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Question: What information would you assemble for healthcare leadership in your organization to monitor healthcare quality? Would that differ if you work in a hospital versus a physician practice or other organization?

Answer 1

MONITORING QUALITY OF HEALTH CARE

A revolution is taking place in the field of healthcare. The concept of “quality of care,” a major concern in the ’90s, is now reverberating into the new millennium, speeded by the advent of healthcare reform in many countries. Providing quality healthcare within the constraints of available resources is a challenging undertaking.

Quality in healthcare means providing the care the patient needs when the patient needs it, in an affordable, safe, effective manner. Quality healthcare also means engaging and involving the patient, so the patient takes ownership in preventive care and in the treatment of diagnosed conditions.

Six Domains of Health Care Quality

A handful of analytic frameworks for quality assessment have guided measure development initiatives in the public and private sectors. One of the most influential is the framework put forth by the Institute of Medicine (IOM), which includes the following six aims for the health care system.

• Safe: Avoiding harm to patients from the care that is intended to help them.
• Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively).
• Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
• Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care.
• Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy.
• Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

METHODS OF MONITORING HEALTH CARE QUALITY IN A HOSPITAL AS A LEADER OF A TEAM

Systematic approach to implementing quality monitoring in a hospital

· Providing feedback to healthcare workers

· Training and supporting staff to undertake improvements leading to quality care,

· Designing solutions for closing identified quality gaps

Criteria :An effective monitoring system meets the following criteria:

■ Data are collected regularly and over a significant period of time so that the hospital can monitor the trends in the indicators

■ Data collection is a routine activity integrated into daily tasks

■ Data are used to identify the presence and causes of system problems that can result in poor performance

■ Data are used to guide management decisions

A standard is an expectation of quality that is explicit (written) or implicit (understood).

1. “Implicit” healthcare standards derive from the expertise of professionals who work in a specific environment.

For example, professionals who work on the pediatric ward may know the treatment that a dehydrated child needs, but differ on ideas about the most appropriate way to provide the treatment (e.g., dosage, duration, and frequency).

2. “Explicit” healthcare standards appear in a variety of forms, such as specifications, procedures, or protocols.

These standards may be developed by a Ministry of Health, professional organizations (e.g., International Council of Nurses, medical associations), international organizations (e.g., the World Health Organization: standards for the treatment of malaria), accrediting organizations (e.g., Joint Commission Resources, Zambia Health Accreditation Council), or by a hospital itself.

Applied standards should be based on following parameters

■ Realistic: The standard can be followed or achieved with existing resources

■ Reliable: Following the standards for a specific intervention results in the same outcome (all factors being equal)

■ Valid: The standard is based on scientific evidence or other acceptable experience

■ Clear: The standard is understood in the same way by everyone concerned and is not subject to distortion or misinterpretation

■ Measurable: The standard is amenable to assessment and quantification

The Hospital as a System:

Hospitals are complex systems. Many services, such as rendering emergency care and providing meals, not only must be kept in operation over two or more shifts, but also must be implemented across departments. A systems view, for example, can reveal the process involved in transporting a patient treated in the emergency department to another part of the hospital for surgery.

Quality Monitoring Framework :

The framework presented in Figure is based on the systems model.

As the diagram shows, a patient who enters the hospital becomes involved in a variety of processes that will lead to an outcome.

Most patients will experience all or most of these processes during an inpatient stay. Some of the processes can be defined as “supportive” in as much as they are not direct care.

For example, the admission process and medical record systems are needed to support patient care and treatment. During the admission process, the patient or family provides biographical information, and the staff creates a medical record (the information system).

The physician, laboratory, and radiology staff carry out various diagnostic exams, tests, and procedures. Nursing care is an integral process to the hospital system as are other complementary services such as nutrition, social services, and physical therapy.

Counseling and patient education take place all along the continuum of care as physicians, nurses, and others explain what can be expected during the tests, procedures, and treatment processes as well as the diagnosis and follow-up/ discharge plan.

HOSPITAL PROCESS

Pt enters Hospital

Admission

Diagnostic Exams

Medical Treatment

Pt. Outcomes

Nursing Care

Complementary services

Counselling and Pt education

Follow –up/ Discharge

External and Internal Monitoring

“External monitoring” is monitoring conducted by someone from outside the hospital.

The monitor may be a representative of the Ministry of Health, a neighborhood health committee, or an agency contracted to measure compliance with specific standards; these standards are often established by the external entity doing the measuring. Accreditation of the hospital, as conducted by Joint Commission International and Council for Health Service Accreditation of Southern Africa (COHSASA), is an example of an external monitoring system. A discussion of external monitoring is not within the scope of this guide.

“Internal monitoring” is a system set up by the hospital staff who adopt standards written by another credible group (e.g., the World Health Organization) or by the hospital itself; the hospital can conduct a self-assessment to measure the degree of compliance. An approach to developing an internal monitoring system follows.

· Ongoing Monitoring versus Spot Checks

Ongoing monitoring involves regularly measuring quality indicators. Some indicators may be important enough (e.g., maternal mortality or infection rates) to measure frequently and regularly (e.g., monthly)

· An Incremental Approach

Two approaches are proposed:

1. The Quick Start—monitoring a minimum number of key indicators

2. Implementing a Monitoring System— planning and organizing a monitoring system and monitoring key processes                                                                                                                         

Step 1: Identify a Quality Coordinator :

Hospital management will want to select someone to coordinate the monitoring effort. This individual should have an interest in quality monitoring, have the respect of staff, have an ability to facilitate teamwork, and be allotted time to devote to this activity.

Step 2: Form a Quality Team :

A team of six to eight staff members should be organized to implement the monitoring. Because the two indicators that will be monitored in this Guide are surgical infection rates and mortality rates, the team should include staff who are involved in processes that could result in infection or mortality, e.g., staff from surgery, obstetrical services, hospital wards, and other departments.

