Karin Cox, RN, MSN, Quality Consultant: Critical Care Neurosciences Services

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Inova Fairfax Hospital Karin Cox, RN, MSN, Quality Consultant: Critical Care & Neurosciences Services

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Inova Fairfax Campus 833 authorized beds 2 million square feet 36 Off-site properties >7,000 workers Quality Staff of 13.5 Outcomes Staff of 16

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What we will cover History of Quality Efforts in Healthcare What is an Ideal Healthcare System Role of the Quality Consultant Quality at Inova Fairfax Hospital

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The Quality Professional's Perspective Do the Right Thing Right, the First Time Continuous Process Improvement Timeliness Reliability Efficacy Availability Affordability Standardization Freedom from Deficiencies Customer Satisfaction

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Quality from the Patient's Perspective Keep me safe Heal me Be pleasant to me In that request! Security + quality + fulfillment = Excellent Care

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Measuring Quality: Romeo and Juliet I do recall a pharmacist,- - And hereabouts he abides,- - which late I noted In tatter'd weeds, with overpowering foreheads, Culling of simples; small were his looks, Sharp wretchedness had worn him to the bones: And in his poor shop a tortoise hung, A croc stuff'd, and different skins Of not well formed fishes; and about his retires A flat broke record of discharge boxes, Green earthen pots, bladders and smelly seeds, Remnants of packthread and old cakes of roses, Were meagerly scatter'd, to make up a show.

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History of Quality: Florence Nightingale Went to Scutari Hospital with 38 attendants 3,000 – 4,000 troopers Deplorable conditions 43% mortality Set up kitchens, clothing, fundamental sanitation, nursing Mortality dropped to 3% Nightingale Fund permitted autonomous enrichment of St. Thomas School of Nursing

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Florence Nightingale as analyst

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Foundation of Process Improvement Set Standards Measure

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Voluntary Standards Formed 1913 – American College of Surgeons established 1917 – Minimal Standards for Hospital – five Physicians must be alumni of School of Medicine Physicians needed to apply for Medical Staff benefits Organized Medical Staff needed to meet at any rate yearly to survey nature of care Medical Record Hospital administrations directed by a qualified individual

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Voluntary Standards Formed 1913 – American College of Surgeons established 1917 – Minimal Standards for Hospital – five Physicians must be alumni of School of Medicine Physicians needed to apply for Medical Staff benefits Organized Medical Staff needed to meet at any rate every year to audit nature of care Medical Record Hospital administrations administered by a qualified individual 1918 – First examination Only 89 out of 692 doctor's facilities met guidelines

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Pressure to Change: Standards Evolve 1950s A period of progress Number of benchmarks increments 3,200 doctor's facilities accomplish gauges American College of Physicians, American Hospital Association, American Medical Association, Canadian Medical Association frame the Joint Commission on Accreditation of Hospitals 1965 Congress passes Social Security and "esteems" that doctor's facilities certify by JCAH can partake in Medicare 1970s Expansion and Segmentation Nurses, Hospital Administrators, Dentists Required accommodation of remediation arrangements

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Pressure to Change: Standards Evolve (TJC) Develop Standards for Different Types of Organizations Hospitals Behavioral Health Ambulatory Care Home Care Critical Access (Rural) Hospitals International Develop Disease Specific Standards (starting 2002) Stroke Cystic Fibrosis Renal Disease

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Standards Proliferated in Many Areas Rights and Ethics Provision of Care Medication Management Infection Control Performance Improvement Environment of Care Leadership Medical Staff Nursing Human Resources

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International Comparison of Spending on Health, 1980–2004 Average spending on wellbeing per capita ($US PPP) Total consumptions on wellbeing as percent of GDP Data: OECD Health Data 2005 and 2006. Source: Commonwealth Fund National Scorecard on U.S. Wellbeing System Performance, 2006 16

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Wake Up Call in Public and Private Sectors Fee for Service Rewarded usage No motivations for quality Discount in return for volume Prospective Payment – Public Sector DRG (Diagnosis Related Groups) Prospective Payment – Private Sector HMO's Capitation

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Standards Evolve Joint Commission 1980s "Plan for Change" Response to Criticism First "Open" individuals Outcome Measurements: Core Measures 1987 - 2001 Sentinel Events

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Different Approaches TJC Primary Processes of care, continuum, correspondence, nonstop change Secondary Inspection, insufficiencies CMS Primary Inspection, lacks Secondary Processes of care, continuum, correspondence, constant change

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Was it enough? We made guidelines We gauged to these models

