#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.

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#MEQAPI – Tweetchat Feb 15-2018 3:00ET Amplifying Women’s Voices

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

It is a fact that women in science and medicine have less voice than men. This manifests in women being interrupted more, being asked for opinion less, being on fewer expert panels, etc. It is seen when a female physician is assumed to be a nurse, the male nurse is assumed to be a physician, and patients, families, and clinicians alike will turn to the male in the discussion to corroborate what the woman says.

These are facts.

In one thin slice of this unfortunate pie, women use social media such as Twitter less than men (47% vs 53%), get retweeted less frequently, have few followers, and are again, often spoken over in conversations.

This is, quite naturally, very irritating and demoralizing to  the women involved, but it shadows a more dangerous threat – it harms quality and safety. Undersampling, ignoring, and failing to engage women’s voices in medicine degrades quality, increases risk, and worsens the health outcomes of patients. Everything runs slower, has more errors, and costs more when we mute the voice of half the healthcare workforce.

This chat will look at several dimensions pertinent to the problem, and ask how to improve the situation.

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.

Women Voice

 

  • Policies
    • Facility or work unit policies, practices, rules
    • Specialty-specific policies
    • Human Resource guidelines, policies, etc.
    • Workflow and standard practices
    • Training
  • Work
    • Projects in which women are selected, lead, initiate, etc
    • Consultation of women for input, expert opinion, etc.
    • Recognition for achievement, effort, support, etc.
    • Plagiarism, theft or unattributed use of ideas, work, etc.
    • Sabotage of women’s work
    • Space, physical, time, and mental space to do creative work
    • Built environment, situation of toilets, parking, change rooms, rest areas, etc.
    • Time
  • Social Media
    • Follows
    • Retweets and Likes
    • Online bullying
    • Interruptions
    • Shunning
  • Conferences
    • Selection of speakers, panel members, judges, etc.
    • Seating
    • Interruptions
    • Questions
    • Disruptions
    • Post-conference follow up
  • People
    • Patients
    • Providers/HCP
    • Role Models
    • Sexualization
    • Diminishment
    • Peer support
    • Attitudes and bullying
  • Other
    • Environment
    • Pay
    • Equipment
    • Measurement
    • Recruitment
    • Other

Topics

  1. What POLICIES increase or reduce the ability of Women to be Heard in Medicine and Science
  2. What WORK factors increase or reduce the ability of Women to be Heard in Medicine and Science
  3. What SOCIAL MEDIA issues increase or reduce the ability of Women to be Heard in Medicine and Science
  4. What CONFERENCE issues increase or reduce the ability of Women to be Heard in Medicine and Science
  5. What PEOPLE factors increase or reduce the ability of Women to be Heard in Medicine and Science
  6. What OTHER factors increase or reduce the ability of Women to be Heard in Medicine and Science

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 Affordability, 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 at Whitney, Bradley, and Brown Inc. focused on healthcare improvement, and serves on the board of directors of the Blue Faery Liver Cancer Association. Matthew is the founder of the Monitoring & Evaluation, Quality Assurance, and Process Improvement (MEQAPI) organization, and is a KM and quality improvement author, and regularly blogs for Physician’s Weekly. Matthew’s pro bono roles have included support for the Queensland Emergency Medicine Research Foundation and the St. Andrew’s Medical Research Institute. Matthew is active on social media related to healthcare improvement and hosts the weekly #MEQAPI chat. Matthew also trains others in the use of MAXQDA. You can find his contact info in his MAXQDA professional trainer profile

 

 

#MEQAPI – Tweetchat Nov 30-2017 3:00ET Obesity: Effects on Practice

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

The steep rise in prevalence of obesity has had an effect on how medical practices operate. Everything from the width of doorways to seating configurations in waiting rooms, OR and inpatient bed reinforcements, gurney and stretcher design, hypodermic needle length, and dosage increments have had to accommodate the increasing size of patients.

Many years ago on an ambulance call to a local restaurant, and before the obesity epidemic, I came face to face with the practical problems related to obesity. The patient was a middle-aged male complaining of radiating chest pain, shortness of breath, and that old specter of “impending sense of doom”. Immediate history was a large meal, several units of wine, brandy and cigars, and a fierce argument with his wife over desert. What may have started with indigestion, anger, and a touch of gastric reflux turned into stress-induced angina. Of course, his 5’8″ 250 lb frame and history of hypertension added to the mix.

