hsre lect10 weiner
TRANSCRIPT
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Quality of Care and Its Measurement in the HSRE
Context
Jonathan P. Weiner, DrPHJohns Hopkins University
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This Lecture Will Address the Following:
Definitions Paradigms and frameworks
Policy context
Applications within HSR&E Approaches to measurement
Sources of benchmarks
Data sources Practical issues (related to “individual exercise” case study)
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Section A
Definitions, Paradigms, and Frameworks
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“Quality”
Defined
The degree to which health services for individuals andpopulations increase the likelihood of desired health
outcomes
And the degree to which health services are consistent withcurrent professional knowledge
Notes Available
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“Quality”
Defined
The quality “performance” of a provider or organization canbe assessed by measuring . . .
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Their patients’
outcomes (end-results), or;
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The degree to which they adhere to an accepted careprocess
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“Quality”
Defined
Everything that’s not money−
Weiner, 1982
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The “Value”
Equation
Value
Quality
Cost
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The Theoretical Cost/Quality “Plateau”
Relationship
A B
Quality
Cost
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“To Err is Human”
“Crossing the Quality Chasm”
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Though as much political as scientific in nature, we canlearn much from these IOM reports
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See www.iom.edu
Two Recent Institute of Medicine Reports Have Been
Influential:
http://www.iom.edu/http://www.iom.edu/
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IOM’s Framework for Quality Improvement:
Quality problems may relate to the following:−
Underuse
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Overuse
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Misuse The IOM effectively used the issue of “patient safety” to
capture the public’s attention and the media’s attention
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IOM’s Suggestions for Future
It is not acceptable to have a wide “quality chasm” betweenactual and best possible performance
Quality and safety must be designed into a system and must
not be the responsibility of just individual providers
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Is It HSRE or Care Management?
Quality of care is central to several domains:−
Basic research and development
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Research to set policy agenda
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Program management/improvement−
Program impact evaluation
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A Schema for Categorizing Health Services Research,
Evaluation, and Related Activities
New Knowledge for Society
Research
Provider/Program Focus
Evaluation
Science
baseProgram
management
CQI
OR/efficiencyDisease/outcomemanagement
Policy Makers (public and private)
Performance monitoring
Program effectiveness
Non-policy
Policy
Methods development
Outcomes/tech assessment
Policy research /
analysis
Social policy research
Health system
improvement and
development
Program
Assessment /
Development
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A Schema for Categorizing Health Services Research,
Evaluation, and Related Activities
New Knowledge for Society
Research
Provider/Program Focus
Evaluation
Science
baseProgram
management
CQI
OR/efficiencyDisease/outcomemanagement
Policy Makers (public and private)
Performance monitoring
Program effectiveness
Non-policy
Policy
Methods development
Outcomes/tech assessment
Policy research /
analysis
Social policy research
Health system
improvement and
development
Program
Assessment /
Development
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Some Specific QOC Applications Include . . .
Clinical quality improvement / TQM Performance monitoring
Evidence-based outcomes research
Health system improvement
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The “Continuous Quality Improvement”
(CQI) Cycle
Problem Identification
and Prioritization
Determination of Quality Criteria
Measurement of Degree
to which Criteria is Attained
Design of System Improvement
Implementation of System Change
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Section B
Measurement
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Approaches to Measuring Quality
1.
Structure of care−
Facilities
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Provider qualifications and credentialing
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Availability / resource adequacy
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Approaches to Measuring Quality
2.
Process of care−
Provider adherence to practice standards
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Appropriateness of care
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Process Measures
Adequacy of patient/population utilization Ease of access to care/case finding rates
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Approaches to Measuring Quality
3.
Outcomes of care−
Patient function/health status/quality of life
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Adverse/sentinel events
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Mortality/longevity
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Outcome Measures
Prevention/avoiding disease/morbidity Patient satisfaction/patient-centeredness
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Type of Measure
Data Source Structure Process Outcome
Site Visit X
Administrative Files X X X
Claims/Encounter X X
Data Sources for Quality
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Type of Measure
Data Source Structure Process Outcome
Site Visit X
Administrative Files X X X
Claims/Encounter X X
Data Sources for Quality
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Type of Measure
Data Source Structure Process Outcome
Medical Record (paper or
electronic)
X
Patient Interview X X X
Population Survey X X
Data Sources for Quality
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Insured beneficiary/enrollee group
Persons living in a geographic area
A selected vulnerable population group Provider organization/institution
An individual provider
Remember Your “Denominators”:
Populations of Interest for QOC Research
f QO d d/ f
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Basis for QOC Standard/Reference
Process or structure of care: Normative—based on peer judgment and literature
Empirical—based on observations of actual practices
See http://www.qualitymeasures.ahrq.gov/(http://www.ahrq.gov/qual/)
S d d/R f
http://www.qualitymeasures.ahrq.gov/http://www.qualitymeasures.ahrq.gov/
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Standard/Reference
Outcomes of care: Accepted standards with face validity (e.g., infant mortality,
disability)
Constructed standards (e.g., functional health status,satisfaction)
QOC C S d (S I di id l E i )
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QOC Case Study (See Individual Exercise)
1.
CABG in Western MD2.
Prenatal care “gray-area”
women
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Meeting national standards of care
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Improved quality for target populationA.
Intent and implications for design
B.
Measures
C.
Sources of data