Upload
dinhlien
View
214
Download
0
Embed Size (px)
Citation preview
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
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 2
Tip of the iceberg
Outcome
Process
Access
Structure
04/12/2012
Disability-adjusted life expectancy
Quality ?
Healthcare providers
Insurance / Health plans
Regulators
Seminàrio Internacional « Qualidade em Saùde » 3
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
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 4
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
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 5
Agency theory
Performance measures = align the interests of the agent with those of the principal
04/12/2012
Voters / Consumers /
Patients
Government
Healthcare providers
Insurances
Health agencies
Performance measures
Seminàrio Internacional « Qualidade em Saùde » 7
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
04/12/2012
“efforts to improve quality require efforts to measure it”
Seminàrio Internacional « Qualidade em Saùde » 8
How to improve quality ? A few examples
Outcome
Process
Access
Structure
04/12/2012
Accreditation
Guidelines Continuing Medical Education
Finan
cial ince
ntives
Pu
blic rep
ortin
g Eq
uity - sa
fety
Structure of healthcare
Seminàrio Internacional « Qualidade em Saùde » 10
Mea
sure
s
Improve the structure of healthcare
Equity
Access
Strong preventive care
Care coordination
Strong primary care
Effectiveness
Timeliness
Safety
Efficient secondary care
04/12/2012
Universal coverage
Health Systems Infrastructure
Capabilities
Seminàrio Internacional « Qualidade em Saùde » 11
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
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 12
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
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 13
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
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 14
NCQA Accreditation
Quality Management and Improvement
Response to medical necessity
Credentialing
Members’ Rights and Responsibilities
Member Connections
HEDIS
Quality measures
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 15
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
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 16
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
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 17
Continuing Medical Education
Maintain competence and learn about new and developing areas of their field
Often mandatory
Relicencing
Continuing professional development
Practice assessment
Measures
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 18
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
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 19
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
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 20
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
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 21
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
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 22
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
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 23
Public reporting
Accountability Political pressure
Consumer’s choice vote with their feet
Provider’s reputation
Communication Easy-to-read
Explanatory messages
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 24
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
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 25
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
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 27
Safety
Centers for Medicare & Medicaid Service (2007)
no-payment rule for hospital-acquired conditions
Safety culture
Measured by quantitative surveys
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 28
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
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 29
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.
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 31
Domains of measurement
Health Care Delivery
Structure / Access / Process / Outcomes
Patient experience
Population Health
Health state
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 32
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 ?
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 33
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 ?
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 34
Outcomes
An outcome of care is a health state of a patient resulting from health care
Proportion of hospital acquired-infection ?
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 35
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 ?
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 36
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)
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 37
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
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 38
Measure selection process
Importance of what is being measured
Potential to improve health
Actionable
Meaningful
Scientific soundness
Feasibility
04/12/2012
“Idade do capitão ?”
Seminàrio Internacional « Qualidade em Saùde » 39
Actionable
Definition
capable of being acted on
Population based or outcomes indicators
VS
Process, structure or access indicators
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 40
Scientific soundness
Reliability
Validity
Comprehensible Allowance for
patient/consumer factors as required
Scientific evidence
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 41
Internal versus external
Measuring
Financial Incentives
Public reporting
Accreditation
Quality improvement
initiatives
04/12/2012
Internal usage External usage
Seminàrio Internacional « Qualidade em Saùde » 43
Balance between external and internal
usage
Internal External
Initiative Voluntary Imposed
Means Learning, improvement Accountability, control
Motivation Intrinsic Extrinsic
Resistance Low High
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 44
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.
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 45
Cautions
Separate programs lead to confusion
Fix national objectives for quality improvement
Capacity limit of healthcare system
Health information technology
Healthcare data infrastructure
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 46
Questions
Dr Henri Leleu
04/12/2012 Seminàrio Internacional « Qualidade em Saùde » 47