Japan Council for Quality Health Care Clinical Outcome Improvement and Strategic Organizational Management July 8, 2014 Yuichi Imanaka, MD PhD Executive Board Member, Japan Council for Quality Health Care Professor, Kyoto University Graduate School of Medicine Dept. Healthcare Economics and Quality Management 1 Japan Council for Quality Health Care Overview Improvement of clinical outcomes is dependent on the efforts of clinical staff at each site. However, this is not limited to the efforts of individual medical personnel, as it is vitally important to build a foundation for healthcare through “overall hospital management.” This requires management will and efforts. Here, I present and discuss an organization review checklist (Preliminary Ver. 1.1) aimed at strengthening management ability. 2 Japan Council for Quality Health Care Acute Heart Failure Outcomes Crude and Expected In-Hospital Mortality Rates 40 ・ Expected Mortality Rate (95% CI) 35 Mortality rate (%) Crude Mortality Rate 30 25 20 15 10 5 0 Hospitals Sasaki N, ImanakaY, et al. Can J Cardiol 2013;29:1055-61 3 Japan Council for Quality Health Care Predictors of In-hospital Mortality Adjusted odds ratio (95% CI) Female Age (reference: 20-59 y) Model with NYHA functional classification 0.96 (0.80-1.15) Model without NYHA functional classification 0.96 (0.80-1.15) 60-69 1.32 (0.72-2.41) 1.32 (0.71-2.44) 70-79 2.21 (1.29-3.79)** 2.24 (1.30-3.86)** 80-89 ≥90 4.10 (2.44-6.87)*** 7.53 (4.42-12.82)*** 4.15 (2.46-6.99)*** 7.47 (4.36-12.79)*** Emergency (with ambulance use) 1.39 (1.06-1.84)* 1.09 (0.82-1.45) Emergency (without ambulance use) 1.11 (0.85-1.44) 1.00 (0.76-1.31) Admission route (reference: scheduled admission) NYHA functional class at admission (reference: Class II) III IV – – 2.28 (1.66-3.12)*** 5.67 (4.20-7.65)*** Severe respiratory failure due to AHF 3.09 (2.40-3.98)*** 2.49 (1.91-3.24)*** Ischemic heart disease 0.58 (0.47-0.71)*** 0.57 (0.47-0.70)*** Hypotension (incl. hypertensive heart disease) 0.28 (0.23-0.34)*** 0.29 (0.24-0.36)*** Atrial fibrillation 0.61 (0.49-0.76)*** 0.64 (0.52-0.79)*** Life-threatening arrhythmia 2.04 (1.34-3.10)** 1.93 (1.26-2.95)** Chronic renal failure (mild to moderate) Shock (incl. cardiogenic shock) Hosmer-Lemeshow test C-statistic (95% CI) 1.59 (1.25-2.01)*** 3.36 (2.08-5.40)*** P=0.44 0.76 (0.74-0.78) 1.53 (1.20-1.95)** 2.86 (1.71-4.76)*** P=0.88 0.80 (0.78-0.82) NYHA：New York Heart Association ***P<0.001; **P<0.01; *P<0.05. Sasaki, Imanaak et al. Can J Cardiol 2013;29:1055-61 Variables 4 Japan Council for Quality Health Care This excellent risk-adjustment method has drawn attention, even in North America Japan Council for Quality Health Care Identification of hospital strategic factors for improving AMI treatment outcomes: Research Example (1/2) Bradley EH et al. Hospital Strategies for Reducing Risk-Standardized Mortality Rates in Acute Myocardial Infarction. Ann Intern Med 2012 156:618-626 【 Objective 】 To identify factors associated with low risk-standardized mortality rates (RSMRs) in acute myocardial infarction (AMI) patients 【 Methods 】 Using AMI 30-day RSMRs calculated from CMS hospital management data (2005–2008), a web-based survey was conducted on 537 acute care hospitals between 2008 and 2009 (response rate: 91%). A multivariate regression analysis was then performed to determine the associations between survey items and mortality rates. 6 Japan Council for Quality Health Care Identification of hospital strategic factors for improving AMI treatment outcomes: Research Example (2/2) 【 Results 】 <5 factors identified> Monthly meetings with emergency physicians to review AMI cases Specialists always stationed on-site 24 hours a day Organizational culture that encourages clinicians to take initiative in problem solving for care processes Nurses do not hold concurrent posts in ICUs and the cardiac catheterization laboratory Appointing both clinicians and nurses as leaders responsible for improving mortality rates 【 Conclusions 】 Several hospital factors were associated with lower