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  • /K/ .

  • Orthopaedic Surgeryand Healthcare QualityKonstantinos D. Theologou, M.D., D.Sc., M.Sc, rthopaedic Surgeon.

  • QUALITY DEFINITION

    A MEASURE OF EXCELLENCE A STATE OF BEING FREE FROM DEFECTS, DEFICIENCIES AND SIGNIFICANT VARIATIONS. STRICT AND CONSISTENT COMMITMENT TO CERTAIN STANDARDS THAT ACHIEVE UNIFORMITY OF A PRODUCT IN ORDER TO SATISFY SPECIFIC CUSTOMER OR USER REQUIREMENTS.

    http://www.businessdictionary.com/definition/quality.html#ixzz2OvFer6mb)

  • IS IT TIME TO TAKE A HARDER LOOK AT THE QALY*?

    HOW MUCH A PERSONS HEALTH ACTUALLY COST?

    HOW DO YOU DETERMINE THAT?

    SHOULD HIGH-PRICED BIOLOGICS BE COVERED IF THEY ARE NOT COST-EFFECTIVE?

    Amanda Brower, Biotechnol Healthc v.5(3); Sep-Oct 2008

  • PUTTING A PRICE ON TREATMENT

    HEALTH CARE IS CHANGING RAPIDLY.

    ALL THINGS TO ALL PEOPLE-IMPOSSIBLE.

    MAKE CHOICES

    HOW MUCH LONGER THE TREATMENT WILL ALLOW YOU TO LIVE,

    HOW IT IMPROVES THE LIFE YOU HAVE.

    J Bone Joint Surg Am. 2005 Jun;87(6):1253-9.

  • ORTHOPAEDIC COMMUNITY UNDERSTAND AND APPLY ECONOMIC EVALUATIONS

    IT CAN BE USEFUL FOR SETTING PRIORITIES AND GUIDING RESEARCH.

    Cost-utility analyses in orthopaedic surgery.Harvard Center for Risk Analysis, Harvard School

  • HEALTH SYSTEMS IN THE UNION - EFFORTS TO ENSURE IMPROVING QUALITY AND SAFETY STANDARDS TAKING INTO ACCOUNT:

    ADVANCES IN MEDICAL SCIENCE

    GOOD MEDICAL PRACTICES

    NEW HEALTH TECHNOLOGIES.DIRECTIVE 2011/24/EU OF THE EUROPEAN PARLIAMENT

  • WHERE ARE YOU GOING

  • THE FUTURE STARTS TODAY, NOT TOMORROW.

    Pope John Paul II

  • TO MAKE NO MISTAKES IS NOT IN THE POWER OF MAN; BUT FROM THEIR ERRORS AND MISTAKES THE WISE AND GOOD LEARN WISDOM FOR THE FUTURE.

    Plutarch. 46 120 AD,

  • MEDICAL ERRORS

    PATIENTS PERCEPTIONS AND EXPERIENCE OF CARE ARE VERY IMPORTANT.

    PATIENTS MAY MISCHARACTERIZE AN OUTCOME AS AN ADVERSE EVENT OR COMPLICATION -LACK SPECIFIC MEDICAL KNOWLEDGECouncil on Research and Quality AAOS

  • ERROR DEFINITION

    OCCASIONS IN WHICH A PLANNED SEQUENCE OF MENTAL OR PHYSICAL ACTIVITIES

    FAILS TO ACHIEVE ITS INTENDED OUTCOME

    AND WHEN THESE CANNOT BE ATTRIBUTED TO THE INTERVENTION OF SOME CHANCE AGENCY.

    Professor James Reason

  • RROR IS N ACTION OR DECISION THAT RESULTS IN ONE OR MORE UNINTENDED NEGATIVE OUTCOMES

    (STRAUCH Barry (2004). Investigating human error: incidents, accidents, and complex systems. Ashgate (Aldershot, UK),

  • WHEN FACED WITH UNCERTAINTY,A SUBJECT CAN MAKE TWO POSSIBLE ERRORS IN THE DECISION MAKING PROCESS:

    A TYPE I ERROR IS A FALSE-POSITIVE.

    A TYPE II ERROR IS A FALSE-NEGATIVE, OR THE SIDING WITH SKEPTICISM.

    Haselton, M. G., & Buss, David. (2000) Error Management Theory: A New Perspective on Biases in Cross-Sex Mind Reading

  • REDUCING MEDICAL ERRORS AND ADVERSE EVENTS.

