Term Paper on "Quality Improvement"

Term Paper 7 pages (1786 words) Sources: 6 Style: APA

[EXCERPT] . . . .

Healthcare Quality Improvement Program

Proposed Quality Improvement Program

This memo covers the reasons for implementing a quality improvement program.

It then outlines three quality improvement programs which can serve as models for our institution. Finally, this memo recommends which elements of these quality improvement programs should be adopted in an eventual quality improvement program by our hospital.

Reasons for Adopting Quality Improvement in our Institution

Quality improvement in healthcare has always been a goal ever since medicine was first practiced. It has become a special focus in the United States in recent years in response to three major trends. This paper will deal with the increased incentives for quality improvement in healthcare, and discuss programs to improve quality. This paper will focus particularly on the nursing and allied professions.

The impetus for quality improvement has been driven in recent years by three main factors:

The amount of money that the U.S. spends on healthcare per capita and as a percent of GDP is far higher than any other country in the world. We spend 15% of GDP, with the next-highest countries, Germany and France, at 10% of GDP. This high level of spending has not brought higher life spans or quality of life years. Those who pay the bills are therefore asking if they are getting quality for the money that we are spending on our health care.

The healthcare institution is under competitive pressure in a way that was less obvious in previous decades. Alternative healthcare delivery means have been encroaching on the market share of "traditional" hospitals and clinics. HMO's have brought a capitated model with an emphasis on preventative care. Specialist hospitals have focused on high-profit procedures, such as heart catheterization and orthopedics, leaving traditional hospitals less-profitable procedures. These alternative institutions compete not on price, but quality of the outcomes and the patient experience. Traditional healthcare institutions must therefore adapt in order to compete.

States and the federal government are now implementing quality measurements into healthcare procedures. Some states, such as New York and Massachusetts, have published results. The trends in hospitals and by specialty are clear: quality is not only measured on an absolute basis, but compared across specialties and institutions. Those hospitals and clinics which fail to continuously improve their quality -- measured in patient outcomes -- will fall behind in their census and the ability to attract top healthcare staff.

The above trends make quality improvement particularly necessary in today's environment. Healthcare institutions have tried to incorporate quality improvement schemes from industry, but the success has been mixed at best. The most common attempt has been with procedures-based medicine, in which best practices are inculcated amongst staff, and specific procedures are to be followed. These measures have led to resistance from staff, as comparability between patients has been challenged.

Best Practices in 4 Hospitals

The Commonwealth Fund sponsored a study of the most improved hospitals in quality improvement (Silow-Carroll, 2007). In their general survey of hospital quality improvement, they found that there was generally a 'trigger,' which unfortunately was frequently a problem which led to deaths or significant publicity, and could include the replacement of the CEO with a new one who delivers a 'clean sweep.'

The trigger leads to changes in structure and a re-focus on quality improvement by the new decision-making structures in the organization. The most egregious problems are sorted out, and changes in practice worked out with healthcare staff.

As the practice changes are put in place, better patient outcomes result in identification of new problems, and new solutions. An example of this process (although not cited in the above report) is the Dana Farber Cancer Hospital in Boston. This teaching hospital had delivered the wrong dosage of chemotherapeutic drugs to a patient, which resulted in that patient's death, and a subsequent scandal which played out in the local press.

Dana Farber's new CEO put into place a quality improvement system which focused particularly on improving communication amongst the healthcare professionals, particularly between nurses and physicians. The resultant improvements in quality improved Dana Farber's morbidity and mortality statistics substantially (Dana Farber, 2005).

Tenet Healthcare

As with the above model in the Commonwealth Report, scandal provoked a change in management and an improvement in patient quality care at Tenet Healthcare, a for-profit healthcare system based in Santa Barbara, California. Tenet's facility in Redlands, California, was found to implement open-heart surgeries and cardiac catheterizations well out of proportion to patient need or community demographics -- as many as 17,000 angioplasties in a community of less than 100,000 people. The resultant scandal demonstrated that Tenet's focus on profitability had reduced its focus on quality.