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Published 2000 by Institute of Medicine Adverse occasions happen in 2.9 to 3.7 % of hospitalizations 33.6 million hospitalizations for every year in United States 44,000 to 98,000 unfriendly occasions for each year Adverse occasions result in death 6.6 to 13.6 % Death because of therapeutic blunders as 8 th driving reason for death To Err is Human

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Responding to IOM Reduction in Federal repayment by 2% for not submitting information on Core Measures: How regularly a doctor's facility sticks to confirm based clinical practice for heart assault, heart disappointment, pneumonia, surgery (2003) Transparency: Public site to show Core Measures comes about (2005) www.hospitalcompare.hhs.gov Reduction in Federal repayment by 2% for not submitting HCAHPS persistent fulfillment information (2007)

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National Events

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Components of a "Perfect" Health Care System Long, sound, profitable lives Quality Access Efficiency Equity Capacity to develop and enhance

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Mortality Amenable to Health Care Mortality from causes considered amiable to social insurance is passings before age 75 that are possibly preventable with auspicious and fitting restorative care Deaths per 100,000 population* International variety, 1998 State variety, 2002 Percentiles * Countries' age-institutionalized demise rates, ages 0–74; incorporates ischemic coronary illness. See Technical Appendix for rundown of conditions considered managable to medicinal services in the examination. Information: International assessments—World Health Organization, WHO mortality database (Nolte and McKee 2003); State gauges—K. Hempstead, Rutgers University utilizing Nolte and McKee strategy. Source: Commonwealth Fund National Scorecard on U.S. Wellbeing System Performance, 2006 26

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Medical, Medication, and Lab Errors Among Sicker Adults, 2005 Percent reporting restorative misstep, medicine blunder, or lab mistake in recent years International correlation United States, by race/ethnicity, wage, and protection status UK=United Kingdom; GER=Germany; NZ=New Zealand; AUS=Australia; CAN=Canada; US=United States. Information: Analysis of 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults; Schoen et al. 2005a. Source: Commonwealth Fund National Scorecard on U.S. Wellbeing System Performance, 2006 27

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Went to ER for Condition That Could Have Been Treated by Regular Doctor, Among Sicker Adults, 2005 Percent of grown-ups who went to ER in recent years for condition that could have been dealt with by standard specialist if accessible International examination United States, by race/ethnicity, pay, and protection status GER=Germany; NZ=New Zealand; UK=United Kingdom; AUS=Australia; CAN=Canada; US=United States. Information: Analysis of 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults; Schoen et al. 2005a. Source: Commonwealth Fund National Scorecard on U.S. Wellbeing System Performance, 2006 28

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Percentage of National Health Expenditures Spent on Health Administration and Insurance, 2003 Net expenses of wellbeing organization and medical coverage as percent of national wellbeing uses a b c * a 2002 b 1999 c 2001 * Includes claims organization, guaranteeing, showcasing, benefits, and other managerial costs; in view of premiums short claims costs for private protection. Information: OECD Health Data 2005. Source: Commonwealth Fund National Scorecard on U.S. Wellbeing System Performance, 2006 29

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National Health Expenditures Invested in Research and Spent on Public Health Activities Compared with Administration and Insurance Costs, 2000 and 2004 Dollars (in billions) Percent of national wellbeing uses Data: CMS Office of the Actuary, National Health Statistics Group; and U.S. Dept. of Commerce, Bureau of Economic Analysis and U.S. Department of the Census (Smith et al. 2006). Source: Commonwealth Fund National Scorecard on U.S. Wellbeing System Performance, 2006 30

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Scorecard-Related Publications Cathy Schoen, Karen Davis, Sabrina K. H. How, and Stephen C. Schoenbaum, "U.S. Wellbeing System Performance: A National Scorecard," Health Affairs Web Exclusive (Sept. 20, 2006):w457–w475. Accessible online at: http://content.healthaffairs.org/cgi/republish/25/5/w457 Commonwealth Fund Publications: Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Comes about because of a National Scorecard on U.S. Wellbeing System Performance (Sept. 2006). Cathy Schoen and Sabrina K. H. How, National Scorecard on U.S. Wellbeing System Performance: Technical Report (Sept. 2006). Cathy Schoen and Sabrina K. H. How, National Scorecard on U.S. Wellbeing System Performance: Complete Chartpack and Chartpack Technical Appendix (Sept. 2006). These Fund distributions are accessible for nothing download on The Commonwealth Fund's Web website at www.cmwf.org. 31

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Where are we now with Quality: Financial Accountability 1987 - 2002: Hospitals were required to gather information and write about institutionalized – or "center" – execution measures. Inability to report brings about lessened repayment. Center

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