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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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
1) The 1990s – Evidence based medicine
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
Balas EA, Boren SA. Managing clinical knowledge for health care improvement. Yrbk of Med Informatics 2000; 65-70
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.
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
2) The 2000s – ADD Evidence based delivery
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.”
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
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
Shift and narrow the curve:
What is the norm?
Cut the tail:
What is unacceptable?
Extend the ambition:
What is great? (What is possible?)
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
The steps must all be completed to succeed
The “all or none” feature is the source of the bundle’s power
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
To make NHS Scotland a world leader in healthcare quality improvement.
To do so in a way that is meaningful to all.