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APPENDIX D

Selected Approaches to Thinking About Quality and the National Health Care Quality Report

The committee reviewed many of the approaches available to assess quality of health care and health care systems including those outlined in this appendix. Elements of these are part of the framework proposed by the committee in this report. The National Health Care Quality Framework rests on the Foundation for Accountability (FACCT) consumer reporting framework (Foundation for Accountability, 1997) and the health care system aims for quality improvement defined by the Institute of Medicine (Institute of Medicine, 2001). The framework builds on other efforts as well. The Institute of Medicine National Roundtable on Health Care Quality proposed a classification system for the different types of quality problems that exist in health care as problems of overuse, underuse, and misuse (Chassin and Galvin, 1998). To a large extent, these overlap with the quality components of effectiveness and safety in the National Health Care Quality Framework.

In their framework, Evans and Stoddart (1990) emphasize that the health care system is only one of several determinants of a person's health. Aspects such as how and where a person grew up, and his or her family, community, environment, and physical makeup can all influence health. Examining the context of health care goes beyond the scope of the National Health Care Quality Report (also referred to as the Quality Report), but the committee recognizes that health care does not operate in a vacuum and interested researchers can examine the data presented in the Quality Report in relation to frameworks of the determinants of health such as this.



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Page 189 APPENDIX D Selected Approaches to Thinking About Quality and the National Health Care Quality Report The committee reviewed many of the approaches available to assess quality of health care and health care systems including those outlined in this appendix. Elements of these are part of the framework proposed by the committee in this report. The National Health Care Quality Framework rests on the Foundation for Accountability (FACCT) consumer reporting framework (Foundation for Accountability, 1997) and the health care system aims for quality improvement defined by the Institute of Medicine (Institute of Medicine, 2001). The framework builds on other efforts as well. The Institute of Medicine National Roundtable on Health Care Quality proposed a classification system for the different types of quality problems that exist in health care as problems of overuse, underuse, and misuse (Chassin and Galvin, 1998). To a large extent, these overlap with the quality components of effectiveness and safety in the National Health Care Quality Framework. In their framework, Evans and Stoddart (1990) emphasize that the health care system is only one of several determinants of a person's health. Aspects such as how and where a person grew up, and his or her family, community, environment, and physical makeup can all influence health. Examining the context of health care goes beyond the scope of the National Health Care Quality Report (also referred to as the Quality Report), but the committee recognizes that health care does not operate in a vacuum and interested researchers can examine the data presented in the Quality Report in relation to frameworks of the determinants of health such as this.

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Page 190 The committee acknowledges the usefulness of Donabedian's (1966, 1980) classification of structure, process, and outcomes of care and considers his characterization of quality as an additional way of thinking about the types of measures that should be included in the Quality Report. The role of these three types of measures is discussed in Chapter 3. The overall purpose of the system proposed by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry was adopted by the committee for the National Health Care Quality Framework. The aims proposed by the commission are largely subsumed by the ones in the framework proposed by the committee (Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1998). As discussed, many of Healthy People 2010's focus areas are included in the National Health Care Quality Framework as suggested conditions for which to examine quality of care (U.S. Department of Health and Human Services, 2000). Although the Health Plan Employer Data and Information Set (HEDIS) 2001 was developed to measure health plan performance rather than to track the quality of health care at the national level, specific HEDIS measures were considered as examples for the National Health Care Quality Data Set (National Committee for Quality Assurance, 2000). Some of the categories of measures, such as effectiveness, included in HEDIS 2001 overlap with the components of health care quality contemplated in the National Health Care Quality Framework. Finally, as discussed in Chapter 1, the committee considered various international efforts in designing the framework. Several of the measure categories in the United Kingdom's National Health Service (NHS) Performance Assessment Framework are similar to those in the National Health Care Quality Framework. For example, “patient experience of the NHS” overlaps with the quality component of “patient centeredness,” as does “effective delivery of appropriate health care” with “effectiveness” (Department of Health, 1999a, b, 2000). A short description of each of the approaches examined by the committee follows. This description includes the definition of quality used (if applicable), a summary of the model or elements of the approach, including units of analyses, the intended audience, the main categories of measures, examples of measures, and brief comments on the nature of the framework or approach, including possible gaps, and the pros and cons when considering it for the National Health Care Quality Report.

