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HealthInforma.cstoTrackQuality
LeoAnthonyCeliMDMSMPHIns.tuteforMedicalEngineeringandScience,MIT
BethIsraelDeaconessMedicalCenter,HarvardMedicalSchool
Everysystemisperfectlydesignedtoachievetheresultsthatitgets.
WhatisQuality?
• Noclear,universallyagreedupondefini.onofhealthcarequality
• Mul.pledefini.onsexistfromdifferentorganiza.onsandrepresentthevaluesoftheorganiza.on
• Safe• Effec.ve• Pa.ent-centered• Timely• Efficient• Equitable
SixWorthyAimsaccordingtoIHI
• Noneedlessdeaths• Noneedlesspainorsuffering• Nounwantedwaits• Nohelplessness• Nowaste
Iftheairlineindustrytoleratedtheerrorratethathealthcareindustrydoes,therewouldbe3jumbojetcrashesevery2days.
WhyisHealthcareUnsafe?
• Lackofawarenessofmagnitudeoftheproblem
• Perceivedasunusualevents–“outliers”• Pooroutcomesfromerrorblamedoncomplica.onofdiseaseorinherentriskofprocedure,e.g.hospital-acquiredinfec.on
WhyisHealthcareUnsafe?
• Healthcareculturenotpar.cularlyconduciveforerrordetec.on
• Mistakesareunacceptable• Errorasfailureofcharacter– “Youweren’tcarefulenough.“– “Youdidn’ttryhardenough.”
• Relianceonindividualsnottocommiterrorsratherthanassumingthattheywill
MedicalerrorsarecommiZedbycompetent,caringpeopledoingwhatothercompetent,caringpeoplewoulddo
“Qualityproblemsoccurnotbecauseofafailureofgoodwill,knowledge,effort,orresourcesdevotedtohealthcare,butbecauseoffundamentalshortcomingsinthewayscareisorganized.”
BUTHealthcareisDifferent!
• Anesthesia:1deathper200,000cases25xmoredangerousthanflying• Morethan155,000possiblediagnoses,morethan7,800possibleinterven.ons
• Industriesofhighintrinsichazardsarealsocomplicated(andyetmuchsafer)!
• Maindifference:organiza.onanddesign
OtherHighRiskIndustries:• Focusedonintegra.ngnewdiscoveriesanddisciplinesintowell-harmonizedsystems
• Relentlesslyrigorousiniden.fyingwhendesignsareinadequate
• Constantlylookoutforunan.cipatedoutcomes• Detec.ngerrorsandconver.ngthemintoexper.searecrucialtoopera.ons
Healthcarevs.OtherHighRiskIndustries
Healthcarevs.OtherHighRiskIndustries
Healthcare:• Organizedaroundguilds(doctors,nursing,pharmacy)
andspecial.es• “Design”aresultofhistorical,poli.calandeconomic
forces,nottheanaly.calconsidera.onofhowtoachievethebestresults
• Nursesanddoctorsexpectedtoconstantlyworkaroundto“getthejobdone”
• SamebaZlesfoughteverydaybutliZleheadwayinmakingthingsbeZer
The definition of insanity is continuing to do the same thing over and over again and expecting a different result.
BarrierstoQualityImprovement• Old-stylecontrol-orientedmanagement• Strongsenseofprofessionalhierarchyanden.tlement
• Lackofintegra.onofthehealthcaresystemwithcommunityresources
MeasuringQuality
ElementsofQuality:1.Applica.onofevidence-basedinterven.onstoindividualpa.ents
everysingle.me
Evidence-BasedMedicine
• Prospec.verandomizedcontrolledtrial(PRCT)isconsideredgoldstandard
• PRCTs– provideaverageeffect– evaluates1interven.onata.me– haveinclusionandexclusioncriteriathatlimitexternalvalidity
• Errorsandbiasesabound:1/3ofthemostcitedoriginalclinicalresearchlaterrefuted(Ioannidis,JAMA2005)
“… half of what we know might be wrong, and the other half useless…”
Evidence-BasedMedicine
• 2007analysisof>1000Cochranesystema.creviews– 49%:currentevidencedoesnotsupporteitherbenefitorharm
– 96%:addi.onalresearchisrecommended
• Mostofwhatcliniciansdohasneverbeenformallyputtothetest
Measuring“effec.vecare”islimitedtoafewdiagnosesand
narrowinscope.
ElementsofQuality:Service
Compassion
Goodpa.ent-providercommunica.onShareddecision-making
• Pa.ents’percep.onofqualityiscoloredbywhetherornottheirexpecta.onsweremet.
ElementsofQuality:3.Teamworkandcultureofquality
CultureofQuality
• Pertainstohoweverymemberofthesystem,healthcareproviderornot,isempoweredandcommiZedtoimprovingprocessesandcon.nuouslearning
• Notcurrentlymeasuredbyhospitalaccredita.onorganiza.ons
• Pa.entsandprovidersareopenoblivioustothiselementofquality
TheHolyGrail:DigitalQualitySystem
• Tracksallthecomponentsofqualitycon.nuouslyandinreal-.me(vs.episodicretrospec.vereports)
• Providesac.onableitemsatthepoint-of-care
WheredoesmHealthcomein?
mHealthandQualityImprovement
• Providesevidence-basedmedicineatthepoint-of-careandallowsstandardiza.onofcare
• Facilitatescommunica.onbetweendifferentprovidersandbetweenpa.entsandproviders
• Documentsprocessesofcareandoutcomesinamachine-readyformatforresearch
SecondaryAnalysisofHealthData