Download Emergency Department Care

Reflections on Defining and
Measuring Quality of Emergency
Care in Denmark
Philip D. Anderson, MD
Assistant Professor, Harvard Medical School
Department of Emergency Medicine
Beth Israel Deaconess Medical Center
Boston, Massachusetts USA
Overview
• EM-specific quality and performance
measurement
• The Balanced Scorecard approach
• Categories and Examples of Indicators
2
Progress towards a new model of
emergency care delivery in Denmark
• Specific plans from all Regions describing implementation of
recommendations from Sundhedsstyrelsen
• Fagomraadsbeskrivelsen for akutmedicin by DMS – education
based on this has started
• Many FAME enheder established at regional hospitals
• Agreements with primary sector and psychiatry for cooperation with
FAME enheder
• New national model for klinisk basisuddannelse – all nye læger
spend some time in FAM
3
Defining and Measuring Quality:
A Significant Challenge Worldwide
• Multi-dimensional nature of Quality
– Safe, Effective, Patient-centered, Timely, Efficient, Equitable
– Meaningful understanding requires multiple measures
• Complexity of emergency care delivery
– Wide range of patients, providers, processes
• Outcomes alone inadequate measures of quality
– Variability due to many factors
– Isolating effect of EM care from subsequent care
– Difficult to interpret in terms of what to fix
– Infrequent occurrence of bad outcomes = low statistical power
4
International Experience with Defining and
Measuring EM Quality
• EM quality measurement literature
– current concepts, strategies
• EM quality measurement
strategies in 4 countries
– Canada, UK, Australia, USA
– Wide range of EM specific
indicators
– “no one has a perfect strategy”
• Existing emergency healthcare
data gathering in Denmark
– Klinisk Epidemiologisk Afd.
Aarhus Universitet
5
Why is there an urgent need for EM
specific quality measurement tools?
• Historic national quality improvement initiative
– General goals, model for emergency care is clearly defined
– Many details of how to implement not clearly defined
• Individualized regional, local hospital strategies
– Increase potential for variability in implementation
– Some variability unavoidable to accommodate local circumstances
– Too much variability threatens larger quality goals
• Success depends on uniform standards
– What structure / process elements don’t want to compromise on?
– Incorporate these into quality standards
• Regions will be judged on success / failure of implementation
– Better to define own success criteria, rather than use someone else’s
6
What challenges do
Healthcare Leaders face?
• Clearly articulate a specific quality agenda for hospital-based
emergency care:
– What do we want to improve / change? (indicators)
– How will we measure success? (standards)
• Promote uniform development of FAM system:
– Organizational structures
– Clinical practice model
– FAM staffing, education and training
• Successfully balance multiple (competing) agendas:
– Quality / Safety / Satisfaction
– Financial
– Organizational / Operational
– Innovation / Sustainability
7
Unique Opportunities for
Emergency Medicine in Denmark
• Implement a world-class model of
emergency care delivery
– Strengths of Danish healthcare
system
– Build on international EM
experience
• Create a “best-practices”
framework for measuring quality,
impact of care
– Existing national quality tools
– National healthcare databases
8
Existing National Quality Tools:
• Den Danske Kvalitetsmodel (DKM):
– General accreditation model for all healthcare institutions
– Leadership and quality improvement tool
– Framework for developing standards
• Det Nationale Indikatorprojekt (NIP):
– Development, testing and implementation of healthcare quality
indicators
– Evidence-based,
– Diagnosis / condition-specific
These seem to be perfect; why is there a need for anything else?
9
Potential limitations for use in
measuring emergency care quality?
•
Early stages of development?
– Much EM specific content yet to be developed
– How long will it take to develop? When is a quality measurement tool needed?
•
Too general?
– Do they contain the necessary detail to provide useful guidance for development
of emergency care system?
•
Political dimensions?
– Committee-driven process w/ many stakeholders, many agendas
– Tend towards least controversial standards, maintain status quo
– Will they produce standards that push a necessary paradigm shift?
10
Existing emergency healthcare
data sources offer great potential:
• ”Vores overordnede konklusion er, at LPR kan anvendes
til en overordnet monitorering af akut området...”
• ”For at optimere monitorering af akutområdet bør den
nuværende registrering ændres og udvides til at omfatte
oplysning som tillader en bedre karakteristik af
indlæggelsesforløbene...”
Christensen, et al. Akutte indlæggelsesforløb og skadestuebesøg på hospitaler
i Region Midtjylland og Nordjylland 2003-2007, Klinisk Epidemiologisk Afd.,
Aarhus Universitet, 2009.
11
Electronic capture of administrative and
process data at departmental level
•
Electronic time stamps for actions of interest
– Administrative data, demographics, patient
movements
– Computerized Provider Order Entry
– Test results, medications, interventions
•
Automated reporting of benchmarking data
– Start simple : add more data elements over
time
12
Regional EM Data
Reporting System
Landspatientregister
Regional administration
Local FAM administration
Health systems research
13
National Ambulatory Care
Reporting System (NACRS)
• The Canadian Institute for
Health Information (CIHI)
– an independent, not-for-profit
