Health Care Quality Measurement and Improvement Overview

The Culture of Health Care Quality Measurement and Improvement Lecture a This material (Comp 2 Unit 7) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

Quality Measurement and Improvement Learning Objectives Define health care quality and the major types of quality measures: structural, process, and outcome measures (Lecture a). Describe the current state of health care quality in the United States (Lecture a). Discuss quality measures used in various health care settings in the United States, including those required for the HITECH meaningful use program (Lecture b). Describe the role of information technology in measuring and improving health care quality (Lecture c). Describe the results of current health care quality efforts in the United States (Lecture c). 3

Definitions and Operationalization What is health care quality? Different views Donabedian, 1988: That kind of care which is expected to maximize an inclusive measure of patient welfare, after one has taken account of the balance of expected gains and losses that attend the process of care in all its parts (in Blumenthal, 1996) Lohr, IOM, 1990: The degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge (in Blumenthal, 1996) In an era of rising costs and concerns about quality, physicians and the health care system must have public accountability (Chassin et al., 2010, Chassin & Loeb, 2011) Value based reimbursement models 4

Donabedian Model of Quality (2002) Three categories: Structural: Factors that make it easier or harder to deliver high-quality care (e.g., hospital location, volume, association with teaching hospital) Process: Factors describing health care content and activities (e.g., adherence to screening, guidelines) Outcomes: Changes attributable to care (e.g., mortality, morbidity, functional status) Implemented and measured at different levels at an institution (e.g., individual, department, organization) 5

Examples in Donabedian Model Type of Measure Structural Individual Department Organization - Professional certification - Credential review - Staffing analysis - Equipment safety checks - Licensure - Fire safety inspections Process - Peer review - Performance evaluations - Review of performance indicators - Infection surveillance - Review of utilization data Outcome - Practice profiles - Rework required - Error/complication rate analysis - Mortality rates - Quality sanctions 7.1 Table: Adapted from Donabedian, 2002 6

Process vs. Outcomes In general, want to focus on outcomes Represents what actually happens to patient But difficult to measure; confounding factors Do we know about relationship between process and outcomes? In acute coronary syndromes, strong correlation between process and outcome measures (Peterson et al., 2006) In other areas, however, not a strong relationship between satisfaction with care ( global ratings ) and its technical quality (Chang et al., 2006) The science behind care also changes (e.g., recognition that too tight of control [HgbA1C] in diabetes can be detrimental) (Aron & Pogach, 2009) Consensus not always reached (e.g., drugs to avoid in elderly) (Steinman et al., 2009) 7

Ideal Quality Measures Quality measures should be (Landon et al., 2003): Evidence-based Agreed-on standards for satisfactory performance Standardized specifications Adequate sample size for reliable estimates Adjustment for confounding patient factors Care attributable to individual physician Feasible to collect Representative of activities of specialty In God we trust, all others bring data W. Edwards Deming, statistician (1900 1993) Adage from business management: An organization can t improve what it cannot measure 8

Other Definitions Pay for performance (P4P) (Rowe, 2006) Often equated with quality assessment but is just one approach (Rosenthal, 2008) Based on notion that health care providers and organizations should be held accountable financially and otherwise Value-based purchasing (CMS, 2016) Application of P4P Accountable health care (Chassin et al., 2010) Health care that is accountable to patients, purchasers, and others Transitions of care Population health 9

What We Know about Health Care Quality McGlynn et al. (2003) and similar studies NCQA annual reports Commonwealth Fund scorecards Agency for Healthcare Research and Quality (AHRQ) annual reports Other studies 10

Quality for Population at Large (McGlynn et al., 2003) One of most widely cited studies Contacted 17,937 adults in 12 metropolitan areas asking if they would agree to release records for assessment of quality 6,712 agreed to do so Records reviewed for 439 indicators of quality of care for 30 acute and chronic diseases and preventive measures (McGlynn et al., 2003) Percentage receiving recommended care varied for different conditions Overall 54.9%, varying from atrial fibrillation (24.7%) to senile cataract (78.7%) 11

