ASSESSING QUALITY ACROSS THE REGION

1. ASSESSING QUALITY ACROSS THE REGION

2. What is quality? • How good or bad something is • The standard of something as measured against other things of a similar kind; the degree of excellence of something (Oxford Dictionary) • In manufacturing, a measure of excellence or a state of being free from defects, deficiencies  • A modern definition of quality derives from Juran's "fitness for intended use."  This definition basically says that quality is "meeting or exceeding customer expectations."  Deming states that the customer's definition of quality is the only one that matters.  So, who is the customer?

3. Definition of Health Quality safe, effective, patient-centered, timely, efficient and equitable”— Institute of Medicine (IOM), 2001 “doing the right thing for the right patient, at the right time, in the right way to achieve the best possible results”— Agency for Healthcare Research and Quality (AHRQ)

4. Health Quality Perspectives • Conventional wisdom = more is better • Quantity • Technology • Cost

5. Health Quality Perspectives • Continuous improvement quality healthcare will lead to: • Higher quality patient care • Improved patient satisfaction • Better morale • Lower cost of service delivery • Better health outcomes

6. WHO working definition Needs to take a whole-system perspective, and reflect a concern for the outcomes achieved for both individual service users and whole communities (WHO)

7. Health Outcomes Health Outcomes are a change in the health status of an individual, group or population which is attributable to a planned intervention or series of interventions, regardless of whether such an intervention was intended to change health status.

8. Quality Dimensions Donabedian

9. Requirements • Universally acceptable clinical guidelines, indicators and definitions • Standards • Benchmarks • Universally available data • Claims data • Demographic information • Clinical data (diagnoses and laboratory results) • Infrastructure surveys • Patient satisfaction surveys • Trends over time • Participation

10. Limitations • Main limitations relate to the data that is universally available and the reliability thereof • Data granularity • Claims data • Demographic data • Diagnostic data • Other clinical data (e.g. pathology results) • Capitation providers • Survey data • Patient experience/perceptions/satisfaction • Infrastructure availability and capacity • Human resources

11. Why is it important to measure quality? • Enable consumers to make informed choices and pursue the best available care (NCQA) • Provision of feed back to healthcare insurers and professionals (NCQA) • Improvement over time (NCQA) • Goal in assessing performance is to create a system that promotes the best clinical standards and ensures the highest quality of patient care through transparency, accountability, and credibility (Tooker, J.)

12. Why is it important to measure quality? “Measurement is the first step that leads to control and eventually to improvement. If you can’t measure something, you can’t understand it. If you can’t understand it, you can’t control it. If you can’t control it, you can’t improve it.” – H. James Harrington “When performance is measured, performance improves. When performance is measured and reported back, the rate of improvement accelerates” - Thomas S. Monson IMPROVING MEASURING PROCESSES PEOPLE PERFORMANCE SYSTEMS MANAGING

13. Why is it important to measure quality?

14. Six areas for improvement • Effectiveness:delivering healthcare that is adherent to an evidence base and results in improved health outcomes for individuals and communities, based on need; • Efficiency:delivering healthcare in a manner which maximises resource use and avoids waste; • Accessibility:delivering healthcare that is timely, geographically reasonable and provided in a setting where skills and resources are appropriate to medical need; • Acceptability/patient-centredness:delivering healthcare which takes into account the preferences and aspirations of individual service users and the cultures of their communities; • Equity:delivering healthcare which does not vary in quality because of personal characteristics such as gender, race, ethnicity geographical location or socio-economic status: • Safety:delivering healthcare which minimises risks and harm to service users

15. The elephant in the room

16. Key questions? • How can health quality be measured: • Viably • Sustainably • Accurately • Understandably? • If the measurement of health outcomes is the holy grail, what can be done along the way?

17. Continuous improvement philosophy • Kaizen: Japanese term for continuous improvement. A step-by-step improvement of business processes. • PDCA: Plan-do-check-act as defined by Deming. • Benchmarking : what do top performers do? Do Plan Act Check

18. Categories of Health Quality Problems • Underuse – patients do not receive medically necessary care • Misuse – patients receiving the wrong care • Overuse – patients receiving care that is not needed or for which there is an equally effective alternative that costs less money or causes fewer side-effects Source: NCQA

