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Quality Measurement and Improvement

Healthcare organizations and public health programs aim to improve the health of individuals and the population. The Institute of Medicine (IOM) in the United States defines quality healthcare as care that is safe, effective, patient centered, timely, efficient, and equitable. Quality, simply defined, is the degree of excellence compared with predetermined standards or benchmarks. Quality measures (QMs) used to determine quality and improve care can broadly be categorized as follows: process, outcome, patient perception Perception The process by which the nature and meaning of sensory stimuli are recognized and interpreted. Psychiatric Assessment, organizational structure, and/or system. An example of an outcome-based QM is the number of people who received a service or action (such as breast cancer screening Breast cancer screening Breast cancer is the most common cancer in women and the 2nd-leading cause of cancer-related deaths in women in the United States. Early detection and improved pathology-specific treatments have resulted in a decrease in death rates. Breast Cancer Screening) divided by the number of people who should have received the particular service or action based on a predetermined benchmark. A QM is defined as good if it is important, measurable, and feasible. Models for quality improvement have been developed to guide quality-improvement efforts. LEAN, Plan-Do-Study-Act (PDSA), and 6 Sigma are examples of some of these models. The key to successful quality improvement is an organizational commitment to a culture of continual improvement.

Last updated: 21 Feb, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Introduction

Definitions of quality:

  • WHO: the degree to which health services for individuals and populations increase the likelihood of desired health outcomes
  • Public health: the degree to which policies, programs, services, and research Research Critical and exhaustive investigation or experimentation, having for its aim the discovery of new facts and their correct interpretation, the revision of accepted conclusions, theories, or laws in the light of newly discovered facts, or the practical application of such new or revised conclusions, theories, or laws. Conflict of Interest increase the desired public health outcomes for a healthy population
  • Institute of Medicine (IOM): healthcare that is safe, effective, efficient, patient centered, timely, and equitable
  • European Commission: healthcare that is effective, safe, and responds to the needs and preferences of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship

Quality measures in healthcare are developed to:

  • Assess the current status of healthcare quality
  • Set goals for quality improvement (QI) using a predetermined standard or benchmark

Quality Measures (QMs)

QMs:

  • Used to determine quality and improve care
  • Based on evidence from research Research Critical and exhaustive investigation or experimentation, having for its aim the discovery of new facts and their correct interpretation, the revision of accepted conclusions, theories, or laws in the light of newly discovered facts, or the practical application of such new or revised conclusions, theories, or laws. Conflict of Interest and clinical practice
  • Mostly begin as clinical guidelines

Categories:

  • Process measures:
    • Steps that should be followed to provide quality care
    • Example: medication reconciliation
  • Outcome measures:
    • Results of healthcare, adjusted for risks as needed
    • Example: controlling high blood pressure
  • Patient perception Perception The process by which the nature and meaning of sensory stimuli are recognized and interpreted. Psychiatric Assessment:
    • Experience of care provided, as assessed by the patient or their family/caregiver
    • Example: assessment of a healthcare provider or health system by a patient
  • Organizational structure and/or system:
    • Measures infrastructures such as equipment, personnel, or policies
    • Example: nurse:patient ratio

A QM is defined as good if it is:

  • Important:
    • Evidence based
    • Prevalent and significant in the population
    • Potential for improvement that will impact patient or population health
  • Measurable:
    • Reliable
    • Valid
    • Specific
    • Easily interpreted
  • Feasible:
    • Readily available or easily obtainable data

Benchmarks

Benchmarking is the process of comparing performance or clinical practice to a predetermined standard (benchmark). The process can be internal or external (local or national).

Example of an internal benchmark

A clinical practice may decide that all providers in the establishment should aim to achieve low-density lipoprotein Low-density lipoprotein A class of lipoproteins of small size (18-25 nm) and light (1. 019-1. 063 g/ml) particles with a core composed mainly of cholesterol esters and smaller amounts of triglycerides. The surface monolayer consists mostly of phospholipids, a single copy of apolipoprotein B-100, and free cholesterol molecules. The main ldl function is to transport cholesterol and cholesterol esters to extrahepatic tissues. Cholesterol Metabolism cholesterol Cholesterol The principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils. Cholesterol Metabolism levels < 100 for all individuals with diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus visiting their establishment.

