Exam 3 Flashcards
IOMs quality dimensions
Safe Effective Patient-centered (or personalized) Timely Efficient Equitable
Quality in healthcare
Can be defined, measured, and improved
2020 scorecard health system performance
- Affordability and out of pocket costs are worsening.
- Increased prices for health care services are a major driver of overall spending
- Premature deaths from treatable conditions, suicide, alcohol, and drug overdose continue to impact life expectancy
Have deaths amenable to heathcare in the US been steadily declining?
Yes
What country preforms the best at preventative measures?
US
Dimensions in gaps of care
Safety, effectiveness, patient-centered, timeliness, efficiency, equitable
Strategies for health care quality improvement
Regulation
Marketplace competition
Continuous quality improvement
Payment incentives
Strategies for health care quality improvement- Regulation
Mandating minimum standards of behavior by health care providers and insurers
Health reform is driving quality
Expanded access to care
Improved SAFETY- 50,000 fewer people died as a result of preventable errors and infections in hospitalizations from 2010-2013
Strategies for health care quality improvement- marketplace competition
Providing good information about healthcare quality and value to patients and payers will encourage competition
Strategies for healthcare quality improvement- payment incentives
Pay for Performance to healthcare providers
Strategies for health care quality improvement- continuous quality improvement
Management philosophy that emphasizes system process improvement
Strategies for quality improvement in pharmacy
Regulation- respond to internal, external audits
Marketplace competition
Continuous quality improvement- participate in accreditation or certification activities
Payment incentives- lead quality improvement projects
How many states have continuous quality improvement (CQI) program regulations?
16, may others exploring implementation
Quality Improvement (QI) (Not quality Assurance)
QI becomes important as health system become more complex
QI and patient safety are inseparable disciplines
Healthcare organizations often use QI methodologies to create safer systems and implement safer practice
Defining Quality Improvement
QI is a formal approach to analyzing and improving processes in systems.
Various QI models exist including- model for improvement (PDSA), six sigma, lean
Characteristics of QI
Identifies measures of quality
Is customer (patient) centered
Collects and analyzes quality using statistical process control tools
Focuses on continually improving the system
Quality assurance consists of:
Checking the quality after production
Throwing out defects and changing elements of the process if too many defects are detected
Otherwise, continue with status quo
Its reactive
Model for improvement- PDSA
Continuous QI approach
Changes are tested in small cycles
In involves planning, doing, studying, acting (PDSA), before returning to planning and so on
These cycles are linked with 3 key questions
-What are we trying to accomplish? (GOAL-SMART)
-How will we know what a change is an improvement? Measures
-What change can we make that will result in improvement? Changes
SMART goals
Specific Measurable Attainable Relevant Timely
Measures
Structure
Process
Outcomes
Need to balance measures
Steps in quality improvement
- ) Plan a change
- ) Do it on a small scale
- ) Study the impact of the “Do Stage”
- ) Act on the results
Steps in quality improvement: Plan
Determine tasks needed to assess change, and predict what will happen.
Who will implement the plan?
What will they do?
When, where, and how long will they do it?
What do you predict will happen and how will you know?
Steps in quality improvement: Do
Collect data to measure change
Observe what happen
Identify unexpected problems.
Steps in quality improvement: study
Study the effects of the change
Describe the results and how they compared to the predictions
Did you meet the goal?
What did you learn?
Steps in quality improvement: Act
Adopting, adapting, or abandoning
Describe what modifications to the plan will be made for the next cycle from what you learned.
What did you conclude from this cycle?
If it did not work, what can you do differently in your next cycle?
Principle PDSA
Small changes have big, accumulated impact.
Short QI cycles lead to many small improvements.
SIERRA
Simple initiatives Interdisciplinary teams Early adopters Rapid pilots Rapid feedback Advertise gains
PDSA Plan stage tool
Flowchart
Brainstorm SWOT
FIshbone
Flowchart symbols
Circle- begin/end
Rectangle- action step
Triangle- decision
Fishbone diagrams: Four Ps Root Causes
People, Procedures, Policies, Place
Statistical process control (SPC) tools
SPC is the use of statistical techniques to measure change in systems because:
Consistency is important in quality products and services.
Statistical analysis detects inconsistency; and
SPC tools help differentiate acceptable and unacceptable inconsistency.
Which statistical process control tools are used to identify and monitor quality?
Run charts and control charts
Scatter diagrams
Histograms
Pareto charts
Run chart
A running record of a process over time
Monitor data over time to detect trends, shifts, or cycles
Compare a measure before and after the implementation of solution.
Histogram
Easy way to see distribution of the data, its average, and variability
For fewer data points
Pareto Charts
Identify and rank problems/causes in the quality process in descending order.
It helps a team focus on problems that offer the greatest potential for improvement.
80/20 rule
Lean and Six Sigma quality improvement models
Increase productivity by eliminating steps that do not add value to the process.
- ) Lean methodology focuses on reducing waste and improving workflow.
- ) Six Sigma strives to decrease variation through detailed data collection and analysis
What is a measure?
A standard, basis for comparison
Why do we make measures?
How do we know something is good?
How can we improve it if we dont measure it?
Measures inform consumers (STAR ratings)
Measures influence payment
National Quality Forum (NQF)
What/who- membership based, consists of leaders in healthcare industry and clinicians
What they do- NQF evaluates potential measures, endorses measures, recommends measures for use in payment and reporting.
How- consensus building, transparency and engagement, public and private collaboration.
Criteria for a good measure
Importance to measure and report Scientific acceptability of measure properties Feasibility Usability and use Related and competing measures
What measures should I use?
Measures available in the marketplace are evidence based, tied to reimbursement, and nationally recognized. They may not be specific to the organization.
Measures created internally are specific to organizational goals but may not be connected to reimbursement or broadly applicable.
Process of developing measures
Identify area to evaluate
Conduct a literature review
Develop measure and provide specifications on how to measure
Evaluate feedback
Field test measure to ensure validity, reliability, and feasibility
HEDIS measures
Healthcare Effectiveness Data and Information Set
- Standardization measures designed by the NCQA
- Used by 90+% of health plans to measure performance
- 90 measures across 6 domains
- Allows consumer comparisons
HEDIS Measure use
By health plans- STAR ratings, apply to payment models
By providers- identify gaps in care, earn maximum or additional revenue
By pharmacists- impact pt care, align out goals with org and national goals, justification of services.
Med rec post-discharge eqn
Patients 18+ discharged from hospital and had meds reconciled within 30 days
over
All patients 18+ discharged from hospital.
Measuring medication adherence
Direct measures- directly observed therapy, drug or drug metabolite in blood, biological marker in blood.
Indirect measures for measuring med adherence
Self-reports
Pill counting
Refills
Proportion of days covered eqn
PDC: (Number of days in period “covered”/ number of days in period) x 100
PDC calculation inaccuracies
Med samples
Discount cards
Free pharmacies
Filling at multiple pharmacies
PDC adherence threshold
> 80%
Consumer satisfaction
Agency for healthcare research and quality (AHRQ)
-collects data and maintains consumer assessment of healthcare providers and systems
CAHPS- assesses patient experience, reports survey results, helps org use results
Hospital consumer assessment of healthcare providers and systems (HCAHPS)
Goals- observe patient perspective of care, public reporting, enhanced accountability.
Examples- communication from healthcare team, pain control, hospital facilities, understanding medications at discharge
Where does data from HCAHPS come from?
Administrative- insurance claims
Hybrid- insurance claims + medical record data
Survery- CAHPS
IHI quadruple aim
Patient experience
Population health
Reducing costs
Care team well-being
Healthcare reform
Fee for service (FFS)
pay for performance
IHI triple/quadruple aim
Star ratings- how to improve
Identify “care gaps”
Through EMR or reports from payers
How can we target opioid crisis?
Opioid stewardship programs (OSP)
Opioid Stewardship Programs (OSP)
Defined as coordinated interventions designed to improve, monitor, and evaluate the use of opioids in order to support and protect human health.
Components of an OSP
Prevention, treatment, harm reduction, information technology
What does the joint commission want OSPs to do?
Identify pain assessment and pain management, including safe prescribing.
Actively involve the organized medical staff in leadership roles in organization performance improvement activities to improve quality of care.
