1 / 62

Clinician-led quality and safety improvement Converting the vision into reality

Clinician-led quality and safety improvement Converting the vision into reality. Ian Scott Director of Internal Medicine and Clinical Epidemiology Princess Alexandra Hospital Associate Professor of Medicine University of Queensland Brisbane Hunter New England Quality Exposition

Audrey
Télécharger la présentation

Clinician-led quality and safety improvement Converting the vision into reality

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Clinician-led quality and safety improvementConverting the vision into reality Ian Scott Director of Internal Medicine and Clinical Epidemiology Princess Alexandra Hospital Associate Professor of Medicine University of Queensland Brisbane Hunter New England Quality Exposition Tamworth 16/9/10

  2. Quality and safety improvement • Aims • To provide safe, effective, efficient, appropriate, responsive, timely, patient-centred care • To provide care at the right time to the right person in the right manner • To maximise the comfort, dignity and health of a patient’s journey through the healthcare system • Which is more successful? • Clinician-led vs managerially-led Q+S improvement • 3 elements of Q+S improvement • Capacity: workforce, infrastructure, skill set • Processes: models of care • Outcomes: clinical and non-clinical • In-hospital care • Ambulatory care • Generic principles

  3. In-hospital care Peri-discharge In-patient Acute Transition to community care Preparation for discharge Post-discharge follow-up Community-based care services and support Communication to care providers Initial evaluation Diagnostic work-up Clinical stabilisation Formulation of care plans Disposition decisions Execution of care plans Completion of comprehensive assessments Management of background medical problems Avoidance of complications Patient/carer education Recovery/rehabilitation Disposition decisions Diagnosis and treatment of acute problem(s) Optimisation of function and physiology Enabling smooth transition to community care + preventing readmission

  4. Proposed service principles QH Statewide General Medicine Clinical Network 2010

  5. Proposed service principles QH Statewide General Medicine Clinical Network 2010

  6. In-hospital care Peri-discharge Acute In-patient Initial evaluation Diagnostic work-up Clinical stabilisation Formulation of care plans Disposition decisions Diagnosis and treatment of acute problem(s)

  7. Medical assessment and planning units Transferring patients from ED to more suitable medical environment, reducing ED overcrowding Higher level monitoring for more acutely ill patients Cohorting of acute medical patients after-hours Early multidisciplinary assessment Identification and discharge of short-stay patients

  8. Evidence for acute medical units Peer review literature No controlled trials Nine before-after analyses of 7 units in UK and Ireland • Two studies, one prospective, reported significant reductions in in-patient mortality of between 0.6 and 5.6 percentage points • Four studies reported significant reductions in LOS: 1.5 to 2.5 d • One study reported 30% decrease in waiting times for patient transfer from ED to medical beds • Two studies described significant improvements in patient and staff satisfaction with care • Three studies saw the proportion of medical patients discharged directly home from AMU increase by 8 to 25 percentage points • Three studies noted no increase in 30-day readmission rates following unit commencement Grey literature • Eight non-peer-reviewed reports relating to 48 units confirmed reductions in length of stay. Scott, Vaughan, Bell Int J Qual Health Care 2009

  9. Plethora of variants • Acute medical assessment unit (AMAU) • Medical assessment and planning units (MAPU) • Acute assessment unit (AAU) • Acute medical wards (AMW) • Acute planning units (APU) • Rapid assessment medical units (RAMU) • Rapid assessment and planning units (RAPU) • Early assessment medical units (EMU) • Observation medicine units (OMU) • Short stay medicine units (SSMU) • Surgical assessment and planning units (SAPU)

