‫‪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)
Degree to which care increases likelihood of desired health
outcomes & consistent with current professional knowledge
Safe
Timely
Effective
Patient centered
Equitable
Efficient
Overuse (antibiotics, imaging)
Underuse (prevention)
Misuse (errors & complications)



Evidence-based
Patient-centered
System-minded
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
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
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."
Cycles of Improvement (Industry Model)
Statistical Process Control
PDSA
Example: monitoring of surgical infection rate is
now recognized as important tool to prevention
Quality of General Intensive Care
Survival at Hadassah vs. Israel Average
Prof. Elisheva Simchen, Ministry of Health
p<0.001
Despite higher severity score, patients
had better survival at Hadassah
Quality of Neonatal Intensive Care
Survival at Hadassah vs. Israel Average
Dr. Zivanit Ergaz, Prof. Ilan Arad & Gertner Institute
Quality of Treatment in Trauma
Mortality at Hadassah vs. US level I centers
Dr. Yoav Mintz, Ms. Irina Gertcenchtein & Prof. Avraham Rivkind
30%
20%
Hadassah - Total Mortality
US National
Trauma
ISS 16+ Mortality
Data Hadassah
Bank -from
51
level-I trauma
20.9%
19.7%
centers,
18.4% n= 263,524
14.4%
NTDB - Total Mortality
20.2%
13.6%
Hadassah data
NTDB - ISS 16+ Mortality
Israeli National
Trauma
Registry
20.5%
19.6%
n=7,391
13.4%
11.5%
10%
5.3%
5.8%
5.5%
3.2%
2.6%
2.7%
5.8%
2.9%
6.7%
2.1%
0%
1999
2000
2001
2002
2003
Quality indicators for myocardial
infarction, Hadassah vs. US data
Hadassah (%) 89 90 50 83 69
44’
102’
Referral to cardiac rehabilitation only 21%
Percent of patients receiving
adequate anticoagulation
Before
p<0.001
%
After Intervention
p<0.001
p<0.001
p<0.02
Catheter-related Bloodstream Infections
Intervention in 108 ICU’s resulted in 66% reduction
in rates of catheter-related bloodstream infection
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.
1.0
Catheter-related Bloodstream
Infections
Survival Function for pat
0.9
0.
9
Cum Survi
val
0.
8
0.
7
0.
6
0.
5
Proportion of
catheters
remaining
without
infection
0.
4
0.
3
0.
00
(Cox regression)
S
ur
vi
va
l F
un
ct
io
Survival Function for pa
0.9
0.7
n
0.8
0.6
1.0
Survival
Function
for
patterns
1
-
fo
r
2
NewGroup
.00
1.00
1.0
0.9
0.8
Cum Survival
1.
0
urvival Cum SurvivalCum Survival
Following intervention, improvement in technique
1.0
was observed;0.8
rate of infection declined by 62%,
from 13.2% to 5.0% (17/337 catheters, p<0.001).
0.7
pa
tt
er
ns
0.6
1
0.5
0.4
0.3
0.00
20.00
40.00
60.00
80.00
100.00
DaysOfFollowUp
0.7
0.5
0.9
0.6
0.4
0.8
0.5
0.3
0.7
p<0.001
After the
intervention
20
.0
0
40
.0
D
ay 0
sO
fF
60
ol
.0
lo
0
w
U
p
Days of catheter
0.00
20.00
Before the
intervention
80
.0
0
40.00
10
0.
00
60.00
Catheter-related Bloodstream Infections
Unit
Before Intervention
After Intervention
Catheter
days
N
infected
Rate*
Catheter
days
N
infected
Rate*
Rate
Reduction
(%)
ICU-A
1176
6
5.1
1296
3
2.3
55
ICU-B
1240
7
5.6
879
2
2.3
60
ICU
Medicine
995
16
16.1
1715
6
3.5
78
Neurosurgery
225
4
17.8
173
1
5.8
67
Cardiac
surgery
562
5
8.9
551
4
7.3
18
ICCU
150
4
26.7
63
1
15.9
40
Total
4348
42
9.66
4677
17
3.63
62.4**
* Rate of infection per 1000 catheter-days
** p<0.001
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
Summary of surveys in recent years
Rate of hand-washing out of contacts with patients
Ein Kerem
Mt. Scopus
Medicine
65%
55%
Pediatrics
55%
62%
Surgery
35%
66%
Ob-Gyn
25%
Use of Hadassol has been widely adopted
but rate of hand hygiene unchanged
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.