organization
– provides essential data and
analysis on Canada’s health
system and the health of
Canadians.
• The National Ambulatory Care
Reporting System (NACRS)
– contains data for all hospitalbased and community-based
ambulatory care:
– day surgery, outpatient clinics
and emergency departments.
• Individual ED patient visit level
data reporting
• 179 Emergency Departments
reporting in Ontario
• 82 data elements in 2009
version:
–
–
–
–
–
–
–
Administrative
Demographics
Referral – Disposition**
Chief complaint
Acuity
Time-motion data
Therapeutic Interventions
**allows for accurate linking of “kontakter”
to reconstruct overall “patientforløb”
14
Charting the Course Forward
• Create EM specific quality measurement
tools
– Establish uniform standards
– Drive uniform development
• Develop national databases and IT tools
to meet emergency care data needs
– Clinical care, administration, research
– Input from relevant stakeholders is critical
• Balanced scorecard approach
– Align organizational strategy with
performance measurement
– Many perspectives and indicators to
consider
15
The Balanced Scorecard: a performance
measurement and strategic planning methodology
Kaplan and Norton. Harv Bus Rev, 1992;70(1):71-79
Financial
Priority is to
generate profit for
shareholders
Customer
How do our
customers
perceive us?
Priority is to fulfill
mission and satisfy
stakeholders
Healthy finances a
necessary condition
rather than ultimate goal
Mission &
Stakeholders
Financial
Internal
Processes at which we need
to excel in order to satisfy our
customers
Internal
Learning and Growth
Basic infrastructure to
improve, create value and
achieve mission
Learning and Growth
For-profit organizations
Not-for-profit (Healthcare)
organizations
16
Applying the Balanced Scorecard in
Healthcare Provider Organizations
Inamdar and Kaplan. J Healthc Manag. 2002;47(3):179-195
Study of 9 Provider Organizations
•
•
•
Integrated healthcare delivery systems
Academic medical centers
Community hospitals
Benefit Themes:
•
•
•
•
•
•
•
Clarify and gain consensus on strategy
Increase credibility of management
with board members
Framework for executive decision
making
Set priorities by identifying,
rationalizing and aligning initiatives
Link strategy with resource allocation
Greater accountability
Enabled learning and continuous
improvement
Organizational Performance
improvement = 64%
•
•
•
•
Volume of provided services
Productivity
Patient satisfaction
Utilization management
Improved Financial Position =
76%
•
•
Cost reduction
Revenue enhancement
17
Ontario Hospital Association
Balanced Scorecard for ED Care
Hospital Report 2007: Emergency Department Care
•
•
•
•
•
Publically financed healthcare system
25 indicators across 4 performance areas
124 participating hospital emergency departments across Ontario
Voluntary participation: 109 (88%) 1 quadrant; 85 (69%) 4 quadrants
“High-Performing” Hospitals identified for each quadrant
18
Balanced Scorecard for the
Dutch Health System
ten Asbroek at al. Int J Qual Health Care. 2004;16 Suppl 1:i65-i71
Perspectives and
indicator areas of
balanced scorecard for
Dutch Health System
Financial Perspective
•
•
•
Health system costs
Efficient use of resources
Financial viability
Internal Process Perspective
Consumer Perspective
•
•
•
•
Effectiveness
Patient safety
Patient satisfaction
•
•
Quality of healthcare delivery
processes
Concentration of care provision
Human resources (availability,
vacancies, satisfaction)
Innovation Perspective
•
•
•
•
•
Funds for learning and growth
Information infrastructure
Innovative working environments
Development and diffusion of
organizational innovations
“Anticipate need for new
professionals for healthcare
delivery of tomorrow”
19
What system perspectives would
you prioritize?
?
?
?
?
Which indicators would you
choose?
20
System Elements Related to Quality
Structure
Process
Outcome
“the resources we
use, and conditions
under which, we
deliver care”
“what we do to
patients in the
process of delivering
care
“what happens to
patients as a result
of our delivering care
to them”
“Good structures increase the likelihood of good processes, and
good processes increase the likelihood of good outcomes.”
Donabedian, JAMA, 1988
21
Categories & Characteristics of Indicators
Structure
•
•
•
Material resources
Human resources
Organizational
structures
•
Indicators should be:
•
Process
•
•
Representative tasks
Representative
conditions
Outcome
•
•
Health status
Patient satisfaction
–
Relevant (matter to stakeholders)
–
Meaningful (can be influenced by healthcare system, room for improvement)
–
Scientifically sound (validity, reliability)
–
Evidence-based (causal linkage to desired outcomes)
–
Measurable (clearly defined numerator, denominator, technically feasible to collect data)
Indicators can change over time to reflect evolving quality agenda
22
Structural Indicators of Emergency Care Quality
Structure
What characteristics of the
emergency care system affect the
system’s ability to provide the
desired emergency care?
Process
•
Outcome
Material Resources
– Facilities
– Equipment
– Financing
•
Human Resources
– Type, number of staff
– Staff qualifications
•
Organizational Structures
– FAM level
– Hospital level
– Regional level
23
Indicators Related to Material Resources
Structure
Process
Outcome
Material Resources:
Examples:
Features of the FAM facilities that
describe how well suited it is to provide
efficient and effective emergency care
FAM configuration:
Does our FAM have the space / beds
that we need to care for our patients?
Do we have the access we need to key
functions to provide care effectively



