Quality in Health Care: Building Systemic Capacity

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Quality in Health CareBuilding Systemic Capacity

• Sheila Leatherman
• Adjunct Professor, University of North Carolina
• Sr. Associate, University of Cambridge, England

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Seminar Outline

1. What is the state of quality?
2. Building Systemic Capacity A Model
3. Change Strategy and Methods
4. Accountability and Public Reporting
5. The Way Forward

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Ireland Health Strategy

• PRINCIPLES
• Equity
• People-centeredness
• Quality
• Accountability

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Ireland Health Strategy

• NATIONAL GOALS
• Better health for everyone
• Fair access
• Responsive and appropriate care
• High performance

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Quality

• the degree to which health services for
  individuals and populations increase the
  likelihood of desired health outcomes and are
  consistent with current professional knowledge

IOM Definition 1999
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Concerns Regarding Quality

• Physician Perceptions (1999-2000)
• 5 country survey (Australia, NZ, UK, Canada, and
  USA)

• saying ability to provide quality care
• worsened over 5 years
• Australia 38
• Canada 50
• New Zealand 53
• United Kingdom 46
• United States 57

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Concerns Regarding Quality

• Nurses Perceptions (1998-1999)
• 5 country survey (Canada, Germany, Scotland,
  England and USA)
• 17-44 reported quality had deteriorated in last
  year

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Concerns Regarding Quality

• Public Perception (1998)
• 5 country survey ( Australia, Canada, NZ, UK, and
  USA)
• Overwhelmingly stated that health care system
  needed fundamental change or complete overhaul

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1998 American Consumer Satisfaction Index

• Hospitals ranked between the U.S. Post Office
  and the Internal Revenue Service (tax agency)

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Performance Domains

• Effectiveness
• Efficiency
• Equity/Access
• Safety
• Responsiveness/Patient-Centered
• Applicable at individual and population level

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Concerns Regarding Quality Hard Facts

• Inappropriate use of resources
• US data indicates overuse and underuse
• Unexplained variation/postcode lottery
• Safety/Adverse events
• Adverse event rate 10 of hospitals (UK and USA)
• Serious errors 2.3
• 16.6 of hospital admissions in Australia (1995)

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Poor resource use Financial risk
Suboptimal Quality

• Adverse events cost USA 4 of total health
  expenditures 1996
• Outstanding claims for alleged clinical
  negligence in UK was 3.9 billion

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What is needed?

• Will to address problems
• Articulated national policy

• Priority setting
• Performance monitoring capability

• Essential infrastructure
• new organizations
• legal framework
• IT
• Knowledge aids (protocols, DSS)

• Incentives

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Building Systemic Capacity A Model
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Organizing and Integrating Performance
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Organizing and Integrating Quality
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Organizing and Integrating Performance
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Ireland
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Effecting Change Strategy and Methods
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Methods for Improving QualityApplications and
Uses of Performance Data

• External Oversight
• External review/inspection
• Accreditation, licensing and certification
• Setting performance targets

• Knowledge/Skill enhancement
• of providers
• Peer review and data feedback
• Use of guidelines and protocols

• Incentives
• Financial (pay-for-performance)
• Non-financial

• Patient engagement/empowering
• consumers
• Providing performance information
• Enacting patient charters/patient
• rights legislation

• Regulations
• Government regulations
• Professional/self regulation

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External Oversight

• External review/inspection
• Accreditation, licensing and certification
• Setting performance targets

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Patient Engagement/ Empowering Consumers

• Providing performance information
• Enacting patient charters/patient rights
  legislation

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Regulations

• Government regulations
• Professional/self regulation

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Incentives

• Financial (pay-for-performance)
• Non-financial

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Knowledge/Skill Enhancement

• Peer review and data feedback
• Use of guidelines and protocols

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Knowledge/Skill Enhancement

• Problem
• Both WILL and SKILL problems
• Impossibility to assimilate new knowledge
• Numbers of articles published from RCTs
• 1960 1000 annually
• 1990 10,000 annually

• Use of Performance Data
• Scant evidence that physicians can/will use for
  behavior change
• Evidence that multiple interventions are needed
• Published protocols/guidelines
• Computer assisted decision support
• Peer review/practice comparisons

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Strategy for Improving Performance
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Drivers of Performance
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Accountability and Public Reporting
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What?

• The systematic standardized measurement of
  performance and public disclosure of data

• Performance Domains (individual and/or population
  level)
• Effectiveness
• Efficiency
• Responsiveness
• Equity
• Safety

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Performance Reporting Why?

• Unjustified variation/ postcode lottery
• Accountability a growing movement
• Performance monitoring needed for regulation
• The Information Age
• Public confidence eroding

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Principle Purposes for Public Disclosure

• Regulation (include public accountability)
• Purchasing or commissioning decisions
• Facilitation of consumer selection/choice
• Provider/systems behavior change

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Performance Reporting

• National Quality Reports
• Report Cards
• League Tables
• Provider profiling

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Current Status

• Measurement and public reporting inevitable
• Inadequate evaluation research - what works?
• Challenge How to move ahead responsibly

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Evidence of Effectiveness of Performance
Reporting USA

• Public
• Provider
• Purchaser/payers
• Policymakers

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The PublicEvidence from the USA

• Performance data used minimally
• Not meaningful to the public
• Most data designed for other purposes
• Not easily comprehended or actionable
• Not salient (example CABG mortality rates)
• Not motivated - individuals believe their
  care/provider is good

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The ProvidersEvidence from the USA

• Institutions (hospitals, systems) do pay
  attention and use
• To improve appropriateness of care
• To identify poor performers
• To alter processes responsive to complaints
• Individual providers less responsive to data

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Major Question Public or Confidential
Reporting of Performance DataCase Study
Reporting System in New York

• Publicly reported risk-adjusted mortality past
  CABG
• New York had the lowest risk-adjusted mortality
  rate in the USA after 4 years.
• First 3 years mortality rate fell 41
• Rate of decline in New York was twice the average
  national rate of decline in first 5 years

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Major Question Public or Confidential Reporting
of Performance DataCase Study Reporting
System in New York

• New York CRS What drove the improvement?
• Improvement driven through actions taken by
  hospital staff
• Changes in leadership
• curtailment of operating privileges
• Intensive peer review
• Consumer or market force minimal action
• BUT .WAS PUBLIC DISCLOSURE THE DRIVER?

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Purchasers/Payers/CommissionersEvidence from the
USA

• Little evidence of performance to exercise
  market clout
• Two large studies (15,000 employers nation wide)
• Data used minimally
• Price still main selection factor
• Data suffers as not designed for buyer
  decision-makers.
• Reliance on purchasers and payers to use
  performance data not a reliable strategy

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Policymakers

• Some evidence that policymakers do use
  comparative performance indicators
• New national initiatives in Australia, United
  Kingdom and United States for national
  performance reporting

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Risks and Challenges

• Methodologic issues
• Manipulation of data
• Tunnel vision
• Unintended effects on access
• Erode patient trust
• Jeopardize QI environment

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Accountability Models
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The Way Forward Common Pitfalls
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Common Pitfalls

• Confusion
• Role of government regulation and self-regulation
• Too Ambitious
• Too many new initiatives
• Too many goals/targets
• Lack of coherence
• Inadequate resources
• Will
• Skill
• Infrastructure
• IT
• Workforce
• Infrastructure/capacity
• Rhetoric exceeds reality
• Cynicism,
• Failure to deliver

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Knowing is not enough, we must apply Willing is
not enough, we must do.

Goethe
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Accountability Models
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Key Strategies
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Drivers of Performance
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Strategy for Improving Performance