RSMRs in AMI patients, but these factors are not currently implemented in most hospitals Ann Intern Med 2012 156:618-626 7 Japan Council for Quality Health Care 【Quality Sustainability Project】 By MO Medical Outcomes FO Financial Outcomes SP System and Process Management HR Human Resource and Organizational Development and Management EP Environment and Management Planning MV Mission, Vision and Values HA History and Achievements JCQHC Japan Council for Quality Health Care Strategic Organizational Management for Clinical Outcome Improvement Checklist Ver. 1.1 9 Japan Council for Quality Health Care 1. Outcomes Improvement Team 1.1. Development of a team whose mission is to improve outcomes and is centered around a physician leader. 1.2. Development of a multidisciplinary team with proactive participation by a physician in charge, nurse leader, allied health personnel, emergency services personnel, and administrative personnel (eg, medical information office and policy planning office staff). 1.3. Hospital executive management provides support and grants the necessary authority and responsibilities to the team. 10 Japan Council for Quality Health Care 2. Commitment of Hospital Executive Management 2.1. Hospital executive management is also involved with the outcomes improvement team, providing support through the transfer and distribution of in-hospital resources, budget allocation, and the fundamental direction and policies of the hospital. 2.2. Improvement of outcomes in a certain disease should be implemented by the entire hospital. 11 Japan Council for Quality Health Care Example of Improvement to Mortality Rate in AMI Patients AMI Mortality Rate (Excl. patients who died within 24 h of admission) 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 2001 2002 2003 2004 2005 2006 Year Expected Value (Lower Limit) Expected Value (Upper Limit) Observed Value Quality Indicator/Improvement Project http://med-econ.umin.ac.jp/QIP/ 12 Japan Council for Quality Health Care 3. Visualization and Follow-up of Outcomes 3.1. Periodic measurement of indicators (Weekly, monthly, quarterly, biannually, etc.). 3.2. Results are shared within the team (Department heads, staff physicians, nurses, allied health & administrative personnel). 3.3. Results are made accessible to various people within the hospital (Hospital director, assistant director, all department heads/ all clinical staff/ all managerial staff). 13 Japan Council for Quality Health Care “You can't manage what you can't measure” – Drucker PF • In order to improve performance, that performance (quality, cost, etc.) must be measured and visualized. Japan Council for Quality Health Care System Management System: a set of interacting components that function collectively as a whole Healthcare is a system A system requires a comprehensive approach Japan Council for Quality Health Care 4. Comprehensive Review of In-hospital Mortality Cases for Specific Diseases 4.1. Comprehensive review by a multidisciplinary team (incl. administrative personnel) (Root cause analysis framework can serve as a reference). 4.2. Review conducted on the clinical decisions and technical aspects of treatment. 4.3. Review of the overall treatment process (incl. observation of factors that occurred outside the hospital prior to hospitalization and their linkage with all processes). 16 Japan Council for Quality Health Care Framework for the Comprehensive Search for Performance Factors External Environment Factors ・Economic conditions, health policy, and political context ・Medical needs and healthcare provision systems of medical service areas Organization and Management Factors ・Revenue sources and organizational structure ・Policy standards and objectives ・Safety culture and priorities Work Environment Factors ・Staffing practices that take into account work level and skill; workload ・Effectiveness and maintenance of facilities ・Support from the business management department Medical Team Factors ・Communication, guidance, and support ・Team structure and leadership Individual Staff Factors ・Knowledge, skills, and qualifications ・Motivation and attitude ・Mental and physical health Task Factors ・Task design and structural transparency ・Effectiveness and use of protocols ・Effectiveness and adequacy of test results Patient Factors ・Disease condition (complexity and severity) ・Language, communication, and socioeconomic status 17 Japan Council for Quality Health Care 5. Utilization of Clinical Pathways for Target Diseases 5.1. Multidisciplinary participation under physician leadership in the development of a clinical pathway for a target disease. 