    Medical errors account for at least 44,000, and perhaps as many as 98,000 deaths per year in the United States. They increase disability and costs and decrease confidence in the health care system. Annu Rev Med. 2012;

    Johns Hopkins University School of Medicine

  • MEDICAL ERROR (HUMAN ERRORS IN HEALTHCARE)

    A PREVENTABLE ADVERSE EFFECT OF CARE (whether or not it is evident or harmful to the patient). This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, . etc

    Zhang, J., Patel, V.L., & Johnson, T.R (2008).

  • MEDICAL ERROR

    INAPPROPRIATE METHOD OF CARE OR RIGHT SOLUTION BUT EXECUTED IT INCORRECTLY.

  • CAUSES

    INADEQUATE DOCTOR-PATIENT COMMUNICATION

    NOT THOROUGH REPORT ON THE RISKS AND BENEFITS OF EACH TREATMENT

    FAILURE TO DOCUMENT THE SELECTION BY THE PHYSICIAN

    NON-VISIBLE AND NON UNDERSTANDABLE MEDICAL NOTES,

    NON-COMPLIANCE WITH THE PROFESSIONAL-SCIENTIFIC RULES

    THE RECORDED DISCREPANCY EG BETWEEN DOCTORS AND NURSES IN MEDICAL DOCUMENTS .

    http://www.aaos.org/

  • COGNITIVE FACTORS ARE CRITICAL AT VARIOUS LEVELS OF THE HEALTHCARE SYSTEM HIERARCHY OF MEDICAL ERRORS

    Jiajie Zhang et al Am Med Inform Assoc. 2002 Nov-Dec; 9(6 Suppl 1): s75s77. In science, cognition is a group of mental processes that includes attention, memory, producing and understanding language, learning, reasoning, problem solving, and decision making.

  • AT THE LOWEST CORE LEVEL, IT IS INDIVIDUALS WHO TRIGGER ERRORS. ( most critical role here).

    NEXT LEVEL, INTERACTIONS BETWEEN AN INDIVIDUAL AND TECHNOLOGY.

    AT THE NEXT LEVEL, INTERACTIONBETWEEN GROUPS OF PEOPLE WHO INTERACT S WITH COMPLEX TECHNOLOGY .

    AT THE NEXT FEW LEVELS UP, ORGANIZATIONAL STRUCTURES INSTITUTIONAL FUNCTIONS NATIONAL REGULATIONS.

  • MEDICAL ERRORS INVOLVING TRAINEES:

    ERRORS IN JUDGMENT ( [72%]),TEAMWORK BREAKDOWNS ( [70%]), (LACK OF SUPERVISION)

    LACK OF TECHNICAL COMPETENCE ( [58%]).

    Trainee errors appeared more complex than nontrainee errors

    Houston Center for Quality of Care and Utilization Studies, USA.Arch Intern Med. (2007)

  • REVIEWS OF LIABILITY CLAIMS AGAINST SURGEONS:

    MOST ERRORS ARE PREVENTABLE.

    COMPETENT SURGEONS.FAILURE TO OPERATE WITHIN A PROPER SCOPE-OF-PRACTICEPATIENT FACTORS FAILED JUDGMENT AND POOR DECISION-MAKING INSTEAD OF LACK OF KNOWLEDGE. Adv Surg. (2009).Department of Surgery, Louisiana State University Health Sciences

  • COGNITIVE ERROR - MEDICAL INJURY: -CLAIMS IN JAPAN.

    COGNITIVE ERRORS ( ERROR IN JUDGMENT) WERE COMMON

    POOR TEAMWORK (11/274, 4%) and TECHNOLOGY FAILURE (5/274, 2%) were less common.

    REDUCTION OF THIS TYPE OF ERROR IN JUDGMENT IS REQUIRED TO PRODUCE SAFER HEALTHCARE.

    J Hosp Med. (2011)University of Tsukuba Japan.

  • MODELS OF PHYSICIANPATIENT RELATIONSHIP

    Number 395, January 2008

  • PATERNALISTIC MODEL

    ONLY INFORMATION ON RISKS AND BENEFITS OF A PROCEDURE THAT THE PHYSICIAN THINKS . IndicationsUnconscious patients Patient is ill and unable to engage in a discussion

  • INFORMATIVE MODEL

    THE PATIENT HAS COMPLETE CONTROL OVER SURGICAL DECISION MAKING, AND THE PHYSICIAN'S VALUES ARE NOT DISCUSSED. NOT IDEAL for patient care in most situations

  • INTERPRETIVE MODEL

    PHYSICIAN ACTING AS AN INFORMATION SOURCE

    HELPS THE PATIENT TO KNOW MORE CLEARLY " .

