HA 3344 Exam 1 DR.Pradhan

What is quality? Who is it measured by?

Quality is a measure of the degree to which a good or service meets established standards or satisfies the customer.

The customer and the producers

What is healthcare quality?

Health care quality is optimal care from the appropriate provider in the most appropriate setting in the most appropriate manner for the patient's unique circumstances

-Right care, right place, right time, right cost

What are the 5 D's of HC quality?

Death, disability, disease, discomfort, dissatisfaction

What are opportunities for better hc quality?

-Evidence-based medicine

-Knowledge-based management (engineering-hc partnership, adoption of EHRs)

-More active role from consumer (self-care, internet, consumer-directing hc savings account)

-Machine learning and AI

Levels of the Healthcare System

Level A: Patient

Level B: Microsystem

Level C: Organization

Level D: Environment (political, social, economic)

System Stability characteristics

-Structure of a system is the primary mechanism producing an outcome

-No system is stable

Performance is modified and controlled by __________?

Feedback

Feedback is defined as:

A problem of feedback is:

-any reciprocal flow of influence

-Delay

Two types of feedback

Reinforcing or balancing

What is operations management?

the design, operation, and improvement of the processes and systems that create and deliver the organization's products and services. Goal is to produce and deliver the organization's products more effectively and efficiently.

Operations management in hc organizations

-Control costs

-Improve level of service

-Improve quality

What is the current U.S. health expenditure as percent of GDP in 2019?

17.8%

What is Frederick Taylor known for?

-The Principles of Scientific Management (1911)

-"Wasted" human effort

-One best way

-Four Principles: Standard work, training, cooperation, planning

Frank and Lillian Gilbreth

-One best way to complete a task, the specific process that should be done

-Time and motion studies- reduce the number of motions in a task, increase efficiemcy

-Cheaper by the Dozen

What tools were used for project management?

-Gantt chart

-Program evaluation and review technique (US Navy)

-Critical Path Method (Dupont and Remington Rand)

Ignaz Semmelweis

handwashing reduces deaths

Florence Nightingale

cut hospital deaths by improving the food, clothing provided to patients, reduced overcrowding, and ventilating the wards

Ernest Codman

American physician known for championing long-term follow up patients, peer comparison and public release of medical results. Believed all patients should be tracked for at least one year to determining outcome of care.

Walter Shewhart

Statistical Process Control (SPC) and Plan-Do-Check-Act (PDCA)

W. Edwards Deming

-father of the quality movement

-1970s energy crisis

-Common cause vs special variation

-14 points

-System of profound knowledge (appreciation for a system, knowledge about variation, theory of knowledge, knowledge of psychology)

Joseph M. Juran

Quality trilogy:

-Quality planning

-Control

-Improvement

TQM (Total Quality Management)

-less codified than Six Sigma

-based on teachings of Shewhart, Deming and Juran

-Top management support and leadership

-Continous improvement

-Define, measure, analyze, improve, implement, control (DMAIIC), PDCA

-Six Sigma goal of 3.4 defects per million opportunities (DPMO)

Quality Certification- ISO 900

-To be certified, an organization must demonstrate compliance with the standards

-Standards are concerned with the processes of ensuring quality

Quality Award- Baldrige Award

-Based on organization excellence in seven categories

-Dissemination of best practices

Just In Time (JIT)

Inventory management strategy aimed at reducing inventory

Lean

Philosophy of eliminating waste

Agile

ability to respond quickly to changing conditions

Supply Chain Management

encompasses the planning and management of all activities involved in sourcing and procurement, conversion, and all logistics management activities. It also includes coordination and collaboration with channel partners, which can be suppliers, intermediaries, third-party service providers, and customers.

In essence, supply chain management integrates supply and demand management within and across companies.

Performance Improvement

Improve the quality, safety, efficiency, and effectiveness of healthcare using knowledge-based tools, techniques, and programs for system improvement.

