Quality Principles in Pharmacy PracticeNicole Mollenkopf MacLaughlin, PharmD, BCPSThe Johns Hopkins HospitalIf you enjoyed and learned from the last three introductory classes on safety and quality …. Please consider taking the Spring 2013 elective: PHMY 508: Patient Safety in HealthcareWho Got Quality Care? Patient A Kind and loving care Pleasant room Good food Care paid for Patient B Aloof physician Cold, tasteless food Curtains in the room ragged Small co-pay requiredQUALITY: Who defines it?PatientsPayorsProvidersProfessional/ Regulatory BodiesQuality: What does it mean? It depends…. Providing a caring and pleasant environment Conformity to standards Doing the right thing well Minimizing cost Decreasing readmissions Improving quality of life Correctly using evidence based therapyQuality: What does it mean? Degree of excellence or superiority (Webster) Quality is a value, so by its very nature it is subjective! The ability to achieve desirable objectives using legitimate means. (A. Donabedian) Incorporates an objective component The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. (Institute of Medicine)Quality: What does it mean? Institute of Medicine (IOM) Aims  Safe  Effective  Patient Centered  Timely  Efficient  EquitableMore people die from medical mistakes than from AIDs, breast cancer and motor vehicle accidents in the US every year, IOM 1999Between the care that we have, and the care that we should have lies not just a gap, but a chasm, IOM 2001Are quality and safety the same?QualitySafetyQuality Alphabet Soup QA – Quality Assurance QC – Quality Control SQC – Statistical Quality Control TQM – Total Quality Management CQI – Continuous Quality Improvement PI – Performance Improvement QI – Quality ImprovementHistorical Perspective Post WWII : US vs Japan US – Frederick Winslow Taylor Control performance through standards and rules Top-heavy management structure Focus on end of line inspection (It works but leads to waste) Ridged organization – slow to adjustHistorical Perspective Post WWII : US vs Japan US – Frederick Winslow Taylor Control performance through standards and rules Top-heavy management structure Focus on end of line inspection (It works but leads to waste) Ridged organization – slow to adjust Japan – William Edwards Deming Problems are systemic, managements job to improve system so workers can do their jobs better Work smarter not harder Empower employees to do things better Productivity function of design rather than people motivation Sought to understand and reduce variability & rejects (Statistical Quality Control) Work with vendors to improve quality of raw materials“85% of the reasons for failure to meet customer requirements are related to deficiencies in systems and processes . . . Rather than the employee. . . The role of management is to change the process rather than badgering individuals to do better.”- W. Edward DemingDeming’s 14 Points1. Establish constancy of purpose2. Adopt the philosophy of quality in its entirety 3. Cease dependence on mass inspection4. Stop awarding business solely on based on price5. Constantly improve every system6. Institute training on the job7. Institute leadershipDeming’s 14 Points8. Drive out Fear9. Breakdown barriers between departments10. Abandon slogans11. Eliminate numerical “quotas”12. Eliminate annual ratings, replace with “pride”13. Promote education and self-empowerment14. Put everybody to workDeming’s 14 Points Constancy  Create constancy of purpose toward improving product and service.  Adopt the quality philosophy We can no longer live with commonly accepted levels of delays, mistakes, defective materials and defective workmanship. Cease dependence on mass inspection Require instead, statistical evidence that quality is built in, thereby eliminating mass inspection.Deming’s 14 Points Price  End the practice of awarding business based solely on price. Instead, depend on meaningful measures of quality and price. Constantly improve every system  Improvement is not a one time effort. It is management's job to work continually on the system.  Training  Institute systematic on the job training.  Leadership The responsibility of supervisors/managers must be changed from “cracking the whip” to helping employees do their job better (be a leader).Deming’s 14 Points Fear  Drive out fear so that everyone may work effectively for the company. “Non-Punitive” Environment Barriers  Break down barriers between departments. Multidisciplinary Approach! Abandon slogans, focus on methods  Eliminate numerical goals, posters, and slogans for the work force that ask for new levels of productivity without providing methods.Deming’s 14 Points Quotas  Eliminate work standards that prescribe numerical quotas.  Pride  Remove barriers that stand between the hourly worker and his right to pride of workmanship. Remove poor supervisors, faulty equipment and poor materials. Provide education and self-empowerment Institute a vigorous program of education and retraining, let people contribute to making themselves and their work better Put everybody to work Not just management’s job!“Quality is never the problem. Quality is the solution to your problem.”Why do we care about quality?Why do we care about quality? Using recommended guidelines would help avoid harmful consequences: Hypertension 68,000 avoidable deaths Heart Attack 37,000 avoidable deaths Pneumonia10,000 avoidable deaths Colorectal cancer 9,600 avoidable deaths- Woolf, SH (JAMA 1999) 45% of patients DO NOT receive care in accordance with best practices - McGlynn, et al (RAND 2003)Why do we care about quality? Poor quality is costing providers money Cost of errors and malpractice Regulatory-driven emphasis on reporting TJC comparisons across hospitals CMS reporting for physicians / hospitals Consumer-driven emphasis on reporting Published “web grades” “Straight to consumer” approach Directing business based on quality Leapfrog group Payment for performance CMS / Healthcare