Transcript Dr. David A. Fishman - Hadassah Medical Center
Clinical Quality
תינילק תוכיא
הסדהבו םלועב
סיזרב ריאמ ' פורפ תינילק תוחיטבו תוכיאל זכרמה תירבעה הטיסרבינואהו הסדה םילשורי
www.hadassah.org.il/departments/quality
Definitions of Quality (Institute of Medicine)
Degree to which care increases likelihood of desired health outcomes & consistent with current professional knowledge
Safe Timely Effective Patient centered Equitable Efficient
Overuse (antibiotics, imaging) Underuse (prevention) Misuse (errors & complications)
Evidence-based Patient-centered
System-minded
Performance Evaluation
• • • • • Voluntary Quality Indicators Mandatory Performance Evaluation Public Data Including Individual Surgeon Pay for Performance Non-payment for Preventable Complications
Challenges: measurement error, socioeconomic confounders, manipulation, denial, gaming
Ego bias: “I’m above the average”
(Kahneman & Tversky. Heuristics and Biases. The Psychology of
Stages of Facing Reality*
Stage 1. “The data are wrong” Stage 2. “The data are right, but it’s not a problem” Stage 3. “The data are right; it is a problem; but it is not my problem.” Stage 4. “I accept the burden of improvement”
* Harvard Professor Don Berwick, Institute for Health Improvement
Donald M. Berwick, MD, MPP, FRCP Professor at Harvard School of Public Health President, Institute for Health Improvement, Boston, Massachusetts, USA
“In short, academic medical centers should not just have best knowledge, they should model the best execution …They do not. Unreliability, waiting, lack of focus on patient ’s needs and safety are every bit of characteristic of academic medical centers …and that needs not be the case. The same intellectual fervor and talent that allow places like the Brigham to raise the bar in technical clinical care can equally be used to raise the bar in the quality of medical care. …it’s going to take much more acute self-awareness among academicians and academic medical centers ….
…a duty to encourage healthcare leaders and clinicians everywhere to become involved in improvement."
Cycles of Improvement (Industry Model)
Statistical Process Control
PDSA
Example: monitoring of surgical infection rate is now recognized as important tool to prevention
Quality of General Intensive Care
Survival at Hadassah vs. Israel Average
Prof. Elisheva Simchen, Ministry of Health
p<0.001
Despite higher severity score, patients had better survival at Hadassah
Quality of Neonatal Intensive Care Survival at Hadassah vs. Israel Average
Dr. Zivanit Ergaz, Prof. Ilan Arad & Gertner Institute
Quality of Treatment in Trauma
Mortality at Hadassah vs. US level I centers
Dr. Yoav Mintz, Ms. Irina Gertcenchtein & Prof. Avraham Rivkind
30% 20% 10% 0%
US National Trauma Data Bank from 51 level-I trauma centers, n= 263,524 14.4% 5.3% 3.2%
1999
5.8% 2.6%
2000 2001
20.2% NTDB - Total Mortality Hadassah data Israeli National Trauma Registry n=7,391 19.6% 13.6% 13.4% 11.5% 5.5% 2.7% 5.8% 2.9% 6.7%
2002 2003
2.1%
Quality indicators for myocardial infarction, Hadassah vs. US data
Hadassah ( %) 89 90 50 83 69 44’ 102’ Referral to cardiac rehabilitation only 21%
%
Percent of patients receiving
Before After Intervention
p<0.001
p<0.001
p<0.001
p<0.02
Catheter-related Bloodstream Infections
Intervention in 108 ICU ’s resulted in 66% reduction in rates of catheter-related bloodstream infection
Catheter-related Bloodstream Infections
I. Gross, S. Benenson, M. Cohen, C. Bloch
At Hadassah, baseline observations over five months revealed a rate of infection of 13.2% (42/318 catheters), on the high side of reported ranges.
Observations in ICU ’s and OR: aseptic conditions not always strictly kept during catheter insertion.
