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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5537_Библиотеки_им_академика_М_И_Перельмана.pdf
Quality
Evaluating the quality of care is a necessary prerequisite for improving it. In
earlier eras, when medicine had few effective treatments to offer, evaluating
the quality of care was most often a subjective assessment of the strength of
the doctor-patient relationship. In the context of the contemporary armamentarium, evaluating the quality of care should assess objectively the extent
to which appropriate diagnostic and therapeutic interventions are used to
advance the health of individuals and populations, or “increase the likelihood
of desired health outcomes.”
3
Donabedian4pointed out that one could assess three different aspects
of quality:
• Structure — the environment in which care is delivered.
• Process — the steps taken in the delivery of care.
• Outcome — the impact of care on patients.
While it is important to assess outcomes — since the ultimate goal of care
is to have a positive impact on patients — efforts at improving those outcomes necessarily involve making changes to structure and process. For
example, it is important to track the mortality of patients admitted with
acute myocardial infarction (AMI) (now publicly reported by the Center
for Medicare and Medicaid Services for all acute care hospitals), but lowering mortality requires examining and improving how care for AMI
patients is delivered. Successful process improvement involves the systematic selection of the right questions and the application of effective
techniques for improving performance.
Choosing Performance Improvement Targets
Choosing which elements of care to address is a critical first step in effective performance improvement. The focus should be on elements:
• That can be measured (and, preferably, measured without expending
considerable resources).
• That are under the control of the organization.
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I.S. Nash
• On which the institution currently performs poorly.
• That have a clear causal relationship with the outcome of interest.
For many contemporary performance improvement efforts, the selection
of performance improvement targets is driven by external organizations,
such as the Joint Commission or The Center for Medicare and Medicaid
Services (CMS) in the United States. These agencies have established
“core measures” of hospital performance,
5
which are process measures
chosen based on criteria similar to those stated. These process measures
are also used in public report cards on hospital performance, and as elements of “pay for performance” formulas, which link hospital payment to
quality measures — two strong reasons why they have become the central
focus for many institutional quality improvement efforts. Indeed, there is
concern that so much attention has been paid to these measures that may
be driving out other valuable efforts aimed at improving patient care.
6
For many important areas of care, there are no clearly prescribed
processes to address, or the stated process is itself too complex to tackle
directly. For example, the drive for quality improvement may start with an
observation about poor performance on an outcome, such as higher than
expected mortality for a particular procedure or diagnosis, or the recognition that an important process, such as the assignment of inpatient care
teams to patients admitted from the emergency department, does not work
as well as it should. What next?
Do Your Homework — Gather Baseline Data
The first step should be to verify the impression that performance is not
what it should or could be. Gather preliminary data. Try to define best
practice through the use of public reports on hospital performance, published scholarly work, contacts at other institutions, or the use of comparative data from hospital cooperatives to which your institution may
belong, such as the University HealthSystem Consortium (UHC)
7
or the
Association of American Medical Colleges (AAMC).
8
This may also
require reviewing clinical records to verify that data generated from
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Process Improvement Tools
administrative (e.g. billing) systems, which are generally most readily
available and often the source of the initial observation or concern, reflect
the actual care and outcomes.
Form the Right Team
Successful process improvement, especially in complex organizations
such as hospitals, is always a “team sport.” Administrators control
resources, but lack clinical expertise; front line clerical staff understand
many processes at “the ground level,” but may lack perspective on how
their work impacts other areas of the institution; physicians have the most
sophisticated medical knowledge, but often lack understanding of nursing
workflows; nurses understand how care is delivered at the bedside, but are
not necessarily clinical content experts. Pulling together the right combination of participants is the next step in successful process improvement.
Seek a balance of individuals — clinical experts as well as experts on the
current practice. Whenever possible, engage the physician and nursing
leadership in the unit or department where the care is provided, so that
solutions and improvements come “from within” and are therefore more
likely to be embraced than those designed and “imposed” by outsiders.
Although it may seem obvious to recruit participants who are enthusiastic
and invested in improving the status quo, this important consideration is
often overlooked.
Define Goals
Specify the level of performance you hope to achieve. Sometimes a
particular level of future performance will be demanded by others, such
as the Board of Trustees or senior institutional leadership. Very often,
however, it will be up to those engaged in a project to define “success.”
Avoid the temptation to leave the goal vague, such as “improved patient
satisfaction” or “lower rates of central line associated bacteremia.”
Directional change does not motivate participants as much as hitting a
target does, and only a specified endpoint allows progress to be tracked
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I.S. Nash
in a meaningful way. When the ultimate goal may be quite distant, or
even perhaps unattainable with the best medical practice (e.g. “no
central line infections”), it is important to specify intermediate levels
of improvement (e.g. “a 50% decline in central line infections by the
second quarter of next year”), or the achievement of rates comparable
with the best reported (e.g. “lowest decile of infection rates in the
state”).
Break Down the Problem — Process Maps
Improving a complex process or a specific clinical outcome ultimately
comes down to changing one or more specific steps in care. A very useful tool for determining what those steps are is a flow chart or process
map. A process map has directionality (a beginning and an end) and is
a graphic representation of the specific actions and decisions that are
embedded in a larger process (Fig. 1). The typical convention uses rectangles for actions and diamonds for branch points. Breaking down a
complex process this way allows team members to come to a consensus on how a particular process is currently working, helps point out
complexity and redundancy that can often be eliminated, and allows for
the selection of specific points in the process to collect data and target
interventions.
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Process Improvement Tools
Fig. 1. An example of a process map for ordering lab tests and reporting on the results.
