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Top Management’s Needs and Responsibilities for a Quality Programme
Shane SolomonShane SolomonChief ExecutiveHospital Authority, Hong KongChief ExecutiveHospital Authority, Hong Kong
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Fire!
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Mad cow’s disease!
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“We won’t operate with him anymore”
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So what does top management need from a quality programme?
Do no harm!!!!
BUT HOW????
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What is quality of care?
In short:1. The outcome is what you expected (no mistakes, no surprises)2. Service intervention (treatment) is based on the best available
evidence (appropriate care)
(Institute of Medicine, Committee to Design a Strategy for Quality Review and Assurance in Medicine, 1990)
“Degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”
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What is the Hospital Authority, Hong Kong?
No. of hospitals and institutions
No. of beds
A&E attendances (2006/07)
Outpatient attendances (2006/07)
27,800
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2.1 million
Specialist: 7.2 million General practitioner: 4.8 million
Bed days 7.4 million (91% market)
Staff and organisation 53,000 staff in 7 Clusters, all part of a single organisation
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The Clinical Governance Loop
Monitoring performance
Define quality at your place
Programmes and incentives
to improve quality
Quality diagnosis
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First, define quality at your place
Guidelines
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First, define quality at your place (cont’d)
Clinical Pathways
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First, define quality at your place (cont’d)
Appropriate management checkliste.g. adult patients with acute stroke
• Received treatment in an ASU • Received CT/MRI of brain ≤12 hrs of A&E registration• Not to give short acting antihypertensive (nifedipine) ≤3 days of
admission• 7-day case-fatality• Screened for swallowing disorder ≤24 hrs of admission• Received aspirin/plavix ≤48 hrs of admission• Received warfarin for AF• Assessed by PT ≤
3 days of admission• Assessed by OT ≤
7 days of admission• Prescribed aspirin/plavix on discharge
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Standards
First, define quality at your place (cont’d)
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Second, diagnose qualityIncident reporting system
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Essential local management tool for dealing with individual incidents, but how can this
information improve system quality?
Second, diagnose quality (cont’d)
Advanced Incident Reporting System (AIRS)
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Advanced Incident Reporting System:
13,000 incidents per annum
Risk stratification:
Second, diagnose quality (cont’d)
Insignificant Minor Moderate Major ExtremeSI=0,1 SI=2 SI=3 SI=4 SI=5,62,025 1,128 129 82 23
Actual Outcome Risk Quantification Summary Report by Date of Occurrence
Outcome (Jul - Sept 2007)
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AIRS - Nature of Incidents (Jul - Sept 2007)
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Second, diagnose quality (cont’d)
Mandatory reporting of 9 types of Sentinel Events
1. Surgery / interventional procedure involving the wrong patient or body part.2. Retained instruments or other material after surgery / interventional procedure requiring re-
operation or further surgical procedure.3. Haemolytic blood transfusion reaction resulting from ABO incompatibility.4. Medication error resulting in major permanent loss of function
or death of a patient.5. Intravascular gas embolism resulting in death or neurological damage.6. Death of an in-patient from suicide (including home leave). 7. Maternal death or serious morbidity associated with labor or delivery.8. Infant discharged to wrong family or infant abduction.9. Unexpected death or serious disability reasonably believed to be preventable (not related to
the natural course of the individual’s illness or underlying condition). Assessment should be based on clinical judgment, circumstances and context of the incident.
