Transcript Healthcare Quality Improvement

Healthcare Quality
Improvement
2012.5.
이 은봉
Contents
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Definition of healthcare quality
Measurement of healthcare quality
Implementation of quality improvement
Conclusion
Definition of healthcare quality?
What is healthcare quality?
• “The balance of health benefits and harm
is the essential core of a definition of
quality.” (Donabenan, 1990)
• Quality is the optimal achievement of
therapeutic benefit and avoidance of risk
and minimization of harm. (Joint
commission)
Components of healthcare quality
Patient
Centered
Efficiency
Timeliness
Effective
ness
Equity
Safety
Source: Institute of Medicine 'Crossing the Quality Chasm'
Different definitions
Clinician
Patient
Payer
Manager
Society
Technical
performan
ce
Interperson
al
Relationship
Amenit
ies
Access
Patient
preferenc
es
Equity
Efficiency
Cost
effectiven
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Wyszewianski, 2009
Definitional attributes
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Technical performance
Management of interpersonal relationship
Amenities
Access
Responsiveness of patient preferences
Equity
Efficiency
Cost-effectiveness
Wyszewianski, 2009
Technical performance
• How well current scientific medical
knowledge and technology are applied
in a given situation
• Timeliness and accuracy of the diagnosis,
appropriateness of therapy, medical skills
Interpersonal relationship
• How well the clinician relates to the
patient on a human level.
• Doctor-patient relationship
• Technical performance is directly related
with interpersonal relationship.
Amenities
• Characteristics of settings in which the
encounter between patient and clinician
takes place such as comfort, convenience
and privacy.
• Examples include ample and convenient
parking, good directional signs,
comfortable waiting rooms, and tasty
hospital foods.
Access
• Degree to which individuals and groups
are able to obtain needed services.
• Medical costs, location, provided days
and times, cultural characteristics
Responsiveness to patient
preferences
• Acceptability
• Respect for patients’ values, preferences
and expressed needs
Equity
• Application of all the necessary services
of modern, scientific medicine to the
needs of all people.
Efficiency
• How well resources are used in achieving
a given result.
• Wasteful care is either directly harmful or
is harmful by displacing more useful care.
Cost-effectiveness
Benefit
• How much benefit, typically measured in
terms of improvement in health status
the intervention yields for a particular
level of expenditure.
Expenditure
Different definitions
Clinician
Patient
Payer
Manager
Society
Technical
performan
ce
Interperson
al
Relationship
Amenit
ies
Access
Patient
preferenc
es
Equity
Efficiency
Cost
effectiven
ess
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Wyszewianski, 2009
Measurement of healthcare
quality
Purpose of measurement
• Assessment of current performance
• Demonstration and verification of
performance improvement
• Control of performance
Components
• Structure
– Organization structure, specialty services
provided, patient census
• Process
– Clinical care (clinical evaluation, diagnosis,
therapeutic and palliative interventions)
• Outcome
– Health status, functionality, well-being of the
patients
Donebedian
Choice of performance measures
• Precise
– Relevant
– Precisely defined and specified
– Interpretable
– Risk-adjusted or stratified
• Practical
– Cost-effective
– Under the control of the provider
• Reliable
Classification of measures
• Continuous variable measures
– Precise measurement that can fall anywhere
along a continuous scale
– E.g. A number of days from surgery to
discharge
• Rate-based measures
– Frequency of events expressed as ratio or
proportion
– E.g. pneumonia patients over all patients
국내 주요 임상 질 지표
외래
입원
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계획에 없던 재입원율
계획에 없던 재수술율
사망률
수술취소율
수술대기시간
퇴원예고 퇴원율
재원일수
장기재원환자 비율
타과의뢰 회신율
의무기록 완성률
민원 및 VOC
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신환율
외래대기일수
외래진료대기시간
민원 및 VOC
중환자실
 재입실률
 사망률
환자안전
응급실
 응급실 체류시간
 응급실 재방문율
 타과호출후 도착시간
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낙상발생률
욕창발생률
투약오류발생률
수혈오류발생률
심정지발생률
병원감염률
Performance of quality
improvement
PDCA method
Plan
• Defining the problem or issue that requires redress
• Defining the ideal or desired state
• Data collection to determine the problem in terms of
deviance from the ideal state
• Ascertaining the root cause for the problem or issue
• Evaluating the various possible interventions to solve
the problem and their possible outcomes
• Selecting the best possible intervention
• Scheduling the corrective process by planning for res
ources, determining people responsible for the correc
tive action
• Mapping the corrective process through flowcharts,
control charts, and other tools
Fishbone diagram (Ishikawa chart)
Do
• Implementation of the selected solution
• Training the employees for the adopted
quality intervention.
• Small scale to large scale
Check
• Quality inspection or Study stage
• Defining workmanship standards such a
s upper specification limit (USL) and low
er specification limit (LSL) and then com
paring the product specifications against
such standards.
• Weeding out unacceptable products.
Shewhart control chart
Comparison chart
Observed rate
Outlier
Upper limit
Expected rate
Lower limit
July
Aug
Sep
Classification of Quality defect
Underuse
예) Mammography
Overuse
예) Antibiotics
Misuse
예) Wrong drug
Journal of the American Medical Association’s National Roundtable report(1998)
Act
• Standardization of the successful solution and ad
opting the same for whole process improvement
• Involving other stakeholders such as other depar
tments, suppliers and customers in the changed
process
• Creating safeguards to check relapse into the pr
evious stage
• Explore opportunities for further improvements
Conclusion
• Healthcare quality is to the optimal
achievement of therapeutic benefit with
avoidance of any harm.
• Quality improvement is a continuing
process in which PDCA cycle is applied.