The most immediate problem was that he had sagged into a low chair, and our three-person EMT team was unable to lift him onto the collapsible ambulance gurney – which was also too narrow and did not have sufficiently strong struts in the collapsible undercarriage to bear his weight.

This Mobi Ambulance stretcher is a good example of equipment that is designed to be light-weight, and for its ability to load and secure easily in a standard ambulance. Ours was similar, but also many years ago, before fancy titanium alloys.

mobi-3g-aluminum-alloy-stretcher

Plan-B was to use the scoop stretcher.

Civiere_a_aubes

Author CDang

We quickly realized that we couldn’t get the halves together without manhandling the patient, pinching him, or tearing chunks out of ourselves. Once on the stretcher, we found he was overflowing the sides which were putting pressure on his tissue to an alarming degree. On lifting him, our alarm shifted to an unexpected degree of bowing in the stretcher frame that threatened to pop open the catches at the ends.

Naturally, the elevator was too short to accommodate us, and the two flights of stairs to the ground level was a physical challenge, as was the process of lifting him into the back of the ambulance.

The patient was safely delivered to a ED without being dropped or harmed, but the experience and our painful backs taught us that our equipment was just not suited to heavy patients, and that we had to rethink what we would dispatch to calls that involved high-BMI patients.

In this chat, we will scan the six arms of the QI framework, and discuss what challenges are encountered in medical practices, clinics, and hospitals, and what adaptations are required to provide care  for patients with high BMI.

 

 

Obesity

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, etc
      • Workflow: how things are done including new patient onboarding, care provision, care coordination, ordering/prescribing, billing, patient transfer, etc.
      • Quality Improvement Policies
      • Subsidies and funding
      • Facility Policies
      • Specialty Policies
      • Employment policies
      • National and State Laws
      • Training
      • Navigable processes and policies
      • Patient Centeredness
      • Evidence Based Medicine standards
      • Value-based Care
    • Machines (incl equipment, EHR)
      • Personal Safety Equipment
      • Real Time Locator Systems (RTLS)
      • Med Equipment
      • Test and scanning equipment
      • Equip Ergonomics
      • Interoperability
      • EHR/Software
      • TeleHealth
      • Home Equipment
      • Access Control
      • Office Equipment
      • Product tracking
      • Outcomes tracking
    • People
      • Staffing: sufficient and qualified staff
      • Patients – objectives, attitudes, ability to cope, beliefs, power-distance, health literacy
      • Subject Experts
      • Malpractice suits
      • Role Models, celebrity influence
      • Peer support/conflict
      • Training
      • Vendors
      • Friends/Family
      • Patient participation
      • Attitudes/Bullying
    • 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, inferior fax paper,
      • Data: ability to securely share with correct patient, specialist, lab, etc., and Access to Information
      • Patient self-care materials including checklists and how-to instructions, contact information for questions, and self-care consumables
      • OTC and home remedies and drugs
      • Impurities and variances in product strength and effect
      • Internet sources and access
      • Checklists, SoPs
      • Uniforms, footwear, personal protective equipment
      • Costed consumables
    • Measurement
      • Health outcomes
      • KPIs: operational metrics required by practice, local government, state, federal
      • Quality and safety metrics
      • Adverse effects reporting and metrics
      • Targets: set by practice, insurer, etc. as well as patient goals
      • Gini Index
      • Incentives and rewards
      • Adverse Event reporting
      • Effectiveness of measurement
      • Productivity Metrics
      • Patient Goals
    • Environment
      • Noise: distracting noises, sound levels too high, etc. due to computer systems
      • Space: Cramped, uncomfortable work space etc.
      • Time: Too little time per patient or order, too little time in a day, too many demands
      • Location: things where they should be on the screen, click distance, and location of workstation relative to point of care and patient
      • Control: the degree to which the individual can control their workload and how to accomplish it
      • Fairness: the perception that the burdens and rewards, the effort and outcomes are spread amongst stakeholders in an equitable way
      • Contamination and impurities
      • Temperature: too cold, too hot, too variable
      • Interruptions
      • Political climate
      • Social norms and group identity
      • Electrical Power
      • Climate and weather
      • Income inequality
      • Time
      • Direct marketing to patients

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 METHODS are involved in risks, issues, or practice adaptations to obesity
  2. What MACHINE factors are involved in risks, issues, or practice adaptations to obesity
  3. What PEOPLE factors are involved in risks, issues, or practice adaptations to obesity
  4. What MATERIALS are involved in risks, issues, or practice adaptations to obesity
  5. What MEASUREMENT factors are involved in risks, issues, or practice adaptations to obesity
  6. What ENVIRONMENTAL factors are involved in risks, issues, or practice adaptations to obesity

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 Affordability, 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 to the Blue Faery Liver Cancer Association. Matthew is a peer reviewer for the international journal of Knowledge Management Research and Practice, and writes on topics related to healthcare quality improvement and knowledge management.

