#MEQAPI – Tweetchat Aug 2-2018 3:00ET Wait Times

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement, and you can visit us at http://www.meqapi.org.

Waiting is a non-value-added activity.

While an individual may try to recoup the time sitting in a waiting room, waiting for an appointment, or staring at the wall between the time the nurse took vitals and when the physician enters, the net effect is wasted time.

Patients wait between almost every healthcare transaction – from clarifying if they are covered by insurance, to getting an appointment, to be called by the nurse, to seeing the physician, to waiting for test results, to getting medications, to starting treatment. At every step, a patient can expect to be mostly waiting.

There are many causes for waiting, ranging from clinician shortages, to uneven geographical distribution of healthcare facilities, to insurance bureaucracy, and complex conditions,  but the biggest cause is probably a simple matter of process focus. By and large, healthcare is focused on profit and utilization management of high cost and capital resources. The focus is utilization of physicians and capital resources such as operating rooms, MRI scanners, etc. This focus views the patient as a consumer, and therefore externalizes any time they spend waiting. In contrast, an idle physician or MRI or operating room is seen as a disaster.

Waiting is in a large part, therefore, a feature, rather than a defect – as seen through the lens of healthcare priorities.

The effect on patients is heightened frustration and a poor experience, but also decreased access, increased health risks, and increase in missed opportunities. Diseases and injuries seldom wait idly, and generally get worse because of waiting. So the net effect goes beyond frustration, and translates into real harm – increased morbidity, and increased mortality.

This chat is to talk about waiting in the healthcare system – for appointments, for lab results, to see the doctor, … every time the patient or their clinician is simply waiting.

 

Waiting

Topics

  1. Policy: How are wait times influenced by laws, policies, rules, regulations in healthcare?
  2. Equipment: How do equipment and devices used in healthcare affect wait times? Everything from transport, to gurneys, beds, scanners, infusion sets, etc.
  3. Measurement: How do quality, safety, and performance metrics relate to wait time, what metrics are not being collected?
  4. Environment: What environmental factors relate to increased patient wait times?
  5. People: How do the people in healthcare – the staff, cleaners, clinicians, researchers, public, media, friends, family, etc affect patient wait times?
  6. Materials: What affect does the “medical stuff” patient sneed affect wait times? – the medications, instruction sheets, information, medication, test results, etc?

Background

MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.

To quote the IHI on what the Triple Aim encompasses:

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered. We expand this to include Accessibility, STEEEPA.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.

http://www.meqapi.org

The Author and Moderator: Matthew is a principal analyst for healthcare improvement at the Washington D.C. based firm of Whitney, Bradley, and Brown (WBB), and is a strategic adviser and board member at the Blue Faery Liver Cancer Association. Matthew is a peer reviewer for the international journal of Knowledge Management Research and Practice, and blogs regularly for Physician’s Weekly.

 

 

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#MEQAPI – Tweetchat July 26th 2017 3:00ET: Indistinct Medication Errors

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement.

Here’s the basic problem, and it can be deadly.

This image shows a medical error waiting to happen.

Indistinct

Medical error is arguably the third leading cause of death in the US, but we are not measuring medical error effectively, nor is medical error 100% avoidable.  While many arguments can be made that the underlying research is imperfect, it is clear that medication error is a large contributor to  injury and death, and also often unnecessary.

As was said in a previous blog “Medication errors result in missed opportunities, injury, and death. When the incorrect dose, incorrect medication, or wrong patient are in play, harm often results. Harm can also occur when incompatible combinations of drugs are administered – either because one drug reduced the efficacy of another, or because they worked similarly and resulted in an effective overdose”.

In an attempt to reduce drug-related harm, vendors and providers have tried many different fixes – ranging from making the fonts more readable, to electronic drug-drug interaction checks, to dispensing robots. However, the most obvious of all problems is that of indistinct medications – drugs and substances that can easily be misidentified or confused. This is especially so in the hurried and distracted environment in which medication is often dispensed, delivered, or administered.

Many medications are presented in forms that are indistinguishable without close scrutiny, with the result that many injuries and deaths are related to simple mix-ups between drugs or between drug concentrations.

