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Quality of Care
In general, quality of health care issues have been defined as the
absence or shortage of financial, material, and human inputs (De Geyndt 1995).
However, not only is there a need to know the inputs that go into the care,
there is a need for the evaluation of the quality of care. This has not
previously been done because it was thought too difficult and costly. De Geyndt
in his paper made the statement:
“Outcome
measures were not used in the developing country studies. Improving outcomes
is a presumptive result of improving the process and is not documented mainly
for lack of valid and reliable measuring tools and indicators, the expense
involved and the tenuous cause-effect relationship between process and
outcome.
and the reason:
“Until
recently, detailed average cost studies were not available for hospitals in
developing countries. Such analyses were seen as too difficult because of the
lack of general accounting information and not useful because of the probable
imprecision of the results. This view was not correct; a number of studies,
many employing variations on the step down costing methodology, have recently
demonstrated the feasibility and usefulness of doing cost studies in a variety
of economic and developmental environments. To date, this costing method has
been applied only as an exception. The experience from these applications
suggest, however, that it would be possible to institutionalize type of
accounting methodology at the hospital, regional, or ministerial level. (Barnun
1993, pg 83)
If
the information is not collected, the costs and sufferings in the long run will
be even greater.
In the
WHO Technical Report 819, The Hospital in
rural and urban districts the functions of the health management team was
listed as:
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Defining
the health needs of the population to be served and identifying the measures
required to address those needs.
-
Planning
and co-coordinating health activities to ensure the optimal utilization of the
resources (human, financial, and material) available to the district.
-
Ensuring
and maintaining good standards of care in all health institutions within the
district.
-
Ensuring
that health activities in the district are adequately supervised and that
arrangements are made for the ongoing training of the staff involved.
-
Being
responsible for: the collection of data on such subjects as community health
needs, coverage with services, and the impact of interventions; data
analysis and recording; and the use of information for the improvement of
services.
It is the last listed
function that makes all the rest possible.
Although many manual
have been produced (WHO, UNICEF, USAID, etc.) that "pictures" good forms and how
to enter data into these written form, very little has been written on how to
use the data for management purposes. Without the ability
to use the data once it has been recorded, the
forms are useless.
Social and Economic Data
Social and Economic are just important to the care of the
individual as the physical Symptoms. Without this data, comprehensive care
cannot be provided. Examples are:
Economic –
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Individual doesn’t come for care until he is really
sick/it is too late
-
Individual does not buy the medicine as prescribed (he
doesn't have the money, and most healthcare professional do not know what
the drugs cost or ask the patient if he can afford them)
-
Individual does not eat/live the life style as prescribed
(the individual "wants a pill" to made him better")
Social
Religion and Ethnicity groups have preconceived ideals of
health (Republicans and Democrats !)
Diagnosis Errors
The Agency for Healthcare Research and Quality (AHRO) funded a project to
determine how diagnosis fails. What they found out was that diagnosis errors are
common and underemphasized. In several studies of malpractice claims, it was
revealed that diagnosis errors far outnumber medication errors as a cause of
claims lodged (26 percent versus 12 percent in one study; 32 percent versus 8
percent in another study...and it gets worse (see this link for additional
statistics and references.
Diagnosing
Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project (pdf
file) This article has a good analysis, and offers a long list of additional
references. I will not repeat this excellent work here.
Since all Analysis of health care is based on the Diagnosis (care plan,
medication, payments, statistics, etc) what happens when the diagnosis is
incorrect? What is the consequences to the patient if the their is a diagnosis
error?
-
The first problem is that when a diagnosis is made, it
prejudice all future analysis of care for that patient. Very few healthcare
professionals will "criticize" another's diagnosis.
http://hyoumanity.blogspot.com/2008/12/cognitive-bias-and-error-in-diagnosis.html
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All care planning including medication orders are based on this diagnosis. It is
likely that more medications errors are made because of a error in the diagnosis
than in the other factors
-
There is usually no supporting data (patient history, family
history, history of problem, symptoms, findings, etc) included when the Healthcare Professional
"makes a Diagnosis, there is no way to either prove or disprove that the
Diagnosis made is incorrect, i.e. the data can not be reviewed later to
determine if the diagnosis was incorrect.
