Quality measures in healthcare

Transcription

1 Quality measures in healthcare Henri Leleu

2 Performance of healthcare systems (WHO 2000) Health Disability-adjusted life expectancy Responsiveness Respect of persons Client orientation Fairness France #1 2

3 Tip of the iceberg Disability-adjusted life expectancy Outcome Regulators Healthcare providers Insurance / Health plans Process Access Structure Quality? 3

4 Quality in the industry Deming Good quality means a predictable degree of uniformity and dependability with a quality standard suited to the customer Six Sigma means no more than 3.4 defects per million opportunities ISO Degree to which a set of inherent characteristics fulfills requirements 4

5 Quality in healthcare The degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (IOM) Uncertainty Fast changing Social construct 5

6 Why measures quality? 6

7 Government Healthcare providers Voters / Consumers / Patients Health agencies Insurances Performance measures Agency theory Performance measures = align the interests of the agent with those of the principal 7

8 Low quality of care To err is human 44,000 to 98,000 people die each year as a result of preventable medical errors Crossing the quality chasm U.S. health care delivery system does not provide consistent, high quality medical care to all people efforts to improve quality require efforts to measure it 8

9 Strategies to improve quality 9

10 How to improve quality? A few examples Outcome Guidelines Continuing Medical Education Structure of healthcare Accreditation Process Access Structure Financial incentives Public reporting Equity - safety 10

11 Measures Improve the structure of healthcare Equity Access Strong preventive care Universal coverage Strong primary care Care coordination Health Systems Infrastructure Capabilities Effectiveness Timeliness Safety Efficient secondary care 11

12 Health at a glance 2011(OECD) Effectiveness Cancer care Screening, Survival Care for communicable diseases vaccination Care for chronic conditions Avoidable admissions Care for acute exacerbation of chronic conditions In-hospital mortality Safety Patient safety 12

13 Health at a glance 2011(OECD) Access to Care Unmet health care needs Coverage Burden of out-of-pocket Geographic distribution of doctors Inequalities Timeliness Waiting times Health Expenditure and Financing 13

14 Accreditation External assessment of performance against a pre-determined set of standards that are objective and measurable Accreditation Hospitals Physicians groups Physicians Accreditation of health plans NCQA 14

15 NCQA Accreditation Quality Management and Improvement Response to medical necessity Credentialing Members Rights and Responsibilities Member Connections HEDIS Quality measures 15

16 Guidelines Evidence-based health care is the conscientious use of current best evidence in making decisions about the care of individual patients or the delivery of health services Evidence Up-to-date information from relevant, valid research 16

17 Netherlands Clinical guidelines in primary care (1987) Performance measures Based on guidelines Accreditation tool (2005) Using performance measures Physicians Contracting Change reimbursement based on level of quality Pay-for-performance 17

18 Continuing Medical Education Maintain competence and learn about new and developing areas of their field Often mandatory Relicencing Continuing professional development Practice assessment Measures 18

19 Développement Professionnel Continu (2009) Objectives Practice assessment, medical education, quality and safety improvement, public health priorities and cost control Practice assessment Voluntary accreditation Safety problem disclosure Clinical audit Check list Clinical pathway Use of clinical measures 19

20 Financial incentives Pay-forperformance Bonus based on measured performance Value-based purchasing Payment based on measured performance Tiers payment Premium or reimbursement based on measured performance 20

21 Pay for performance Bonus payment indexed on performance measures Quality measures Objectives Quality Outcome Framework (UK) 30% of primary care physicians tied to performance measures Pacific Business Group on Health Retain et redistribute money of health plans based on quality 21

22 Value based purchasing Payment mechanism tied to quality measures Shifting of the usual payment to quality based payment Affordable Care Act (2012) Hospital payment reduced by 1% Funds use for incentives payment 22

23 Tiers payment Insurance premiums or reimbursement depend are indexed on quality measures Ranked physicians or hospitals in tiers based on quality measures CIGNA Care Network (2008) Absence of physician incentives No physicians exclusion Patients may pay differential copayments/coinsurances 23

24 Public reporting Accountability Political pressure Consumer s choice vote with their feet Provider s reputation Communication Easy-to-read Explanatory messages 24

25 Chrysler, Ford, GM & United Auto Workers (1999) Private purchasers of health plans Measure quality of health insurances Framework for reporting NCQA Accreditation status Consumer satisfaction Access & Services Staying healthy Getting better 25

26 Heart surgery - State of New York Data on quality of heart surgery (1989) - State of New York Annual risk-adjusted mortality following coronary artery bypass graft surgery by hospital and surgeon Deaths fell 41 percent over the first four years. Individual hospitals made changes No market incentives Many critics Gaming High risk patients exclusion Additional work required to identify what is wrong 26

27 Safety Prevention of harm to patients Preventing errors Safety practices (processes) Learning from the errors that do occur Continuing professional development Specific methodologies Having a patient safety culture Check-list 27

28 Safety Centers for Medicare & Medicaid Service (2007) no-payment rule for hospital-acquired conditions Safety culture Measured by quantitative surveys 28

29 Equity Inequity Disparities in health that are systemic and avoidable and, therefore, considered unfair or unjust Reduce inequity in health or healthcare Stratify measures by social group 29

30 What are quality measures? 30

31 Definitions Measure A tool to assign a quantity to an attribute by comparing it with a criterion. Quality measure A tool to assign a quantity to quality of care by comparing it with a criterion. 31

32 Domains of measurement Health Care Delivery Structure / Access / Process / Outcomes Patient experience Population Health Health state 32

33 Structure Structure of care is a feature of a health care organization or clinician related to the capacity to provide high quality health care Protocols for hospital-acquired infections prevention? 33

34 Process A process of care is a health care-related activity performed for, on behalf of, or by a patient Proportion of physicians washing their hands after each patient? 34

35 Outcomes An outcome of care is a health state of a patient resulting from health care Proportion of hospital acquired-infection? 35

36 Access Access to care is the attainment of timely and appropriate health care by patients or enrollees of a health care organization or clinician Waiting times for cancer surgery? 36

37 Patient experience Experience of care is a patient's or enrollee's report of observations of and participation in health care, or assessment of any resulting change in their health. Validated questionnaires Picker Institute (UK) OCDE CAHPS (US) 37

38 Efficiency Ratio between what the service costs and the outcome received from it Depends on the perspective Most efficiency measures today are cost measure No quality No validation 38

39 Measure selection process Importance of what is being measured Potential to improve health Actionable Meaningful Scientific soundness Feasibility Idade do capitão? 39

40 Actionable Definition capable of being acted on Population based or outcomes indicators VS Process, structure or access indicators 40

41 Scientific soundness Reliability Scientific evidence Validity Allowance for patient/consumer factors as required Comprehensible 41

42 How to use quality measures? 42

43 Internal versus external Internal usage Financial Incentives External usage Quality improvement initiatives Measuring Public reporting Accreditation 43

44 Balance between external and internal usage Internal External Initiative Voluntary Imposed Means Learning, improvement Accountability, control Motivation Intrinsic Extrinsic Resistance Low High 44

45 Strategy Identify core sets of quality measures for standardized reporting All sectors of health care Establish a framework and capacity for quality measurement and reporting. Ensure that comparative information on health care quality is valid, reliable, comprehensible, and widely available in the public domain. 45

46 Cautions Separate programs lead to confusion Fix national objectives for quality improvement Capacity limit of healthcare system Health information technology Healthcare data infrastructure 46

47 Questions Dr Henri Leleu 47