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Clinical Quality. איכות קלינית בעולם ובהדסה. פרופ' מאיר ברזיס המרכז לאיכות ובטיחות קלינית הדסה והאוניברסיטה העברית ירושלים www.hadassah.org.il/departments/quality. Definitions of Quality (Institute of Medicine)

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slide1

Clinical Quality

איכות קלינית

בעולם ובהדסה

פרופ' מאיר ברזיס

המרכז לאיכות ובטיחות קלינית

הדסה והאוניברסיטה העברית

ירושלים

www.hadassah.org.il/departments/quality

slide2

Definitions of Quality (Institute of Medicine)

Degree to which care increases likelihood of desired health outcomes & consistent with current professional knowledge

SafeTimelyEffective Patient centered

Equitable

Efficient

Overuse (antibiotics, imaging)

Underuse (prevention)

Misuse (errors & complications)

  • Evidence-based
  • Patient-centered
  • System-minded
performance evaluation

Performance Evaluation

Voluntary Quality Indicators

Mandatory Performance Evaluation

Public Data Including Individual Surgeon

Pay for Performance

Non-payment for Preventable Complications

Challenges: measurement error, socioeconomic confounders, manipulation, denial, gaming

stages of facing reality

Ego bias: “I’m above the average”

(Kahneman & Tversky. Heuristics and Biases. The Psychology of Intuitive Judgment)

Stages of Facing Reality*

Stage 1. “The data are wrong”

Stage 2. “The data are right, but it’s not a problem”

Stage 3. “The data are right; it is a problem; but it is not my problem.”

Stage 4. “I accept the burden of improvement”

* Harvard Professor Don Berwick, Institute for Health Improvement

slide5

Donald M. Berwick, MD, MPP, FRCP

Professor at Harvard School of Public Health

President, Institute for Health Improvement, Boston, Massachusetts, USA

“In short, academic medical centers should not just have best knowledge, they should model the best execution…They do not.

Unreliability, waiting, lack of focus on patient’s needs and safety are every bit of characteristic of academic medical centers…and that needs not be the case.

The same intellectual fervor and talent that allow places like the Brigham to raise the bar in technical clinical care can equally be used to raise the bar in the quality of medical care.

…it’s going to take much more acute self-awareness among academicians and academic medical centers….

…a duty to encourage healthcare leaders and clinicians everywhere to become involved in improvement."

slide6

Cycles of Improvement (Industry Model)

Statistical Process Control

PDSA

Example: monitoring of surgical infection rate is now recognized as important tool to prevention

slide8

Quality of General Intensive Care

Survival at Hadassah vs. Israel Average

Prof. ElishevaSimchen, Ministry of Health

p<0.001

Despite higher severity score, patients had better survival at Hadassah

slide9

Quality of Neonatal Intensive Care

Survival at Hadassah vs. Israel Average

Dr. Zivanit Ergaz, Prof. Ilan Arad & Gertner Institute

slide10

Quality of Treatment in Trauma

Mortality at Hadassah vs. US level I centers

Dr. Yoav Mintz, Ms. Irina Gertcenchtein& Prof. Avraham Rivkind

US National Trauma Data Bank from 51 level-I trauma centers, n= 263,524

Hadassah data Israeli National Trauma Registry n=7,391

slide12

Percent of patients receiving adequate anticoagulation

p<0.001

p<0.001

p<0.001

p<0.02

%

Surgery A

Surgery B

Surgery C

Gynecology A

Gynecology B

slide13

Catheter-related Bloodstream Infections

Intervention in 108 ICU’s resulted in 66% reduction in rates of catheter-related bloodstream infection

slide14

Catheter-related Bloodstream Infections

I. Gross, S. Benenson, M. Cohen, C. Bloch

  • At Hadassah, baseline observations over five months revealed a rate of infection of 13.2% (42/318 catheters), on the high side of reported ranges.
  • Observations in ICU’s and OR: aseptic conditions not always strictly kept during catheter insertion.
  • Intervention included discussion of results with staff, training for correct aseptic technique, use of a checklist, and authorization to nurses to feedback and stop physicians breaching asepsis.
slide15

Catheter-related Bloodstream Infections

Following intervention, improvement in technique was observed; rate of infection declined by 62%, from 13.2% to 5.0% (17/337 catheters, p<0.001).

