Quality in Health Care: Building Systemic Capacity

1. Quality in Health Care:Building Systemic Capacity Sheila Leatherman Adjunct Professor, University of North Carolina Sr. Associate, University of Cambridge, England

2. Seminar Outline • What is the state of quality? • Building Systemic Capacity: A Model • Change: Strategy and Methods • Accountability and Public Reporting • The Way Forward

3. Ireland Health Strategy PRINCIPLES • Equity • People-centeredness • Quality • Accountability

4. Ireland Health Strategy NATIONAL GOALS • Better health for everyone • Fair access • Responsive and appropriate care • High performance

5. Quality “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” IOM Definition 1999

6. Concerns Regarding Quality Physician Perceptions (1999-2000) • 5 country survey (Australia, NZ, UK, Canada, and USA) • % saying ability to provide quality care • worsened over 5 years • Australia 38% • Canada 50% • New Zealand 53% • United Kingdom 46% • United States 57%

7. Concerns Regarding Quality Nurses Perceptions (1998-1999) • 5 country survey (Canada, Germany, Scotland, England and USA) • 17-44% reported quality had deteriorated in last year

8. Concerns Regarding Quality Public Perception (1998) • 5 country survey ( Australia, Canada, NZ, UK, and USA) • Overwhelmingly stated that health care system needed “fundamental change or complete overhaul”

9. 1998 American Consumer Satisfaction Index Hospitals ranked between the U.S. Post Office and the Internal Revenue Service (tax agency)

10. Performance Domains • Effectiveness • Efficiency • Equity/Access • Safety • Responsiveness/Patient-Centered Applicable at individual and population level

11. Concerns Regarding Quality: Hard Facts • Inappropriate use of resources • US data indicates overuse and underuse • Unexplained variation/postcode lottery • Safety/Adverse events • Adverse event rate 10% of hospitals (UK and USA) • Serious errors 2.3% • 16.6% of hospital admissions in Australia (1995)

12. Poor resource use Financial risk Suboptimal Quality • Adverse events cost USA 4% of total health expenditures; 1996 • Outstanding claims for alleged clinical negligence in UK was £3.9 billion

13. What is needed? • “Will” to address problems • Articulated national policy • Incentives • Priority setting • Performance monitoring capability • “Essential infrastructure • new organizations • legal framework • IT • Knowledge aids (protocols, DSS)

14. Building Systemic Capacity: A Model

15. National Policy Formulation & Infrastructure Regional Performance Monitoring Macromanagement Institutional Operations Management Governance Clinical Service Provision Individual Accountability Individual Organizing and Integrating Performance

16. Policy Formulation & Infrastructure Performance Monitoring Macromanagement Operations Management Governance Clinical Service Provision Individual Accountability Organizing and Integrating Quality

17. Policy Formulation & Infrastructure Performance Monitoring Macromanagement United States United Kingdom Operations Management Governance Clinical Service Provision Individual Accountability Organizing and Integrating Performance

18. Policy Formulation & Infrastructure Performance Monitoring Macromanagement Operations Management Governance Clinical Service Provision Individual Accountability Ireland

19. Effecting Change: Strategy and Methods

20. Methods for Improving QualityApplications and Uses of Performance Data • External Oversight • External review/inspection • Accreditation, licensing and certification • Setting performance targets • Knowledge/Skill enhancement • of providers • Peer review and data feedback • Use of guidelines and protocols • Incentives • Financial (pay-for-performance) • Non-financial • Patient engagement/empowering • consumers • Providing performance information • Enacting patient charters/patient • rights legislation • Regulations • Government regulations • Professional/self regulation

21. External Oversight • External review/inspection • Accreditation, licensing and certification • Setting performance targets

22. Patient Engagement/ Empowering Consumers • Providing performance information • Enacting patient charters/patient rights legislation

23. Regulations • Government regulations • Professional/self regulation

24. Incentives • Financial (pay-for-performance) • Non-financial

25. Knowledge/Skill Enhancement • Peer review and data feedback • Use of guidelines and protocols

26. Knowledge/Skill Enhancement Problem • Both WILL and SKILL problems • Impossibility to assimilate new knowledge • Numbers of articles published from RCTs • 1960 1000 annually • 1990 10,000 annually • Use of Performance Data • Scant evidence that physicians can/will use for behavior change • Evidence that multiple interventions are needed • Published protocols/guidelines • Computer assisted decision support • Peer review/practice comparisons