Other Results from McGlynn and Related Data Differences between sociodemographic groups much greater than within groups (Asch et al., 2006) From this and other data, quality of care increases with number of chronic conditions (Higashi et al., 2007) Similar analysis applied to patients in Veterans Health Administration found overall quality higher than national sample for process measures but not outcomes (Asch et al., 2004; Trivedi et al., 2011) In light of history of suboptimal care within VA, transformation called remarkable and attributed in part to EHR system (Greenfield & Kaplan, 2004; Baker, 2006; Congressional Budget Office, 2009) 12

Commonwealth Fund National Scorecard (Schoen, 2011) Up to 84,000 fewer Americans would die prematurely from causes amenable to health care if United States achieved lower mortality rate of three other leading countries Reducing insurance administrative costs to comparable costs of other best countries would save $114 billion per year Medicare could save $4.2 billion per year by reducing hospitalizations for preventable conditions 13

Agency for Healthcare Research and Quality (AHRQ) Annual Reports Annual AHRQ reports on quality and disparities show progress is being made but is still suboptimal Annual reports at http://www.ahrq.gov/qual/measurix.htm Can view measures by o Indicator: http://www.ahrq.gov/qual/qrdr10.htm o State (State Dashboard): http://statesnapshots.ahrq.gov/snaps10/index.jsp 14

Additional Resources Quality Improvement Organizations (QIOs) Program HCI3 s Bridges to Excellence Pharmacy Quality Alliance (PQA) Quality Enhancement Research Initiative (QUERI) National Committee for Quality Assurance (NCQA) National Association for Healthcare Quality (NAHQ) National Quality Forum (NQF) The Joint Commission 15

Additional Resources Continued National Quality Measures Clearinghouse (NQMC) CMS tools and resources: Clinical Quality Measures Basics Specialty Reporting Tools: CMS Hospice Quality reporting program Hospice Item Set endorsed by the National Quality Foundation 16

What Else We Know: Providers Rate of deaths from treatable conditions ( amenable to healthcare ) has declined much more slowly in US than in other developed countries (Nolte & McKee, 2008) Physicians who score better on maintenance of certification exams have higher rates of quality based on process measures (Holmboe et al., 2008) Use of hospitalists associated with better performance on quality indicators in hospitals (L pez et al., 2009) In primary care, visit duration (Chen, Farwell, & Jha, 2009) and patient connectedness (Atlas et al., 2009) associated with quality Underinsured, minority, disabled, and/or non-English-speaking patients associated with lower-quality rankings for primary care physicians (Hong et al., 2010) 17

What Else We Know: Organizations Training at an organization associated with a best doctor rating for cardiac bypass surgeons did not lower adjusted mortality rates (Hartz, Kuhn, & Pulido, 1999) Being US News & World Report Best Hospitals associated with lower 30- day mortality from acute MI, but some best hospitals had worse mortality (Wang et al., 2007) Organizations with direct leadership, accountability for quality and safety, and culture of collaboration have measurable differences (Keroack et al., 2007) Higher quality seen in larger (more integrated) subspecialty medical groups (Weeks et al., 2010) Resources available to compare organizations http://www.hospitalcompare.hhs.gov Hospital Compare from the Hospital Quality Alliance (HQA) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) 18

Relationship between Expenditures and Quality Medicare data: Great variation in cost among patients but little relationship to quality (Fisher et al., 2003a, 2003b) Inverse relationship between expenditures per capita and state rank of quality (Baicker & Chandra, 2004) No association between per capita expenses and perceptions of quality by patients (Fowler et al., 2008) 19

Quality Measurement and Improvement Summary Lecture a Health care quality is defined as best possible delivery of care and its resulting outcomes There are three major types of quality measures: structural, process, and outcome measures Current state of health care quality in the United States shows significant gaps between care as delivered and best possible delivery 20

