Quality Management

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Quality Management by Mind Map: Quality Management

1. According to Emanuel (2008): • Patient safety is a discipline in health care that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery.   • Patient safety is also an attribute of health care systems; it minimizes the incidence and impacts of, and maximizes recovery from adverse events.

2. -Quality assurance  -Quality improvement - Continuous quality improvement - Total quality management

2.1. Quality assurance  Donabedian (2003)

2.1.1. Def: all actions taken to plan, control, assure and improve the quality of health care

2.1.2. Activities System design and resources − Including factors such as education, training, certification, equipment and organization of the care facility Performance monitoring and readjustment − Obtaining information about the level of quality − Taking actions needed to protect and improve quality Steps in monitoring and improving clinical performance Donebedian 2003 -determining what to monitor • determining priorities in monitoring • selecting approaches to assessing performance • formulating criteria and standards • obtaining the necessary information • choosing when to monitor • choosing how to monitor • constructing a monitoring system •bringing about behaviour change Continuous quality improvement (CQI) Def. A structured organizational process for involving personnel in planning and executing a continuous flow of improvements to provide quality health care that meets or exceeds expectations Def. CQI is simultaneously  a management philosophy and a management method. “adding value” or “cost-effectiveness” is often added to this definition. Characteristics and functions of CQI: Main characteristics of CQI

2.2. Quality assessment

2.2.1. Quality of care can be assessed by evaluating its structure the attributes of the settings in which care is provided and the resources needed for healthcare (material, intellectual and human resources) process the use of resources in terms of what is done in giving and receiving care (patient related processes and organizational aspects) outcome changes in individuals and populations that can be attributed to health care (e.g. health outcomes, satisfaction)

2.2.2. Macro Level Legislation and policies on quality of care • Ensuring patient safety (national systems) • Approval of pharmaceutical and medical devices • Registration and licensing • Training of professionals • Training in methods to ensure quality of care • Health technology assessment

2.2.3. Meso Level The International Organization for Standardization (ISO): − The ISO model provides standards against which organizations may be certificated by accredited auditors -European Foundation for Quality Management (EQFM): − The EFQM provides a framework for self-assessment used by facilities applying for external review to achieve European or national awards • Accreditation: − Procedures that seek to obtain public and peer recognition of the quality of an organization • European Practice Assessment Practice Management: − The EPA-PM framework offers a means of assessing how well general practices are organized and managed and is designed to facilitate international comparisons

2.2.4. Micro Level Clinical guidelines • Quality indicators • Peer review • Surveys of health care users and the public

3. Patient safety

3.1. Definitions

3.1.1. According to Conklin (2008): • Patient safety is the freedom for a patient from unnecessary harm or potential harm associated with health care that can lead to or increase risk

3.1.2. Two groups of definitions Definitions that define safety as freedom from harm resulting from protection measures − accidents as caused by breaking the protection measures (example: Conklin, 2008) Definitions that treat safety as a dynamic property of the health care system that emerges from the interaction of several elements − incidents as resulting from the ineffective interactions between the actors (example: Emanuel, 2008)

3.2. Analyse incidents

3.2.1. Root cause analysis (RCA) • The analysis of what went wrong when an adverse event has occurred (retrospective)

3.2.2. Failure modes and effects analysis (FMEA) •An engineering approach, that seeks to imaginatively identify potential failures and their effects (prospective)

3.2.3. Human factors engineering (HFE) •HFE is a framework for efficient and constructive thinking which includes methods and tools to help healthcare teams perform patient safety analyses, such as root cause analyses. • HFE is a discipline concerned with the designs of tools, machines, and systems that take into account human capabilities, limitations, and characteristics.

3.3. Managing patient safety

3.3.1. Macchi (2011) defines four concepts • Safety definition: the desired result of safety management • Safety management system: collection of systematic organizational processes that are needed in order to steer the organization to ensure and develop safety. • Safety management model: background assumptions made in an organization to manage and improve safety • Safety model: the description of the way in which an organization functions and accidents happen

3.3.2. Two types of safety models: • Linear safety models − In linear thinking accidents are explained as: A causes B that causes C, or as A+B causes C − Not useful for complex systems • Non linear safety models − Non-linear thinking recognizes that changes in one part of the system can have disproportional consequences in other parts of the system − Non-linear models are suited for complex organizations

3.3.3. Conclusion •An organization should explicitly define patient safety, safety model, and patient safety management model. • Patient safety definition, safety model, patient safety management model, and patient safety management system should be coherent with each other.

