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Wikipedia

Health care quality

January 29, 2023

Health care quality is a level of value provided by any health care resource, as determined by some measurement. As with quality in other fields, it is an assessment of whether something is good enough and whether it is suitable for its purpose. The goal of health care is to provide medical resources of high quality to all who need them; that is, to ensure good quality of life, cure illnesses when possible, to extend life expectancy, and so on. Researchers use a variety of quality measures to attempt to determine health care quality, including counts of a therapy's reduction or lessening of diseases identified by medical diagnosis, a decrease in the number of risk factors which people have following preventive care, or a survey of health indicators in a population who are accessing certain kinds of care.

Definition

Health care quality is the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes.[1] Quality of care plays an important role in describing the iron triangle of health care relationships between quality, cost, and accessibility of health care within a community.[2] Researchers measure health care quality to identify problems caused by overuse, underuse, or misuse of health resources.[3] In 1999, the Institute of Medicine released six domains to measure and describe quality of care in health:[4]

  1. safe – avoiding injuries to patients from care that is intended to help them
  2. effective – avoiding overuse and misuse of care
  3. patient-Centered – providing care that is unique to a patient's needs
  4. timely – reducing wait times and harmful delays for patients and providers
  5. efficient – avoiding waste of equipment, supplies, ideas and energy
  6. equitable – providing care that does not vary across intrinsic personal characteristics

While essential for determining the effect of health services research interventions, measuring quality of care poses some challenges due to the limited number of outcomes that are measurable.[5] Structural measures describe the providers' ability to provide high quality care, process measures describe the actions taken to maintain or improve community health, and outcome measures describe the impact of a health care intervention.[5] Furthermore, due to strict regulations placed on health services research, data sources are not always complete.[6]

Assessment of health care quality may occur on two different levels: that of the individual patient and that of populations. At the level of the individual patient, or micro-level, assessment focuses on services at the point of delivery and its subsequent effects. At the population level, or macro-level, assessments of health care quality include indicators such as life expectancy, infant mortality rates, incidence, and prevalence of certain health conditions.[7]

Quality assessments measure these indicators against an established standard. The measures can be difficult to define in health care.[8]

Methods to assess and improve

The Donabedian model is a common framework for assessing health care quality and identifies three domains in which health care quality can be assessed: structure, process, and outcomes.[9] All three domains are tightly linked and build on each other. Improvements in structure and process are often observed in outcomes. Some examples of improvements in process are: clinical practice guidelines, analysis of cost efficiency, and risk management, which consists of proactive steps to prevent medical errors.

Cost Efficiency Cost Efficiency, or cost-effectiveness, determines whether the benefits of a service exceed the cost incurred to provide the service.[7] A health care service is sometimes not cost efficient due to either overutilization or underutilization. Overutilization, or overuse, occurs when the value of health care is diluted with wasted resources. Consequently, depriving someone else of the potential benefits from obtaining the service. Costs or risks of treatment outweigh the benefits in overused health care. In contrast, underutilization, or underuse, occurs when the benefits of a treatment outweigh the risks or costs, but it is not used.[7] There are potential adverse health outcomes with underutilization. One example is the lack of early cancer detection and treatment which leads to decreased cancer survival rates.

Critical Pathways Critical Pathways are outcome-based and patient-centered case management tools that take on an interdisciplinary approach by "facilitating coordination of care among multiple clinical departments and caregivers".[7] Health care managers utilize critical pathways as a method to reduce variation in care, decrease resource utilization, and improve quality of care.[10] Using critical pathways to reduce costs and errors improves quality by providing a systematic approach to assessing health care outcomes. Reducing variations in practice patterns promotes improved collaboration among interdisciplinary players in the health care system.[7]

Health professional perspective

The quality of the health care given by a health professional can be judged by its outcome, the technical performance of the care and by interpersonal relationships.[11]

"Outcome" is a change in patients' health, such as reduction in pain,[12] relapses,[13] or death rates.[14] Large differences in outcomes can be measured for individual medical providers, and smaller differences can be measured by studying large groups, such as low- and high-volume doctors.[15] Significant initiatives to improve healthcare quality outcomes have been undertaken that include clinical practice guidelines, cost efficiency, critical pathways, and risk management.[7]

Clinical Practice Guideline "Technical performance" is the extent to which a health professional conformed to the best practices established by medical guidelines.[11] Clinical practice guidelines, or medical practice guidelines, are scientifically based protocols to assist providers in adopting a "best practice" approach in delivering care for a given health condition.[7] Standardizing the practice of medicine improves quality of care by concurrently promoting lower costs and better outcomes. The presumption is providers following medical guidelines are giving the best care and give the most hope of a good outcome.[11] Technical performance is judged from a quality perspective without regard to the actual outcome - so for example, if a physician gives care according to the guidelines but a patient's health does not improve, then by this measure, the quality of the "technical performance" is still high.[11] For example, a Cochrane review found that computer generated reminders improved doctors' adherence to guidelines and standard of care; but lacked evidence to determine whether or not this actually impacted patient centered health outcomes.[16]