Medical Decision-Making Process: Overuse

delivery of care when the medical risks exceed the expected benefit

ex. CT scan: 200 x Xray radiation

Medical Decision-Making Process: Underuse

the failure to deliver medical services when benefits exceed risk

ex. not prescribing aspirin for patients with history of chest pain

Medical Decision-Making Process: Misuse

occurs when interventions are used improperly

ex. wrong medicine

Medical Decision-Making Process: Small Area Variations

occurs when a proper medical treatment is selected but a deliver error occurs

ex. right medicine, inconsistent dosing

Medical Decision-Making Process: David Eddy

Author of a series of articles on clinical decision making emphasizing the roles of medical evidence and patient preferences

Medical Decision-Making Process

1. Evidence

2. Analysis-clinical judgement

3. Treatment Options- beneficence, non-maleficence

4. Analysis- patient preferences (autonomy)

5. Treatment Decision- justice

James Reason

author of Human Error known for his classification of error types, how they arise and may be prevented, and how people respond to error

Planning errors

an error arising from the selection of inappropriate means to pursue an end (wrong plan)

Storage errors

an error arising from a lag between the formulation and execution of a plan (wrong time)

Execution errors

an error arising from a lag between the formulation and execution of a plan (wrong execution)

Skill-based errors

an error arising from a lag between the formulation and execution of a plan (wrong person)

Rule-based errors

misapplication of good rules or application of bad rules (wrong policy)

Knowledge-based errors

the inability to analyze and evaluate a situation and devise an effective action plan (wrong ability / capability)

Small Area Variations & John Wennburg

John Wennberg medical researcher known for documenting wide differences in utilization of medical treatment across relatively homogeneous populations

Practice style

the impact of medical education and colleagues on choice of treatment a physician selects for a patient

Supplier-induced demand

the ability of suppliers to stimulate the demand for the product they sell

Target income hypothesis

a model under which a physician selects a desired income and adjusts the volume of services he or she provides to produce the desired income

Practice Guidelines & Brent James

Brent James physician known for advocating greater standardization of medical practice (RCTs, clinical pathways, clinical practice guidelines)

Randomized controlled trial (RCTs): a study design that assigns subjects to experimental or control groups by chance to minimize selection bias and compare outcomes

James describes the process of developing a guideline for adult respiratory distress syndrome (ARDS). This work was motivated by a mortality rate of two-thirds for ARDS patients, a somewhat defined ventilator therapy treatment process that identified high-risk patients (those with a 10% chance of survival), and the development of a new treatment (ECCO2R).

The effect of this initiative was enormous. Patient survival rates increased to 38% compared to 9% to 15% in other institutions (James 1993)

Avedis Donabedian

healthcare quality advocate known for the structure-process-outcome paradigm

Structure-process-outcome

model for examining health care quality by focusing on resources, what is done, and the effects of care

Structure identifies the context in which health care is delivered, what resources are used, and how decisions are made

Process assesses whether care is delivered according to generally accepted standards

David Nash- Three Faces of Quality

provides one road map for quality improvement in health care

Three Faces of Quality: system for health care improvement focusing on quality management theory, medical practice tools, and outcomes

Quality Management Theory

Body of knowledge that provides the foundation for quality improvement efforts

Medical practice tools- Outcomes management, Disease management, Physician profiles

set of tools to document how care is delivered, provide comparisons to other providers, and supply information to assist medical decision making

Outcomes- Evidence Based Medicine

the use of the best available medical research to inform medical decision making and treatment

Outcomes- Clinical Practice Guidelines

a scientifically determined set of specifications for the provision of care to typical patients in given disease or injury categories

Outcomes- Case management

a system to improve health care treatment for specific patients, typically high-risk or high-cost patients

Sensitivity & Specificity in Outcomes Analysis

Sensitivity: the probability of a positive test (outcome) given the presence of disease/condition

Specificity: the probability of a negative test result given the absence of disease

Controlling Variation & Improving Outcomes

1. Identify high-risk patients

2. Provide resource use incentives

3. Identify and act on outliers

4. Continuously improve

5. Implement disease management programs

6. Provide provider-level information technology

7. Encourage the practice of EBM

8. Involve patients in care process

9. Control capacity

Evidenced-Based Medicine

use of the current best evidence in making clinical decisions about the care of individual patients by integrating individual clinical expertise with the best available clinical evidence from systematic research...