  • DELIBERATIVE MODEL

    SIMILAR TO THE INTERPRETIVEBEYOND THE INTERPRETIVE MODELPHYSICIAN MUST CONSCIOUSLY COMMUNICATE TO THE PATIENT HIS OR HER HEALTH VALUES;

    http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/QALY.pdf

  • WHEN OBTAINING INFORMED CONSENT FOR TREATMENTThe orthopaedic surgeon is obligated to present to the patient or to the person responsible for the patient, in UNDERSTANDABLE TERMS, PERTINENT MEDICAL FACTS AND RECOMMENDATIONS CONSISTENT WITH GOOD MEDICAL PRACTICE. Code of Ethics and Professionalism for Orthopaedic Surgeons AAOS

  • SUCH INFORMATION SHOULD INCLUDE

    Alternative modes of treatment,

    Objectives,

    Risks and possible complications of treatment,

    Complications and consequences of no treatment.

    Code of Ethics and Professionalism for Orthopaedic Surgeons AAOS

  • COUNCIL ON RESEARCH AND QUALITY -AAOS

    EDUCATE ITS MEMBERS, THE PUBLIC, AND PUBLIC POLICY MAKERS REGARDING

    evidenced-based medical practice,orthopaedic devicesbiologics regulatory pathways and standards development,patient safety,occupational health,technology assessment, andother areas of importance.

  • The Patient Protection and Affordable Care Act (PPACA) -pressure on providers: to improve outcomes lower the cost of care.

    Market forces being exerted by both consumers and businesses -demand for better healthcare at lower costs.

    http://www.aaos.org/news/aaosnow/jan13/advocacy7.asp

  • MEASURE QUALITY /COST

    QUALIFIED PHYSICIANS TO MEASURE QUALITY / VALUE

    PUBLIC AND PRIVATE PAYERS HAVE BEGUN TO DEVELOP THEIR OWN RATING AND PAYMENT SYSTEMS TO MEASURE PROVIDER COST AND QUALITYKevin J. Bozic, AAOS Council on Research and Quality

  • FUTURE QUALITY OBJECTIVES

    DENTIFY THE EVIDENCE GAPS AND QUALITY CHALLENGES.

    MEASUREMENT OF QUALITY AND PHYSICIAN PERFORMANCEEMPHASIS ON PATIENT OUTCOMES AND PATIENT SATISFACTION.AAOS Council on Research and Quality

  • DEFINITIONS OF QUALITY OF CARE

    NO CONSENSUS ON HOW TO DEFINE QUALITY OF CARE

    LACK OF A COMMON SYSTEMATICFRAMEWORK

    (from European Observatory of Health System and policiesOdservatory studies No 12)

  • DEFINITIONS OF QUALITY OF CARE

    THE DEGREE TO WHICH HEALTH SERVICES FOR INDIVIDUALS AND POPULATIONS

    INCREASE THE LIKELIHOOD OF DESIRED HEALTH OUTCOMES CONSISTENT WITH CURRENT PROFESSIONAL KNOWLEDGE.Doing the right things (what)to the right people (to whom)at the right time (when)and doing things right first time.

  • PERFORMANCE MANAGEMENT AND QUALITY IMPROVEMENT

    PERFORMANCE MANAGEMENT AND QUALITY IMPROVEMENT TOOLS IN ORDER TO INCREASE THE EFFECTIVENESS

    Centers for Disease Control and Prevention

    http://www.cdc.gov/stltpublichealth/performance/

  • MEDICAL ETHICS AND VALUES ARE FUNDAMENTAL ASPECTS OF HEALTH CARE ORGANIZATIONS

    The Strategic Management of Health Care Organizations

    Peter M. Ginter - 2013

  • UNIVERSITY OF PENNSYLVANIA HELATH SYSTEMCORE VALUES ARE:

    EXCELLENCE/ CREATIVITY AND INNOVATION.

    INTEGRITY.DIVERSITY

    PROFESSIONALISM

    INDIVIDUAL OPPORTUNITY.TEAMWORK AND COLLABORATIONT