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Page 191 CROSSING THE QUALITY CHASM: A NEW HEALTH SYSTEM FOR THE 21ST CENTURY Description Author: Institute of Medicine (IOM), 2001. Definition of Quality: Adopted the IOM definition of quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” (Institute of Medicine, 1990:21) Unit of Analysis: Health care organizations and the system as a whole. Audiences: Policy makers, general public, patients, providers, administrators. Categories The aims for health care improvement are as follows: Safety: Avoiding injuries to patients from care that is intended to help them. Effectiveness: Providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit (avoiding overuse and underuse). Patient centeredness: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. Timeliness: Reducing waits and sometimes harmful delays for both those who receive and those who give care. Efficiency: Avoiding waste, in particular waste of equipment, supplies, ideas, and energy. Equity: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. Comments General: This framework is grounded in the assumption that the health care system is in need of major restructuring. Specifying the aims that capture the desirable characteristics of a delivery system provides a common direction for the country's efforts to improve quality. SOURCE: Institute of Medicine, 2001.

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Page 192 FACCT CONSUMER INFORMATION FRAMEWORK Description FACCT's philosophy is that measures should reflect the needs and values of the consumer. The framework is a comprehensive approach to communicating health care quality information to consumers. It was originally defmed for the Medicare program and tested with a broad section of consumers. Author: Foundation for Accountability, 1997. Definition of Quality: None specified. Model: The framework organizes comparative information about quality performance into five reporting categories based on how consumers think about their care. Emphasis is on consumer-relevant measures that are outcome- and patient-focused. FACCT has designed a multistep process to create composite scores for the measures. Measures come from a variety of sources including HEDIS, FACCT measurement sets, CAHPS (Consumer Assessment of Health Plans Survey), and public health databases. Performance is measured with respect to the population as a whole and for specific health conditions. Audiences: Consumers and purchasers. Unit of Analysis: Varies, includes health plans. Categories and Measures The Basics (getting the basics of access, communication, and service from provider and plan; data source is CAHPS): Doctor communication (e.g., provider who listens carefully and explains things clearly) Doctor access and service (e.g., can get an appointment quickly for routine care) Plan rules for getting care (e.g., have an easy time getting referrals to specialists) Plan information and service (e.g., receive clear information from plan) Staying Healthy (help to avoid illness and stay healthy; data source is HEDIS): Screening for problems Immunizations Checkups Help for healthier living (e.g., proportion of patients who smoke who report being advised to quit smoking)

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Page 193 Getting Better (help to recover when sick or injured; data source is FACCT condition-specific patient surveys): Appropriate treatment and follow-up Experience and satisfaction with treatment Recovery and functioning Living with Illness (help with ongoing, chronic conditions; data source is FACCT condition-specific patient surveys): Appropriate care Experience and satisfaction with care (e.g., score on provider communication or skill scale from FACCT asthma patient survey) Education and teamwork Day-to-day living (e.g., can maintain daily activities) Changing Needs (caring for people and their families when needs change dramatically because of disability or terminal illness): Care for disabilities Caregiver support End-of-life care Comments General: FACCT has designed a patient survey FACCT|ONE that addresses quality of care for people living with illness—specifically, asthma, diabetes, and coronary artery disease. It has also defined specific quality measurement sets for adult asthma, alcohol misuse, breast cancer, diabetes, major depressive disorder, health status, health risks, and consumer satisfaction. (Note: Lists of measures for each of these aspects are available, but measures are generally classified into “steps to good care,” “experience and satisfaction,” and/or “results,” rather than the five categories listed above.) Gaps: FACCT has organized several groups to develop quality measures in gap areas such as children and adolescents, end of life, and HIV/AIDS. The availability of measures for each of the five categories of the framework varies. Pros and Cons: The purpose of the framework is to report information on quality to consumers, but it can also be used to define areas of measurement. Categories do not address a particular entity or provider, but rather the essential aspects of health care from a consumer viewpoint, so the framework can be used to measure the results of care regardless of the delivery system. The framework can be used to present information on quality measures from other sources and to present condition-specific quality data. The fact that it was de-