Risk Management Risk management consists of "proactive efforts to prevent adverse events related to clinical care" and is focused on avoiding medical malpractice.[7] Health care professionals are not immune to lawsuits; therefore, health care organizations have taken initiatives to establish protocols specifically to reduce malpractice litigation.[7] Malpractice concerns can result in defensive medicine, or threat of malpractice litigation, which can compromise patient safety and care by inducing additional testing or treatments. One widely used form of defensive medicine is ordering costly imaging which can be wasteful. However, other defensive behaviors may actually reduce access to care and pose risks of physical harm.[17] Many specialty physicians report doing more for patients, such as using unnecessary diagnostic tests, because of malpractice risks.[17] In turn, it is especially crucial that risk management approaches employ principles of cost efficiency with standardized practice guidelines and critical pathways.[7]

Patient perspective

Patient satisfaction surveys are the main qualitative measure of the patient perspective. Patients may not have the clinical judgement of physicians and often judge quality on the basis of practitioner's concern and demeanor, among other things.[18] As a result, patient satisfaction surveys have become a somewhat controversial measure of quality care. Proponents argue that patient surveys can provide needed feedback to physicians to assist on improving their practice. In addition, patient satisfaction often correlates with patient involvement in decision making and can improve patient-centered care. Patients' evaluation of care can identify opportunities for improvement in care, reducing costs, monitoring performance of health plans, and provide a comparison across health care institutions.[19] Opponents of patient satisfaction surveys are often unconvinced that the data is reliable, that the expense does not justify the costs, and that what is measured is not a good indicator of quality.[20]

The Department of Health and Human Services bases 30 percent of hospitals' Medicare reimbursement on patient satisfaction survey scores on a survey, known as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).[21] "Beginning in October 2012, the Affordable Care Act implemented a policy that withholds 1 percent of total Medicare reimbursements—approximately $850 million—from hospitals (that percentage will double in 2017). Each year, only hospitals with high patient-satisfaction scores and a measure of certain basic care standards will earn that money back, and top performers receive bonuses from the pool."[22]

Technology and security perspective

Technology also may affect patients' perception of health care quality.[23] A 2015 survey of cancer patients shows that those who have a more positive attitude towards the health information tools from their providers use the tools more and subsequently have a higher perceived care quality from their provider. The same survey also shows that those who believe their provider acts more securely and have a lower level of privacy concern are more likely to have a positive attitude towards the health information tools from their providers and thus a higher perception of the care they received.

History in the United States

As early as the 19th century, healthcare quality improvement interventions were implemented in an effort to improve healthcare outcomes.[24] Healthcare quality improvement further developed in the 1900s, with notable improvements for the modern field of quality improvement taking place in the late 1960s.

In the early 1900s, Dr. Ernest Codman of Massachusetts General Hospital suggested a measure that tracked each patient of the hospital to determine effectiveness of their treatment. His proposal of a system to track patient care to determine quality and standard of hospital care dubbed him one of the earliest advocates of healthcare quality.[25] Shortly after, influenced by the work of Dr. Codman, the American College of Surgeons (ACS) was founded. In 1918, the ACS developed the Minimum Standard for Hospitals, which was one page. As a result of the 1918 Minimum Standard for Hospitals, ACS began performing on-site inspections of hospitals to determine if they were up to par. During the first on-site inspections of 692 hospitals, only 13% met the minimum standard.[25]

In 1945, Joseph Juran and Edwards Deming established Quality Improvement (QI) as a formal approach to analyzing systematic efforts to improve performance.[25] Specifically, Deming, a philosopher, placed emphasis on the macro level of organizational management and improvement via a systems approach. Juran, on the other hand, strategized quality planning, control, and improvement at the micro level. He encouraged questions, believing they deepened understanding of problems and led to increased effectiveness in planning and taking action. Together, their work influenced quality of both American public and private organizations in fields from healthcare and industry to government and education.

The Joint Commission on Accreditation of Hospitals (JCAH) was established in 1951 as an independent and non-profit organization that provided voluntary accreditation to hospitals that met minimum quality standards.[26] JCAH was formed by the combined forces of the American College of Physicians, the American College of Surgeons, the American Hospital Association, the American Medical Association, and the Canadian Medical Association. In 1952, the ACS formally transferred its Hospital Standardization Program to JCAH. JCAH began to charge a fee for surveys in 1964.

