1. Introduction to Quality Improvement and Health Information Technology
Welcome to Quality Improvement: Introduction to Quality Improvement and Health Information Technology. This is Lecture b.
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 IU24OC

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

3. Quality Improvement Introduction to QI and HIT
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)
According to an Institute of Medicine report, “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.”
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture b

4. Quality Healthcare—Who defines it?
So who defines healthcare quality? Lots of people do, and each does so from his own unique perspective. Take healthcare providers, for instance. They are more likely to view quality as the application of evidence-based professional knowledge to the needs of individual patients. Patients and families, on the other hand, may place more importance on how the provider talks with them or how long they have to sit in the waiting room. Payers value patient satisfaction and use of preventive services rather than focusing on clinical outcomes of the patient. And regulatory bodies, like the Joint Commission or the CMS, or professional organizations, such as the American Medical Association, view quality as conforming to their standards.
The image is a composite of four intersecting circles, each containing a category of entities that help define quality healthcare: healthcare providers (application of evidence-based principles), patients and families (communication & timeliness), professional and regulatory bodies (conformity with standards), and payers (cost vs. outcomes).
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)
National Committee for Quality Assurance (NCQA) 
Provider organizations
AMA’s Physician Consortium for Performance Improvement (PCPI)
Joint Commission (JC)
Institute for Healthcare Improvement (IHI)
These are some of the regulatory bodies and organizations that help define and bring consensus around QI issues.
A non-profit organization, the National Quality Forum (NQF), is charged with improving the quality of healthcare in America.
They have a three-part mission that includes:
Working in partnership to achieve consensus around performance improvement based on national goals and priorities;
Supporting standards for publicly measuring and reporting performance based on national consensus; and
Supporting the use of outreach programs and educational interventions to attain national goals.
The National Committee for Quality Assurance is a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality.
It develops quality standards and performance measures for a broad range of healthcare entities. These measures and standards are the tools that organizations and individuals can use to identify opportunities for improvement. 
The American Medical Association’s Physician Consortium for Performance Improvement (the PCPI) is a national, physician-led initiative dedicated to improving patient health and safety.
According to their website they achieve this by:
“Identifying and developing evidence-based clinical performance measures and measurement resources that enhance quality of patient care and foster accountability;
Promoting the implementation of effective and relevant clinical performance improvement activities; and
Advancing the science of clinical performance measurement and improvement”.
The Joint Commission is an independent, not-for-profit organization that accredits and certifies more than 19,000 healthcare organizations and programs in the United States. 
The Institute for Healthcare Improvement (IHI) is an independent not-for profit-organization located in Cambridge, Massachusetts. The IHI is concerned with investigating new models of care and how they perform, (while partnering with patients, families and healthcare professionals). In addition, IHI is focused upon encouraging and supporting change while helping to maintain the momentum and commitment to serious and transformational health-system change. Finally, the IHI is committed to innovation and wide-scale adoption of best practices, high-quality care, and cost-efficient services for all.
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
Each year, the Agency for Healthcare Research and Quality, or the AHRQ, partners with the Department of Health and Human Services to report on progress and opportunities for improving health care quality. In 2009, the report concluded that the US health care system needs to be improved, especially for the uninsured, and that patient safety and healthcare-associated infections warrant urgent attention. Although quality is improving, the pace is slow, especially in preventive care and management of chronic disease.
Some Americans receive health care that is worse than other Americans. These disparities are often due to differences in access to health care, provider biases, poor provider-patient communication, and poor health literacy. The AHRQ tracks gaps where some people receive poor or worse health care than others and looks for improvement over time. Emphasis is on race, ethnicity, and socioeconomic status, but also includes attention to broadly defined priority populations (groups with unique health care needs or issues that require special focus such as recent immigrants or people with limited-English proficiency, women, children, older adults, residents of rural areas, and disabled individuals).
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): )
24.7% of Medicare patients admitted to the hospital for heart failure are readmitted within 30 days.
(CMS, 2009)
So how are we doing in terms of healthcare quality?
Many of the measures available to us would suggest we are not doing so well.
In a national phone survey, McGlynn and colleagues found that participants in the survey received 54.9 percent of recommended care. There was hardly any difference among the proportion of recommended preventive care (54.9%), recommended acute care provided (53.5 %), and recommended care provided for chronic conditions (56.1 percent). The study raised concern for the health of the American public.
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure stated that two- thirds of hypertensive individuals were being inadequately treated.
Saydah and his colleagues in a review of data from the Third National Health and Nutrition Examination Survey (NHANES III, conducted ) and NHANES , cross-sectional surveys of a nationally representative sample of the noninstitutionalized civilian US population described that two- thirds of individuals with diabetes had uncontrolled levels of HgbA1c (a measure of diabetes control).
In another study, Afonso and colleagues also described that two-thirds of individuals with elevated cholesterol levels had not reached adequate control.
This is not only true in the world of ambulatory care. The same kind of quality concerns are found in the hospital environment. Examples of this include the level of hospital acquired infections. In a recent review, Umscheid and colleagues found that anywhere from 50% to 70% of these infections are preventable. Another measure of quality lapses in the hospital world includes the high rate of readmissions. A fourth of the patients admitted with heart failure in this country will be readmitted within 30 days.
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.
This lack of quality is not only reflected in the outcomes of care but also in the patient’s experience of care. In a national survey conducted in 2006 by the Commonwealth Fund’s Dr. Beal and colleagues, they found that only 27 percent of adults who actually had a primary-care provider could easily contact their physician over the phone to obtain care or medical advice or get timely office visits.
In another national survey found that only half of the adults receive very good information, find it easy to get an appointment, or do not feel they waste their time when they visit their physician.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture b