Intervention included discussion of results with staff, training for correct aseptic technique, use of a checklist, and authorization to nurses to feedback and stop physicians breaching asepsis.
Survival Function for patterns 1 - 2
1.0
Catheter-related Bloodstream Infections
Survival Function for patterns 1 - 2
0.9
Following intervention, improvement in technique was observed; rate of infection declined by 62%,
0.9
0.8
Cu m Su rvival
0.7
0.6
0.5
Proportion of
0.4
remaining
0
without infection (Cox regression)
1.0
0.9
0.5
0.4
0.3
0.00
0.9
20.00
S ur viv Survival Function for patterns 1 - 2 Survival Function for patterns 1 - 2 al Fu nc
NewGroup .00
1.00
tion fo r pa tt ern s 1 - 2
80.00
100.00
40.00
60.00
DaysOfFollowUp
20 .0
0
p<0.001
After the intervention
Ne wG rou .0
0 1.
00 p NewGroup .00
1.00
0.8
0.7
40
Da
.0
0
ysO fFo llo
.0
0
wU Days of catheter p Before the intervention
80 .0
0 NewGroup .00
1.00
NewGroup .00
1.00
0.4
0.6
0.00
20.00
40.00
10 60.00
0.0
0
DaysOfFollowUp
80.00
100.00
0.3
0.5
0.00
20.00
40.00
60.00
DaysOfFollowUp
80.00
100.00
0.4
0.3
0.00
20.00
40.00
60.00
DaysOfFollowUp
80.00
100.00
Catheter-related Bloodstream Infections
Unit Before Intervention Catheter days N infected Rate* After Intervention Catheter days N infected Rate* Rate Reduction (%) ICU-A 1176 6 5.1
1296 3 2.3
55 1240 7 5.6
879 2 2.3
60 ICU-B ICU Medicine Neuro surgery Cardiac surgery ICCU 995 225 562 150 16 4 5 4 16.1
17.8
8.9
26.7
1715 173 551 63 6 1 4 1 3.5
5.8
7.3
15.9
78 67 18 40 Total 4348 42 9.66
4677 17 3.63
62.4** * Rate of infection per 1000 catheter-days ** p<0.001
Catheter-related Bloodstream Infections
Pronovost P. et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725
Physicians’ Hand Hygiene at Hadassah
Summary of surveys in recent years
Rate of hand-washing out of contacts with patients
Ein Kerem Mt. Scopus Medicine 65% 55% Pediatrics 55% 62% Surgery 35% 66% Ob-Gyn 25%
Use of Hadassol has been widely adopted but rate of hand hygiene unchanged
Surgical Infections in General Surgery
N. Minster, M. Zarhia, G. Almogy, A. Rivkind, S. Benenson, M. Cohen
Rate of post-operative wound infection is 8-12%, within the range reported in the literature.
Pre-operative antibiotic administration is documented as given on time in 59% of cases.
A significant proportion of infections are diagnosed after discharge from the hospital.
Infection monitoring is recognized as an important tool to keep rates low.
Quality of Inguinal Hernia Repair in Adults and in Children at Hadassah
T. Yemini, M. Badriah, Y. Mintz, R. Udassin, A. Rivkind
Satisfaction
high to very high in 94% of adults and children; problems: waiting & relation with staff
Complications
Children Adults Rate of infection (95% CI) 6% (2-13) 12% (7-20) 0.7-14%* Children Adults Rate of hematoma (95% CI) 10% (5-18) 13% (8-21) 11-15%*
*Range in literature varies by motive (voluntary or mandatory)
Quality of Special Surgeries
Outcomes of special surgery in the Departments of Ear, Nose & Throat (ENT), Ophthalmology, Plastic and Neurosurgery ENT Ophthalmology Plastic surgery Neurosurgery Snoring, tonsillectomies Corneal transplant, Lasik Breast reconstruction Prevention of shunt infection
Management of Snoring Disorders with Radiofrequency at Hadassah Optimal
L. Gordon
,
S. Catinari, R. Eliashar
p<0.005
p<0.01
p ≤0.05
%
Lasik (Myopic Corneal Refractive Surgery) at Hadassah Optimal (N=109)
N. Orwa, A. Solomon, Y. Frucht-Peri
%
Evaluation of Outcomes for Tonsillectomies at Hadassah (2008)
O. Frenkel, R. Eliashar
Hadassah (N=106) Literature UK audit & others (N>30,000) % with any bleeding % needed readmission % needed reoperation 28 20 4.7
?