  10. Integrated hospital emergency care • Reconfiguration of EDs into several different functional areas • high acuity/high complexity (or critical care areas) • low acuity/low complexity patients (observation bays) • low to medium acuity/high complexity patients • Co-location of medical assessment and planning units (MAPUs) with EDs • low to medium acuity/high complexity patients • Aim to discharge or transfer patients with 24 to 48 hours • Daily, consultant-led ward rounds, early multidisciplinary assessment, and prioritised access to ancillary services • Admission avoidance and rapid response community teams within EDs • Screen, identify and provide community care for patients who do not need inpatient care • Multi-purpose short stay wards adjacent to ED • For fully assessed and medically stable patients undergoing treatments or procedures prior to discharge within 24 hours. • Dedicated emergency surgical teams • Exclusively on call to assess and organise emergency surgery for ED patients • Patient pull strategiesby receiving units • Streamlined assessment and admission processes • Optimal use of transit and discharge lounges

  11. Integrated hospital emergency care • Results of redesigned emergency care systems: • 16% decrease in acute medical admissions • 4% decrease in acute surgical admissions1 • Australian experiments involving 60 acute hospitals in NSW and Flinders Medical Centre in Adelaide: decreases in ED access block2 • Boyle et al. Emerg Med J 2008; 25: 78-82. • O’Connell et al. Med J Aust2008; 188 (5 Suppl): S9-S13.

  12. Integrated hospital emergency care Scott IA, Wills R, Watson M, et al Qual Saf Health Care 2010 (under review)

  13. In-hospital care In-patient Acute Peri-discharge Older patients with complex needs High prevalence of cognitive impairment, physical dependency, social isolation At risk for hospital-acquired complications (delirium, falls, polypharmacy, immobilisation) Need for high functioning multidisciplinary teams Need for patient/carer/family education and support Optimisation of function and physiology

  14. In-hospital quality and safety issues 16 hospitals Issues raised on reviewing deaths 2002-2007 Behal & Finn Acad Med 2009; 84: 1657-1662

  15. Failure to rescue • Strong consistent correlation between risk-adjusted failure to rescue rates and risk-adjusted in-hospital mortality rates for all 6 conditions • AMI, CHF, pneumonia, stroke, GI haemorrhage, hip fracture R = 0.20-0.38; p<0.01 • Hospitals with best failure to rescue rates had between 22% and 31% lower relative mortality rates across all 6 conditions compared to hospitals with worse rates 4504 US hospitals 2003 PSI data Isaac et al JGIM 2008; 23: 1373-8

  16. Clinical care processes • Track and trigger systems and rescue responses for deteriorating patients • Hand hygiene/barrier nursing/infection control systems • Clinical handover systems/continuity of care • Interdisciplinary communication and teamwork • Evidence-based process of care packages (‘care bundles’) for specific diagnoses • AMI, CHF, COPD, stroke, sepsis • Hip surgery, PCI, CABG, vascular surgery • Prophylactic measures • Catheter-associated bacteraemias • Surgical site infections • Ventilator-associated pneumonia • Falls and pressure areas • DVT/PTE • Medication reconciliation/medication safety practices • WHO surgery checklist • Infection control systems • Palliative care service • Post-operative care • Family/carer communication • Post-death debriefing

  17. Clinical care processes • Comprehensive assessment of patient risks and proactive prophylactic intervention • High-risk patient care areas • Patients at high risk of falls, pressure sores, delirium, behavioural problems • Regular MDT meetings using patient journey boards • Daily morning ward rounds by medical teams • Team-based nursing care at the bedside • Fast-track access to comprehensive geriatric assessment teams, ACAT teams, other gate-keepers • Same day consultant responses for inter-specialty requests for advice on acute management

  18. Effects of diagnosis-specific care bundles on HSMR • Implementation of eight diagnosis-specific care bundles • Central venous catheter/line asepsis • Diarrhoea and vomiting • Stroke • Ventilator acquired pneumonia • MRSAinfection • Heart failure • Surgical site infections • COPD HSMR of 13 diagnoses reflecting care bundles

  19. Effects on mortality Physician led improvement teams Early goal-directed treatment of sepsis Central line and ventilator bundles to prevent infections Rapid response teams Standardised care protocols for cardiac surgery, stroke, etc Patient safety programs including clinical handover Feedback to transferring hospitals Improved clinical documentation and coding Increased resourcing: nurse levels ICU, defibrillators, intensivists Hospice-in-the-hospital program Senior managerial work rounds Behal & Finn Acad Med 2009; 84: 1657-1662 Greater than average decrease seen for all US hospitals Observed total mortality dropped as well as risk-adjusted index