9. Quality Improvement Introduction to QI and HIT
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.
These are just a few examples of the state of health care in the US. Given the current quality of care received by Americans, the introduction of quality improvement initiatives is imperative. As we look at the different ways to improve our healthcare system we should consider the role of HIT could play in this improvement.
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.
Paul Batalden, MD Director Health Care Improvement Leadership Development famously states, “Every system is perfectly designed to achieve the results it achieves.”
Thus the way to improve our healthcare system is to redesign it.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture b

11. Basics of Quality Improvement
There are a number of methodologies used to improve the quality of a system: model for improvement, lean thinking, six sigma, theory of constraints, customer inspired quality … and many others. The detailed review of these multiple methodologies is beyond the scope of this lecture. However, at the core of all these methodologies there are the same basic principles that we will now review.
The quality improvement process starts when you set an aim. You cannot improve a system if you do not have a clear idea of what you need to improve. Subsequently, a continuous cycle of measurement, change, and learning starts. Measurement is an essential component of quality since you must have the ability to measure change to direct change in the appropriate direction. Change is the second essential component of any improvement process. As an old proverb states, “you can’t fatten the cow by weighing it.” Finally, the third essential component of improvement is our ability to learn and better understand the system we are changing. To achieve long-lasting change we need to move away from the project mentality and dive into the system we are trying to change.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture b

12. Quality Improvement Introduction to QI and HIT
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
The aim we set needs to be very specific; if at all possible a numeric aim should be set. It is very difficult to improve a system if your aim is vague. “We will improve our infection rate” is a much harder aim to attain than “we will cut our rate of hospital acquired pneumonia by half.” However this aim, although better than the former, could be improved. What is your current rate of infection? Where are the majority of infections happening? Is there any shift or time of year where these infections are worse? The inclusion of all those aspects into your aim denotes an understanding of the system you are working on and assists you in achieving your goal. A better aim would read “we will reduce the number of hospital-acquired pneumonias from the current 35% to 15% in the ICU.”
Assigning a timeline is an important component of setting an aim. If you don’t have a timeline to achieve your improvement, it is difficult to see it through or to engage a team that usually is busy with many other responsibilities.
Making your aim measureable will assist you in seeing it through. There are very commendable aims that cannot be accomplished because they cannot be measured. An example of an immeasurable goal is, “we will make 90% of our patients happy in 6 months.” Although it is specific and it has a numeric value, we have to choose a variable that can be measured. How will we measure if they are happy? A better option for this aim could be “90% of our patients will rate our services as ‘excellent’ and will state they would recommend our services to a friend or family member.” This captures the essence of the original aim and allows you to measure it.
Make sure you challenge your team with the aim you choose. An aim you can achieve in a week may make you look good in the short term, but is unlikely to bring permanent improvement to your system.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture b

13. Quality Improvement Introduction to QI and HIT
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?
As we mentioned before, measurement is an essential component of quality since you must have the ability to measure change in order to direct change in the appropriate direction.
There are three types of measure we will be focusing on.
Process measures. These measures look at the steps in the system and determine if the system is performing as it should. Performance measures will improve before the outcome measures do. They assist us in determining if we are on track to get the improvements we want to see in our system.
Outcome measures. These measures determine the impact of our changes in the system. They measure results from the view of patients about their health and wellbeing. These measures may also look at the impact on other stakeholders such as payers, employees, or the community.
Balancing measures. These measures are designed to look at the whole system and make sure we are not causing new problems in other parts of the system while trying to fix something. Although these measures tend to be measures of cost or patient experiences, any of the process or outcome measures could be used as balancing measures if they help us look at the whole system.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture b

