Initiatives in Health Care Quality Improvement Flashcards
Private purchasers of all types are desperate for ______
relief
Government is worried that health care costs are
consuming a steadily larger portion of the _________.
Budget
What are the six goals promulgated by the Institute of Medicine (IOM)* following
the two landmark reports identifying widespread quality problems nationally
within the U.S. health care system?
- Safety
- Timeliness
- Equity
- Efficiency
- Patient centeredness to 6. The more longstanding goal of effectiveness
Studies by the RAND Corporation showed that, on average, guideline-recommended acute, chronic and preventive care was received by
adults only __% of the time in 12 metropolitan areas of the United States and later studies showed similar findings for child health care.
55%
While primary care medicine has been the focus of redesign and improvement
efforts, why has that area of care continued to deteriorate?
Fewer young doctors are going into primary
care, most primary care practices are financially insecure, and primary care doctors
are being forced to focus primarily on productivity
It is widely believed by policy makers that one reason developed countries other
than the United States spend a much lower proportion of their gross domestic product on health care and enjoy better quality than we do is because their care
systems are ______ ________ ______ ______.
built on a strong primary care base
What three elements characterize the “triple aim” in health care, and what is meant by a quest for value?
(a) Improving health
(b) Enhancing patient experience of care
(c) Reducing costs.
This quest for value entails pursuing _______ _______ and experience at ______ cost.
- Higher quality
2. Lower
Need to change the payment system from ___ ___ _______ to one that pays for value rather than individual services alone.
fee-for service
Describe the evolving structure and function of primary care delivery organizations in the United States.
Organizations that provide primary care have been evolving from largely solo-doctor
practices to small single-specialty groups and now to ever larger medical groups, many of which have become multispecialty organizations able to provide almost
every type of medical service.
When doctors first banded together, it was to share after-hours calls, billing systems
and other infrastructure in a common office or clinic site. These sites usually
consisted of two to ten doctors, typically of the same specialty, with three to five being the most efficient unit size. Later, and particularly in regions with high penetration and pressure from managed care plans, many of these single-site groups
merged or were bought out by large care systems or hospitals that were hoping to
create a captive referral network and/or gain negotiating power with insurance plans.
While some of these larger aggregations continue to chiefly contain a single primary
care specialty, many have become multispecialty as well as multisite. Larger
organizations are referred to as medical groups, some of which continue to practice at a single site, but most have multiple sites or clinics; some establish smaller
satellites, particularly in rural areas.
Explain the historical lack of integration within most medical groups and why
this situation has required the larger evolving organizations to address quality improvement (QI).
The historical lack of integration within most medical groups, even large multispecialty groups, created a situation where these larger evolving organizations had to address quality improvement (QI). Formed primarily for economic or crosscoverage reasons, the physicians in early medical groups tended to maintain separate
medical practices with individual autonomy in approach to care. This meant that
unless an individual physician was unusually interested in organizing care patterns,
there was little consistency, coordination or outreach involved in patient care. Each
patient and each visit was unique, and any care actions had to be recalled or created
anew. Over time, this individualization of practice tended to decline as it became
clearer that both efficiency and effectiveness could be improved by systems that
crossed individual physician or specialty boundaries or that added nonphysician
clinicians. Nevertheless, this integration continued to vary enormously among different medical groups and sometimes even at different sites within an individual
group.
Discuss the reasons for the emergence of increasingly complex medical organizations necessitating a focus on integrating QI championed by organizational
leaders.
The emergence of increasingly complex medical organizations has required
leadership, such that medical groups found a need for a medical director, a chief
administrator, committees and boards of directors. As they became larger, multisite groups also usually created medical and administrative leaders for individual clinic sites. And as the pressure for QI and cost-efficiency increased, medical groups
usually found it necessary to develop greater integration of their various sites and
departments and to create an infrastructure that could develop and maintain common systems to support consistent and even standardized care. To be most effective, this infrastructure includes a specific approach to QI as well as a coordinator and a physician leader who can connect the QI efforts to organizational
priorities, plans and resources. Recently, more groups have incorporated the responsibility for QI into their overall leadership structure, since it has become more
and more apparent that it is impossible to drive real improvement (i.e., care
redesign) from a separate department. The entire leadership team and often large
organizational resources are needed to support these kinds of changes.
Of course, there are still many solo or small medical practices in many parts of the country, especially in rural areas. To survive, these practices will need to follow the historical pattern of merger or buyout by larger groups and will also require effective internal leadership.
Provide examples of practice systems that make for consistent care for the common aspects of many acute, chronic and/or preventable conditions.
(a) Registries of patients with chronic conditions
(b) Routine identification of risk factors during office visits
(c) Paper or electronic systems to monitor whether patients are up to date on preventive services and whether consistent care is being provided for chronic
conditions
(d) Delegation of orders or delivery of many preventive and screening services to nursing staff
(e) Coordination of care transitions between inpatient and outpatient settings and
between primary and subspecialty care services
(f) Care managers for patients with stable chronic conditions.
Discuss the redesign of primary care medical practice to a medical home model.
Standardized practice systems that ensure comprehensive, continuous and
coordinated care are at the heart of the primary care practice redesign and are
currently called medical homes. The presence of these systems, built to implement the domains of the chronic care model, also form the core of the assessment being
used by the National Committee for Quality Assurance (NCQA) for recognition of medical homes at three levels of competence. The real challenge is how to transform traditional primary care medical practices into medical homes. The American
Academy of Family Physicians (AAFP) funded the National Demonstration Project
in 2006 as a controlled trial of external facilitation of this transformation. Early
evaluation of this project concluded that transformation is a very difficult process,
one that requires physicians to reconsider their own roles as well as the ways in
which they deliver care. It is precisely this practice transformation process that is
reshaping medical care. The crux of this transformation involves how to best move
beyond incremental changes to a whole new design for primary care medicine