Quality Measurement and Improvement References Lecture a References Aparicio, J., Borras, F., Ortiz, L., & Pastor, J. T. (2014). Benchmarking in healthcare: An approach based on closest targets. In Emrouznejad, A., & Cabanda, E. (Eds.), Managing service productivity (pp. 67 91), Heidelberg: Springer. Aron, D., & Pogach, L. (2009). Transparency standards for diabetes performance measures. JAMA, 301, 210 212. Asch, S., Kerr, E..A, Keesey, J., et al. (2006). Who is at greatest risk for receiving poor-quality health care? New England Journal of Medicine, 354, 1147 1156. Asch, S., McGlynn, E., Hogan, M. M., et al. (2004). Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Annals of Internal Medicine, 141, 938 945. Atlas, S., Grant, R., Ferris, T., Chang, Y., & Barry, M. (2009). Patient-physician connectedness and quality of primary care. Annals of Internal Medicine, 150, 325 335. Baicker, K., & Chandra, A. (2004). Medicare spending, the physician workforce, and beneficiaries quality of care. Health Affairs Millwood Va then Bethesda Ma, 23: W4-184 W4-197. Baker, M. L. (2006). VAs EHR system wins Harvard award. Eweek.com. Retrieved from http://www.eweek.com/servers/VAs-EHR-System-Wins-Harvard-Award Blumenthal, D. (1996). Quality of care What is it? New England Journal of Medicine, 335, 891 894. Burke, L., and Ryan, A. (2014) The complex relationship between cost and quality in US health care. AMA Journal of Ethics, 16, 2: 124 130. 21

Quality Measurement and Improvement References Lecture a Continued Centers for Medicare & Medicaid Services. (n.d.). Fact sheet: The hospice item set (HIS) NQF measures. Retrieved from https://www.cms.gov/medicare/quality-initiatives-patient-assessment- instruments/hospice-quality-reporting/downloads/his-fact-sheet.pdf Centers for Medicare & Medicaid Services. (2015). Clinical quality measures basics. Retrieved from https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/ clinicalqualitymeasures.html Centers for Medicare & Medicaid Services. (2016). Hospital compare. Retrieved from https://www.cms.gov/medicare/quality-initiatives-patient-assessment- instruments/hospitalqualityinits/hospitalcompare.html Centers for Medicare & Medicaid Services. (2016). Hospital value-based purchasing. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf Chang, J., Hays, R. D., Shekelle, P. G., et al. (2006). Patients global ratings of their health care are not associated with the technical quality of their care. Annals of Internal Medicine, 144, 665 672. Chassin, M., & Loeb, J. (2011). The ongoing quality improvement journey: Next stop, high reliability. Health Affairs, 30, 559 568. Chassin, M., Loeb, J., Schmalz, S., & Wachter, R. (2010). Accountability measures--using measurement to promote quality improvement. New England Journal of Medicine, 363, 683 688. Chen, L., Farwell, W., & Jha, A. (2009). Primary care visit duration and quality: Does good care take longer? Archives of Internal Medicine, 169, 1866 1872. 22

Quality Measurement and Improvement References Lecture a Continued 2 Congressional Budget Office. (2009). Quality initiatives undertaken by the Veterans Health Administration. A CBO paper. Pub. No. 3234. Retrieved from https://www.cbo.gov/sites/default/ files/111th-congress-2009-2010/reports/08-13-vha.pdf Donabedian, A. (Ed.). (2002). An introduction to quality assurance in healthcare. Cambridge, MA: Oxford University Press. Donabedian, A. (1988). The quality of care: how can it be assessed? JAMA, 260, 1743 1748. Ettorchi-Tardy, A., Levif, M., & Michel, P. (2012). Benchmarking: A method for continuous quality improvement in health. Healthcare Policy, 7 (4), e101 e119. Fisher, E., Wennberg, D., Stukel, T., Gottlieb, D., Lucas, F., & Pinder, E. (2003a). The implications of regional variations in Medicare spending. Part 1: The content, quality, and accessibility of care. Annals of Internal Medicine, 138, 273 287. Fisher, E., Wennberg, D., Stukel, T., Gottlieb, D., Lucas, F., & Pinder, E. (2003b). The implications of regional variations in Medicare spending. Part 2: Health outcomes and satisfaction with care. Annals of Internal Medicine, 138, 288 298. Fowler, F., Gallagher, P., Anthony, D., Larsen, K., & Skinner, J. (2008). Relationship between regional per capita Medicare expenditures and patient perceptions of quality of care. JAMA, 299, 2406. Greenfield, S., & Kaplan, S. (2004). Creating a culture of quality: The remarkable transformation of the Department of Veterans Affairs health care system. Annals of Internal Medicine, 141, 316 318. Hanlon, J., & Schmader, K. E. (2013). The medication appropriateness index at 20: Where it started, where it has been, and where it may be going Drug Aging, 30 (11), 893 900. 23

