National Healthcare Quality Indicators Operationalisation of the conceptual framework

Transcription

1 THE ROLE OF STATISTICS IN SOCIETY SESSION F National Healthcare Quality Indicators Operationalisation of the conceptual framework Mario Gaarder Norwegian Directorate of Health

2 National Healthcare Quality Indicators Operationalisation of the conceptual framework Mario Gaarder 1 The Norwegian directorate of health is responsible for development and publication of national healthcare quality indicators (NHQI). The purpose of NHQI is to measure the healthcare systems performance and contribute to transparency by making the results available to the public, the politicians, the healthcare-professionals and leaders. The OECD conceptual framework-model for presentation of the healthcare systems performance was adopted in In short the model consists of six dimensions of quality, by which the healthcare services are measured. NHQI was developed by expert-groups, and in large dependent on preferences in each individual group. This experience led to the decision to revise and refine the framework. The aim of the revision was to standardise the development of NHQI across healthcare disciplines, by operationalisation of each of the six defined dimensions of quality in healthcare. Key words: standardisation, healthcare quality indicator 1 Directorate of Health, Senior Advisor, Oslo, Norway, mario.gaarder@helsedir.no

3 1. Introduction The Norwegian National Healthcare Quality Indicator (NHQI) system was established in March 2012 by the Norwegian Directorate of Health (NDH) after receiving regulatory instructed responsibility to develop, publish and maintain Norwegian NHQI. The NHQI system aim to be a sustainable and relevant tool for several target audiences, and its purpose is to; Give patients and their next of kin a basis for making qualified and informed choices. Provide the public with information about the quality in the healthcare services. Provide the decision makers with relevant information about the quality in the healthcare services. Provide leaders and healthcare professionals with a tool for quality improvement work and national, regional and local quality comparisons. 2. Background The NHQI system is based upon the Organisation for Economic Co-operation and Development (OECD) conceptual framework for development of healthcare quality indicators. The NHQI system define quality of healthcare services as services that; are effective, are safe, involves the patient, are coordinated and continuous, are utilising available resources, and are available and equally attainable to the public. These areas constitute the six dimensions of quality in the Norwegian NHQI system. A NHQI aim to show the quality of a given health service on all levels of the healthcare system; national, regional and local (eg unit, department and hospital). When developing a NHQI there are some key considerations. The indicator need to be valid and reliable; be evidence based; permit useful comparisons; and relate to clearly identifiable events for the user (J. Mainz, 2003). It is also imperative that a unit/hospital/region held accountable for a result also is able to affect the result of the indicator through local interventions. By the end of May 2016 there were a total of 113 NHQI covering healthcare areas within the somatic and mental healthcare services. All are made available to the public via the internet portal Due to rapid growth in numbers of NHQI and also areas of interest, the need for standardisation of the development process has become evident. Thus far the experience is that the development of NHQI is not as standardised as it ought to be. To some degree the availability of data determined which indicators were developed, which in turn has led to an imbalance in the NHQI system. To make sure the NHQI that are developed are relevant and important, a revision of the NHQI framework was decided.

4 2.1 Aim The aim of the revision was to operationalise each dimension of quality in the framework, by establishing a list of three to five keywords, or focal areas, describing what to measure within each of the frameworks six quality dimensions, to standardise and unify the development of future NHQI. 3. The process of developing focal areas It was decided to review the existing research literature, and national and international initiatives on development of healthcare quality indicators. Operationalisation of the six dimensions of quality defined in the Norwegian system was the focus of the review. A panel of representatives from across the healthcare services was established. The panel consisted of experts and decision makers in the healthcare services, national health registries, and representatives from patient organisations. The panel was asked to; discuss the findings from the litterature review, and contribute to these with complimentary input; consider data availability; and prioritise areas on which to focus. The expert panel met in three workshops to establish a consensus on the operationalisation of the quality dimensions. The final consensus document was intended as a guide and a tool for priorisation in future development of NHQI. The NHQI team in the NDH did the literature review in the field of developing NHQI. The literature consisted of scientific papers found via searches in PubMed and internet searches for similar initiatives on national and international level. The literature review was not exhaustive. A review of 250 individual indicators from Sweden were analysed and related to either of the six dimensions of quality in the Norwegian framework. The purpose beeing to uncover potential common traits from indicators within the same dimension. The frameworks of similar systems, primarily from the Netherlands, Canada, USA and OECD, were also reviewed. The primary aims of these reviews were to describe the dimensions of quality, and how they were operationalised. All of the national systems mentioned above had descriptions of what the dimensions of quality in their respective systems should cover, but none had explicitly operationalised them in focal areas. A non-scientific analysis of the literature resulted in a list of keywords describing potential focal areas within each dimension of quality from the reviewed quality indicator systems. The panel of experts, consisting of representatives from across a variety of medical fields and service levels, representaives from national health registries, as well as user representatives, took part in three separate workshops. The workshops were held by the NDH. Briefly,during the first workshop the NHQI system, and the task of operationalising the dimensions, were presented. The panel was asked to come up with suggestions on how to operationalise the dimensions in a brainstorm session, before the result of the literature review was presented. The panel was subdivided into smaller groups where the result of the litterature review and the brainstorm session was discussed. The results of these sub-group discussions were presented in a final plenary discussion. The results of these sessions was structured and revised by the NHQI team before the second workshop. The second workshop consisted of