The Social Security Amendments of 1965 were passed by Congress in an attempt to grant hospitals accredited by JCAH "deemed status". As such, those same hospitals were said to meet the necessary requirements to participate in Medicare and Medicaid.[26] Until 1966, when Avedis Donabedian, MD published his "Evaluating the Quality of Medical Care", the study of health care quality was based on structure (e.g., licensing, staffing levels, accreditation). Donabedian demonstrated a new perspective on analyzing healthcare quality that was based on structure, process, and outcome.[25]

The National Academy of Sciences established the Institute of Medicine (IOM) in 1970. The IOM, a non-profit and independent scientific advisor, was created to improve health on a national scale. The Accreditation Association for Ambulatory Health Care (AAAHC) formed in 1970 to improve healthcare quality for patients served by ambulatory health care organizations by setting standards for ambulatory healthcare accreditation, similar to JCAH. The Agency for Healthcare Research and Quality (AHRQ) was created in 1989 in order to improve quality, safety, efficiency, and effectiveness of health care through research.

In 1990, the National Committee for Quality Assurance (NCQA) was entrusted to offer accreditation programs for managed care organizations. The NCQA was established as an independent non-profit dedicated to improving health care quality through accreditation and performance measurement.[27] In 1991, Dr. Don Berwick's non-profit Institute for Healthcare Improvement (IHI) was founded. Rather than only focus on national health care quality improvement, IHI campaigned but nationally and worldwide. Directing the focus onto the patient as a consumer, the National Patient Safety Foundation was established in 1996. In 1998, by presidential directive, the Quality Interagency Coordination Task Force (QuIC) was created to increase coordination of federal agencies that work toward improving quality care.[25] When the IOM published To Err is Human in 1999, revealing high medical error mortality rates, the QuIC published a report that inventoried regulatory and legislative initiatives that sought to improve issues surrounding medical error. Also in 1999, the National Quality Forum was founded. The private, non-profit forum aims to standardize health care delivery and measurements of quality.[28] In response to the patient safety concerns discussed in To Err is Human, the United States enacted the Patient Safety and Quality Improvement Act in 2005.

More recently, the focus of quality improvement has been emerging health information technology (e.g., electronic health records and patient-centered care.[citation needed] As a result, the formation of Patient-Centered Medical Homes (PCMH) began to gain popularity in 2007. Under PCMH, care among personal primary care physicians and specialists increased coordination and integration of care for the patient. Furthermore, technology was used to maintain personal health information and enhance quality and safety. Since 2007, various studies have demonstrated the wide array of benefits of PCMHs in healthcare quality improvement.[citation needed]

Organizations which determine quality

Organizations which work to set standards and measures for health care quality include Government health systems; private health systems, accreditation programs such as those for hospital accreditation, health associations, or those who wish to establish international healthcare accreditation; philanthropic foundations; and health research institutions.[29] These organizations seek to define the concept of quality in healthcare, measure that quality, and then encourage the regular measurement of quality so as to provide evidence that health interventions are effective.[29]

In the United States

Multiple organizations have established measures to define quality since providers, patients and payers have different views and expectations of quality. This complex situation creates a challenge because most often the measures of quality are not comparable across organizations and there are issues of transferability and merging across systems.[7] Consequently, while measuring health care quality for these reasons, high quality longitudinal provides a substantive framework from which health services researchers can work.

The Centers for Medicare and Medicaid Services (CMS) designs quality evaluations, collects quality, and manages funding for the central government Medicare and Medicaid programs.[30] In 2001, CMS started multiple quality initiatives including, but not limited to: the Home Health Quality Initiative, the Hospital Value-based Purchasing Program, the Hospice Quality Reporting Program, the Inpatient Rehabilitation Facilities Quality Reporting, and the Long-Term Care Hospitals Quality Reporting.[31] CMS established initiatives to measure and improve the quality of care for Medicaid and CHIP beneficiaries for services provided under the umbrella of Early Periodic Screening, Diagnosis, and Treatment Program (EPSDT), including maternal and infant health, home and community-based services, preventative care, health disparities, patient safety, external quality review, and improving care transitions.[30] For broader quality control, CMS also created Hospital Compare, which is a large public reporting program that measures and also reports processes of care and outcomes for various health care interventions including heart failure, pneumonia, and acute myocardial infarction.[32]

The Agency for Healthcare Research and Quality (AHRQ) is a central government organization which collects public reports of health quality evaluation to increase the safety and quality of health care. AHRQ works together with the United States Department of Health and Human Services to make ensure that evidence is understood and used by the medical communities to elevate the quality of care.[33] To fulfill its mission, AHRQ contracts with several subsites.

CMS and AHRQ have collectively established the Hospital Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. The CAHPS survey collects uniform measures of patients' perspectives on various aspects of the care they receive in inpatient settings.[34] The results are published on the Hospital Compare website, which may be used by health care organizations and researchers to improve the quality of their services. Purchasers, consumers, and researchers may also use the data to make informed business choices.

