Summary The Health Care Quality Book Essay

Chapter 1: science and knowledge foundation

Two notable contributions to the industry from the Journal of American Medical Association: 1. Assessment of the state of quality  serious and widespread quality problems 2. Categorization of three defects:Summary The Health Care Quality Book Essay

a. Underuse: many scientifically sound practices are not used as often as they should be b. Overuse: can be seen in areas such as imaging studies for diagnosis in acute asymptomatic low back pain or prescription of antibiotics when not indicated for infections. c. Misuse: when the proper clinical care process is not executed appropriately, such as giving the wrong drug to a patients.Summary The Health Care Quality Book Essay

To Err Is Human: publication that shows the severity of the quality problems in a way that captured the attention of all key stakeholders for the first time  this report spoke about the negative, not how it should be improved. Crossing the quality chasm: provided a blueprint for the future that classified and unified the components of quality through six aims for improvement, chain of effect and simple rules for redesign of health care.Summary The Health Care Quality Book Essay

Six dimensions of quality (Berwick):
Outcome measures and goals (IOM) = Institute of Medicine’s Safe
Percentage of overall mortality rates/patients experiencing adverse events or harm Effective: science and evidence should be applied and serve as the standard for delivery of care. How well are evidence based practices followed? Percentage of time diabetic patients receive all recommended care at each doctor visit.. Efficient: Care and service should be cost effective, and waste should be removed. Analyzing the costs of care by patient, organization, provider or community Timely: no waits or delays in receiving care

Measured by waits and delays in receiving needed care, service, and test results. Patient centered: system should revolve around the patient, respect
its preferences and put the patient in control Patient or family satisfaction with care and service. Summary The Health Care Quality Book Essay

Equitable: Disparities should be eradicated.
Examining differences in quality measures by race, gender, income or other factors.

The underlying framework for achieving these aims depicts the health care system in four levels: Level A: what happens with the patient
Level B: the micro system where care is delivered by small provider teams Level C: organizational level: the macro system or aggregation of the Microsystems and supporting functions. Level D: external environment where payment mechanisms, policy and regulatory factors reside (verblijven). Summary The Health Care Quality Book Essay

Chapter 2: Basic concepts of health care quality

The following attributes relevant to the definition of quality of care are important: Technical performance  refers to how well current scientific medical knowledge and technology are applied in a given situation (it is usually assessed in terms of timeliness and accuracy of the diagnosis, appropriateness in of therapy) Management of the interpersonal relationship  refers to how well the clinician relates to the patient on a human level.Summary The Health Care Quality Book Essay

The quality of this relationship is important because: By establishing a good relationship with the patient the clinician is able to fully address the patient’s concerns, reassure the patient and relieve the patient’s suffering It can affect technical performance: the clinician is better able to elicit from that patient are more complete and accurate medical history, which can result in a better diagnosis Amenities (voorzieningen)  refers to the characteristics of the setting in which the encounter between patient and clinician takes place, such as comfort, convenience and privacy. Amenities are valued both in their own right and for their effect on the technical and interpersonal aspects of care. Amenities can yield (opleveren) benefits that are more indirect.Summary The Health Care Quality Book Essay

Access  refers to the degree to which individuals and groups are able to obtain needed services. Responsiveness to patient preferences  respect for patients’ values, preferences and expressed needs affects quality of care as a factor in its own right. Equity  the amount, type or quality of health care provided can be related systematically to an individual’s characteristics, particularly race and ethnicity, rather than to the individual’s need for care or healthcare preferences, have heightened concern about equity in health care. Medicine does not fulfill its function adequately until the same perfection is within the reach of all individuals. Efficiency  refers to how well resources are used in achieving a given result. Cost-effectiveness  how much benefit, typically measured in terms of improvement in health status, the intervention yields for a particular level of expenditure.Summary The Health Care Quality Book Essay

For each stakeholder in health care, quality can be differently defined: page 30 + 31. These definitions have a great deal in common: Each definition emphasizes different aspects of care Definitions conflict only in relation to cost-effectiveness

All evaluations of quality of care can be classified in terms of one of the three aspects of caregiving they measure: Structure: when quality is measured in terms of structure, the focus is on the relatively static characteristics of the individuals who provide care and of the settings where the care is delivered. These characteristics include the education, training and certification of professionals. Process: refers to what takes place during the delivery of care, also can be the basis for evaluating quality of care. Outcomes: Outcome measures, which capture whether healthcare goals were achieved, are another way of assessment of quality of care. Outcome measures have to include the costs of care as well as patients’ satisfaction with care. Which one is better to use?  none of them, all depends on the circumstances.Summary The Health Care Quality Book Essay

To assess quality using structure, process or outcome measures, we need to know what constitutes good structure, good process and good outcomes. We need criteria and standards we can apply to those measures of care: Criteria = specific attributes that are the basis for assessing quality Standards = express quantitatively what level the attributes must reach to satisfy preexisting expectations about quality. For example  type of measure:
structure and focus on primary care group practice: Criterion: percentage of board-certified physicians in internal or family medicine – Standard: 100% of physicians in the practice must be board certified in internal or family medicine.Summary The Health Care Quality Book Essay

Optimal standards: denote the level of quality that can be reached under the best conditions, typically conditions similar to those under which efficacy is determined  useful as reference point.