 

 

#MEQAPI – Tweetchat Nov 2-2017 3:00ET Complementary Modalities

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

Firstly, some definition around what we mean by “complementary care” modalities.

We are distinguishing between care modalities that are “alternative” and those that are “complementary”. By alternative, we mean any care modality that is not Evidence Based Medicine (EBM) and which replaces EBM. Offering aromatherapy, yoga, or homeopathy instead of EBM, would be seen in this context as “alternative”.

In contrast, some of the same modalities may be seen as complementary where they are used in conjunction with EBM. Here there is a lot to say for modalities which enhance access or efficacy of EBM and which thereby lead to improved patient outcomes.

In looking at complementary modalities, we should perhaps examine them in the light of the MEQAPI standard – will they lead to care that is STEEEPA. Will the resulting care be Safe, Timely, Effective, Efficient, Equitable, Patient-Centered, and Affordable?

Consider this: while we might dismiss the use of aromatherapy as a replacement for drugs to treat cancer, what if the aromatherapy could help the patient to stick with their chemotherapy? What if art therapy didn’t replace clinical talk therapy and anti-psychotics, but enabled the patient to attend sessions and stay on their medication?

If a complementary care modality results in a patient achieving their health goals in a way that is STEEEPA, is there any reason to object? If their drumming sessions, acupuncture, or meditation puts them in a mental place from which they are more able to access, use, and stay with their EBM care plan, should it be encouraged?

There are obviously considerations and potential complications – will the complementary modality add any risks, affect dosages or create additional side effects, or lead to confusion in results of medical tests?

The potential downsides to complementary care are numerous: they are often unregulated and have wide variation is dosage and effect. Herbal and other potions, lotions, and products may containvery serious contaminants, including arsenic, lead, and mercury. Physical manipulations such as chiropractic have been linked to internal injuries, including broken bones, and may create a significant stroke risk.

Some “natural” remedies have very serious interactions with EBM drugs, and many cases have been listed of injury and death because the remedy either reduced the efficacy of a critical drug, or added to the effect in ways that resulted in harmful overdose.

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.

Complimentary Care

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, etc
      • Workflow: how things are done including new patient onboarding, care provision, care coordination, ordering/prescribing, billing, patient transfer, etc.
      • Quality Improvement Policies
      • Subsidies and funding
      • Facility Policies
      • Specialty Policies
      • Employment policies
      • National and State Laws
      • Training
      • Navigable processes and policies
      • Patient Centeredness
      • Evidence Based Medicine standards
      • Value-based Care
    • Machines (incl equipment, EHR)
      • Personal Safety Equipment
      • Real Time Locator Systems (RTLS)
      • Med Equipment
      • Test and scanning equipment
      • Equip Ergonomics
      • Interoperability
      • EHR/Software
      • TeleHealth
      • Home Equipment
      • Access Control
      • Office Equipment
      • Product tracking
      • Outcomes tracking
    • People
      • Staffing: sufficient and qualified staff
      • Patients – objectives, attitudes, ability to cope, beliefs, power-distance, health literacy
      • Subject Experts
      • Malpractice suits
      • Role Models, celebrity influence
      • Peer support/conflict
      • Training
      • Vendors
      • Friends/Family
      • Patient participation
      • Attitudes/Bullying
    • 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, inferior fax paper,
      • Data: ability to securely share with correct patient, specialist, lab, etc., and Access to Information
      • Patient self-care materials including checklists and how-to instructions, contact information for questions, and self-care consumables
      • OTC and home remedies and drugs
      • Impurities and variances in product strength and effect
      • Internet sources and access
      • Checklists, SoPs
      • Uniforms, footwear, personal protective equipment
      • Costed consumables
    • Measurement
      • Health outcomes
      • KPIs: operational metrics required by practice, local government, state, federal
      • Quality and safety metrics
      • Adverse effects reporting and metrics
      • Targets: set by practice, insurer, etc. as well as patient goals
      • Gini Index
      • Incentives and rewards
      • Adverse Event reporting
      • Effectiveness of measurement
      • Productivity Metrics
      • Patient Goals
    • Environment
      • Noise: distracting noises, sound levels too high, etc. due to computer systems
      • Space: Cramped, uncomfortable work space etc.
      • Time: Too little time per patient or order, too little time in a day, too many demands
      • Location: things where they should be on the screen, click distance, and location of workstation relative to point of care and patient
      • Control: the degree to which the individual can control their workload and how to accomplish it
      • Fairness: the perception that the burdens and rewards, the effort and outcomes are spread amongst stakeholders in an equitable way
      • Contamination and impurities
      • Temperature: too cold, too hot, too variable
      • Interruptions
      • Political climate
      • Social norms and group identity
      • Electrical Power
      • Climate and weather
      • Income inequality
      • Time
      • Direct marketing to patients