The Joint Commission Accreditation for Healthcare Organization (JCAHO) is a nonprofit organization that assesses quality at multiple levels by inspecting health care facilities for adherence to clinical guidelines, compliance with rules and regulations for medical staff skills and qualifications, review of medical records to evaluate care processes and search for medical errors, and inspects buildings for safety code violations. JCAHO also provides feedback and opportunities for improvement, while simultaneously issuing citations for closures of facilities deemed noncompliant with set measures of quality standards.[35] howdy

In the United Kingdom

In the UK, healthcare is publicly funded and delivered through the National Health Service (NHS) and quality is overseen by a number of different bodies.[36] Monitor, a non-departmental public body sponsored by the Department of Health, is the sector regulator for health services in England. It works closely with the Care Quality Commission (CQC) a government-funded independent body responsible for overseeing the quality and safety of health and social care services in England, including hospitals, care homes, dental and GPs and other care services. The National Institute for Health and Care Research (NIHR) has a number of infrastructure programmes supporting quality in healthcare, including the Collaborations for Leadership in Applied Health Research and Care (CLAHRCs).[37]

Medical professions in the UK have their own membership and regulatory associations. These include the General Medical Council (GMC), the Nursing and Midwifery Council, the General Dental Council and the Health and Care Professions Council. Other healthcare quality organisations include the Healthcare Quality Improvement Partnership (HQIP), a charity and limited company established by the Academy of Medical Royal Colleges, the Royal College of Nursing, National Voices; and Healthwatch, a statutory national body that works with groups across the country to ensure that patients' views are at the heart of decisions about the healthcare system.

A number of health think tanks, including the King's Fund, the Nuffield Trust and the Health Foundation offer analysis, resources and commentary around healthcare quality. In 2013, the Nuffield Trust and the Health Foundation launched QualityWatch, an independent research programme tracking how healthcare quality in England is changing in response to rising remand and limited funding.[38]

In India

Healthcare quality efforts in India are beginning to gain strength. Some organizations involved in this work include the National Accreditation Board for Hospital & Healthcare providers (NABH), Patient Safety Alliance, ICHA and National Health Systems Resource Center (NHSRC). The All India Institute of Medical Sciences is also leading some of the healthcare quality work in India and in the SEARO region.

