605: Week 15 Flashcards
1
Q
Health Quality
- What is it?
- Parties interested in quality?
- Factors contributing to health quality movement
A
Health Quality: According to IOM, “health quality is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”
Parties interested in health quality:
- Patients
- Want to receive high quality services
- Payers (employers; government)
- receive value for $ spent
- Insurance companies
- Want to ensure high quality services provided for given expenditure
- Providers & health plans
- high patient satisfaction and positive health outcomes
- competition for contracts
Factors Contributing to Health Quality Movement:
- Refined (better) metrics and definitions of quality
- Faster computers; better data availability
- Increased emphasis on science and evidence in identifying appropriate treatment
- Application to health from earlier quality movement in other industries (e.g., auto industry)
- Demand for accountability by patients & payers
2
Q
Quality assessment vs. assurance
A
Quality assessment
- Compare quality of care vs. standards of care
- Questions: How to measure quality; which indicators important; appropriate data and statistical techniques
Quality assurance
- Attempt to improve quality
- Institutionalize quality improvement focus in organizations
- Requires leadership/support from upper management
- Institutionalize quality improvement focus in organizations
- CQI: Continuous Quality Improvement
3
Q
Dimensions & Measurement of Quality: The Donabedian Model
A
1. Structure (resource inputs)
- Environment (including health system) in which care provided
- Good structure enables (but doesn’t guarantee) high quality care
- Often used as indirect measure of quality
- Ex: Accreditation is proxy for quality, but does not guarantee high quality care provided.
- e.g. Facilities (licensing, accreditation), equipment, staffing levels, staff qualifications (licensure/accreditation, training), delivery system (distribution of hospital beds and physicians)
2. Process (actual delivery of care)
- How services are provided
- Resources used (# and accuracy of tests, treatments, etc.)
- MD-patient interaction
- e.g. Technical aspects of care (dx, tx procedures, correct prescriptions, accurate drug admin., pharmaceutical care, waiting time, cost); interpersonal aspects of care (communication, dignity and respect, compassion and concern)
3. Outcome (final results)
- Reflects end result of the care provided
- Depends on structure and process
- e.g. Patient satisfaction, health status, recovery, improvement, nosocomial infections, iatrogenic illnesses/injuries, rehospitalization, mortality, incidence and prevalence of disease
- May include costs to organization, provider, or patient
4
Q
Continuous Quality Improvement (CQI) in healthcare
A
- Pioneers: Deming; Shewhart
- More than just set of tools . . . a systems approach to improving quality within organization
- Philosophy & strategic strategies supported by top-level administration
- Develops rational strategies to manage processes
- identify and correct deficiencies leading to bad or costly outcomes
- Objective: create a culture of improvement throughout organization in which staff ask:
- How are we doing?
- How can we do better?
- Continual focus throughout organization on changing processes to improve quality
- NOT a one-time activity
- Elements of CQI:
- Focus on patient as customer
- Strive for satisfied patients
- Decision making based on data and analysis
- Empower employees; encouraging quality focus
- QI teams of employees identify processes to deliver medical care
- Strategic focus on, & use of, CQI throughout organization
- Develop organizational culture that values quality
- Focus on patient as customer
5
Q
Process Variation (Quality Variation)
- Two types of processes
- Control? (difficult or easy for each type)
- How to improve quality
A
Two factors lead to quality/process variation:
-
Difficult to control: Common cause variation
- Common & natural causes of variation in quality
- E.g., variation in quality of raw materials
- Common & natural causes of variation in quality
-
Easier to control: Special cause variation
- Unusual, infrequent events result in quality variation
- E.g., worker errors, incorrect use of raw materials or incorrectly working equipment
- Unusual, infrequent events result in quality variation
- To improve quality . . .
- Eliminate special cause variation
- Minimize common cause variation
6
Q
Statistical process control (SPC)
A
Method to measure and track quality
- Graph quality data over time
- Examine % of time quality exceeds upper or lower control limits
- Shows % of time quality is controlled
- i.e., “within accepted limits”
- Often +/- 3 standard deviations from mean
- Shows % of time quality is controlled
- Provides quantitative standards to identify why quality “out of control”
7
Q
An approach to quality improvement (QI): PDCA
A
PDCA
Promote improvement by answering:
- What are we trying to accomplish? What is goal?
- How will we know that a change is an improvement?
- What changes can we make that result in improvement?
Use PDCA cycle to test proposed change in work setting:
- *Plan**: identify changes; design improvements
- *Do**: implement quality improvement plan
- *Check**: measure changes (collect data; analyze)
- *Act**: evaluate results; identify successful processes
8
Q
QI in public health
A
- Most QI approaches and methods apply to both private and public health organizations
- Goals, methods, customers, processes may differ
- Less use of QI in PH
New focus: Public Health Accreditation Board (PHAB)
- Accreditation for state, local, and tribal health departments
- Must demonstrate high level of performance in 12 domains; also CQI throughout organization
9
Q
Public Health Department Accreditation
- Participation (HDs)
- Standards
- Goal
- What does it do?
- Accreditation benefits for health departments
- Who oversees accreditation process?
