Highlights from the 15th Annual National Forum of Quality Improvement in Health Care

December 4-5, 2003

 Sandy McGrath, RN, MSN

California Rural Indian Health Board, Inc.

 

Courage

The courage to face reality…

the courage to meet the people we help

on their terms, not ours…

the courage to become impatient…

the courage to recognize our habits are only habits…

the courage not to wait any longer…

the courage to cooperate with each other…

the courage to stop being satisfied with today’s averages.

                                                                                    -Dr. Paul Farmer

 

 The above except from Dr. Paul Farmer’s presentation encapsulated the conference theme of Courage.  It also touched on issues we have been working on at California Rural Indian Health Board, in the quality improvement project, over the last 2 ½ years, and is very relevant to the work still needing to be done. 

The courage to face reality:  Health care is in crisis.  This includes all of health care, not just the California Indian clinics.  Costs are high, and resources are short.  In order to provide quality care to our patients we must re-evaluate what we do and how we do it. We must become efficient with the resources that are available, including productivity of staff, automation of paperwork, and take advantage of current knowledge available and apply it.

The courage to meet the people we help on their terms, not ours:  We must look at our current patient teaching methods, and motives.  What does the patient want?  What are the patient’s goals? What does the patient believe he/she needs?  How can our knowledge help and how will they best receive it?  Self-management is the key.

The courage to become impatient:  Can we continue to work in a poor system where productive communication is always lacking?  Where the patient receives care that is just ”status quo”.  GPRA rates for our community are sometimes inching higher, but far from 100%. 

The courage to recognize our habits, are only habits:   Recognize that the complaints we voice when change is proposed are because we are stuck in a comfort mode.  Maybe because “We’ve always done it this way” doesn’t mean it is the best way.  Maybe it is the reason we have not improved our patient care, or our patient’s overall health status.   Defense of the status quo won’t help improve anything. Technology has continually improved the tools we work with….and have access to.  Using paper and pencil was a wonderful improvement from the stone age.  We are now in the year 2004 and must grow with the tools that are now available in order to provide the best care we are capable of.

The courage to not wait any longer: Our systems will not improve themselves if we continue to sit on the side lines and accept every day the same as the last.  Every day is an opportunity for improvement.

The courage to cooperate with each other: Building teams are essential.   This includes not only the clinical staff, but anyone who is involved in patient care, or a project.

The courage to stop being satisfied with today’s averages:  We must take a good look at today’s averages and plan for improvement.  Identify the areas of priority and make them a part of every day’s work, weave improvement into the system.  Don’t continue to accept the numbers as provided.  Take an active part in identifying why they are what they are and ways to make them better.

  

Presentations

The NextGen EMR  will be a valuable addition to quality improvement in the Indian Clinics who implement it, as presented below. 

 Using Patient Data to Improve Care

 Current practice in healthcare organizations (including Indian Clinics):

bullet Many flow sheets         
bullet Large folders with disorganized data
bullet Lost data
bullet Data does not integrate across conditions
bullet Data from periodic chart review and anecdotal impressions
bullet Difficult to identify groups & subgroups of patients in need of care

NextGen will be valuable in reporting “live data” for these principles.

Principles for Using Data to Improve Care

  1. Data flow is interactive and continuous.
  2. A condensed, evidence-based packaging of data is used at the patient/care team interface
  3. The data are available to the care team for proactive care activities in between encounters and to evaluate/improve population management.