Example of an external benchmark

Healthcare Effectiveness Data and Information Set (HEDIS):

  • A comprehensive set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) as an approach to compare health plans
  • The NCQA collects data from health plans and other organizations.
  • Includes 90 measures over 6 domains:
    • Effectiveness of care
    • Access/availability of care
    • Experience of care
    • Utilization and risk-adjusted utilization
    • Descriptive information of health plans
    • Measures reported using electronic clinical data systems
  • Measures related to significant public health issues such as cancer, diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus, heart disease, asthma Asthma Asthma is a chronic inflammatory respiratory condition characterized by bronchial hyperresponsiveness and airflow obstruction. The disease is believed to result from the complex interaction of host and environmental factors that increase disease predisposition, with inflammation causing symptoms and structural changes. Patients typically present with wheezing, cough, and dyspnea. Asthma, and smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases
  • The measurement set is revised annually based on recommendations by the NCQA committee on performance measurement.
  • By comparing organizational data to HEDIS performance data, opportunities for improvement can be identified and QI can be monitored.
  • Examples: breast cancer screening Breast cancer screening Breast cancer is the most common cancer in women and the 2nd-leading cause of cancer-related deaths in women in the United States. Early detection and improved pathology-specific treatments have resulted in a decrease in death rates. Breast Cancer Screening, blood pressure control, asthma Asthma Asthma is a chronic inflammatory respiratory condition characterized by bronchial hyperresponsiveness and airflow obstruction. The disease is believed to result from the complex interaction of host and environmental factors that increase disease predisposition, with inflammation causing symptoms and structural changes. Patients typically present with wheezing, cough, and dyspnea. Asthma medication use, advising smokers to quit

Quality in Healthcare

Healthcare quality is defined by the IOM using 6 domains:

  • Safety: avoiding harm to patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship resulting from care that is intended to help them
  • Effectiveness: providing evidence-based care that is likely to benefit patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship
  • Patient centered: providing respectful care aligned with patient values, preferences, and needs
  • Timeliness: reducing waiting time and harmful delays for individuals receiving or providing care
  • Efficiency: avoiding wastefulness (equipment, supplies, energy, ideas)
  • Equitability: providing the same quality of care to all individuals regardless of gender Gender Gender Dysphoria, ethnicity, geography, or social status

Models for QI

Clinical practice teams embrace QI by having regular Regular Insulin meetings to address quality and performing QI projects. The models and tools for QI help guide these initiatives.

QI models

  • Model for improvement (MFI):
    • Most commonly used QI approach in healthcare
    • Steps:
      • Goals and aims are set.
      • Changes that will result in an improvement are determined.
      • Measurement of the effectiveness of these changes is decided.
      • Plan-Do-Study-Act (PDSA): The change is studied in a work setting.
    • Example:
      • Goal: Improve patient experience.
      • Aim: Decrease patient wait times.
      • Change: Remind patients of their appointments a day in advance.
      • Measurement: Timestamp patient flow through the clinic.
      • PDSA: Plan to study the change for a set time period and reevaluate.
  • Total quality management (TQM):
    • Based on the premise that QI and patient satisfaction can be achieved by having all members of the team focus on improving quality
    • TQM framework can be defined by 3 Cs and 3 Ps.
    • 3 Cs:
      • Culture
      • Communication
      • Commitment
    • 4 Ps:
      • Process
      • People
      • Planning
      • Performance
  • Rapid cycle improvement (RCI):
    • Involves testing interventions on a small scale in rapid cycles (> 3 months)
  • PDSA cycle Cycle The type of signal that ends the inspiratory phase delivered by the ventilator Invasive Mechanical Ventilation:
    • Combines TQM and RCI
    • Plan: Identify a goal, formulate a change, and define success metrics.
    • Do: Implement the plan.
    • Study: Monitor outcomes, short cycle Cycle The type of signal that ends the inspiratory phase delivered by the ventilator Invasive Mechanical Ventilation, small-scale tests, and analyze results.
    • Act: Integrate the learning generated by the process or change the intervention.
  • LEAN:
    • Developed for Toyota car manufacturing
    • Improving quality by reducing waste and increasing efficiency
    • 5 core principles:
      1. Define value.
      2. Map the value stream by identifying the steps for efficient production.
      3. Make the process flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure seamlessly by reducing steps that cause interruption.
      4. Pull from the customer, supplying only from demand.
      5. Pursue perfection through continuous improvement.
    • LEAN principles in healthcare: Focus Focus Area of enhancement measuring < 5 mm in diameter Imaging of the Breast is on cutting out the 8 wastes.
      1. Reduce waiting: Idle time is wasted time.
      2. Minimize inventory: tied-up capital and storage costs
      3. Eradicate defects to improve quality and increase reimbursement.
      4. Reduce movement of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship, supplies, and equipment to improve patient flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure.
      5. Prevent injuries and save time by decreasing movement that does not add value to patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship.
      6. Minimize healthcare overproduction and redundancies.
      7. Remove overprocessing: unnecessary work that goes into treating patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship, such as filling out different forms with the same information
      8. Understand how healthcare waste leads to untapped human potential.
  • 6 Sigma:
    • First designed for use in manufacturing
    • Often used in tandem with LEAN
    • Reducing variability and defects in processes and procedures
    • Statistical tools are used to identify and correct the root causes of variation.