Tenet put in place a quality improvement program in three steps: (1) replacing management, with a new CEO and top management team, (2) put in place a high-level MD with responsibility for system-wide quality improvement, and (3) began to evaluate its management and physician teams in each hospital and region by quality measures, in addition to previously-measured financial outcomes (Tenet, 2003).

On a broad basis, Tenet's quality improvement program focused on 4 initiatives:

Ensuring Patient Safety and Reporting Results

Supporting Physician Excellence

Improving the Practice, Resourcing and Leadership of Nursing

Facilitating Patient Flow and Care Delivery to Create Operational Efficiency (Tenet, 2003)

Cleveland Clinic Stroke Improvement Plan

Ischemic stroke affects over 700,000 Americans per year. Although the benefits of tPA (tissue plasminogen activator) have been demonstrated in a number of double-blinded clinical trials, the adoption of tPA for ischemic stroke treatment has been slow, resulting in the needless deaths of patients. Part of the reason for lack of adoption has been the concern that some patients may suffer from intracranial hemorrhage, and such an administration may worsen the state of the patient.

The Clinic put in place a program to increase use of tPA in order to improve patient outcomes (Katzan, 2003). It created a quality improvement program which set goals and monitored progress in stroke treatment and tPA administration. Most importantly, the CC created a "dashboard" which showed how all 9 hospitals in the Cleveland Clinic system were adhering to tPA administration guidelines, and comparing results to national and regional statistics.

The results of the Cleveland Clinic trial are stated in the Discussions section of the journal article:

Two years after the initial Cleveland audit, the rate of symptomatic ICH with intravenous tPA dropped from 13.4% to 6.4% in the 9 CCHS hospitals. During this same time period, the rate of 3 specified protocol deviations declined from 33% to 17.0%, and the intravenous tPA usage rate increased from 1.8% to 2.7% among all patients with ischemic stroke.

Treatment of CHF Patients

Patients with CHF (Congestive Heart Failure) tend to have poor compliance to medical prescriptions, which can cause more frequent visits to the CCIC unit in the hospital, and impact the morbidity and mortality in this set of patients.

One of the drugs which has been shown to improve the course of CHF are ACE inhibitors. A Canadian study (Weil, 2001) found that only 23% of CHF patients who were candidates for ACE treatment were actually given these treatments; in many cases, the ACE dosage prescribed was below the dosages indicated to be effective in clinical trials.

While the Canadian retrospective study encouraged better administration of CHF drugs like ACE inhibitors, some U.S. centers are doing something about it. The Primary Care Physicians Group in Pittsburgh put in place a patient quality program to improve compliance to medical prescriptions for CHF patients (Civitarese, 1999). The group put in place a program which included the following steps:

All patients with CHF were measured for their left ventricular function.

Those patients who corresponded to the target group benefiting from ACE inhibitor medication were prescribed the drug

Nurses and in-home professionals followed up with patients to insure compliance.

The results of the program are demonstrated below, measured as the number of patients admitted to the hospital with CHF with systolic dysfunction:

Recommendations for Our Institution

The above examples illustrate two key elements of a quality improvement program for our institution. The first is that quality improvement will be implemented at our institution for positive or negative reasons. As in the Tenet Healthcare and Dana Farber cases, major mistakes and lack of supervision resulted in a change of upper management and a renewed focus on quality of delivered healthcare.

The other two examples illustrate how specific, targeted programs have resulted in significant improvements in patient outcomes.

The four programs outlined have several elements in common:

An emphasis from upper management on the importance of quality improvement.

Relating quality improvement to specific procedures which have been demonstrated in clinical trials to bring improvements in patient care.

Measurement of patient compliance and results, including a focus on procedural implementation during the program.

Measurement and communication of the results.

Although Dana Farber and Tenet have put in place industry-leading quality improvement programs across the whole institution, it may make the most sense for our institution to take the incremental approach. The Cleveland Clinic's… READ MORE

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