Health System Goals and Measurement

PA 574: Health Systems Organization

Session 3 – April 17, 2013

What Goals - What Measurement?

Intrinsic Goals:• Relatively independent of other goals• More is always better• Hard to find

Instrumental Goals:• Often interdependent with other goals• More not always better• Indirect to “desired” goal• Common but numerous and imperfect

Where Have We Been – Where Are We Going?

Struggle to find simple, informative system goals

Striving for single, intrinsic goal measure has led to important realizations and goal/measurement thinking (WHO, etc.)

Recognition that a set of instrumental goals related to “true” goal is likely best

Some of the points along the way….

Institute of Medicine Six Aims/Ten Rules

Six Aims Safe Effective Patient-centered Timely Efficient Equitable

Ten Rules for System Redesign…

Institute of Medicine Ten Rules for System Redesign

1. Care is based on continuous healing relationships;

2. Care is customized according to patient needs/values;

3. The patient is the source of control;

4. Knowledge is shared and information flows freely;

5. Decision making is evidence-based;

6. Safety is a system property;

7. Transparency is necessary;

8. Needs are anticipated;

9. Waste is continuously decreased; and,

10.Cooperation among clinicians is a priority.

Access, Cost and Quality Note: All three are instrumental… Access:

• Availability

• Opportunity

• Knowledge (e.g. health literacy)? Quality:

• Better health related outcomes?

• Other things e.g. convenience?

• From who’s perspective? Cost:

• Yes..but is this perhaps the most instrumental…

WHO 2000 Three intrinsic goals… Population Health

• Yes..but overall, in distribution..that easy.. Fairness in Financial Contribution

• Macro issue about how resources collected• Does this speak to level of expenditure?

Responsiveness to People’s Expectations in Regards to non-Health Related Matters• Multi-dimensional• Culturally divergent?• Why non-health?

The Triple Aim (IHI/Berwick, Nolan & Whittington, 2008)

Where we are now…. Goals:

Improving the experience of care Improving the health of populations Reducing per capita costs of health care

Preconditions: “Enrollment” of population Commitment to universality Role of “integrator”

The Triple Aim Intrinsic or instrumental?? Leave out some high macro concerns

e.g. fairness of contribution??? Can be acted on globally and locally –

perhaps a key element.. Basis of most “new” system and care

transformation – Primary care homes, Accountable care organizations, etc..

Five Responsibilities of the “Integrator” in the Triple Aim

Partner with individuals/families Redesign of primary care Population health management Financial Management System integration at macro

level

Levels of the Health Care System (Berwick, 2002)

Level 1: Patient and Community• Experience of patients

Level 2: Microsystem• Functioning of small units of care delivery

Level 3: Organization• Functioning of organizations that house

microsystems Level 4: Environment

• Policy, payment, regulation, accreditation• Shapes behavior, interests and opportunities of

Level 3 organizations

Measuring Goals Donabedian:

• Structure,Process,Outcome Structural measures easiest – how

much stuff do we have Process Next – what did we do Outcome Best but Hardest – first two

are instrumental• Striving to get here…

Measuring Goals Population Health:

• Disability or quality adjusted life years (DALYs/QUALYs)

• Amenable Mortality• Distribution of health states e.g. percentage

of population considered obese• Process measures (health as “quality”):

NCQA/HEDIS process measures Ambulatory Care Sensitive Admissions All Cause Re-admission

Measuring Goals Experience of Care

• Consumer Satisfaction (?)• Timeliness• Safety• Cultural Competence• Patient-centeredness

Reducing Per Capita Costs• Population level – note this needs

“population”

Measuring Goals Well lets look at some international

comparative measurements…..