Examples of QI tools

  • Run and control charts: Monitor performance and visualize variation.
  • Pareto chart:
    • Bar chart demonstrating the various factors contributing to an overall effect
    • The most vital contributing factors are graphed in descending order.
    • Visually highlights the factors that need the most attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment
  • Process maps: a chart that visually describes the workflow
  • Cause and effect (Ishikawa or fishbone) diagram: to analyze root causes contributing to an outcome
A plan-do-study-act cycle chart

A Plan-Do-Study-Act chart

Image by Lecturio.

References

  1. Institute for Healthcare Improvement. (2001). Retrieved November 13, 2021, from http://www.ihi.org/resources/Pages/Measures/default.aspx
  2. Agency for Healthcare Research and Quality. Six domains of quality measures. Retrieved November 13, 2021, from https://www.ahrq.gov/talkingquality/measures/six-domains.html
  3. Derose, S.F., Schuster, M.A., Fielding, J.E. Asch, S. M. (2002). Public Health Quality Measurement; Concepts and Challenges. Annual review of Public Health. 23, 1-21. Retrieved November 13, 2021, from https://www.annualreviews.org/doi/10.1146/annurev.publhealth.23.092601.095644
  4. U.S. Department of Health and Human Services. Consensus Statement on Quality in the Public Health System. (2008). Office of Public Health and Sciences. Office of Assistant Secretary for Health. Public Health Quality Form. Retrieved November 13, 2021, from https://www.apha.org/-/media/files/pdf/topics/qi/phqf_consensus_statement_92208.ashx
  5. WHO. Quality care. Retrieved November 15, 2021, from https://www.who.int/health-topics/quality-of-care#tab=tab_1
  6. Examples of Hospital Quality Measures for Consumers. Agency for Healthcare Research and Quality. Retrieved November 13, 2021, from https://www.ahrq.gov/talkingquality/measures/setting/hospitals/examples.html
  7. American Association of Family Physicians. Quality Measures. Retrieved November 25, 2021, from https://www.aafp.org/family-physician/practice-and-career/managing-your-practice/quality-measures.html
  8. National Quality Forum. Retrieved November 13, 2021, from https://www.qualityforum.org/Measuring_Performance/ABCs_of_Measurement.aspx
  9. An Overview of Improvement Models. Retrieved November 13, 2021, from https://www.ahrq.gov/cahps/quality-improvement/improvement-guide/4-approach-qi-process/sect4part2.html
  10. Basics for Quality Improvement. Retrieved December 8, 2021, from https://www.aafp.org/family-physician/practice-and-career/managing-your-practice/quality-improvement-basics.html
  11. Quality Improvement Essential Toolkit. Retrieved December 8, 2021, from http://www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx
  12. What is Lean Healthcare. Retrieved December 8, 2021, from https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0193
  13. Module 7: Measuring and Benchmarking Clinical Standards. Retrieved December 8, 2021, from https://www.ahrq.gov/ncepcr/tools/pf-handbook/mod7.html
  14. HEDIS Measures. Retrieved December 13, 2021, from https://www.ncqa.org/hedis/
  15. Busse, R., Klazinga, N., Panteli, D., Quentin, W. (2010). Improving healthcare quality in Europe. Characteristics, effectiveness and implementation of different strategies. Health Policy Series, No. 53. Copenhagen (Denmark): European Observatory on Health Systems and Policies. https://www.ncbi.nlm.nih.gov/books/NBK549276/

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