  20. In-hospital general medicine services Peri-discharge In-patient Acute Transition to community care Preparation for discharge Post-discharge follow-up Community-based care services and support Communication to care providers Enabling smooth transition to community care + preventing early readmission

  21. Readmissions a common problem • 3% to 11% all discharges readmitted within 30 days1 • 90% unplanned • 80% relate to an acute medical complication • 60% occur in patients >65 years age • Highest readmission rates in US2 • Heart failure 12.5% • Pneumonia 9.5% • PTCA 10.0% • COPD 10.7% • Other vascular 11.7% • CABG 13.5% • AMI 13.4% 1.Jencks et al N Engl J Med 2009 2. MedPAC, “Report to Congress: Promoting Greater Effi ciency in Medicare,” June 2007; U.S. Department of Health and Human Services, “Hospital Compare,” available at: http://www.hospitalcompare.hhs.gov, accessed September 5, 2009; MedPAC June 2007; Cardiovascular Roundtable interviews and analysis.

  22. Patient predictors OR • Age ≥ 80 yrs 1.8 • Previous admission <30 dys 2.3 • ≥5 co-morbidities 2.6 • History of depression 3.2 • Living alone • Cognitive impairment • Functional status • Nutritional status • Disease severity • Longer index LOS • Lack of health insurance • Residential care • Previous readmissions • Non-adherence Marcantonio et al Am J Med 1999 Older patient cohort ≥60 yrs Thomas & Holloway Med Care 1991 Sullivan J Am Geriatr Soc 1992 Librero et al J Clin Epidemiol 1999 Fethke et al Med Care 1986 Corrigan & Martin Health Serv Res 1992 Smith et al J Clin Epidemiol 2000 Au et al Ann Acad Med Singapore 2002 Silverstein et al Proc (Bayl Univ Med Cent) 2008

  23. Predicting patients most at risk of readmission • Several attempts at risk prediction models in general acute medical patients • Most are not very discriminatory • AUROC 0.61-0.70 • Smith et al J Clin Epidemiol 2000 • Billings et al BMJ 2006 • Bottle et al J R Soc Med 2006 • Howell et al BMC Health Serv Res 2009 • Hasan et al JGIM 2009 • Novotny et al Nurs Res 2008 • Disease-specific risk prediction models • Congestive heart failure: AUROC 0.60 • Ross et al Arch Intern Med 2008 • Accurate model (AUROC 0.83) • requires detailed data on co-morbidities and functional capacity - 20 variables Coleman et al Health Serv Res 2004

  24. How preventable are readmissions? • 9% to 48% in 7 studies published to 1998 • Median 16% • Benbasset et al Arch Intern Med 2000 • 5.5% of 437 readmissions JHH • Miles, Lowe J Qual Clin Pract 1999 • 19% of 363 to one Spanish hospital • Jimenez-Puente et al Int J Technol Assess Health Care 2004 • 27% of 390 to 12 US hospitals • Halforn et al Med Care 2006 • 34% of 204 to PAH • Scott et al 2001 (unpublished) • 33% of 271 to Israeli hospital • Balla et al Medicine 2008

  25. How preventable are readmissions? • In one study of general medicine patients 33% readmissions vs 6% controls had quality of care problems • Age and sex adjusted only • Main errors • incomplete evaluation (33%) • too short hospital stay (31%) • inappropriate medication (44%) • diagnostic error (16%) • Most preventable readmissions involved CV event or CHF • Mean time to readmission: 10 days • Inpatient mortality 6.7% vs 1.7% among readmissions with no QOC problems (p=0.05) Balla et al Medicine 2008; 87: 294-300

  26. How preventable are readmissions? • Avoidable complications of care 47% • Drug-related adverse events 13% • Erroneous diagnosis/inappropriate care 11% • Premature discharge 20% • Poor discharge preparation 9% Halforn et al Med Care 2006

  27. Reducing readmissions Discharge planning/preparation • Screening for high-risk patients in need of more post-discharge support • Multidisciplinary discharge rounds, case conferences • Discharge planning protocols and checklists • Discharge care plans • Patient-carer educational interventions • Liaison nurses, discharge co-ordinators, case managers • Pharmacist-facilitated discharge program • GP input into discharge planning • Nurse-led intermediate care units • Patient/carer self-management • Advanced care plans Discharge support/aftercare • Augmented hospital-primary care communication • Post-discharge home visits • Post-discharge telephonic contact • Post-discharge community support Hospital avoidance programs • Hospital in the home • Chronic disease management programs Scott Aust Health Rev 2010 (in press)

  28. Discharge planning • Cochrane review updated Jan 2010 • Discharge planning defined as: • Inpatient assessment and preparation of discharge plan based on individual needs • Multidisciplinary assessment involving patient and family • Communication between relevant professionals within hospital • Implementation of discharge plan • Monitoring • For elderly patients with medical condition (usually heart failure) readmission rate at 4 weeks reduced by 15% OR = 0.85 (0.74-0.97) Shepperd et al 2010

  29. Comprehensive discharge planning and post-discharge support • RCT; 363 patients ≥65 years (mean age 75 years) • Specialist nurse-led assessment, discharge planning, patient-carer education; written care plans and medication lists; discharge summaries; co-ordination of post-discharge services; home visits (24 hrs and 7-10 days), telephonic follow-up • Results at 6 months: • Readmissions: 20% vs 37% p<0.001 • Health costs: $0.6m vs $1.2m p<0.001 • No effects on mortality, functional status, patient/carer satisfaction Naylor et al JAMA 1999

  30. Comprehensive discharge planning and post-discharge support • Meta-analysis of 18 RCT; 3304 patients with CHF; mean age ≥70 yrs • Intervention components • Specialist nurse or clinical pharmacist-led review • Patient education and self-management strategies • Discharge planning • Written care plans and medication lists • Home visits, telephonic follow-up, early clinic review • Enhanced communication between providers • Results at 8 months: • Readmissions: 35% vs 43% RR=0.75 (0.64-0.88) • All-cause mortality: 14% vs 17% RR=0.87 (0.73-1.03) • % increase QOL score: 26% vs 14% p=0.01 • Health care costs: No difference Phillips et al JAMA 2004

  31. Comprehensive discharge planning and post-discharge support • Transition coaching • Self-management tuition in medication use, relapse recognition, personal health record, timely follow with GPs and specialists • Lower readmission rates • at 30 days - 8% vs 12%; p=0.05 • at 90 days - 17% vs 23%, p=0.04 • Coleman et al Arch Intern Med 2006

  32. Comprehensive discharge planning and post-discharge support • Comprehensive nursing and physiotherapy assessment • Nurse-led education and self-management strategies • Individualised program of exercise strategies • Written guidelines for post-discharge care • Arrangement of community services and social support • Nurse-conducted home visit and telephone follow-up commencing in hospital and continuing for 24 weeks after discharge • High risk elderly cohort At 6 months: • Fewer readmissions - 22% vs 47%; p=0.007 Courtney et al J Am Geriatr Soc 2009; 57: 395-402.

  33. Improving peri-discharge processes • A nurse discharge advocate worked with patients during their hospital stay to: • arrange follow-up appointments • confirm medication reconciliation • conduct patient education with individualized instruction booklet that was sent to their primary care doctor • Clinical pharmacist called patients 2 to 4 days after discharge to reinforce the discharge plan and review medications Jack et al Ann Intern Med 2009; 150: 178-187

  34. Improving peri-discharge processes Jack et al Ann Intern Med 2009; 150: 178-187

  35. Improved peri-discharge processesTransition from hospital to home

  36. Ambulatory care Hospital-based clinics Chronic disease management End-of-life care Palliative care Advanced care planning Acute care in RACF Avoidance of hospitalisation Review of recently discharged patients Assessment of priority new patient referrals Secondary and tertiary prevention Optimisation of disease control, symptom relief, functional capacity Avoidance of hospitalisation Holistic care for multi-system disease Primary/secondary care collaboration Compassionate and appropriate care at end of life Timely access to specialist review Optimisation of function and physiology

