Quality and Evidence

Based Health Management

CPHHA Workshop
March 2010
AGI Consulting
Consulting, LLC
USA

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If you sit in a hot bath, you think the

whole town is warm.
--- Yiddish Proverb

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Quality is Evolving!
Outcomes orientation
Process focus
Structure driven
Outcomes Management
Performance Improvement
Evidence Based - Patient Focused

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Health Care Quality

The degree to which health services for
individuals and populations increase the
likelihood of desired health outcomes
and are consistent with current
professional knowledge.
IOM 1990
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Performance Measures
Methods or instruments to estimate or
monitor the extent to which the actions
of a health care p
practitioner or p
provider
conform to the clinical practice
guideline.

IOM 1992
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Each system is perfectly

designed to meet the
objective for which it is
designed!
--- Edward Deming

HEALTH SYSTEM
PERFORMANCE

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Crossing the Quality

Chasm
Safety
Timeliness
Effectiveness
Efficiency
Equity
Personalized Care

Source: Institute of Medicine Report: Crossing the Quality Chasm: A

New Health System for the 21st Century, Washington, D.C (2001).

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Current Dominant Logic

Autonomous professionals providing
largely self-defined expert care within
organizational
g
p
payment,
y
, and regulatory
g
y
environments involving conflicting
incentives, goals, and objectives.

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New Dominant Logic

Patient-centered teams providing
evidence-based medicine in supportive
organizational payment
organizational,
payment, and regulatory
environments.

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Evidence Based Medicine

Plus
Evidence Based Management

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seeing a problem

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E B Health Management
What is?
Who is Who in EBHM?
How to perform EBHM?

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Three Suggested
Practices
ICU Physician Staffing
Evidence based Hospital Referral
Evidence-based
Computer Physician Order Entry
Leapfrog Group (2002)

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ICU Physician Staffing

More than four million patients are admitted
to ICUs each year in the U.S. and more than
500,000 of these patients die.
Studies reveal that at least one in ten patients
who die every year in ICUs would have an
increased chance to live if intensivists were
present in the ICU and managing their care
for at least eight hours per day.
Leapfrog Group (2002)

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Evidence-based Hospital
Referral
Hospitals with extensive experiences in
certain high risk procedures and
conditions have demonstrated better
patient outcomes than those hospitals
that dont.
practice makes perfect!
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Leapfrog Standards
Coronary Artery Bypass500/year
Coronary Angioplasty400/year
Abdominal Aortic Aneurysm Repair
..30/year
Carotid Endarterectomy100/year
Esophageal CA Surgery7/year
High Risk Deliv. & NICUs.>/=15/day
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Computer Physician
Order Entry
Bates (1999) of Bostons Brigham and
Womens Hospital, demonstrated that CPOE
reduced error rates by 55%-- from 10.7 to 4.9
per 1000 patient days.
Rates of serious medication errors fell by
88% in a subsequent study by the same
group.
7,000 die of med errors each year!! (IOM,2000)
CPOE could prevent over 500,000 serious
medication errors each year (Birkmeyer, 2001)
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STUDY OF 3,000 CABG PATIENTS

IN 16 HOSPITALS
A group-oriented, collaborative, participative
culture was significantly associated with higher
patient physical and mental functional health
status
t t scores six
i months
th post-discharge
t di h
and
d
shorter post-operative intubation times.

Shortell, Jones, Rademaker, and Gillies et al. 2000.

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Hospital top management leadership is

positively associated with greater clinical

involvement in TQM
Linkage to organizations mission
and strategic priorities
Allocation of human and financial resources
Aligning compensation and performance
appraisal systems
Personal involvement in teaching TQM
and participating on project teams
Targeting selected physicians
Developing a supportive culture
Weiner, Alexander, and Shortell, 1996; Weiner, Shortell and Alexander, 1997.

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In a nine hospital study of patients

with total hip and total knee replacement,
relational coordination was significantly
associated with less post-operative pain,
greater post-operative functioning, and
shorter length of stay.
Source: J. Gittel, K. Fairfield, and B. Bierbaum, et al.Impact of Relational
Coordination on Quality of Care,Post-Operative Pain and Functioning and
Length of Stay, Medical Care, 2000, 38(3):807-819.

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Increased Beta Blocker

Use After Myocardial
Infarction
Hospitals with greater improvement were
distinguished by four characteristics:
Shared
Sh
d goals
l ffor iimprovementt
Substantial administrative support
Strong physician leadership
Credible data feedback
Source: Bradley, Holmboe, Mahern, et al. JAMA, May 23/30, 2001,
285(20):2604-2610.
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CARE SYSTEMS MORE IMPORTANT THAN

INDIVIDUAL SPECIALTY DIFFERENCES
Cochrane collaborative review of specialty
differences in diabetic treatment outcomes found
that physicians in any specialty practicing in well
organized care settings had better outcomes than
physicians of any specialty practicing in less
organized care settings.

S. Griffin and A.L. Kinmouth, 1998. Diabetes Care: The Effectiveness

of Systems for Routine Surveillance for People with Diabetes
(Cochrane Review), The Cochrane Library 13, Oxford: Update Software.
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CARE SYSTEMS MORE IMPORTANT THAN

INDIVIDUAL SPECIALTY DIFFERENCES
(cont.)
Similarly trained primary care physicians
practicing in different organizational environments
provided significantly different quality of care for
diabetic patients after adjusting for patient
characteristics.

J. Desai, P.J. OConnor, and D.B. Bishop et al 1997. Variation in Process

and Outcomes of Diabetes Care in HMO Owned and Controlled Clinics,
Proceedings, CDC Diabetes Trans. Conference, Atlanta, GA.
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Remember again
Each system is perfectly designed to
meet the objective for which it is
designed!
D. Edward Deming

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Barriers
Little demand for higher quality!!
Lack of information technology
Skewed financial incentives

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There has been an alarming

increase in the number of things
we know nothing about.
--- Scientific American

Any ???

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