Team members are selected based on their knowledge and experience in the area and their willingness to participate.

The coordinator will orient the team to the rationale for quality monitoring and the process.

Measuring the Quality of Physician Care in Physician practice organizations

Consumers are very interested in information about the quality of physician care. To meet that demand, researchers, medical societies, and health care experts have made a concerted effort to address the many issues encumbering physician quality measurement. As a result, sponsors of quality reports can find a growing set of valid and reliable physician quality measures and look to a number of successful public reporting projects. Learn more:

Why Measuring Physician Quality Is Challenging

Technical and political issues have contributed to the limited use of physician measures in public reports.

• Technical challenges include:
  • The difficulty of constructing valid measures with data generated from small patient populations.
  • Data sources that are not comprehensive.
  • Information systems that are not standardized.
• Political issues include:
  • The wariness of physician stakeholders.
  • A lack of consensus about which measures are appropriate for reporting to consumers.

Measuring Groups Versus Individuals

Physician quality measures can be used to evaluate the performance of an individual physician or groups of physicians that practice together (such as a pediatric group practice). However, while consumers have indicated a preference for quality information at the level of individual physicians, most information on quality is at the level of medical groups or practices.

The advantage of constructing scores at the group level is the availability of a larger patient population. When measuring quality at the medical group level, you can create a sample by combining patient data from each physician in the group.

It is more difficult to produce adequate sample sizes for individual physicians, who do not necessarily have a sufficient number of patients with the disease or condition addressed by the measure.

The minimum number of required observations needed to calculate a score for an individual performance measure varies; recommendations range from 30 to 50 patients per physician. However, a larger sample is often necessary depending on the characteristics of the measure or data source.

Other Technical Issues in Measuring Physician Performance

Measurement experts have been working on various methodological issues to advance physician-level data collection and reporting. Resolving the issues listed below is critical to getting the consistent and valid results necessary for public reporting.

• Rules for attributing patients to individual physicians. Attribution rules determine which physicians will be accountable for the care provided.

For example, visit-based attribution uses the number of visits a patient has with a physician; cost-based attribution uses physicians responsible for the greatest health care expenditures for that patient; and assignment-based attribution uses the primary care physician or specialist assigned to the patient. Determining the "best" method is the subject of considerable debate.

• Methods for aggregating data from different sources. You can attain a valid sample for either a group or an individual by collecting patient data for a particular physician or medical group from each health plan (or hospital or nursing home) where the care was provided. The patient data collected from each source is then aggregated to produce the performance score.
• Methods for creating composite scores. Composite scores combine results across individual measures to create results for a broad topic—a particular aspect of care (e.g., prevention) or condition (e.g., diabetes care). For example, a composite score for diabetes care could include rates for measures relating to blood sugar testing and control, eye exams, cholesterol screening and control, kidney function tests, blood pressure control, foot exams, and smoking status. Results for a broad topic (rather than individual measures) are more understandable to consumers and can also address small sample sizes (i.e., small patient populations).
• Calculation of benchmarks and assignment of peer groups for comparing physician performance. Peer group comparison can generally be defined by the patient population (e.g., Medicaid beneficiaries) and the physician specialty. In many situations, specialty cannot be determined simply based on credentialed specialty, stated specialty, or board-certified specialty alone.
• Processes for auditing/validating results. Once the results are collected, aggregated, and analyzed, they need to be validated. Approaches include having physicians review their data to confirm accuracy and using third-party auditors.

The Six Domains of Health Care Quality among Physicians.

Researchers have found that consumers are interested in quality measures that convey information about a physician’s technical care as well as interpersonal skill.

Typically, technical quality is measured using clinical information found in administrative databases, electronic health records, or medical charts, whereas interpersonal quality is measured

Patient Safety Measures:

• Screening, risk-assessment, and plan of care to prevent future falls in older adults.
• Screening for osteoporosis for women 65–85 years of age.
• Avoidance of antibiotic treatment in adults with acute bronchitis.

Effectiveness Measures:

• Percentage of patients receiving recommended care or treatment for various conditions, including respiratory disease, bone and joint conditions, diabetes, heart disease, mental health, and substance abuse.
• Percentage of patients receiving recommended preventive care and screening services for health concerns, such as cancer, obesity, and smoking cessation.

Patient-Centeredness Measures:

• Patients' reports on the care and service they received from their physicians.
• Education and counseling for patients with certain conditions (e.g., hepatitis, heart failure).

Timeliness Measures:

• Patients' reports on the timeliness of care and service they received from their physicians.
• Percentage of surgical patients who received certain medications (e.g., antibiotics, beta blockers) within a certain time period prior to surgery.

Efficiency Measures:

• Appropriate use of imaging studies for low back pain.
• Appropriate use of DXA scans in women under 65 years who do not meet the risk factor profile for osteoporotic fracture.
• Percentage of all cardiac stress imaging performed for initial detection and risk assessment in patients who are asymptomatic and at low risk for coronary heart disease.

Descriptive Measures: While not associated with any particular IOM domain, descriptive measures can convey the physician's capacity for providing quality of care and service. Examples include:

• The use of electronic patient medical records, personal health records, or prescription ordering systems.
• Percentage of physicians who are board-certified and who maintained their certification.
• The number of surgical procedures (e.g., hip replacement, carotid endarterectomy) a physician performed. This type of measure—referred to as volume--is considered a proxy for quality. However, with the exception of a few high-risk procedures, researchers have not yet determined the exact relationship between volume and good patient care.

Thus health care quality monitoring are varied in different ways in a hospital as well as a physician practice organizations. The above mentioned data clearly defines the variations in both the settings of hospital and physician organizations.