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Clinical Quality פרופ ' מאיר ברזיס המרכז לאיכות ובטיחות קלינית הדסה והאוניברסיטה העברית ירושלים www.hadassah.org.il/departments/quality איכות קלינית בעולם.

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Presentation on theme: "Clinical Quality פרופ ' מאיר ברזיס המרכז לאיכות ובטיחות קלינית הדסה והאוניברסיטה העברית ירושלים www.hadassah.org.il/departments/quality איכות קלינית בעולם."— Presentation transcript:

1 Clinical Quality פרופ ' מאיר ברזיס המרכז לאיכות ובטיחות קלינית הדסה והאוניברסיטה העברית ירושלים איכות קלינית בעולם ובהדסה

2 Definitions of Quality (Institute of Medicine) Degree to which care increases likelihood of desired health outcomes & consistent with current professional knowledge Safe Timely Effective Patient centered EquitableEfficient Overuse (antibiotics, imaging) Underuse (prevention) Misuse (errors & complications) Evidence-based Patient-centered System-minded

3 Performance Evaluation Voluntary Quality Indicators Voluntary Quality Indicators Mandatory Performance Evaluation Mandatory Performance Evaluation Public Data Including Individual Surgeon Public Data Including Individual Surgeon Pay for Performance Pay for Performance Non-payment for Preventable Complications Non-payment for Preventable Complications Challenges: measurement error, socioeconomic confounders, manipulation, denial, gaming

4 * Harvard Professor Don Berwick, Institute for Health Improvement Stages of Facing Reality* Ego bias: “I’m above the average” (Kahneman & Tversky. Heuristics and Biases. The Psychology of Intuitive Judgment) Stage 1. “The data are wrong” Stage 2. “The data are right, but it’s not a problem” Stage 3. “The data are right; it is a problem; but it is not my problem.” Stage 4. “I accept the burden of improvement”

5 “In short, academic medical centers should not just have best knowledge, they should model the best execution…They do not. Unreliability, waiting, lack of focus on patient’s needs and safety are every bit of characteristic of academic medical centers…and that needs not be the case. The same intellectual fervor and talent that allow places like the Brigham to raise the bar in technical clinical care can equally be used to raise the bar in the quality of medical care. …it’s going to take much more acute self-awareness among academicians and academic medical centers…. …a duty to encourage healthcare leaders and clinicians everywhere to become involved in improvement." Donald M. Berwick, MD, MPP, FRCP Professor at Harvard School of Public Health President, Institute for Health Improvement, Boston, Massachusetts, USA

6 Cycles of Improvement (Industry Model) PDSA Example: monitoring of surgical infection rate is now recognized as important tool to prevention Statistical Process Control

7

8 Quality of General Intensive Care Survival at Hadassah vs. Israel Average Prof. Elisheva Simchen, Ministry of Health p<0.001 Despite higher severity score, patients had better survival at Hadassah

9 Quality of Neonatal Intensive Care Survival at Hadassah vs. Israel Average Dr. Zivanit Ergaz, Prof. Ilan Arad & Gertner Institute

10 Quality of Treatment in Trauma Mortality at Hadassah vs. US level I centers Dr. Yoav Mintz, Ms. Irina Gertcenchtein & Prof. Avraham Rivkind Hadassah data Israeli National Trauma Registry n=7,391 US National Trauma Data Bank from 51 level-I trauma centers, n= 263,524

11 Quality indicators for myocardial infarction, Hadassah vs. US data Hadassah ( % Hadassah ( %) ’ 102’ Referral to cardiac rehabilitation only 21%

12 Percent of patients receiving adequate anticoagulation% Surgery A Surgery B Surgery C Gynecology A Gynecology B p<0.001p<0.001p<0.001p<0.02

13 Catheter-related Bloodstream Infections Intervention in 108 ICU’s resulted in 66% reduction in rates of catheter-related bloodstream infection

14 Catheter-related Bloodstream Infections  At Hadassah, baseline observations over five months revealed a rate of infection of 13.2% (42/318 catheters), on the high side of reported ranges.  Observations in ICU’s and OR: aseptic conditions not always strictly kept during catheter insertion.  Intervention included discussion of results with staff, training for correct aseptic technique, use of a checklist, and authorization to nurses to feedback and stop physicians breaching asepsis. I. Gross, S. Benenson, M. Cohen, C. Bloch

15 Catheter-related Bloodstream Infections Following intervention, improvement in technique was observed; rate of infection declined by 62%, from 13.2% to 5.0% (17/337 catheters, p<0.001). Days of catheter Proportion of catheters remaining without infection (Cox regression) Before the intervention After the intervention p<0.001

16 Catheter-related Bloodstream Infections UnitBefore InterventionAfter Intervention Rate Reduction (%) Catheter days N infected Rate* Catheter days N infected Rate* ICU-A ICU-B ICU Medicine Neuro- surgery Cardiac surgery ICCU Total ** * Rate of infection per 1000 catheter-days** p<0.001

17 Catheter-related Bloodstream Infections Pronovost P. et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725

18 Physicians’ Hand Hygiene at Hadassah Mt. ScopusEin Kerem 55%65% Medicine 62%55% Pediatrics 66%35% Surgery 25% Ob-Gyn Rate of hand-washing out of contacts with patients Summary of surveys in recent years Use of Hadassol has been widely adopted but rate of hand hygiene unchanged

19 Surgical Infections in General Surgery  Rate of post-operative wound infection is 8-12%, within the range reported in the literature.  Pre-operative antibiotic administration is documented as given on time in 59% of cases.  A significant proportion of infections are diagnosed after discharge from the hospital.  Infection monitoring is recognized as an important tool to keep rates low. N. Minster, M. Zarhia, G. Almogy, A. Rivkind, S. Benenson, M. Cohen

