Improving Healthcare Quality
Improving Healthcare Quality Purpose The purpose of this paper is to identify aspects of quality improvement in healthcare. This research is conducted by examining and reviewing various literature regarding the definition and makeup of quality healthcare, need for improvements in healthcare, various quality measures or indicators and weighing the cost of improving healthcare quality. Defining Healthcare Quality
Before any discussion can take place regarding improving healthcare quality, an examination of the definition of healthcare quality must be conducted. There are legitimately varying perceptions of what is consider to be the critical dimensions of quality healthcare. These views on quality largely results from the perspective one adopts as a patient, healthcare provider, health care manager, purchaser, payer, or public health official. The same health care experience may be assessed differently depending upon the person’s role.
For example: ? The patient may view his or her experience with the health care system both by its outcome and personal feelings, such as whether the physician listened well, communicated clearly, and was compassionate as well as skilled in delivering healthcare services. ? A healthcare provider may view quality in a technical sense, such as whether an accurate diagnosis is made, whether a surgical procedure is performed proficiently and whether the patient’s health has improved.
From this view, quality is the difference between what is technically sound and possible, and the actual practice and delivery of healthcare services. ? The health care manager, payer, or purchaser (employer health plan, or government program) may want to know if the healthcare services provided are cost effective. ? Public health officials may want to know if resources are being utilized appropriately to optimize population health and provided equitably within the population.
Quality as defined in Clair G. Meisenheimer’s book, Improving Quality: A Guide to Effective Programs, is “. . . the totality of features and characteristics of a health care process that bear on its ability to satisfy stated or implied needs; a process or outcome that consistently conforms to requirements, meets expectations, and maximizes value or utility for the customer. For the customer: getting what you were expecting and more; for the supplier: getting it right the first time, every time. The Institute of Medicine of the National Academies (IOM), a not-for-profit, non-governmental organization whose purpose is to provide national advice on issues relating to biomedical science, medicine, and health, and to serve as adviser to the nation to improve health, defines healthcare quality as the “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. ” (Retrieved July 11, 2009 from http://www. iom. edu). Further expounding the definitions provided, the IOM developed six dimensions of quality healthcare: 1.
Timeliness – refers to the length of time it takes to provide care to patients. For example, how long it takes a patient to receive a treatment or follow-up care once a breast mass is detected. Delays should be shortened to increase the efficacy of treatments and to ease the patient’s fears. 2. Safety – refers to the ability or need to avoid injuries that result from the provided care that is intended to help the patient. Injuries such as those resulting from administering the wrong drug or wrong dosage, incorrect diagnoses, etc. 3.
Effectiveness – the extent to which healthcare service is provided based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit, that is avoiding over-and underuse of resources. 4. Equity – the extent to which quality care is provided without regards to a patient’s gender, geographic location, gender and socioeconomic status. 5. Efficiency – the extent to which equipment, supplies and energy waste is avoided. 6. Patient-Centeredness – the extent to which the patient’s preferences, values and needs are taken into account when providing healthcare service.
Care should be provided respectful of and responsive to the patient. Comparatively, in his book An Introduction to Quality Assurance in Health Care, Avedis Donabedian provides seven components of what he considers quality in health care. Three of these components are included in the IOMs dimension of quality healthcare; effectiveness, efficiency and equity. The remaining four are: 1. Efficacy – the extent to which healthcare technology and science are able to bring about health improvements when used under the most ideal circumstances. 2.
Optimality – balancing the cost of healthcare improvements against the actual improvements, or in other words, by use of cost/benefit analysis ensuring that costs are not incurred which do not result in benefits do not exceed the cost or investment required. 3. Acceptability – the extent to which the expectations, desires and wishes of the patient and responsible members of their families are conformed to. There are five parts to the development of this definition: ? Accessibility – the ease with which patients can obtain healthcare ?
The patient-provider relationship – the extent to which the healthcare provider exhibits towards the patient personal concern, good manners, honesty, truthfulness, attention to the preferences of the patients, making efforts to provide explanations, patience, empathy, respectfulness and the avoidance of condescension. ? Amenities of care – the desirable aspects of the circumstances and/or environment under which healthcare is provided and includes cleanliness, adequate parking, convenience, privacy, comfort, restfulness, availability of refreshments, good food, etc. Patient preferences regarding the risks, cost and effects of care – recognition that the patient’s value of the consequences of care may differ for that of the healthcare provider and from patient to patient. Healthcare providers should take the time to explain to the patient the expected cost, risk and effects of alternatives and be guided by the informed opinions of the patients or responsible family member. ? Patient’s definition of fair and equitable As initially mentioned there are various legitimate definitions of what constitutes healthcare quality.