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 METHODS increase or reduce risks related to use of Complementary Care Modalities
  2. What MACHINE factors increase or reduce risks related to use of Complementary Care Modalities
  3. What PEOPLE issues increase or reduce risks related to use of Complementary Care Modalities
  4. What MATERIALS increase or reduce risks related to use of Complementary Care Modalities
  5. What MEASUREMENT factors increase or reduce risks related to use of Complementary Care Modalities
  6. What ENVIRONMENTAL factors increase or reduce risks related to use of Complementary Care Modalities

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 Affordability, 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 to the Blue Faery Liver Cancer Association. Matthew is a peer reviewer for the international journal of Knowledge Management Research and Practice, and writes on topics related to healthcare quality improvement and knowledge management.

 

 

#MEQAPI – Tweetchat Nov 2-2017 3:00ET Complementary Modalities

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

Firstly, some definition around what we mean by “complementary care” modalities.

We are distinguishing between care modalities that are “alternative” and those that are “complementary”. By alternative, we mean any care modality that is not Evidence Based Medicine (EBM) and which replaces EBM. Offering aromatherapy, yoga, or homeopathy instead of EBM, would be seen in this context as “alternative”.

In contrast, some of the same modalities may be seen as complementary where they are used in conjunction with EBM. Here there is a lot to say for modalities which enhance access or efficacy of EBM and which thereby lead to improved patient outcomes.

In looking at complementary modalities, we should perhaps examine them in the light of the MEQAPI standard – will they lead to care that is STEEEPA. Will the resulting care be Safe, Timely, Effective, Efficient, Equitable, Patient-Centered, and Affordable?

Consider this: while we might dismiss the use of aromatherapy as a replacement for drugs to treat cancer, what if the aromatherapy could help the patient to stick with their chemotherapy? What if art therapy didn’t replace clinical talk therapy and anti-psychotics, but enabled the patient to attend sessions and stay on their medication?

If a complementary care modality results in a patient achieving their health goals in a way that is STEEEPA, is there any reason to object? If their drumming sessions, acupuncture, or meditation puts them in a mental place from which they are more able to access, use, and stay with their EBM care plan, should it be encouraged?

There are obviously considerations and potential complications – will the complementary modality add any risks, affect dosages or create additional side effects, or lead to confusion in results of medical tests?

The potential downsides to complementary care are numerous: they are often unregulated and have wide variation is dosage and effect. Herbal and other potions, lotions, and products may containvery serious contaminants, including arsenic, lead, and mercury. Physical manipulations such as chiropractic have been linked to internal injuries, including broken bones, and may create a significant stroke risk.

Some “natural” remedies have very serious interactions with EBM drugs, and many cases have been listed of injury and death because the remedy either reduced the efficacy of a critical drug, or added to the effect in ways that resulted in harmful overdose.

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.