20 Complications Rate of infection (95% CI) %* 6% (2-13) Children 12% (7-20)Adults Rate of hematoma (95% CI) 11-15%* 10% (5-18) Children 13% (8-21)Adults *Range in literature varies by motive (voluntary or mandatory) Satisfaction high to very high in 94% of adults and children; problems: waiting & relation with staff Quality of Inguinal Hernia Repair in Adults and in Children at Hadassah T. Yemini, M. Badriah, Y. Mintz, R. Udassin, A. Rivkind

21 Quality of Special Surgeries Outcomes of special surgery in the Departments of Ear, Nose & Throat (ENT), Ophthalmology, Plastic and Neurosurgery Snoring, tonsillectomiesENT Corneal transplant, LasikOphthalmology Breast reconstructionPlastic surgery Prevention of shunt infectionNeurosurgery

22 Management of Snoring Disorders with Radiofrequency at Hadassah Optimal % p<0.01p≤0.05p<0.005 L. Gordon, S. Catinari, R. Eliashar

23 Lasik (Myopic Corneal Refractive Surgery) at Hadassah Optimal (N=109) % N. Orwa, A. Solomon, Y. Frucht-Peri

24 Evaluation of Outcomes for Tonsillectomies at Hadassah (2008) Hadassah (N=106) Literature UK audit & others (N>30,000) % with any bleeding 28? % needed readmission % needed reoperation O. Frenkel, R. Eliashar

25 Quality of Reconstruction Surgery After Mastectomy R. Yanko-Arzi, M. J. Cohen, R. Braunstein, E. Kaliner, R. Neuman Dept of Plastic Surgery & Center for Clinical Quality & Safety A survey of 140 women after reconstructive breast surgery for cancer showed satisfaction related mostly to expectations before surgery. % Severe moderatehigh Complications Success Satisfaction Would Recommend Hadassah

26 Intervention Neurosurgical shunt infections Mortality in infected cases dropped from 50% to 0% I. Paldor, Z. Israel, C. Block with the dept of Neurosurgery

27 Is the X-ray interpretation by the junior staff on duty correct? Dr. Y. Mintz, Dr. D. Kisselgoff, Y. Gronowitz, A. Shaham, R. Hefez, Dr. D. Shaham - Departments of Surgery, Radiology, and Center for Clinical Quality & Safety Pulmonary Embolism SurgeryTrauma % agreement resident vs. specialist 95%77%94%

28 Effect of Translators on Understanding & Satisfaction of Arab Parents Department of Pediatrics & ER, Mt Scopus & Center for Clinical Quality & Safety, Hadassah Hebrew University Medical Center

29 The Presence of a Translator Significantly Improved Parental Understanding Regarding Diagnosis, Treatment and Follow-up p<0.001, n=194

30 Will patient’s empowerment improve efficacy & safety of oral anticoagulation? Will patient’s empowerment improve efficacy & safety of oral anticoagulation? Self-management for Coumadin H. Goldberg, Y.Ben David, U. Izhar, L. Gordon, T. Baevsky, M.Burzstyn & M.Brezis with the Departments of Cardiothoracic Surgery and Medicine

31 % of tests within target INR 60%60%60%60% * p< % ControlIntervention Patient’s knowledge & satisfaction significantly improved Patient’s empowerment improves efficacy & safety of oral anticoagulation

32 Communicating with Families & Satisfaction with End-of-Life Decisions Departments of Medicine & Center for Clinical Quality & Safety InterventionControl % of relatives agreeing with statement: 13*35 “I felt the team didn’t care about my opinion” 10*43 “It upset me I didn’t know what was going on” 3*44 “Patient’s problems weren’t explained to me” 17*46 “Management options were not explained” 10*38 “I was afraid to ask questions” 17*52 “I felt excluded in the decision-making” Communication with families of patients near end of life improves perceived quality of care *p<0.005 in favor of the intervention group

33 Rate of patient’s recall for explanations on risks & alternatives: informed consent? Discussion of alternativesExplanations about risks N Type of procedure Ward 20%60%178OperationSurgery 19%57%198OperationObGyn 40%42%117 Diagnostic or therapeutic procedureMedicine 8%39%120AngiographyCardiology 21%51% 613 Total הצעה לשיפור : שלש שאלות צמודות לטופס ההסכמה האם יש לך שאלות ? האם יש לך שאלות ? האם את / ה רוצה לשמוע יותר על סיכונים או חלופות ? האם את / ה רוצה לשמוע יותר על סיכונים או חלופות ? כדי למנוע אי הבנה, האם תוכל / י בבקשה לחזור על ההסבר שקיבלת ? כדי למנוע אי הבנה, האם תוכל / י בבקשה לחזור על ההסבר שקיבלת ? International Journal for Quality in Health Care 2008

34 Rate of patient’s recall for explanations on risks & alternatives: informed consent? Discussion of alternativesExplanations about risks N Type of procedure Ward 20%60%178OperationSurgery 19%57%198OperationObGyn 40%42%117 Diagnostic or therapeutic procedureMedicine 8%39%120AngiographyCardiology 21%51%613Total International Journal for Quality in Health Care 2008

35 Conclusion Projects help make healthcare at Hadassah more evidence-based, patient-centered & system-minded. Projects help make healthcare at Hadassah more evidence-based, patient-centered & system-minded. Over 100 projects presented at National Meetings of Israeli Society for Quality in Healthcare; over 48 theses and 19 peer- reviewed publications. Over 100 projects presented at National Meetings of Israeli Society for Quality in Healthcare; over 48 theses and 19 peer- reviewed publications. Center for Clinical Quality & Safety


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