hsc 6636: healthcare quality 1 dr. lawrence west, health management and informatics department,...

HSC 6636: Healthcare Quality

1Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest

Topics

• Quality• The Donabedian Model• Quality Complexity• Pay for Performance• Issues and Trends• With Uncertainty Present (revisited)

“…the misalignment of financial incentives creates a formidable obstacle to the adoption of quality interventions…”

Leatherman, et al., 2003



Quality

• The pursuit of quality in any field is a study in tradeoffs constrained by physical laws, engineering knowledge, available time, and human capabilities.

• Delivered products and services marked by:– Time to deliver– Cost– Design appropriate for intended use

• Interaction with other products & services– Freedom from defects

My Thoughts



Quality (cont.)

• Consider the IOM report “should be” list:– Safe ‒ Timely– Effective ‒ Efficient– Patient-Centered ‒ Equitable

• Other findings of the cited reports– 44,000—98,000 patient deaths from medical

mistakes– $37 billion annual cost of errors



Quality (cont.)

• What resources are needed for improvement?• How do we measure…

– …current status?– …progress?

• What are responsibilities of individual participants as elements of an entire healthcare system?

• What role might you play in this area?• Who will pay?• Who benefits?



Quality (cont.)

• The textbook addresses quality – From several points of view– From different measurement approaches– For different social objectives

• It does not directly address the disparity between who pays and who benefits for quality improvement decisions– Economists argue that misalignment in costs and

benefits leads to underinvestment– We want to look for this issue throughout



Quality (cont.)

• We want to look for regulatory drivers of quality measurement throughout

• Ditto for legal liability as drivers of quality oriented behaviors



The Donabedian Model

• Donabedian identified inputs and measures of the HC system– Inputs: See Figure 15.1– Measures:

• Structure • Processes• Outcomes

• We will see references to these measures later in the chapter



The Donabedian Model (cont.)

• How does each measure stack up on…– …ease of measurement?– …appropriateness?– …assignment of responsibility?

• Structure• Processes• Outcomes



Quality Complexity

• How should we consider the discussion on pp. 412-414?

• What does the following mean to our quest for quality?

• What other industries are marked by similar “zones of complexity”

“In the zone of complexity, the probability that a given action will yield a specific outcome can vary greatly, depending n the many factors previously enumerated. Yet, the zone of complexity is where significant portions of health care occur. Clinicians’ only choice is to take a probabilistic approach.”

Text, p 414



Quality Complexity (cont.)

• Individual Outcomes and Analysis (pp. 414—417)

– What are the difficulties in judging quality by observing individual patient outcomes?

– Which measures do different stakeholders favor?• Are measures in conflict with each other?

– “Other industries have improved the quality of their outputs by reducing variability in the quality of their inputs” (p. 416)




• Individual Outcomes and Analysis (cont.)– What does it mean when the authors write,

“Given these difficulties, perhaps evaluators should focus on assessing process measures of quality.” (p. 416)

– “Providers have the most control over…” • Right Care • Right Patient• Right Way • Right Time• Right Amount

– But what conflicts do we see in pursuing these goals?




• Population Outcomes and Analysis– Book identifies two problems

• Lack of meaningful data• Low funding levels

– Other issues• How does finding lead to remediation?

– Who is to blame?– Who can correct?




• Population Outcomes and Analysis (cont.)– Book illustrates three types of studies that have

been performed• Underuse of effective care• Misuse of preference-sensitive care• Overuse of supply-sensitive care

– Why do you think that these studies could be performed?

• What potential change in the HC system might increase the use and effectiveness of population-level analysis?




• Population Outcomes and Analysis (cont.)– Disparity Studies examine differences among

groups regarding HC services and outcomes– Differentiate between inherent vs. social or market

drivers of disparities– We still have the same question regarding

remediation (slide 12)• Who is to blame?• Who can correct?



Pay for Performance

• “One of the chief barriers to quality improvement has been the difficulty of specifying a clear and compelling ‘business case’ for high-quality health care” (p. 423)

• “A hospital in the Midwest implemented a program to improve choices of initial antibiotics to treat pneumonia. Mortality rates went down, hospital days went down, and costs went down, but it cost the hospital money because these patients were less sick, their DRG categories were less serious, and the hospital received less money.” (p. 423)

See text for original sources for both quotes.



Pay for Performance (cont.)

• In P4P an entity attempts to use incentives to induce another party to perform as the paying entity desires– Who are the potential paying parties?– Who can be targeted with incentives?– What behavior would they like to change?

• Structure • Processes• Outcomes

– How can incentives be structured?– Will they work?

Where have we seen these before?



Risk-Adjusted Outcomes

• “Risk adjustment attempts to account for the differences that patients bring to the health care encounter so that outcomes can be compared across different patient groups, treatments, providers, health plans, or populations” (p. 427)

• “Risk adjustment is most often accomplished using administrative data, usually claims data.”

– Why?– “…many important variables needed for risk

adjustment are not present”

• What are goals and limitations of risk adjustment?



Issues and Trends in Quality Assessment

• Data Transparency– The LTC chapter mentioned federal efforts to

make nursing home data public– What economic efficiencies might be achieved if

HC provider quality data become public?• (What does publicizing school ‘report card’

scores achieve?)• Consumer Reports?• Have you ever checked a merchant with the

Better Business Bureau?• How does eBay feedback work?



Issues and Trends in Quality Assessment (cont.)

• Data Transparency (cont.)– What costs are incurred to achieve data

transparency?• What incremental costs are incurred?

– Does total disclosure have to take place to realize the benefits of transparency?

– Have you ever lived in a small town?




• Competing External Constituencies– How many different external bodies or groups do

HC providers respond to?• Small practices?• Medical practice groups?• Hospitals• Hospital chains

– Multi-state hospital chains– How many bodies must they respond to?




• The Chronic Care Model– Seeks institutional reform around six elements

• Delivery system design• Patient self-management support• Decision support• Clinical information systems• Community resources• Leadership support

– Why has implementation been limited?– What changes may increase popularity?




• Other Strategies– Other industries have been pursuing quality

initiatives for decades• Leadership initiatives• Cultural change• Investment in systems




• Measurement Strategies– Many organizations have focused on easily

obtained data• May not be appropriate for the needs

– An alternative, but more strategy is to determine goals and objectives

• Determine data needed to measure status• Invest in gathering and analysis techniques

– Systems ‒ Processes– Training




• Learning Organizations– Knowledge can be lost in large organizations like

an improperly shelved library book– Invest in systems and attitudes to recognize and

disseminate information• After-action reviews• Lessons learned archives• Publicize successes and failures



With Uncertainty Present (revisited)

• Who decides what to do?• What will be your role at different stages of your

careers?

“With the introduction of uncertainty—the fact of ignorance and the necessity of acting upon opinion rather than knowledge—into this Eden-like situation, its character is entirely changed… With uncertainty present doing things, the actual execution of activity, becomes in a real sense a secondary part of life; the primary problem or function is deciding what to do and how to do it.”

Frank Knight

hsc 6636: healthcare quality 1 dr. lawrence west, health management and informatics department,...

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