Complimentary Care

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, etc
      • Workflow: how things are done including new patient onboarding, care provision, care coordination, ordering/prescribing, billing, patient transfer, etc.
      • Quality Improvement Policies
      • Subsidies and funding
      • Facility Policies
      • Specialty Policies
      • Employment policies
      • National and State Laws
      • Training
      • Navigable processes and policies
      • Patient Centeredness
      • Evidence Based Medicine standards
      • Value-based Care
    • Machines (incl equipment, EHR)
      • Personal Safety Equipment
      • Real Time Locator Systems (RTLS)
      • Med Equipment
      • Test and scanning equipment
      • Equip Ergonomics
      • Interoperability
      • EHR/Software
      • TeleHealth
      • Home Equipment
      • Access Control
      • Office Equipment
      • Product tracking
      • Outcomes tracking
    • People
      • Staffing: sufficient and qualified staff
      • Patients – objectives, attitudes, ability to cope, beliefs, power-distance, health literacy
      • Subject Experts
      • Malpractice suits
      • Role Models, celebrity influence
      • Peer support/conflict
      • Training
      • Vendors
      • Friends/Family
      • Patient participation
      • Attitudes/Bullying
    • 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, inferior fax paper,
      • Data: ability to securely share with correct patient, specialist, lab, etc., and Access to Information
      • Patient self-care materials including checklists and how-to instructions, contact information for questions, and self-care consumables
      • OTC and home remedies and drugs
      • Impurities and variances in product strength and effect
      • Internet sources and access
      • Checklists, SoPs
      • Uniforms, footwear, personal protective equipment
      • Costed consumables
    • Measurement
      • Health outcomes
      • KPIs: operational metrics required by practice, local government, state, federal
      • Quality and safety metrics
      • Adverse effects reporting and metrics
      • Targets: set by practice, insurer, etc. as well as patient goals
      • Gini Index
      • Incentives and rewards
      • Adverse Event reporting
      • Effectiveness of measurement
      • Productivity Metrics
      • Patient Goals
    • Environment
      • Noise: distracting noises, sound levels too high, etc. due to computer systems
      • Space: Cramped, uncomfortable work space etc.
      • Time: Too little time per patient or order, too little time in a day, too many demands
      • Location: things where they should be on the screen, click distance, and location of workstation relative to point of care and patient
      • Control: the degree to which the individual can control their workload and how to accomplish it
      • Fairness: the perception that the burdens and rewards, the effort and outcomes are spread amongst stakeholders in an equitable way
      • Contamination and impurities
      • Temperature: too cold, too hot, too variable
      • Interruptions
      • Political climate
      • Social norms and group identity
      • Electrical Power
      • Climate and weather
      • Income inequality
      • Time
      • Direct marketing to patients

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 METHODS increase or reduce risks related to use of Complementary Care Modalities
  2. What MACHINE factors increase or reduce risks related to use of Complementary Care Modalities
  3. What PEOPLE issues increase or reduce risks related to use of Complementary Care Modalities
  4. What MATERIALS increase or reduce risks related to use of Complementary Care Modalities
  5. What MEASUREMENT factors increase or reduce risks related to use of Complementary Care Modalities
  6. What ENVIRONMENTAL factors increase or reduce risks related to use of Complementary Care Modalities

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 Affordability, 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 to the Blue Faery Liver Cancer Association. Matthew is a peer reviewer for the international journal of Knowledge Management Research and Practice, and writes on topics related to healthcare quality improvement and knowledge management.

 

 

#MEQAPI – Tweetchat Oct 19-2017 3:00ET #ChoosingWisely

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

I want you to look at the following chart. It categorizes the current level of waste in the U.S. Healthcare system in billions of dollars, per year.

MEQAPI- Waste

The “good” news is that we aren’t missing too many opportunities to prevent illness – only $55 Billion dollars a year are lost because we didn’t effectively address a preventable illness.

The rest of the news is pretty appalling. We waste more on fraud and abuse than missed opportunities, and even knowing that medical prices in the U.S. are exorbitant, excessive prices are easily outstripped by how inefficiently we deliver care. And then there is oversupply. $210 Billion in oversupply is a stunning number, made even more ironic because even with that, we still had the $55 Billion worth of missed opportunities.

One component of a solution to bringing down these embarrassing numbers is to partner with patients in a value-based and patient-centered approach to using evidence-based medicine in a way that addresses the patients health goals.

Let’s unpack that jargon-stew.

  • Patient partnership: plainly put, if the patient isn’t part of the team, then chances are they won’t comply at a very high rate, and the care plan will address something other than what the patient sees as priorities. Priorities must be a joint effort, and not dictated by the physicians if we want the patients to comply with the plan and have a sense of ownership, and not left to the patient if we want the plan to be medically sound.
  • Value-based: The alternative option is Fee-for-Service, which prioritizes profit over patient well-being, and nothing will shut down patient trust and partnership faster than the thought that the selection of the care plan is about profits rather than health.
  • Patient-Centered:  IOM (Institute of Medicine) describes patientcentered care as: “Providing care that is respectful of, and responsive to,  individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.”
  • Evidence-based medicine: This is about using things that work, and updating practice to stay in line with what we can prove is working. Masic et al, describe EBM is follows “… the conscientious, explicit, judicious and reasonable use of modern, best evidence in making decisions about the care of individual patients. EBM integrates clinical experience and patient values with the best available research information.