See also

References

  1. ^ "Understanding Quality Measurement". www.ahrq.gov. Retrieved 2016-11-21.
  2. ^ Carroll, Aaron; MD; MS (2012-10-03). "JAMA Forum — The "Iron Triangle" of Health Care: Access, Cost, and Quality". news@JAMA. Retrieved 2016-11-21.
  3. ^ Chassin, M. R. (1998). "The Urgent Need to Improve Health Care Quality: Institute of Medicine National Roundtable on Health Care Quality". JAMA: The Journal of the American Medical Association. 280 (11): 1000–1005. doi:10.1001/jama.280.11.1000. PMID 9749483.
  4. ^ Richardson, William C. (2000). (PDF). National Academy of Sciences. Archived from the original (PDF) on August 28, 2019. Retrieved November 20, 2016.
  5. ^ a b "Types of Quality Measures". www.ahrq.gov. Retrieved 2016-11-21.
  6. ^ (ASPA), Assistant Secretary for Public Affairs (2015-01-29). "Laws & Regulations". HHS.gov. Retrieved 2016-11-21.
  7. ^ a b c d e f g h i j k Shi L, Singh DA. Delivering Health Care in America: a Systems Approach. 6th ed. Sudbury, MA: Jones and Bartlett; 2015
  8. ^ Maxwell, R J (1984-05-12). "Quality assessment in health". British Medical Journal (Clinical Research Ed.). 288 (6428): 1470–1472. doi:10.1136/bmj.288.6428.1470. ISSN 0267-0623. PMC 1441041. PMID 6426606.
  9. ^ Donabedian, Avedis (1988-01-01). "Quality Assessment and Assurance: Unity of Purpose, Diversity of Means". Inquiry. 25 (1): 173–192. JSTOR 29771941. PMID 2966122.
  10. ^ Every NR, et al. (2000). ""Pathways " A Review. AHA Journal". Circulation. 101 (4): 461–465. doi:10.1161/01.CIR.101.4.461. PMID 10653841.
  11. ^ a b c d Donabedian, A (23 September 1988). "The quality of care. How can it be assessed?". JAMA: The Journal of the American Medical Association. 260 (12): 1743–8. doi:10.1001/jama.1988.03410120089033. PMID 3045356.
  12. ^ Lau, Rick (1986). "The role of surgeon volume on patient outcome in total knee arthroplasty: a systematic review of the literature". BMC Musculoskelet Disord. 20 (5): 1290–8. PMID 3534547.
  13. ^ Neumayer, LA (1992). "Proficiency of surgeons in inguinal hernia repair: effect of experience and age". Scand J Work Environ Health. 18 Suppl 1: 27–30. PMID 1357742.
  14. ^ Birkmeyer, JD (27 November 2003). "Surgeon volume and operative mortality in the United States". N Engl J Med. 349 (22): 2117–27. doi:10.1056/nejmsa035205. PMID 14645640. S2CID 15548566.
  15. ^ "Doctors Do Better when They Do Procedures Often". Retrieved 12 December 2014.
  16. ^ Arditi, Chantal; Rège-Walther, Myriam; Durieux, Pierre; Burnand, Bernard (2017-07-06). "Computer-generated reminders delivered on paper to healthcare professionals: effects on professional practice and healthcare outcomes". Cochrane Database of Systematic Reviews. 2017 (7): CD001175. doi:10.1002/14651858.cd001175.pub4. PMC 6483307. PMID 28681432.
  17. ^ a b Studdert DM, Mello MM, Sage WM, DesRoches CM, Peugh J, Zapert K, Brennan TA (2005). "Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice Environment". JAMA. 293 (21): 2609–2617. doi:10.1001/jama.293.21.2609. PMID 15928282.
  18. ^ Asadi-Lari, Mohsen; Tamburini, Marcello; Gray, David (2004-01-01). "Patients' needs, satisfaction, and health related quality of life: Towards a comprehensive model". Health and Quality of Life Outcomes. 2: 32. doi:10.1186/1477-7525-2-32. ISSN 1477-7525. PMC 471563. PMID 15225377.
  19. ^ Al-Abri, Rashid; Al-Balushi, Amina (2016-11-21). "Patient Satisfaction Survey as a Tool Towards Quality Improvement". Oman Medical Journal. 29 (1): 3–7. doi:10.5001/omj.2014.02. ISSN 1999-768X. PMC 3910415. PMID 24501659.
  20. ^ White, Brandi. "Measuring Patient Satisfaction: How to Do It and Why to Bother - Family Practice Management". www.aafp.org. Retrieved 2016-11-21.
  21. ^ "HCAHPS Hospital Survey". www.hcahpsonline.org. Retrieved 2016-11-21.
  22. ^ Robbins, Alexandra. "The Problem With Satisfied Patients". The Atlantic. Retrieved 2016-11-21.
  23. ^ Kisekka, Victoria; Giboney, Justin (2018). "The Effectiveness of Health Care Information Technologies: Evaluation of Trust, Security Beliefs, and Privacy as Determinants of Health Care Outcomes". Journal of Medical Internet Research. April (4): e107. doi:10.2196/jmir.9014. PMC 5917085. PMID 29643052.
  24. ^ Marjoua, Youssra; Bozic, Kevin J. (2012-09-09). "Brief history of quality movement in US healthcare". Current Reviews in Musculoskeletal Medicine. 5 (4): 265–273. doi:10.1007/s12178-012-9137-8. ISSN 1935-973X. PMC 3702754. PMID 22961204.
  25. ^ a b c d e "The Evolution of Quality and Safety in Healthcare". patientsafetyed.duhs.duke.edu. Retrieved 2016-11-21.
  26. ^ a b "The Joint Commission: Over a century of quality and safety" (PDF). Retrieved November 20, 2016.
  27. ^ "National Committee for Quality Assurance - NCQA". healthfinder.gov. Retrieved 2016-11-21.
  28. ^ Chassin, Mark R.; Loeb, Jerod M. (2011-04-01). "The Ongoing Quality Improvement Journey: Next Stop, High Reliability". Health Affairs. 30 (4): 559–568. doi:10.1377/hlthaff.2011.0076. ISSN 0278-2715. PMID 21471473.
  29. ^ a b Cleary, P. D. (1997). "Health Care Quality - Incorporating Consumer Perspectives". JAMA: The Journal of the American Medical Association. 278 (19): 1608–1612. doi:10.1001/jama.1997.03550190072047. PMID 9370508.
  30. ^ a b "Centers for Medicare and Medicaid Services". www.cms.gov. 2016-11-18. Retrieved 2016-11-21.
  31. ^ "Quality Initiatives General Information". www.cms.gov. 2016-02-08. Retrieved 2016-11-27.
  32. ^ "HospitalCompare". www.cms.gov. 2016-10-19. Retrieved 2016-11-27.
  33. ^ "AHRQ Mission & Budget". www.ahrq.gov. Retrieved 2016-11-21.
  34. ^ AHRQ (2014). "About CAHPS | cahps.ahrq.gov". cahps.ahrq.gov. Retrieved 13 June 2014.
  35. ^ "Top Performer on Key Quality Measures | Joint Commission". www.jointcommission.org. Retrieved 2016-11-21.
  36. ^ "Health watchdogs explained". NHS Choices. UK government. Retrieved 19 February 2015.
  37. ^ . www.nihr.ac.uk. Archived from the original on 2019-04-08. Retrieved 2017-11-07.
  38. ^ "QualityWatch". www.qualitywatch.org.uk/. Nuffield Trust and Health Foundation. Retrieved 19 February 2015.