Structural measures are well suited to detecting lack of capacity to deliver care of acceptable quality. They are also only as good and useful as strength of their relation to desired processes and outcomes. To evaluate structure, process and outcome measures criteria and standards are essential. Whereas the formulation of criteria is expected to be evidence driven (efficacy). The setting of standards is not similarly tied to scientific literature. The decision to set standards at a minimal, ideal or achievable level is most meaningful if driven by the goals behind the specific quality of care evaluation for which the standards are to be used.

Chapter 3: Variation in medical practice and implications for quality

Variation  the difference between an observed event and a standard or norm. Without this standard, or best practice, measurement of variation offers little beyond (biedt niet meer dan) a description of the observations. Random variation = physical attribute of the event or process, adheres to the laws of probability and cannot be traced to a root cause. (houdt zich aan de wetten van waarschijnlijkheid en kan niet worden herleid tot een oorzaak). It is not worth to study it in detail.Summary The Health Care Quality Book Essay

Assignable variation = arises from a single or small set of causes that are not part of the event or process and therefore can be traced, identified, and implemented and eliminated  subject to potential misunderstanding because of complexity of design and interpretation. 1. Process variation = the difference in procedure throughout an organization (use of various screening methods for colorectal cancer) Technique  multitude of ways in which a procedure can be performed within the realm of acceptable medical practice. 2. Outcome variation = difference in the result of a single process (mostly focus on this measure) – the process yielding optimal results  outcomes research 3. Performance variation = the difference between any given result and the optimal ideal result. This threshold or best practice is the standard against which all other measurements of variation are compared. Performance variation tells us where we are and how far we are from where we want to be, and suggests ways to achieve the desired goal.Summary The Health Care Quality Book Essay

Variation can be desirable?  a successful procedure that differs from other, less successful procedures is by definition variation. The objective then for quality improvement is not simply to identify variation but to determine its value. How can the variation be eliminated or reduced in the ways that focus on the variation rather than on the people involved? So, understanding the implications for quality of variation in medical practice is not simply learning how eliminate variation but learning how to improve performance by identifying and accommodating good or suboptimal variation from a predefined best practice.

Variability plays a role in identifying, measuring and reporting quality indicators (effective, efficient, equitable..) and process-of-care improvements.Summary The Health Care Quality Book Essay

Some hospitals are reluctant to use quality improvement measures (they perceive them as biased towards academic medical research centers or large health care organization)  untrue! Quality improvements efforts can be and have been successfully applied to small organization and practices.

The size of an organization also effects the ability to disseminate (verspreiden) best practices. Large organization tend to have rigid frameworks or bureaucracies; change is slow and requires perseverance (doorzettingsvermogen) and the ability to make clear to skeptics and enthusiasts the value of the new procedure in their group and across the system.Summary The Health Care Quality Book Essay

An organization ‘s commitment to paying for quality improvement studies and
implementation is equally affected by its size and infrastructure, but there are some minimum standard levels of quality and linked reimbursement schemes to achieving goals established by the Joint Commission, CMS and Medicare  all organizations obligated to meet these standards.

Quality improvement effort must consider organizational mind-set, administrative and physician worldviews, and patient knowledge and expectations. Physician buy-in is critical to reducing undesired variation or creating new and succesfull preventive systems of clinical care, therefore: training physician champions and inciting (aanzetten) them to serve as models, mentors and motivators and it reduces the risk of alienating (vervreemden) the key participants in quality improvement efforts.Summary The Health Care Quality Book Essay

Patient education in quality of care is equally subject to variation; patients are aware of the status of health care providers in terms of national rankings, public news of quality successes and so on. Educating patients about a health care organization and its commitment to quality makes variation and process-of-care measures available to the public.

Organizational mind set  organizational infrastructure is an essential component in minimizing variation, disseminating best practices and supporting a research agenda associated with quality improvements. Economic incentives may be effective in addressing variation in health care by awarding financial bonuses to physicians and administrators who meet quality targets or withholding bonuses from those who do not. Goals of incentives: to help people understand that their organization is serious about implementing quality changes and minimizing unwanted variation to ensure alignment with national standards an directions in quality of care and to encourage them to use the resources of the organization to achieve this alignment .Summary The Health Care Quality Book Essay