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PubMedDate not supplied

Value-based health care, Part 2. The physician imperative: define, measure, and improve health care quality.

Health care is the only major industry that lacks agreed-upon metrics to objectively define the quality of its products and services. The fundamental deficiency has led to the use of price as the de facto metric for patient contracting. Provider selection defaults to price because quality is assumed to be equal across all physicians and hospitals. This assumption is erroneous and now obsolete. Health care quality can be accurately measured using sophisticated illness modeling techniques that objectively risk-adjust patients level data. Providers' clinical data can be correlated with patient self-assessed outcomes for all episodes of inpatient and outpatient care. Physicians and their hospitals currently managing financial risks and those positioning themselves for these opportunities find such tools and techniques to be invaluable. Credible information creates a power shift away from price-based contracting to a true competitive marketplace that rewards quality of care. Purchasers and patients seek providers who objectively demonstrate their value on both quality and price. Part I of this article appeared in the January/February issue of The Physician Executive.

Cohort Studies↗
PubMed1997

Evaluation of the HEDIS measure of behavioral health care quality. Health Plan Employer Data and Information Set.

OBJECTIVE: The Health Plan Employer Data and Information Set (HEDIS) is the most widely used "report card" system comparing health care plans across different dimensions of performance. HEDIS uses only one measure of the quality of behavioral health care-the rate of follow-up after hospitalization for major affective disorder. This study used data from a national Veterans Affairs database to evaluate the generalizability of the HEDIS behavioral health quality measure. METHODS: Using administrative data from a nationwide sample of 114 VA hospitals, the HEDIS (version 2.5) quality measure was compared with several related performance measures including readmission rates and outpatient follow-up rates for other psychiatric disorders and for substance use disorders. The magnitude and statistical significance of Pearson's r value for correlation between measures was calculated. RESULTS: The HEDIS measure was moderately correlated with 30-day follow-up after hospitalization for other psychiatric disorders and with other performance measures of outpatient care. However, it was poorly correlated with follow-up for substance use disorders, inpatient measures including readmission rates, and several other measures of quality. CONCLUSIONS: Caution is needed in drawing conclusions about the quality of behavioral health plans based on the single measure used in HEDIS, version 2.5. Inclusion of other performance measures may be warranted.

Adult↗
PubMedDate not supplied

The role of strategic alliances in ensuring health care quality: a health care system perspective.

The Chronic Illness Management Research and Development Project (CIMRDP) was created as part of an effort to implement clinical process improvements in HealthSystems Minnesota, a vertically integrated care system in Minneapolis. CIMRDP's objective is to introduce sustainable improvements in the management of chronic illness. These types of quality improvement efforts require fundamental change at the organizational level, which often does not occur, and the programs do not continue beyond the initial stage. Using CIMRDP as a model for a sustainable chronic illness management program, this paper explores the process of implementing clinical guidelines for the management of chronic illness and contending with the complex problem of initiating change at an organizational level. It reviews factors critical to the success of such a program, including the use of focus groups to ensure a patient-centered approach, the advantage of hiring an outside consultant, the question of whether to accept external funding, and an evaluation outline of the six main tasks the program requires. Methods for marketing and integration are also presented.

Chronic Disease↗
PubMed2000

Important attributes of quality health care: consumer perspectives.

PURPOSE: Despite extensive research on defining and measuring health care quality, little attention has been given to consumers' perspectives of high-quality health care. The purposes of this study were to (a) identify the importance to consumers of attributes of health care quality and nursing care quality, and (b) examine the relationship of consumer perspectives to health status and selected demographic variables. DESIGN: Exploratory. Consumers (N = 239) were recruited from waiting rooms of clinics and in neighborhoods of a large metropolitan area in the Midwestern United States that included both urban and suburban populations. METHODS: Participants completed the Quality Health Care Questionnaire (QHCQ) and the SF-36 Health Survey. On the QHCQ, they rated the importance of 27 attributes of health care and nursing care quality. The SF-36 is a 36-item instrument for measuring health status in eight general areas. FINDINGS: The most important indicators of high-quality nursing care to consumers were: being cared for by nurses who are up-to-date and well informed; being able to communicate with the nurse; spending enough time with the nurse and not feeling rushed during the visit; having a nurse teach about the illness, medications, treatments, and staying healthy; and being able to call a nurse with questions. The lowest-rated item was having an opportunity to be cared for by nurse practitioners. Ratings differed by race, age, years of education, income, and health status. CONCLUSIONS: The importance that consumers place on teaching by the nurse was emphasized, particularly among people with less education, low income levels, and chronic illnesses.

Adult↗
PubMed1998

The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality.

