This conference was organized by

Hacettepe University

School of Health Administration

for the 35th anniversary of the establishment of Hacettepe University

Time: May 6, 2003 Place: Hacettepe Üniversitesi Kültür Merkezi, Yeşil Salon Hour: 10.00 - 12.30

Quality of Health Care in the United States: Practice and Promise Professor Joseph D. Restuccia Boston University School of Management

Quality of Health Care

“Degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with professional knowledge.” - Institute of Medicine (IOM)

Strengths of the United States Health Care System  Modern, well-equipped hospitals and ambulatory facilities  Highly trained physicians, nurses and other medical personnel  Availability of high technology diagnostic and therapeutic procedures

Weaknesses of the United States Health Care System  Overuse and inappropriate care  Underuse of effective care  Misuse and error in medical care  Inefficiency and waste

Assessment of US Health Care System to Achieve 6 Aims

“In its current form, habits, and environment, American health care system is incapable of providing the public with the quality of health care it expects and deserves.” - IOM Committee on Health Care in America

“Every Defect is a Treasure”  Japanese saying: every defect is a treasure because identifying a defect enables us to find the root cause and to eliminate it and, thus, to make improvements in the future  If defects are jewels, recent investigations to identify and quantify defects in US health care have discovered a treasure chest (or Pandora’s box)

Weaknesses of the United States Health Care System  Overuse and inappropriate care  Underuse of effective care  Misuse and error in medical care  Inefficiency and waste

Overuse (Rate of Inappropriate Use)  Advanced Antibiotics for Otitis Media 30%  Antibiotics Used for the Common Cold 60%  Heart Revascularization 10-20%  Hysterectomies 16-80%  Hospital Admissions: 5-15%  Hospital Days of Care: 10-30%

Overuse (Rate of Inappropriate Use) Other procedures commonly overused:  Bed Rest for Low Back Pain  Prostate Specific Antigen Testing  Ultrasound in Uncomplicated Pregnancy  Sedation of elderly patients

Weaknesses of the United States Health Care System  Overuse and inappropriate care  Underuse of effective care  Misuse and error in medical care  Inefficiency and waste

Underuse (Financial Access)

 Over 40 million people are uninsured at any point in time  Over 75 million are uninsured as some time during the year  About an equal number are severely underinsured  The majority of the uninsured and underinsured are the working poor and their dependents

Underuse (Rate of Use of Effective Care)  Beta-blockers in Elderly Heart Attack Victims 21%  Pneumococcal Vaccine in Elderly: 28%  Appropriate Dx and Tx of Hypertension: 30%  Physician Advice to Quit Smoking: 37%  Eye Examination in Diabetics: 46%  Pharmacotherapy of Depression: 45%

Weaknesses of the United States Health Care System  Overuse and inappropriate care  Underuse of effective care  Misuse and error in medical care  Inefficiency and waste

Misuse  Adverse drug events (ADEs) caused by medication errors occur in 1.8/100 hospital admissions  ADEs add $4,700 per admission  20% of ADEs are life threatening  There are an estimated 500,000 preventable medication errors per year causing 7,000 deaths

Misuse  An estimated 2.9% – 3.7% of hospital admissions have an adverse event (from all causes)  Over 1 million adverse events per year  Estimated national cost of adverse events is $38-50 billion per year – almost half preventable (2-4% of total health costs)

Misuse  An estimated 180,000 deaths per year due to adverse events (= 3 jumbo jet crashes every two days)  Between 44,000 - 98,000 due to preventable adverse events  More deaths than due to motor vehicle accidents (43,438), breast cancer (43,297) or AIDS (16,516)

Weaknesses of the United States Health Care System  Overuse and inappropriate care  Underuse of effective care  Misuse and error in medical care  Inefficiency and waste

Inefficiency and Waste  Waits and Delays  Operating Room Throughput  Emergency Department Diversions  Time to Treatment of Coronary Conditions  Medical Records Availability  Mismatch Between Capacity and Demand

Assessment of US Health Care System to Achieve 6 Aims

“In its current form, habits, and environment, American health car is incapable of providing the public with the quality of health care it expects and deserves.” - IOM Committee on Health Care in America

IOM’s Six Aims for Improvement • Safety • Effectiveness • Patient-centeredness • Timeliness • Efficiency • Equity

Safe Care  A patient receiving medical care should be as safe as he is in his own home  Example: Computerized physician order entry system to prevent medication errors  Example: Surgeons “sign your site” of the body part that will be operated upon

Effective Care  Avoid overuse and underuse of services  Example: Redesign processes based on best practices such as ensuring that patients at risk for heart disease take appropriate medications  Example: Implement utilization management to reduce inappropriate hospital use

Patient Centered Care  Respect patient needs, preferences, and culture  Example: Give patient access to his own medical record  Example: Give patients information on alternative treatments and decision-making in treatment choice