Quality of Inguinal Hernia Repair in
Adults and in Children at Hadassah
T. Yemini, M. Badriah, Y. Mintz, R. Udassin, A. Rivkind
Satisfaction high to very high in 94% of adults and
children; problems: waiting & relation with staff
Complications
Rate of infection (95% CI)
Children
Adults
6% (2-13)
12% (7-20)
0.7-14%*
Rate of hematoma (95% CI)
Children
Adults
10% (5-18)
13% (8-21)
11-15%*
*Range in literature varies by motive (voluntary or mandatory)
Quality of Special Surgeries
Outcomes of special surgery in the Departments
of Ear, Nose & Throat (ENT), Ophthalmology,
Plastic and Neurosurgery
ENT
Snoring, tonsillectomies
Ophthalmology
Corneal transplant, Lasik
Plastic surgery
Breast reconstruction
Neurosurgery
Prevention of shunt infection
Management of Snoring Disorders with
Radiofrequency at Hadassah Optimal
L. Gordon, S. Catinari, R. Eliashar
p<0.005
%
p<0.01
p≤0.05
Lasik (Myopic Corneal Refractive Surgery) at
Hadassah Optimal (N=109)
N. Orwa, A. Solomon, Y. Frucht-Peri
%
Evaluation of Outcomes for
Tonsillectomies at Hadassah (2008)
O. Frenkel, R. Eliashar
% with any
bleeding
% needed
readmission
% needed
reoperation
Hadassah
(N=106)
Literature
UK audit &
others
(N>30,000)
28
?
20
3-10
4.7
0.5-2.0
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
%
0
20
40
60
Severe
Complications
Success
Satisfaction
Would
Recommend
Hadassah
moderate
high
80
A survey of 140
women after
reconstructive
breast surgery
for cancer
showed
satisfaction
related mostly
to expectations
before surgery.
Neurosurgical shunt infections
I. Paldor, Z. Israel, C. Block with the dept of Neurosurgery
% of shunts
infected
Intervention
40
35
30
25
20
15
10
5
0
Num ber of
shunts inserted
2001
10
2002
17
2003
21
2004-5
24
Mortality in infected cases dropped from 50% to 0%
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
% agreement
resident vs.
specialist
Pulmonary
Embolism
95%
Surgery Trauma
77%
94%
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
The Presence of a Translator Significantly
Improved Parental Understanding Regarding
Diagnosis, Treatment and Follow-up
100
96
86
78
80
74
72
%
60
40
34
38
23
20
0
Understanding of
diagnosis
p<0.001, n=194
Necessary follow-up
translator
When return visit to ER
necessary
no translator
Dosage & duration of
medication
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
60
% of
tests
within
target
INR
50
* p<0.001
60%
40
30
38%
20
10
0
Control
Intervention
Patient’s knowledge & satisfaction significantly improved
Communicating with Families &
Satisfaction with End-of-Life Decisions
Departments of Medicine & Center for Clinical Quality & Safety
% of relatives agreeing with statement:
Control
Intervention
“I felt the team didn’t care about my opinion”
35
13*
“It upset me I didn’t know what was going on”
43
10*
“Patient’s problems weren’t explained to me”
44
3*
“Management options were not explained”
46
17*
“I was afraid to ask questions”
38
10*
“I felt excluded in the decision-making”
52
17*
*p<0.005 in favor of the intervention group
Communication with families of patients near
end of life improves perceived quality of care
Rate of patient’s recall for explanations on
risks & alternatives: informed consent?
Ward
Type of
procedure
N
Explanations
about risks
Discussion of
alternatives
Surgery
Operation
178
60%
20%
ObGyn
Operation
198
57%
19%
Medicine
Diagnostic or
therapeutic
procedure
117
42%
40%
Cardiology Angiography
120
39%
8%
613
51%
21%
Total
International Journal for Quality in Health Care 2008
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 peerreviewed publications.
Center for Clinical Quality & Safety