1. Quality & Safety at Hadassah
A Progress Report
September 12, 2006
Mayer Brezis, MD MPH, Professor of Medicine
Center of Clinical Quality & Safety Chairman, Quality & Safety Committee
מי צריך לקבוע מה היא איכות: מטפל? מטופל?, מנהל? מבטח? משרד בריאות? עתונאי? שופט?

2. Quality at Hadassah: some statistics
2006
2005
2004 36 40 41
Total number of projects 18 14 8
Completed projects 12 9
Cross-institutional projects 28
Number of physicians involved
33*
36* 23
Presentations at annual meeting of Society for Quality in Medicine
* Best poster presentation award
מי צריך לקבוע מה היא איכות: מטפל? מטופל?, מנהל? מבטח? משרד בריאות? עתונאי? שופט?
36 projects completed as MD or MPH theses; 20 peer-reviewed publications

3. Outline of presentation
Appropriateness of Coronary Revascularization
Quality of Elective Surgery for Inguinal Hernia Repair
Reduction of Neurosurgical Shunt Infections
Quality of Reconstruction Surgery After Mastectomy
Hand-washing by Medical Staff
Progress on Previous Projects
Evaluation of Specific Patient Care
מי צריך לקבוע מה היא איכות: מטפל? מטופל?, מנהל? מבטח? משרד בריאות? עתונאי? שופט?

4. Appropriateness of Coronary Revascularization Procedures at Hadassah Hospital: Adherence to Clinical Practice Guidelines
Dr. Dalit Cayam-Rand, Dr. Ronny Alcalai, Prof. Amir Elami & Prof. Mayer Brezis
Heart Institute, Department of Cardiothoracic Surgery & Center for Quality & Safety, Hadassah
Coronary Artery Bypass Graft (CABG) surgery
Percutaneous Coronary Intervention

5. Development of guidelines
Institutional guidelines were developed by senior cardiologists and cardiac surgeons at Hadassah, in collaboration with the Center for Clinical Quality & Safety. The guidelines were derived from those of the American College of Cardiology and Heart Association, adapted on basis of most recent literature.
The guidelines were approved by staffs of both the Heart Institute and Department of Cardiothoracic Surgery at Hadassah.
Six months after approval, implementation of guidelines was examined.

6. Sample from guidelines
CABG is the first option for:
            1. Left main coronary artery stenosis (level of evidence A)
            2. Obstruction of origin of left anterior descending (LAD) artery and of circumflex artery (level of evidence A)
            3. Triple vessel disease, with diabetes or renal failure (level of evidence A)
            4. Proximal LAD with high risk for angiographic treatment (level of evidence B)
            5. Triple vessel or proximal LAD and failure of angiographic treatment (level of evidence C)

7. Rate of adherence to guidelines
Rating N %
(1) Complete adherence to guidelines
271
85%
(2) Both procedures appropriate 19 6%
(3) Deviation for medical reasons 6 2%
(4) Deviation for patient’s preference 4 1%
(5) Deviation with no notable reason 18
Overall rate of inappropriateness: 6% Corrected rate (out of referrals): 8%

8. Rates of appropriateness according to angiogram results
Normal coronaries or insignificant disease 86
86 (100%)
Single-vessel coronary disease 99
95 (96%)
Double-vessel coronary disease 71
70 (99%)
Triple-vessel disease (TVD) 62
49 (79%)
TVD & diabetes or renal failure 20
7 (35%)
Proximal LAD disease with high risk for angiographic treatment 17
10 (59%)

9. “For patients with two or more diseased coronary arteries, CABG is associated with higher adjusted rates of long-term survival than stenting.” Hannan, E. et al.
N Engl J Med :

10. “CABG is still the best treatment for multivessel and left main disease” Professor David P Taggart Cardiovascular Surgery, Oxford
BMJ, April 2, 2005

11. Conclusion Overall adherence to guidelines satisfactory (over 90%)
Adherence is suboptimal among specific subgroups of patients:
with proximal LAD, triple vessel disease & diabetes or renal failure
Results discussed with staff
Are patients sufficiently informed?

12. Evaluation of Quality of Elective Surgery for Inguinal Hernia Repair in Adults and in Children at Hadassah
Dr. Tal Yemini, Dr. Mahmid Badriah, Dr. Yoav Mintz, Prof. Raphael Udassin, Prof. Avraham Rivkind and Prof. Mayer Brezis
Departments of General and Pediatric Surgery, Ein Kerem and Mt Scopus & Center for Quality & Safety, Hadassah Hebrew University Medical Center

13. Goal & Methods
Evaluation of quality of care for unilateral hernia repair by following criteria:
Overall satisfaction
Pain
Return to activity
Complications
Comparison to literature
Prospective phone survey of
114 adults (age 14-87)
102 children (age 2-6)

14. Satisfaction
Satisfaction was high to very high in 94% of both adults and children;
88% of adult patients and 95% of parents would recommend having such operation at Hadassah
Problems reported: waiting and relation with staff

15. Pain & return to activity
Analgesics
3-4 days
1 day
Children
10-15 days
5 days
Adults
Results concord with reports in literature
About 10% of adults had still more pain after surgery than before and not returned to work after 4-6 weeks.
These results are consistent with the notion that patients with minimally symptomatic hernia may not need surgical repair JAMA 2006;295:285.