These images courtesy of Dr. Rob Hackett (@patientsafe3)

In some cases of injury, the bottles of medication are identical, bar some very small lettering. This accident happens because we rely on nurses to be 100% vigilant, 100% suspicious of drug labels, 100% of the time. We assume that, like a robot, the nurse will never be distracted, never grow accustomed to a drug being in a known place, and never administering a drug before carefully rechecking the label against the patient and order.

indistinct 4

While that is theoretically admirable, in practice we are just setting up the conditions for failure and blame. In many cases the products are bar-coded, but there we rely on ubiquitous availability of scanners and connectivity at the bedside, and 100% vigilance.

indistinct 16

Even then, not all products that could be barcoded, are in fact barcoded, and again we rely on a very high degree of suspicion and awareness to avoid a catastrophe.

indistinct 13

Even when the drug is correct, the concentration may vary. Again, we rely on 100% alertness by the nurse to avoid a disaster.

 

indistinct 22

In some cases, the vendors add colored rings, or other (somewhat subtle) differences, but on the whole they rely on very small writing on the labels to distinguish plain water from Lignocaine, or Ergometrine from Epinophrine, or Xylocaine that is double the concentration between identical packages. In some cases, patients received a dose 100x the prescribed amount, simply because the concentrations were unclear. Often the only difference between a ten-fold difference in the same drug, or between entirely different drugs, is writing barely 2mm high.

What healthcare has NOT adopted, is the concept of Poka Yoke or “Mistake Proofing“. In simple terms, it should be almost impossible in practice to mistake two drugs or mistake two concentrations.

This requires standardization across all vendors and across all facilities. Barcodes should be on all medication containers, and the shape, color, and other identifying markings of drugs should be unmistakable, and consistent.

  • Barcoding is a very effective way to reduce errors, but this must be universal, and it must be practical to scan at the bedside in every case.
  • A cylindrical and clear ampoule should always be the same class of drug, and the concentration should be unmistakable, and a dimpled blue vial should always have the same drug, regardless of the vendor or location.

Medication safety requires that vendors and facilities not make up their own drug presentations or vary adoption of barcoding. Drug presentation should be based on what’s in the container and at what concentration it is, not based the manufacturing ease or marketing aesthetics of the vendor.

We will take a QI approach, and discuss the  topic using each of the typical arms of the basic Quality Improvement Ishikawa diagram to guide and support discussion. An Ishikawa diagram will be provided ahead of time and during the chat.

MEQAPI Medication Error

Participants will bring their own experiences, perspectives, and expectations to the discussion, but the topics might break down something along these lines:

    • Methods
      • Policies: office, organization, or national policies, including MU, HIPAA, etc
      • Workflow: how things are done including new patient onboarding, care provision, care coordination, ordering/prescribing, billing, patient transfer, etc.
      • Insurance Models, payer systems
      • Vendor policies and processes
      • Home visits
    • Machines (equipment, EHR)
      • Medical or office equipment
      • Home equipment specific to the patient condition
      • Integration/interoperation with other office or medical systems, or user personal health records
      • Medication dispensing systems
    • People
      • Staffing: sufficient and qualified staff
      • Training: base training, ongoing training, CME, and patient or carer training
      • Attitudes: staff attitudes to technology, adoption vs resistance
      • Fatigue (especially alert fatigue)
    • Materials
      • Patients: as the “raw material” of the medical process. Patients may come with a range of attitudes, health problems, life situations, and ability to comply with treatment that are challenging and stressful.
      • Supplies: medical or office
      • Data: ability to securely share with correct patient, specialist, lab, etc
      • Patient self-care materials including checklists and how-to instructions, contact information for questions, and self-care consumables
      • Drug information sheets
    • Measurement
      • KPIs: operational metrics required by practice, local government, state, federal
      • Quality and safety metrics
      • Targets: set by practice, insurer, etc.
      • Monitoring of home-care
      • Adverse Effects reporting
    • Environment
      • Noise: distracting noises, sound levels too high, distractions, etc.
      • Space: Cramped, uncomfortable work space etc.
      • Lighting: too dim, shadows, flickering light, reflection
      • Time: Too little time per patient or order, too little time in a day, too many demands
      • Location: things where they should be  relative to point of care and patient

Some of the authors of the works cited above may be responding to the following topics, and participants are invited to describe their experiences of medication errors, and offer their insights and observations.

