1. Quality Management in Your Practice: A Nuts and Bolts Primer Richard P. Dutton, MD MBA Executive Director Anesthesia Quality Institute 10/11/2014

2. Some people need feedback on their work performance

3. Introduction I am an anesthesiologist. I have led QM programs at the department and hospital levels Now I get to try it at the national level!

4. Introducing Yourself Please send us a message (in the system or by email to j.mlodoch@asahq.org):j.mlodoch@asahq.org –Who are you? What is your title? –Why are you listening? –Do you have any specific questions or topic areas?

5. Why Have Quality Management? To improve patient outcomes To improve business efficiency To meet regulatory requirements

6. 10/11/20146 The Challenge The government wants to know that Ma and Pa are getting the healthcare they deserve … and that our taxes pay for.

7. The Eight Step Program: One Who’s in charge here? An effective QM program often depends on the initiative of a single person

8. What the leader does … Promotion of open dialogue Timely feedback Getting "buy in" from providers Support after a bad outcome –Accurate analysis by experts –A forum for discussion –Prevention of future events

9. The Eight Step Program: Two What do we need to know? Sometimes, knowing your destination makes it easier to find the best route

10. Typical QM Questions How many cases did we do last year? How many deaths? –Anesthesia related? –Preventable? How many complications? How satisfied are our patients? How do our results compare with others? 10/11/201410

11. Data: Indicators Business (numbers, times, dollars) Outcomes (deaths, complications) Processes –Steps that lead to outcomes … –Often problematic Focused reviews Sentinel events

12. The Quality Triangle Risk Factors Outcomes Process

13. The Eight Step Program: Three Gather the data! First, steal as much as you can Only then consider making your own

14. He who has the data controls the future

15. What to Collect? “Administrative” data AIMS data Hospital EHR data Quality and outcome data –Your group –Other specialties Patient satisfaction information Anecdotes

16. How to Make Your Own Data http://aqihq.org/AQIVendors.aspx

17. The Eight Step Program: Four Share with your friends Produce a regular QM report Publish it internally Excerpt it externally

18. “We have lots of information technology, we just don’t have any information”

19. Who has your data already? The federal government CMS – Medicare Data AHRQ – CAHPS Data Private insurance companies The Joint Commission The ABA Your IT vendors

20. Data “Safety” You cannot hide your data You can see yourself as others will see you You can pre-empt illegitimate use

21. The Eight Step Program: Five Capture the interesting cases One of your goals should be to learn from the mistakes of others -- this is more fun than making the mistakes yourself.

22. Lessons From Aviation The US National Civil Aviation Review Commission Chaired by Senator Norman Mineta “Avoiding Aviation Gridlock & Reducing the Accident Rate,” December 1997. FOQA and other safety risk management programs are based on trust. Keeping this data confidential is the key to acquiring it in the first place.

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24. Focus on Systems Not about weeding out "bad apples” W. Edwards Deming: 94% of the potential for improvement resides in system performance, only 6% is individual Dutton’s corollary: “system performance” usually equals “communication”

25. Management BY Anecdote Over-reaction to isolated events Layered bureaucracy Failure to discover root causes Failure to assess both benefits and risks Frequent disposal of both baby and bathwater!

26. Management OF Anecdotes Have a process for addressing sentinel events –Discovery –Reporting –Disclosure –Fact finding: who? –Analysis –Discussion and System Changes

28. The Eight Step Program: Six Change things. Don’t be afraid to tinker with your systems and processes.

29. PACU Reintubation Rate Provider Education and Rocuronium Removed Rocuronium Introduced

30. The Eight Step Program: Seven Lather, rinse, repeat QM becomes easier over time, and more effective. You want to embed this process in the fabric of your practice.

31. Control Chart Analysis Anesthesiology

32. The Eight Step Program: Eight Report your data externally. Collect benchmarks you can use. Participate in the AQI!

33. Where is the Improvement?

34. “The unexamined life is not worth living.” -- Socrates, Apology 38a

35. Contact Us! www.aqihq.org or r.dutton@asahq.org