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

2. 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

3. 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

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

5. 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”

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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 % 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

13. 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

14. 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

15. 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

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

17. 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

18. 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

19. 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

20. 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”

21. O/E Trend Comparison

22. Lives Saved by Qtr by System

23. Clinical Priority: Mortality

24. 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

25. Questions?