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)
פרופ' מאיר ברזיס
המרכז לאיכות ובטיחות קלינית
הדסה והאוניברסיטה העברית
Degree to which care increases likelihood of desired health outcomes & consistent with current professional knowledge
SafeTimelyEffective Patient centered
Overuse (antibiotics, imaging)
Misuse (errors & complications)
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
(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
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."
Statistical Process Control
Example: monitoring of surgical infection rate is now recognized as important tool to prevention
Survival at Hadassah vs. Israel Average
Prof. ElishevaSimchen, Ministry of Health
Despite higher severity score, patients had better survival at Hadassah
Survival at Hadassah vs. Israel Average
Dr. Zivanit Ergaz, Prof. Ilan Arad & Gertner Institute
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
Referral to cardiac rehabilitation only 21%
Intervention in 108 ICU’s resulted in 66% reduction in rates of catheter-related bloodstream infection
I. Gross, S. Benenson, M. Cohen, C. Bloch
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
After the intervention
Before the intervention
Days of catheter
* Rate of infection per 1000 catheter-days
Pronovost P. et al. An intervention to decrease catheter-related bloodstream infections in the ICU.
N Engl J Med 2006;355:2725
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
N. Minster, M. Zarhia, G. Almogy, A. Rivkind, S. Benenson, M. Cohen
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)
Outcomes of special surgery in the Departments of Ear, Nose & Throat (ENT), Ophthalmology, Plastic and Neurosurgery
Management of Snoring Disorders with Radiofrequency at Hadassah Optimal
L. Gordon,S. Catinari, R. Eliashar
Lasik (Myopic Corneal Refractive Surgery) at Hadassah Optimal (N=109)
N. Orwa, A. Solomon, Y. Frucht-Peri
O. Frenkel, R. Eliashar
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.
I. Paldor, Z. Israel, C. Block with the dept of Neurosurgery
Mortality in infected cases dropped from 50% to 0%
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
Department of Pediatrics & ER, Mt Scopus & Center for Clinical Quality & Safety, Hadassah Hebrew University Medical Center
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
Patient’s empowerment improves efficacy & safety of oral anticoagulation
% of tests within target INR
Patient’s knowledge & satisfaction significantly improved
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
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