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Quality czar points out safety problems, suggests solutions

Joshua TepperTORONTO – Ontario’s healthcare system is falling short on many quality measures, says Dr. Joshua Tepper (pictured), a family physician and the president and chief executive officer of Health Quality Ontario. But instead of simply focusing on the failings, he said, it’s time to create strategies to do better.

“We’re doing a horrible thing by showing people graphs and data that they’re not doing well, and not telling them how to do better,” he said. Dr. Tepper spoke at the annual Mobile Health Summit at the end of January, organized by the Strategy Institute, a conference company.

He stressed that quality is a skill, and that healthcare practitioners should be educated in quality techniques as part of their training. “You should know the basics,” he said, about collecting and assessing quality metrics.

He asserted that clinicians and healthcare MBAs and MPHs shouldn’t graduate without knowledge of quality techniques such as PDSA (Plan, Do, Study, Act) cycles, run charts, tests of change and the seven basic tools of quality, a common method of troubleshooting quality problems.

For those who don’t have this knowledge, he said, “You don’t need a PhD degree in quality, you need a two to three week course.”

As well, healthcare professionals should be striving to do things a little bit better each day, to improve the workings of their facilities and to ameliorate the condition of their patients. In a video, he showed how using iPods for a cognitively unresponsive patient completely changed his daily experience, bringing back memories of better days and improving his mood for the better.

“If you’re a nurse or in healthcare IT, you should be doing things a bit better each day,” he said.

Dr. Tepper did point to serious problems in the healthcare sector, particularly in the area of long-term care. His organization conducted a study of 628 of the province’s nursing homes and found that:

• The incidence of Stage 2-4 pressure ulcers ranges from 2% to 14% from one facility to another. “That’s a huge variation,” he said. Pressure ulcers result from lying in the same position for too long, and can become infected. “They’re incredibly painful and debilitating,” he said.

• Use of daily physical restraints ranges from 0 to 45% of patients in homes, depending on the facility. These restraints should be avoided whenever possible, he said, as they’re associated with “physical and emotional harm.”

• The use of anti-psychotics in patients without psychosis ranges from 4% to 60%, from one facility to another. This practice is often used to sedate agitated residents, but should be avoided whenever possible, he said, as it associated with a higher death rate.

• Patient falls range from 5% to 30%, depending on the facility. Dr. Tepper reminded the audience that falls in the elderly are serious matters, and that many who experience a fall will never recover: “For the elderly who fall and break their hips, the odds of being dead in a year are incredibly high.”

He observed that Ontario’s 600 to 700 nursing homes, with the exception of some of the chains, “operate in isolation from each other,” when they should be collaborating. “We should be working as a group, and learning from each other.”

“Alone, we can only do so much on quality,” added Dr. Tepper. “Together, we can do a lot.”

He emphasized that technology could be of great help to long term care facilities when it comes to quality, but noted that the sector traditionally hasn’t invested much on the technological front. “It hasn’t been a sector that has adopted technology, even compared with home care, which isn’t setting the bar very high.”

Unfortunately, many long-term care centres still don’t have electronic patient records, he said.

Dr. Tepper identified several other areas in which technology could be effectively used in long-term care:

• Medication optimization, including the over-medicating of residents.
• Remote patient monitoring
• Assistive technologies
• Remote training and supervision
• Disease management
• Cognitive fitness
• Social networking

He observed that the Internet of Things could be of great value in keeping tabs on frail seniors in long-term care. One example is already being used in forward-thinking hospitals, where “smart beds” contain sensors to determine when patients need turning to avoid bedsores.

Sensors are also used to detect when frail patients are attempting to leave their beds and are in danger of falling. Nurses are alerted, and can find out why the patients are trying to get up, and to take appropriate actions.

Some of the biggest problems occur at the transition points in care, when patients leave hospital for long-term care facilities or to go home.

There is often little communication among caregivers about care plans and new medications – which can result in the patients getting sick and returning to hospital. “When patients are discharged, how do we know they’re staying on their meds?” he asked. Often enough, they stop taking the meds that were prescribed at the hospital, as the long-term care facilities or home care providers didn’t know about the new prescriptions.

‘Medication reconciliation’ systems, tied together by electronic communications, are needed to keep all care providers on the same page, said Dr. Tepper. “Right now, there are elements of quality, but we don’t have a system of quality,” he said. “There are fractured entities.”

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1 Comment responses

  1. Avatar
    February 07, 2016

    The quality issue in health care is mostly rhetoric vs people actually walking the talk. The main issue is that the second thing to go in health facilities is the Quality Assurance (QA) and the Quality Control (QC), the first being staff professional development. As an example, Diagnostic Image (DI) facilities cut the the QC technologist position years ago, which is why there are so many issues now regarding medical radiation protection for all those who are or may be exposed to ionizing and non-ionizing radiations. You can’t have a system when essential parts are removed from it.

    I have personal experience with nursing homes and it wasn’t all that good concerning my parents. Everything you say is needed, believe me. Staff in long term centres and those looking after the elderly in hospitals often lack the education to deal with their patients. Further, the budget issue arises over and over so that there are often one nurse assigned to an area, few RPNs, some PSWs and no one there when patients are calling for help on their call bells or screaming out loud for help. There is NO staff to help the “inmates” — often a they are understaffed and overwhelmed by that or the lack of the appropriate skill sets.

    I dread the day I have to go into long term care if it is the way it is now. I know of a case here in Hamilton where a patient fell out of bed, broke his hip and was put back in bed with no investigation. He then fell out again because of no response to his pain and broke the other hip. Is this patient-centred care? No, it is patient abuse. Pretty bad for people who worked so hard for society and contributed so much in taxes and other ways to be rewarded at the end of their days as a burden and of no use.

    I agree with you Josh about the need for real integration of all aspects of health care from conception until one’s final hours and that does mean well established communications up, down, laterally, internally and externally as part of an effective, quality-rooted, patient-centered, patient-caring “System”.

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