19. International Approaches • Measurement of Health Quality is extremely topical and various agencies and organisations exist • Agency for Healthcare Research and Quality (AHRQ) – initially tasked with development of clinical guidelines, but is now focussed on improving the quality, safety, efficiency, and effectiveness of health care for all Americans • National Quality Forum (NQF) • National Guideline Clearinghouse (NGC) – searchable database of clinical guidelines and evidence • National Quality Measure Clearinghouse (NQMC) • National Health Service (NHS) Confederation Quality and Outcomes Framework Indicators • Healthcare Effectiveness Data and Information (HEDIS) – consists of 81 measures to measure various dimensions of care and service • National Committee for Quality Assurance (NCQA) accredits and certifies healthcare organisations

20. Southern Africa • Quality measurement primarily focussed on environmental and public health aspects such as: • Water • Sanitation • Poverty • Education • Focus on the management and measurement of communicable diseases: • HIV/AIDS • Tuberculosis • Ebola

21. South Africa • Health Quality Assessment (HQA) • Voluntary organisation • 14 Schemes • 66 Benefit options • 4.58 million beneficiaries • 183 Indicators

22. Process for building a strategy for quality Source: WHO, Geneva 2006

23. HQA Outputs • Indicator Report • Methodology Report • Industry Report • Descriptive statistics • Dimensions • Process • Primary Care (Incl. screening) • Maternity and New-born • Chronic disease management • Usage • Primary Care (Incl. screening) • Maternity and New-born • Hospitalisation • Chronic disease management • Outcomes

24. HQA Outputs • Excel spreadsheets • Indicator values • Benchmarks • Trends over time • Graphs

25. HQA Outputs • Scheme results and trends via secure portal – scheme specific • Plan is to update quarterly

26. Quality Dimensions • Structural Elements • Characteristics of: • Community • Institution • Provider • Patient • Examples • Geographic location of facility • Availability of technologies • Hospital size • Provider qualifications • Process Elements • Treatment process • Stages of treatment • Appropriateness • Services process • Examples • Use of efficacious therapy • Use of diagnostic tests • Use of procedures • Treatment delays (incl. wait times) • Outcomes • Death • Adverse events • Readmissions to hospital • Resource use (costs, length of stay in hospital) • Patient satisfaction with care • Quality of life • Patient ability to function in daily activities

27. Structural Elements

28. Quality Dimensions • Structural Elements • Characteristics of: • Community • Institution • Provider • Patient • Examples • Geographic location of facility • Availability of technologies • Hospital size • Provider qualifications • Process Elements • Treatment process • Stages of treatment • Appropriateness • Services process • Examples • Use of efficacious therapy • Use of diagnostic tests • Use of procedures • Treatment delays (incl. wait times) • Outcomes • Death • Adverse events • Readmissions to hospital • Resource use (costs, length of stay in hospital) • Patient satisfaction with care • Quality of life • Patient ability to function in daily activities

29. Process Elements • Typically pertain to: • A defined population • Age group • Gender • Chronic disease • Health status • Screening and preventative care • Chronic disease management • Can generally be measured by using claims data • Member and dependant data • Tariff codes • Chronic disease statuses will be required

30. Quality Dimensions • Structural Elements • Characteristics of: • Community • Institution • Provider • Patient • Examples • Geographic location of facility • Availability of technologies • Hospital size • Provider qualifications • Process Elements • Treatment process • Stages of treatment • Appropriateness • Services process • Examples • Use of efficacious therapy • Use of diagnostic tests • Use of procedures • Treatment delays (incl. wait times) • Outcomes • Death • Adverse events • Readmissions to hospital • Resource use (costs, length of stay in hospital) • Patient satisfaction with care • Quality of life • Patient ability to function in daily activities

31. Outcomes Elements • Many would regard this as the holy grail • Accuracy is limited by availability and detail of diagnostic data (ICD) • Condition-specific admissions • All cause admissions • Some proxy measures are feasible in our imperfect world • Re-admissions • Lengths of stay

32. Areas for quality improvement • Numbers of children who are fully immunised • Proportions of patients who are at risk that are screened • Proportions of patients with chronic diseases that are screened for complications • Adherence to clinical best practice with respect to the management of diseases • Quantifying potential under-, mis- or overuse Source: NCQA

33. HQA Results

34. HQA Results

35. HQA Results

36. HQA Results

37. Benchmarking

38. Conclusion • It is essential to measure healthcare quality in order to: • Better understand value • Facilitate improvement over time • Create a system that promotes best clinical standards • Strive toward the measurement of outcomes • Care should be taken not to over-complicate matters and to start with the “basics” • The “basics” are possible even within the data constraints that we are facing

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