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Developing measures to manage quality and safety in integrated care in New Zealand. Tom Love. 14 November 2013. Why are you measuring stuff?. Q uality improvement? Performance management? What do you want to do with measures? Peer review and professional development?
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Developing measures to manage quality and safety in integrated care in New Zealand Tom Love 14 November 2013
Why are you measuring stuff? • Quality improvement? • Performance management? What do you want to do with measures? • Peer review and professional development? • Service development and integration? • Are measures linked to incentives/sanctions? For whom? • Linked to public information and reporting? • Linked to access to services?
Measuring performance: some general points • Different kinds of activity have different kinds of characteristics for observing performance; • There are different inherent limitations to what you can observe for different kinds of activity.
Key points • Outcomes are intellectually desirable measures, but there is often good reason why you can’t or shouldn’t measure them; • The nature of knowledge and evidence around health care activity is highly variable, constantly changing, and often disputed; • Services are often provided to an individual, and it is hard to know what the counterfactual would have been; • At the individual level, numbers can be too small to provide robust statistics.
Back to why measuring? • Both of: • Quality improvement • Performance management • In different ways at different levels • Decentralised: quality improvement among professionals, both individually and in multidisciplinary teams; • Central view: performance management across the system and its components: the system isn’t working well unless the whole system is working well.
We don’t live in a vacuum • Lots of quality improvement goes on throughout the sector • But we suspect that clinical governance may be patchy, done better in some places than in others • A fair bit of performance management goes on throughout the sector • But we suspect that it could be better aligned to quality improvement and integration
So…. • Need to: • observe systems and processes across the complex system; • have good information across the system; • encourage reflection and learning across the system. • While: • promoting individual professional participation in safety and quality improvement activities; • and collaborative development of integrated services in a way which improves a number of things, including quality and safety.
What to measure, and who does it? • System measures • Responsibility across the District for elements of those measures. • A system isn’t good unless all of its components contribute • Nationally defined • Based upon HQSC Triple Aim, with capacity/capability element • An impetus towards integration • Contributory measures for improvement • Largely locally determined (from a menu, which provides some definition and advise about how to manage the relevant information) • Improvement measures should be chosen to contribute towards the goals captured in the system measures, but should reflect local priorities for doing so.
Constructing measures • System measures • Small number, nationally determined • Several life-cycle based, some capability based • Composite measures • Mixture of outcomes and outputs • Used to assess performance of systems at District, and potentially regional level • Improvement measures • Large number, locally chosen through alliances • Largely process/activity measures for local quality improvement • Some elements of quality assurance: RNZCGP Foundation Standards • Alliances are the engine
Examples of measures • System measure: Supported end of life • Composite of: • Percentage deaths in usual place of residence • Average number of hospital days in the last six months of life • Average number of urgent ambulance transfers in the last six months of life • Contributory measures: • Number of advanced care directives in place • Pain intensity quantified • Plan of care for pain • Aperients/laxatives initiated in patients on opioids • Polypharmacy
What do we expect to happen? • Promote integration through: • Clear articulation of what constitutes good health care across the system; • Joint accountability across all participants of the system for achieving good services; • Promote quality improvement through: • Building on alliance structures to identify local priorities and areas for quality improvement and service development; • Consistent expectations about capacity and capability of quality improvement activities;
Squaring the circle: • Addressing the dilemma of: • Undertaking performance measurement… • While supporting quality improvement… • While encouraging local collaboration • In a complex environment with limited direct levers for control. • There is no perfect answer to achieving these different goals at the same time, but there are better and worse trade-offs between them.