In developing this research paper, each of the definitions above will be utilized to address the issue of improving healthcare quality. The State of Quality Healthcare Surveys show growing concern over the eroding performance of the health care system. In November of 1999, the Institute of Medicine released a report entitled To Err Is Human: Building a Safer Health System, which concluded that 44,000 to 98,000 people die each year in hospitals due to preventable medical errors. In 2003 The National Committee for Quality Assurance (NCQA) released their first annual State of Healthcare Quality eport which found: More than 57,000 Americans die needlessly each year because they do not receive appropriate health care. The majority, almost 50,000 die because known conditions – high blood pressure or elevated cholesterol – are not adequately monitored and controlled. Others die or are at increased risk of death because they have not received the right preventative or follow-up care. [This is because] people with high blood pressure do not have it controlled, . . . people who have suffered a heart do not have their cholesterol levels monitored . . . and] smokers receive no advice to quit. Put simply, the healthcare system regularly fails to deliver care we know to be appropriate. (Nash & Goldfarb (2006) p 7-8) Although quality improvements have been made in some areas since that first report, the NCQA’s 2007 report illustrated significant room for improvement. In the area of medication management and prescription, the report found inappropriate use of some treatment medications, specifically antibiotics. Americans suffer an estimated one billion upper respiratory infections or common colds annually.
Colds are especially common among children, who suffer approximately three to eight colds a year. Because the common cold is most often viral, existing clinical guidelines do not prescribe the use of antibiotics as a treatment measure. Nevertheless, antibiotics are frequently prescribed to children with colds. Complications ranging from fevers and rashes to drug allergies, prolonged hospital stays and even death often arise from antibiotic treatment. Additionally, inappropriate antibiotic use contributes to bacterial resistance to antibiotics and represents wasted health care resources.
Annually $227 million is spent for inappropriate treatment for the common cold. The impact upon the elderly is just as damaging. Despite medical consensus that certain medications increase the risk of adverse effects to the elderly and should generally be avoided, these medications are still often prescribed to the elderly. One in 20 prescriptions filled by the elderly are for drugs deemed as “always avoid”. More than 1 in 10 filled prescriptions are for drugs that would rarely be considered appropriate.
Studies show that 21 to 37 percent of elderly patients had prescriptions filled for at least one potentially inappropriate drug and more than 15 percent had filled at least two. More than 40 percent of serious, life-threatening or fatal adverse drug events and 80 percent of adverse drug events in the elderly are avoidable. One study found that almost 3 percent of all elderly patients in a managed care organization suffered a preventable adverse drug event in a year. Reducing the number of inappropriate prescriptions can lead to improved patient safety and significant cost savings.
Conservative estimates of extra costs due to potentially inappropriate medications in the elderly average $7. 2 billion a year. The 2007 State of Healthcare Quality report found in total between 38,300 and 88,900 avoidable deaths due to unexplained variations in care and avoidable hospital costs between $1. 9 and $3. 5 billion. Additionally, the report determined an estimated 51. 6 million avoidable sick days due to unexplained variation in care at a cost of lost productivity of approximately $8. 5 billion.
These findings alone suggests and supports the employment of continuous improvement measures in the quality of healthcare. Quality Indicators “In health care as in other arenas, that which cannot be measured is difficult to improve. Providers, consumers, policy makers, and others seeking to improve the quality of health care need accessible, reliable indicators of quality that they can use to flag potential problems, follow trends over time, and identify disparities across regions, communities, and providers. (Guide to Prevention Quality Indicators: Hospital Admission for Ambulatory Care Sensitive Conditions, 2007, p 4) There are a number of measures that have been developed or defined by various organizations, measures that are utilized to determine, adjust and/or improve healthcare quality. One such organization has developed and implemented quality indicators (QI) to assist providers, policy makers, and researchers in the analysis of data to identify variations in the quality of either inpatient or outpatient care; the Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ).