Contiguous clinical areas in FAM
Admin/educ space adjacent to FAM
Proximity to vagtlaege konsultation
Access to other hospital functions:


x-ray, laboratory
ICU, OR, cath lab
Hospital inpatient resources:


Access to inpatient floor beds
Access to inpatient ICU beds
24
Indicators Related to Material Resources
Structure
Process
Outcome
Examples of Access related indicators:
• Access Block for ED patient, wait > 8 hours
– Percent of patients admitted, planned for admission but discharged,
transferred to another hospital or died in ED, whose total ED time
exceeded 8 hours
• Access Block for ED patients, wait > 4 hours
– Percent of mental health or critical care patients who wait greater than
4 hrs in the ED after the time of decision to admit them
Australasian Clinical Indicator Report: 2001-2007. ACHS, 2008.
25
Indicators Related to Human Resources
Structure
Process
Outcome
Human Resources:
Examples:
Characteristics of the FAM staffing
that describe how well suited it is to
provide efficient and effective
emergency care
Adequate number of physicians for:
Do we have sufficient numbers of staff
to provide adequate clinical coverage?
Do our staff have the necessary
education and training to provide the
desired scope of care?

24/7 clinical coverage?

Administrative functions?

Education (self, junior physicians)
Staff Qualifications:

Percent of FAM physician staff with
recommended training in EM

Percent of FAM nursing staff with
recommended training in EM
26
Indicators Related to Organizational Structures
Structure
Process
Organizational Structures:
•
Characteristics of the organization,
policies and practices that:
– encourage delivery of cost effective,
high quality care
– support growth and development of
robust, sustainable FAM organization
• Attractive work environment
• Desirable career choice
• Professional recognition
Outcome
Examples:
System Integration:
 Use of Standardized Protocols
 Internal coordination of care
 External partnerships
Medical Informatics:
 Clinical data collection
 Use of clinical information technology
FAM Department Leadership:
 reports directly to hospital leadership
 able to hire own physician staff
Strategic Alignment of Incentives:
 appropriateness of inpatient admission
 employment, compensation models
27
Indicators Related to Organizational Structures
Structure
Process
Outcome
Organizational Structures:
•
Characteristics of the organization, policies and practices that:
– encourage delivery of cost effective, high quality care
– support growth and development of robust, sustainable FAM organization
• Attractive work environment
• Desirable career choice
• Professional recognition
28
Process Indicators of Emergency Care Quality
Structure
Process
What did we do to the patient?
How well was it done?
•
Representative tasks performed
in the FAM
– Diagnostics
– Therapeutics
– Others
Process measures ideally need
compelling evidence linking them to
desired outcomes to be valid
When hard evidence doesn’t exist,
process measures can be based on
expert consensus
Outcome
•
Representative conditions seen
in the FAM
– Common problems
– Across spectrum of acuity
29
Process Indicators of Emergency Care Quality
Structure
Process
Outcome
Representative tasks performed in the FAM:
•
Triage
•
Emergency stabilization
•
Focused history and physical exam
•
Diagnostic studies
•
Determine diagnosis
•
Therapeutic interventions
•
Pharmacotherapy
•
Observation and reassessment
•
Consultation and disposition
•
Prevention and education
•
Documentation
Thomas et al. Acad Emerg Med. 2008:15(8);776-779
30
Process Indicators of Emergency Care Quality
Structure
Process
Outcome
Representative conditions encountered in FAM:
•
Treated in most FAM
•
Wide spectrum of age groups
•
Represent different degrees of patient acuity
•
Common reasons for seeking emergency care
•
Evidence that “best practice clinical care” in FAM may have impact on patient
outcome or lead to enhanced clinical efficiency
•
Rare conditions or where improving FAM care unlikely to change patient outcomes
should be excluded
Lindsay et al. Acad Emerg Med, 2002, 9(11):1131-1139.
31
Process Indicators of Emergency Care Quality
Structure
Process
Outcome
Example of a set of Representative Conditions:
•
Asthma
•
Pneumonia
•
Acute myocardial infarction
•
Deep venous thrombosis / pulmonary embolus
•
