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Quality Health care seen as a Rubic cube. Quality The Russian Doll of Health Care.

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Presentation on theme: "Quality Health care seen as a Rubic cube. Quality The Russian Doll of Health Care."— Presentation transcript:

1 Quality Health care seen as a Rubic cube

2 Quality The Russian Doll of Health Care

3 Quality Just something for health care in developed economies???

4 “Concern about the quality of care is as old as medicine. But honest concern about quality, however genuine, is not the same as methodical assessment based on reliable evidence”. (Robert Maxwell BMJ 1984)

5 All health systems have problems 12% patients suffer from errors caused by health system International comparisons show deficits in all health systems Variations within systems Attention grabbed by head line catastrophic failures of care Institute of Medicine “Crossing the Chasm”

6 Challenge …….should you decide to accept it…... Is to reverse “Institutional Blindness” to problems of quality and safety.

7 Five themes from 30 enquiries into care disasters in the UK. Poor communication Disempowerment of staff and patients Ineffective systems and processes Isolation Inadequate leadership/management

8 Terminology

9 Quality: Agenda Management Benchmarking Total Quality Management Industry Audit

10 Quality: Assessment Assurance Control Improvement Quality vs. Safety Clinical governance

11 What else is “quality” Performance indicators (54) Standards Report cards Public access to performance data League tables Comparative health status data

12 Quality improvement in UK Confidential enquiry into maternal deaths Laboratory quality assurance External inspection residential care homes CEPOD

13 Pre 1989 “Doctor knows best” 1989 Medical audit 1991 Clinical audit 1999 Clinical governance Quality improvement in UK

14 Quality improvement in the UK 1996 Calman Hine Cancer report 1997 Clinical Governance 1998 NICE and CHI 1998 National Service Frameworks 1999 Cancer Care Collaboratives 2000 An Organisation with a Memory 2000 NHS 10 year plan much CQI

15 The Rubric Cube – dimensions of quality : (Maxwell BMJ 1984) Effectiveness Efficiency Equity Appropriateness Acceptability Access

16 More dimensions - for 2006 Choice Respect Provision of “real information” Safety

17 Frameworks for assessing quality of care-(Donabedian) Structure Process Outcome Medical technical Interpersonal

18 Everyone talks about it: but no one does anything about it Mark Twain on English weather

19 Who cares about “quality”? Politicians Purchasers of health care Provider institutions Professionals Public - media Patients

20 Checking where we are? Health care system Interface between organisations Provider organisation Interface between clinical services Clinical teams Patient - practitioner interface Or…responding to headlines???

21 Quality in terms of the system or service: National/regional waiting lists Health outcomes Or …?health outcomes of health care Provision of specialist services

22 In terms of hospital or practice: Access/equity Process of care for groups of patients % appropriate use of effective treatments Efficiency - or costs- or value for money?

23 In terms of Patient - practitioner interface: Choice Access: no waits Effective treatment/relief Involvement in decision making Medico-technical skills of clinicians Communication skills of clinicians

24 Quality: Link between organisational behaviour and clinical practice and health care outcomes Any improvement in clinical care requires an organisational change.

25 Quality Improving the quality of care within current resources. Making changes that can be shown to improve care for patients Practical approach to closing gaps between the ideal, what is wanted, what is expected and what is actually happening Making sure more winners than losers and more winning than losing Being smart, thinking out of the box and taking others with you

26 Quality: Balancing needs of populations and individuals Giving patients a better deal Always giving THE patient very good care Some professionals sometimes find this tough

27 Quality: is about change management Defining the gaps in care Understanding the causal problems Working out a solution Managing the change Reassessing the affects of that change

28 Health leader and quality of care. Needs to be able to describe the quality of care Needs mechanisms for further improvement Needs early warning response mechanisms. Articulates expectations to employees Exerts proper role as “employer” Carries a sense of “ Chronic Anxiety” about the quality and safety of care that is being delivered

29 Health leader’s role in quality? Philosopher: having the ideas Politician: getting the ideas across Plumber: putting the ideas into action

30 Philosopher Set out values Understand the complexities of the issues Works out priorities Relate concerns to practice Connect between worlds Reflective part of role

31 Six worlds: (after Dawson 1997) Pure science Clinical trials Meta analysis Guidelines and protocols Organisation Clinical practitioner

