Day 7: Quality Improvment

Question 1

What is an indicator?

Answer 1

Valid and quantitative measure of performance within a timeframe

EX: number of ER visits in 6 months b/c of penicillin allergy

Question 2

What is a sentinel event?

Answer 2

Negative result requiring immediate investigation typically involving death

Question 3

What is a benchmark / standard?

Answer 3

Point of reference for measurement and comparison / provides a baseline

Question 4

What is a normative standard?

Answer 4

What we think “it” should be

EX: 100% of patients should be adherent to their medications

Question 5

What is an Empirical Standard?

Answer 5

What “it” really is

EX: if only 75% of those patients are adherent, “we did a great job”

Question 6

What is quality assurance?

Answer 6

Activities that ensure that services are appropriate, effective and efficient

Question 7

What is Continuous Quality improvement?

Answer 7

Structured, systematic, perpetual process

Pro-active: identify problems in advance

Question 8

What is a root cause analysis (RCA)?

Answer 8

When a problem happens you trace it back to its source and perform a systematic investigation that is evidence-based

Question 9

What is a failure mode and effects analysis (FMEA)?

Answer 9

Studies consequences of identified failures

Used when new systems are designed

Question 10

What is Risk evaluation and mitigation strategy (REMS)?

Answer 10

FDA program that requires manufacturers to create REMS

Tailor programs to risk-benefit profiles of a specific drug

Question 11

What are the four components of a REMS?

Answer 11

1. Med guide
2. Communication plan
3. Elements to ensure safe use
4. Implementation system

Question 12

What is the joint commission?

Answer 12

Founded in 1951 and an independent NOT-FOR-PROFIT leader in promoting quality

They accredit and certify health care organization around the US

***** MAY NEED ACCREDITATION in order to be reimbursed for care

Question 13

What is the agency for healthcare research and quality (AHRQ)

Answer 13

Health services research arm of the US health and human services

Question 14

What are the center for Medicare and Medicaid services (CMS)?

Answer 14

Contract with private groups in each state to monitor care

Question 15

What is the Institute of Medicine (IOM)?

Answer 15

Component of national academy of scene cue

Advisor to the nation to improve health

Question 16

What 3 things should be evaluated when it comes to health care quality?

Answer 16

1. Structure
2. Process
3. Outcomes

Question 17

What does structure mean in terms of a part of health care quality?

Answer 17

It refers to material and Human Resources as well as policies and procedure

EX: 
Material resources (money, technology, facilities) 

Human Resources (RPh, techs)

Policies and procedure (committees, error management policies)

Question 18

What are the pros and cons of assessing structure in terms of health care quality?

Answer 18

Pros:

Easy to evaluate and measure

Objective

Cons:
It is tired to outcomes - where is the data

Question 19

What is evaluating process mean in terms of evaluating health care quality?

Answer 19

Asks: How well is the structure ring used?

Activities that go on within and between practitioners and patients

EX: 
# of meds dispensed by an RPh per hour

of patients counseled by RPh per hour

% of pregnant mothers counseled to quit smoking

Question 20

What are the pros and cons of assessing process as a form of health care quality?

Answer 20

Pros: Good to assess process when:
Outcomes are rare (death, med errors)

Patients have multiple disease states

Cons
It’s tied to outcomes - where is the date
EX: Do pharmacists who dispense 10 RX’s or less an hour make less errors?

Can be difficult to asses process (what is actually go or what is bad could turn out to be good in the future)

Question 21

What does evaluating outcomes mean in terms of health care quality?

Answer 21

Changed in the patients health status

The 5 D’s:

1. Death
2. Disease
3. Disability
4. Discomfort
5. Dissatisfaction

Question 22

What is the issue with the 5 d’s when it comes to measuring outcomes in health care quality?

Answer 22

1. Death :
   May be uncommon - deaths from ear infection
2. Disease
   How diagnosed - HTN vs Depression vs ADD
3. Disability
   How is it measured - how much is “acceptable”
4. Discomfort
   How to assess quality of life
5. Dissatisfaction
   Correlation with quality, pt can still be stratified with ”quacks”

Question 23

What is efficacy when in the context of outcomes in health care quality?

Answer 23

Outcomes in an ideal setting

EX: randomized clinical trial, everything is done under strict control and accounted for

Question 24

What is effectiveness when in context of outcomes and health care quality?

Answer 24

Outcomes when care is provided by a typical provider to a typical pt

How many patients will ACTUALLY take the drug (real life compliance, not always great compared to a clinical trial)

Will a doc really order the lab tests to measure if its being effective

Question 25

What is efficiency when it comes outcomes in the context of health quality care?

Answer 25

Role of cost in assessing quality Higher spending might not mean higher quality

Question 26

What is selection bias as a concern for about outcomes for quality health care?

Answer 26

Do sicker pts seek the better providers If so, “good” provider could be at risk for poor outcomes (which could lead them to bad reviews or reports)

Question 27

What is meant by potential for “skimming the cream from the top” when it comes to concerns about outcomes in quality health care?

Answer 27

Do providers avoid treating high risk pts b/c of the risk of obtaining poor outcomes

Question 28

What are the pros and cons of assessing outcomes in health care quality?

Answer 28

Pros: Promotes innovation Ends justify the means Cons: May not know outcomes for many years (people not usually die at a young age when they get diabetes) Multiple factors influence outcomes (genetics, lifestyle, nutrition) Still need to connect structure and process to outcomes (why did this intervention work or fail?)

Question 29

What are the pros and cons of Medical record being a source of health care quality?

Answer 29

Pro: objective source of info Cons: Can be incomplete (limited documentation) Poor source of data on interpersonal care May not document ppt education, disability measures Hard when multiple provider involved

Question 30

What are the pros and cons of administrative (claims) data as a source of health care quality?

Answer 30

Pros Can document access - did pt get drug Measurable Cons: Biased - used to optimize reimbursement Poor source of data on interpersonal care Does not document pt education DOES NOT CAPTURE DATA from pts who pay CASH b/c no claim is submitted ($4 generic drug in cash or good RX is not submitted)

Question 31

What are the pros and cons of patient reports in terms of health care quality?

Answer 31

Pros: Best resource to assess interpersonal care Cons: Subjective: pt can forget and emotions can influence reports Poor resource to assess technical competence

Question 32

What are the pros and cons of provider reports for as a source of health care quality?

Answer 32

Pros: Good resource to assess technical skills Cons: Subjective, providers can have selective recall and emotions can influence the report Can be different than how the patient perceives the interaction

Question 33

What are the pros and cons of provider report card in evaluations of quality?

Answer 33

Pros: Can show value of individual provider Can help providers understand what to improve Cons: Results daily misinterpreted “What” is being evaluated: do consumers really know to use Will they used to get price discounts?

Question 34

What are the concerns about publicizing quality evaluations?

Answer 34

Invalid results mislead the public and payers (pt and payers can make poor choices) Will hospitals and health care providers risk publishing reports of poor performance? Study in 2007 could not find ANY hospital that published poor performance on its website Public reporting or quality measure should meet same reporting standards as financial organization and pharmaceutical ads

Question 35

What are the concerns about standers when it comes to health quality care?

Answer 35

Some standards only supported by expert opinion or suboptimal evidence Guidelines and standards supported by observational evident and/or “experts” are commonly rejected when subjected to test of controlled trials Organizations can reach different conclusions when looking at the same evidence EX: AMerican cancer society and US preventative services task force had differences in the value of early cancer screenings