27. Strategy for Improving Performance

28. Drivers of Performance

29. Accountability and Public Reporting

30. What? The systematic standardized measurement of performance and public disclosure of data • Performance Domains (individual and/or population level) • Effectiveness • Efficiency • Responsiveness • Equity • Safety

31. Performance Reporting: Why? • Unjustified variation/ “postcode lottery” • Accountability a growing movement • Performance monitoring needed for regulation • “The Information Age” • Public confidence eroding

32. Principle Purposes for Public Disclosure • Regulation (include public accountability) • Purchasing or commissioning decisions • Facilitation of consumer selection/choice • Provider/systems behavior change

33. Performance Reporting • National Quality Reports • “Report Cards” • League Tables • Provider profiling

34. Current Status • Measurement and public reporting inevitable • Inadequate evaluation research - what works? • Challenge: How to move ahead responsibly

35. Evidence of Effectiveness of Performance Reporting: USA • Public • Provider • Purchaser/payers • Policymakers

36. The PublicEvidence from the USA • Performance data used minimally • Not meaningful to “the public” • Most data designed for other purposes • Not easily comprehended or actionable • Not salient (example: CABG mortality rates) • Not motivated - individuals believe their care/provider is “good”

37. The ProvidersEvidence from the USA • Institutions (hospitals, systems) do pay attention and use: • To improve appropriateness of care • To identify poor performers • To alter processes responsive to complaints • Individual providers less responsive to data

38. Major Question: Public or Confidential Reporting of Performance DataCase Study: Reporting System in New York • Publicly reported risk-adjusted mortality past CABG • New York had the lowest risk-adjusted mortality rate in the USA after 4 years. • First 3 years mortality rate fell 41% • Rate of decline in New York was twice the average national rate of decline in first 5 years

39. Major Question: Public or Confidential Reporting of Performance DataCase Study: Reporting System in New York New York CRS: What drove the improvement? • Improvement driven through actions taken by hospital staff • Changes in leadership • curtailment of operating privileges • Intensive peer review • Consumer or market force: minimal action BUT ….WAS PUBLIC DISCLOSURE THE DRIVER?

40. Purchasers/Payers/CommissionersEvidence from the USA • Little evidence of performance to exercise “market clout” • Two large studies (15,000 employers nation wide) • Data used minimally • Price still main selection factor • Data suffers as not designed for buyer decision-makers. • Reliance on purchasers and payers to use performance data not a reliable strategy

41. Policymakers • Some evidence that policymakers do use comparative performance indicators • New national initiatives in Australia, United Kingdom and United States for national performance reporting

42. Risks and Challenges • Methodologic issues • Manipulation of data • “Tunnel vision” • Unintended effects on access • Erode patient trust • Jeopardize QI environment

43. Conception Domain Methods of patients of accountability ProfessionalRecipient of Patient, physician Licensure, Certification prof. services Prof. Association Malpractice suit EconomicConsumer of Marketplace and Choice and “exit” health care regulation Commodity PoliticalCitizen Government “Voice” and receiving reforms and government pressure public good actions Adapted from Emanuel and Emanuel Annals of Internal Medicine, Jan 15, 1996 Accountability: Models

44. The Way Forward: Common Pitfalls

45. Common Pitfalls • Confusion • Role of government regulation and self-regulation • Too Ambitious • Too many new initiatives • Too many goals/targets • Lack of coherence • Inadequate resources • “Will” • “Skill” • Infrastructure • IT • Workforce • Infrastructure/capacity • Rhetoric exceeds reality • Cynicism, • Failure to deliver

46. Knowing is not enough, we must apply Willing is not enough, we must do. Goethe

47. Conception Domain Methods of patients of accountability ProfessionalRecipient of Patient, physician Licensure, Certification prof. services Prof. Association Malpractice suit EconomicConsumer of Marketplace and Choice and “exit” health care regulation Commodity PoliticalCitizen Government “Voice” and receiving reforms and government pressure public good actions Adapted from Emanuel and Emanuel Annals of Internal Medicine, Jan 15, 1996 Accountability: Models

48. Policy Formulation & Infrastructure Performance Monitoring Macromanagement Operations Management Governance Clinical Service Provision Individual Accountability

49. Key Strategies

50. Drivers of Performance