The American Board of Internal Medicine (ABIM) has launched the “Choosing Wisely” campaign as an attempt to move us down this path.

Choosing Wisely aims to promote conversations between clinicians and patients by helping patients choose care that is:

  • Supported by evidence
  • Not duplicative of other tests or procedures already received
  • Free from harm
  • Truly necessary

 

The following pertinent articles have been provided by Physician’s Weekly:

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.

ChoosingWisely

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, etc
      • Workflow: how things are done including new patient onboarding, care provision, care coordination, ordering/prescribing, billing, patient transfer, etc.
      • Quality Improvement Policies
      • Subsidies and funding
      • Facility Policies
      • Specialty Policies
      • Employment policies
      • National and State Laws
      • Training
      • Navigable processes and policies
      • Patient Centeredness
      • Evidence Based Medicine
      • Value-based Care
    • Machines (incl equipment, EHR)
      • Personal Safety Equipment
      • Real Time Locator Systems (RTLS)
      • Med Equipment
      • Equip Ergonomics
      • Interoperability
      • EHR/Software
      • TeleHealth
      • Home Equipment
      • Access Control
      • Office Equipment
      • Product tracking
      • Outcomes tracking
    • People
      • Staffing: sufficient and qualified staff
      • Patients – objectives, attitudes, ability to cope, beliefs, power-distance, health literacy
      • Subject Experts
      • Malpractice suits
      • Role Models, celebrity influence
      • Peer support/conflict
      • Training
      • Vendors
      • Friends/Family
      • Patient participation
      • Attitudes/Bullying
    • 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, inferior fax paper,
      • Data: ability to securely share with correct patient, specialist, lab, etc., and Access to Information
      • Patient self-care materials including checklists and how-to instructions, contact information for questions, and self-care consumables
      • Internet sources and access
      • Checklists, SoPs
      • Uniforms, footwear, personal protective equipment
      • Costed consumables
    • Measurement
      • Health outcomes
      • KPIs: operational metrics required by practice, local government, state, federal
      • Quality and safety metrics
      • Targets: set by practice, insurer, etc. as well as patient goals
      • Gini Index
      • Incentives and rewards
      • Adverse Eventss reporting
      • Effectiveness of measurement
      • Productivity Metrics
      • Patient Goals
    • Environment
      • Noise: distracting noises, sound levels too high, etc. due to computer systems
      • Space: Cramped, uncomfortable work space etc.
      • Time: Too little time per patient or order, too little time in a day, too many demands
      • Location: things where they should be on the screen, click distance, and location of workstation relative to point of care and patient
      • Control: the degree to which the individual can control their workload and how to accomplish it
      • Fairness: the perception that the burdens and rewards, the effort and outcomes are spread amongst stakeholders in an equitable way
      • Temperature: too cold, too hot, too variable
      • Interruptions
      • Political climate
      • Social norms and group identity
      • Electrical Power
      • Climate and weather
      • Income inequality
      • Time
      • Direct marketing to patients

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 METHODS increase or reduce risks related to achieving the aims of #ChoosingWisely
  2. What MACHINE factors increase or reduce risks related to achieving the aims of #ChoosingWisely
  3. What PEOPLE issues increase or reduce risks related to achieving the aims of #ChoosingWisely
  4. What MATERIALS increase or reduce risks related to achieving the aims of #ChoosingWisely
  5. What MEASUREMENT factors increase or reduce risks related to achieving the aims of #ChoosingWisely
  6. What ENVIRONMENTAL factors increase or reduce risks related to achieving the aims of #ChoosingWisely

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.

