9. Quality

Question 1

Porter’s perspective on value?

Answer 1

Value is NOT a code word for cost reduction. We should be increasing value in a couple of ways.

Question 2

In what ways should we be increasing value?

Answer 2

Define value around the patient, this idea encompasses concept of EFFICIENCY

Question 3

How to encompass the concept of efficient?

Answer 3

Value is an efficiency measure of outcome relative to cost. Cost reduction not related to outcome, doesn’t make sense. Cost IS part of outcome AND cost happens over time. We need to follow the process to see how outcome plays out over time. Now, Cost is FULL CYCLE over time, not just separate doc bills, consults, etc

Question 4

How can we measure outcome now?

Answer 4

With SURVIVAL RATE, measured with mortality rate.

Question 5

What other measures of outcomes can we use?

Answer 5

Degree of health/recovery, time to recovery, problems with care, sustainability

Question 6

3 examples of degree of health/recovery?

Answer 6

Functional level achieved, pain level achieved, and extent of return to physical activities.

Question 7

3 examples of time to recovery?

Answer 7

Time to treatment, time to return to physical activities, time to return to work

Question 8

3 examples of problems with care?

Answer 8

Pain, length of hospital stay, infection

Question 9

3 examples of sustainability?

Answer 9

Maintained functional level, ability to live independently, need for revision/cooperation

Question 10

What should we be looking at, diagnosis wise (porter)?

Answer 10

Gotta take into account primary Dx AND all the other associated dx, OVER TIME. Right now we have no idea what the total costs are for everyone.

Question 11

Current organization and informations systems? (4)

Answer 11

1) Not designed to measure or deliver value, impossible to find out. 2) Current measures are either too narrow (department) or broad (infection rate) to apply to individual pt outcome/value. 3) Currently measured by PROCESSES 4) Outcomes are unknown, continuity sucks (e.g. surgeons dunno how the pts doing 6 months post-op, everything’s been designed for short term)

Question 12

Challenges with current organization and information system? (3)

Answer 12

1) No one collects patient level long term outcome data (Providers could use info to improve outcomes, but not available) 2) Costs collected and reported around structures not patients 3) Care involves shared resources; cost for each patient impossible to discern but huge variation exists

Question 13

Tom Lee’s response?

Answer 13

This is all cool and everything, but unfortunately value is seen by docs as cost reduction. Current data reports show what we did; not what happened to patients. The PROBLEM is that this shit requires teamwork?an unnatural act in healthcare; shared accountability ? need a shitload of coordination.

Question 14

According to Lee, what’s the best way of dealing with value?

Answer 14

Compare this years performance with last year’s performance…improve an outcome without sacrificing another, and reduce costs while achieving the same outcome.

Question 15

4 steps being taken for value?

Answer 15

Value dashboards, pause points, individual checklists, and disease oriented teams (like, one for DM, stroke, etc)

Question 16

Pause points?

Answer 16

What should happen at each point (e.g. palliative care consult at point of lung cancer diagnosis)

Question 17

Individual checklists?

Answer 17

Based on research showing relationships to improved outcome for condition.

Question 18

What ways can we use to improve quality in the meantime?

Answer 18

Ways to REDUCE ERROR by standardizing things that could go wrong. 1) Simplify, organize, reduce variability into a checklist, AND follow through. (big part of quality improvement). 2) Ensure all patients reliably receive intervention 3) Set up teams.

Question 19

Set up teams?

Answer 19

YES…doctors can’t be in charge of doctors, what shit dun work. They tried putting out the checklists and not much happened?this is cuz doctors didn?t actually do it. THEN they were like, nurse covers checklists and can stop the procedure if they didn?t. Point? Not JUST the checklist, needs structure/authority for enforcement

Question 20

How to define quality?

Answer 20

Right care, right time, the FIRST time. This includes, safe, timely, effective, efficient, equitable (all groups in society get RC, Rt, FT), and patient centered

Question 21

Quality: US v. Other countries?

Answer 21

US managed to spend more/get less results than many other countries.

Question 22

IT Utilization: US v. Other countries?

Answer 22

EMR is also more heavily used in other countries. Changing rapidly in states, but still a lot further behind other countries

Question 23

How do Americans view health care?

Answer 23

BIG GAP between professional (e.g. porter) view of quality and that of general public. Overall, 80% think very good! Positive views increase with income and age, and overall you have consumer skepticism about evidence based care. Republican ratings&raquo_space; democrat ratings.

Question 24

Public’s perception of state of the US healthcare system?

Answer 24

16% of us usually thinks that we?re in a CRISIS. Most think major problem.

Question 25

Public’s perception of the most urgent US health problem?

Answer 25

Access, then cost, then obesity, the cancer. Quality doesn’t even show up.