Quality Measurement and Improvement References Lecture a Continued 3 Hartz, A., Kuhn, E., & Pulido, J. (1999). Prestige of training programs and experience of bypass surgeons as factors in adjusted patient mortality rates. Medical Care, 37, 93 103. Health Affairs and Robert Wood Johnson Foundation. (2014). Health policy brief: Geographic variation in Medicare spending. Health Affairs. Retrieved from http://www.healthaffairs.org/ healthpolicybriefs/brief.php?brief_id=109 Health Information and Management Systems Society. (2016). 2016 HIMSS cost accounting survey. Retrieved from http://www.himss.org/2016-cost-accounting-survey Higashi, T., Wenger, N. S., Adams, J. L., et al. (2007). Relationship between number of medical conditions and quality of care. New England Journal of Medicine, 356, 2496 2504. Holmboe, E., Wang, Y., Meehan, et al. (2008). Association between maintenance of certification examination scores and quality of care for Medicare beneficiaries. Archives of Internal Medicine, 168, 1396 1403. Hong, C., Atlas, S., Chang, Y., et al. (2010). Relationship between patient panel characteristics and primary care physician clinical performance rankings. JAMA, 304, 1107 1113. Hwang, (2013) Effects of integrated delivery system on cost and quality. America Journal of Managed Care,19 (5), 175 184. Joint Commission. (2016). Top performer on key quality measures. Retrieved from http://www. jointcommission.org/mobile/measurement/top_performers_on_key_quality_measures.aspx 24

Quality Measurement and Improvement References Lecture a Continued 4 Keroack, M., Youngberg, B. J., Cerese, J. L., Krsek, C., Prellwitz, L. W., & Trevelyan, E. W. (2007). Organizational factors associated with high performance in quality and safety in academic medical centers. Academic Medicine, 82, 1178 1186. Korom-Djakovic, D., Canamucio, A., Lempa, M., Yano, E. M., & Long, J. A. (2016). Organization complexity and primary care providers perceptions of quality improvement culture within the Veterans Health Administration. American Journal of Medical Quality,31 (2), 139 146. Kurfman, G. (2015, May 27). Report proposes new vital signs to measure the nations health [Web blog post]. Harvard Health Blog. Retrieved from http://www.health.harvard.edu/blog/report-proposes- new-vital-signs-to-measure-the-nations-health-201505278048 Landon, B., Normand, S., Blumenthal, D., & Daley, J. (2003). Physician clinical performance assessment: prospects and barriers. JAMA, 290, 1183 1189. Lieberthal, R. D., & Comer, D. M. (2014). What are the characteristics that explain hospital quality? A longitudinal PRIDIT approach. Risk Management and Insurance Review, 17 (1), 17 35. Lohr, K. (Ed.). (1990). Medicare: A strategy for quality assurance. Washington, DC: National Academies Press. L pez, L., Hicks, L., Cohen, A., McKean, S., & Weissman, J. (2009). Hospitalists and the quality of care in hospitals. Archives of Internal Medicine, 169, 1389 1394. Lovaglio, P. G. (2012). Benchmarking strategies for measuring the quality of healthcare: problems and prospects. Scientific World Journal, 2012 (7392), 1 13. Article ID 606154. 25

