Issues in Quality of CareCost-Quality-AccessQuality of CareDefining Quality of CareQuality AssessmentQuality ImprovementQuality AssuranceHistory of Quality FocusDonabedian ModelHow to Measure Quality…Measuring Quality NOWMajor Quality InitiativesCQI vs. Quality AssuranceHow do we measure Quality?Monitoring and Regulating QualitySummaryIssues in Quality of CareChapter 20Dr. Tracey Lynn Koehlmoos HSCI 678: Intro to US Healthcare SystemCost-Quality-AccessACCESSQUALITY COSTFocus Varies over timeQuality of Care•A relatively “new science”–Inaccurate–Needs more emphasis, more research•Various perspectives–Physician–Patient– Hospital, Clinic•Terms and ideas borrowed from industryDefining Quality of CareLack 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.Quality Assessment•QAssessment: Measures the essential elements of quality of care–Technical proficiency–Interpersonal patient/physician relations–Outcomes of careQuality Improvement•QImprovement–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 PRODUCTQuality Assurance•Embraces the full cycle of activities and systems for maintaining the quality of patient care.QAssurance = QAssessment + QImprovementHistory 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.Donabedian ModelAvedis Donabedian—seminal quality researcher (1980)Structure—characteristics: size, type, qualifications of providers (easy capture)Process—tech quality, patient/phys. interactionOutcome—patient’s subsequent health status post-intervention (intangible)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 CardsMeasuring 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 schemeMajor 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 customersCQI vs. Quality AssuranceHow is CQI different from Qassurance?Focus on understanding and improving underlying work processes and systems rather than just correcting errors.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?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.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