1. Quality Improvement Introduction to Quality Improvement and Health Information Technology Lecture b This material (Comp12_Unit1b) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.

2. Introduction to Quality Improvement and Health Information Technology Learning Objectives ─ Lecture b Explain healthcare quality and quality improvement (QI). Describe quality improvement as a goal of meaningful use. 2 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Introduction to QI and HIT Lecture b

3. Quality Healthcare “Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge.” (IOM, 2001) 3 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Introduction to QI and HIT Lecture b

4. Quality Healthcare—Who defines it? 4 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Introduction to QI and HIT Lecture b

5. Organizations That Are Part of the Tapestry of QI and Healthcare National Quality Forum (NQF) www.qualityforum.orgwww.qualityforum.org National Committee for Quality Assurance (NCQA) www.ncqa.orgwww.ncqa.org Provider organizations –AMA’s Physician Consortium for Performance Improvement (PCPI) www.ama-assn.org/ama/pub/physician-resources/clinical- practice-improvement/clinical-quality/physician-consortium- performance-improvementwww.ama-assn.org/ama/pub/physician-resources/clinical- practice-improvement/clinical-quality/physician-consortium- performance-improvement Joint Commission (JC) www.jointcommission.orgwww.jointcommission.org Institute for Healthcare Improvement (IHI) 5 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Introduction to QI and HIT Lecture b

6. US Healthcare System: How Are We Doing? Needs to be improved, especially for the uninsured Patient safety & healthcare-associated infections warrant urgent attention Quality is improving, but pace is slow, especially in preventive care & chronic disease management Disparities are common and lack of insurance is a contributor Many disparities are not decreasing; those that warrant increased attention include care for cancer, heart failure, and pneumonia 6 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Introduction to QI and HIT Lecture b

7. Quality of Care in the US— or Lack Thereof National study of physician performance for 30 medical conditions plus preventive care: physicians provided only 55% of recommended care. (McGlynn et al. NEJM 2003; 348:2635) 66% of people with hypertension are inadequately treated. (JNC 7, JAMA 2003;289: 2560) 63% of people with diabetes have HbA1c levels greater than 7.0%. (Saydah, et al. JAMA 2004;291:335) 62% of people with elevated LDL cholesterol have not reached lipid goals. (Afonso, Am J Man Care 2006;12:589) 50-70% of healthcare-associated infections are preventable. (Umscheid et al. Infect Control Hosp Epidemiol. 2011 Feb;32(2):101-14.) 24.7% of Medicare patients admitted to the hospital for heart failure are readmitted within 30 days. (CMS, 2009) 7 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Introduction to QI and HIT Lecture b

8. More Issues with Quality of Care Only 27% of adults with a regular PCP could easily contact their physician over the telephone, obtain care or medical advice after hours, or experience timely office visits. Only 57% of adults rate the information they get about their health issues as very good; only 43% find it easy to get an appointment; and only 56% find the physician’s office to be well-organized and feel their time is not wasted. 8 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Introduction to QI and HIT Lecture b

9. Why Is QI Important? Given the current sub-optimal quality of care received by Americans, the introduction of QI initiatives is imperative. HIT has an important role to play in QI initiatives. 9 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Introduction to QI and HIT Lecture b

10. How Do We Improve Healthcare? “ Every system is perfectly designed to achieve the results it achieves.” (Paul Batalden, M.D, 2008) So, the answer must lay in the system redesign. 10 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Introduction to QI and HIT Lecture b

11. Basics of Quality Improvement 11 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Introduction to QI and HIT Lecture b

12. Set an Aim Make it specific –Assign it a number if possible Assign it a timeline Make it measurable Make sure it is challenging but doable 12 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Introduction to QI and HIT Lecture b

13. Measure PROCESS MEASURE: Are we doing what we must to get the improvement we seek? OUTCOME MEASURE: Are we getting what we expect? BALANCING MEASURE: Are we causing new problems in other parts of the system? 13 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Introduction to QI and HIT Lecture b

14. Examples Hospital –AIM: we will reduce the number of ventilator-associated pneumonias (VAP) in the ICU from the current 23% to under 10% in 4 months –MEASURES: Process measure: –Ventilator days –Over-sedation hours –Oral care performed Outcome measure: Number of VAP Balancing Measure: –Cost of care –Re-intubation rates Ambulatory –AIM: we will reduce the amount of time it takes our patients to get an appointment (request to appointment) from 23 days to 0 days in 6 months –MEASURES: Process measure: –Supply –Demand –No-show rate Outcome measure: third next available appointment Balancing Measure: Patient satisfaction 14 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Introduction to QI and HIT Lecture b