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Page 194 signed based on consumer research makes it particularly well suited for a report to the public. SOURCES: Foundation for Accountability, 1997, 1999. THREE-WAY CLASSIFICATION OF QUALITY PROBLEMS Description Author: Mark R. Chassin, 1991. Definition of Quality: Chassin cites the IOM definition of quality of care—“the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Institute of Medicine, 1990:21). Model: This is a classification system for quality problems, rather than a model. Unit of Analysis: Not specified. Audiences: Researchers, policy makers. Classification Categories Underuse is defined as “failure to provide an effective health care service when it would have produced favorable outcomes” (e.g., missed childhood immunizations, proportion of patients with depression not detected early) (Chassin, 1991:3472). Overuse is defined as “providing a health service when its risk of harm exceeds its potential benefit” (e.g., prescribing antibiotic for a cold, rate of inappropriate hysterectomies) (Chassin, 1991:3472). Misuse is defined as “avoidable complications of appropriate health care” (e.g., avoidable complications of surgery, patient injuries resulting from medication errors) (Chassin 1991:3472). Comments General: Other important issues related to quality such as variations in care, physician training, and composition of the work force are seen as causal or explanatory factors related to specific problems of underuse, overuse, and misnse. For this reason, the system of quality problems is viewed as comprehensive. Gaps, Pros and Cons: This approach should be combined with a method for defining priorities among quality problems in terms of misuse, overuse, and underuse. If one can truly divide all quality problems into these three categories, the classification provides a clear and concise way to define quality

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Page 195 measures. It is not clear whether this classification and corresponding measures will provide enough feedback information to define policy and improve care based on the indicators. Also, it may place less importance on quality problems that do not fit directly into this classification system but should be considered as important measures for other reasons. SOURCES: Chassin, 1991; Chassin and Galvin, 1998. FIELD MODEL OF THE DETERMINANTS OF HEALTH Description Authors: R.G. Evans and G. L. Stoddart, 1990. Definition of Quality: None specified since this is not the purpose of the model. Model: This model builds on Blum's (1981) and Lalonde's (1974) earlier health field framework that considered four determinants of health: environment, heredity, life-style, and health care services. The focus of the model is not on quality but on the determinants of health defmed as social environment, physical environment, genetic endowment, health care, and individual biological and behavioral responses. Outcomes included in the model distinguish disease (as defined and treated by the health care system), health and functioning (as perceived by individuals), well-being, and prosperity. Health care is not considered the most important determinant of health and is most closely linked to illness. The conceptual model in Figure D. 1 shows the elements in the model and the causal pathways among them. Unit of Analysis: The health care system and social determinants of health. Audiences: Policy makers, researchers. Categories and Measures The elements or categories in the model are shown in Figure D.1. This is not a model for quality assessment, so measures are not contemplated by the authors. Comments General: The framework has broad appeal. In addition to being used in Canada (at the provincial and national levels), this model has reportedly been adopted by the U.S. Department of Health and Human Services for Healthy People 2010. It has also been used in the work of several Institute of Medicine committees (1997, 1999).

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Page 196 ~ enlarge ~ FIGURE D.1 Model of the determinants of health. SOURCE: Evans and Stoddart, 1990. Reprinted with permission from Elsevier Science. Gaps, Pros and Cons: The framework does not focus on quality so it would have to be combined with others. It is useful for examining the health care system within a broader context. If the goal of the health care system and of providing care is to improve health, this model can point to other factors that may influence health and should therefore be considered. SOURCES: Evans and Stoddart, 1990; Institute of Medicine, 1997, 1999. QUALITY ASSESSMENT TRIAD OF STRUCTURE, PROCESS, AND OUTCOME Description Author: Avedis Donabedian, first proposed in the 1960s. Definition of Quality: Quality is seen as a property of the medical care process and is defined as “the expected ability [of care] to achieve the highest possible net benefit according to valuations of individuals and society” (Donabedian, 1980:22). At the individual level, the process of medical care consists of technical and interpersonal aspects and is influenced by the amenities of the setting of care. Model: Donabedian's classic characterization of the approach to quality assessment includes elements of the structure of the health care delivery system, the process of care, and the outcomes of care. Structure refers to the resources

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Page 197 available, including characteristics of the providers and settings of care. Process refers to provider performance and includes normative behavior. Outcomes refer to any change in a patient's current and future health status that can be attributed to antecedent health care, including patient satisfaction. These three elements are causally linked so that structure affects the probability of good performance or the process of care, which in turn can affect outcomes such as health status and quality of life: Structure → Process → Outcome Unit of Analysis: It may vary. It can focus on different levels of aggregation of the providers and recipients of care. In the case of the Quality Report, it could focus on the overall health care system as the provider and the general population as the recipient. Audiences: Health services researchers, providers interested in quality assurance. Categories and Measures The following list is a selection of the most relevant categories and measures for the Quality Report and is adapted from a schematic classification proposed by Donabedian in 1968 (Donabedian, 1980: Appendix B). Possible examples of measures not proposed by Donabedian but within his schema are in brackets rather than parentheses. Characteristics of the Settings of Care (structure) Presence or absence of certain facilities or equipment related to specific care functions [e.g., proportion of hospitals with computerized adverse drug event systems] Accreditation [e.g., proportion of health plans accredited by the National Committee for Quality Assurance (NCQA); proportion with public reporting of quality data] Qualifications of health care professionals [e.g., proportion of board-certified specialist physicians; type and specialty of primary care provider] Geographic accessibility [e.g., average distance to hospital] Characteristics of Provider Behavior in Management of Health and Illness (screening, diagnosis, treatment, referral, coordination, continuity) and Other Aspects (process) Frequency of recommended screening tests for a specific population Validation of diagnosis (e.g., comparison of admission and discharge diagnoses)