A
Voluntary participation to measure health dept performance against standards that are (i) nationally recognized, (ii) practice-focused, & (iii) evidence-based
- Local health departments (LHDs)
- State health departments (SHDs)
- Tribal health departments
Goal: to improve and protect health of public by advancing quality and performance of tribal, state, local, and territorial PH depts.
What does accreditation do?
- Measures capacity to deliver 3 core functions of PH and 10 Essential PH services.
- Provides platform for continuous quality improvement
- Encourages continual refinement of standards and measures
- Accreditation: 1 large ongoing quality improvement project
Accreditation benefits for health departments:
- National recognition
- Increased visibility, credibility, & accountability
- Increased understanding of PH
- Potential access to new funds
- Potential streamlined reporting
Who oversees accreditation process?
- Public Health Accreditation Board (PHAB)
- Nonprofit organization established 2007
- “striving to make every health department PHABulous”
- PHAB oversees accreditation process
- Also provides training for health departments in how to complete required documentation
10
Q
3 Core Public Health Functions
and
10 Essential Public Health Services
A
3 Core PH Functions
- Assessment
- Policy Development
- Assurance
Assessment: assess health of population
-collect, analyze, and disseminate information about community’s health
Policy development:
-use scientific knowledge to develop strategies to improve population’s health
Assurance:
-make services available and accessible to everyone
10 Essential Public Health Services
- Research
- *Assessment**:
2. Monitor health
3. Diagnose & Investigate - *Policy Development:**
4. Inform, Educate & Empower
5. Mobilize Community Partnerships
6. Develop Policies - *Assurance**:
7. Enforce Laws
8. Link to/Provide Care
9. Assure Competent Workforce
10. Evaluate
11
Q
PH Dept Accreditation Application Process
A
1. Pre-Application
- Determine eligibility
- Readiness checklists
- Identify Accreditation Coordinator
- Primary contact for PHAB
- Complete online orientation
- Submit Statement of Intent
2. Application
- Submit online application Upload 3 “prerequisites”
- (1) CHA: Community Health Assessment
- Collect, analyze, and use data to educate and mobilize communities, develop priorities, garner resources, and plan actions to improve public’s health (data on health status, needs, community assets, resources, and other determinants of health) (important element: community engagement and collaborative participation)
- (2) CHIP: Community Health Improvement Plan
- Long-term, systematic effort to address PH issues & problems based on results of CHA.
- Set priorities & coordinate target resources
- Addresses strengths, weaknesses, challenges, and opportunities in community to improve health statu
- (3) Health Department Strategic Plan
- Guides what H dept does, and why it does it
- Includes dept’s vision, mission, guiding principles and values, and strategic priorities
- Describes measurable & time-framed goals andobjectives
- Includes steps to implement the CHIP
- (1) CHA: Community Health Assessment
- Letter of support from governing authority
- Pay fees (12K-95K, depending on population)
- Once accepted: attend in-person training
3. Document Selection and Submission
- Select specific measures and upload required documentation
- Based on PHAB standards and measures - 12 domains (10 essential PH services + administration and governance)
- 12 accreditation domains: conduct assessments of pop. health status; investigate health problems/hazards; inform and education; engage community to solve health problems; develop policies and plans; enforce laws and regulations; promote strategies to improve access to services; maintain competent PH workforce; evaluate and continuously improve programs and interventions; contribute and apply evidence base of PH; maintain admin and mgnt capacity; built strong and effective relationship with governing entity
- In each domain: selected standards
- For each standard: selected measures
- For each measure: required documentation and explanation (guidance) of what to provide
- Based on PHAB standards and measures - 12 domains (10 essential PH services + administration and governance)
- Complete within 12 months of application
4. Site Visit
- 2-3 day visit by 3-4 trained individuals to review submitted documentation, ask questions, visit with community partners, request additional documentation, etc.
- Submit site visit report to H Dept. within 2 weeks
5. Accreditation Decision
- Report reviewed by PHAB
- Decision made
- If accreditation granted: duration = 5 years
6. Reports
- Submit annual report to PHAB
- Must report if any major changes in leadership or ability to conform with PHAB standards during accreditation period.
7. Reaccreditation (5 years)
- Reapply
- Participate in entire accreditation process
- May use original materials with appropriate changes and updates
12
Q
Accredited health departments
A
Cover 45% of U.S. population
Not distributed evenly across U.S.
- 40 accredited LHDs in 5 states (Kentucky, Wisconsin, Illinois, Michigan, Ohio)
13
Q
Access to care
- 3 cornerstones of healthcare delivery
- Importance of measuring access to care
- Factors that influence access to care (3)
- Additional dimensions of access to care with managed care (2 steps)
A
Cornerstone of health care delivery
- Access
- Cost
- Quality
- Importance of measuring access to care
- A measure of potential effectiveness of HC sector
- Included as an objective in HP2020
- Major factor underlying health status
- Associated with quality of care
- Affordable Care Act seeks to increase access
- A measure of potential effectiveness of HC sector
- Importance of measuring access to care
- Often interested in whether different population subgroups have equal access to care
- Conceptual framework (Aday-Andersen): what factors influence access to care
- Medical Need (health status)
-
Predisposing characteristics
- sociodemographic characteristics: age, gender, education, etc.
