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Quality of Care and Its Measurement in the HSRE
Context
Jonathan P. Weiner, DrPH
Johns Hopkins University
This Lecture Will Address the Following:
Definitions
Paradigms and frameworks
Policy context
Applications within HSR&E
Approaches to measurement
Sources of benchmarks
Data sources
Practical issues (related to individual exercise case study)
Section A
Definitions, Paradigms, and Frameworks
Quality Defined
The degree to which health services for individuals and
populations increase the likelihood of desired health
outcomes
And the degree to which health services are consistent with
current professional knowledge
Notes Available
Quality Defined
The quality performance of a provider or organization can
be assessed by measuring . . .
Their patients outcomes (end-results), or;
The degree to which they adhere to an accepted care
process
Quality Defined
Everything thats not money
Weiner, 1982
The Value Equation
Cost
Value
Quality
The Theoretical Cost/Quality Plateau Relationship
Quality
Cost
Two Recent Institute of Medicine Reports Have Been
Influential:
To Err is Human
Crossing the Quality Chasm
Though as much political as scientific in nature, we can
learn much from these IOM reports
See www.iom.edu
10
IOMs Framework for Quality Improvement:
Quality problems may relate to the following:
Underuse
Overuse
Misuse
The IOM effectively used the issue of patient safety to
capture the publics attention and the medias attention
11
IOMs Suggestions for Future
It is not acceptable to have a wide quality chasm between
actual and best possible performance
Quality and safety must be designed into a system and must
not be the responsibility of just individual providers
12
Is It HSRE or Care Management?
Quality of care is central to several domains:
Basic research and development
Research to set policy agenda
Program management/improvement
Program impact evaluation
13
A Schema for Categorizing Health Services Research,
Evaluation, and Related Activities
Science
base
New Knowledge for Society
Research
Methods development
Outcomes/tech assessment
CQI
OR/efficiency
Disease/outcome
management
Program
management
Social policy research
Health system
improvement and
development
Performance monitoring
Program effectiveness
Program
Assessment /
Development
Non-policy
Policy
Policy research /
analysis
Provider/Program Focus
Evaluation
Policy Makers (public and private)
14
A Schema for Categorizing Health Services Research,
Evaluation, and Related Activities
Science
base
New Knowledge for Society
Research
Methods development
Outcomes/tech assessment
CQI
OR/efficiency
Disease/outcome
management
Program
management
Social policy research
Health system
improvement and
development
Performance monitoring
Program effectiveness
Program
Assessment /
Development
Non-policy
Policy
Policy research /
analysis
Provider/Program Focus
Evaluation
Policy Makers (public and private)
15
Some Specific QOC Applications Include . . .
Clinical quality improvement / TQM
Performance monitoring
Evidence-based outcomes research
Health system improvement
16
The Continuous Quality Improvement (CQI) Cycle
Problem Identification
and Prioritization
Implementation of System Change
Determination of Quality Criteria
Design of System Improvement
Measurement of Degree
to which Criteria is Attained
17
Section B
Measurement
Approaches to Measuring Quality
1. Structure of care
Facilities
Provider qualifications and credentialing
Availability / resource adequacy
19
Approaches to Measuring Quality
2. Process of care
Provider adherence to practice standards
Appropriateness of care
20
Process Measures
Adequacy of patient/population utilization
Ease of access to care/case finding rates
21
Approaches to Measuring Quality
3. Outcomes of care
Patient function/health status/quality of life
Adverse/sentinel events
Mortality/longevity
22
Outcome Measures
Prevention/avoiding disease/morbidity
Patient satisfaction/patient-centeredness
23
Data Sources for Quality
Type of Measure
Data Source
Structure
Site Visit
Administrative Files
Claims/Encounter
Process
Outcome
24
Data Sources for Quality
Type of Measure
Data Source
Structure
Site Visit
Administrative Files
Claims/Encounter
Process
Outcome
25
Data Sources for Quality
Type of Measure
Data Source
Structure
Medical Record (paper or
electronic)
Patient Interview
Population Survey
Process
Outcome
26
Remember Your Denominators:
Populations of Interest for QOC Research
Insured beneficiary/enrollee group
Persons living in a geographic area
A selected vulnerable population group
Provider organization/institution
An individual provider
27
Basis for QOC Standard/Reference
Process or structure of care:
Normativebased on peer judgment and literature
Empiricalbased on observations of actual practices
See http://www.qualitymeasures.ahrq.gov/
(http://www.ahrq.gov/qual/)
28
Standard/Reference
Outcomes of care:
Accepted standards with face validity (e.g., infant mortality,
disability)
Constructed standards (e.g., functional health status,
satisfaction)
29
QOC Case Study (See Individual Exercise)
1. CABG in Western MD
2. Prenatal care gray-area women
Meeting national standards of care
Improved quality for target population
A. Intent and implications for design
B. Measures
C. Sources of data
30