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Page 198 Preventive management and supervision of certain diseases [e.g., proportion of diabetics who had an eye exam] Patterns of use of drugs, blood, and biologicals (e.g., total prescribed drug utilization per capita and per 1,000 physician visits) Surgical rates by type of procedures more open to abuse (e.g., hysterectomy) Patterns of multiple operations Number of providers involved in care of a single patient over a period of time or episode Other Provider Behaviors Possibly Indicative of Strength or Weakness in the Organization of Care (structure) Staff turnover [e.g., turnover of primary care providers in health plans] Client Behaviors Indicative of Defects in the Organization of Care or Relationship with Provider (process or outcome) Discharge against advice Characteristics of Use of Service (process or outcome) Volume of care (e.g., utilization by certain population characteristics) Use by place of care (e.g., hospital, nursing home, home) Characteristics of Health and Other Outcomes (outcome) General mortality, morbidity, and disability rates (check for trends, geographic variations) Mortality in special subgroups (e.g., infants, maternal, by race) Average number of days lost from work or school due to disability Case fatality rates and operative mortality rates by type of illness or operation Readmission rates of patients previously hospitalized due to mental illness Patient satisfaction Comments General: Donabedian discusses several definitions of quality including an “absolutist” one that focuses on technical aspects, an “individualized” one that takes into account patient valuations of care, and a “social” one that takes into account the distribution of benefits. This last one would be useful in examining disparities. The author advocates the simultaneous use of process and outcome measures. Outcomes can be used as more inclusive, integrative measures of the total quality of care for a particular individual. Process measures allow for any needed corrective actions. Each can serve as a validity check on the other. Structural measures can supplement process and outcome measures

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Page 199 and can be used to assess the capacity of the system to provide high-quality care. Aspects such as access to care, continuity, and coordination of care are attributes of care that can influence quality, yet are considered separate from it. They may or may not be used as quality measures. Client satisfaction is a consequence of care that can be used as a quality measure. Gaps: This framework focuses more on medical care than on health care, in general. It seems better suited for evaluating individual organizations or providers than the overall system; however, Donabedian stated it could be used for both. Pros and Cons: This is a very flexible framework that can be used with different conceptualizations of quality at different levels of aggregation. However, it does not contemplate the determinants of health beyond medical care, so the measures proposed tend to concentrate on the medical care process. It is based on a linear conception of the health care system that simplifies its use but may make interpretation of results more difficult. It is a well-known framework, used and built on by many others. For example, one of the proposals is to classify process measures into those that focus on technical aspects of care and those that focus on interpersonal aspects of quality (see, for example, McGlynn, 1996). SOURCES: Donabedian, 1966, 1980. PRESIDENT'S ADVISORY COMMISSION ON CONSUMER PROTECTION AND QUALITY IN THE HEALTH CARE INDUSTRY Description Author: President's Advisiory Commission on Consumer Protection and Quality in the Health Care Industry, 1998. Definition of Quality: Adopted the IOM definition of quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Institute of Medicine, 1990:21). Model: The commission did not have a model but declared that “the purpose of the health care system must be to continuously reduce the impact and burden of illness, injury and disability, and to improve the health and functioning of the people of the United States” (Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1998:2). The commission defined a set of national aims for improvement (see below). Unit of Analysis: National health care industry as a whole and individual sectors. Audiences: Several, but mainly policy makers.