Further reading

  • Mays, N.; Pope, C. (2000). "Qualitative research in health care: Assessing quality in qualitative research". BMJ. 320 (7226): 50–52. doi:10.1136/bmj.320.7226.50. PMC 1117321. PMID 10617534.
  • Lytle, R. S.; Mokwa, M. P. (1992). "Evaluating health care quality: The moderating role of outcomes". Journal of Health Care Marketing. 12 (1): 4–14. PMID 10116754.
  • Downs, S. H.; Black, N. (1998). "The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions". Journal of Epidemiology & Community Health. 52 (6): 377–384. doi:10.1136/jech.52.6.377. PMC 1756728. PMID 9764259.

January 29, 2023
health, care, quality, level, value, provided, health, care, resource, determined, some, measurement, with, quality, other, fields, assessment, whether, something, good, enough, whether, suitable, purpose, goal, health, care, provide, medical, resources, high,. Health care quality is a level of value provided by any health care resource as determined by some measurement As with quality in other fields it is an assessment of whether something is good enough and whether it is suitable for its purpose The goal of health care is to provide medical resources of high quality to all who need them that is to ensure good quality of life cure illnesses when possible to extend life expectancy and so on Researchers use a variety of quality measures to attempt to determine health care quality including counts of a therapy s reduction or lessening of diseases identified by medical diagnosis a decrease in the number of risk factors which people have following preventive care or a survey of health indicators in a population who are accessing certain kinds of care Contents 1 Definition 2 Methods to assess and improve 2 1 Health professional perspective 2 2 Patient perspective 2 3 Technology and security perspective 3 History in the United States 4 Organizations which determine quality 4 1 In the United States 4 2 In the United Kingdom 4 3 In India 5 See also 6 References 7 Further readingDefinition EditHealth care quality is the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes 1 Quality of care plays an important role in describing the iron triangle of health care relationships between quality cost and accessibility of health care within a community 2 Researchers measure health care quality to identify problems caused by overuse underuse or misuse of health resources 3 In 1999 the Institute of Medicine released six domains to measure and describe quality of care in health 4 safe avoiding injuries to patients from care that is intended to help them effective avoiding overuse and misuse of care patient Centered providing care that is unique to a patient s needs timely reducing wait times and harmful delays for patients and providers efficient avoiding waste of equipment supplies ideas and energy equitable providing care that does not vary across intrinsic personal characteristicsWhile essential for determining the effect of health services research interventions measuring quality of care poses some challenges due to the limited number of outcomes that are measurable 5 Structural measures describe the providers ability to provide high quality care process measures describe the actions taken to maintain or improve community health and outcome measures describe the impact of a health care intervention 5 Furthermore due to strict regulations placed on health services research data sources are not always complete 6 Assessment of health care quality may occur on two different levels that of the individual patient and that of populations At the level of the individual patient or micro level assessment focuses on services at the point of delivery and its subsequent effects At the population level or macro level assessments of health care quality include indicators such as life expectancy infant mortality rates incidence and prevalence of certain health conditions 7 Quality assessments measure these indicators against an established standard The measures can be difficult to define in health care 8 Methods to assess and improve EditThe Donabedian model is a common framework for assessing health care quality and identifies three domains in which health care quality can be assessed structure process and outcomes 9 All three domains are tightly linked and build on each other Improvements in structure and process are often observed in outcomes Some examples of improvements in process are clinical practice guidelines analysis of cost efficiency and risk management which consists of proactive steps to prevent medical errors Cost Efficiency Cost Efficiency or cost effectiveness determines whether the benefits of a service exceed the cost incurred to provide the service 7 A health care service is sometimes not cost efficient due to either overutilization or underutilization Overutilization or overuse occurs when the value of health care is diluted with wasted resources Consequently depriving someone else of the potential benefits from obtaining the service Costs or risks of treatment outweigh the benefits in overused health care In contrast underutilization or underuse occurs when the benefits of a treatment outweigh the risks or costs but it is not used 7 There are potential adverse health outcomes with underutilization One example is the lack of early cancer detection and treatment which leads to decreased cancer survival rates Critical Pathways Critical Pathways are outcome based and patient centered case management tools that take on an interdisciplinary approach by facilitating coordination of care among multiple clinical departments and caregivers 7 Health care managers utilize critical pathways as a method to reduce variation in care decrease resource utilization and improve quality of care 10 Using critical pathways to reduce costs and errors improves quality by providing a systematic approach to assessing health care outcomes Reducing variations in practice patterns promotes improved collaboration among interdisciplinary players in the health care system 7 Health professional perspective Edit The quality of the health care given by a health professional can be judged by its outcome the technical performance of the care and by interpersonal relationships 11 Outcome is a change in patients health such as reduction in pain 12 relapses 13 or death rates 14 Large differences in outcomes can be measured for individual medical providers and smaller differences can be measured by studying large groups such as low and high volume doctors 15 Significant initiatives to improve healthcare quality outcomes have been undertaken that include clinical practice guidelines cost efficiency critical pathways and risk management 7 Clinical Practice Guideline Technical performance is the extent