Healthcare Quality Improvement 2012.5. 이 은봉

Contents Definition of healthcare quality Measurement of healthcare quality Implementation of quality improvement Conclusion

Definition of healthcare quality?

What is healthcare quality? “The balance of health benefits and harm is the essential core of a definition of quality.” (Donabenan, 1990) Quality is the optimal achievement of therapeutic benefit and avoidance of risk and minimization of harm. (Joint commission)

Components of healthcare quality Safety Patient Centered Efficiency Timeliness Quality Effectiveness Equity Source: Institute of Medicine 'Crossing the Quality Chasm'

Different definitions Technical performance Interpersonal Relationship Amenities Access Patient preferences Equity Efficiency Cost effectiveness Clinician +++ + - Patient ++ Payer Manager Society Wyszewianski, 2009

Definitional attributes Technical performance Management of interpersonal relationship Amenities Access Responsiveness of patient preferences Equity Efficiency Cost-effectiveness Wyszewianski, 2009

Technical performance How well current scientific medical knowledge and technology are applied in a given situation Timeliness and accuracy of the diagnosis, appropriateness of therapy, medical skills

Interpersonal relationship How well the clinician relates to the patient on a human level. Doctor-patient relationship Technical performance is directly related with interpersonal relationship.

Amenities Characteristics of settings in which the encounter between patient and clinician takes place such as comfort, convenience and privacy. Examples include ample and convenient parking, good directional signs, comfortable waiting rooms, and tasty hospital foods.

Access Degree to which individuals and groups are able to obtain needed services. Medical costs, location, provided days and times, cultural characteristics

Responsiveness to patient preferences Acceptability Respect for patients’ values, preferences and expressed needs

Equity Application of all the necessary services of modern, scientific medicine to the needs of all people.

Efficiency How well resources are used in achieving a given result. Wasteful care is either directly harmful or is harmful by displacing more useful care.

Cost-effectiveness How much benefit, typically measured in terms of improvement in health status the intervention yields for a particular level of expenditure. Benefit Expenditure

Different definitions Technical performance Interpersonal Relationship Amenities Access Patient preferences Equity Efficiency Cost effectiveness Clinician +++ + - Patient ++ Payer Manager Society Wyszewianski, 2009

Measurement of healthcare quality

Purpose of measurement Assessment of current performance Demonstration and verification of performance improvement Control of performance

Components Structure Process Outcome Organization structure, specialty services provided, patient census Process Clinical care (clinical evaluation, diagnosis, therapeutic and palliative interventions) Outcome Health status, functionality, well-being of the patients Donebedian

Choice of performance measures Precise Relevant Precisely defined and specified Interpretable Risk-adjusted or stratified Practical Cost-effective Under the control of the provider Reliable

Classification of measures Continuous variable measures Precise measurement that can fall anywhere along a continuous scale E.g. A number of days from surgery to discharge Rate-based measures Frequency of events expressed as ratio or proportion E.g. pneumonia patients over all patients

국내 주요 임상 질 지표 입 원 외 래 중환자실 환자안전 응급실 신환율 계획에 없던 재입원율 외래대기일수 계획에 없던 재수술율 외래진료대기시간 민원 및 VOC 계획에 없던 재입원율 계획에 없던 재수술율 사망률 수술취소율 수술대기시간 퇴원예고 퇴원율 재원일수 장기재원환자 비율 타과의뢰 회신율 의무기록 완성률 민원 및 VOC 재입실률 사망률 환자안전 낙상발생률 욕창발생률 투약오류발생률 수혈오류발생률 심정지발생률 병원감염률 응급실 응급실 체류시간 응급실 재방문율 타과호출후 도착시간

Performance of quality improvement

PDCA method

Plan Defining the problem or issue that requires redress Defining the ideal or desired state Data collection to determine the problem in terms of deviance from the ideal state Ascertaining the root cause for the problem or issue Evaluating the various possible interventions to solve the problem and their possible outcomes Selecting the best possible intervention Scheduling the corrective process by planning for resources, determining people responsible for the corrective action Mapping the corrective process through flowcharts, control charts, and other tools

Fishbone diagram (Ishikawa chart)

Do Implementation of the selected solution Training the employees for the adopted quality intervention. Small scale to large scale

Check Quality inspection or Study stage Defining workmanship standards such as upper specification limit (USL) and lower specification limit (LSL) and then comparing the product specifications against such standards. Weeding out unacceptable products.

Shewhart control chart

Comparison chart Observed rate Outlier Upper limit Expected rate Lower limit July Aug Sep

Classification of Quality defect Underuse 예) Mammography Overuse 예) Antibiotics Misuse 예) Wrong drug Journal of the American Medical Association’s National Roundtable report(1998)

Act Standardization of the successful solution and adopting the same for whole process improvement Involving other stakeholders such as other departments, suppliers and customers in the changed process Creating safeguards to check relapse into the previous stage Explore opportunities for further improvements

Conclusion Healthcare quality is to the optimal achievement of therapeutic benefit with avoidance of any harm. Quality improvement is a continuing process in which PDCA cycle is applied.