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Page 201 cess to quality health services is one of them. Its objectives place an emphasis on areas where significant disparities in access to quality health services exist between the general population and vulnerable populations and where access to care is likely to affect years of healthy life. The framework of determinants of health draws from the Evans and Stoddart (1990) model. Policies and interventions can be used to improve health by targeting factors related to individuals and their environment, including access to quality health care. Unit of Analysis: The nation (can also apply to states and smaller geographic levels). Audiences: Policy makers in the health care arena and the general public. Categories, Objectives, and Measures Access to Quality Health Services. The goal of this focus area is to improve access to comprehensive, high-quality health care services. It includes four categories and specific objectives for each as listed below. Clinical Preventive Services Persons with health insurance Health insurance coverage for preventive services (e.g., proportion of patients who have coverage for preventive services) Counseling about health behaviors (e.g., proportion of current smokers counseled about smoking at last visit) Primary Care Source of ongoing primary care Usual primary care provider Difficulties or delays in obtaining needed health care (e.g., proportion in fair or poor health who report no visits in previous year) Core competencies in health provider training Racial and ethnic minority representation in the health professions Hospitalization for ambulatory care-sensitive conditions (e.g., reduce rate of pediatric asthma, pneumonia and influenza in elderly, and diabetes) Emergency Services Delay or difficulty in getting emergency care Rapid pre-hospital emergency care (e.g., proportion who have access to rapidly responding emergency medical services [less than 9 minutes between call and arrival in urban areas]) Single toll-free number for poison control center Trauma care systems

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Page 202 Special needs of children Long-Term Care and Rehabilitative Services Long-term care services Pressure ulcers among nursing home residents (e.g., reduce proportion of nursing home residents with pressure ulcers at stage 2 or greater) Comments General: Criteria for the selection of Healthy People 2010 leading indicators included the ability to motivate action by the public and others, the availability of data to measure progress, and relevance as a broad public health issue. The rationale for the focus of Healthy People 2010 on access is that “adequate access to health care services can significantly influence patient use of the health care system and, ultimately, improve health outcomes. Consequently, measures of access to care provide an important mechanism for evaluating the quality of the Nation's health care system” (U.S. Department of Health and Human Services, 2000:1–4). Gaps: The authors recognize that there are gaps in this focus area (access to quality health services) regarding secondary and tertiary clinical care. Pros and Cons: Taking this framework into consideration in defining the Quality Report would facilitate the link with the Healthy People 2010 objectives. SOURCE: U.S. Department of Health and Human Services, 2000. HEALTH PLAN EMPLOYER DATA AND INFORMATION SET Description NCQA developed the Health Plan Employer Data and Information Set to assess health plan performance and continually revises it. HEDIS 2001 includes measures from CAHPS to assess member satisfaction with the quality of care provided by plans. Since 1996, NCQA has produced annual “Quality Compass” reports that include comparative HEDIS and accreditation data on health plans. Measures are reported yearly, except for a few that are reported only every two years. Author: National Committee for Quality Assurance, since 1996; latest version (HEDIS 2001) published in 2000. Definition of Quality: None specified. Model: HEDIS measures are selected through expert committees and draw on open calls for measures. The main criteria for the selection of measures are

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Page 203 relevance, scientific soundness, and feasibility. Measures fall into seven categories representing basic aspects of health plan performance thought to be important to purchasers and consumers. The first category, effectiveness of care, is the one most directly relevant to quality, although others may also contain useful measures depending on the selected conceptualization of quality of care. Audiences: Health plans and purchasers, including employers and consumers. Unit of Analysis: Health plans and the corresponding enrolled population. Categories and Measures Effectiveness of Care Childhood immunization status Adolescent immunization status Breast cancer screening Cervical cancer screening Chlamydia screening in women Controlling high blood pressure Beta-blocker treatment after a heart attack Cholesterol management after acute cardiovascular events Comprehensive diabetes care Use of appropriate medications for people with asthma Follow-up after hospitalization for mental illness Antidepressant medication management Advising smokers to quit Flu shots for older adults Pneumonia vaccination status in older adults Medicare Health Outcomes Survey Access to or Availability of Care Adults' access to preventive or ambulatory health services Children's access to primary care practitioners Prenatal and postpartum care Annual dental visit Availability of language interpretation services Satisfaction with the Experience of Care HEDIS/CAHPS 2.0H, Adult HEDIS/CAHPS 2.0H, Child