Quality Measurement and Improvement References Lecture a Continued 5 McGlynn, E., Asch, S., Adams, J., et al. (2003). The quality of healthcare delivered to adults in the United States. New England Journal of Medicine, 348, 2635 2645. McKesson Health Solutions. (2014). The state of value-based reimbursement and the transition from volume to value in 2014. Retrieved from http://mhsinfo.mckesson.com/rs/ mckessonhealthsolutions/images/MHS-2014-Signature-Research-White-Paper.pdf Medicare.gov. (n.d.). Hospital Compare. Retrieved from https://www.medicare.gov/hospitalcompare/search.html National Association of Clinical Nurse Specialists (NACNS). (n.d.). Definition of transitional care. Retrieved from http://www.nacns.org/docs/TC-definitions.pdf National Committee for Quality Assurance (NCQA). (n.d.). NCQA primer on healthcare quality. Retrieved from https://www.ncqa.org/Portals/0/Publications/Resource%20Library/NCQA_ Primer_web.pdf National Quality Forum (NQF). (2010). Preferred practices and performance measures for measuring and reporting care coordination. Retrieved from https://www.qualityforum.org/Publications/ 2010/10/Preferred_Practices_and_Performance_Measures_for_Measuring_and_Reporting_Car e_Coordination.aspx Nolte, E., & McKee, C. (2008). Measuring the health of nations: Updating an earlier analysis. Health Affairs, 27, 58 71. 26

Quality Measurement and Improvement References Lecture a Continued 6 Pawlick. T., Urbach, D.R., & Halverson, A. L. (2013). Is there an association between implementation of a medical team training program and surgical mortality? Canadian Journal of Surgery, 56 (1), 6y5 68. Peterson, E., Roe, M. T., Mulgund, J., et al. (2006). Association between hospital process performance and outcomes among patients with acute coronary syndromes. JAMA, 295, 1912 1920. Rosenthal, M. (2008). Beyond pay for performance Emerging models of provider-payment reform. New England Journal of Medicine, 359, 1197 1200. Rowe, J. (2006). Pay-for-performance and accountability: Related themes in improving health care. Annals of Internal Medicine, 145, 695 699. Rabin, R. (2014, April 21). 15-Minute visits take a toll on the doctor-patient relationship. Kaiser Health News. Retrieved from http://khn.org/news/15-minute-doctor-visits Radisic, R., & Newbold, K. B. (2016). Factors influencing health care and service providers and their respective at risk populations adoption of the Air Quality Health Index (AQHI): A qualitative study. BMC Health Services Research,16 (1),107. Reyes-Alc zar, V., Almuedo-Paz, A., Torres-Olivera, A., & Nu n ez-Garci a, D. (2012). Critical success factors for quality assurance in healthcare organizations (Chap. 15). In M. Savsar (Ed.), Quality assurance and management, Rijeka, Croatia : InTech. 27

Quality Measurement and Improvement References Lecture a Continued 7 Schoen, Cathy. (2011). Why not the best? Results from the national scorecard on U.S. health system performance, 2011. The Commonwealth Fund. Retrieved from http://www.commonwealthfund.org/~/media/Files/News/Nat%20Scorecard/SchoenNatl%20Score card%202011%20Presentation1012%20final%20v3.ppt Steinman, M., Rosenthal, G. E., Landefeld, C. S., Bertenthal, D., & Kaboli, P. J. (2009). Agreement between drugs-to-avoid criteria and expert assessments of problematic prescribing. Archives of Internal Medicine, 169, 1326 1332. Trivedi, A., Matula, S., Miake-Lye, I., Glassman, P. A., Shekelle, P., & Asch, S. (2011). Systematic review: Comparison of the quality of medical care in Veterans Affairs and non-Veterans Affairs settings. Medical Care, 49, 76 88. Wang, T., Fonarow, G. C., Hernandez, A. F., et al. (2009). The dissociation between door-to-balloon time improvement and improvements in other acute myocardial infarction care processes and patient outcomes. Archives of Internal Medicine, 169 (15), 1411 1419. Weeks, W., Gottlieb, D. J., Nyweide, D. E., et al. (2010). Higher health care quality and bigger savings found at large multispecialty medical groups. Health Affairs, 29, 991 997. Charts, Tables, Figures 7.1 Adapted from Donabedian, A. (Ed.). (2002). An Introduction to quality assurance in healthcare. Cambridge, MA: Oxford University Press. 28

The Culture of Health Care Quality Measurement and Improvement Lecture a This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. 29