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

#MEQAPI – Tweetchat Oct 12-2017 3:00ET Vaccine Refusal

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

Last week we chatted about how antibiotic resistance is a threat that just keeps giving, and how vaccines can help to reduce the impact. Yet vaccine adoption has its own problems. Two medical causes of non-adoption are allergies to vaccine components, and compromised immune systems. However, the biggest obstacle to adoption is that there is an influential and vociferous anti-vaccine movement that results in vaccine Hesitancy in the public. Vaccine Hesitancy can be further divided into two main categories:

  1. Vaccine Refusal: includes people who are susceptible, but who themselves refuse to take vaccines at the prescribed times, or deny vaccines as guardians to minors or others.
  2. Vaccine Delay: includes those who are open to being vaccinated themselves or for vaccination of their dependents, but who wait until some time after the recommended time of inoculation. This may involve wanting single vaccines instead of the combination versions such as the Measles, Mumps and Rubella (MMR), and the Diphtheria, Tetanus, and Pertussis vaccine (DTaP).

McKee and Bohannon list four categories for vaccine refusal or delay:

  • Religious reasons,
  • Personal beliefs or philosophical reasons,
  • Safety concerns, and
  • Desire for more information from healthcare providers.

The sizable (and increasing) number of hesitant people raises fears of increased outbreaks, especially of the pathogens with high basic reproduction number, such as Measles, Diphtheria, and Rubella.

The risks are not unknown to healthcare professionals, and some practices  have “fired” patients who refuse vaccines, on the grounds that these patients present a real and significant risk to other patients that they might encounter in waiting rooms.

The following pertinent articles have been provided by Physician’s Weekly:

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.

Vaccine Hesitancy

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, etc
      • Workflow: how things are done including new patient onboarding, care provision, care coordination, ordering/prescribing, billing, patient transfer, etc.
      • Quality Improvement Policies
      • Subsidies and funding
      • Facility Policies
      • Specialty Policies
      • Employment policies
      • National and State Laws
      • Training
      • Navigable processes and policies
      • Vaccine refusal laws
    • Machines (incl equipment, EHR)
      • Personal Safety Equipment
      • Real Time Locator Systems (RTLS)
      • Med Equipment
      • Equip Ergonomics
      • Interoperability
      • EHR/Software
      • TeleHealth
      • Home Equipment
      • Access Control
      • Office Equipment
      • Product tracking
    • People
      • Staffing: sufficient and qualified staff
      • Patients – objectives, attitudes, ability to cope, beliefs, power-distance, health literacy
      • Subject Experts
      • Malpractice suits
      • Role Models, celebrity influence
      • Peer support/conflict
      • Training
      • Vendors
      • Friends/Family
      • Crime and safety
      • Attitudes/Bullying
    • 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, inferior fax paper,
      • Data: ability to securely share with correct patient, specialist, lab, etc., and Access to Information
      • Patient self-care materials including checklists and how-to instructions, contact information for questions, and self-care consumables
      • Internet sources and access
      • Checklists, SoPs
      • Uniforms, footwear, personal protective equipment
      • Costed consumables
      • Combo vaccines
      • “Show me a needle” advertising
    • Measurement
      • Health outcomes
      • KPIs: operational metrics required by practice, local government, state, federal
      • Quality and safety metrics
      • Targets: set by practice, insurer, etc. as well as patient goals
      • Gini Index
      • Incentives and rewards
      • Adverse Eventss reporting
      • Effectiveness of measurement
      • Productivity Metrics
      • Patient Goals
      • R0, outbreaks, and spread
    • Environment
      • Noise: distracting noises, sound levels too high, etc. due to computer systems
      • Space: Cramped, uncomfortable work space etc.
      • Time: Too little time per patient or order, too little time in a day, too many demands
      • Location: things where they should be on the screen, click distance, and location of workstation relative to point of care and patient
      • Control: the degree to which the individual can control their workload and how to accomplish it
      • Fairness: the perception that the burdens and rewards, the effort and outcomes are spread amongst stakeholders in an equitable way
      • Temperature: too cold, too hot, too variable
      • Interruptions
      • Political climate
      • Social norms and group identity
      • Electrical Power
      • Climate and weather
      • Income inequality
      • Time
      • Direct marketing to patients

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 METHODS increase or reduce risks related to Vaccine Hesitancy
  2. What MACHINE factors increase or reduce risks related to Vaccine Hesitancy
  3. What PEOPLE issues increase or reduce risks related to Vaccine Hesitancy
  4. What MATERIALS increase or reduce risks related to Vaccine Hesitancy
  5. What MEASUREMENT factors increase or reduce risks related to Vaccine Hesitancy
  6. What ENVIRONMENTAL factors increase or reduce risks related to Vaccine Hesitancy

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.

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