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Improvement methodology. “quality improvement”. The combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners, administrators, educators – to make changes that will lead to

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quality improvement

“quality improvement”

The combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners, administrators, educators – to make changes that will lead to

better patient outcome, better system performance, and better professional development.

Batalden P, Davidoff F. Qual. Saf. Health Care 2007;16;2-3

eras of quality
Eras of quality

1) The 1990s – Evidence based medicine

LOX-GNH145-20071113-BVJM

evidence sign
Evidence – SIGN

1++ High quality meta-analyses, systematic reviews of RCTs or RCTs with a very low risk of bias

1+ Well conducted meta-analyses, systematic reviews of RCTs or RCTs with a low risk of bias

1- Meta-analyses, systematic reviews or RCTs with a high risk of bias

2++ High quality systematic reviews of case control or cohort studies

2+ Well conducted case control or cohort studies

2- Case control or cohort studies with a high risk of confounding

3 Non-analytic studies – case reports, case series

4 Expert opinion

slide12
17 years to apply 14% of research knowledge to patient care!

Balas EA, Boren SA. Managing clinical knowledge for health care improvement. Yrbk of Med Informatics 2000; 65-70

slide14
Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trialsGordon C S Smith, Jill P Pell. BMJ 2003;327;1459-1461

Aim: To determine whether parachutes are effective in preventing major trauma related to gravitational challenge.

Design: Systematic review of randomised controlled trials

Results: Our search strategy did not find any randomised controlled trials of the parachute.

slide15
Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trialsGordon C S Smith, Jill P Pell. BMJ 2003;327;1459-1461

Conclusion:

As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials.

Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data.

We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute

eras of quality16
Eras of quality

2) The 2000s – ADD Evidence based delivery

LOX-GNH145-20071113-BVJM

slide17
“Society’s huge investment in technological

innovations that only modestly improve efficacy,

by consuming resources needed for improved delivery of

care, may cost more lives than it saves.”

“Health, economic, and moral arguments make the case

for spending less on technological advances and more

on improving systems for delivering care.”

fidelity vs efficacy

Fidelity vs Efficacy

$100 Million

$29 Billion

$32 Billion

0.002%

the aspirin example
The aspirin example

In patients who have had a stroke or TIA aspirin reduces risk by 23%

100,000 patients – 23,000 fewer strokes

58% of eligible patients receive aspirin = 13,340 fewer strokes

two options
Two options

Fidelity – increase to 100% of eligible patients = 9,660 strokes

Efficacy – requires a proportional improvement over aspirin of 74%

Clopidogrel = 10% more efficacy than aspirin

the quality curve
The “Quality Curve”

Shift and narrow the curve:

What is the norm?

2

3

1

Cut the tail:

What is unacceptable?

Extend the ambition:

What is great? (What is possible?)

what is a bundle
What is a Bundle?

It is a set of evidence based steps that experts believe are critical 

Having the steps joined provides a “forcing function.”

Evidence based medicine  Evidence based care delivery

bundle implementation
Bundle Implementation

The steps must all be completed to succeed

The “all or none” feature is the source of the bundle’s power

Pass/fail

ventilator bundle
Ventilator Bundle

Elevating the head of the patient’s bed

Daily "sedation vacations," or gradually lightening  the use of sedatives each day

Daily assessment of the patient’s readiness to extubate or wean from the ventilator

Chlorhexidine oral care

slide30
103 ICUs Working on Central Line Infections:
    • 82% Reduction in Mean Rate
    • 1,578 Lives Saved
    • 81,020 Hospital Days Saved
    • “Over $165million in costs averted”

30

proposed new quality aims
Proposed New Quality Aims

To make NHS Scotland a world leader in healthcare quality improvement.

To do so in a way that is meaningful to all.

slide34

“Expectations will always exceed capacity. The service must always be changing, growing and improving…”. Aneurin Bevan, 1948

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