to which a health professional conformed to the best practices established by medical guidelines 11 Clinical practice guidelines or medical practice guidelines are scientifically based protocols to assist providers in adopting a best practice approach in delivering care for a given health condition 7 Standardizing the practice of medicine improves quality of care by concurrently promoting lower costs and better outcomes The presumption is providers following medical guidelines are giving the best care and give the most hope of a good outcome 11 Technical performance is judged from a quality perspective without regard to the actual outcome so for example if a physician gives care according to the guidelines but a patient s health does not improve then by this measure the quality of the technical performance is still high 11 For example a Cochrane review found that computer generated reminders improved doctors adherence to guidelines and standard of care but lacked evidence to determine whether or not this actually impacted patient centered health outcomes 16 Risk Management Risk management consists of proactive efforts to prevent adverse events related to clinical care and is focused on avoiding medical malpractice 7 Health care professionals are not immune to lawsuits therefore health care organizations have taken initiatives to establish protocols specifically to reduce malpractice litigation 7 Malpractice concerns can result in defensive medicine or threat of malpractice litigation which can compromise patient safety and care by inducing additional testing or treatments One widely used form of defensive medicine is ordering costly imaging which can be wasteful However other defensive behaviors may actually reduce access to care and pose risks of physical harm 17 Many specialty physicians report doing more for patients such as using unnecessary diagnostic tests because of malpractice risks 17 In turn it is especially crucial that risk management approaches employ principles of cost efficiency with standardized practice guidelines and critical pathways 7 Patient perspective Edit Patient satisfaction surveys are the main qualitative measure of the patient perspective Patients may not have the clinical judgement of physicians and often judge quality on the basis of practitioner s concern and demeanor among other things 18 As a result patient satisfaction surveys have become a somewhat controversial measure of quality care Proponents argue that patient surveys can provide needed feedback to physicians to assist on improving their practice In addition patient satisfaction often correlates with patient involvement in decision making and can improve patient centered care Patients evaluation of care can identify opportunities for improvement in care reducing costs monitoring performance of health plans and provide a comparison across health care institutions 19 Opponents of patient satisfaction surveys are often unconvinced that the data is reliable that the expense does not justify the costs and that what is measured is not a good indicator of quality 20 The Department of Health and Human Services bases 30 percent of hospitals Medicare reimbursement on patient satisfaction survey scores on a survey known as the Hospital Consumer Assessment of Healthcare Providers and Systems HCAHPS 21 Beginning in October 2012 the Affordable Care Act implemented a policy that withholds 1 percent of total Medicare reimbursements approximately 850 million from hospitals that percentage will double in 2017 Each year only hospitals with high patient satisfaction scores and a measure of certain basic care standards will earn that money back and top performers receive bonuses from the pool 22 Technology and security perspective Edit Technology also may affect patients perception of health care quality 23 A 2015 survey of cancer patients shows that those who have a more positive attitude towards the health information tools from their providers use the tools more and subsequently have a higher perceived care quality from their provider The same survey also shows that those who believe their provider acts more securely and have a lower level of privacy concern are more likely to have a positive attitude towards the health information tools from their providers and thus a higher perception of the care they received History in the United States EditAs early as the 19th century healthcare quality improvement interventions were implemented in an effort to improve healthcare outcomes 24 Healthcare quality improvement further developed in the 1900s with notable improvements for the modern field of quality improvement taking place in the late 1960s In the early 1900s Dr Ernest Codman of Massachusetts General Hospital suggested a measure that tracked each patient of the hospital to determine effectiveness of their treatment His proposal of a system to track patient care to determine quality and standard of hospital care dubbed him one of the earliest advocates of healthcare quality 25 Shortly after influenced by the work of Dr Codman the American College of Surgeons ACS was founded In 1918 the ACS developed the Minimum Standard for Hospitals which was one page As a result of the 1918 Minimum Standard for Hospitals ACS began performing on site inspections of hospitals to determine if they were up to par During the first on site inspections of 692 hospitals only 13 met the minimum standard 25 In 1945 Joseph Juran and Edwards Deming established Quality Improvement QI as a formal approach to analyzing systematic efforts to improve performance 25 Specifically Deming a philosopher placed emphasis on the macro level of organizational management and improvement via a systems approach Juran on the other hand strategized quality planning control and improvement at the micro level He encouraged questions believing they deepened understanding of problems and led to increased effectiveness in planning and taking action Together their work influenced quality of both American public and private organizations in fields from healthcare and industry to government and education The Joint Commission on Accreditation of Hospitals JCAH was established in 1951 as an independent and non profit organization that provided voluntary accreditation to hospitals that met minimum quality standards 26 JCAH was formed by the combined forces of the American College of Physicians the American College of Surgeons the American Hospital Association the American Medical Association and the Canadian Medical Association In 1952 the ACS formally transferred its Hospital Standardization Program to JCAH JCAH began to charge a fee for surveys in 1964 The Social Security Amendments of 1965 were passed by Congress in an attempt to