1. Issues in Quality of Care Chapter 20 Dr. Tracey Lynn Koehlmoos HSCI 678: Intro to US Healthcare System

2. Cost-Quality-Access ACCESS QUALITYCOST Focus Varies over time

3. 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

4. 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.

5. Quality Assessment Q Assessment: Measures the essential elements of quality of care –Technical proficiency –Interpersonal patient/physician relations –Outcomes of care

6. Quality Improvement Q Improvement –Set of techniques for continuous study and process improvements to meet consumer needs Because QI is from industry—note the terminology: customer, patient, users Health services become a PRODUCT

7. Quality Assurance Embraces the full cycle of activities and systems for maintaining the quality of patient care. Q Assurance = Q Assessment + Q Improvement

8. History of Quality Focus Codman: late 1800’s Boston/ “efficiency” Wennberg, Donabedian, Brook: 1970‘s Early studies found: Higher costs and more treatment correlated to a high number of physicians in a geographic area.

9. Donabedian Model Avedis Donabedian—seminal quality researcher (1980) Structure—characteristics: size, type, qualifications of providers (easy capture) Process—tech quality, patient/phys. interaction Outcome—patient’s subsequent health status post-intervention (intangible)

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

11. 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 events—IOM, AHRQ –Avoidable patient deaths (50K-100K per year) –Potential for national reporting scheme

12. Major Quality Initiatives TQM/CQI—borrowed from industry –Focus on process and systems –Statistically based problem-solving –Cross-functional employee teams –Employee empowerment –Focus on internal and external customers

13. CQI vs. Quality Assurance How is CQI different from Q assurance ? Focus on understanding and improving underlying work processes and systems rather than just correcting errors.

14. 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 validated— according to an ideal model of care?

15. Monitoring and Regulating Quality JCAHO—Hospitals, nursing homes, more NCQA—Health Plan Employer Data and Information Set (HEDIS), 1991, HMOs 1982— TEFRA : Tax Equitability and Fiscal Responsibility Act –Switched to Peer Review Orgs for Medicare –Preadmission, DRG outliers, DRG validation –PROs became QIOs in 2002.

16. 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?