quality in health care: building systemic capacity
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Quality in Health Care: Building Systemic Capacity. Sheila Leatherman Adjunct Professor, University of North Carolina Sr. Associate, University of Cambridge, England. Seminar Outline. What is the state of quality? Building Systemic Capacity: A Model Change: Strategy and Methods - PowerPoint PPT PresentationTRANSCRIPT
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Quality in Health Care:Quality in Health Care:Building Systemic CapacityBuilding Systemic Capacity
Sheila LeathermanAdjunct Professor, University of North Carolina
Sr. Associate, University of Cambridge, England
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Seminar OutlineSeminar Outline
I. What is the state of quality?
II. Building Systemic Capacity: A Model
III. Change: Strategy and Methods
IV. Accountability and Public Reporting
V. The Way Forward
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Ireland Health StrategyIreland Health Strategy
PRINCIPLESPRINCIPLES– Equity– People-centeredness– Quality– Accountability
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Ireland Health StrategyIreland Health Strategy
NATIONAL GOALS– Better health for everyone– Fair access– Responsive and appropriate care– High performance
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QualityQuality
“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 QualityConcerns 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 QualityConcerns 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 QualityConcerns 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 1998 American Consumer Satisfaction IndexSatisfaction Index
Hospitals ranked between the U.S. Post Office and the Internal Revenue Service (tax agency)
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Performance DomainsPerformance Domains
EffectivenessEfficiencyEquity/AccessSafetyResponsiveness/Patient-Centered
Applicable at individual and population level
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Concerns Regarding Quality: Concerns Regarding Quality: Hard FactsHard 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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Adverse events cost USA 4% of total health expenditures; 1996
Outstanding claims for alleged clinical negligence in UK was £3.9 billion
Suboptimal QualitySuboptimal Quality Poor resource usePoor resource use
Financial riskFinancial risk
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What is needed?What is needed?
Incentives
“Will” to address problems Articulated national policy
Priority setting Performance monitoring capability
“Essential infrastructure new organizations legal framework IT
Knowledge aids (protocols, DSS)
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Building Systemic Capacity: Building Systemic Capacity: A ModelA Model
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Organizing and Integrating PerformanceOrganizing and Integrating Performance
Policy Formulation & Infrastructure
Performance Monitoring Macromanagement
Operations ManagementGovernance
Clinical Service ProvisionIndividual Accountability
Regional
National
Institutional
Individual
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Policy Formulation & Infrastructure
Performance Monitoring Macromanagement
Operations ManagementGovernance
Clinical Service ProvisionIndividual Accountability
Organizing and Integrating QualityOrganizing and Integrating Quality
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Organizing and Integrating Organizing and Integrating PerformancePerformance
Policy Formulation & Infrastructure
Performance Monitoring Macromanagement
Operations ManagementGovernance
Clinical Service ProvisionIndividual Accountability
Uni
ted
Kin
gdom
United States
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Policy Formulation & Infrastructure
Performance Monitoring Macromanagement
Operations ManagementGovernance
Clinical Service ProvisionIndividual Accountability
IrelandIreland
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Effecting Change: Effecting Change: Strategy and MethodsStrategy and Methods
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Methods for Improving QualityMethods for Improving QualityApplications and Uses of Performance DataApplications and Uses of Performance Data
External Oversight• External review/inspection• Accreditation, licensing and certification • Setting performance targets
Patient engagement/empowering consumers
• Providing performance information• Enacting patient charters/patient rights legislation
Regulations• Government regulations• Professional/self regulation
Incentives• Financial (pay-for-performance)• Non-financial
Knowledge/Skill enhancement of providers
• Peer review and data feedback• Use of guidelines and protocols
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External OversightExternal Oversight
External review/inspectionAccreditation, licensing and
certificationSetting performance targets
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Patient Engagement/ Patient Engagement/ Empowering ConsumersEmpowering Consumers
Providing performance informationEnacting patient charters/patient
rights legislation
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RegulationsRegulations
Government regulationsProfessional/self regulation
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IncentivesIncentives
Financial (pay-for-performance)Non-financial
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Knowledge/Skill EnhancementKnowledge/Skill Enhancement
Peer review and data feedbackUse of guidelines and protocols
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Knowledge/Skill EnhancementKnowledge/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 Strategy for Improving PerformancePerformance
Regulation Purchasing Facilitation ofconsumer choice
Provider/ Systemsbehavior change
Accountability
Public
Providers
Purchasers
Policymakers
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Drivers of PerformanceDrivers of PerformanceU.S. U.K.