3-10 0.5-2.0
Quality of Reconstruction Surgery After Mastectomy
R. Yanko-Arzi, M. J. Cohen, R. Braunstein, E. Kaliner, R. Neuman Dept of Plastic Surgery & Center for Clinical Quality & Safety
% 0 20 40 60 80 Severe Complications Success Satisfaction Would Recommend Hadassah
moderate high
A survey of 140 women after reconstructive breast surgery for cancer showed satisfaction related mostly to expectations before surgery.
Neurosurgical shunt infections
I. Paldor, Z. Israel, C. Block with the dept of Neurosurgery
% of shunts infected 40 35 30 25 20 15 10 5 0 Num ber of shunts inserted 2001 10 2002 17 2003 21 Intervention 2004-5 24 Mortality in infected cases dropped from 50% to 0%
Is the X-ray interpretation by the junior staff on duty correct?
Dr. Y. Mintz, Dr. D. Kisselgoff, Y. Gronowitz, A. Shaham, R. Hefez, Dr. D. Shaham - Departments of Surgery, Radiology, and Center for Clinical Quality & Safety Pulmonary Embolism 95% Surgery Trauma 77% 94%
Effect of Translators on Understanding & Satisfaction of Arab Parents
Department of Pediatrics & ER, Mt Scopus & Center for Clinical Quality & Safety, Hadassah Hebrew University Medical Center
The Presence of a Translator Significantly Improved Parental Understanding Regarding Diagnosis, Treatment and Follow-up 96 100 86 78 80 74 72 60 38 40 34 23 20 0 Understanding of diagnosis p<0.001, n=194 Necessary follow-up When return visit to ER necessary Dosage & duration of medication translator no translator
Will patient’s empowerment improve efficacy & safety of oral anticoagulation?
Self-management for Coumadin
H. Goldberg, Y.Ben David, U. Izhar, L. Gordon, T. Baevsky, M.Burzstyn & M.Brezis with the Departments of Cardiothoracic Surgery and Medicine
Patient’s empowerment improves efficacy & safety of oral anticoagulation
60
% of tests within target INR
50 40 30 20 10
38 %
* p<0.001
60%
0
Control Intervention
Patient ’s knowledge & satisfaction significantly improved
Communicating with Families & Satisfaction with End-of-Life Decisions
Departments of Medicine & Center for Clinical Quality & Safety
% of relatives agreeing with statement:
“I felt the team didn’t care about my opinion” “It upset me I didn’t know what was going on” “Patient’s problems weren’t explained to me”
Control 35 43 44
“Management options were not explained” “I was afraid to ask questions”
46 38
“I felt excluded in the decision-making”
52 *p<0.005 in favor of the intervention group Intervention 13* 10* 3* 17* 10* 17* Communication with families of patients near end of life improves perceived quality of care
Ward Surgery ObGyn Medicine Cardiology Total Type of procedure Operation Operation Angiography N 178 198 Diagnostic or therapeutic procedure 117 120 613 60% 57% 42% 39% 51%
International Journal for Quality in Health Care 2008
20% 19% 40% 8% 21%
Conclusion
Projects help make healthcare at Hadassah more evidence-based, patient-centered & system-minded. Over 100 projects presented at National Meetings of Israeli Society for Quality in Healthcare; over 48 theses and 19 peer reviewed publications.
Center for Clinical Quality & Safety