3.3.4. 2 approaches for analyzing incidents/risks: (Reason ,2000) The persons approach − This approach focuses on the unsafe acts (errors and procedural violations) of care professionals − It views these unsafe acts as arising from mental processes such as forgetfulness, inattention, poor motivation, carelessness, etc. • The system approach − The basic premise in the system approach is that humans are fallible and errors are to be expected − Errors are seen as consequences rather than causes, having their origins in systemic factors such as errors traps in the workplace and the organizational processes that give rise to them

3.3.5. Reporting systems play an important role in managing patient safety •Main purpose − The primary purpose of patient safety reporting systems is to learn from experience •Main function − The most important function of reporting system is to use the results of data analysis and investigation to formulate and disseminate recommendations for systems change. 2 Types of Reporting Systems • Learning systems • Accountability systems Important aspects of reporting systems: Clear objectives • Clarity about who should report and what gets reported • Reporting is safe for the individuals who report • Expertise and adequate financial resources are available to allow meaningful analysis of reports • The system must be capable of disseminating information on hazards and recommendations for changes • Mechanisms for receiving reports and managing data • Technical infrastructure and data security

4. Many Definitions

4.1. “Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM, 1990)

4.2. Donebedian: “Quality of care is the kind of care which is expected to maximise an inclusive measure of patient welfare, after one has taken account of the balance of expected gains and losses that attend the process of care in all its parts” (Donabedian, 1980)

5. Domains of quality of care:

5.1. efficiency

5.2. effectiveness

5.3. access

5.4. equity

5.5. safety

5.6. Additional domains are: appropriateness, timeliness, acceptability, patient-centredness, satisfaction, continuity of care, relevance, efficacy and assessment

5.7. patient-centeredness

5.7.1. is considered an essential domain of quality of care According to Berwick (2009) patient-centered care is: • The experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care.

6. Personalization of care

6.1. What is it about?

6.1.1. Personalization involves intense communication and interaction between customer and supplier • Personalization in general is about selecting or filtering information objects for an individual by using information about that individual and then negotiating the selection with the individual. • This leads to strategies that are directed at what is called “a market of one”.

6.2. Health care applications of personalization

6.2.1. • individualized care and shared decision making • personalized medicine • greater focus on patient characteristics, needs, and preferences in decision making about their care

6.3. Shared decision making

6.3.1. Definition Elwyn (2012) defines shared decision making as: “…an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences.

6.3.2. Important aspects of SDM: • accepting that individual self-determination is a desirable goal • clinicians support patients to achieve individual self-determination wherever feasible • recognizing the need to support autonomy by building good relationships, respecting both individual competence and interdependence on others

6.3.3. Three-step model for clinical practice: Choice talk − the step of making sure that patients know that reasonable options are available • Option talk − Providing more detailed information about options • Decision talk − Supporting the work of considering preferences and deciding what is best.

6.4. Patient involvement in quality improvement

6.4.1. Developments in patient involvement There are several social changes that attributed to an increase in patient involvement in health care: • Decline in medical and provider dominance • Shift in expertise of patients (lay experts) • The politicization of various groups and their own efforts to reestablish and legitimize their medical traditions as part of disenfranchised cultures (such as aboriginals, native Americans) • The growth in “alternative” or complementary medicine •The arrival of the internet

6.4.2. Why involve patients in quality improvement? Increasing public awareness and disquiet about the incidence of medical errors • A series of high profile cases of negligence, incompetence, and/or medical homicide began to appear in the press • Rising levels of complaints and litigation faced by health services, both public and private. Patient and their families can no longer be treated as passive recipients of care!

