Seminàrio Internacional « Qualidade em Saùde€¦ · Performance of healthcare systems (WHO...

Quality measures in healthcare Seminàrio Internacional « Qualidade em Saùde »

Henri Leleu

04/12/2012

Performance of healthcare systems

(WHO 2000)

Health

Disability-adjusted life expectancy

Responsiveness

Respect of persons

Client orientation

Fairness

France #1

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Tip of the iceberg

Outcome

Process

Access

Structure

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Disability-adjusted life expectancy

Quality ?

Healthcare providers

Insurance / Health plans

Regulators

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Quality in the industry

Deming Good quality means a predictable degree of uniformity and dependability with a quality standard suited to the customer

Six Sigma means no more than 3.4 defects per million opportunities

ISO Degree to which a set of inherent characteristics fulfills requirements


Quality in healthcare

The degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (IOM)

Uncertainty

Fast changing

Social construct


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Why measures quality ?


Agency theory

Performance measures = align the interests of the agent with those of the principal

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Voters / Consumers /

Patients

Government

Healthcare providers

Insurances

Health agencies

Performance measures


Low quality of care

To err is human

44,000 to 98,000 people die each year as a result of preventable medical errors

Crossing the quality chasm

U.S. health care delivery system does not provide consistent, high quality medical care to all people

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“efforts to improve quality require efforts to measure it”


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Strategies to improve quality


How to improve quality ? A few examples

Outcome

Process

Access

Structure

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Accreditation

Guidelines Continuing Medical Education

Finan

cial ince

ntives

Pu

blic rep

ortin

g Eq

uity - sa

fety

Structure of healthcare


Mea

sure

s

Improve the structure of healthcare

Equity

Access

Strong preventive care

Care coordination

Strong primary care

Effectiveness

Timeliness

Safety

Efficient secondary care

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Universal coverage

Health Systems Infrastructure

Capabilities


Health at a glance 2011(OECD)

Effectiveness Cancer care • Screening, Survival

Care for communicable diseases • vaccination

Care for chronic conditions • Avoidable admissions

Care for acute exacerbation of chronic conditions • In-hospital mortality

Safety Patient safety


Health at a glance 2011(OECD)

Access to Care Unmet health care needs

Coverage

Burden of out-of-pocket

Geographic distribution of doctors

Inequalities

Timeliness Waiting times

Health Expenditure and Financing


Accreditation

External assessment of performance against a pre-determined set of standards that are objective and measurable

Accreditation Hospitals

Physicians groups

Physicians

Accreditation of health plans • NCQA


NCQA Accreditation

Quality Management and Improvement

Response to medical necessity

Credentialing

Members’ Rights and Responsibilities

Member Connections

HEDIS

Quality measures


Guidelines

Evidence-based health care is the conscientious use of current best evidence in making decisions about the care of individual patients or the delivery of health services

Evidence

Up-to-date information from relevant, valid research


Netherlands

Clinical guidelines in primary care (1987)

Performance measures Based on guidelines

Accreditation tool (2005) Using performance measures

Physicians • Contracting

– Change reimbursement based on level of quality

Pay-for-performance


Continuing Medical Education

Maintain competence and learn about new and developing areas of their field

Often mandatory

Relicencing

Continuing professional development

Practice assessment

Measures


Développement Professionnel Continu

(2009)

Objectives Practice assessment, medical education, quality and safety improvement, public health priorities and cost control

Practice assessment Voluntary accreditation Safety problem disclosure Clinical audit Check list Clinical pathway…

Use of clinical measures


Financial incentives

Pay-for-performance

• Bonus based on measured performance

Value-based purchasing

• Payment based on measured performance

Tiers payment

• Premium or reimbursement based on measured performance


Pay for performance

Bonus payment indexed on performance measures Quality measures

Objectives

Quality Outcome Framework (UK) 30% of primary care physicians tied to performance measures

Pacific Business Group on Health Retain et redistribute money of health plans based on quality


Value based purchasing

Payment mechanism tied to quality measures

Shifting of the usual payment to quality based payment

Affordable Care Act (2012)