OBJECTIVE: To identify issues related to the quality of health care in the United States, including its measurement, assessment, and improvement, requiring action by health care professionals or other constituencies in the public or private sectors. PARTICIPANTS: The National Roundtable on Health Care Quality, convened by the Institute of Medicine, a component of the National Academy of Sciences, comprised 20 representatives of the private and public sectors, practicing medicine and nursing, representing academia, business, consumer advocacy, and the health media, and including the heads of federal health programs. The roundtable met 6 times between February 1996 and January 1998. It explored ongoing, rapid changes in health care and the implications of these changes for the quality of health and health care in the United States. EVIDENCE: Roundtable members held discussions with a wide variety of experts, convened conferences, commissioned papers, and drew on their individual professional experience. CONSENSUS PROCESS: At the end of its deliberations, roundtable members reached consensus on the conclusions described in this article by a series of discussions at committee meetings and reviews of successive draft documents, the first of which was created by the listed authors and the Institute of Medicine project director. The drafts were revised following these discussions, and the final document was approved according to the formal report review procedures of the National Research Council of the National Academy of Sciences. CONCLUSIONS: The quality of health care can be precisely defined and measured with a degree of scientific accuracy comparable with that of most measures used in clinical medicine. Serious and widespread quality problems exist throughout American medicine. These problems, which may be classified as underuse, overuse, or misuse, occur in small and large communities alike, in all parts of the country, and with approximately equal frequency in managed care and fee-for-service systems of care. Very large numbers of Americans are harmed as a direct result. Quality of care is the problem, not managed care. Current efforts to improve will not succeed unless we undertake a major, systematic effort to overhaul how we deliver health care services, educate and train clinicians, and assess and improve quality.

Health Services Misuse↗
PubMed1995

The changing role of the consumer in health care quality.

Traditionally, health care quality has been provider defined and focused, even though consumers define and evaluate health care quality. And, there is no relationship between consumer and provider perceptions of quality. Importantly, consumers use their evaluations when they decide to sue, recommend or return for services, and comply with treatment regimens. This article examines the changing role of the consumer in health care quality, explicates the need for a change in the health care paradigm, and suggests strategies for increasing patient participation in health care planning and quality assessment.

Community Participation↗
PubMedDate not supplied

Using Web sites on quality health care for teaching consumers in public libraries.

More and more consumers are searching the Internet for health information. Health Web sites vary in quality, though, and not all consumers are aware of the need to evaluate the information they find on the Web. Nurses and other health providers involved in patient education can evaluate Web sites and suggest quality sites for patients to use. This article describes a project we implemented in 2 public libraries to educate consumers about quality health care and patient safety using Web sites that we had evaluated earlier. Participants (n = 103) completed resources on health care quality, questions patients should ask about their diagnoses and treatment options, changes in Medicare and Medicare options or ways to make their health benefits work for them, and tips to help prevent medical errors. Most consumers were highly satisfied with the Web sites and the information they learned on quality care from these resources. Many participants did not have Internet access at home or work and instead used the library to search the Web. Information about the Web sites used in this project and other sites on quality care can be made available in libraries and community settings and as part of patient education resources in hospitals. The Web provides easy access for consumers to information about patient safety initiatives and health care quality in general.

Adolescent↗
PubMedDate not supplied

Parents' perceptions of quality health care.

PURPOSE: To examine differences in definitions of health care quality and the importance of indicators of quality between consumers with dependent children and consumers with no dependents. STUDY DESIGN AND METHODS: This was an exploratory study using a convenience sample of 229 consumers--96 with one or more dependent children and 133 with no dependent children. Consumers were asked four open-ended questions as to their definitions of health care and nursing care quality. Consumers then rated the importance of 27 indicators of quality care. RESULTS: There were no differences between parents with dependent children and other consumers in how quality care was defined. Important indicators of quality nursing care to parents with children were: Being cared for by nurses who are up to date, well informed, and certified in their specialty; being able to communicate with the nurse; spending enough time with the nurse; and teaching by the nurse. Although having access to midwives was of lowest importance to consumers overall, it was significantly more important to subjects with children (p < 0.05). Getting care and services when needed was also more important to parents than to consumers without children (p = 0.05). Parents gave more importance to their interactions with the nurse than did subjects without children (t = 1.93, df = 229, p = 0.05). CLINICAL IMPLICATIONS: Parents and consumers without children have similar views of what constitutes quality nursing care--having nurses who are concerned about them and their children, demonstrating caring behaviors and staying attentive to their needs, being competent and skilled, communicating effectively, and providing the teaching needed for managing their own and their family's health problems.

Adult↗
PubMed2005

Identifying health care quality attributes.

Evaluating health care quality is important for consumers, health care providers, and society. Developing a measure of health care service quality is an important precursor to systems and organizations that value health care quality. SERVQUAL has been proposed as a broad-based measure of service quality that may be applicable to health care settings. Results from a study described in this paper verify SERVQUAL dimensions, but demonstrate additional dimensions that are specific to health care settings.

Consumer Behavior↗
PubMed2005

Health care quality from the perspective of health care providers and patients during and shortly after acute care restructuring in Newfoundland and Labrador.

