Issues in Quality of Care

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Issues in Quality of Care

• Chapter 20
• Dr. Tracey Lynn Koehlmoos
• HSCI 678 Intro to US Healthcare System

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Cost-Quality-Access
ACCESS
Focus Varies over time
QUALITY
COST
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Quality of Care

• A relatively new science
• Inaccurate
• Needs more emphasis, more research
• Various perspectives
• Physician
• Patient
• Hospital, Clinic
• Terms and ideas borrowed from industry

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Defining Quality of Care

• Lack of consensus
• IOM Consists of the degrees to which health
  services for individuals and populations increase
  the likelihood of desired health outcomes and are
  consistent with current knowledge
• Difference Quality of Care v. Quality of Life.

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Quality Assessment

• QAssessment Measures the essential elements of
  quality of care
• Technical proficiency
• Interpersonal patient/physician relations
• Outcomes of care

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Quality Improvement

• QImprovement
• Set of techniques for continuous study and
  process improvements to meet consumer needs
• Because QI is from industrynote the
  terminology customer, patient, users
• Health services become a PRODUCT

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Quality Assurance

• Embraces the full cycle of activities and systems
  for maintaining the quality of patient care.
• QAssurance
• QAssessment QImprovement

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History of Quality Focus

• Codman late 1800s Boston/ efficiency
• Wennberg, Donabedian, Brook 1970s
• Early studies found
• Higher costs and more treatment correlated to a
  high number of physicians in a geographic area.

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Donabedian Model

• Avedis Donabedianseminal quality researcher
  (1980)
• Structurecharacteristics size, type,
  qualifications of providers (easy capture)
• Processtech quality, patient/phys. interaction
• Outcomepatients subsequent health status
  post-intervention (intangible)

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How to Measure Quality

• Depends on the data source
• Easiest Claims/administrative (limited)
• Harder Patient chart
• Hardest recordings, interviews
• 1960s Quality as increased access
• 1970s Physician peer review by Medicare
• 1980s Quality Assurance
• 1990s Public Report Cards

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Measuring Quality NOW

• Focus on OUTCOMES RESEARCH
• AHRQ Agency for Healthcare Research and Quality
  (formerly AHCPAR) (1989)
• PORT, Minority Health Research, National
  Guidelines Clearinghouse
• Adverse eventsIOM, AHRQ
• Avoidable patient deaths (50K-100K per year)
• Potential for national reporting scheme

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Major Quality Initiatives

• TQM/CQIborrowed from industry
• Focus on process and systems
• Statistically based problem-solving
• Cross-functional employee teams
• Employee empowerment
• Focus on internal and external customers

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CQI vs. Quality Assurance

• How is CQI different from Qassurance?
• Focus on understanding and improving underlying
  work processes and systems rather than just
  correcting errors.

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How do we measure Quality?

• Several methods focusing on
• Was the process adequate?
• Could better care have improved the outcome?
• Considering process outcome was the overall
  quality of care acceptable?
• Use process criteria to have experts evaluated
  care that was already delivered
• Have outcome results been validatedaccording to
  an ideal model of care?

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Monitoring and Regulating Quality

• JCAHOHospitals, nursing homes, more
• NCQAHealth Plan Employer Data and Information
  Set (HEDIS), 1991, HMOs
• 1982TEFRA Tax Equitability and Fiscal
  Responsibility Act
• Switched to Peer Review Orgs for Medicare
• Preadmission, DRG outliers, DRG validation
• PROs became QIOs in 2002.

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Summary

• Quality, access and cost
• Quality research, end goal Just Right care
• Carrot or Stick in TQM/CQI
• Provider skepticism
• QA too much on credentials/not enough outcomes
• Lack of evidence of QA effectiveness
• Quality or Cost as objective?