5.2. Full utilization of the clinical pathway for the target disease. 5.3. Full utilization of the patient-version clinical pathway. 18 Japan Council for Quality Health Care 6. Strengthening Staff Organization and Cooperative Systems 6.1. Clarification and improvement of the skill levels based on the work (role, allotted responsibilities/coordination) of each staff member. 6.2. Review and improve staff organization and doctor-on-duty systems. 6.3. Systematically developing and securing the necessary human resources. 19 Japan Council for Quality Health Care Ｏｕｔｃｏｍｅ Ｐｒｏｃｅｓｓ Ｓｔｒｕｃｔｕｒｅ 20 Japan Council for Quality Health Care Volume Outcome Relationship - Two Aspects Outcomes and Case Volume Example: Surgical procedures that require specialist expertise Outcomes and Physician Volume Example: Medical emergencies that require the availability of a medical team on continuous standby 21 Japan Council for Quality Health Care Factors Associated with AMI Outcomes • After adjusting for patient and hospital variables: 30-day in-hospital mortality Hospital level factors OR P value Number of AMI cases 1.000 0.559 Number of cardiologists 0.956 0.038 In-hospital mortality OR P value 1.000 0.876 0.953 0.049 There was no association between case volume and mortality rate Higher numbers of specialists were associated with reduced mortality Park S, Imanaka Y et al. Int J Cardiol 2013;168:4470-1 Japan Council for Quality Health Care Adjusted Odds Ratios of Prescribing Discharge Medications in AHF 1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 - ACEI or ARBs - *p<0.001 0* 1-4 (ref) 5-9* ≥10* n=955 n=15,867 n=15,337 n=6,509 Number of cardiologists per hospital Kyoto University Graduate School of Medicine Department of Healthcare Economics and Quality Management Japan Council for Quality Health Care Adjusted in-hospital mortality - Risk-Adjusted Mortality in AHF (%) 12 *p<0.001 10.7 10 8 7.1 7.0 5.4 6 4 2 0 0* n=955 1-4 (ref) 5-9 ≥10* n=15,867 n=15,337 n=6,509 Number of cardiologists per hospital Kyoto University Graduate School of Medicine Department of Healthcare Economics and Quality Management Japan Council for Quality Health Care 7. Improvements to the Environment for Growth Promotion 7.1. Improvements to the environment that allow the professional growth of staff. 7.2. Strengthening of the training systems for current staff and junior physicians, as well as training systems for nurses and allied health personnel. 7.3. Facilitating the proactive presentation of work at conferences. 7.4. Strengthening student education and training. 25 Japan Council for Quality Health Care Hospital reputation from patients’ perspective Organizational Climate and Patient Satisfaction Staff satisfaction regarding professional growth http://med-econ.umin.ac.jp/PSOC/ http://www.iryo-keiei.org/psoc/ 26 Japan Council for Quality Health Care 8. Building Relationships with Surroundings 8.1. Strengthening relationships with other clinics and hospitals; Conducting collaborative seminars and training workshops. 8.2. Strengthening relationships with regional emergency services systems and personnel. Contributing to the training of emergency life-saving technicians. 8.3. Proactively conducting lectures and educational activities for patients and the general public. 27 Japan Council for Quality Health Care 9. Establishment of Organizational Climate by Leaders Organizational Culture: A powerful force that determines the (often unconscious) behavior and the thought patterns of people within an organization 9.1. Stimulating continuous professional growth. 