 

Data Flow is Interactive and Continuous

bullet Any data available at any time (EMR)
bullet “Recent” data are not waiting for processing (as with RPMS).
bullet Questions can be asked of data (drill down) in a user friendly way.
bullet Measures and performance are evaluated regularly (constantly) holding up a mirror to your own performance.
bullet Integrated throughout the “system of care”
bullet All patients
bullet All services and locations
bullet At the Patient/Care Team Interface
bullet Pertinent data are gathered and organized in a condensed, user-friendly format (encounter note).
bullet Able to enter new data on the Encounter Note.
bullet Evidence-based guidelines impose content and layout of Encounter Note (e.g. o color for reminders).
bullet Full histories of patient data (e.g. cancer screening, labs, immunizations, etc.) available to the care team.
bullet Data customized for patient reports to the patients
bullet Proactive are Between Encounters
bullet Care team has access to easy to use (and create) queries that produce lists of patients who meet certain criteria, along with display of data
bullet Summary reports on key quality measures (for any sub-group of patients) produces regularly.
bullet More on Proactive Care (Using Reports)
bullet Patients not meeting evidence-based standard goas (Diabetic patients with A1c>7.0 not seen in past 3 months).
bullet Patients needing specific care (CAD patients not on Aspirin or Beta-blocker)
bullet Patients who need feedback on results (Pap Smear results)
bullet Summary Report
bullet Aggregates and enormous amount of patient care-related data for specific groups of patients over a defined time period
bullet Like a comprehensive chart review/report card for individual providers or groups of providers on rates of different process and outcome measures.
bullet To monitor and evaluate care and outcomes regularly
bullet Uses of the Summary Report
bullet To track measures over time- alert to undesirable trends as well as improvements.
bullet To evaluate measures after changes/interventions aimed at improvement have been implemented
bullet Having multiple pieces of data and measures together in one place enhances awareness of an insight into associations.
bullet Condensed summary data can act as a powerful motivator for improvement.
bullet Reports can identify “outliers” within a practice group in terms of rates of different measures.

 

 

Measuring System Level Performance 

Will all your local efforts and projects add up to great quality and value for those you serve?   What quality measures could you use to drive improvement of the system? 

bullet What metrics does your system use to measure the performance/quality of your health system?
bullet How well does this work?
bullet Does it link mission and strategy with actual performance/
bullet Is it a vital: dashboard” that guides the leadership of improvement at the executive level?

Approach to Measuring Quality

bullet Aim is system transformation to best possible quality
bullet Changing the entire system
bullet Calls for systemic change
bullet Calls for measurement of overall system performance

Working Towards Perfection

bullet How would we know if we were making progress?

Aim: to identify a core set of quality metrics….that form a system of measures….to drive quality improvement in health systems.

Approach

bullet Start with a balanced set of metrics that “people care about”
bullet Balanced – don’t make a change in one area that will mess up another
bullet When possible, show monthly trends over time (Excel spreadsheets visibly displayed)
bullet Build on existing data sources (GPRA, OSHPD)
bullet Cover the entire system rather than detailed measures of one component

Examples:

IOM Dimensions                                              Measures

1.  Safe                                                            Medication errors

2.  Effective & Equitable                                   Functional outcomes

3.  Patient-centered                                          Patient satisfaction

4.  Timely                                                         3rd available appointment

5.  Efficient                                                       Health care costs per capita

 

High Reliability Organization Tools to Improve Patient and Family Centered Care

 

Attributes of High Reliability Organizations

bullet Commitment to culture via Leadership, Human resource strategies Policies and Standards.
bullet Leadership must demonstrate and take quality seriously, employee satisfaction and patient satisfaction go hand-in-hand, enhance trust, competencies.
bullet Able to Operate in Centralized and Decentralized Levels
bullet Leadership from top, decision-making at front line, various levels of communication, communication of principles vs. detailed policies
bullet Reluctance to Simplify
bullet Take the time to look at data to identify what areas need to be worked on. Look at National Standards and issues.  Don’t take short cuts for quality,.
bullet Commitment to Resilience
bullet Mid-course correction strategies, local level changes as needed; problem-mitigation rounds, don’t just ignore, find out how issues impact staff and patients; post-event debriefings, pull everyone together…Where did it go wrong?   CEO is familiar with system issues.
bullet Preoccupation with Failure
bullet Maintain and review “glitch logs”, complaint letters, anonymous reporting