Healthcare quality

1. ECMH Grand Rounds, December 14th, 2012 Moderators: Donna Woods, Kris Gleason, Dan Evans Healthcare quality

2. Institute of MedicineSix Aims for Improvement • Safe • Timely • Effective • Efficient • Equitable • Patient-centered • S • T • E • E • E • P

3. Safe • Healthcare should not cause unnecessary harm • Make planned actions occur as intended • Avoid incorrect or more dangerous plans • Timely • Avoid long delays • Improve flow of care with patients’ interest in mind • Effective • Care based on best scientific knowledge • Maximize use of services likely to produce benefits • Avoid services unlikely to result in benefits

4. Efficient • Avoid waste • Reduce administrative and production costs of care • Use lower-cost choices if efficacy is comparable • Equitable • Secure the benefits of healthcare for all people • Improve access and care delivery based on need • Reduce disparities between groups • Treat all individuals fairly • Patient-Centered • Deliver care responsive to patients’ values, preferences and expressed needs

5. Is healthcare in the u.s. safe?

6. An Epidemic of Medical Error Source: US Mortality Data 1997 / CDC / IOM

8. Is healthcare in the u.s. effective?

11. Comparative Reliability Between Industries PPM Mammography Screening Difficulty with Referral IRS - Tax Advice (phone-in) (140,000 PPM) 1,000,000 100,000 • 10,000 Airline Baggage Handling Post Heart Attack Medications Low Back TX 1,000 U.S. Anesthesia Deaths Inpatient Medication Safety 100 10 Domestic Airline Flight Fatality Rate (0.43 PPM) 1 0 Defects Sigma 50% 31% 7% 1% 0.02% 0.0003% 1 2 3 4 5 6 Sigma Scale of Measure

12. 49 yo with sarcoidosis, congenital colonic malrotation with chronic abd pain, major depression, and uncontrolled diabetes… Had been hospitalized in Oct for glc of 1,100 ! Presents (after multiple team outreach calls) to discuss her severe depression, passive suicidal thoughts, her glucose of 450 last week, and her continuing abd & back pain… ROS: + cough (sarcoid?) + burning hands/feet Case #1:

13. BP control for DM LDL control for DM Cervical Ca screening Breast Ca screening DM foot exam DM eye exam DM – attn to nephropathy DM a1c measurement BMI documentation, counseling Influenza vaccination PNA vaccination Which quality indicators did we satisfy?

14. Which quality indicators did we satisfy? • BP control for DM • LDL control for DM • Cervical Ca screening • Breast Ca screening • DM foot exam • DM eye exam • DM – attn nephropathy • DM a1c measurement • BMI & counseling • Influenza vaccination • PNA vaccination • No (140/89) • No (149 in Oct ‘12) • No (last pap ’06) • Yes (Oct ‘12) • No • No • No • Yes (11, down from 16) • No • Yes • Yes

15. 84 yo had not seen MD for 20+ yrs until slurred speech while at Treasure Island in ‘11 Next 12 mths: CVA (HTN, HL), colon cancer (found when she bled on heparin), pneumonia, DVT/PE, c.diff, deconditioning, SNF, more c.diff, hemi-colectomy with ostomy, more SNF, another CVA, depression, recovers – goes home! 3 mths later dx with B breast cancer (on femara) Comes to see us for a planned visit, check-up Case #2:

16. Which quality indicators did we satisfy? • BP control • LDL control for IVD • Statin for CVA • Depression med mgmt • BMI & counseling • Influenza vaccination • PNA vaccination • ASA for hx of CVA • Yes (120/74) • No (108 in ‘11) • Yes • Yes • Yes • Yes • Yes • No !!!!!!!!!!!!!!!

17. Are your patients receiving QUALITY CARE? • How would you MEASURE their quality of care? Questions for the audience…

18. December ‘12 Student chart audits:first 100 ECMH patients logged

20. 66% female, 33% male 60% minorities, 40% white 66% of ECMH patients have HTN 20% have CAD 8% with afib, 6% with prior MI, 6% with CHF 8% with asthma 60% on meds that require monitoring 33% diabetes 63% have a BMI > 30 Analysis of the first 100 charts logged:

21. Controlled Blood pressure

22. Anti-platelet drug & statins for ischemic vascular disease

23. Vaccination: pneumococcal

24. Women’s health: Cervical ca, breast ca, & chlamydia screening

25. Diabetes a1c control

26. Diabetic foot & eye exams

27. Bmi & counseling

28. Colon ca screening

29. Quality metric Q & A

30. Over the next month… We need to establish our baseline performance We need your help to track thequality of care We need a team captain for each ECMH clinic Compile your “official panel” list Make sure 1 person “owns” each patient Fill out the QI survey for each patient that you OWN Due date = mid January (before next GR) Going forward…

31. We will focus on best practices across each ECMH clinic, use the hour for students to present ideas for improvement Remember – you can’t improve things unless you have baseline data! Please keep logging your patients! https://www.surveymonkey.com/s/ECMH_QI_chart_audit_scorecard Next Grand Rounds: