PHHE 461 Prescott College Healthcare Quality Discussion

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Health Care Quality PHHE 461 1 Housekeeping (1) ⚫Quiz 2 online (available Mar 20-22) ⚫Materials: since last exam through Access to Care module ⚫Exam 2 ⚫Week of March 24 ⚫Study guide posted ⚫Doodle poll to determine date of exam 2 Housekeeping (2): DB This Week ⚫Based on the PowerPoint exercises and our assigned readings, give an example of a structure, process, and outcome in health care/human services quality improvement. ⚫Explain why you think it is important that health care quality improvement is measured at any of these levels. ⚫For this question, make sure to post on at least 2 different days of the week, and respond to a peer in at least of your posts. ⚫Each post should be at least 50 words, and be free of grammatical/spelling, punctuation errors. The assignment is due Sunday, March 8 @ 11:59 PM. 3 Internship & Job Fairs (1) ⚫Career Hotspot ⚫Visit the Career Hotspot table for quick and convenient help from NIU Career Services. Get your resume, cover letter, or LinkedIn profile reviewed and learn to use Huskies Get Hired to access over 1,500 internship/job openings. ⚫Wednesday, March 18, March 25, April 1, April 8, April 15, April 22 at 11:00 AM to 1:30 PM ⚫Founders Memorial Library, 71 North, Lower Level ⚫217 Normal Rd, DeKalb, IL 60115 ⚫LinkedIn: The Basics ⚫Tuesday, March 17 at 3:30 PM to 4:45 PM ⚫Campus Life Building, 160 ⚫545 Lucinda Ave, DeKalb, IL 60115 4 Internship & Job Fairs (2) ⚫LinkedIn: Beyond the Profile ⚫Thursday, March 19 at 3:30 PM to 4:45 PM ⚫Campus Life Building, 160 ⚫545 Lucinda Ave, DeKalb, IL 60115 ⚫2020 NIU Health and Wellness Fair ⚫The Employee Assistance Program and Recreation Services ⚫Wednesday, April 1st ⚫Holmes Student Center, Ballroom (on the main floor) ⚫10:00 a.m. to 1:00 p.m. 5 LeadingAge Illinois ⚫LeadingAge Illinois is one of the largest and most respected associations of providers serving Illinois older adults. ⚫The LAI annual conference is March 17 19 at the Schaumburg Convention Center. This is a great opportunity to get a glimpse into the industry, meet people, and attend fantastic educational sessions. ⚫Free student registration; fill out the attached form and send to info@leadingageil.org 6 ⚫Julie Boggess, MPA, LNHA Career Services ⚫NIU Career Services, 220 Campus Life Building ⚫815-753-1641 ⚫www.niu.edu/careerservices ⚫www.niu.edu/careerservices/huskies gethired ⚫Search jobs, upload resume ⚫Practice interviews online 24-7 ⚫www.perfectinterview.com/niu 7 ⚫Record & review your responses to typical interview questions Lecture Outline ⚫ Statistics on quality in US health ⚫ ⚫ ⚫ ⚫ ⚫ 8 care Why there are health care quality problems Challenges in addressing multiple health care conditions Quality measurement categories External accreditors of quality Quality tools Health Care Quality ⚫Varies A LOT; NOT clearly related to $$ spent ⚫Matters – can be measured and improved ⚫Measurement science is evolving: ⚫Structure, process and outcomes ⚫Broad recognition that patient experience is essential component ⚫Strong focus on public reporting ⚫Motivates providers to improve ⚫Not yet ‘consumer friendly’ 9 Source: KaiserEDU.org 70 Million Americans Benefit from Quality Measurement 96% of heart attack victims were prescribed beta-blocker treatment in 2005, up from 62% in 1996* ⚫ 77.7% of children enrolled in private health plans received all recommended immunizations, up 5% from 72.5% in 2004* ⚫ Evidence-based guidelines from the American College of Cardiology and the American Heart Association have reduced mortality among patients who 10 have had a heart attack ⚫ National Reports: Some Good News, Need for Improvement ⚫ For all populations & all settings of care, the rate of improvement in quality between 1994 and 2005 was 2.3%, down from 3.1% from 19942004 ⚫ More than 60% of the disparities in quality of care have stayed the same or worsened for Blacks, Asians and the poor, and approximately 56% of disparities have not improved for Hispanics Overall Scope – Quality in Healthcare ⚫Patients receive the proper diagnosis and treatment only about 55% of the time* ⚫Overall, disparities in health care quality and access are not getting smaller ** ⚫U.S. health care spending grew 4.3 percent in 2016, reaching $3.3 trillion or $10,348 per person. ⚫As a share of the nation’s Gross Domestic Product, health spending accounted for 17.9 * McGlynn E, Asch S, et al. The Quality of Health Care Delivered to Adults in the United States (CMS, 2018) N Engl J percent Med 2003;348:2635-45. Source: KaiserEDU.org ** AHRQ 2007 National Healthcare Disparities Report *** National Health Expenditure Accounts 12 Why Do We Have Healthcare Quality Problems? ⚫The “why” is a systems challenge: ⚫The U.S. has extremely talented and qualified health care professionals who have not been trained to work in teams ⚫The delivery system is fragmented, so information doesn’t follow patients as they move from hospitals to other sites of care ⚫Payment is quality neutral ⚫We pay for volume, not quality ⚫Providers do more “things” and get more $ 13 Defining Quality 14 IOM’s definition 6 dimensions of quality “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” ⚫Safe ⚫Effective ⚫Patient-centered ⚫Timely ⚫Efficient ⚫Equitable © 2015 Springer Publishing Company, LLC Challenges in Addressing Multiple Conditions Interactions between illnesses Interactions between treatments Multiple medications Multiple providers 15 Source: KaiserEDU.org Tension between therapeutic goals Healthcare Quality Measurement More emphasis needs to be placed on what’s most important We measure what we can 16 Source: KaiserEDU.org Rather Than Identifying what counts and determining how it can be measured The Goal ⚫Historically, the focus has been on structure ⚫In recent years, there has been more interest in process – the right care ⚫Tomorrow’s goal? Outcomes and end results 17 Source: KaiserEDU.org Quality Measurement Categories ⚫Structure measures ⚫Organization capacity or potential for providing quality services ⚫Process measures ⚫Whether activities performed during healthcare service delivery are provided satisfactorily ⚫Outcome measures ⚫Results of healthcare services: effect of 18 Source: Spath,& 2009; Kovner & Knickman, 2011 structure process Donabedian (1980) Quality Measurement Model external environment Societal values, politics, resources, scientific discovery, etc. structure process feedback 19 outcomes Structure in Quality Improvement ● Physical facility ● Equipment, information technology ● Staffing ● Licensure & accreditation status ● Organizational culture Source: Jonas & Kovner, 2008 ; Kovner & Knickman, 2011 20 Process in Quality Improvement (1) ⚫Focus on ways in which care is delivered ⚫Diagnostic services (examples) ⚫Mammograms ⚫Computer aided detection (CAD) ⚫CT (computed tomography) scans. ⚫Angiography and interventional services. ⚫Diagnostic x-ray and fluoroscopy. ⚫Ultrasound. ⚫Osteoporosis testing. ⚫MRI (Magnetic resonance imaging) 21 Source: Jonas & Kovner, 2008 ; Kovner & Knickman, 2011 Process in Quality Improvement (2) ⚫Focus on ways in which care is delivered ⚫Treatment services (examples) ⚫Annual preventive office visit ⚫Specialist office visit ⚫Hand surgery ⚫Tonsillectomy ⚫Heart bypass surgery 22 Source: Jonas & Kovner, 2008 ; Kovner & Knickman, 2011 Outcomes in Quality Improvement ⚫What outcome is being targeted? ⚫Cost reduction? ⚫Physiological status? Disease reduction? ⚫Mortality? Morbidity? Disability? Functional status? ⚫Patient satisfaction? ⚫Quality of life ⚫Average length hospital stay 23 Source: Jonas & Kovner, 2008; Kovner & Knickman, 2011 Organizational Plans for Ongoing Quality Improvement (1) 1. “Learning organization” ⚫ Continual education focused on quality, safety education ⚫ Organization-wide: CEO to maintenance staff ⚫ Across organizational cultures ⚫ Quality not a “fad”: part of the organizational culture Source: Jonas & Kovner, 2008 24 Organizational Plans for Ongoing Quality Improvement (2) 2. Proactive versus reactive approach ⚫ System for identifying, reporting errors ⚫ Openness to fixing what isn’t working 3. Invest in data & tools ⚫ Information technologies ⚫ Decision support tools Source: Jonas & Kovner, 2008 25 Data Transparency ⚫CMS Hospital Quality Initiatives Program ⚫Hospital Compare (CMS-developed) ⚫Improve care provided by nations’ hospitals ⚫Provide quality info to consumers & others ⚫Indicators for heart attacks, heart failure, pneumonia, surgical infection prevention ⚫30-day risk-adjusted mortality rates for acute myocardial infarction and heart failure ⚫CMS Nursing Home Compare ⚫Detailed comparative info on Medicare & Medicaid-certified nursing homes Source: Jonas & Kovner, 2008 26 External Accreditors of Quality ⚫Joint Commission: Joint Commission on Accreditation of Healthcare Organizations ⚫NCQA: National Committee for Quality Assurance ⚫NQF: National Quality Forum Source: Jonas & Kovner, 2008 27 Joint Commission (1) ⚫Joint Commission on Accreditation of Healthcare Organizations formed in 1951 ⚫Accreditation of healthcare organizations & programs (15,000) ⚫Minimum bar for healthcare quality ⚫ Voluntary process by which organization performance measured v. nationally accepted standards ⚫Largest independent accreditor of health care organizations ⚫Hospitals, ambulatory care facilities, lab services, assisted living, health care networks Source: Jonas & Kovner, 2008 28 Joint Commission (2) ⚫Quasi-regulatory: Joint Commission’s accreditation > > ⚫Meet requirements to bill Medicare & other private payers ⚫Challenges to Joint Commission’s effect on quality ⚫High accreditation scores necessarily good outcomes ⚫Criticized e.g., board2008 dominated Source:⚫ Jonas & Kovner, 29 groups not by hospital and physician NCQA (National Committee for Quality Assurance)(1) ⚫Founded in 1990 ⚫Not-for-profit organization improving quality ⚫Accreditation ⚫Certification ⚫Physician recognition ⚫Credentialing for specific disease types (e.g., diabetes, stroke) ⚫Works with large employers, 30 policymakers, doctors, patients, and health Source: Jonas & Kovner, 2008 plans NCQA (National Committee for Quality Assurance)(2) ⚫Formula for improvement: measure, analyze, improve ⚫HEDIS (Health Plan Employer Data & Information Set) ⚫Tool used by 90% of America’s health plans to measure performance on important dimensions of care and service. ⚫Addresses a broad range of health issues, i.e.: ⚫Asthma Medication Use ⚫Persistence of Beta-Blocker Treatment after a 31 Heart Attack ⚫Controlling High Blood Pressure ⚫Comprehensive Diabetes Care Source: Jonas & Kovner, 2008 ⚫Breast Cancer Screening NQF (National Quality Forum)(1) ⚫Not-for-profit organization operating under a 3-part mission: 1. Building consensus on national priorities and goals for performance improvement 1. Endorsing national consensus standards for measuring and publicly reporting on performance Promoting the attainment of national goals through education and outreach programs Source: Jonas & Kovner, 2008 1. 32 NQF (National Quality Forum)(2) ⚫Membership: wide variety of healthcare stakeholders, i.e., ⚫Consumer organizations ⚫Public and private purchaser ⚫Physicians ⚫Nurses ⚫Hospitals ⚫Accrediting and certifying bodies ⚫Supporting industries ⚫Healthcare research and quality Source:improvement Jonas & Kovner, 2008 33 organizations NQF (National Quality Forum)(3) ⚫300 measures, indicators, etc. ⚫NQF “Never events”: 28 medical errors that shouldn’t happen ⚫Surgery performed on the wrong body part or on the wrong patient ⚫Leaving a foreign object inside a patient after surgery ⚫Discharging an infant to the wrong person ⚫NQF used by Leapfrog Group (2007) ⚫Consortium employers, health insurers, governmental purchasers to promote safety, & 2008 affordability of care Source:quality, Jonas & Kovner, 34 Pay-for-Performance (P4P) ⚫Financial incentives given to physicians and other health care providers for meeting ⚫ Quality, efficiency, or other quality targets ⚫AHRQ (Agency for Healthcare Research & Quality) ⚫Research & tools on P4P ⚫Third-party payers beginning to provide ⚫Direct financial incentives ⚫Financial bonuses 3 35 5 ⚫Quality improvement grants Indirect financial incentives ⚫ Jonas & Kovner, 2008 Source: ⚫Reducing patient load Tools to Evaluate Performance & Gauge Performance Improvement 36 Philip Crosby ⚫“Quality is free” ⚫“No quality production costs $” ⚫Strive for zero defects – use QI teams w/ commitment ⚫For a successful quality effort, organizations must identify & address hidden costs of poor quality. ⚫Visible costs: ⚫Customer complaints ⚫Excessive overtime ⚫Billing errors 37 ⚫Invisible costs: ⚫Lack competitive knowledge Source: Spath, 2009 ; Kovner & Knickman, 2011 ⚫Bad reputation Iceberg of Visible-Invisible Costs of Poor Quality Visible costs Customer complaints Billing errors Lack competitive knowledge Lost/dissatisfied patients invisible costs Source: Spath, 2009 38 Bad reputation Statistical Process Control (SPC) ⚫Highlights variations in performance that should be investigated ⚫Based on upper & lower limits of the normal distribution theories ⚫68% of values from normal distribution: 1 standard deviation from mean ⚫95% of values from normal distribution: 2 standard deviations from mean Source: Spath, 2009 39 Statistical Process Control (SPC) Tools ⚫Line graphs ⚫Ideally 20 data points ⚫Trend: 7-8 data points moving steadily upward or downward ⚫Control charts ⚫Upper and lower control limits indicated on chart Source: Spath, 2009 40 Line Graph – Clinic Wait Time minutes waiting 41 trend Source: Spath, 2009 ; Kovner & Knickman, 2011 Control Chart– Rejected Insurance Claims Rejected claims 42 Source: Spath, 2009 ; Kovner & Knickman, 2011 Pareto Analysis ⚫80/20 rule: 80% of defects/errors caused by 20% of process factors ⚫e.g., 20% of physicians causing 80% of case delays ⚫Separate important few from many causes of problems Source: Spath, 2009 43 Pareto Analysis Example: Surgery Scheduling Delays 100% Cumulative % of delays 50% 0% Scheduling software problems Source: Spath, 2009 44 scheduling desk delays physician understaffing emergency surgeries Lean Quality Improvement Process 1. 2. 3. 4. 5. 45 Specify value from standpoint of end customer Identify all steps in value stream Make value-creating steps occur in tight sequence As flow is introduced, customers pull value from next upstream activity As value is specified, value streams are identified, wasted steps removed, and flow & pull introduced © 2015 Springer Publishing Company, LLC Performance Improvement ⚫Shewhart ⚫PDCA: Plan-Do-Check-Act ⚫Deming (taught Japanese, allied occupation post WWII) ⚫PDSA: Plan-Do-Study-Act Source: Spath, 2009 46 Act Plan Study Do Plan-Do-Study-Act (PDSA)(1) ⚫Plan ⚫State objectives of improvement project ⚫Determine needed improvements ⚫Develop plan to carry out changes (define who, what, when, where) ⚫Identify data needed to be collected to determine whether changes produced desired results 47 ⚫Do ⚫Implement changes on small scale ⚫Document problems & unexpected results ⚫Gather data to assess the changes’ effect on Source: Spath, 2009 process Plan-Do-Check-Act (PDSA)(2) ⚫Study ⚫Analyze data to determine whether changes were effective ⚫Compare results w/ expectations ⚫Summarize lessons learned pre & post implementation 48 ⚫Act ⚫If changes weren’t successful, repeat PDSA cycle ⚫If changes successful, or partially successful, Source: Spath, 2009 modify & implement on wider scale ⚫Predict results PDSA Example (1) Model Phase Plan 49 Examples Objective: improve patient knowledge medications taken post-discharge Plan: pharmacists meet w/ patients w/i 24 hours prior discharge: education session noted in patient record Expected result: patients will understand medications to be taken at home Measures: Monitor completion medication education through review of patient record. Monitor patient understanding through follow-up call Source: Spath, 2009 PDSA Example (2) Model Phase • Pharmacists educated 42/49 patients discharged. • The 7 not educated were discharged on Sunday. • Of these 42, 39 reported they received appropriate & adequate information about medications. • Two patients did not remember being educated. One patient could Source: Spath, 2009 not be contacted. Study 50 Examples PDSA Example (3) Model Phase Act 51 Examples • Modify plan for Sunday discharges. Have discharging nurse educate patients leaving on Sunday. • Evaluate efficacy of instruction by nurses v. pharmacists • Implement a PDSA cycle to measure & improve compliance that F/U calls be made to patients on 4+ medications w/i 2 weeks of discharge to check on • Their understanding of medications • Compliance w/ dosing schedule • Side effects Source: Spath, 2009 Fishbone/Cause & Effect Diagrams ⚫ Good for problem solving exercises ⚫ Problem: long clinic wait times procedures environment Can’t find medication cabinet key Too much paperwork Registration takes too long Disorganized files Not enough exam rooms central problem: long clinic wait times Unscheduled patients Poor maintenance Patient late for appointment Nurse not available Equipment people 52 Source: Spath, 2009 Wrap-Up ⚫Statistics on quality in US health care ⚫Why there are health care quality problems ⚫Challenges in addressing multiple health care conditions ⚫Quality measurement categories ⚫External accreditors of quality ⚫Quality tools 53 Based on the PowerPoint exercises and our assigned readings, give an example of a structure, process, and outcome in health care/human services quality improvement. Explain why you think it is important that health care quality improvement is measured at any of these levels. At least 75 words. Respond to the following: An example of quality improvement can be seen through SunnyBrook Health Science Centre (SHSC). For its 8th annual QI plan, Sunnybrook Health had four strategic goals that were supported by multiple activities to improve the quality of service. Three of the top areas of focus for 2018/2019 included: Patient engagement. Sunnybrook created an external website to support patients, as well as an internal website to guide staff on engaging patients. Compassionate care, this is measured in several ways, including patient surveys. Safety, reduce patient and staff infections by pioneering a hand hygiene measurement system. Bugumba Citation “Quality Improvement Plan.” Quality Improvement Plan – Sunnybrook Hospital, sunnybrook.ca/content/?page=quality-improvement-plan. At least 75 words.

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