OBJECTIVES: To monitor changes in providers' perceptions of health care quality and the importance of health reform, and in patients' satisfaction with services during and two years after restructuring, comparing the region of the province that was restructured (St John's) with those regions in which hospitals were not aggregated. METHODS: The Employee Attitude Survey questionnaire was sent to acute care providers (n = 5353) to assess personal characteristics and perceptions of the impact of reform on workplace conditions, work-related attitudes and turnover intentions. The response rate for 2000 and 2002 was 42% (n = 1222 and 1034, respectively). Only respondents in both surveys (n = 589) were used in the analysis because study results were the same for both the repeat sample and total samples. A Patient Satisfaction Survey questionnaire was administered to patients discharged from acute care facilities in 2000 (n = 1741) and 2002 (n = 704). Response rates were 82.5% and 90.2%, respectively. RESULTS: Most providers felt, at both time periods, that restructuring of the health care system was a positive step, but felt that health care quality was low. In the St John's region, perceptions of quality and standards of care improved over time. Patients were extremely satisfied with the admission process and hospital stay at both time periods in St John's. However, satisfaction declined in 2002 in regions outside St John's. CONCLUSIONS: Aggregation of acute care hospitals is possible without adverse effects on providers' perceptions of health care quality or on patient satisfaction.

Adult↗
PubMedDate not supplied

Review: feedback about practice patterns for measurable improvements in quality of care--a challenge for PROs under the Health Care Quality Improvement Program.

The Health Care Quality Improvement Program (HCQIP), administered by the Health Care Financing Administration and implemented through Utilization and Quality Control Peer Review Organizations (PROs), is a new approach to monitoring the health care received by Medicare beneficiaries. The HCQIP shifts the focus of the PRO program from regulatory quality management to quality improvement principles. Through a series of cooperative projects, each focusing on a specific medical condition or procedure, PROs will conduct pattern analysis and share information about these analyses with health care organizations for the purpose of stimulating internal quality improvement efforts. As a fundamental shift in the way PROs have conducted quality-related activities, the HCQIP presents PROs with numerous challenges. This paper provides insight into one of their most significant challenges, the development of a model for constructive, nonevaluative feedback. Successful HCQIP feedback efforts may serve as models for quality management programs that will accompany national health care reform.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2001

Limitations of the facility-specific standardized mortality ratio for profiling health care quality in dialysis.

Health care quality is assessed by profiling measures of care and/or health outcomes. However, such tools to measure outcome as standardized mortality ratio (SMR) are often used without thorough validation of their strengths and limitations. Our study compared the dialysis facility-specific SMR and SMR-based rating using different statistical methods and followed them over time. All Fresenius Medical Care, North America dialysis facilities (n = 377) that contributed patient data from 1993 to 1995 (>103,500 patient-years) were included. Four distinct statistical methods (US Renal Data System [USRDS], Poisson, logistic, and Cox regression) were used to compute facility-specific SMRs and rank and classify facilities. The analysis compared the SMR and SMR-based rating of dialysis facilities between SMR method and over time. Different methods produced statistically significant differences in SMR distribution (P < 0.05). The USRDS method produced SMR values that decreased over time (P < 0.001). Based on 90% confidence intervals to determine outliers, the SMR-dependent ranking of dialysis facilities varied by method (P < 0.001). SMR-based ranking was stable over time except for the USRDS method (P < 0.001). Contingency table analysis showed up to a 33% total misclassification rate between SMR methods when ranking facilities. The facility-specific SMR and SMR-based ranking are both sensitive to statistical technique. Because the SMR yields different results in a year and over time and because there is no demonstrable gold standard, conclusions based on any one technique are unstable and unreliable. Regulatory monitoring, actions, and/or performance awards should be avoided based on this measure. However, a facility-specific SMR estimated in any valid way may be useful as an epidemiological research tool.

Adult↗
PubMed2006

The role of academic medicine in improving health care quality.

Academic medicine, often entrenched in biomedical and clinical research, has largely ignored the development and application of quality metrics to ensure the delivery of high-quality health care. Nevertheless, academic medicine has substantial opportunities to lead the charge in building a quality infrastructure with the goal of delivering high-quality and cost-efficient health care to all Americans. The American College of Cardiology (ACC) and American Heart Association (AHA) have worked jointly to measure and improve the quality of cardiovascular care. This effort has led to the development of clinical practice guidelines, performance measures, data standards, national registries, and appropriateness criteria for cardiovascular care. Academic medicine should actively embrace and promote the type of quality metrics and criteria developed by ACC and AHA and apply this model across the entire academic medicine community. Academic medicine, with its many resources, could lead the way in the expanding field of quality science by supporting fundamental research in quality improvement, supporting academicians to improve quality at their own institutions, developing educational models for quality assessment and improvement, creating and implementing data registries, and serving as a conduit for developing the emerging science of quality assessment. In this and many other ways, academic medicine must offer the health care community leadership for improving our nation's health care quality with the same fervor presently exhibited for the advancement of basic science, the development of specialized and experimental therapy, and as centers for tertiary and quaternary patient care.

Academic Medical Centers↗