Measuring the Quality of Health Care (1999) / Chapter Skim
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Measuring the Quality of Health Care
Measuring the Quality of Health Care
Pages 1-24
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. That white paper was the start of a special initiative on quality of health care that included the formation of the IOM's National Roundtable on Health Care Quality, which has issued this statement.
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In particular, measurement of health care quality serves a range of objectives, including the following: · providing data to inform quality improvement efforts; · inspecting and certifying that a facility or individual meets previously established standards; · comparing groups for a variety of purposes, including selective contracting by purchasers and choice of providers and practitioners by individuals; · informing patients, families, and employees about the health care decisions and choices they face; · identifying and possibly eliminating substandard performers those whose performance is so far below an acceptable level that immediate actions are needed; · highlighting, rewarding, and disseminating best practices; · monitoring and reporting information about changes in quality over time; and · addressing the health needs of communities. The Roundtable emphasizes that although quality measurement has many uses, one of the most important is to provide information that can be used to improve performance.
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Conversely, patients may do well despite poor quality care because humans are resilient creatures. The term likelihood recognizes that there is always an unknown aspect of health care, but the services provided are expected to provide more benefit than harm, based on the best available information both about the patient and about the effectiveness of a particular kind of treatment for patients with similar health problems.
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No matter how good the understanding or measures of quality are today, health care professionals must always be prepared to revise them as new knowledge is generated about what works and what does not work effectively in health care to produce good outcomes for patients. Although the knowledge and practices of individual clinicians are important for high-quality care, no health practitioner can stay abreast of this growing body of knowledge without the assistance of good systems of care and good information systems to help ensure that relevant and accurate health information is available when needed.
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These tasks call for applying quality measures to all types of providers in both the private and the public sectors and to the extent feasible under all financing mechanisms. To measure underuse, however, requires denominator information that is, identification of the group for whom services
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Organizations with enrolled populations, such as managed care organizations, can assess underuse of appropriate services such as preventive care, because they have a defined denominator population that is eligible to receive these services. Misuse: Shortcomings in Technical and Interpersonal Aspects of Care Inferior care results when the performance of health care professionals or support systems is inadequate or if practitioners lack mastery of their clinical-practice fields, do not adequately explain key aspects of care, or cannot communicate well with their patients.
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Much of the discussion of nursing home quality and regulation for remedying known problems concerns the role of structure in determining quality the facilities, staffing, and training of those who care for nursing home residents. Many residents of nursing homes have serious disabilities and problems that require skilled nursing care.
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The results of such measurement are being given to employees, for example, to help them choose health plans. They are sometimes used to create consumer "report cards" that present the results of a variety of quality measures in a standardized format that allows comparisons among plans.
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That is, the effect of health care services may be quite small in comparison to the effects of the social and physical environment, or a patient's genetic makeup or behaviors that affect a patient's health. Furthermore, to be useful for quality improvement, outcomes data need to provide information with a high level of clinical detail and be provided in a sufficiently clear manner that providers and managers can know what processes must be changed.
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Measurement as a Continuous Process that Serves Multiple Purposes During the last decade, many in the health care system have begun to apply a model of quality improvement called continuous quality improvement or total quality management. One assumption of this model is that the health care organizations and systems within which professionals practice can always improve.
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Such measurements seek to assess the performance of whole systems as well as the performance of parts of those systems for defined episodes of care so that quality improvement efforts within the system can be efficiently targeted. · The translation of well-developed clinical practice guidelines (e.g., those for screening and prevention as well as those for condition-specific treatments)
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One example is the New York State Cardiac Surgery Reporting system instituted in the late 1980s, when large differences among hospitals in mortality rates following bypass surgery were being reported. The state health department compared the expected hospital mortality rates with the observed rates (Hannan et al., 1994~.
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has developed a database for guidelines on screening and prevention and for condition-specific treatments that serve as the basis for quality measurement. The Pacific Business Group on Health, a coalition of large health care purchasers, has developed a collaborative reporting effort among health plans in California, the California Collaborative Healthcare Reporting Initiative, which reports performance and outcomes data.
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These scores provided clinical practice profiles that show the relationship between quality and cost and were used to identify "best-practice hospitals" and to understand how those hospitals achieved what they did. Amassing and Accessing the Burgeoning Toolkit of Quality Measures With the ever increasing number of measures available, it will be increasingly difficult to create a manageable measurement program.
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Further, quality measurement may require collating information from many sources inpatient and outpatient medical records, laboratory records, and pharmacy records to retrieve the information that is needed. The multiplicity of public agencies at the federal and state levels with oversight responsibility and the range of private organizations that accredit health care organizations and review care, as well as the internal quality improvement efforts of health plans, would lead some to believe that assurance of quality is well in
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The development, evaluation, and dissemination of the next generation of quality measures will be expensive if they are done well, but such an investment is a public good that is unlikely to be supported and shared by one organization in a competitive marketplace if the benefits are to be gained by all. Thus, those who develop quality measures must look to public and philanthropic sources of funding for the needed investment as is the case for health-services researchers, government agencies, health plans, purchaser coalitions, and others who have done much to improve ways of measuring health outcomes, comparing the outcomes of different health care practices, evaluating the performance of health care providers and practitioners, and developing credible and useful guidance for patients and clinicians in making medical decisions.
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This is extraordinarily labor intensive. For example, the Kaiser Foundation Health Plans have estimated that they performed 150,000 chart reviews for the first year of HEDIS Version 3.0 reporting (Lowry, 1997~.
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Many patients are not in managed care organizations, however, and such rates cannot now be measured. The Evidence Base of Medicine and Health Care Knowledge about effective clinical care is needed for the development of clinical guidelines for care and for the development of accurate review for measurement of the quality of health care.
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Such risk-adjustment tools are critical, in particular, when making comparisons among individual practitioners and organizations. The paucity of suitable routinely collected data on patient risk characteristics is a key barrier to risk adjustment.
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Third, are the benefits of quality improvement large enough to justify expenditures for quality improvement? The cost of measuring and improving quality of care cannot be understood without an estimate of the cost of poor quality.
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Measuring quality for public reporting may divert considerable resources that might otherwise be used to provide additional services or to improve services. The well-known HEDIS reporting system, although voluntary for health plans, is only one data set to which health plans are asked to respond.
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The costs of measurement, however, need to be acknowledged. Both internal quality improvement efforts and external monitoring have important places in health care.
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MEASURING THE QUALITY OF HEALTH CARE 23 They include the need to inform policymakers and others responsible for determining how quality is to be measured so that they may: · identify the populations for whom quality of care should be monitored, from individuals and members of health plans to groups with special health needs, communities, and the nation as a whole as part of an effort to monitor the quality of care across the entire system; · confront the full range of quality-of-care problems, including overuse and underuse of services as well as deficiencies in the technical and interpersonal aspects of health care; · include valid quality measures whether based on process or outcomes of care; · consider how to create reliable, uniform data systems and collect consistent data from a variety of sources; · apply and refine tools and techniques of quality measurement and improvement that will help health care reform succeed; · devise means of providing valid, useful information on health care quality to consumers, providers, payers, and policymakers; and · promote communication and education about quality of care and the use of quality measures. · include quality measurement into systems of improvement that actually promote and create high quality, cost-effective care delivery.
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