Chest pain
•
Minor head trauma
•
Ankle / foot trauma
Lindsay et al. Acad Emerg Med, 2002, 9(11):1131-1139.
32
Process Indicators of Emergency Care Quality
Structure
Process
Outcome
Examples of disease specific process measures:
•
Asthma
– Beta-agonist administration in all patients presenting to the ED with an
exacerbation of asthma (within 15 minutes of arrival in ED)
– Corticosteroid administration in all ED patients with asthma with:
• 1) moderate to severe exacerbations,
• 2) failure to respond promptly to inhaled beta-agonists,
• 3) admitted to hospital,
• 4) already on steroids at time of ED arrival
– Oral corticosteroids at discharge in all asthmatic patients who meet criteria to
receive steroids in the ED
Sullivan et al. Acad Emerg Med. 2007; 14:1182–1189
33
Process Indicators of Emergency Care Quality
Structure
Process
Outcome
Examples of disease specific process measures:
•
Acute myocardial infarction
– Timely ECG in all patients who present to ED with symptoms suggestive of
ACS (door-ECG time < 15 minutes)
– Delivery of aspirin / anti-platelet agent to all patients without contraindication
who present with symptoms suggestive of ACS
– Delivery of reperfusion therapy to all AMI patients who meet criteria for
reperfusion therapy
• door-to-needle time < 45 minutes for iv thrombolytic therapy
• door-to balloon time < 60 minutes for primary angioplasty
Sullivan et al. Acad Emerg Med. 2007; 14:1182–1189
34
Process Indicators of Emergency Care Quality
Structure
Process
Outcome
Examples of Laboratory Turnaround Time indicators:
•
•
Urgent serum potassium
–
result within 60 minutes, during normal working hours
–
result within 60 minutes, out of hours
Urgent haemoglobin
–
result within 60 minutes, during normal working hours
–
result within 60 minutes, out of hours
Australasian Clinical Indicator Report: 2001-2007. ACHS, 2008.
35
Outcome Indicators of Emergency Care Quality
Structure
Process
What happened to the patient as a
result of the care that was provided?
To what extent can we expect changes
in FAM care delivery to change the
outcome?
Need for risk adjustment of outcomes?
Outcome
•
Health Status
– Morbidity
– Mortality (???)
– Disability
•
Patient Satisfaction
–
–
–
–
Overall Impressions
Communication
Consideration
Responsiveness
36
Outcome Indicators of Emergency Care Quality
Structure
Process
Outcome
Examples of Outcome Indicators:
•
Proportion of Pneumonia Patients with Inpatient LOS ≤ 2 days
•
Return Visit Rate for Asthma (≤ 24 hrs, 24-72 hrs)
•
X-ray Rate for Ankle or Foot Injury Patients
•
Return X-ray Rate for Ankle of Foot Injury Patients (≤ 7 days)
Hospital Report 2007: Emergency Department Care. Ontario Hospital Assoc.
37
Outcome Indicators of Emergency Care Quality
Structure
Process
Outcome
Examples of Outcome Indicators:
•
Percentage of ED visits where Adverse Drug Event recorded
•
Percentage of ED visits where Adverse Transfusion Event recorded
Australasian Clinical Indicator Report: 2001-2007. ACHS, 2008.
38
Outcome Indicators of Emergency Care Quality
Structure
Process
Outcome
Examples of Patient Satisfaction Indicators:
•
Overall Impressions
–
•
Communication
–
•
Patients’ assessments of how well information was communicated to them or their family
during their ED stay
Consideration
–
•
Patients’ assessments, overall, of their ED stay
Patients’ assessments of whether they were treated with respect and courtesy by doctors,
nurses and staff during their stays in the ED
Responsiveness
–
Patients’ assessments of the amount of time they waited to see doctors and nurses and
receive test results, assessments of pain management; assessments of team work; and
staff’s responsiveness to their needs
Hospital Report 2007: Emergency Department Care. Ontario Hospital Assoc.
39
Putting it all together
•
Excellent foundation with existing quality frameworks, metrics, data
gathering
– Danske Kvalitetsmodel (DKM), National Indikator Project (NIP)
– Patients Administrative Systemer (PAS)
– Landspatientregistret (LPR)
•
Simplified overview of key perspectives, indicators to drive uniform
development
– Balanced scorecard
•
Additional indicators to create a meaningful framework of measures:
– Wide range of examples from international experience
– Structural conditions that support development of effective FAM system
– Focus on patients, processes seen in the FAM
40