problems addressed after they occur

Quality Assurance (QA)

• a program for systematic monitoring and evaluation of various aspects of a project, service, or facility to ensure that standards of quality are being met

• focus is strictly on quality, regardless of cost

Quality Improvement (QI)

• a process of approaching systemic problems in healthcare and aims to achieve predictable outcomes from these processes that improve pt care

• processes have characteristics that can be measured, analyzed, improved, and controlled

• continuous effort to achieve stable and predictable process results to reduce process variation and improve outcomes of processes for pts, orgs, and system

Quality Assurance main characteristics

• individual focused

• perfection myth

• solo practitioners

• peer review ignored

• errors punished

Quality improvement characteristics

• systems focused

• fallibility recognized

• teamwork

• peer review valued

• errors seen as opportunities for learning

Continuous Quality Improvement (CQI)

• continual improvement of processes associated with providing a good or service that meets, or exceeds, customer expectations

• aka QI process, Total quality management, or total quality control

• represents total systems perspective concerning quality

• requires that QI process is continuous or never-ending

• promotes identification of the cause of a problem via fact-based management and scientific methodology

• constantly striving for improvement in every aspect of the med use system

• continually improving the process/product without sacrificing quality

• cost reduction falls under CQI

• QA+CI=CQI

Core concepts of CQI

• plan

• design

• measure

• assess

• improve

• based on scientific model (background→ methods→results→conclusions/recs)

Deming PDSA

• plan, do, study, act

• model for improvement

• have aim (specific outcomes), measures (appropriate measures to track success), and changes (identify key changes you will actually test)

• have multiple PDSA cycles

Lean

• create value for customer by minimizing/eliminating waste

• origin: toyota

• uniformity in process output to increase value for customer

Six sigma

• reduce defects by solving problems

• removal of variability in process

• origin motorola

• outcome: reduction in flow time to increase quality

lean six sigma

solving problems and improving processes to be faster and more efficient

FMEA

• failure mode and effects analysis

• prospective

• identify areas for QI before they become problematic

RCA

• root cause analysis

• retrospective

• systematic process used to identify exact cause of problem

• used after quality problem discovered to prevent recurrence

• identify what issues could have contributed to the quality problem

CQI team improvement

• interdisciplinary

• include those who are a part of, or will be affected by, the plan

• subject matter experts

• decision makers

• frontline personnel

• diversity promotes effective team function (higher variability in ideas, creativity, innovation)

CQI process and outcome measures

• used to assess progress toward goals

• use mixture of both

• measure what is important (vs easy)

• do not measure things you cannot change or interpret

• is data not already collected or being collected, devise plan to collect

• plan for statistical analysis to ensure you are collecting all necessary info

Compliance

quality standards put forth by many agencies or associations

Mandated CQI

QI activities required as part of accreditation, registration, licensing, and certification processes

QI and compliance

• department of health

• board of pharmacy

• DEA: audit pharmacies and wholesalers

DOH/BOP QI rules

require pharmacy to establish CQI program with review at least every 3 months with planned process to record, measure, assess, and improve the quality of pt care and the procedure for reviewing quality related events

The Joint Commission

• TJC

• independent, non-profit focused on continuous improvement of health care for the public

• responsible for evaluation, provision of guidance, and granting of accreditation to health care orgs/programs

• hospital, ambulatory care, home/behavioral health care, independent clinical labs

• NOT retail pharmacy unless owned/operated by TJC accredited health system

• voluntary participation (but viewed as mandatory for prestige and reimbursement status)

• key dimensions: efficacy, appropriateness, abailability, timeliness, effectiveness, continuity, safety, efficiency, respect, caring

• national pt safety goals (NPSG)

• medication management standards (MM)

National Committee for QA

• NCQA

• independent non-profit that performs quality care reviews with standardized quality measurements

• reviews and accredits broad range of healthcare programs

• health plans, pt-centered medial homes, preferred providers orgs, and independent physicians

• points the way to healthcare that science says works

• studies how well health plans and doctors provide scientifically recomennded care

• identifies orgs that are run in ways that make care better

Health Plan Employer Data and Info Set

• HEDIS

• tool to measure performance developed by NCQA

• used by >90% of US health plans to measure performance

• >90 performance measures over 6 domains

• domains; effectiveness of care, access/availability to care, experience of care, utilization and risk adjusted utilization, health plan descriptive information, measure collected using electronic clinical data systems

• standardizes health plan performance data allowing for normalization and comparison

• healthcare purchasers and consumers → informed decisions

• health plan → where to focus quality improvement

• many measures involve med management

Leapfrog group

• national nonprofit org driving movement for giant leaps forward in quality and safety of American health care

• developed to create a market that rewards quality by providing quality, safety, and efficiency info to consumers

• utilizes process and outcome measures to assign letter grades (safety grades) to hospitals, outpt, and ambulatory surgery centers based on record of pt safety, helping consumers protect themselves from errors, injuries, accidents, and infections

Pharmacy Quality Alliance

• PQA

• national non-profit quality org

• non-accredited

• healthcare educator, researcher, stake-holder engagement

• dedicated to improving med safety, adherence, and appropriate use

• used by many value-based programs (CMS part D star ratings program)

• metrics focus on 6 areas: adherence, appropriate med use, med safety, MTM, opioid prescribing practices, specialty meds

Agency for Healthcare Research and Quality

• lead federal agency charged with improving safety and quality healthcare for all Americans

• AHRQ develops the knowledge, tools, and data needed to improve the healthcare system and help consumers, healthcare pros, and policymakers make informed health decisions

• AHRQ+DOD devleoped TeamSTEPPS, training program designed for health care pros to improve pt safety, comm, and teamwork skills