Why this course? Our Context.

Module 1b.

Measuring Quality in Indian Health

IHS Director’s Priorities

1. To renew and strengthen our partnership with tribes

2. In the context of national health insurance reform, to bring reform to IHS

3. To improve the quality of and access to care

4. To make all our work accountable, transparent, fair and inclusive

The Environment We Are In

• IOM reports get the ball rolling– Crossing the Chasm– To Error is Human– Performance Measurement—Accelerating

Improvement

• National Performance Measurement Initiatives, i.e., HEDIS, NCQA*

• JCAHO—ORYX Measures• CMS Reporting & Quality Initiatives

*Health Effectiveness Data and Information Set National Committee on Quality Assurance

Quality Measurement in Health Care Reform

Quality Measurement in HealthCare Reform

• Many Provisions of PPQCA.

• Chronic Care Model & Medical Homes

• Payment Reform– Feds and States want to pay for quality, not

procedures.– Example: CMS and Re-hospitalization.

Quality Improvement and Measurementis taking off in Public Health as well……

State health departments have formed the same kind of learning collaborative as clinical facilities do to improve healthcare.

Within Indian Health Care:The Initiatives that Surround Us

• GPRA, EO, Meaningful Use, and other CRS Adventures.

• Special Diabetes Program for Indians

• Improving Patient Care Initiative

• Patient Safety

• Ongoing Injury Surveillance

• Other, Other, Other, and Other.

The 4 Contexts

ContinuousQuality Improvement

PublicAccountability

Quality Surveillance

Evaluation

Four Different Purposes for Measurement

Aspect Improvement Accountability Surveillance Evaluation

Aim: Improvement of care within one site

Comparison, choice, reassurance

Detect & investigate trends to improve care

across sites

New knowledge

Methods: Test observable No test, evaluate current performance

No test Test blinded or controlled

Bias: Accept consistent bias

Measure and adjust to reduce bias

Accept & evaluate consistent bias.

Design to eliminate bias

Sample Size:

“Just enough” data, small sequential

samples

Obtain 100% of available, relevant

data

Adequate for precision

More “Just in case”

“Just in case” data

Flexibility of

Hypothesis:

Hypothesis flexible, changes as learning

takes place

No hypothesis Hypothesis Generating

Fixed hypothesis

Four Different Purposes for Measurement (Cont.)

Aspect Improvement Accountability Surveillance Evaluation

Testing Strategy:

Sequential tests No tests No Tests One set of tests

Determining if a Change is anImprovement:

Run charts or Shewhart control

charts

No change focus Trend w/ Confidence

Intervals

Hypothesis, statistical tests (t-

test, F-test, chi square, p-values)

Confidentiality of the Data:

Data used only by those involved with improvement

Data available for public

consumption and review

Individual identities protected

Research subjects’ identities protected

Frequency of Use:

Daily, weekly, monthly

Quarterly, annually

Weekly to annually

At end of project

Improved health and wellness for American Indian and Alaska Native individuals, families, and

communities

Delivery SystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

C ommunity

Health Care Organization

DRAFT IPC Care Model

Activated Family and Community

Informed Activated Patient

Prepared Proactive Care Team

Prepared,Proactive

Community PartnersEFFECTIVE RELATIONSHIPS

EfficientSafe EffectiveEquitable

TimelyPatient-Centered

IPC Care Model

See The Carey and Lloyd RoadmapSPC as a process improvement strategy.

Benchmarks vs. Benchmarking

• Benchmarking—A complete improvement process

“Search for industry best practices that leads to superior performance.” Camp, 1989

1. Measure

2. Identify benchmark performers (companies, clinics)

3. Learn from them.

4. Modify and implement best practices

5. Measure.

Model for Improvement

IHI Breakthrough Series Model

Planning Group

Identify Change

Concepts

Prework

LS 1

P

S

A DP

S

A D

LS 3LS 2

Supports

Email Conference Calls Assessments Senior Leader Reports Site Visits Listserv

Time for setting aims, allocating resources, preparing baseline data leading to the first two-day

meeting.

Action Period 1: Adapt and test the ideas for

improved system of care

Action Period 2: Further develop the system of care at the pilot site and spread the system to other

sites and/or practitioners

Harvesting and Spread

Expert Panel

The Triple Aim

“improving the experience of care, improving

the health of populations, and reducing per capita costs of health care”

Don Berwick- Health Affairs, 2008