Timely Care  Reduce waits for those who receive and who give care  Example: Availability of appointments after work hours and on weekends   Example: Email and telephone access to physicians and nurse practitioners Example: “Open access” to physicians and nurse practitioners

Efficient Care  Reduce waste of facilities, equipment, supplies, and people  Example: implement inventory management systems to reduce amount of drugs and other supplies  Example: Use flexible staffing systems based on patient numbers and needs to adjust number of nurses per patient care unit

Equitable Care  Reduce racial, ethnic, geographic and socio economic differences  Example: Provide interpreters for non English speaking patients  Example: Train more physicians from minority racial and ethnic groups  Example: Establish universal health insurance coverage

Purpose of Health Care System

“To reduce continually the burden of illness, injury, and disability, and to improve the health status and function of the people of the United States” - President’s Advisory Commission on Consumer Protection and Quality

Focus of Quality

Quality must be defined in terms of experience and outcomes of the patient and the population that generates patients

Levels of Needed Health Care System Change Patient Microsystem (patient units, physician offices) Organization (hospitals, medical groups) Environment (insurers, purchasers, government)

Levels of Needed Change  The patient’s experience  The functioning of small units (“microsystems”) that provide patient care  The functioning of organizations that contain microsystems  The environment of policy, payment, accreditation and regulation

Levels of Needed Health Care System Change

 All levels of the system must work together to meet the patient’s needs  The patient must be at center, the first priority of the health care system  The major question to ask in changing the system or in treating the patient must be, “Is this the best thing we can do for the patient?”

Examples of Efforts by Provider Organizations to Achieve the IOM’s Six Aims

Cincinnati Children Hospital Medical Center  Includes families of hospitalized children in morning physician rounds  Permits adolescent patients with chronic diseases (e.g., juvenile diabetes) to set their own schedule of treatments and activities and to make entries into their medical records  Pays physicians for involvement in major quality management activities

Cambridge Health Alliance  Developed registries for chronic patients to identify needed diagnostic and therapeutic interventions, help teach patient self management, and track patient outcomes  Provides translators for over 30 languages  Works with governmental agencies to establish coverage programs for the uninsured

Tallahassee Medical Center  Conducts surveys of satisfaction on every inpatient and outpatient and shares results broadly  Implemented palliative care project to ensure that terminal patient receive comfort care instead of intensive care  Put communication devices in ambulances, moved EKG lab, and changed cardiologist schedule to enable PTCA within 90 minutes

Hackensack Medical Center  Hired physician “intensivists” to care of hospitalized medical patients  Developed nursing career ladder to help hire, retain and further train nursing staff  Implemented advanced practice nurses to work with physicians and patients to coordinate care  Implemented daily multidisciplinary patient rounds (physician, nurses, ancillary therapists, etc.) to improve communication and teamwork

Brigham and Women’s Hospital  Developed computerized physician order entry system (CPOE)  Physician orders entered via terminals  Test results and treatment summaries transmitted to electronic patient record  Orders screened against knowledge base of rules to detect medication errors  Reduced serious medication errors over 80%

CareGroup  Developed internet-based electronic medical record  Allows physicians password protected internet access to patient records  Allows patients password protected internet access to their own records  Allows patients to write in their own record and to request appointments with physicians

Rosemont Medical Center  Developed “open access” program for patient appointments  Produced same day access for most patient visits  Reduced average wait time for routine visits from over 2 months to 1 day

Massachusetts General Hospital  Implemented utilization management to reduce inappropriate hospital days  Case managers apply MCAP (derivative of the AEP) to facilitate day to day decision making and data collection to change system  Over 10 years, inappropriate days have been reduced by more than 50%

SSM Health Care  Continuous Quality Improvement (CQI) - 13 year sustained effort  Alignment of goals and measures of performance throughout the organization  Use team work to solve problems and motivate employees  Human resources are part of strategic plan  Only health care organization to win Malcolm Baldridge National Quality Award

Continuous Quality Improvement  Top Management Commitment  Worker Empowerment  Team Work  Customer focus  Application of Scientific Method (Measurement and Reporting)  Recognition of success

AIM/PDSA Model for Internal Quality Improvement 1. AIM: What are we trying to accomplish?

2. MEASURES: How will we know that a change is an improvement?

3. CHANGES: What changes can we make that we predict will lead to an improvement?

7. ACT 4. PLAN 6. STUDY 5. DO

Examples of Efforts by Government Agencies to Achieve the IOM’s Six Aims

Department of Veterans Affairs Health System  System of 171 hospital medical centers, 350 outpatient centers  Implemented electronic patient record & CPOE  Implemented open access (reducing wait time by 90% in Region 1)  Implemented Quality Enhancement Research Initiative (QUERI) to give providers evidence based care on 8 priority conditions  Recognized by IOM for these efforts

Agency for Health Care Research and Quality (AHRQ)  Supports research on patient outcomes  Prevention, diagnosis and treatment  Quality measurement and improvement  Medical errors and public safety  Examples  Diagnosis of heart attack  Screening for pregnant women  Consumer Assessment of Health Plans Survey (CAHPS)