14. Quality Improvement Introduction to QI and HIT
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
We will now present two examples of measures selected for improvement projects.
The first is a hospital example. In this example, the staff of the ICU set an aim to reduce the number of ventilator-associated pneumonias (VAP). They set a specific aim with a clear timeline. For process measures, they choose factors that have been chosen to relate to VAP. For example the more days a patient is connected to a ventilator the more likely he will become infected. The outcome measure is actually the number (or rate) of VAP. This measure ties directly to the aim. In this case, staff members have chosen to use cost of care as a balancing measure since there is a chance that by incorporating the changes they must decrease the rate of VAP, and the cost of care will improve. They also included the rate of re-intubation as a balancing measure since it is possible that some of the changes they incorporate may cause patients to be extubated too soon. These are two examples of how balancing measures look at the rest of the system.
In our ambulatory example, the team members want to improve their access to care. To do so they will reduce the time it takes patients to get an appointment. In this case, the process measures are the supply (or amount of slots available for practitioners to see their patients), the demand for appointments, and the no-show rate. The staff chose to include the no-show rate in the process measures because they believe that by reducing their no-show rate they will have more space to see patients sooner. If they thought that the changes they wanted to incorporate would increase the number of no-shows in the schedule, they would have added this measure to the balancing measures. The outcome measure is the third next available appointment. It is a good measure of access, since it disregards appointments that are available due to last moment cancelations. Again the outcome measure ties directly to the aim. Finally, the balancing measure the staff chose is a measure of patient satisfaction.
As you can see, setting a measurement strategy is not cut and dry. You need to make some assumptions regarding where you envision your system is going.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture b

15. Quality Improvement Introduction to QI and HIT
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.
After you set your measurement strategy it is time for you to consider the change you want to test. As you consider change you will first need to decide on basic concepts or strategies that you want to focus on. Overall ideas for change will lead you to improvement, but they are not specific enough for testing change.
In our VAP example, our concepts and strategies could be:
Reduce the number of ventilator days,
Reduce over-sedation
And improve oral hygiene.
Once you have established the overall categories, you will design tests to measure change. To accelerate improvement, the tests of change need to be small, fast, and frequent. This way you will be able to build new tests of change on your initial improvement and head toward your aim. Examples of tests of change in our example could be some of the following.
To reduce the number of ventilator days: we could have the respiratory therapist test the settings every two hours to determine when a patient is ready for extubation, the rounds should include discussion of extubation for all patients, trials of spontaneous breathing could be included as part of the routine. As you can see, these are specific tests that can be done fairly fast and of which we could have results in a day or two.
To determine the effect of a test, you may need to include measures and discussion of the test. Continuing with the example we have been using, we could meet with the respiratory therapist to determine at the end of the first day how the tests are going and determine if they need some tweaking.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture b

16. Example of a Change Package
In designing your change package you may want to consider using pre- existing change packages. These are built by QI professionals based on scientific evidence.
This is an example of one such change package. The table contains a partial copy of the California Academy of Family Physicians Diabetes Initiative Care Model Change Package. It was originally developed by Lumetra, California’s Quality Improvement Organization, under contract with the Centers for Medicare and Medicaid Services to assist practitioners to improve the care of patients with diabetes.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture b

17. Quality Improvement Introduction to QI and HIT
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.
The final component of improvement is learning about your system. Intertwined in all aspects of improvement is the concept of the importance of understanding your system in order to be able to improve it. This is based on a system theory proposed by William Deming, a well-known statistician. His theory of profound knowledge is based on the principle that each organization, (department, site) is composed of a system of interrelated processes and people. Improvement of the system depends on the capability to organize the balance of each component to enhance the entire system. Thus understanding and learning about your system is essential to improving it.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture b

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

19. Quality Improvement Introduction to QI and HIT
Introduction to Quality Improvement and Health Information Technology References—Lecture b
References
Agency for Healthcare Research and Quality (AHRQ). Available from:
Batalden, Paul M.D in The Improvement Collaborative: An Approach to Rapidly Improve Health Care and Scale Up Quality Services. June Available from:
Beal et al. Closing the Divide: How Medical Homes Promote Equity in Health Care. Commonwealth Fund, 2007
Centers for Medicare and Medicaid Services.
IOM—International Institute of Medicine. Available from:
Institute for Healthcare Improvement (IHI) Available from:
Joint Commission. Available from:
National Committee for Quality Assurance. Available from:
National Quality Forum (NQF). Available from:
Physician Consortium for Performance Improvement (PCPI)- American Medial Association. Available from:
Wasson, J. & Benjamin, R. How is your health: what you can do to make your health and healthcare better, Available from:
No audio.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture b

20. Quality Improvement Introduction to QI and HIT
Introduction to Quality Improvement and Health Information Technology References—Lecture b
Charts, Tables, Figures
1.2 Example of a Change Care Package. California Academy of Family Physicians Diabetes Initiative Care Model Change Package. Available from:
Images
Slide 4: Quality Health Care: Who Defines It? Courtesy of Dr. Anna Maria Izquierdo-Porrera
Slide 6: Cover of the National Quality Healthcare Report and the 2009 National Healthcare Disparities Report. Available from:
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
No audio.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture b