Medical Quality: a Brief Primer and History Keith Marton, MD Chief Medical Quality Officer Providence Health & Services

Today’s Goals To retrace the history of quality efforts in the US To describe the present day status of healthcare quality work in the US

The Beginning Who said this? “ So I am called eccentric for saying in public: that hospitals, if they wish to be sure of improvement, (1) must find out what their results are, (2) must analyze their results, to find out their strong and weak points; (3) must compare their results with those of other hopsitals…and (8) must welcome publicity not only for their successes but for their errors” Ernest A Codman, MD 1916

The real Beginning Florence Nightingale Statistical analysis of surgical outcomes in the 1850’s The Flexner report on Medical Education- 1909

Other noteworthy Events 1952—Joint Commission on Accreditation of Hospitals—JCAH---is created (1987—JCAHO, 2009—JC) 1961—Kerr White, MD publishes seminal articles on health services research “the objective of medical care research is reduction of the time lag between advances in the laboratory and measurable improvement in the health of society’s members”

1980’s: things pick up Edward Deming—the father of modern manufacturing 1982: “Out of the Crisis” Focus on the Toyota method (“Lean”) Avedis Donabedian 1982: “Quality, cost and health: an integrative Model “ Focus on structure, process, outcome

1990’s: we rock and roll 1990: National Clinical Quality Association (NCQA) 1991: Institute for Healthcare Improvement (IHI) 1999: National Quality Forum (NQF) 2000: the Leapfrog Group 2000: Institute of medicine (IOM)—To err is human

21st Century—it starts to come together The advent of quality strategic plans Plus, many new tools/incentives: Quality dashboards Public reporting Six sigma/Lean Culture of safety/high reliability organizations

Some present day principles Reduce variation (six sigma) Reduce waste (Lean) Create cultures that nourish widespread collaboration, teamwork, accountability (high reliability) Measure both processes and outcomes and do it in real time. STEEEP The Triple Aim

Profile of Market Leaders Expert Opinion: Profile of Market Leaders Superior safety / quality / operational efficiency as non-negotiable Transparency of performance and process Leadership engagement and accountability Cultural work - just, fair, flexible Reliable processes / robust improvement methodologies Philosophy of learning organization Measurement and feedback Leonard, M. Benchmarking Market Leaders in Quality & Safety, Kaiser Permanente, 2008

Case Studies on Patient Safety Five innovations identified to hold great promise Promoting an organizational culture of safety Improving teamwork and communication to promote patient safety Enhancing rapid response to prevent heart attacks and other crises in the hospital Preventing health care-associated infections Preventing adverse drug events throughout the hospital Committed to Safety: Ten Case Studies on Reducing Harm to Patients, Douglas McCarthy and David Blumenthal, The Commonwealth Fund, April 2006

Dana-Farber Cancer Institute Total commitment to a culture of safety 150 patients involved in every committee in the hospital, including peer review 4-fold increase in revenue over the last 10 years Nursing turnover = 0.4 % U.S Average is 10-12 % with cost per RN turnover $86K Estimate 1 million short in 10 years Leonard, M. Benchmarking Market Leaders in Quality & Safety, Kaiser Permanente, 2008 12

Principles of a Fair & Just Culture From Dana-Farber Cancer Institute Create a learning environment and workplace that supports core values of impact, excellence, respect, compassion, & discovery in every aspect of work Support the efforts of every individual to deliver the best work possible Commit to holding individuals accountable for their own performance Promote an interdisciplinary discussion of untoward events Improve all areas of the workplace by implementing changes based on analysis of problems & potential or actual harm Commit to a culture of inclusion & education Assess success in promoting a learning environment by evaluating our willingness to communicate openly & by the improvements we achieve Principles adapted from Allan Frankel, M.D. and the Patient Safety Leaders at Partners Healthcare System www.macoalition.org/Initiatives/docs/Dana-Farber_PrinciplesJustCulture.pdf https://www.justculture.org