-improves clinical outcomes and reduce costs

History of EBM

David Sackett- Father of EBM

Gordon Guyatt- coined the term

Little emphasis on patient values and preferences

"Cookbook" medicine

Current Status of EBM

-Growing rapidly

-Advances in research methods

-Many physicians not practicing medicine based on current evidence

-Many published studies are false or have misleading conclusions

What is the chronic care model?

-population based outreach

-treatment sensitive to patient's preferences

-most current EBM is employed

What is a healthcare home?

Care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate and culturally effective

3 Components for success:

1. Individualized and intense caring for patients w/ chronic illness

2. Efficient service provision

3. Careful selection of specialists

Clinical Guidelines

developed to assist physician and patient decisions about appropriate healthcare for specific clinical circumstances

What are some obstacles to the use of guidelines by physicians?

-Lack of knowledge of why guidelines exist for specific conditions

-Lack of familiarity

-Disagreement with guideline recommendation

-Inability to effectively apply due to lack of skill, resource, training

-Lack of trust to improve outcomes

-Resistance to change

-External factors

Clinical guidelines obstacles for patients:

-Patient characteristics

-Difficulty recognizing symptoms and adhering to therapies prescribed

-Complex therapeutic regimes

-Relationship and personal interaction b/w patient and physician

Archimedes Model

A full-scale mathematical simulation of human physiology that can be used to test the effect of diseases and their treatments

Standard and custom care: Model A Separate and Select

-Provides initial sorting by patients themselves

-If the patient doesn't meet the clinical conditions by the provider then the patient will get referred to a provider who can offer customized care

ex. specialty hospitals or walk in clinics inside a pharmacy or retail clinics

Standard and custom care: Model B Separate and Accomodate

-two methods into one provider organization

-Patients are initially sorted, those who need standard care are cared for by a nurse practitioner using the standard care

-Remaining patients are cared for using custom care

-Nurse practitioner and physician come together in best interest of patient

Standard and custom care: Model C- Modularized

-This is when the clinician goes from the care provider to the one who designs the care for the patient

-A patient who needs multiple departments of care will need a care plan so the clinician designs the care plan

Medicare Value Purchasing Program

-rewards better value, outcomes and innovations instead of merely volume

-Goal is to enhance quality and better experience for patients

What are HC facilities graded on? 3 main categories:

1. Mortality rates & complications

2. HC associated infections

3. Patient safety

4. Patient experience

5. Process

6. Efficiency and cost reduction

1. Quality

2. Patient Experience

3. Cost of care

CMS scores hc facilities based on:

1. Achievement

2. Improvement

Calculation: (clinical processes of care x 70%) + (patient experience x 30%)

Value-based purchasing funding

-Govt holds approx. 2% of all medicare funding for the value-based purchasing program

-Based on facilities scores, they receive funding from the govt

Clinical Decision Support

-Works along with EHRs

-Helps to assist medical professionals in decision making for patients

-Uses the patients medical history, EBM, physician knowledge and the interface

Institute for Clinical Systems Improvement

-Builds a criteria for running tests on patients

-Works hand-in-hand with the patients EHR

Risk Adjustment

Raising or lowering fees to providers based on the basic factors

What is pay for performance?

