Value & Quality Related to Sedation Systems
Reviewed by Nancy Crego, PhD, RN
Dr. George Blike is a Professor in the Departments of Anesthesiology and Community & Family medicine at the Dartmouth-Hitchcock System and also serves as the Chief Quality and Value officer. He has published extensively on topics related to quality and safety in healthcare and is a founding member of the Society for Pediatric Sedation (SPS). The purpose of this plenary session was to review quality and safety concepts that have influenced health delivery science and how these have been applied to value based care, pediatric sedation quality and safety systems.
Dr. Blike began the presentation by reviewing the development of High Reliability Organizations (HROs) and how they have been beneficial in mitigating risk in complex organizations such as aviation, nuclear power generation and submarine systems. These HRO principles are also applicable to healthcare. He described the utility of the Capability Maturity Model, a methodology used to develop and refine development of organizational processes.
The model depicts a five-level, step-wise evolutionary process necessary for organizations to become more systematic and mature and was utilized by Dartmouth-Hitchcock in focusing quality healthcare initiatives that place an emphasis on the value of care provided rather than the volume of care. The maturity levels and characteristics of the Capability Maturity Model are listed below:
- Initial- Processes are unpredictable, Ad-Hoc-with heroic effort needed to complete
- Ad Hoc Managed- Introduction of methods and processes but these are often reactive
- Defined- Processes are characterized for the organization and is proactive, often tailored from organizational standards
- Quantitatively Managed- Processes are measured and controlled
- Optimizing- Focus is on process improvement
Another lesson from HROs is that bad outcomes are a function of high-risk situations and bad/risky behaviors. In considering error/harm in healthcare, an important question posed by Dr. Blike is whether or not “zero” harm is possible, this is relevant to healthcare especially in light of the Institute of Medicine (IOM) report “To Err is Human” that put the spotlight on the high rate of error in the United States healthcare system. Therefore, what is needed in order for healthcare to reach HRO levels of safety? Solutions require a combination of behavioral accountability and process design in order to optimize outcomes.
Important organizational factors necessary to replicate the success of an HRO include: (1) leadership at the highest organizational level, including the organization’s board, making quality a priority throughout the organization, (2) developing a robust process improvement program and (3) building a culture of safety. Dr. Blike identified challenges in healthcare delivery science, including the need to “tame the complexity” of the healthcare delivery system in order to understand and improve it. Reliability is an important element of quality and value in health care and aligns with the fundamental commitment of doing “no harm”. Models of quality such as Six-Sigma, a quality improvement framework based on Toyota manufacturing processes, seeks to decrease variation in processes with a goal of eliminating variation and is instrumental in reaching a “zero harm” goal in healthcare. Dr. Blike then reflected on how the SPS has embraced these safety concepts and integrated them into many aspects of the society resources and programs.
Using the Six-Sigma quality aims and IOM definitions as a framework for defining quality pediatric sedation is described in “Great Expectations-Defining Quality in Pediatric Sedation: Outcomes of a Multidisciplinary Consensus Conference”, published by a multi-disciplinary group of SPS members. Many of these concepts are also found in Value-Based Care models, defined as providing Quality Care (Effective-Safe-Centered) that is accessible and appropriate.
Dr. Blike provided examples and insights as to the importance of the components of Value-Based Care focusing on efficiency of care. Efficiency considers the value stream within a system such as; value added steps/activities and non-value added steps (business necessary but don’t directly make patient care more efficient). Non-value added processes represent waste; processes such as turn-around times and first pass yield (how well it was done the first time) are examples of how waste can reduce efficiency within a system. Waste in healthcare is concerning for two reasons:
- Waste in Healthcare is costly but adds no value to care and are system defects (errors), including: over production (redundant work), waiting (lost time), down time (not using talent/ skills), transportation (unnecessary patient movement within systems), inventory (excess materials), motion (excess movement by staff), extra processing.
- Waste drains all of our staff and decreases work place satisfaction
Lastly, Dr. Blike pointed out that in order to drive value into systems, meaningful measurement is necessary because processes can’t improve if we can’t measure them. The need for measurement to improve the quality of sedation was the initial impetus for the Pediatric Sedation Research Consortium (PSRC) database, which has been instrumental in providing data to assess the quality and safety of pediatric sedation in the U.S. and continues to be an important part of SPS.
It is also an example of measuring what matters, which is necessary for value to emerge within systems. Dr. Blike described Michael Porter’s “Outcome Measures Hierarchy”, that uses a series of tiers (1, 2, and 3) to consider the relative value of different types of outcome measures. Tier 1 measurements (health status achieved such as survival) is the lowest level of quality measurement, while tier 2 consists of measures of the recovery process such as time to return to normal activities and measurements of the disutility of care or treatment (diagnostic errors, adverse events, treatment-related discomfort) and tier 3 measures the sustainability of health, such as the long-term consequence of treatment.
Tier 2 and tier 3 outcome measures will be necessary to make significant improvements in the quality of healthcare systems.