32 Politician Translating the philosophy into strategy Linking external drivers to internal mechanisms Picking up and responding to concerns Communicating to many groups Ensure relevance to everyone involved in change Understanding the impact on different groups Ensure local ownership of problem and solutions Working under constant pressure

33 Plumber Managing change Working through ambiguities Understanding incentives Measure results Working under constant pressure

34 Plumber’s role: unblocking the system If you go on doing what you are doing – you go on getting what you’ve got. Everyone wants to improve – but there are many blocks Someone is going to have to change how they work

35 Block 1- demonstrating problem Evidence of problem or need for change Acceptance of problem Ownership of problem Availability of data Timeliness of change

36 Nature of evidence Often contended/challenged Plural of anecdotes = data Has not been reliable or complete or relevant Need to understand clinical data in the context of organisational practice

37 Nature of “evidence” of problem Beyond reasonable doubt:clinical trials On the balance of probabilities: quality improvement

38 Block 2 - understanding systems Complexity of care Improving the quality of care always involves changing the system of care Clinical education focussed almost solely on the care of individuals Little emphasis in education on care of systems

39 Three central laws of improvement Results are the properties of systems Every system is perfectly designed to get exactly the results that it gets. For every complex problem there is a simple solution: and it is wrong

40 “Swiss cheese model”

41 Three bucket model of error likelihood

42 Blocks 3 - global Time Territory Tradition Trust Training

43 “New clinical skills” - ability to: Perceive and work in interdependencies Work in teams Understand work as a process Collect and analyse outcome data Collaborative exchange with patients Collaborative exchange with lay managers

44 Quality Puts values into practice? Describes clinical practice in organisational terms? Balances best deals for populations with excellence for individuals?

45 Quality Workforce + education+ training = Improved quality of clinical care

46

47 Assumptions are things that you don’t know you are making. Douglas Adams

48 History of Quality Improvement in the UK

49

50 Quality improvement in UK Confidential enquiry into maternal deaths Laboratory quality assurance External inspection residential care homes CEPOD

51 Pre 1989 “Doctor knows best” 1989 Medical audit 1991 Clinical audit 1999 Clinical governance Quality improvement in UK

52 Moving on from audit Evidence for intervention Evidence for deficiency in care - audit Link problem to organisational context Define the processes of care Define the organisational problem Make organisational change

53 Quality improvement in the UK 1996 Calman Hine Cancer report 1997 Clinical Governance 1998 NICE and CHI 1998 National Service Frameworks 1999 Cancer Care Collaboratives 2000 An Organisation with a Memory 2000 NHS 10 year plan much CQI

54 Quality in terms of customers needs Customers needs priority for everyone Existence of internal and external customers Measurement as basis for change Remove barriers between staff Promote effective team working Training for everyone

55 Improving Care: Change Change is difficult - uncertainty Continuous process Involves every one Based on continuing training/development for all staff

56 Example of complexity

57 Quality: the whole picture 6 months in the life of an engineer 3 months cough Chest x ray shadow Investigationslung cancer Further testsoperable tumour Pneumonectomy“complete” excision Steady recoveryback to work

58 Quality: the whole picture who is involved? Receptionist Radiographer -3 Nurse practitioner-3 Physician - 2 Radiologist- 3 Pathologist - 1 Pathology technician ECG technician Lung function tech Phlebotomist Day care receptionist Day care nurse -2 Secretary Contracts manager

59 Which population? All people in clinic waiting room? All people with lung cancer? All people with cough? All people who smoke? All people who live in hospital catchment? All people in UK?

60 At what level improvement? Patient Practitioner Clinical teams Service Service interface Organisation Organisational interface

61 Levels of concern about the Quality of health care Patient Institution (s) System

62 Some definitions

63 Effectiveness: Is the extent to which a health care intervention, when used in routine practice, achieves the desired outcome.

64 Appropriate Health Care (1) “... the selection, from the body of interventions that have been shown to be efficacious for a disorder, of the intervention that is most likely to produce the outcomes desired by the individual patient”

65 Appropriate Health Care (2) Availability of competent technical skills Intervention to be performed in an acceptable way Patient to have information about a range of interventions Discussion of possible adverse outcomes with patient Patient preferences to guide choice

66 STRUCTURE PROCESS OUTCOME Effectiveness Efficiency Equity Appropriateness Acceptability Access


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