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Page 204 Health Plan Stability Practitioner turnover Years in business or total membership Use of Services Frequency of ongoing prenatal care Well-child visits in the first 15 months of life Well-child visits in the third, fourth, fifth, and sixth years of life Adolescent well-care visits Frequency of selected procedures Inpatient utilization—general hospital or acute care Ambulatory care Inpatient utilization—non-acute care Discharge and average length of stay—maternity care Cesarean section rate Vaginal birth after cesarean rate Births and average length of stay, newborns Mental health utilization—inpatient discharges and average length of stay Mental health utilization—percentage of members receiving services Chemical dependency utilization—inpatient discharges and average length of stay Chemical dependency utilization—percentage of members receiving services Outpatient drug utilization Informed Health Care Choices Management of menopause Health Plan Descriptive Information Board certification or residency completion Practitioner compensation Arrangements with public health, educational, and social service organizations Total enrollment by percentage Enrollment by product line (member-years or member-months) Unduplicated count of Medicaid members Diversity of Medicaid membership Weeks of pregnancy at time of enrollment in managed care organization Comments Gaps: HEDIS measures have evolved over time. The original clinical focus on preventive care has broadened, and the latest set includes some measures on

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Page 205 the quality of chronic care. HEDIS contains measures for different age groups, including the elderly. Pros and Cons: HEDIS measures have gone through a rigorous selection process and are being used by many health plans. However, the focus is on the accountability of health plans, rather than on tracking health care quality at a national level. There is incomplete reporting of measures and health plans resulting in lack of representativeness at the national level. There is no explicit rationale for the categories of measures that were defined. However, measures within each category can be used in other frameworks and the HEDIS measure set is widely known and accepted. Vermont, for example, produces an annual health care quality report based on its own categories of quality but using HEDIS measures for the data (Vermont Program for Quality in Health Care, 2000). SOURCE: National Committee for Quality Assurance, 2000. NATIONAL HEALTH SERVICE (NHS) PERFORMANCE INDICATORS AND PERFORMANCE ASSESSMENT FRAMEWORK Description Author: NHS Executive, United Kingdom, since 1998. Definition of Quality: Not explicit in source document. Model: The performance framework is based on a three-pronged strategy to improve quality: setting standards nationally, delivering standards locally, and monitoring standards externally. The six areas of the framework are interdependent. As stated, “From an initial view of the health of the communities (health improvement), they need to ensure that everyone with needs (fair access) receives effective care (effective delivery), offering good value (efficiency) and convenient, sensitive care (user/carer experience) so as to obtain good health outcomes (health outcomes of NHS care) and maximize the contribution to improved health (back to health improvement)” (Department of Health, 1999a:8). The framework is supported by 49 indicators (Department of Health, 2000). NHS states that the indicators are not direct measures of quality but can serve to draw attention to specific related issues. Unit of Analysis: Nation, NHS Trusts, NHS Health Authorities. Audience: Policy makers in health care arena and the general public. Categories and Measures Health Improvement Deaths from all causes (ages 15–64) Deaths from all causes (ages 65–74)

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Page 206 Deaths from cancer Deaths from all circulatory diseases Suicide rates Deaths from accidents Serious injury from accidents Fair Access Inpatient waiting list Adult dental registrations Early detection of cancer Cancer waiting times Number of general practitioners Practice availability Elective surgery rates Surgery rates—coronary heart disease Effective Delivery of Appropriate Health Care Childhood immunizations Inappropriately used surgery Acute care management Chronic care management Mental health in primary care Cost-effective prescribing Returning home following treatment from a stroke Returning home following treatment for a fractured hip Efficiency Day case rate Length of stay Unit cost of maternity unit Unit cost of caring for patients in receipt of specialist mental health services Percentage of generic prescribing Patient/Carer Experience in the NHS Patients who wait less than 2 hours for emergency admissions Patients with operations canceled for nonmedical reasons on the day of or after admission Delayed discharge from hospital for people age 75 or over Percentage of first outpatient appointments that patient did not attend Percentage of outpatients seen within 13 weeks of general practitioner referral

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Page 207 Percentage of those on waiting list waiting 18 months or more Health Outcomes of NHS Care Conceptions below age 18 Decayed, missing, and or filled teeth in 5-year-olds, average number Readmission to hospital following discharge Emergency admissions to hospital for people aged 75 or over Emergency psychiatric readmissions rates Stillbirths and infant mortality Breast cancer survival Cervical cancer survival Lung cancer survival Colon cancer survival Deaths in hospital following surgery (emergency admissions) Deaths in hospital following surgery (non-emergency admissions) Deaths in hospital following a heart attack (ages 35–74) Deaths in hospital following a fractured hip Additional Comments General: At the international level, England (Department of Health, 2000) and Australia (National Health Performance Committee, 2000) are two of the countries that have defined national strategies for evaluating the quality of health care. The information is reported at the national level as well as at the level of NHS Trusts (regional) and Health Authorities (local). Gaps: There is an attempt to cover ambulatory and hospital care. The framework includes indicators of structure, process, and outcomes of care. Pros and Cons: The objective of this framework is similar to the one for the U.S. National Health Care Quality Report since the purpose is to assess the quality of care delivery at the national level. This framework includes fair access necessary for reducing health disparities and one of the two overarching goals of Healthy People 2010 (U.S. Department of Health and Human Services, 2000). The data collection and reporting system used is facilitated by the fact that England has a national health system and a uniform, centralized health information system. SOURCE: Department of Health, 1999a, 1999b, 2000.

