1. Quality of care Israel De Alba, MD MPH Clinical Professor
Health Sciences
University of California, Irvine

2. Content Introduction: quality of care today Core measures
HCAPS Patient Satisfaction Survey
Hospital Readmission Reduction Program
Universal Protocol (Time out)

3. The new face of health care
Emphasis on efficient, lean care
Change in payment structure
Emphasis on disease rather than on health
Disease makes money; health doesn’t
The standard fee-for-service system that encourages doctors and other caregivers to give lots of tests, individual treatments and to prescribe drugs, instead of keeping patients well
Oversight:
Governtment agencies
Insurance companies
Quality agencies
Patients

4. Quality of care (Institute of Medicine)
Safe – avoiding injuries to patients from the care that is supposed to help them.
Effective – providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse).
Patient-centered – providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
Timely – reducing waits and sometimes harmful delays for both those who receive and those who give care.
Efficient – avoiding waste, in particular waste of equipment, supplies, ideas, and energy.
Equitable – providing care that does not vary in quality because of personal characteristics, such as gender, ethnicity, geographic location, and socioeconomic status.

7. Center for Medicaid and Medicare Services
HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey is the first national, standardized, publicly reported survey of patients' perspectives of hospital care.
Contains 18 core questions
communication with nurses and doctors
responsiveness of hospital staff
the cleanliness and quietness of the hospital environment
pain management
communication about medicines
discharge information
overall rating of hospital
would they recommend the hospital

8. Patient satisfaction

9. Core Measures: Joint Commission

10. Heart failure

11. MI timely care

12. MI effective care

13. Pneumonia markers

14. DVT prevention

15. Hospital acquired infections

16. Hospital readmission reduction

17. Decreasing Hospital Readmissions
Beginning in fiscal year (FY)2013, hospitals with higher than expected readmission rates will experience a decrease in payment for all Medicare discharges
Reduce payment to hospital by 1% in FY 2013 and 2% in 2014 and 3% beyond
Expected to save $7.1 billion over 10 years
Performance data will initially be based on 30 day readmissions for MI, HF and pneumonia
Additional conditions added in 2015 (COPD, CABG, PCA)

18. Avoidable Readmissions
Evidence suggests many rehospitalization may be preventable
No one knows what proportion of readmissions are truly “avoidable”?
Large interstate and inter-hospital variation
Many readmissions are outside the control of the hospital or health system
Many readmissions are appropriate and the goal is not to avoid all readmissions
Some interventions have demonstrated the ability to decrease readmissions

19. Readmission rates

20. The patient perspective
Patients did not necessarily see hospital readmissions as a problem
Many patients felt they were discharged too soon.
Many did not understand their discharge instructions.
Care instructions were too general.
Patients and caregivers wished they had been more assertive.
New diagnoses posed special challenges.
Primary care physicians were missing from the picture.
Some had only limited or no support once home.
Some were not ready to change behaviors
A few had chronic health conditions for years but were not educated about their illnesses.

21. The physician perspective
The issue is on their radar.
Readmissions are complicated.
There are financial pressures to discharge as soon as possible.
The quality and training of the providers can make a difference.
Some hospitals are improving the discharge process and in-hospital experience to reduce readmissions.
Some hospitals try to avoid readmissions by referring patients to their own outpatient clinics for follow-up care.

23. Project RED Discharge Checklist
Eleven mutually reinforcing components:
1. Medication reconciliation
2. Reconcile discharge plan with national guidelines
3. Follow-up appointments
4. Outstanding tests
5. Post-discharge services
6. Written discharge plan
7. What to do if problem arises
8. Patient education
9. Assess patient understanding
10. Discharge summary sent to PCP
11. Telephone reinforcement 23 23

25. What is Universal Protocol?
The Joint Commission Board of Commissioners originally approved the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery
Process that involves 3 steps
Pre-procedure verification
Site marking
Time out

26. Universal Protocol
Three steps to patient safety
1. Pre-procedure verification
2. Site marking
3. Time Out

27. 1. Pre-procedure verification
The first SAFETY CHECK
Is a process of information gathering and confirmation, including verification of:
Correct patient, correct procedure, correct site
Documentation (H&P/interval note, consent form, other assessments)
Supplies: blood products, implants, devices, and/or special equipment for the procedure
Other: labeled diagnostic and radiology test results
Assures that missing information or discrepancies are addressed before starting the procedure

28. 2. Site Marking
Required prior to procedures involving incisions or percutaneous puncture or insertion
Mark the site before the procedure is performed and involve the patient in the site marking process, if possible
The site does not need to be marked for bilateral structures
Department Name | Month X, 201X

29. 3. Time-Out Final SAFETY CHECK before starting the procedure
Activities are suspended so that ALL team members can fully engage in the time out.
The focus is on ACTIVE confirmation of the patient, site, and procedure
For bedside or ambulatory practice procedures, the physician performing the intervention or other trained member of the procedural team may lead the time-out.
The procedure is NOT started until all questions or concerns are resolved.

30. Time-Out The time-out must address:
Correct patient identity
Accurate procedure consent form or physician order
Correct side/site marked
Agreement on procedure to be done
The time-out should also address, where applicable:
Correct patient position
Relevant images/results displayed
The need to administer antibiotics or fluids for irrigation
Safety precautions based on patient history or medication use.

31. QUEST Documentation
Department Name | Month X, 201X

32. Department Name | Month X, 201X

33. Summary and conclusions
Quality of care: why it matters to you
New paradigm
These changes will affect how we practice medicine