Diagnosis errors can be made at a number of points in patient care:
-
Patient does not relate the history of problem correctly or
leaves out important information, or the healthcare professional may
misunderstand the patient.
-
Healthcare Professional fails to ask the right questions,
-
Healthcare Professional cannot remember all the requirements and probability of
each diagnosis (ICD10 has over 50 diagnosis for diabetics)
-
Healthcare Professional fails to remember the various presentations of the
disease.
-
Healthcare Professional has limited experience with the problem type
-
Healthcare Professional fails to do a full examination (he already has a
preconceived notion of the diagnosis)
-
Correct Testing is not ordered or the Healthcare professional may lack the
ability to interpret the results.
-
Patient may have taken a drug or eaten something that interferes with the
results of the test.
-
Healthcare Professional does not understand the sensitivity, specificity and
predictive value of the test.
-
Healthcare professional fails to record the description of the diagnosis
correctly.
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Use of Synonyms and abbreviations to describe the "problem.
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There are constant changes in the "coding system" for diagnosis...and there
many.
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Confusing code definitions
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"Upping" the diagnosis classification in order to "cover yourself"
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Forcing Healthcare professionals enter a "diagnosis" before being paid, or a
hospital admitting the patient.
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Having multiple "types" of diagnosis (preliminary, working, admitting,
differential diagnoses pre-surgery, primary, secondary, post-surgery...you get the message!)
Solutions
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Record All data and not just the data that the Healthcare
Professional thinks is important (can be review later)
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List the "Problems" instead of the "diagnosis" where the diagnosis has not been
proven.
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Use of "Expert Systems" for "real time analysis" (Decision tree)
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List "supporting evidence" for that diagnosis in the medical record.
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Multidisciplinary care
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Data Mining for case analysis (real time -error detection)
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Implement "blame-free" reporting and evaluation
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Limit the liability of Healthcare professionals for "failure" to make a
diagnosis....Physicians cannot know everything.
-
Combo all health records for an individual from all sources (physician, nursing,
therapy, consulting, etc)
A
Diagnosis error is probably more fatal then any single error...including
medication, yet, there seems to be no effort being made to improve the diagnosis
made by healthcare professionals. The greatest advances in Healthcare can come
from improving the system of "Problem" determination. The traditional approach
to determining diagnosis error was from Autopsies....this is not very
comforting! However, now with a good HIS, masses amounts of data can be analysis
in real time.
Medication Errors
It
seems that safety is a foremost goal among healthcare leaders around the
world...so says the Physicians...and medication errors are one of the many. The
errors are only a very small part of medications problems...a bigger problem
having a medication prescribe that did absolutely nothing for your problem...or
having a medication prescribe that was 10 times more expensive than another drug
that would have done the same thing...These types of problems are almost never
reported....it would make the HCP look bad!
Errors have been reported to come from the following
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Ordering medications that are contraindicated because of
allergies, gender, age or the patient problem
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Duplication of orders
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Delivery of drug to the wrong patient
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Drug-Drug Interactions
However we are assuming that the correct medication is being ordered! (See the
above section)
but what about the following!!!
-
Examination error in that the HCP fail to get all the
information required from the patient (the patient does know what he needs
to tell the HCP)
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The HCP prescribe the wrong drug for the condition (he is
just too busy and writes up the wrong order)
-
In general, many drugs have the same type of action.
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"reporting the 'relevant' clinical
findings"...The assumption is that the reporter knows what is relevant!"
Relevant" only relates to the individual that is doing the reporting. It may
have absolutely no relevance to the problem of the patient.
In
our experience we have found the following:
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A HCP is prescribing the same drug to everyone that he sees
no matter what the problem (he was getting kick-backs from the drug
company)!
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The HCP would prescribe three different drugs that all
contained the same class of medicine...or a combination of medicines that
were of the same class...
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The drug prescribed was not intended for the condition
Even the checks that many healthcare organization have to check drug-drug
interactions, there are many different types of drugs that are similar that have
the same of drug-drug reactions....relying on a computer...without thinking...is
probably not a very good thing to do.
Bar Coding
Bar Coding could catch many errors that are caused by giving the drug to the
wrong patient but actually bar coding was developed to control
inventory....interestingly....a nurse could still scan the patient's band...and
pocket the drug. It is a very expensive process that may not produce any better
results.