5 plenary discussion that led to further refinement of the focal areas, by merging and/or excluding areas, thus decreasing the total number of keywords. The NHQI team revised and presented a final draft in a third workshop, in which consensus was reached. 4. The proposed focal areas The focal areas agreed upon are keywords which are intended to serve as both limitation and inspiration for development of new NHQI (Table 1). These keywords are the result of plenary discussions between experts in a wide range of healthcare disciplines (primary- and specialist-, somatic- and mental healthcare services); leaders and decision makers in the healthcare services; and representatives from different user/patient organisations. The keywords represent relevant and important areas of interest for both patients and healthcare professionals. The purpose of the keywords is to ensure the development of relevant and important NHQI. Table 1. Suggested focal areas for development of quality indicators. Dimension of quality in healthcare services Effective Safe Patient centeredness Coordinated and continous Resource utilisation Available and equally attainable Focal areas for development of quality indicators *Survival *Morbidity *Function and coping *Reaching desired outcome *Patient reported outcome *Patient safety *Proper treatment level *Guidelines and clinical pathways *Preparedness of the healthcare service *User- Kin- patient experience, involvement and education *Information and communication with users and relatives *Knowledge ofand planing for the patients present and future needs *Coordination and communication between services/providers * Coordination of services and coordinated procedures *Desired outcomes, at proper treatment level, at the lowest effort *Overuse *Prevention *Cost of treatment *Effective patient care and resource planning (capacity/ utilisation/ optimal treatment) *The correct care at the right time *Personell and expertise *Access to resources and equipment *Access and distribution of services *Information availability A short presentation of each dimension and each focal area is given as complementary information to Table Effective (1 st dimension) Effective describes to which degree a desired outcome is reached, given that proper evidence-based healthcare services are offered to patients that potentially have a positive effect, but not to those who do not responded to the treatment. The effect of healthcare is measured by whether a possible improvement is actually achieved through the provision of

6 healthcare. In addition, the effect is measured as reaching the desired outcome without causing harm. (OECD, 2006) The following focus areas were recommended: Survival Direct and indirect measure of the effect of the healthcare service provided. Measures can be both short and long term survival after treatment, or mortality in different groups of patients. Morbidity - Measuring the effectiveness of preventive measures and / or remission after rendered healthcare services in selected groups of patients. Function and coping - Measure change / improvement in social functioning and coping with life after receiving healthcare services. Reaching desired outcomes - Clinical measure of remission after receiving health services Patient reported outcome measures Patient reported efficacy of treatment (PROMs) 4.2 Safe (2 nd dimension) The dimension safe address whether healthcare avoid, prevent and limit adverse events, or whether harm is caused in the process of providing healthcare services. (OECD, 2006) The following focus areas were recommended: Patient safety: Measuring adverse events and incidence of iatrogenic states. Measuring the healthcare providers compliance with preventive guidelines and recommendations. Proper treatment level: Measurement of over treatment (unnecessary interventions and its' associated risk) and under treatment (not sufficient expertise in a given level to provide adequate treatment). Guidelines and clinical pathways: Measurements on health service compliance with health legislation, policies, guidelines and recommendations Preparedness of the healthcare service: Measuring whether healthcare services are provided in compliance with recommendations, and also the healthcare systems ability to provide adequate service in case of unexpected events. 4.3 Patient centeredness (3 rd dimension) Patient centeredness, or involving the patient, focuses on the effect of healthcare from the patients point of view. How the healthcare system encounters and treats patients. The quality of healthcare in this dimension is based on patients own experiences. Key areas are communication, patients experienced care, and patients knowledge and understanding of their own situation. The following focus areas were recommended:

7 User- /kin- / patient- experience, involvement and education: The healthcare service ability to collect and use experiences and feedback from the different demographics (eg PROMs). Information and communication with users and relatives: if information is given in an appropriate manner, and how the patient can communicate with the healthcare provider. 4.4 Coordinated and continuous care (4 th dimension) The dimension is characterised by continuity measures. Measures that describe whether the provided healthcare is coordinated across time and treatment levels. The following focus areas were recommended: Knowledge of- and planning for the patients present and future needs: measuring whether patients are offered essential services, and the healthcare providers are systematically mapping the need for present and future healthcare services. Coordination and communication between services/providers: Measure the use of individual plans 2 or use of binding treatment plans. Coordination of services and coordinated procedures: Coordinator functions and compliance with agreements that regulate interaction across levels and treatment centers in a course of treatment. Continuity of patient care: Measurement of wait -/ warranty-/ and treatment times, and time to follow-up after discharge, for appropriate diagnostic groups. 4.5 Utilisation of available resources (5 th dimension) Purpose of this dimension is to measure the healthcare systems ability to provide maximum positive impact using available resources. Focus is on the allocation and utilisation of resources, both geographically and organisationally, in the healthcare system. The following focus areas were recommended: Desired outcomes, at proper treatment level, at the lowest effort: measure the achieved effect gained from invested resources. Overuse: Measure variation between healthcare providers in offered services and level of care, for the same group of patients. Prevention: Effectiveness of patient education and recommendations. Measuring the healthcare systems focus on providing information to the public, preventive-, and early intervention measures. 2 Individuell plan all patients with the need for long-term healthcare services from several providers have the right by law to have their healthcare services individually planned and coordinated.

8 Cost of treatment: Measure the use of appropriate skilled staff in a sufficient extent when it has been shown to have a positive effect (eg Prioritisation of patients/treatmen, in regard to over- and underuse of healthcare service, and the competence of the healthcare professionals.) Effective patient care and resource planning (capacity / utilisation / optimal treatment): The time spent in course of treatment; lie times, time to discharge, use of outpatient and day surgery, and more. 4.6 Available and equally attainable (6 th dimension) Purpose of this dimension is to measure if healthcare is accessible, both physical and psychological, and fairly distributed. (OECD, 2006) The following focus areas were recommended: The correct care at the right time: Measure whether healthcare is given early enough in a course of treatment, and whether healthcare is provided at the appropriate level. Personnel and expertise: Education level and availability of personnel with the right competence and skills for a given healthcare service. Access to resources and equipment: Available infrastructure required to provide healthcare service to the population. Access and distribution of services: measures of access to healthcare for different groups of patients. Information availability: Measuring whether the information is properly facilitated, eg if key information is available in multiple languages and on multiple platforms. 5. Conclusions and experiences so far Already we see some challenges with the proposed areas. The areas reflect what should be measured or be known. Also, some areas could well be in several dimensions, and will probably be, as the system should serve as inspiration as well as limitation. The biggest challenge, however, seem to be the gap between what is wanted and what can be measured, due to lack of data. The availability of data depends on both registering events, but also agreement on what and how to measure. Determining whether a treatment is given at the right time or at correct level is not always clear cut. Thus the operationalisation introduces problems as well as aiding in the development of future NHQI. However, this process has helped focus the process of developing new NHQI even before the focal areas were made an integral part of the NHQI systems framework. This standardisation in combination with a revision of how the NHQI are presented to the public will help rectify the fragmented and diverse impression the NHQI system gives its users to day.

9 6. References OECD (2006). Health Care Quality Indicators Project Conceptual Framevwork Paper, Available at (accessed 28 May 2016) Mainz, J. (2003). Developing evidence-based clinical indicators: a state of the art methods primer. Int. J. Qual Health Care. 15, 5-11