15. Change Concepts and strategies: decide on the overall changes that will lead to the desired improvement. Specific changes: –Make them small –Make them fast –Make them frequent You may need to include additional measures specifically to decide if a change you have tested is worth keeping or did not lead to improvement. Consider using pre-existing change packages. 15 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Introduction to QI and HIT Lecture b

16. Example of a Change Package 16 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Introduction to QI and HIT Lecture b

17. Learn One of the most important aspects of QI is to understand how your systems actually perform, under a range of conditions. Deming’s theory of profound knowledge is based on the principle that each organization is composed of a system of interrelated processes and people. The improvement of the system depends on the capability to organize the balance of each component to enhance the entire system. Understanding and learning about your system is essential to improve it. 17 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Introduction to QI and HIT Lecture b

18. Introduction to Quality Improvement and Health Information Technology Summary ─ Lecture b The quality of care received in the US needs improvement. Quality improvement is an ongoing process that includes the setting of an aim and a progressive measurement, change test, and understanding of the system. 18 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Introduction to QI and HIT Lecture b

19. Introduction to Quality Improvement and Health Information Technology References—Lecture b References Agency for Healthcare Research and Quality (AHRQ). Available from: http://www.ahrq.gov/http://www.ahrq.gov/ Batalden, Paul M.D in The Improvement Collaborative: An Approach to Rapidly Improve Health Care and Scale Up Quality Services. June 2008. Available from: http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0CCQQFjAB&url=http%3A%2F%2Fw ww.ovcsupport.net%2Flibsys%2FAdmin%2Fd%2FDocumentHandler.ashx%3Fid%3D790&ei=g2nWTtbdFoHn0QH 8uP39AQ&usg=AFQjCNEnga43Tn8Y_Mmf0uUbcRUzhevA0w&sig2=RG7ZXVjV_eKlghcJarz_1A http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0CCQQFjAB&url=http%3A%2F%2Fw ww.ovcsupport.net%2Flibsys%2FAdmin%2Fd%2FDocumentHandler.ashx%3Fid%3D790&ei=g2nWTtbdFoHn0QH 8uP39AQ&usg=AFQjCNEnga43Tn8Y_Mmf0uUbcRUzhevA0w&sig2=RG7ZXVjV_eKlghcJarz_1A Beal et al. Closing the Divide: How Medical Homes Promote Equity in Health Care. Commonwealth Fund, 2007 Centers for Medicare and Medicaid Services. http://www.cms.gov/http://www.cms.gov/ IOM—International Institute of Medicine. Available from: http://iom.edu/http://iom.edu/ Institute for Healthcare Improvement (IHI) Available from: http://www.ihi.org/Pages/default.aspxhttp://www.ihi.org/Pages/default.aspx Joint Commission. Available from: http://www.jointcommission.org/http://www.jointcommission.org/ National Committee for Quality Assurance. Available from: http://www.ncqa.org/http://www.ncqa.org/ National Quality Forum (NQF). Available from: http://www.qualityforum.org/Home.aspxhttp://www.qualityforum.org/Home.aspx Physician Consortium for Performance Improvement (PCPI)- American Medial Association. Available from: http://www.ama-assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinical-quality/physician- consortium-performance-improvement.page http://www.ama-assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinical-quality/physician- consortium-performance-improvement.page Wasson, J. & Benjamin, R. How is your health: what you can do to make your health and healthcare better, 2009. Available from: http://www.howsyourhealth.org/html/HowsYourHealth_4thEd.pdfhttp://www.howsyourhealth.org/html/HowsYourHealth_4thEd.pdf 19 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Introduction to QI and HIT Lecture b

20. Introduction to Quality Improvement and Health Information Technology References—Lecture b Charts, Tables, Figures 1.2Example of a Change Care Package. California Academy of Family Physicians Diabetes Initiative Care Model Change Package. Available from: http://eo2.commpartners.com/users/acme/downloads/CAFP._Diabetes_Change_Package.pdfz http://eo2.commpartners.com/users/acme/downloads/CAFP._Diabetes_Change_Package.pdf Images Slide 4: Quality Health Care: Who Defines It? Courtesy of Dr. Anna Maria Izquierdo-Porrera Slide 6: Cover of the 2009 National Quality Healthcare Report and the 2009 National Healthcare Disparities Report. Available from: http://www.ahrq.gov/qual/qrdr09.htmhttp://www.ahrq.gov/qual/qrdr09.htm Slide11: Basics of Quality Improvement. Courtesy of Dr. Anna Maria Izquierdo-Porrera Slide 13: Process Measure, Outcome Measure, Balancing Measure. Courtesy of Dr. Anna Maria Izquierdo-Porrera 20 Health IT Workforce Curriculum Version 3.0/Spring 2012 Quality Improvement Introduction to QI and HIT Lecture b