Proportion of catheters remaining without infection

(Cox regression)

After the intervention

p<0.001

Before the intervention

Days of catheter

slide16

Catheter-related Bloodstream Infections

* Rate of infection per 1000 catheter-days

** p<0.001

slide17

Catheter-related Bloodstream Infections

Pronovost P. et al. An intervention to decrease catheter-related bloodstream infections in the ICU.

N Engl J Med 2006;355:2725

physicians hand hygiene at hadassah
Physicians’ Hand Hygiene at Hadassah

Summary of surveys in recent years

Rate of hand-washing out of contacts with patients

Use of Hadassolhas been widely adopted but rate of hand hygiene unchanged

slide19

Surgical Infections in General Surgery

N. Minster, M. Zarhia, G. Almogy, A. Rivkind, S. Benenson, M. Cohen

  • Rate of post-operative wound infection is 8-12%, within the range reported in the literature.
  • Pre-operative antibiotic administration is documented as given on time in 59% of cases.
  • A significant proportion of infections are diagnosed after discharge from the hospital.
  • Infection monitoring is recognized as an important tool to keep rates low.
complications

Quality of Inguinal Hernia Repair in Adults and in Children at Hadassah

Complications

T. Yemini, M. Badriah, Y. Mintz, R. Udassin, A. Rivkind

Satisfactionhigh to very high in 94% of adults and children; problems: waiting & relation with staff

*Range in literature varies by motive (voluntary or mandatory)

slide21

Quality of Special Surgeries

Outcomes of special surgery in the Departments of Ear, Nose & Throat (ENT), Ophthalmology, Plastic and Neurosurgery

slide22

Management of Snoring Disorders with Radiofrequency at Hadassah Optimal

L. Gordon,S. Catinari, R. Eliashar

p<0.005

p<0.01

p≤0.05

%

slide23

Lasik (Myopic Corneal Refractive Surgery) at Hadassah Optimal (N=109)

N. Orwa, A. Solomon, Y. Frucht-Peri

%

slide25

0

20

40

60

80

Severe

moderate

high

Quality of Reconstruction Surgery After Mastectomy

R. Yanko-Arzi, M. J. Cohen, R. Braunstein, E. Kaliner, R. Neuman Dept of Plastic Surgery & Center for Clinical Quality & Safety

%

A survey of 140 women after reconstructive breast surgery for cancer showed satisfaction related mostly to expectations before surgery.

Complications

Success

Satisfaction

Would

Recommend

Hadassah

slide26

Neurosurgical shunt infections

I. Paldor, Z. Israel, C. Block with the dept of Neurosurgery

Intervention

Mortality in infected cases dropped from 50% to 0%

is the x ray interpretation by the junior staff on duty correct
Is the X-ray interpretation by the junior staff on duty correct?

Dr. Y. Mintz, Dr. D. Kisselgoff, Y. Gronowitz, A. Shaham, R. Hefez, Dr. D. Shaham - Departments of Surgery, Radiology, and Center for Clinical Quality & Safety

slide28

Effect of Translators on Understanding & Satisfaction of Arab Parents

Department of Pediatrics & ER, Mt Scopus & Center for Clinical Quality & Safety, Hadassah Hebrew University Medical Center

slide29

p<0.001, n=194

The Presence of a Translator Significantly Improved Parental Understanding Regarding Diagnosis, Treatment and Follow-up
slide30

Will patient’s empowerment improve efficacy & safety of oral anticoagulation?

Self-management for Coumadin

H. Goldberg, Y.Ben David, U. Izhar, L. Gordon, T. Baevsky, M.Burzstyn & M.Brezis with the Departments of Cardiothoracic Surgery and Medicine

slide31

Patient’s empowerment improves efficacy & safety of oral anticoagulation

60%

% of tests within target INR

* p<0.001

38%

Control

Intervention

Patient’s knowledge & satisfaction significantly improved

communicating with families satisfaction with end of life decisions
Communicating with Families & Satisfaction with End-of-Life Decisions

Departments of Medicine & Center for Clinical Quality & Safety

*p<0.005 in favor of the intervention group

Communication with families of patients near end of life improves perceived quality of care

slide34

Conclusion

Projects help make healthcare at Hadassah more evidence-based, patient-centered & system-minded.

Over 100 projects presented at National Meetings of Israeli Society for Quality in Healthcare; over 48 theses and 19 peer-reviewed publications.

Center for Clinical Quality & Safety