6.4.3. Levels for involving patients in CQI • Micro level (direct clinician-patient interactions) − Direct involvement in the decision making and management plans associated with individual treatment • Meso level (health services or system level) − Engagement in the planning, management, and evaluation of entire health systems or individual services (members of the public, patients, caregivers or family members, representatives of consumer organisations, members and representatives of population groups or communities) • Macro level (national or international) − Involvement in patient safety activities at a national or international level

6.4.4. Factors affecting patient willingness and ability to participate in quality improvement sense of self-efficacy • acceptance of a new more active role as patients • perceived preventability of incidents • perceived effectiveness of their actions. • health literacy • complexity of the patient’s condition • perceived lack of confidence or skills • socioeconomic issues (such as social status, ethnicity) • anxiety due to power differentials • health care setting and the actual task involved. • organizational issues and personal beliefs of care providers Solecito and Johnson (2013)

6.4.5. Measuring patient satisfaction/experience Why measure it? • to improve quality of care • to provide information to the consumers (which they can use in their decision making about choosing providers) • to ensure more safety • to lower costs • for reasons of accountability (e.g. health care inspectorate) • to provide information to insurers for contracting • as information for potential partners in establishing alliances • external reporting and accreditation requirements • application of continuous quality improvement. How to measure consumer satisfaction? Qualitative modalities, such as: • management observation and documentation of the patient care process • employee feedback programs • work teams and quality circles (continuous employee input) • focus groups of consumers • mystery shoppers Quantitative modalities, such as: • comment cards (ratings) • mail surveys • point of service interviews (questionnaires or interviews directly following service delivery) • telephone interviews Critical considerations regarding data collection:

7. Innovations to improve quality of chronic care

7.1. Impact of chronic disease

7.1.1. • individual patients • health care systems • society

7.1.2. Impact on Individual patients • to alter their behaviour and engage in activities that promote physical and psychological well-being • to interact with healthcare providers • to adhere to treatment regimens • to monitor their health status and make associated care decisions • to manage the impact of illness on physical, psychological and social functioning Nolte (2008)

7.1.3. Impact on health care systems and society •Increase of health care utilization • Increase of complexity in health care • High costs, economic burden

7.2. Why is there a need to improve the care for chronic illness?

7.2.1. • Morbidity and mortality from chronic conditions is enormous, yet is largely preventable

7.2.2. • Quality of care is poor and wide array of deficiencies exists, including insufficient coordination, poor follow-up, a lack of evidence-based practice, etc.

7.2.3. • Costs associated with treatment of chronic diseases strain health care budgets;

7.2.4. • Rising prevalence of chronic conditions creates disbalance between demand for and supply of health care

7.3. Chronic care management

7.3.1. •Chronic care management has many forms, yet programmes and strategies share a similar underlying logic: that improving the quality of care will result in improved outcomes and, ultimately, lower costs • Disease management and the Chronic Care Model (CCM) are the most well-known forms of chronic care management worldwide • Disease management programs are add-ons to existing healthcare systems, where the CCM redesigns these systems                                                                • Disease management programmes aim primarily at patients, where the CCM aims at intensifying the interactions between patients and the care team, and linking health care with community • Whereas the proof for effectiveness of disease management is limited and inconclusive, the CCM is more strongly rooted in scientific evidence Disease management ‘A system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant’ (DMAA, 2003)

7.3.2. The Chronic Care Model (Wagner, 2001) The Chronic Care Model (CCM) identifies the essential elements of a health care system that encourage high-quality chronic disease care. • Bottom-up model: achieve improved outcomes by creating productive interactions between patients and practice teams, which are fostered by evidence-based changes under each of the care components.

7.3.3. Triple Aim According to Berwick (2008) high-value health care cannot be achieved unless improvement initiatives pursue a broader system of linked goals, called the Triple Aim. Components of Triple Aim (Berwick, 2008) 1. improving the individual experience of care 2. improving the health of populations 3. reducing the per capita costs of care for populations The three components influence each other

7.3.4. Characteristics of high-performing chronic care systems Ham (2010) describes 10 characteristics of high performing chronic care systems: 1. Ensuring universal coverage 2. Provision of care that is free at the point of use 3. The delivery system should focus on the prevention of ill health 4. Priority is given to patients to self-manage their conditions with support from carers and family 5. Priority is given to primary health care 6. Population management is emphasized 7. Care should be integrated to enable primary health care teams to access specialist advice and support when needed 8. The need to exploit the potential benefits of information technology in improving chronic care 9. Care is effectively coordinated 10. Link these nine characteristics into a coherent whole as part of a strategic approach to change