HSRE Lect10 Weiner

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    Quality of Care and Its Measurement in the HSRE

    Context 

    Jonathan P. Weiner, DrPHJohns Hopkins University

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    This Lecture Will Address the Following:

    Definitions Paradigms and frameworks

    Policy context

    Applications within HSR&E Approaches to measurement

    Sources of benchmarks

    Data sources Practical issues (related to “individual exercise” case study)

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    Section A

    Definitions, Paradigms, and Frameworks

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    “Quality” 

     

    Defined 

     The degree to which health services for individuals andpopulations increase the likelihood of desired health

    outcomes

    And the degree to which health services are consistent withcurrent professional knowledge

    Notes Available

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    “Quality” 

     

    Defined 

     The quality “performance” of a provider or organization canbe assessed by measuring . . .

     

     Their patients’

     

    outcomes (end-results), or;

     

     The degree to which they adhere to an accepted careprocess

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    “Quality” 

     

    Defined 

    Everything that’s not money−

     

    Weiner, 1982

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    The “Value” 

     

    Equation

    Value

    Quality

    Cost

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    The Theoretical Cost/Quality “Plateau” 

     

    Relationship

    A B

    Quality

    Cost

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    “To Err is Human”

    “Crossing the Quality Chasm”

    − 

     Though as much political as scientific in nature, we canlearn much from these IOM reports

     

    See www.iom.edu

    Two Recent Institute of Medicine Reports Have Been

    Influential:

    http://www.iom.edu/http://www.iom.edu/

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    IOM’s Framework for Quality Improvement:

    Quality problems may relate to the following:−

     

    Underuse

     

    Overuse

    − 

    Misuse  The IOM effectively used the issue of “patient safety” to

    capture the public’s attention and the media’s attention

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    IOM’s Suggestions for Future

    It is not acceptable to have a wide “quality chasm” betweenactual and best possible performance

    Quality and safety must be designed into a system and must

    not be the responsibility of just individual providers

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    Is It HSRE or Care Management? 

    Quality of care is central to several domains:−

     

    Basic research and development

     

    Research to set policy agenda

    − 

    Program management/improvement−

     

    Program impact evaluation

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     A Schema for Categorizing Health Services Research,

    Evaluation, and Related Activities

    New Knowledge for Society

     

    Research

    Provider/Program Focus

     

    Evaluation

    Science 

    baseProgram

     

    management

    CQI

    OR/efficiencyDisease/outcomemanagement

    Policy Makers (public and private)

    Performance monitoring

    Program effectiveness

    Non-policy 

    Policy 

    Methods development

    Outcomes/tech assessment

    Policy research /

    analysis

    Social policy research

    Health system

    improvement and

    development

    Program

     

    Assessment /

    Development

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     A Schema for Categorizing Health Services Research,

    Evaluation, and Related Activities

    New Knowledge for Society

     

    Research

    Provider/Program Focus

     

    Evaluation

    Science 

    baseProgram

     

    management

    CQI

    OR/efficiencyDisease/outcomemanagement

    Policy Makers (public and private)

    Performance monitoring

    Program effectiveness

    Non-policy 

    Policy 

    Methods development

    Outcomes/tech assessment

    Policy research /

    analysis

    Social policy research

    Health system

    improvement and

    development

    Program

     

    Assessment /

    Development

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    Some Specific QOC Applications Include . . .

    Clinical quality improvement / TQM Performance monitoring

    Evidence-based outcomes research

    Health system improvement

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    The “Continuous Quality Improvement” 

     

    (CQI) Cycle

    Problem Identification

    and Prioritization

    Determination of Quality Criteria

    Measurement of Degree

    to which Criteria is Attained

    Design of System Improvement

    Implementation of System Change

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    Section B

    Measurement

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     Approaches to Measuring Quality 

    1. 

    Structure of care−

     

    Facilities

     

    Provider qualifications and credentialing

     

    Availability / resource adequacy

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     Approaches to Measuring Quality 

    2. 

    Process of care−

     

    Provider adherence to practice standards

     

    Appropriateness of care

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    Process Measures

    Adequacy of patient/population utilization Ease of access to care/case finding rates

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     Approaches to Measuring Quality 

    3. 

    Outcomes of care−

     

    Patient function/health status/quality of life

     

    Adverse/sentinel events

     

    Mortality/longevity

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    Outcome Measures

    Prevention/avoiding disease/morbidity Patient satisfaction/patient-centeredness

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    Type of Measure

    Data Source Structure Process Outcome

    Site Visit X

    Administrative Files X X X

    Claims/Encounter X X

    Data Sources for Quality 

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    Type of Measure

    Data Source Structure Process Outcome

    Site Visit X

    Administrative Files X X X

    Claims/Encounter X X

    Data Sources for Quality 

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    Type of Measure

    Data Source Structure Process Outcome

    Medical Record (paper or

    electronic)

    X

    Patient Interview X X X

    Population Survey X X

    Data Sources for Quality 

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    Insured beneficiary/enrollee group

    Persons living in a geographic area

    A selected vulnerable population group Provider organization/institution

    An individual provider

    Remember Your “Denominators”:

     

    Populations of Interest for QOC Research

    f QO d d/ f

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    Basis for QOC Standard/Reference

    Process or structure of care: Normative—based on peer judgment and literature

    Empirical—based on observations of actual practices

    See http://www.qualitymeasures.ahrq.gov/(http://www.ahrq.gov/qual/)

    S d d/R f

    http://www.qualitymeasures.ahrq.gov/http://www.qualitymeasures.ahrq.gov/

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    Standard/Reference

    Outcomes of care: Accepted standards with face validity (e.g., infant mortality,

    disability)

    Constructed standards (e.g., functional health status,satisfaction)

    QOC C S d (S I di id l E i )

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    QOC Case Study (See Individual Exercise)

    1. 

    CABG in Western MD2.

     

    Prenatal care “gray-area”

     

    women

     

    Meeting national standards of care

     

    Improved quality for target populationA.

     

    Intent and implications for design

    B.

     

    Measures

    C. 

    Sources of data