Question 26

Which age groups are more satisfied with quality?

Answer 26

Older people - all on MCARE

Question 27

Public’s perception of cost?

Answer 27

60% of us are satisfied with cost of health care. Tend to be satisfied with insurance, richer you are = more satisfied you tend to be

Question 28

We are skeptical of evidence based care? (3)

Answer 28

We don’t want guidelines (cuz we’re special), and more is better (and less is bad, although this isn?t necessarily true), and that the more you pay, the better care you get.

Question 29

Other perceptions of evidence based practice guidelines?

Answer 29

Few clinical trials back recommendations, mostly expert opinion (just consensus documents, and consensus documents can be wrong). Also, there may be conflicts of interest in expert panels.

Question 30

Where are we going with the long term federal policy?

Answer 30

Feds will develop quality measures for both process of care (e.g. id pt get aspirin within 90 minutes of admission? That kinda thing) and outcome (e.g. low infection rates). They will develop consensus around these measures, get hospitals to collect this data and report, AND over time, select some for use in reimbursement (e.g. MCARE ? withholding 1t, REDISTRIBUTING among higher quality hospitals)

Question 31

5 clinical quality measures?

Answer 31

Process, access, outcome, structure, patient experience

Question 32

Process?

Answer 32

A process of care is a health care-related activity performed for, on behalf of, or by a patient

Question 33

Access?

Answer 33

Access to care is the attainment of timely and appropriate health care by patients or enrollees of a health care organization or clinician.

Question 34

Outcome?

Answer 34

An outcome of care is a health state of a patient resulting from health care.

Question 35

Structure?

Answer 35

Structure of care is a feature of a health care organization or clinician related to the capacity to provide high quality health care.

Question 36

Patient Experience?

Answer 36

Experience of care is a patient’s or enrollee’s report of observations of and participation in health care, or assessment of any resulting change in their health

Question 37

Manager view of quality?

Answer 37

Changes based on manager, some think 1) Compliance with regulation, 2) Respond to financial incentives 3) Reduce error/risk 4) Quality as a competitive advantage (marketing tool) 5) Quality as efficiency 6) quality as value (emerging view, but not really big yet)

Question 38

What does the Mayo Clinic think is quality?

Answer 38

HOW THE CUSTOMERS perceive it. Customers are detectives and can sense quality through clues

Question 39

What kinda signals for patients to look for in Mayo Clinic?

Answer 39

Functional clues, mechanic clues, and humanic clues.

Question 40

Functional clues?

Answer 40

Do things run smoothly, TEAMS (very well organized, continuity is great, docs come to see YOU instead of the other way), efficiency

Question 41

Mechanic clues?

Answer 41

First impressions matter, when you show up at the front door we’re expecting you

Question 42

Humanic clues?

Answer 42

Exceeding expectations, pleasant surprises, and the MAYO DRESS CODE (everyone’s dressed neatly, been that way forever)

Question 43

What are flow charts good for?

Answer 43

To figure out what the process is that we go through. Could be helpful for checklists, very important tool for recognizing where things can go wrong.

Question 44

What’s the point of charts?

Answer 44

If you chart it, you can improve it, I you don?t, you don?t know what happened. Keep track of activity so you can understand the nature of it/improve it.

Question 45

Main points of the LEAN Toyota production model? (5)

Answer 45

1) Eliminate waste 2) Respect people who do work, 3) Standardize work (Reduce variation with the CURRENT best way) 4) Get right the first time 5) Constantly improve

Question 46

Respect for people who do work?

Answer 46

Quality of the job is the WORKER, who has control over his/her quality and can recognize errors/stop production

Question 47

8 kinds of waste in hospitals?

Answer 47

Defects, overproduction, transportation, waiting, inventory (e.g. nurses hoard), motion, overprocessing, and human potential.

Question 48

5 challenges to good management in hospitals?

Answer 48

Easier to make money than manage cost, Professional autonomy with non-aligned goals, separation of quality control from production (you have a separate quality and compliance office0, multiple payers with conflicting incentives, and poor information systems and flows

Question 49

What was the initiative of the Virginia Mason Case?

Answer 49

Wanted to create a formal contract between physicians. He wanted to align the physician AND hospital interests. Couldn?t get them on team except through some formal contract (With clear responsibilities, involvement with hospital success was central, no longer independent factors with their own interests)

Question 50

Strategy at Virginia Mason?

Answer 50

Strategy at Virginia mason ? primary goal is the be the QUALITY leader through the corporate strategy (people quality, service, innovation)

Question 51

The 5 S’s of Toyota production - organizing space?

Answer 51

Sort, simplify, sweep, standardize, self-discipline/sustain

Question 52

Seven flow’s of medicine?

Answer 52

Patients, providers, medications, supplies, equipment, information, and instruments