Assess and manage the patients pain and minimize the risks associated with treatment.
Collect data to monitor its performance
Compile and analyze data
CMS roadmap
Prevention
Treatment
Data
Prevention of Opioid use disorder
Promote safe and appropriate use of opioid meds
Promote effective, non-opioid pain treatments
Refer patients with complex pain needs
Improve screening for opioid use disorder (OUD)
Guide providers through opioid tapers, when indicated `
Guidelines for opioid tapering
Common tapers involve dose reduction of 5% to 20% every 4 weeks.
Slower or faster tapers may be indicated. All tapering plans should be individualized
Monitoring and f/u during an opioid taper.
meds to treat symptoms of opioid withdrawal.
Patient education
Order sets
Can help standardize prescribing practices for routing procedures and guide prescribers to order multimodal, opioid sparing pain control
Enhanced recovery after surgery (ERAS) protocols are a paradigm shift in perioperative care focused on enhancing recovery and reducing complications perioperatively.
A major focus of ERAS is opioid-sparing pain control
Nudge theory
An intervention that alters peoples behaviors in a predictable way without forbidding any options or significantly changing their economic incentive.
Example- everything is default in. (less opioids day supply)
Prescription Drug Monitoring Program (PDMP)
An electronic database that tracks controlled substances within a state. PDMPs can provide prescribers with a controlled substance prescribing history to help identify patients who may be at risk for opioid AE
OARRS
PDMP in Ohio
OARRS
Need to check prior to writing a prescription for an opioid or benzo
The CMS is urging hospitals to integrate PDMP into EHR
Yes
Leftover prescription opioids
A huge amount of opioids after surgery do not get used.
Need to educate to store in a locked area and proper ways to get rid of them.
Drug take back programs
When can you flush opioids?
ONLY if there is no drug take back location available
Treatment for OUD
Rapid opioid dependence screen (RODS)
Medications- ER naltrexone, methadone, buprenorphine
ER naltrexone
Intramuscular injection every 4 weeks
Effective in reducing opioid use, but only if patients can successfully detox (7-8 days)
Higher risk of OD immediately after discontinuation!!! Counsel on risk of OD
Methadone
Oral dosing QD
Effective in reducing opioid use, reducing mortality, reducing HIV infections, and retention to care
Have to go to clinic 6-7 days/week
At risk of OD during initiation
Buprenorphine
Formulations indicated for OUD: Injection, implant, SL, buccal
Effective in reducing opioid use, reducing mortality, and retention into care.
Providers must have X waivers
Has a ceiling effect, very hard to OD
Naloxone
Opioid antagonist
Harmless if not experiencing opioid overdose
Admin of opioid OD will lead to opioid withdrawal symptoms
Inappropriate antimicrobial use increases risk of
C.DIff infections/ MDR organisms
Excess mortality and cost
Adverse drug events/toxicity
Antimicrobial resistance
Continues to increase in US
Few antibiotics with novel mechanisms of action are in the manufacturing pipeline. Happens quickly.
Resistance is more common in
Healthcare acquired/associated infections vs community
Antimicrobial stewardship programs
Ongoing efforts to optimize antimicrobial use amongst hospitalized patients in order to:
Improve pt outcomes
Reduce AE and unintended consequences
Ensure cost-effective therapy
Development of an ASP
Leadership commitment is key
Leadership must dedicated time and resources to ASP
There should be an alignment between ASP and leadership/org goals
Gather infor on current abx use/resistant orgs
Identify key stakeholders and needed personnel
Assess institutional needs
How to get ASP buyin
Communicate the value- understand that ASP is not one size fits all, resources, measures to prove efficacy
Emphasize importance
Propose full time equivalent associate with ASP (FTE)
If funded, what will the outcomes be?
ASP personnel
Pharmacists, ID trained physicians, maybe data analyst
Operational costs- equipment, office
ASP cost and revenue
Reduced hospital length of stay
Reduced abx resistant paathogens
Reduces abx expenditure
Variable costs of ASP
Pharmacy
Supplies
Lab testing
ASP challenges
Appropriate outcome measures
Direct cost savings
Indirect cost savings