Knowledge:Standardsperformancedata
Competition
Regulation
Accountability
Professionalethos
Incentives
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Accountability and Public Accountability and Public ReportingReporting
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What?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?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 Principle Purposes for Public DisclosureDisclosure
Regulation (include public accountability) Purchasing or commissioning decisions Facilitation of consumer selection/choice Provider/systems behavior change
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Performance ReportingPerformance Reporting
National Quality Reports“Report Cards”League TablesProvider profiling
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Current StatusCurrent 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 Evidence of Effectiveness of Performance Reporting: USAPerformance Reporting: USA
PublicProviderPurchaser/payersPolicymakers
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The PublicThe PublicEvidence from the USAEvidence 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 ProvidersThe ProvidersEvidence from the USAEvidence 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 QuestionMajor Question: : Public or Confidential Reporting of Performance DataPublic or Confidential Reporting of Performance DataCase StudyCase Study: : Reporting System in New York 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: Major Question: Public or Confidential Reporting of Performance DataPublic or Confidential Reporting of Performance DataCase Study: Case Study: Reporting System in New YorkReporting 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/CommissionersPurchasers/Payers/CommissionersEvidence from the USAEvidence 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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PolicymakersPolicymakers
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 ChallengesRisks and Challenges
Methodologic issues Manipulation of data “Tunnel vision” Unintended effects on access Erode patient trust Jeopardize QI environment
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Adapted from Emanuel and EmanuelAnnals of Internal Medicine, Jan 15, 1996
Conception Domain Methodsof patients of accountability
Professional Recipient of Patient, physician Licensure, Certificationprof. services Prof. Association Malpractice suit
Economic Consumer of Marketplace and Choice and “exit”health care regulationCommodity
Political Citizen Government “Voice” and receivingreforms and government pressurepublic good actions
Accountability: ModelsAccountability: Models
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The Way Forward: The Way Forward: Common PitfallsCommon Pitfalls
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Common PitfallsCommon 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 applyWilling is not enough, we must do.
Goethe
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Adapted from Emanuel and EmanuelAnnals of Internal Medicine, Jan 15, 1996
Conception Domain Methodsof patients of accountability
Professional Recipient of Patient, physician Licensure, Certificationprof. services Prof. Association Malpractice suit
Economic Consumer of Marketplace and Choice and “exit”health care regulationCommodity
Political Citizen Government “Voice” and receivingreforms and government pressurepublic good actions
Accountability: ModelsAccountability: Models
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Policy Formulation & Infrastructure
Performance Monitoring Macromanagement
Operations ManagementGovernance
Clinical Service ProvisionIndividual Accountability
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Key StrategiesKey Strategies
Key Strategies for Change
Targets forPerformance
Change
PerformanceReporting
Accreditationand Inspection
Incentives PatientEmpowerment
Regulation Knowledge/Skill
EnhancementProviders X X X X X
ProfessionalBodies
X X X
Public X X X X
Payers andContractorPurchasers
X X X
Policy makers X
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Drivers of PerformanceDrivers of PerformanceU.S. U.K.
Knowledge:Standardsperformancedata
Competition
Regulation
Accountability
Professionalethos
Incentives
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Strategy for Improving Strategy for Improving PerformancePerformance
Regulation Purchasing Facilitation ofconsumer choice
Provider/ Systemsbehavior change
Accountability
Public
Providers
Purchasers
Policymakers