  37. Proposed service principles QH Statewide General Medicine Clinical Network 2010

  38. Proposed service principles QH Statewide General Medicine Clinical Network 2010

  39. Ambulatory care Hospital-based clinics Chronic disease management End-of-life care Improving referrals from GP to specialist Generally effective strategies included dissemination of guidelines with structured referral sheets (four out of five studies) and involvement of consultants in educational activities (two out of three studies). The effects of 'in-house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising. Akbari et al Cochrane Database Syst Rev 2008 Review of recently discharged patients Assessment of priority new patient referrals Timely access to specialist review

  40. Ambulatory care Hospital-based clinics End-of-life care Chronic disease management • Intervention designed to manage or prevent a chronic condition using a systematic, evidence-based approach to care and potentially employing multiple treatment modalities • Weingarten et al 2002 Optimisation of function and physiology

  41. Chronic disease management

  42. Chronic disease management Gwadry-Sridhar FH, Archives of Internal Medicine, 2004, 164: 2315-2320 Gonseth J, et al., European Heart Journal, 2005, 26(3): 314-315 Holland R, et al., Heart, 2005, 91: 899-906 Roccaforte R, et al., European Journal of Heart Failure, 2005 7(7): 1133-1144 Taylor SJ, et al., Cochrane Database of Systematic Reviews, 2005, 2 Clark RA, et al., British Medical Journal, 2007, 334(7600): 942

  43. Chronic disease management Respiratory rehabilitation programs for patients with recent exacerbations of COPD reduce admission rates by up to 87%1 Improve diabetes control; no evidence yet on complications2 CDM items and team care arrangements in primary care have not been as effective as expected3 1. Puhan M, Scharplatz M, Troosters T, et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2009 Jan 21; (1): CD005305. 2. Renders CM, Valk GD, Griffin S, Wagner EH, et al. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database of Systematic Reviews 2000, Issue 4. Art. No.:CD001481.DOI: 10.1002/14651858.CD001481. 3. Hartigan et al. Do Team Care Arrangements address the real issues in the management of chronic diseases? Med J Aust 2009; 191: 99-100.

  44. Chronic disease management Klersy et al. JACC 2009; 54: 1683-1694

  45. Chronic disease management • Co-located specialists in primary care Gruen et al. Cochrane Database Syst Rev 2004 Nine met the inclusion criteria (RCT, controlled B/A trials, ITS). Most studies came from urban populations in developed countries Simple 'shifted outpatients' styles of specialist outreach improved access, but no evidence of impact on health outcomes. Specialist outreach as part of more complex multifaceted interventions involving collaboration with primary care, education or other services associated with improved health outcomes, more efficient and guideline-consistent care, and less use of inpatient services. Up to 30% reduction in future events requiring hospitalisation Additional costs of outreach balanced by improved health outcomes

  46. Chronic disease management • Co-located specialists in primary care • Jackson C, Russell A, Spurling G, et al WCIM 2010 • Inala CDM Program for patients with complex type 2 diabetes mellitus • Community-based general practice with care delivered by a multidisciplinary team of allied health professionals and up-skilled general practitioners who undertook a structured education programme delivered by an endocrinologist who provided ongoing on-site support • Evidence based protocols were adopted and individualised care plans were developed for the patients incorporating principles of self-management • Service evaluated and compared with a control group of similar patients whose care was provided at the tertiary hospital • Significantly greater percentage of patients achieving all 3 targets • HbA1c ≤7.0% • BP ≤130/80 • LDL cholesterol ≤2.5 mmol/l 24% vs 10%; p<0.001 • Sustained funding model needed to maintain new care model

  47. Chronic disease management • Telehealth • Access to ‘live’ interactive specialist consultation • under-staffed regional and rural centres • RCFs • More efficient use of clinics • Fewer unnecessary referrals for hospitalisation • Patient and referrer messaging

More Related