16. Rates of Complications
Range in literature
95%
Rate
Infection
0.7-14%
2-13 6%
Children
7-20
12%
Adults
Hematoma
11-15%
5-18
10%
8-21
13%
confidence interval
Reported range varies by site of study & methodology & motive (is it voluntary or mandatory?)

17. Conclusion
Performance of surgical repair at Hadassah is consistent with standards reported in literature
We could not find similar reports from other Israeli hospitals
Importantly, measurement of rate of infection and feedback to surgeons has recently been shown to be an efficient tool to improve performance and reduce infection rates*
* Reduction in infection rates by surveillance with follow-up and feedback. British J of Surgery 2006;93:

18. Can We Reduce Neurosurgical Shunt Infections?
Dr. Ido Paldor, Dr. Zvi Israel, Prof. Colin Block and Prof. Mayer Brezis
Departments of Neurosurgery and Infectious Diseases & Center for Quality & Safety, Hadassah Hebrew University Medical Center

19. Shunts coated with antibiotics may reduce rate of infection.
Background
Hydrocephalus (accumulation of cerebrospinal fluid due drainage obstruction) is a neurosurgical condition treated by insertion of a shunt draining fluid from the ventricles.
Infection is a serious complication of shunt insertion, with a high mortality rate.
Shunts coated with antibiotics may reduce rate of infection.

20. Results: rate of shunt infection
Intervention
Mortality dropped from 50% (in infected cases) to none after intervention

21. Conclusion
Intervention reduced rate of infection from average of 25% to less than 5%, and abolished mortality from infection
This may derive from antibiotic-coated shunts and also from surveillance itself, shown to reduce surgical site infections*
* Reduced risk of surgical site infections through surveillance in a network. Int J Qual Health Care 2006;18:

22. Quality of Reconstruction Surgery after Mastectomy
Dr. Ravit Yanco, Dr. Matan Cohen, Dr. Ehud Kleiner, Dr. Helen Green & Dr. Avraham Neuman
Department of Plastic Surgery & Center for Quality & Safety, Hadassah Hebrew University Medical Center

23. Results and Conclusion
These results are similar to outcomes reported in the U.S.* and will help make better choice of implant
* Reconstructive breast implantation after mastectomy for breast cancer: clinical outcomes in a nationwide prospective cohort study. Arch Surg. 2005;140:

24. Hand-washing by Medical Staff
Dr. Dror Cantrell, Prof. Zvi Stern, Prof. Colin Block & Prof. Mayer Brezis
Department of Clinical Microbiology & Center for Quality & Safety, Hadassah Hebrew University Medical Center

25. % of physicians washing hands between patient contacts
Increase in physicians hand-washing by alcohol gel *
% of physicians washing hands between patient contacts
* p<0.001 *
Alcohol-chlorhexidine replaced the gel during 1 week
Alcohol Gel Available in Ward

26. Conclusion
A committee for Infection Prevention at Hadassah is now designing a system-wide intervention including: alcohol gel, education and feedback with periodic monitoring of adherence.
Alcohol gel is more expensive that water & soap but if effective, this may have considerable impact on the difficult and costly problem of cross-infections by bugs increasingly resistant to multiple antibiotics.

27. Evaluation of performance by a specific surgeon being considered for tenure at Hadassah
Physician A performs high-risk, complex operations 2.5 more frequently than other surgeons. Post-surgical length of stay for physician A’s patients is shorter by 3-4 days compared to other high complexity patients (p= 0.01). Patients managed by physician A showed a first-month mortality rate of 1 out of (0.28%) not different from the rate of the rest of the urological team over the same period: 7 out of 2164 (0.32%).
The bottom line was that physician A performs at least as well as, and probably even better than the other surgeons of the Urology department.

28. Progress on Previous Projects
Improved glucose control for hospitalized patients with diabetes
Improvement of palliative care
Patient’s empowerment to improve effectiveness and safety of oral anticoagulation
Perioperative prevention of clots
Improved patient instructions at discharge after hip or forearm fractures
מי צריך לקבוע מה היא איכות: מטפל? מטופל?, מנהל? מבטח? משרד בריאות? עתונאי? שופט?

30. Summary & Conclusion
Diverse projects attempt to make healthcare at Hadassah more patient-centered, more evidence-based and more system-minded.
While in some areas, noticeable improvements have been achieved, it is increasingly apparent that further successes require a systematic mode of monitoring and feedback.
מי צריך לקבוע מה היא איכות: מטפל? מטופל?, מנהל? מבטח? משרד בריאות? עתונאי? שופט?

31. Acknowledgments
Prof. Yoel Donchin, Ms. Nurit Porat, Prof. Amir Elami, Dr. Ronny Alcalai, Dr. Mahmid Badriah, Dr. Yoav Mintz, Prof. Raphael Udassin, Prof. Avraham Rivkind, Dr. Zvi Israel, Prof. Colin Block, Dr. Ravit Yanco, Dr. Matan Cohen, Dr. Ehud Kleiner, Dr. Helen Green, Dr. Avraham Neuman, Prof. Zvi Stern, Dr. Rony Braunstein, Dr. Rami Oren, Ms. Lois Gordon, & many other physicians, nurses, pharmacists & students greatly contributed to projects described in this report.
מי צריך לקבוע מה היא איכות: מטפל? מטופל?, מנהל? מבטח? משרד בריאות? עתונאי? שופט?