A logical tool used to expand the use of EBM in the financing system

Medical vs Economic Decision-Making

Need-Based Decision Making: centered solely on what treatment is necessary

Economic Decision Making: based on choice and opportunity cost rather than needs

Public Interest Theory vs Capture Theory

Public Interest Theory: the idea that regulation is instituted for protection of society and not particular interest

Capture Theory: the idea that over time regulation ceases to protect society and is continued in order to serve the regulated entities

Occupational Licensing

-States have the legal right to restrict access to occupations such as medical practice and nursing

-Barrier to entry

-not totally effective in satisfying the public's demand for quality or accountability

-State medical boards continue to restrict the information the public can access regarding licensure actions

Suspension statistics

-10,000 complaints towards California physicians each year

-80% of claims do not survive an initial review, another 15% are eliminated from further action

-Prosecution only recommended for one in four of remaining cases

-Half of the cases eventually result in disciplinary action

-Approx. .24% of physicians were disciplined

-Males, older practitioners, international graduates, non-board certified, family practice, more likely disciplined

-Having more than one violation doubles probability of license revocation

What fields were associated w/ higher rates of license revocation?

anesthesia, general practice, and psychiatry

Facility Licensing

-similar to occupational licensing, focuses on personnel but also covers issues of organizational structure, services offered, equipment and facility standards, safety and sanitation, and record keeping

-Multiple states initiated certificate of need (CON) laws to control health care capacity

CON (certificate of need) laws

require state approval to expand bed count in order to avoid overcapacity, which could stimulate unnecessary demand for hc services

In Texas, how does the Department of State Health Services define what a hospital is?

-a facility with the capability to provide round-the-clock medical care for two or more persons, and a minimum set of medical services, including lab, x-ray, and surgery

-The department has developed rules defining minimum standards for procedures, fees, operational requirements, inspection and investigation procedures, construction, fire prevention and safety requirements, and potential licensure actions, including denial, probation, suspension, and revocation (Texas DSHS).

When did external nongovernmental evaluation of hospitals begin and who started it?

-1917

-American College of Surgeons (ACS) later evolved into the Joint Commission

Accreditation

-received a large boost when Medicare was enacted and required "deemed status" for hospitals to be eligible for reimbursement

Joint Commission

-establishes standards and audits health care organizations' compliance with these standards

What do the JC standards cover?

-provision of care, treatment, and services (PC)

-ethics, rights, and responsibilities (RI)

-surveillance, prevention, and control of infection (IC)

-medication management (MM)

-improving organizational performance (PI)

-leadership (LD)

-management of the environment of care (EC)

-management of human resources (HR)

-information management planning (IM)

-medical staff (MS)

-nursing (NR)

Does Accreditation improve quality?

-Miller et al. (2005) sought to determine if Joint Commission scores (0-100) were correlated with 15 quality indicators

-None of the 15 quality indicators was found to be correlated with the accreditation score.

Credentialing

-The task of granting staff privileges falls to the credentials committee of the medical staff

Malpractice exists to address quality problems when patients are injured. Legal action serves what 2 purposed?

1. To compensate patients for harmful wrongs

2. To deter similar actions in the future

Economics of HC Markets

-HC reimbursement has had a significant effect on how much health care is produced and how it is delivered

Economics in Healthcare

-HC is different

-Insurance creates a moral hazard for use

-Copays disincentives that moral hazard

-Budget constraints affect consumer decision makings

-More is not always better (diminishing marginal utility)

-Demand outstrips supply and is inelastic

Pay for performance

-is an explicit attempt to increase provider revenues for organizations that deliver high-quality care and to decrease payments for poor-quality care.

Pay for performance 4 major issues?

1. What to reward

2. Size of the reward

3. Whether to reward high performers or those achieving greatest improvement or both

4. Whether awards will be given to individuals, teams, organizations, or all the above

Does pay for performance work?

-Studies show no big difference

-Where incentives exist for performance measures in government-owned facilities, there is a higher prosperity for fraudulent activity

Data vs. Information vs. Knowledge

-Knowledge is what we know.

-Data is/are the facts of the World.

-Information allows us to expand our knowledge beyond the range of our senses. We can capture data in information.

What is a process analysis tool?

A tool (often statistical or graphical) to help analyze a process

-If you can't draw a process then it isn't a process

Uses of Process Analysis Tools

1. Identify problems

2. Identify the potential/primary causes of problems

3. Identify potential solutions and select a solution to be implemented

4. Monitor implemented solution, did the solution reduce or eliminate the problem?