• Survival
• Complications
• Process of Care Measures
• Medical Errors
• Patient Satisfaction.

"Hospitals need reliable processes and systems of care delivery to achieve consistent excellence in performance. The result manifests in improved outcomes and risk-adjusted survival".

James White, M.D.

Introduction

As a consumer you will see many types of OUTCOMES and comparisons between institutions. Most of these will use only partially risk-adjusted outcomes and/or simple process of care measures. At INTEGRIS Heart Hospital we have used fully risk-adjusted outcomes plus four different types outcomes: complication rates, process of care measures, medical error reports and patient satisfaction surveys. Complete risk-adjusted survival rates are more expensive to acquire but the results are more consistent and accurate. This means solutions are working. The additional four types of outcomes allow a broader view of patient care and permit us to control important day to day supporting processes that assist patient care. We will discuss the methods of outcome measurement and each one of the types of outcomes so you can understand how quality is optimally measured. Although there are five major outcomes, which include risk-adjusted survival, complications, medical errors, process of care measurements, and patient satisfaction, RISK-ADJUSTED SURVIVAL is the most important and is in effect the sum of all of the other parts. However, risk adjustment, (i.e., comparing how sick patients are before treatment is given), is a complicated process. The method of risk adjustment needs to be both precise and complete.

Outcome Methods and Types of Reports

The gold standard instrument for measuring quality is called a clinically rich data registry. With a registry key patient information is collected in a file that holds information on how severe a patient's illness might be plus a list of any other problems (called co-morbidities) that might influence a patient's outcomes. As the patient progressed through treatment, careful observations are made about how the care is delivered and whether or not any complications have occurred. Periodically these files can be searched to compile reports on the management of a particular illness. These computerized summaries of patient care allow rapid reviews of outcomes without pulling thousands of charts or relying on memory to assess patient results. In the early days of quality management billing data systems or administrative databases were used. These are inexpensive and readily available but hold incomplete or clinically inaccurate data. In the last 15 years these have given way to clinically rich data registries developed specifically to measure outcomes and they permit full risk adjustment plus the ability to evaluate other important outcomes such as complications, process of care measures, medical errors and patient satisfaction. Each of these aspects adds a special perspective to measuring the quality of care and is important to the consumer.

The first and most important outcome is fully RISK-ADJUSTED SURVIVAL. Risk adjustment is a way of comparing the overall severity of illness of patients being treated in different institutions or by different doctors. It is a way of leveling the playing field so that valid comparisons can be made. Specific information on the severity of illness and associated patient problems called co-morbidities can be statistically evaluated to see how likely they are to lead to complications or death. It is possible to calculate a risk score from the prior experience of similar patients treated in the past. The likelihood a patient will survive and how much benefit he might gain on average from a given treatment can be calculated as an EXPECTED SURVIVAL. The actual rate of survival or complications is then summed and this is the OBSERVED SURVIVAL. The expected survival is the BENCHMARK; the object is to always exceed expectations. Risk adjusted survival is the most important outcome because it is the result of all of the contributions of the health care team and all of the supporting processes of care.

The second most important outcome is the COMPLICATION RATE. Sometimes a complicated course is just a slow recovery of a patient related to the severity of their illness. In this context it is considered a near miss and the patient is fortunate to have survived. Other complications occur as a direct consequence of other problems such as diabetes, lung disease or multiple blocked arteries in the rest of the body. Examples of these are infections with diabetes, pneumonia with lung disease and stroke with generalized hardening of the arteries. With certain countermeasures some of these complications can be prevented. We keep track of complication rates to make sure our supporting processes like early and quick removal of breathing tubes, use of antibiotics and careful control of blood sugars and screening patients for blocked neck arteries are being fully utilized. You will see reports that document the frequency of use of these preventive measures and the positive results they have had on stroke and complication rates.

The third most important outcome is the PROCESS OF CARE MEASURES. Certain processes should be considered for all patients. These can be put in place with simple checklists. If all of the basic treatments are supplied, then there is a small but measurable improvement in patient survival. A good example is in the treatment of heart attack. You have seen that heart attack survival rates have improved greatly during the past 30 years as new treatment technologies have arrived. However it is apparent that treatment is not always systematically delivered. For instance each patient should receive aspirin to reduce clots, betablockers to rest the heart, cholesterol drugs to lower late complications and quickly be taken to the catheterization laboratory to open the artery. If all of these things are done, then survival rates can drop from 5.8 percent to 4 percent. These differences are hard to see as an individual practicing physician but if performed nation wide they can result in thousands of lives being saved.

The fourth most important outcome is medical errors. In some cases the delivery of certain treatments can be handled inappropriately and can result in injury or death. These happen rarely in our environment. Surprisingly when these do occur, they can be traced to poorly controlled processes that create numerous near misses that are stopped by alert nurses or physicians before any damage is done. A new approach to stopping medical errors is to redesign the processes so they are more reliable and never lead to process breakdowns. In order to achieve this degree of organization there must be a culture of reporting process breakdowns and errors rather than just working around them. The INTEGRIS Heart Hospital strongly encourages reporting of process breakdowns and employees are thanked rather than criticized for their contributions. A mail box for reporting process breakdowns is kept on every floor and any reports are reviewed immediately by management.

The fifth most important outcome is patient satisfaction. Being hospitalized with a life threatening illness is a major stress and there are a number of actions the hospital can take to lessen this stress and make the environment comforting for the patient and family. After a patient is discharged a detailed questionnaire is mailed to patients so they can report on their general experience at the hospital. Whenever possible improvements are made in the elements of care that lead to higher comfort. Managers are held strictly accountable for the results of the survey.

Conclusion

INTEGRIS Heart Hospital uses multiple types of clinical outcomes to measure the quality of care being delivered. It uses these outcomes to modify the processes of care and to assure the use of all available technology to improve patient outcomes. Future reports will show better than expected risk adjusted survival rates in coronary bypass and coronary stent treatments. Complication rates will be low for infections, stroke and re-operations. Adherence to process of care lists for coronary bypass National Quality forum requirements will be very high. There are also very high adherence rates for quality check lists for congestive heart failure and heart attacks. These are the results of a detailed quality improvement process. Quality improvement is a dynamic process requiring constant measurements and rechecks. The highly accurate clinically rich databases are our basic measurement tools. The measurement of five types of outcomes across ten diagnostic areas gives us a much broader and in depth view of patient quality than is possible with standard reporting.

Outcomes Report
Ten-year Heart Bypass Surgical Survival Rates

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