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Page 208 SELECTION OF QUALITY-OF-CARE MEASURES BASED ON BURDEN OF DISEASE AND EXPECTED IMPACT Description Authors: Albert Siu, Elizabeth A. McGlynn, Hal Morgenstern et al. (1992) based on earlier work by Brook et al. (1977) and by Williamson (1978) and Williamson et al. (1968). Definition of Quality: “Difference between efficacy and effectiveness that can be attributed to care providers” (Brook and Lohr, 1985:711). Model: Instead of a model, the framework includes a process for the definition of conditions of interest in quality measurement. First, identify the major causes of mortality and morbidity in the United States by age and gender, add others thought to be important by experts but not on list due to problems of underreporting, and other reasons. Second, conduct a literature review of the availability and efficacy of medical care interventions (primary, secondary, or tertiary prevention) or health-related behavior changes that can reduce disease burden. Third, estimate expected reductions in deaths, bed-days, or other adverse outcomes for each disease or outcome of interest following the intervention in a particular population. Other considerations are the cost-effectiveness of the intervention, whether providers of interest can influence improvements in care considered, and the availability and feasibility of collecting quality-of-care information. Unit of Analysis: The authors apply the framework to health plans, but the initial selection is based on national estimates of expected impact on morbidity and mortality so it can be used at this level. The focus is on health problems exhibited by a population of interest. Audiences: Policy makers, mainly in health care arena. Categories and Measures The major causes of mortality and morbidity for the United States included in this framework are infant mortality and related conditions, otitis media, asthma, accidents and injuries, suicide, acute respiratory conditions, breast cancer, back conditions, coronary artery disease, arthritis, chronic bronchitis and emphysema, colorectal cancer, lung cancer, stroke and cerebrovascular disease, diabetes, and pneumonia. Additional conditions that do not necessarily meet all criteria but were considered a priority by experts include vaccine-preventable childhood infectious diseases, mental health problems, sexually transmitted diseases, dementia and incontinence, osteoporosis and hip fractures, and sensory impairments.

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Page 209 Examples of Measures for Target Conditions Prevention of low birth weight: process measures to focus on timeliness, frequency, and content of prenatal care. Childhood infectious disease: vaccine rates for diptheria–pertussis–tetanus by age 2. Treatment of otitis media: process measures regarding, use of antibiotics for treatment, etc. Treatment of diabetes mellitus: process and intermediate outcome measures to focus on access, glucose monitoring, eye screening, etc. Overuse of surgical procedures and prevention of complications: proportion of cardiac catheterizations, cholecystectomies, hysterectomies performed for indications rated appropriate; complication rates adjusted for age, sex, and comorbidities. Comments General: A recent article by Woolf (1999) presents evidence of the effectiveness of various interventions and expected benefit that could be combined with this approach. Gaps: This framework does not take into account public valuations or utilities. It does not include structural measures. The framework tends to be biased toward clinical conditions rather than positive health, but the user has the discretion to alter the original list of problems selected for action using expert judgment. Pros and Cons: This framework is specifically designed from a public policy perspective. It can be combined with other frameworks, such as Chassin (1991), to examine quality-of-care problems of overuse, misuse, and underuse. Different methods for assessing the burden of disease can be used, such as the newer disability-adjusted life-years proposed by the World Bank (1993). It is also possible to do sensitivity analysis of the effect of changes in the assumptions on the target conditions selected for quality measurement. The conditions selected and the estimates will have to be revised as new information and therapies become available. The initial selection criteria are explicit and replicable, but others used to modify the original list are not as clear. SOURCE: Siu et al., 1992. REFERENCES Advisory Commission on Consumer Protection and Quality in the Health Care Industry. 1998. Quality First: Better Health Care for All Americans. Washington, D.C. : U.S. Government Printing Office.