The AHRQ’s aim is to improve the quality, safety, efficiency and effectiveness of healthcare and does so through researching: quality improvement and patient safety, outcomes and effectiveness of care, clinical practice and technology assessment, health care organization and delivery systems, primary care including preventive services, healthcare costs and sources of payment. The indicators defined by the AHRQ are used to measure various aspects of health care quality based upon hospital administrative data. The quality ndicators or QIs are grouped into four modules: ? Prevention Quality Indicators (PQI) – used to identify ambulatory care sensitive conditions (ACSC) which are “preventable hospitalizations” or conditions for which good outpatient care can potentially prevent the need for hospitalization, or for which early intervention can prevent complications or more severe disease. Despite these indicators being based upon hospital inpatient data, PQIs provide insight into the quality of healthcare outside the hospital setting.
For example, a diabetic patient may be hospitalized for complications associated with diabetes if their condition is not sufficiently monitored, if they do not receive proper patient education or if they do not manage their condition. Even though other factors outside of the healthcare system may result in hospitalization such as patient failure to follow treatment recommendations, or poor environmental conditions, PQIs are a good beginning point for assessing the quality of healthcare within a community and “serve as a screening tool rather than as definitive measures of quality problems.
They can provide initial information about potential problems in the community that may require further, more in-depth analysis. ” (AHQR, (2007), p 2) Despite the strengths of these indicators, there are a few weaknesses that should be considered. First, differences in socioeconomic status have been shown to explain a large part of the variation in some PQI rates across areas.
The intricacy of the relationship between socioeconomic status and PQI rates makes it difficult to delineate how much of the relationships are due to true difficulties in access to care in potentially underserved populations, or due to other characteristics, unrelated to quality of care, that vary by socioeconomic status. “For some of the indicators, patient preferences and hospital capabilities for inpatient or outpatient care might explain variations in hospitalizations. In addition, environmental conditions that are not under the direct control of the health care system can substantially influence some of the PQIs.
For example, the COPD and asthma admission rates are likely to be higher in areas with poorer air quality. ” (AHRQ, p 17). Second, the question of whether effective treatments in outpatient settings would reduce the overall incidence of hospitalizations has not been adequately addressed. The degree to which the reporting of admission rates for ACSC may result in changes in ambulatory practices and admission rates also is unknown. Patients may be admitted who do not clinically require inpatient care or patient may not be admitted who would benefit from inpatient care. Inpatient Quality Indicators (IQI) – reflect quality of care inside hospitals including inpatient mortality for medical conditions and surgical procedures and comprises three types of measures: ? Volume Measures are indirect measures of quality based upon evidence suggesting that hospitals performing more of selected inpatient procedures may have better outcomes for those procedures. Volume indicators shows the number of admissions in which these procedures were performed. ? In-hospital mortality indicators measure death rates for selected common surgical procedures or medical conditions. Utilization indicators focus on the volume of selected procedures for which research has suggested issues of overuse, underuse, or misuse. The weakeness of these indicators is that they are based upon data which is collected for billing pruposes and not research or measuring quailty. Dispite the insight that may be offered from these indicators, they should not be used as a decisive source of information on the quality of health care. At least three limitations of administrative data warrant caution: ? Coding differences across hospitals.
Some hospitals code more thoroughly than others, making “fair” comparisons across hospitals difficult. ? Ambiguity about when a condition occurs. Most administrative data cannot distinguish unambiguously whether a specific condition was present at admission or whether it occurred during the stay (i. e. , a possible complication). ? Limitations in ICD-9-CM coding. The codes themselves are often not specific enough to adequately characterize a patient’s condition, which makes it impossible to perfectly risk-adjust any administrative data set, thus fair comparisons across hospitals become difficult.
In short, the AHRQ IQIs are a valuable tool that takes advantage of readily available data to flag potential quality-of-care problems. (AHRQ, 2007, p 18) ? Patient Safety Indicators (PSI) measures harm or adverse effects resulting from healthcare services. These indicators are defined on two levels; provider level indicators which measure preventable ill effects by patients who received care and the adverse effects within the same hospitalization, and area level indicators. Area level indicators measures all cases of preventable ill effects that occurred within a specific area. Pediatric Quality Indicators (PDI) like PSIs include provider level and area level indicators to identify potentially preventable complications but as they apply to pediatric patients, that is those under the age of 18 years. The measures and indicators developed by AHRQ are not exclusive nor do any of the indicators alone provide a complete quality assessment of healthcare systems. However, these QIs take advantage of existing data and data collections systems in place in order to develop areas of improvement and some bases of comparison between healthcare organizations, standards, benchmarks, etc.
