12. Health Care Quality and Improvement

Definition

The cumulative efforts of all parties involved in healthcare to “make changes [to systems of care] that will lead to better patient outcomes, better system performance, and better professional development.”

Context

The quality movement has arisen from several concerning observations and areas of research in healthcare, including:

  • Dramatic and often inexplicable variations in health care practices.
  • Disparities in health and health care.
  • Medical errors and the impact on patient safety.
  • Escalating health care costs.

Application

  • How is quality measured? The Donabedian triad categorizes clinical variables as structure, process or outcome measures, each type with its own advantages and disadvantages.

Measure

Definition

Advantages

Disadvantages

STRUCTURE

How care is organized

Examples:

# of ICU beds

EMR use

Easy to measure

 

Quantifies otherwise complex systems

Limited description of quality of care delivered

 

Often no “gold standard”

PROCESS

What care is provided

Examples:

If ASA given for ACS

If medication

reconciliation performed

Often from evidence or consensus-based guidelines

 

Easier to measure and change than outcomes

 

Direct measure of care

Proxy for desired outcomes

 

“Gold standard” not always agreed upon

 

May draw attention away from unmeasured clinical care

OUTCOME

What happened to patient

Examples:

Inpatient mortality

Rates of ventilator-associated PNA

Number of readmissions

What we really care about

Influenced by many factors besides clinical care

 

Often long-term, less common events

 

Comparisons require careful case-mix adjustment
  • Who measures quality? 
    • Health care organizations (hospitals quality committees, health care networks, etc.).
    • Regulatory bodies (e.g., The Joint Commission on Accreditation of Healthcare).
    • Government (e.g., Center for Medicare and Medicaid Services, Agency for Healthcare Quality and Research).
    • Public-private partnerships (e.g., National Quality Forum).
    • Business coalitions (e.g., Leapfrog Group).
    • Foundations (e.g., California HealthCare Foundation).
  • How can housestaff impact quality improvement?  
    • Educational efforts: a dedicated quality improvement rotation for housestaff, participation in Root Cause Analysis (RCA) sessions.
    • Feedback: outpatient report cards or provider performance data compared to “benchmarks,” for example, percent of congestive heart failure patients who receive ACE-I.
    • Financial incentives/penalties: housestaff incentive program, quality and safety initiatives and competitions.
  • What is continuous quality improvement? 
    • Involves a team of clinical and non-clinical members in a continuous cycle of change and measurement.
    • Goals should be SMART: Specific, Measurable, Achievable, Relevant, Time-bound.
    • One example of a continuous quality improvement model is the PDSA cycle.

  • What is the Joint Commission on Accreditation of Healthcare (JCAHO)?  
    • JCAHO is the primary health care standards-setting and accrediting body. Its mission is “to improve the safety and quality of care provided to the public through the provision of health care accreditation.” JCAHO sets the standards for patient safety and quality that are adopted by hospitals throughout the country.

 

ACP Guidelines and Clinical Recommendations. American College of Physicians. 2015

Batalden PF, Davidoff F. What is “quality improvement” and how can it transform healthcare. Qual Saf Health Care. 2007 16:2-3.

Batalden PF, Davidoff F. Teaching Quality Improvement: The Devil is in the Details. JAMA 2007: 1059-1061.

Berwick D, Nolan T. Physicians as leaders in improving health care: a new series in Annals of Internal Medicine. Ann Intern Med 1998;128:289-292.

Boonyasai RT, WIndish DM, Chakraborti C, Feldman LS, Rubin HR, Bass EB. Effectiveness of teaching quality improvement to clinicians: A systematic review. JAMA 2007; 289: 1023-1037.

Meyer, PJ. What would you do if you knew you couldn’t fail? Creating S.M.A.R.T. Goals. Attitude is everything. Meyer Resource Group, Inc. 2003.

Owens DK, Qaseem A, Chou R, Shekelle P, for the Clinical Guidelines Committee of the American College of Physicians. High-Value, Cost-Conscious Health Care: Concepts for Clinicians to Evaluate the Benefits, Harms, and Costs of Medical Interventions. Ann Intern Med. 2011;154:174-180.

Wachter RM, Goldman L, Hollander H.  Hospital Medicine, Second Edition. 2005: Chapter 12: Assessment and Improvement of Quality and Value