Quality of Care

Plan for Today

• Talk about quality of care– What is it?– How do you measure it?– How do you improve it?– How good is the quality of care in HMOs?

• Team meeting

What is Quality?

• Maximizes patient welfare, taking account of expected costs and benefits (Donabedian)

• Contributes to improvement or maintenance of quality/duration of life (AMA)

• Increases likelihood of desired health outcomes and is consistent with current professional knowledge (Institute of Medicine)

Donabedian

“Quality is doing the right thing,

and doing it right.”

Ways of Measuring Quality

• Structure

• Process

• Outcome

Structure

• Credentials, licenses

• Compliance with regulations

• Record-keeping

• Legal agreements

Process

• Utilization rates for specific services

• Adherence to accepted treatment protocols

• Screening and prevention

HEDIS process measure forAdolescent Immunization

• Percentage of 13-year olds who received immunization for measles, mumps, rubella in previous year

• (Booster shot required to ensure continued protection)

What can plans do to increase adolescent immunizations?

• Birthday card reminders

• Educate parents through posters, flyers, member magazines

• Remind and educate doctors to immunize when patient is in the office

Outcomes

• Complication rates

• Mortality

• Patient functioning

• Relief of pain

• Patient satisfaction

Features of Modern Approach to Quality Improvement

• Customer focus

• Integrated, “systems” approach

• Setting and achieving concrete goals– Measurement– Evaluation

Disease Management Programs:Asthma Example

• Less than 5% of asthma is “severe”• Nearly half of care costs are for emergency room

and hospital• Only 10-20% of asthmatics receive inhaled

steroids (Inhaled bronchodilators provide instant relief)

• Asthmatics see pharmacists 5 times more often than physicians

Rationale for Intervention

• High rate of preventable complications• Measurable impact within short time period• Chronic, outpatient-focused condition• High rate of variability in treatment• High rate of patient non-compliance• Consensus on optimal treatment• Desired outcomes are measurable and achievable

Case finding and preventive efforts

Education and morbidity reduction

Management of emergencies

Identify asthma patients

Home environment

Smoking cessation

Measure baseline functional status

Peak flow meter

Inhaled steroids

Home visits by asthma nurse specialist

Phone and mail follow-up

Counseling by pharmacist

Emergency department triage

Protocol for status asthmaticus

Hospitalization Ambulatory follow-up

Critical pathway for asthma exacerbation

Conventional case manager role

Home visits by asthma nurse specialist

Phone and mail follow-up

Counseling by pharmacist

Measurements: Satisfaction surveys, functional status surveys, annual cost of care, readmissions, ER re-visits, medication compliance, missed school/work days

How Good is the Care in HMOs?

How Good Are HMOs onAdolescent Immunizations ?

52.2%

79.1%

24.3%

1997 Average 90th percentile 10th percentile

Are HMOs Better or Worse than Fee-for-Service?

Wide variation in quality

• Good HMOs and not-so-good HMOs

• HMO quality is better in some areas than others

Team Meeting

• Facilitator, recorder

• Recorder’s duties– Give individual contributions to Jen (will be

returned on Thursday)– Mail out notes in next few days