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• Report within 24 hrs• Investigation team within 48 hours &
may include external experts• Root Cause Analysis within 6 weeks• Final report by hospital CE to HAHO
within 8 weeks• Local follow-up action• Publication of learnings
Second, diagnose quality (cont’d)
FOCUS ON SENTINEL EVENTS
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Second, diagnose quality (cont’d)
Clinical AuditComparative Audit 2002- 2007
Mortality
Mortality and survival
YesEsophagectomy – second auditCa rectum
Waiting time of operations
2006-2007
MortalityMortality and survival
YesYes
Emergency colectomyThoracic surgery
2005
Trendmortality
NoYes
Laparoscopic surgery Whipple’s operation
2004MortalityYesTotal cystectomy2003
Focus of comparisonRisk-adjustmentTopicsYearMortalityNo
NoNo
HepatectomyEsophagectomyLiver Transplantation
2002
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Second, diagnose quality (cont’d)
e.g. Esophagectomy audit showed 11% mortality at first audit (1997 to 2001). This improved to 5% in the second audit in 2006.
0
5
10
15
20
1997 1998 1999 2000 2001 2002 2003 2004 2005
% Mortality: Esophagectomy, Hospital Authority, HK
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Third, do something – programmes and incentives to improve qualitySome examples:• Antibiotic Stewardship Programme
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Third, do something – programmes and incentives to improve quality (cont’d)
Hospital A
All HA
Hospital B
Hospital C
-2%
-10%
-27%
+23%
% change
47.8
63.1
36.3
50.1
2007
48.9
69.7
49.6
40.8
2005
Antibiotic Stewardship Programme Outcomes (DDD per 1,000 beddays)
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Third, do something – programmes and incentives to improve quality (cont’d)
“3 checks, 5 rights”
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Third, do something – programmes and incentives to improve quality (cont’d)
“3 checks, 5 rights”
• Nurses from 7 hospitals (n = 64)1st check:10 different interpretations 2nd check:11 different interpretations 3rd check:11 different interpretations
1st CHECK 2nd CHECK 3rd CHECK
Check Patient Check drug Check dosage
Take MAR Check when taking drug from trolley Check 5Rs
Check doctor’s prescription for 5 Rights
Check drug in patient’s bin for 5R Before pouring out drug
Take drug from cupboard to trolley
Check drug bottle against MAR After pouring drug
Take bottle from trolley Take drug from pack / bottle / container
After returning drug to trolley and before giving to patient
Take drug from bottle / packs Check when removing cap When closing the bottle
Check before taking drug from patient’s bin / cupboard / trolley / container
Check before taking / pouring drug out
Before giving drug to patient
Check the drug pack Check after taking / pouring drug out Check MAR when giving drug to patient
Check drug against pack Check before leaving trolley Attend patient
Check before giving to patient Ensure patient take drug
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Third, do something – programmes and systems to improve quality (cont’d)
“3 checks, 5 rights”– not even the experts agree
Authors 1st check 2nd check 3rd checkBigelow-Kemp & Pillitteri
Read the label for name, dose, and route as select the bottle or package
Recheck the labe l before pour it or open the package
Recheck the label against the order before return the stock bottle to the shelf or dispose of the package
Houghton & Whittow
Read the label on the bottle before removing it from the shelf
Read the label on the bottle before pouring out the dose
Check once more (right medicine & right dose) to ensure taking it to right patient
Taylor et al Select medication from the drawer compare with the medication order. Check expiration dates
Check each medication package, card, or preparation with the order as it is poured
Recheck all medications once again (for one patient) with the medication order before taking them to patient
Verolyn Barnes Bolander
Compare medication label with medication card, read entire label, including expiration date
Make certain dose has been calculated accurately.