Agency for Health Care Quality and Research (AHRQ)  National Guidelines Clearinghouse of evidence-based clinical practice guidelines  National Quality Measures Clearinghouse  CAHPS survey  CONQUEST quality measures  Health Care Cost and Utilization Project (HCUP) Quality Indicators

AHRQ HCUP Quality Indicators  Prevention - ambulatory sensitive conditions  Bacterial pneumonia  Dehydration  Inpatient Care  Acute myocardial infarction mortality rate  CABG volume  Patient Safety  Birth Trauma  Complications of anesthesia

Center for Medicare and Medicaid Studies (CMS)  Quality Improvement Organizations monitor Medicare quality  Nursing Home Public Reporting Quality Initiative  Home Health Public Reporting Quality Initiative  Hospital Quality Information Initiative

CMS Hospital Quality Initiative  In collaboration with JCAHO, NQF, AHA and other national hospital associations  Voluntary reporting of quality measures  Examples  AMI: aspirin and beta blocker at hospital arrival and discharge  Pneumonia: initial antibiotic timing, vaccination, oxygenation assessment  Considering paying providers on the basis of quality instead of just fee for service

CMS/AHRQ CAHPS Surveys  National survey of Medicare beneficiaries  Also used for Medicaid and commercial beneficiary surveys  Administered by CMS for Medicare  Comparative Medicare Medical Care Plan Reports are publicly available on internet  Comparative Hospital Reports Scheduled for internet availability in 2003-2004

HCAHPS - Example Questions  How often did nurses/doctors listen to you carefully?

 How often did nurses/doctors spend enough time with you?

 How often was your pain well controlled?

 Before you left the hospital, did you get information in writing about activities you could and could not do?

 Would you recommend this hospital to your friends and family?

Examples of Efforts by Private Organizations to Achieve the IOM’s Six Aims

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)  Develops standards for optimal healthcare  Applies accreditation process to 17,000 healthcare organizations  Provides information to health care organizations, professionals, and the public on strategies to improve safety  Plans to make public comparative performance reports on provider organizations (in 2004)

Examples of JCAHO Initiatives  Quality Performance Measurement  Core (required) measures  Provider selected measures  Pain Management Standards  Staffing Effectiveness Standards  Patient Safety Standards  Sentinel Event Policy and Alert

Foundation for Accountability (FACCT)  Advocates an accountable and accessible health care system responsive to consumers  Members: consumer organizations and purchasers  Collaborates with government and private health care organizations  Reports on federal and state health policy  Provides consumers with information to help assess quality of care and select providers and tools to help manage their own health, e.g. CompareYourCare)

National Committee for Quality Assurance (NCQA)  Accreditation and certification of health plans and utilization review organizations  Administers Health Plan Employer Data and Information Set (HEDIS)  HEDIS is used to compare health plans and choose quality - results released to public as Quality Compass

HEDIS 3.0 Reporting Set Measures

Effectiveness of Care

Childhood Immunization Status Adolescent Immunization Status Advising Smokers to Quit Flu Shots for Older Adults Eye Exams for Diabetics Low Birth Weight Babies Check-ups After Delivery Treating Child Ear Infections Beta Blockers after MI Breast Cancer Screening 1st Trimester Prenatal Care Cervical Cancer Screening Follow-up after Hospitalization Medicare Health Outcome Survey for Mental Illness

Leapfrog Group  Group of very large US companies  Mission is to stimulate improvement in quality, customer service and affordability  Recognizes and rewards health care organizations that implement evidence based patient safety measures  Encourages members to buy health care from these organizations

Leapfrog Group Patient Safety Measures  Referral of specific complex procedures to hospitals with high volume (estimated to reduce deaths > 30%)  Intensive care unit staffing with physicians certified to practice critical care medicine (estimated to reduce ICU deaths > 10%)  Computer physician order entry (estimated to prevent > 500,000 fewer serious medication errors per year)

Institute for Healthcare Improvement (IHI)  Mission: is “driving the improvement in health by advancing the quality and value of health care”  Conferences  Collaborations  Courses  Training Material

Institute for Healthcare Improvement (IHI)  National Director of Robert Wood Johnson Foundation Pursuing Perfection Program  Publishes QualityHealthcare.org (with British Medical Journal)  Website: www.ihi.com

Institute for Healthcare Improvement (IHI)  Examples of Topics for Collaboratives:  Achieving Workforce Excellence  Adult Intensive Care  Adverse Drug Events  Care for Chronic Conditions  Delays and Waiting Times  End of Life Care  Patient Flow  Patient Safety

Major Quality Improvement Will Require Fundamental Changes  Evidence-based medicine  Evidence-based management (CQI)  Electronic patient record with CPOE  Recognition of system interdependence between microsystem, organization, environment  Alignment of incentives and strategy at all levels  Payment based on quality, not just services  Public reporting of comparative provider quality  Universal health coverage