HealthInforma.cstoTrackQuality

LeoAnthonyCeliMDMSMPHIns.tuteforMedicalEngineeringandScience,MIT

BethIsraelDeaconessMedicalCenter,HarvardMedicalSchool

Everysystemisperfectlydesignedtoachievetheresultsthatitgets.

WhatisQuality?

•  Noclear,universallyagreedupondefini.onofhealthcarequality

•  Mul.pledefini.onsexistfromdifferentorganiza.onsandrepresentthevaluesoftheorganiza.on

•  Safe•  Effec.ve•  Pa.ent-centered•  Timely•  Efficient•  Equitable

SixWorthyAimsaccordingtoIHI

• Noneedlessdeaths• Noneedlesspainorsuffering• Nounwantedwaits• Nohelplessness• Nowaste

Iftheairlineindustrytoleratedtheerrorratethathealthcareindustrydoes,therewouldbe3jumbojetcrashesevery2days.

WhyisHealthcareUnsafe?

•  Lackofawarenessofmagnitudeoftheproblem

•  Perceivedasunusualevents–“outliers”•  Pooroutcomesfromerrorblamedoncomplica.onofdiseaseorinherentriskofprocedure,e.g.hospital-acquiredinfec.on

WhyisHealthcareUnsafe?

•  Healthcareculturenotpar.cularlyconduciveforerrordetec.on

•  Mistakesareunacceptable•  Errorasfailureofcharacter– “Youweren’tcarefulenough.“– “Youdidn’ttryhardenough.”

•  Relianceonindividualsnottocommiterrorsratherthanassumingthattheywill

MedicalerrorsarecommiZedbycompetent,caringpeopledoingwhatothercompetent,caringpeoplewoulddo

“Qualityproblemsoccurnotbecauseofafailureofgoodwill,knowledge,effort,orresourcesdevotedtohealthcare,butbecauseoffundamentalshortcomingsinthewayscareisorganized.”

BUTHealthcareisDifferent!

•  Anesthesia:1deathper200,000cases25xmoredangerousthanflying•  Morethan155,000possiblediagnoses,morethan7,800possibleinterven.ons

•  Industriesofhighintrinsichazardsarealsocomplicated(andyetmuchsafer)!

•  Maindifference:organiza.onanddesign

OtherHighRiskIndustries:•  Focusedonintegra.ngnewdiscoveriesanddisciplinesintowell-harmonizedsystems

•  Relentlesslyrigorousiniden.fyingwhendesignsareinadequate

•  Constantlylookoutforunan.cipatedoutcomes•  Detec.ngerrorsandconver.ngthemintoexper.searecrucialtoopera.ons

Healthcarevs.OtherHighRiskIndustries

Healthcarevs.OtherHighRiskIndustries

Healthcare:•  Organizedaroundguilds(doctors,nursing,pharmacy)

andspecial.es•  “Design”aresultofhistorical,poli.calandeconomic

forces,nottheanaly.calconsidera.onofhowtoachievethebestresults

•  Nursesanddoctorsexpectedtoconstantlyworkaroundto“getthejobdone”

•  SamebaZlesfoughteverydaybutliZleheadwayinmakingthingsbeZer

The definition of insanity is continuing to do the same thing over and over again and expecting a different result.

BarrierstoQualityImprovement•  Old-stylecontrol-orientedmanagement•  Strongsenseofprofessionalhierarchyanden.tlement

•  Lackofintegra.onofthehealthcaresystemwithcommunityresources

MeasuringQuality

ElementsofQuality:1.Applica.onofevidence-basedinterven.onstoindividualpa.ents

everysingle.me

Evidence-BasedMedicine

•  Prospec.verandomizedcontrolledtrial(PRCT)isconsideredgoldstandard

•  PRCTs–  provideaverageeffect–  evaluates1interven.onata.me–  haveinclusionandexclusioncriteriathatlimitexternalvalidity

•  Errorsandbiasesabound:1/3ofthemostcitedoriginalclinicalresearchlaterrefuted(Ioannidis,JAMA2005)

“… half of what we know might be wrong, and the other half useless…”

Evidence-BasedMedicine

•  2007analysisof>1000Cochranesystema.creviews– 49%:currentevidencedoesnotsupporteitherbenefitorharm

– 96%:addi.onalresearchisrecommended

•  Mostofwhatcliniciansdohasneverbeenformallyputtothetest

Measuring“effec.vecare”islimitedtoafewdiagnosesand

narrowinscope.

ElementsofQuality:Service

Compassion

Goodpa.ent-providercommunica.onShareddecision-making

•  Pa.ents’percep.onofqualityiscoloredbywhetherornottheirexpecta.onsweremet.

ElementsofQuality:3.Teamworkandcultureofquality

CultureofQuality

•  Pertainstohoweverymemberofthesystem,healthcareproviderornot,isempoweredandcommiZedtoimprovingprocessesandcon.nuouslearning

•  Notcurrentlymeasuredbyhospitalaccredita.onorganiza.ons

•  Pa.entsandprovidersareopenoblivioustothiselementofquality

TheHolyGrail:DigitalQualitySystem

•  Tracksallthecomponentsofqualitycon.nuouslyandinreal-.me(vs.episodicretrospec.vereports)

•  Providesac.onableitemsatthepoint-of-care

WheredoesmHealthcomein?

mHealthandQualityImprovement

•  Providesevidence-basedmedicineatthepoint-of-careandallowsstandardiza.onofcare

•  Facilitatescommunica.onbetweendifferentprovidersandbetweenpa.entsandproviders

•  Documentsprocessesofcareandoutcomesinamachine-readyformatforresearch

SecondaryAnalysisofHealthData