UNDERSTANDING AND DEFINING QUALITY Quality Academy – Cohort 6 April 8, 2013

Defining Quality History: –Institute of Medicine – 7 dimensions –OECD (Organisation for Economic Co-operation and Development ) –BC: Health Quality Network Who’s perspective? –Patient –System

Dimensions of Quality  Acceptability  Appropriateness  Accessibility  Safety  Effectiveness  Efficiency  Equity

Acceptability  Care provided considers patient and family preferences  Respecting cultural values and encouraging family involvement in decision making  Health care providers being empathetic to patients and families,  Following the wishes and expectations of patients and families  Empowering patients and families to be active in their own care.

Avoiding unnecessary visits with good communication (e.g. discharge instructions, case management) Improved adherence to treatment Time taken to deal with complaints

Appropriateness  Care provided is evidence-based and specific to individual clinical needs.  Care provided optimizes an individual‘s health outcome.  Appropriate care weighs the benefits and risks of care – aiming to provide maximum benefit (supporting best outcomes).

Practice variations –Overuse –Underuse –Misuse What are the costs to patient?

Accessibility  Ease with which health services are reached  Extend to which individuals can easily obtain the care when and where it is needed  Aims to ensure there are no physical, financial or psychological barriers to receiving information, care and treatment

Multiple visits due to access problems Misuse of Emergency due to access limitations Costs of maintaining a wait list Missed appointments due to poor access (e.g. mental health appts)

Safety  Avoiding harm resulting from care.  Involves designing and implementing processes to prevent and minimize adverse outcomes or injuries that could unintentionally result from the delivery of care.

Hospital acquired infections Adverse drug events in Community Pressure ulcers in LTC Never events (e.g. wrong surgery) Drug costs and length of stay due to preventable complications

Effectiveness  Care that is known to achieve intended outcomes.  Based on clinical evidence and best practices.  A commitment to effectiveness is demonstrated by continuously studying the results of care to find ways to improve care for all patients

Avoidable hospital admissions/readmission Early discharge Errors in cancer screening leading to recalls Failure to to provide accurate and timely diagnose

Efficiency  Optimal use of resources to yield maximum benefits and results.  Maximizing capacity and eliminating/avoiding waste in the health system.

Reduction of waste  time spent looking for materials, records, information OR cancellations Social impact

Equity  Distribution of health care and its benefits fairly according to population need.  British Columbians have equal access to the health services they need, regardless of gender, ethnicity, socioeconomic status, or where they live.

Areas of Care Staying Healthy –Preventing injury, illness and disabilities. Getting Better –Care for acute illness of injury. Living With Illness and Disability –Care and support for chronic illness and/or disability. Coping with End of Life –Planning care and support for life limiting illness and bereavement.

How Is It Used? Program / Strategic Planning Evaluation Measurement Frameworks

An Example: Surgical Quality Framework

A framework to describe a comprehensive picture of surgical quality BC Health Quality Matrix Dimensions acceptable, appropriate, accessible, safe, effective, efficient + Segments along Surgical Pathway

REFERDECISIONSURGERYRECOVERFOLLOW ACCEPTABLE Patient Experience Experience Survey Patient Experience APPROPRIATE Alignment of determination that benefits outweigh risks of care Patient, primary care provider and surgeon ACCESSIBLE Time to diagnostics Time to specialist, diagnosis Time to SurgeryTime to follow- up care and treatment SAFE Crude Infection Rates (PICNET) Adjusted Infection and Complication Rates (NSQIP) EFFECTIVE Risk Adjusted Mortality Rates, Return to OR (NSQIP) Patient Reported Outcome – functional status and quality of life EFFICIENT Appropriate Referrals Risk Adjusted LOS(NSQIP) Costs saved (lower LOS, fewer complications, fewer readmissions and return to OR) Efficiencies in hospital and OR flow (e.g. cancelled procedures)

REFERDECISIONSURGERYRECOVERFOLLOW ACCEPTABLE Techniques for shared decision making and teamwork among providers and patients; opportunities identified from Patient Experience APPROPRIATE Pathways, guidelines, decision aids, shared decision techniques ACCESSIBLE Decision aids - when to refer Advanced Access for Specialists and DI MoH/PSAC work on prioritization, targeted funding, management of waitlists; Centre for Surgical Innovation Advanced Access SAFE Surgical Checklist, VTE Prophylaxis, SSI Protocol (SHN!, CPSI, Collective) EFFECTIVE Focus on PROMs/QOL EFFICIENT Flow in OR, Discharge Planning, Safety Initiatives

WHERE DOES YOUR PROJECT FIT?