Once areas of improvement have been identified by QI, the job of addressing those identified shortcomings may begin. Methods abound which addresses improving quality, such as Six Sigma, Total Quality Management, etc.. These may be employed within a healthcare setting with as much success as doing so in a manufacturing plant. Conclusion This paper sought to examine one side of the healthcare triad, quality. The other two being cost and access. However, by no means should one presume that quality or any of the three is more critical than the other.
In fact, improving healthcare quality will effect the cost of healthcare, which in turn will effect access to that quality healthcare. Just as, effecting cost will impact quality and access. Admittedly, this paper fails to address in detail the intricate relationship between these three factors – but acknowledges the existence of this relationship. Improving quality requires a clear definition of “health care quality” . Ideally, this definition is based upon identifiable and measurable scientific indicators but without disregarding other indicators such as patient satisfaction.
Once a definition has been formulated, indicators or measures may be developed and employed to identify areas of improvement and to then address those short falls in quality. References Beers, M. H. (1997). Explicit Criteria for Determining Potentially Inappropriate Medication use by the Elderly. Arch Intern Med 157:1531-1536. Curtis, LH, et al. (2004). Inappropriate Prescribing for Elderly Americans in a Large Outpatient Population. Arch Intern Med 164:1621-1625. Donabedian, A. (2003). An Introduction to Quality Assurance in Health Care.
New York: Oxford University Press Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ), (2007). AHRQ Quality Indicators. Fick, D M, et al. (2003). Updating the Beers Criteria for Potentially Inappropriate Medication use in Older Adults. Arch Intern Med 163:2716-2724. Gonzales R, Malone DC, Maselli JH, Sande MA. (2001). Excessive antibiotic use for acute respiratory infections in the United States. Clin Infect Dis 33(6):757-762. Gurwitz, J. H. , T. S. Field, L. R. Harrold, J. Rothschild, K. Debillis, A.
C. Seger, C. Cadoret, L. S. Fish, L. Garber, M. Kelleher, D. W. Bates. (2003). Incidence and Preventability of Adverse Drug Events Among Older Persons in the Ambulatory Setting. JAMA 289(9):1107-1116. Johnson, J. A. and J. L. Bootman. (1995). Drug-Related Morbidity and Mortality: A Cost-of- Illness Model. Arch Intern Med 155:1949-56 MacKinnon NJ, et al. (2003). Indicators of Preventable Drug-related Morbidity in Older Adults: Use Within a Managed Care Organization. J Managed Care Pharm 9:134-41. McCaig L. F. , Besser R. E. , Hughes J. M. (2002).
Trends in Antimicrobial Prescribing Rates for Children and Adolescents. JAMA 287(23):3096-3102. Meisenheimer, C. G. (1997). Improving Quality: A Guide to Effective Programs (2nd ed. ). Gaithersburg, MD: Aspen Publishers, Inc. Nash, D. B. & Goldfarb, N. I. (Eds. ). (2006). The Quality Solution: The Stakeholder’s Guide to Improving Health Care. Sudbury, MA: Jones and Bartlett Publishers National Committee for Quality Assurance. The State of Health Care Quality: 2007. National Institute of Allergy and Infectious Diseases, The Common Cold, December 2007, http://www3. iaid. nih. gov/topics/commonCold/overview. htm (July 14, 2008). Rosenstein N, Phillips WR, Gerber MA, Marcy SM, Schwartz B, Dowell SF. 1998. The Common Cold—Principles of Judicious Use of Antimicrobial Agents. Pediatrics 101(1):181-184. Simon, SR, et al. (2005). Potentially Inappropriate Medication Use by Elderly Persons in U. S. Health Maintenance Organizations, 2000-2001. Journal of the American Geriatrics Society 53(2):227-232. Zhan, C, et al. (2001). Potentially Inappropriate Medication use in the Community-Dwelling Elderly. JAMA 286(22):2823-2868