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Page 210 Blum, H. 1981. Planning for Health: Generics for the Eighties. 2nd ed. New York: Human Sciences Press. Brook, Robert H., Allyson Davies-Avery, Sheldon Greenfield, L. J. Harris, T. Lelah, N. E. Solomon, and John E. Ware, Jr. 1977. Assessing the quality of medical care using outcome measures: An overview of the method. Medical Care 15(Supplement): 1–84. Brook, Robert H., and Kathleen Lohr. 1985. Efficacy, effectiveness, variations, and quality—Boundary-crossing research. Medical Care 23(5): 710–722. Chassin, Mark R. 1991. Quality of care: Time to act. Journal of the American Medical Association 266(24): 3472–3473. Chassin, Mark R., and Robert W. Galvin. 1998. The urgent need to improve health care quality: Institute of Medicine National Roundtable on Health Care Quality. Journal of the American Medical Association 280(11): 1000–1005. Department of Health. 1999a. The NHS Performance Assessment Framework. London: NHS Executive. Available at:. http://www.doh.gov.uk/nhsexec/nhspaf.htm Department of Health. 1999b. Quality and Performance in the NHS: High Level Performance Indicators. London: NHS Executive. Available at: http://www.doh.gov.uk/nhshlpi.htm. Department of Health. 2000. NHS Performance Indicators. Leeds, England: NHS Executive. Available at: http://www.doh.gov.uk/nhsperformanceindicators. Donabedian, Avedis. 1966. Evaluating the quality of medical care. Milbank Memorial Fund Quarterly 44: 166–203. Donabedian, Avedis. 1980. Explorations in Quality Assessment and Monitoring, Vol. 1. Ann Arbor, Mich.: Health Administration Press. Evans, R. G., and G. L. Stoddart. 1990. Producing health, consuming health care. Social Science and Medicine 31(12): 1347–1363. Foundation for Accountability. 1997. Reporting Quality Information to Consumers. Portland, Ore. FACCT. Foundation for Accountability. 1999 Sharing the Quality Message with Consumers. Portland, Ore.: FACCT. Institute of Medicine. 1990. Medicare: A Strategy for Quality Assurance, Vol. 2. ed. Kathleen Lohr. Washington, D.C.: National Academy Press. Institute of Medicine. 1997. Improving Health in the Community: A Role for Performance Monitoring. eds. Jane S. Durch, Linda A Bailey, and Michael A. Stoto. Washington, D.C.: National Academy Press. Pp. 126–65 ; 360–373. Institute of Medicine. 1999. Leading Health Indicators for Healthy People 2010. eds. Carole A. Chrvala and Roger J. Bulger. Washington, D.C.: National Academy Press. Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press. Lalonde, Marc. 1974. A New Perspective on the Health of Canadians. Ottawa: Health and Welfare, Canada. McGlynn, Elizabeth A. 1996. Developing a quality measurement strategy. QMAS conference—Measuring health care for value-based purchasing. Quality Measurement Advisory Service. Available at: http://www.qmas.org. National Committee for Quality Assurance. 2001. HEDIS 2001, Vol. 1. Washington, D.C.: NCQA.

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Page 211 National Health Performance Committee. 2000. Fourth National Report on Health Sector Performance Indicators—A Report to the Australian Health Ministers' Conference , Sydney, Australia: NSW Health Department. Siu, Albert L., Elizabeth A. McGlynn, Hal Morgenstern, Mark H. Beers, David M. Carlisle, Emmett B. Keeler, Jerome Beloff, Kathleen Curtin, Jennifer Leaning, Bruce C. Perry, Harry P. Selker, Andrew Weisenthal, and Robert H. Brook. 1992. Choosing quality of care measures based on the expected impact of improved care on health. Health Services Research 27(5): 619–650. U.S. Department of Health and Human Services. 2000. Healthy People 2010. Washington, D.C.: U.S. Government Printing Office. Vermont Program for Quality in Health Care. 2000. The Vermont Health Care Quality Report [on-line]. Available at: http://www.vpqhc.org. Williamson, J. W. 1978. Formulating priorities for quality assurance activity. Description of a method and its application. Journal of the American Medical Association 239(7): 631–637. Williamson, J. W., M. Alexander, and G. E. Miller. 1968. Priorities in patient care research and continuing medical education. Journal of the American Medical Association 204(4): 303–308. Woolf, Steven H. 1999. The need for perspective in evidence-based medicine. Journal of the American Medical Association 282(24): 2358–2365 . World Bank. 1993. World Development Report 1993: Investing in Health. Oxford, England: Oxford University Press.