9.2. Promotion of interdepartmental and interdisciplinary cooperation and collaboration by the hospital. 9.3. Improvements and innovative changes to procedures and systems for the benefit of patients. 9.4. Establishment of behavioral habits of assured goal achievement for the benefit of patients. 28 Japan Council for Quality Health Care Basic Management Cycle Act Countermeasure Plan Plan Formulation (S) (Standardization) Plan/System Revision Check Data Collection Analysis & Evaluation Do Plan Implementation Organizational Culture 29 Japan Council for Quality Health Care Organizational Culture Study Inter-hospital Comparison 2006 2007 Hospital B Overall Mean A.Teamwork Hospital E 80 60 100 B .Information Sharing C. Morale & Motivation 20 F. Resources D .Professional Growth E. Organizational Values http://med-econ.umin.ac.jp/PSOC/ http://www.iryo-keiei.org/psoc/ H. Improvement System 80 60 B. Information Sharing 40 40 G. Responsibilities & Authority Overall Mean A. Teamwork 100 H. Improvement System 2006 2007 G. Responsibilities & Authority C. Morale & Motivation 20 F. Resources D. Professional Growth E. Organizational Values 30 Japan Council for Quality Health Care Organizational Culture Study Comparison of Hospital/Occupational Positions 80 Organizational culture mean score categorized by 3 levels of occupational positions Executive Management Non-managerial Middle Management Mean Middle Management Executive Management Mean Non-managerial Mean 70 60 50 Hospital AA Hospital http://med-econ.umin.ac.jp/PSOC/ http://www.iryo-keiei.org/psoc/ Hospital B Hospital C Hospital D Hospital E Hospital D Hospital E F Hospital F B Hospital Hospital C Hospital 31 Japan Council for Quality Health Care Results of a Post-implementation Analysis of Improvement Strategies 2006 2007 Overall Hospitals [1] Ensuring Safety Overall Mean 70 Overall Hospitalization 60 1.05 50 40 [5] Safety Culture 2006 2007 Hospital Mean in May 2007 [2] Job Satisfaction 30 Hospital Living Environment 1 Inclination to reuse 0.95 0.9 20 0.85 Nurses Administrative Personnel [4] Harassment [3] Workload Burden Allied Health Personnel Organizational Culture First Year Patient Satisfaction Hospital director increases medical office meetings and individual physician interviews Implementation of morning greetings by NS is expanded to all disciplines Increase in CS Committee and improvement activities http://med-econ.umin.ac.jp/PSOC/ http://www.iryo-keiei.org/psoc/ Physicians Subsequent Year 32 Japan Council for Quality Health Care Data Utilization and Organizational Culture Activities to improve healthcare quality Medical safety management and accident prevention, infection control Service improvement activities Data utilization Examples: quality indicators, incidents, cost/revenue and management indicators Capability for organizational changes in response to environmental changes Efforts toward healthcare for patients and the region It is important to establish an organization that can learn/grow and is able to change 33 Japan Council for Quality Health Care Healthcare Quality Indicator Portal Site http://quality-indicator.net/ Introduction of the QI projects and indicators of the various groups in Japan; Contains shared & detailed definitions for QI 34 Japan Council for Quality Health Care Summary 10. Comprehensive Approach by the Entire Hospital 1. Outcomes Improvement Team 2. Commitment of Hospital Executive Management 3. Visualization and Follow-up of Outcomes 4. Comprehensive Investigation of In-hospital Mortality Cases for Specific Diseases 5. Utilization of Clinical Pathways for Target Diseases 6. Strengthening Staff Organization and Cooperative Systems 7. Improvements to the Environment for Growth Promotion 8. Building Relationships with Surroundings 9. Establishment of Organizational Climate by Leaders 35 Japan Council for Quality Health Care With cooperation from： http://med-econ.umin.ac.jp/QIP/ Thank you very much. 36
© Copyright 2024 ExpyDoc
