Physician Quality Improvement Summit November 19, 2018
disclosures Carolyn Canfield and Dr Hector Baillie have declared that they have no commercial interests to disclose
Hector Baillie MD Specialist in Complex Adult Medicine Nanaimo BC 19 November 2018
Changes in 100 years • Nutrition War • Sanitation Obesity-Diabetes • Housing Hepatitis/HIV • Education Smoking illnesses • Vaccination Travel • Health Service Cancer • Diagnostics Degenerative disease • Medication/Surgery Costs • Peace Situational Lifestyle
COLLABORATION • DOCTORS AND NURSES ARE BURNT OUT – WHY?
COMMUNICATION Communication: 9/10ths of Medicine 9/10ths of Life What’s Missing Here?
COMMUNICATION Communication: 9/10ths of Medicine 9/10ths of Life This is my Aunt Jenny!
FAST MEDICINE - BLOOD TEST - DRUG - OPERATION - DEVICE
SLOW MEDICINE - TALK WITH PATIENT - TALK WITH FAMILY - ACKNOWLEDGE FEAR - END OF LIFE CARE - COMFORT & RESPECT
Physician PATIENT Nurse/ Administration COMMUNICATION Allied HC
SPECIALST SUPPORT COMMITTEE PHYSICIAN QI INITIATIVE • FUNDED BY MINISTRY OF HEALTH, DIRECTED BY DOBC - caregiver re-engagement - better patient outcomes • INDIVIDUAL HEALTH AUTHORITIES • 12 PHYSICIAN LED TEAMS (QI consultant & co-ordinators, data analyst) • 1 YEAR PROJECT • WORKSHOPS • POSTER PRESENTATIONS • LEARNING FROM QUALITY FORUM VANCOUVER/IHI ORLANDO • NOW IN ITS THIRD YEAR
Sleep Disordered Breathing in CHF a common finding in HF - not commonly recognised. TEAM PLAYERS BACKGROUND PROBLEM Sleep disordered breathing is poorly recognised as a • Hector M Baillie MD (Physician Lead) Obstructive Sleep Apnoea (OSA) leads to intermittent cause (and effect) of heart failure. Diagnosis is simple, • Honeylette Abesamis RN (HF Clinic Nurse) hypoxia, increased RV volumes and SNS activation, • Suzanne Beyrodt-Blyt RN (QI Co-ordinator) treatment effective. Patient compliance with both leading to hypertension, arrhythmia, atherosclerosis, • Curtis Bilson (Data Management) and heart failure. Prevalence in the general population seem variable, despite proven benefit in terms of 2-7%, but 30-50% in HF patients. Treatment with outcomes, and quality measures. By using screening AIM OF PROJECT CPAP or mandibular advancement device can improve questionnaire, and intervening with CPAP or a health and increase survival (ACC/AHA class IIa - To determine prevalence SDB in 42 mandibular advancement device, heart function recommendation). consecutive HF patients over a 6 month improves. Central Sleep Apnoea (CSA) often a consequence of period. advanced HF/low cardiac output: CPAP can improve Island Healt h: NRGH Heart Funct ion Clinic S leep Apnea Patient s - To identify an effective screening tool for November 2016 - July 2017 Number of Records by P r e and P ost Heart Rates Sa02 but no survival advantage. OSA’ Range HR / P rePost HR PrePost HR 40-59 60-79 80-99 100+ Nul l PRE POST 20 - To determine if SDB intervention, combined 19 PATIENT VOICE 18 with standard medical therapy, improves HF 16 15 outcome measures (LV-EF, NT-proBNP): “Most nights I 14 13 13 predicted 40% improvement. 12 Num ber of Records spent in the 11 10 PDSA Cycle Lazy-Boy…I 8 8 was sleepy 6 with HF, I Patient identified as SDB 4 3 often felt I was 2 2 - CPAP/MAD therapy drowning”. 0 Act Plan PRE POST PRE POST PRE POST PRE POST - Improvement in EF and NT-proBNP “With CPAP, the difference was immediate... I slept - Improvement in Study Island Health: NRGH Heart Function Clinic Sleep Apnea Patient s Do like a baby for the first time in 3 years.... yes there is November 2016 - July 2017 Number of Records by Pr e and Post Body/Mass Index (BMI) quality of life Range BMI / P reP ost BMI PrePost BMI Under 20 20-24 25-29 30-34 35+ Null PRE some frustration with the mask if the fit isn’t perfect, POST 18 (subjective) 17 but I feel wonderful now” - C.O. 16 14 14 Island Health: NR GH Heart Function C linic Sleep A pnea Pat ients 13 Island Health: NRGH Heart Func tion Clinic Sleep Apnea Patients November 2016 - July 2017 DATA ANALYSIS November 2016 - J uly 2017 Number of R ecords by Pre and Post Apnea-Hypopnea Index (AHI) 12 12 Number of Records by Pati ent Age Ranges and Gender Range AHI / Pre Post AHI Pre Post AHI Range Age S ex Under 10 10-19 20-29 40-49 Nul l RE P Number of Records 11 F emal e OS P T 10 Mal e 20 19 10 18 8 - Prospective consecutive patient enrolment 18 8 7 9 2 from referral cohort to NRGH HF Clinic 3 16 6 5 8 - Age, sex, BMI, HR/BP, AHI, LVEF, BNP noted 14 