Separation of Nursing and Physicians notes
Patients hate the common process of having to answer the same questions multiple
times in a very short period of time..."I just told Dr. Good about that subject.
What is the matter, you do not read his notes? Why do I have to tell you the
story all over again?"
I
find the separation of Nursing and Physicians notes one of the worse things
things that can happen to providing for "Continue" of care. As a nurse, I have
never seen but a very few physicians look at the nursing notes. It seems that
there is a separation that says, "you stay in your place and I will stay in
mind". While we continuously talk about "quality of care" and "Continue of Care"
through better communication by using an HIS, current computer design still
separates "the records of care". There is also the issue of everyone and
their brothers writing "Notes"...notes for this this and notes for that. This is
a very very inefficient process and can lead to poor care and even errors in
care. When reading the different notes, it often appears that you are
reading about several different individuals...not the one patient. This notes
may even lead to different conclusions and different observations that never get
passed along.
InHCc proposes that "notes" of all kind be consolidated for easy viewing. Notes
and observations are arranged in a chronological order that clearly reflects the
history of the patient from all view points. While separation can be made, if
required, this can easily be provided by using a "select" statement in the
viewing of documents.
By
having all notes together, it is also possible to ensure that there are no
errors. If one individual HCP, sees something, all HCP's have an opportunity to
either agree with this observation, correct this observation or add to this
observation without duplicating all the work.
Diagnosis Imaging
Many HIS systems list as one of their advantages the ability
to store images.
While most physicians want to have the diagnosis image in front of them (stored
on the computer), the fact its, most physicians do not know how to read a
diagnosis image. There are "experts" that do this...day-in and day-out.
Letting an untrained physician interpret a diagnosis image is dangerous. What is
needed by the healthcare professional is the "Report/Result" of the particular
test not the image. Today, imagines can be read by simplify sending the
image over the Internet to someone somewhere in the world.
A better and safer procedure is to keep the images where they should
be...in a data storage devise and only storage the radiologist report in the
patient's record. There is no need for the actual x-ray or diagnosis image. In
many cases today, the imaging is actually read by a professional that may be
many miles away.
Evidence Based Medicine
One recent definition of Evidence Based Medicine was "The conscientious,
explicit and judicious use of current best evidence in making decisions about
the care of an individual patient. It means
integrating
individual clinical
expertise
with the
best available external clinical evidence from systematic
research.
Now if you look at
this, you will find a contradict. Individual Client Evidence is based on an
individuals practice methods and a limited number of experience. While External
Clinical evidence is just what it says....based on systematic research. In the
extreme case, if the Individual Healthcare professional has had only one case,
no matter what procedure he used, that was the only one he knew...Not much to
work with here!
The problem that
this person is trying to solve when he "created" this definition is that he is
still trying to say that the individual healthcare professional has
value....when it fact, Evidence Based Medicine really does eliminate the
individual choices of the Healthcare Professional!
Evidence based
medicine requires systems that measure outcomes. Medical processes cannot be
said to be evidence based unless they can be compared.
Collaboration among
care disciplines can become more objective and can be strengthened using
evidence as the driver for care-related decisions, rather than personal
preference or other subjective factors.
Research
Evidence-based-Medicine is based on Outcome
Measures. While health Outcome is one of the most difficult values to measure,
many of the techniques use the subjective evaluation of the Patient.
These subjective evaluations of the Patient
are just that…Subjective. In some research it was found that the longer the
HCP’s spent with the patient, the better the HCP’s ratings...does that make the
HCP a better healthcare professional? In other cases, the more drugs that the
HCP prescribed, the higher the HCP’s ratings? I have a very low option of
subjective evaluations and I do not think that they should be included in
Research.
However, where outcomes are directly
measureable, such as a decrease in the patient’s blood pressure, this value
along does not indicate that the patient has an improved health status. While
regulating one aspect of health and getting “better results” as determined by
some standard, the procedure may cause a worsening of other factors of health.
A good example, is that the effect of lowering Blood Pressure may decrease the
oxygenation of body cells…I do not know...but I never read where is does not!
Research can be improved by using larger populations. With a large centralized
data base using data mining this can be done...with a distributed system with
data scattered all over, this cannot be done. With automatic compiling of lists
of de-identification patient data, data can be made available without comprising
the client or the researcher.
Links
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