Check medication card against medicine bottle again when return it to storage
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Third, do something – programmes and systems to improve quality (cont’d)
“3 checks, 5 rights” – simplified model
DrugConfirm right drug, time,
route, dose
PatientEnsure right patient
(2nd check)(3rd check)
PrescriptionIdentify right prescription
(1st check)
‘3 Checks &5 Rights
Principle’
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Third, do something – programmes and systems to improve quality (cont’d)
“3 checks, 5 rights” – simplified model (cont’d)
Pre(12 months before)
Post(12 months after)
Post-post(another 6 months)
Incidence rate per 1,000 patient bed days
0.55 0.38(↓31%)
0.31(↓44%)
Drugs administration incidents by nurses
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Third, do something – programmes and systems to improve quality (cont’d)
Numerous other HA programmes to improve quality, for example:• HA Drug Formulary to ensure appropriate use of medication• Hand Hygiene program• Electronic prescribing• Consistent bar coding to reduce risk of patient identification error• Patient consent systems• Patient falls programme• Pressure sores programme• Engineering risk management
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Incentives for quality
• US Medicare Pay for Performance• 33 clinical indicators over 5
conditions• 250 hospitals• 2% or 1% bonus if perform well• Led to significant savings through
reduced length of stay, less complications, less readmission
Defined evidence-based, consensus clinical measures•Acute myocardial infarction (AMI)
•Aspirin at arrival•Aspirin prescribed at discharge•ACEI for LVSD•Smoking cessation advice/counseling•Beta blocker prescribed at discharge•Beta blocker at arrival•Thrombolytic received within 30 minutes of hospital arrival•PCI received within 120 minutes of hospital arrival•Inpatient mortality rate
•Coronary artery bypass graft (CABG)•Aspirin prescribed at discharge •CABG using internal mammary artery •Prophylactic antibiotic received within one hour prior to surgical incision •Prophylactic antibiotic selection for surgical patients •Prophylactic antibiotics discontinued within 24 hours after surgery end time •Inpatient mortality rate•Post operative hemorrhage or hematoma•Post operative physiologic and metabolic derangement
•Heart failure•Left Ventricular Systolic assessment •Detailed discharge instructions •ACEI or ARB for LVSD
•Smoking cessation advice/counseling
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Finally, monitor progress
Three key means:1. Clinical KPIs2. Patient survey, patient complaints3. Ongoing audit (not only one-off)
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Finally, monitor progress (cont’d)
Clinical KPIs routinely used for monitoring Cluster and Hospital quality performance:• Standardised admission rate for A&E Patients• Utilisation of big gun antibiotics in acute general hospital (per 1,000 beddays)• Unplanned readmission rate
- Unplanned readmission rate for fracture hip- Unplanned readmission rate for stroke
• MRSA bacteraemia per 1,000 patient days• Surgical site infection (SSI) rate (under development)• Catheter associated bloodstream infection (SABSI) rate in ICU per 1,000 catheter days• % diabetes mellitus patients in outpatients with HbA1c checked in 12-month period• Day surgery and same day surgery rates• % of cancer patients requiring radical radiotherapy started within 28 days• % of adult acute stoke patients with CT scan of brain performed within 12 hours of A&E
registration• % of patients indicated for surgery on fracture hip with surgery performed within 2 days after
admission through A&E• Various waiting time indicators
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Finally, monitor progress (cont’d)
• Next phase of surgical clinical audit is 30,000 operations, using web-based data form, and 30 day post-operation check, adjusting for patient risk
Trigger Form Pre-Operation Post-Operation Printout
Surgical Outcomes Monitoring and Improvement Program (SOMIP)
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Critical Success Factors - Culture
Learning - always
No blame
Uncompromising commitment to quality
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Critical Success Factors - Technology
• Information technology
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Critical Success Factors - Technology
Paediatric
Adult
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Critical Success Factors: Clear Accountabilities
Secretary for Food and HealthSecretary for Food and Health
HA BoardHA Board
HA Chief ExecutiveHA Chief Executive
Director, Quality and Safety (HA Head Office)Director, Quality and Safety (HA Head Office)
Cluster Chief ExecutiveCluster Chief Executive
Hospital Chief ExecutiveHospital Chief Executive
Hospital/Cluster chief clinical administratorHospital/Cluster chief clinical administrator
Peer review (Mortality and Morbidity Committees)Peer review (Mortality and Morbidity Committees)
Front-line clinical levelFront-line clinical level
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Conclusion
Monitoring performance
Define quality at your place
Programmes and incentives
to improve quality
Quality diagnosis
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