4 3 3 7 - Epworth score on all patients 12 Number of Records 11 2 N umberof Rec ords 6 1 1 10 - Level III sleep study 0 9 PRE PRE P OST PRE POST P RE POST P RE POS T PRE P OS T 5 8 8 - Follow-up visits to assess OSA+Rx: with 1 4 8 Image 3: Description / summary of the above 6 measurement of LVEF/BNP/QoL 1 7 5 5 5 data diagram 3 2 4 FINDINGS 2 4 2 2 2 1 3 3 1 2 2 0 1 1 1 PRE P OST PRE POST RE P POS T PRE P OST PRE POST 0 1. OSA is under-recognised by referral 36-40 45-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85 85+ physicians CONCLUSION 2. Prevalence of SDB in HF Clinic: % 3. Epworth Score not a good screening tool: we Heart failure (HF) either with reduced or preserved ejection fraction, is becoming more common as our population ages, will use STOP-BANG questionnaire in future and as the obesity epidemic evolves. Common causes of HF include hypertension, ischemic heart disease and valvular 4. CPAP and MAD treatment had positive dysfunction. Obstructive sleep apnoea is a well recognised cause of refractory hypertension, arrhythmia and oxidative benefit in terms of HF outcomes (Echo, BNP) stress. It is more common in men, and is linked to obesity. Our study shows that it must be considered in all patients with HF, who should be screened and offered appropriate therapy. Quality of life improves, LV function improves, and survival improves. We would like to see the STOP-BANG questionnaire become standard in HF Clinics. The PQI Initiative provides training and support to physicians, through technical resources and expertise, to lead quality improvement (QI) projects, which build QI capacity. This investment increases physician involvement in quality improvement and enhances the delivery of patient care. Please see our website for more details: sscbc.ca
Physician PATIENT Nurse/ Admin COMMUNICATION Allied HC
Patients are taxpayers Patients deserve to know what’s working well, what isn’t Patients are unrepresented in almost all committees I’ve ever been on Patients have important perspectives we should respect: we are all patients- in-waiting
Patient leadership in healthcare Patient focus – safety Patient direction – quality means..? Re-engagement Patients should be an integral part of our PQI teams
Michael E Porter Thomas H Lee
Porter, Michael E. "What is value in health care?." Lee, Thomas H. "Putting the value framework to work.” New England Journal of Medicine 363.26 (2010): 2477-2483.
VALUE EQUATION = OUTCOMES** (QUALITY + SAFETY + SATISFACTION) COST ** “ As is often true in medicine itself, the critical first step is measurement . Provider organizations need to capture data on the outcomes that matter to patients , as well as the costs for a patient over meaningful episodes of care. ” T.H.Lee 2010
⋅ O UTCOMES THAT MATTER TO PATIENTS ⋅ C OMPREHENSIVE COSTS TO CARE FOR A PATIENT ⋅ M EANINGFUL [ to the patient ] EPISODES OF CARE Lee, Thomas H. "Putting the value framework to work.” New England Journal of Medicine 363.26 (2010): 2481-2483.
managing risk SAFETY QUALITY Vincent, C., & Amalberti, R. (2016). Safer healthcare: Strategies for the real world .
Patient Safety: a Definition ^ “Management of RISK over time in order to MAXIMIZE benefit and MINIMIZE harm X to patients in the healthcare system” Vincent, C., & Amalberti, R. (2016) Safer healthcare: Strategies for the real world
studio Mile
Six Levers to Help Organizations to Accelerate Healthcare Improvement https://www.cfhi-fcass.ca/PublicationsAndResources/ResourcesAndTools/six-levers
“the citizen-patient”
Working definition of “citizen-patient” a person who has health services experience (patient, family or community) AND has an interest in supporting system level improvement
patientvoicesbc.ca
We’re all patients, Carolyn!
Work As Imagined* * Why is work-as-imagined different from work-as-done? / Hollnagel, Erik. in Resilient Health Care: The resilience of everyday clinical work. ed. / Robert L Wears; Erik Hollnagel; Jeffrey Braithwaite. Vol. 2 Ashgate, 2015. p. 249-264.
Work As Imagined* http://resilienthealthcare.net/onewebmedia/WhitePaperFinal.pdf
Work As Done* - care networks image credit: BMC Systems Biology 2011, 5:168 * Why is work-as-imagined different from work-as-done? / Hollnagel, Erik. in Resilient Health Care: The resilience of everyday clinical work. ed. / Robert L Wears; Erik Hollnagel; Jeffrey Braithwaite. Vol. 2 Ashgate, 2015. p. 249-264.
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