Quality of Health Care Degree to which health services for individuals and populations increase the likelihood of desired

health outcomes and are consistent with professional knowledge. Strengths of the Health Care System Modern, well-equipped hospitals and ambulatory facilities Highly trained physicians, nurses and other medical personnel Availability of high technology diagnostic and therapeutic procedures Weaknesses of the Health Care System Overuse and inappropriate care Underuse of effective care Misuse and error in medical care Inefficiency and waste Overuse (Rate of Inappropriate Use) Advanced Antibiotics for Otitis Media 30% Antibiotics Used for the Common Cold 60% Heart Revascularization 10-20% Hysterectomies 16-80% Hospital Admissions: 5-15% Hospital Days of Care: 10-30% Other procedures commonly overused: Bed Rest for Low Back Pain Prostate Specific Antigen Testing Ultrasound in Uncomplicated Pregnancy Sedation of elderly patients Underuse (Financial Access) Over 40 million people are uninsured at any point in time Over 75 million are uninsured as some time during the year About an equal number are severely underinsured The majority of the uninsured and underinsured are the working poor and their dependents Underuse (Rate of Use of Effective Care)

Beta-blockers in Elderly Heart Attack Victims 21% Pneumococcal Vaccine in Elderly: 28% Appropriate Dx and Tx of Hypertension: 30% Physician Advice to Quit Smoking: 37% Eye Examination in Diabetics: 46% Pharmacotherapy of Depression: 45% Misuse Adverse drug events (ADEs) caused by medication errors occur in 1.8/100 hospital admissions 20% of ADEs are life threatening There are an estimated 500,000 preventable medication errors per year causing 7,000 deaths An estimated 180,000 deaths per year due to adverse events (= 3 jumbo jet crashes every two days) Between 44,000 - 98,000 due to preventable adverse events More deaths than due to motor vehicle accidents (43,438), breast cancer (43,297) or AIDS (16,516) Inefficiency and Waste Waits and Delays Operating Room Throughput Emergency Department Diversions Time to Treatment of Coronary Conditions Medical Records Availability Mismatch Between Capacity and Demand Six Aims for Improvement Safety Effectiveness Patient-centeredness Timeliness Efficiency Equity Safe Care A patient receiving medical care should be as safe as he is in his own home Example: Computerized physician order entry system to prevent medication errors

 Example: Surgeons sign your site of the body part that will be operated upon Effective Care Avoid overuse and underuse of services Example: Redesign processes based on best practices such as ensuring that patients at risk for heart disease take appropriate medications Example: Implement utilization management to reduce inappropriate hospital use Patient Centered Care Respect patient needs, preferences, and culture Example: Give patient access to his own medical record Example: Give patients information on alternative treatments and decisionmaking in treatment choice Timely Care Reduce waits for those who receive and who give care Example: Availability of appointments after work hours and on weekends Example: Email and telephone access to physicians and nurse practitioners Example: Open access to physicians and nurse practitioners Efficient Care Reduce waste of facilities, equipment, supplies, and people Example: implement inventory management systems to reduce amount of drugs and other supplies Example: Use flexible staffing systems based on patient numbers and needs to adjust number of nurses per patient care unit Equitable Care Reduce racial, ethnic, geographic and socio-economic differences Example: Provide interpreters for nonEnglish speaking patients Example: Train more physicians from minority racial and ethnic groups Example: Establish universal health insurance coverage

Purpose of Health Care System To reduce continually the burden of illness, injury, and disability, and to improve the health status and function of the people. Focus of Quality Quality must be defined in terms of experience and outcomes of the patient and the population that generates patients

Levels of Needed Change The patients experience The functioning of small units (microsystems) that provide patient care The functioning of organizations that contain microsystems The environment of policy, payment, accreditation and regulation Levels of Needed Health Care System Change All levels of the system must work together to meet the patients needs The patient must be at center, the first priority of the health care system The major question to ask in changing the system or in treating the patient must be, Is this the best thing we can do for the patient? Quality Improvement Quality improvement program is an organization is the umbrella program that extends the many areas for the purpose of accountability to the consumer and payor The program is continuous, on going measurement and evaluation process that includes structure, process and outcome Principles of Quality improvement Quality is a central theme to the organization. It is part of the organizations mission and core of the daily activity Leadership is committed to and involved in creating an organizational structure (commonly held beliefs,

values, norms, and expectations that drive the workforce) for quality improvement All staff members are personally responsible for quality: therefore decision-making is done by the people doing the work Education and training must be continual to improve skills and promote self development Process and system operation, in addition to individual performance are monitored Accurate information is available and must be used in decision making Legal implication of QI Failure to provide quality health care can result in lawsuits Institution can face liability for action taken against a practitioner if objective measures are not applied to performance and due process is not provided Total Quality Management (TQM) Is a systematic approach to quality improvement that marries product and service Specification to costumer performance, TQM then aims to produce theses specifications with zero defects. This creates a various cycle of continuous improvement that boosts production, costumer satisfaction and profits TQM can be used to Increase productivity Lower scrap and network costs Improve product reliability Decrease customer service cycles Increase competitive advantage Quality Assurance Focuses on the care and service the patient receives rather than on how well the professional performs the duties that the position requires Quality assurance methods Concurrent and retrospective patient care audits And evaluated while still admitted in the hospital

Retrospective- patient is evaluated on discharged patients Peer review (employee of the same profession, rank and setting)evaluating anothers job performance against accepted standards Quality circles A group of workers doing similar work who meet regularly, voluntarily on normal working time, under leadership of their supervisor, to identify, analyze, and solve work related problems and recommended solution to management Utilization results Feedback on the results of the quality assurance study