-
Enabling conditions
- Ability to access medical care: income, insurance, prices, etc.
- Many population-based data sets available to measure access
With managed care, access to care may involve an additional dimension
Step 1: Select Managed Care health plan
Based partly on:
- plans available (through employer, govmt program, Insurance Exchanges)
- provider networks in plan and reputation
- premium and other financial factors (including person’s income)
- personal characteristics (e.g., demographic factors, person’s experience with managed care, existing MD relationships, etc).
Step 2: Seek care based on health plan selection and other factors (including copays, distance to clinics, effectiveness of gatekeeping, etc.)
14
Q
Measuring Access
- For individuals
- For health plans
- For health care delivery system
A
For individuals:
-
Utilization of services by person
- Whether or not people used services
- Volume (i.e., number) of services by users
-
Patient satisfaction with access
- Exs: differences by race, ethnicity, age, gender, etc.
For health plans:
- Enrollment, accessing services, quality of care
- Examples of measures:
- waiting time for appointment
- waiting time for visit
- comparison of different types of services provided vs. those expected
- availability of interpreters
For health care delivery system:
- Factors affecting access by entire population
- Examples of measures:
- utilization measures per 100,000 population
- mean outpatient visits per capita
- # of MDs per capita
- % immunized
15
Q
Small area analysis of variation
A
Suppose investigate procedure rates across different counties in California.
- Not all areas the same; some variation expected
- Demographic differences.
- Health needs different.
- Observe range of procedure rates:
- From 30 - 40 per 1,000 population in different counties.
- Is this too much variation (i.e., more than “normal”)?
What if variation is:
- 30 - 60?
- 30 - 80?
- 30 - 100?
Questions:
1. How much variation is “reasonable?”
- How much is “excessive?”
2. Why does this variation occur? - Can it be explained by characteristics of the population?
- Do some areas experience too much or too little use of services?
- Or are we simply unable to explain observed variation?
- That is, some other factors causing this variation
- Is observed variation in procedures, expenditures, etc. across different geographic areas due to underuse or overuse of medical services?
- Policy implications if so?
- Quality of care? Health costs?
From the Dartmouth Atlas of Health Care:
- Among 306 hospital regions in the United States, price-adjusted Medicare reimbursements varied twofold in 2010, from about $6,900 per enrollee in the lowest spending region to more than $13,000 in the highest spending region
- These results even after adjusting for age, sex, race, and regional differences in prices
- Use of effective & risky drug therapies by Medicare patients varies widely across U.S. regions
- Health status explains < 1/3 of variation in total Rx use
Possible explanation for geographic variation in medical services:
-
Physician Practice Style Hypothesis
- Wide range of practice styles may develop due to uncertainty and lack of consensus
- MDs uncertain about effects & value of medical procedure
- Consequently, a wide range of practices considered within bounds of appropriate care
- Wide range of practice styles may develop due to uncertainty and lack of consensus
Example: (hospitalization rates)
From the Dartmouth Atlas:
- Medical science provides clear guidelines about the need to hospitalize patients with some conditions. For patients with these conditions, the need for specific kinds of care determines what will be done, and the use of medical resources is not influenced by either the physician’s practice style or the per capita supply of hospital beds in the region.
- For example, patients with hip fractures are almost always hospitalized, because of the severity of their pain and the need for inpatient operative repair. Similarly, patients with newly diagnosed colorectal cancers are almost always hospitalized, because major bowel surgery is the universally accepted method of treating the disease.
- But for many other conditions, medical science and theory may be weak, and the rules of clinical practice are not nearly so clear.
- Many hospital admissions are for medical conditions – such as poorly controlled diabetes or worsening heart failure – which can be treated in either the inpatient or the outpatient setting, and for which hospitalization can often be prevented by better outpatient management.
- Clinicians have identified a group of diagnoses referred to as “ambulatory care-sensitive” conditions. The variations among regions in admission rates of patients with these conditions can be ascribed to differences in clinical decision- making, rather than to differences in underlying illness rates.
- In cases where science-based guidelines are relatively weak, physicians must be guided by their subjective opinions about the effectiveness of admitting such patients to hospitals, rather than providing treatment in another setting.
- Hospitalization rates for these – and for most medical conditions – may also highly correlated with the local supply of hospital beds.
Why would MDs be uncertain?
- Uneven diffusion of information & technology.
- New information & equipment usually available earlier in areas with
- large populations
- teaching hospitals
- relatively more MDs.
- New information & equipment usually available earlier in areas with
- Many symptoms consistent with different diagnoses.
- MDs may not agree on best treatment for same diagnosis.
When doing a small area analysis, it is important to control for:
- Differences across geographic areas that might explain variation
- e.g. demographics; availability of MDs/hospitals
- Patients in different areas may also have different preference for types of procedures, settings (e.g. hospital vs. outpt), or even whether to seek care
- More difficult to observe this