Topics

  1. What Policies, practices, and laws increase or reduce the risk of medication errors from indistinct drugs
  2. What Equipment factors increase or reduce the risk of medication errors from indistinct drugs
  3. What People issues increase or reduce the risk of medication errors from indistinct drugs
  4. What Materials increase or reduce the risk of medication errors from indistinct drugs
  5. What Measurement factors increase or reduce the risk of medication errors from indistinct drugs
  6. What Environmental factors increase or reduce the risk of medication errors from indistinct drugs

Background

MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.

To quote the IHI on what the Triple Aim encompasses:

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:

Improving the patient experience of care (including quality and satisfaction);
Improving the health of populations; and
Reducing the per capita cost of health care.
The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered. We expand this to include Accessibility, STEEEPA.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.

http://www.meqapi.org

The Author and Moderator: Matthew is a principal analyst for healthcare improvement at the Washington D.C. based firm of Whitney, Bradley, and Brown (WBB), and is a strategic adviser and board member at the Blue Faery Liver Cancer Association. Matthew is a peer reviewer for the international journal of Knowledge Management Research and Practice, and blogs regularly for Physician’s Weekly.

#MEQAPI – Tweetchat July 12-2018 3:00ET Women’s Healthcare Experience

Just a reminder, MEQAPI stands for Monitoring & Evaluation, Quality Assurance, and Process Improvement, and you can visit us at http://www.meqapi.org.

This is a very difficult blog for me to write, and although I have received input from several women on their experience of healthcare, it is still a very alien terrain for me. It is also somewhat presumptuous of me, as a man, to think that I understand what it is like to need, seek, and obtain medical care, as a woman.

So even though I may have great intentions, my experience level is zero, and my insight potentially very thin. But then that gap is partially why it is important for men to think though what it may be like for women to seek care.

Imagine, as a man, what it would be like if there were no physicians in your zip code, or perhaps for several zip codes around you, that treated very immediate, frequent, and serious health concerns that you had. Imagine that for women this was different. Imagine they had plentiful choices of physicians. Picture that the state made very restrictive laws around core features of your health, and that you paid 20% more for your healthcare than women – not because it cost more to treat you, but simply because of your gender.

Imagine that your typical experience was somewhat dismissive, derogatory, and suboptimal.

By all accounts, this is the typical female experience of healthcare in the U.S.

This chat is to talk about what it is like as a woman to go though the healthcare system – to need care, to seek it, to get it (or not), to pay for it, to have a say in it.

 

Womens health

Topics

  1. Policy: What is the female experience of the laws, policies, rules, regulations surrounding their healthcare?
  2. Equipment: What is the female experience of the equipment and devices used in their healthcare?
  3. Measurement: What is the female viewpoint of the measurement of healthcare safety, timeliness, effectiveness, efficiency, equitibility, patient-centeredness, and accessibility?
  4. Environment: What is the female experience of their healthcare environment – the location of practices, the waiting rooms, the examination rooms, the transport services, parking, etc.?
  5. People: What is the female experience of the people in healthcare – the staff, cleaners, clinicians, researchers, public, media, friends, family, etc?
  6. Materials: What is the female experience of the “medical stuff” they are given – the medications, the instruction sheets, the information, the gowns, sheets, bedding, etc?

Background

MEQAPI focuses on healthcare improvement, and in the spirit of shameless borrowing (and efficiency), takes existing perspectives from the IHI, AHRQ, and others.

To quote the IHI on what the Triple Aim encompasses:

The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

The six domains of care quality (STEEEP) mapped out by the Agency for Healthcare Research and Quality (AHRQ) are foundational to healthcare improvement. All care, and by inference quality measures, should be focused on being Safe, Timely, Effective, Efficient, Equitable, and Patient Centered. We expand this to include Accessibility, STEEEPA.

The MEQAPI tweetchat aims to give voice to a broad range of stakeholders in healthcare improvement, and it embraces everyone from administrators to zoologists, and includes physicians, nurses, researchers, bed czars, cleaners, and yes, patients and care-givers.

http://www.meqapi.org

The Author and Moderator: Matthew is a principal analyst for healthcare improvement at the Washington D.C. based firm of Whitney, Bradley, and Brown (WBB), and is a strategic adviser and board member at the Blue Faery Liver Cancer Association. Matthew is a peer reviewer for the international journal of Knowledge Management Research and Practice, and blogs regularly for Physician’s Weekly.