Lab Order
Lab Order
Placed
Placed
Label
Label
Printed &
Printed &
Specimen Tube
Specimen Tube
Set Up
Set Up
Specimen
Specimen
Collected
Collected
& Labeled
& Labeled
Specimen
Specimen
Placed in
Placed in
Tube
Tube
Specimen
Specimen
Received
Received
& Inspected
& Inspected
Label
ReRe--Label
??
??
Yes
No
Label
ReRe--Label
Specimen
Specimen
Specimen
Specimen
on
on
Robotic Line
Robotic Line
Results
Results
Posted
Posted
Collect Data
Once the process map is established, collect data about the specific
steps that your group believes may be most problematic, based on
familiarity with the current state. Note that the data you collect may
prove your beliefs wrong. For instance, suppose that you were trying to
reduce lab turnaround time, and had created the process map in Fig. 1.
You would then select steps, such as “specimen collected,” “specimen
labeled” and “specimen placed on robotic line” to see which of these
steps (or others) is contributing the most to the overall delay in getting
from the beginning of the process to the end. A powerful graphical tool
for assisting with this is a Pareto chart (Fig. 2). A Pareto chart is created by plotting, in rank order, the contributions of each step in a
process (typically as vertical bars), and then displaying the cumulative
total contribution (as a line) on the same axes. The simple “80/20” rule
often becomes apparent — 80% of the problem (e.g. the accumulated
turnaround time) is attributable to 20% of the steps in the process. This,
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I.S. Nash
Fig. 2. Pareto Chart.
45%
40%
35%
30%
25%
20%
15%
Percent of Total
10%
5%
0%
ORDER PLACED
Sources of Delay
COLLECTED
TUBE SET UP
LABEL PRINTED
Percent of Total
LABELED
RECEIVED
RELABELED
PLACED IN TUBE
100%
90%
80%
60%
40%
20%
0%
ROBOTIC LINE
RESULTS POSTED
Cumulative Percent
in turn, will allow you to prioritize your efforts, by focusing on those
specific steps.
Analyze the Findings
Once a specific step is targeted for improvement, it is important to understand why it is not working as expected. A “fishbone” diagram, also called
an Ishikawa or cause-and-effect diagram can be used for this purpose
(Fig. 3). Major categories of potentially contributing factors are identified
with successive “layers” of causes for each one. In this example, the factors
contributing to delays in admitting a patient to the medical intensive care
unit are detailed. This allows for a deeper understanding of the problem.
Implement Change
Ultimately, something must be done differently in order to create the new,
desired outcome. It can often be difficult to select which step to change,
or what change to implement. One way to organize your team’s approach
is to make a simple 2 × 2 table and segregate possible interventions
into the four quadrants, defined by whether the intervention/change is
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Process Improvement Tools
Fig. 3. Fishbone Diagram.
hard or easy (based on required resources and training, or on the anticipated resistance or consequences for other activities) and whether is it
likely to have a large or small impact. Clearly, those changes that can have
the biggest potential positive impact at the lowest anticipated cost (in
resources and effort) ought to be tried first. This is often referred to as
“picking the low hanging fruit.”
Measure, Track and Repeat
The final step in any successful quality improvement effort is to measure
the impact of the intervention and track it over time. A graph of the value
of key measures over time (“run charts”) is a useful tool; one can plot
either the overall outcome that sparked the improvement project (e.g. AMI
mortality) or the specific process that was changed. These charts should be
updated frequently so that positive trends can be celebrated, and deteriorating performance can be addressed. Ideally, the measurements made to
track the impact of an intervention should serve as the baseline for further
interventions, following the same steps outlined above, so that performance can be continuously improved. A “control chart” is a specific form of
a run chart, which includes the upper and lower bounds of expected performance, and allows one to assess whether the process being assessed is
functioning as expected.
Summary
High quality healthcare improves patients’ outcomes. A methodical, datadriven approach to process improvement is the best way to achieve it.
References
1. Kohn LT, Corrigan JM, Donaldson MS (Institute of Medicine). (2000)
To Err is Human: Building a Safer Health System. National Academy
Press, Washington, DC.
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2. Committee on Quality of Health Care in America (Institute of
Medicine). (2001) Crossing the Quality Chasm: A New Health System
for the 21st Century. National Academy Press, Washington, DC.
3. Institute of Medicine. (1990) Medicare: A Strategy for Quality
Assurance. National Academy Press, Washington, DC.
4. Donabedian A. (1988) The quality of care: How can it be assessed?
JAMA 260: 1743–1748.
5. Chassin M, Loeb JM, Schmaltz SP, Wachter RM. (2010) Accountability
measures — Using measurement to promote quality improvement.
N Engl J Med 363(7): 683–688.
6. Bardach NS, Cabana. (2009) The unintended consequences of quality
improvement. Curr Opin Pediatr 21(6): 777–782.
7. http://www.uhc.edu
8. http://www.aamc.org
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Teamwork in Hospital Medicine
Kevin J. O’Leary* and Niraj L. Sehgal
†
Key Pearls
• Teamwork and communication failures are a known threat to patient
safety.
• Challenges include large teams with membership that is dynamic and
often dispersed.
• Measurement of teamwork is essential to understand baseline perform-
ance, evaluate the effectiveness of interventions, and demonstrate the
utility of resources invested.
• Successful interventions include formal teamwork training, daily
goals of care forms, interdisciplinary rounds, and nurse-physician unit
co-leadership.
• The optimal approach is implementation of one or more interventions
with adaptations to fit unique clinical settings and local culture.
Background and Essential Elements of Teamwork
Teamwork and communication failures are a known threat to patient
safety and cited by the Joint Commission as the most frequent root cause
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8
Chapter
*Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
†
University of California, San Francisco, CA, USA.