Hospital payment reduced by 1%

Funds use for incentives payment


Tiers payment

Insurance premiums or reimbursement depend are indexed on quality measures

Ranked physicians or hospitals in tiers based on quality measures

CIGNA Care Network (2008) Absence of physician incentives

No physicians exclusion

Patients may pay differential copayments/coinsurances


Public reporting

Accountability Political pressure

Consumer’s choice vote with their feet

Provider’s reputation

Communication Easy-to-read

Explanatory messages


Chrysler, Ford, GM & United Auto

Workers (1999)

Private purchasers of health plans

Measure quality of health insurances

Framework for reporting

NCQA Accreditation status

Consumer satisfaction

Access & Services

Staying healthy

Getting better


Heart surgery - State of New York

Data on quality of heart surgery (1989) - State of New York

Annual risk-adjusted mortality following coronary artery bypass graft surgery by hospital and surgeon Deaths fell 41 percent over the first four years.

Individual hospitals made changes No market incentives

Many critics Gaming High risk patients exclusion Additional work required to identify what is wrong 04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 26

Safety

Prevention of harm to patients

Preventing errors

• Safety practices (processes)

Learning from the errors that do occur

• Continuing professional development

• Specific methodologies

Having a patient safety culture

• Check-list


Safety

Centers for Medicare & Medicaid Service (2007)

no-payment rule for hospital-acquired conditions

Safety culture

Measured by quantitative surveys


Equity

Inequity

Disparities in health that are systemic and avoidable and, therefore, considered unfair or unjust

Reduce inequity in health or healthcare

Stratify measures by social group


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What are quality measures ?


Definitions

Measure

A tool to assign a quantity to an attribute by comparing it with a criterion.

Quality measure

A tool to assign a quantity to quality of care by comparing it with a criterion.


Domains of measurement

Health Care Delivery

Structure / Access / Process / Outcomes

Patient experience

Population Health

Health state


Structure

Structure of care is a feature of a health care organization or clinician related to the capacity to provide high quality health care

Protocols for hospital-acquired infections prevention ?


Process

A process of care is a health care-related activity performed for, on behalf of, or by a patient

Proportion of physicians washing their hands after each patient ?


Outcomes

An outcome of care is a health state of a patient resulting from health care

Proportion of hospital acquired-infection ?


Access

Access to care is the attainment of timely and appropriate health care by patients or enrollees of a health care organization or clinician

Waiting times for cancer surgery ?


Patient experience

Experience of care is a patient's or enrollee's report of observations of and participation in health care, or assessment of any resulting change in their health.

Validated questionnaires

• Picker Institute (UK)

• OCDE

• CAHPS (US)


Efficiency

Ratio between what the service costs and the outcome received from it

Depends on the perspective

Most efficiency measures today are cost measure

No quality

No validation


Measure selection process

Importance of what is being measured

Potential to improve health

Actionable

Meaningful

Scientific soundness

Feasibility

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“Idade do capitão ?”


Actionable

Definition

capable of being acted on

Population based or outcomes indicators

VS

Process, structure or access indicators


Scientific soundness

Reliability

Validity

Comprehensible Allowance for

patient/consumer factors as required

Scientific evidence


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How to use quality measures ?


Internal versus external

Measuring

Financial Incentives

Public reporting

Accreditation

Quality improvement

initiatives

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Internal usage External usage


Balance between external and internal

usage

Internal External

Initiative Voluntary Imposed

Means Learning, improvement Accountability, control

Motivation Intrinsic Extrinsic

Resistance Low High


Strategy

Identify core sets of quality measures for standardized reporting

All sectors of health care

Establish a framework and capacity for quality measurement and reporting.

Ensure that comparative information on health care quality is valid, reliable, comprehensible, and widely available in the public domain.


Cautions

Separate programs lead to confusion

Fix national objectives for quality improvement

Capacity limit of healthcare system

Health information technology

Healthcare data infrastructure


Questions

Dr Henri Leleu

[email protected]


mailto:[email protected]



Seminàrio Internacional « Qualidade em Saùde€¦ · Performance of healthcare systems (WHO...

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