Effect on Claim Frequency & Loss Cost $4,100 $4,200 $4,700 $5,100 $5,800 $4,800 $2,609 $2,389 $3,367 $2,073 $1,807 $1,808 $0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 2001 2002 2003 2004 2005 2006 Losses Per Bed 0.0 0.5 1.0 1.5 2.0 2.5 Frequency Per 100 Beds Losses Nat'l Losses Frequency Source: ASHRM Hospital Professional Liability & Physician Liability 2006 Benchmark Analysis

Sentara Healthcare Selected Hospital Indicators 4/23/2017 Sentara Healthcare Selected Hospital Indicators   2003 2004 2005 2006 2007 Improvement Falls with Injury Per 1,000 adjusted patient days 0.63 0.48 0.43 0.42 0.37 41.3% ↓ Ventilator Associated pneumonia Per 1,000 ventilator days 4.55 2.23 1.57 0.97 90.8% ↓ Blood Stream Infections Per 1000 device days 3.46 2.35 1.78 1.05 69.7% ↓ Surgical Care Infection Prevention Overall Antibiotic Prophylaxis Compliance 90.8 91.0 90.3 93.8 94.8 4.4% ↑ 15

Sentara Healthcare Creating a Safe Day SSE Free for 7 months Serious Safety Event Rate SSER SM

VISION MEASURES OF SUCCESS 2010 PH&S Quality Strategic Plan (QSP) Framework PROVIDENCE CORE STRATEGY: One Ministry Committed to Excellence: Inspired by our heritage, we work together to deliver excellent health care in the communities we serve. We realize the value of being a system through our common strategic directions, systems & structures, tools & resources, knowledge transfer and operational execution and results. QUALITY VISION: We will deliver the best care to every person every time in a safe, timely, efficient, effective, equitable, patient-centered and affordable manner. VISION MEASURES OF SUCCESS VISION GOAL No Preventable Injuries or Deaths Superior Clinical Practice and Outcomes Evidence-based Care Delivery No Preventable Readmissions MEASURED BY: O/E Mortality Ratio and Health Care-Associated Infections Reduction of Variation in Practice and Outcomes Adoption of Clinical Best Practices Observed Readmission Rate Quality Strategies Advance a culture committed to excellence and safety Build sustainable systems and structures for reliability and reduction of harm Reduce unnecessary variation with evidence-based standardization Optimize outcomes through coordinated and efficient models of care

Governance Questions Wise Strategic Thinking Question 1 – Are we clear about our quality strategic aims and focused on the most important improvement opportunities to achieve those aims? Question 2 – Is there a solid strategic rationale for the annual and long term improvement goals that management is recommending? Focused & Effective Execution Question 3 – Are we improving fast enough to meet our annual and long term improvement goals? Question 4 – Do we have any systemic weaknesses that should be addressed to meet our internal improvement aims and/or to respond to external demands for data and accountability? Question 5 – Are there any individual facilities or programs that have weak improvement capabilities or insufficient capacity to improve? Question 6 – What are our experiences with improvement telling us about the changes that are necessary in our Quality Strategic Plan? (widespread learning) Question 7 – Are we sparking innovation, finding and systematically spreading best outcome practices and great ideas? 18

Other key areas of focus Specific disease conditions Sepsis, heart failure, pneumonia, heart attack, Healthcare associated infections, surgical complications Specific processes Medication safety Coordination of care Checklists!! Mortality reduction

Why the emphasis on mortality? It’s the quality equivalent of Net operating income A key indicator that is affected by multiple inputs It’s a “bottom line “ measure (i.e. we all care about it) Data from several sources tell us that we should (and can) be doing better Many systems are aiming for “zero preventable deaths”

O/E Trend Comparison

Lives Saved by Qtr by System

Clinical Priority: Mortality

Conclusions Our focus on quality has increased significantly in the last 10 years Our ability to improve quality and safety has also improved But, we are actually just beginning the real journey

Questions?