grant hospitals accredited by JCAH deemed status As such those same hospitals were said to meet the necessary requirements to participate in Medicare and Medicaid 26 Until 1966 when Avedis Donabedian MD published his Evaluating the Quality of Medical Care the study of health care quality was based on structure e g licensing staffing levels accreditation Donabedian demonstrated a new perspective on analyzing healthcare quality that was based on structure process and outcome 25 The National Academy of Sciences established the Institute of Medicine IOM in 1970 The IOM a non profit and independent scientific advisor was created to improve health on a national scale The Accreditation Association for Ambulatory Health Care AAAHC formed in 1970 to improve healthcare quality for patients served by ambulatory health care organizations by setting standards for ambulatory healthcare accreditation similar to JCAH The Agency for Healthcare Research and Quality AHRQ was created in 1989 in order to improve quality safety efficiency and effectiveness of health care through research In 1990 the National Committee for Quality Assurance NCQA was entrusted to offer accreditation programs for managed care organizations The NCQA was established as an independent non profit dedicated to improving health care quality through accreditation and performance measurement 27 In 1991 Dr Don Berwick s non profit Institute for Healthcare Improvement IHI was founded Rather than only focus on national health care quality improvement IHI campaigned but nationally and worldwide Directing the focus onto the patient as a consumer the National Patient Safety Foundation was established in 1996 In 1998 by presidential directive the Quality Interagency Coordination Task Force QuIC was created to increase coordination of federal agencies that work toward improving quality care 25 When the IOM published To Err is Human in 1999 revealing high medical error mortality rates the QuIC published a report that inventoried regulatory and legislative initiatives that sought to improve issues surrounding medical error Also in 1999 the National Quality Forum was founded The private non profit forum aims to standardize health care delivery and measurements of quality 28 In response to the patient safety concerns discussed in To Err is Human the United States enacted the Patient Safety and Quality Improvement Act in 2005 More recently the focus of quality improvement has been emerging health information technology e g electronic health records and patient centered care citation needed As a result the formation of Patient Centered Medical Homes PCMH began to gain popularity in 2007 Under PCMH care among personal primary care physicians and specialists increased coordination and integration of care for the patient Furthermore technology was used to maintain personal health information and enhance quality and safety Since 2007 various studies have demonstrated the wide array of benefits of PCMHs in healthcare quality improvement citation needed Organizations which determine quality EditOrganizations which work to set standards and measures for health care quality include Government health systems private health systems accreditation programs such as those for hospital accreditation health associations or those who wish to establish international healthcare accreditation philanthropic foundations and health research institutions 29 These organizations seek to define the concept of quality in healthcare measure that quality and then encourage the regular measurement of quality so as to provide evidence that health interventions are effective 29 In the United States Edit Multiple organizations have established measures to define quality since providers patients and payers have different views and expectations of quality This complex situation creates a challenge because most often the measures of quality are not comparable across organizations and there are issues of transferability and merging across systems 7 Consequently while measuring health care quality for these reasons high quality longitudinal provides a substantive framework from which health services researchers can work The Centers for Medicare and Medicaid Services CMS designs quality evaluations collects quality and manages funding for the central government Medicare and Medicaid programs 30 In 2001 CMS started multiple quality initiatives including but not limited to the Home Health Quality Initiative the Hospital Value based Purchasing Program the Hospice Quality Reporting Program the Inpatient Rehabilitation Facilities Quality Reporting and the Long Term Care Hospitals Quality Reporting 31 CMS established initiatives to measure and improve the quality of care for Medicaid and CHIP beneficiaries for services provided under the umbrella of Early Periodic Screening Diagnosis and Treatment Program EPSDT including maternal and infant health home and community based services preventative care health disparities patient safety external quality review and improving care transitions 30 For broader quality control CMS also created Hospital Compare which is a large public reporting program that measures and also reports processes of care and outcomes for various health care interventions including heart failure pneumonia and acute myocardial infarction 32 The Agency for Healthcare Research and Quality AHRQ is a central government organization which collects public reports of health quality evaluation to increase the safety and quality of health care AHRQ works together with the United States Department of Health and Human Services to make ensure that evidence is understood and used by the medical communities to elevate the quality of care 33 To fulfill its mission AHRQ contracts with several subsites CMS and AHRQ have collectively established the Hospital Consumer Assessment of Healthcare Providers and Systems CAHPS survey The CAHPS survey collects uniform measures of patients perspectives on various aspects of the care they receive in inpatient settings 34 The results are published on the Hospital Compare website which may be used by health care organizations and researchers to improve the quality of their services Purchasers consumers and researchers may also use the data to make informed business choices The Joint Commission Accreditation for Healthcare Organization JCAHO is a nonprofit organization that assesses quality at multiple levels by inspecting health care facilities for adherence to clinical guidelines compliance with rules and regulations for medical staff skills and qualifications review of medical records to evaluate care processes and search for medical errors and inspects buildings for safety code violations JCAHO also provides feedback and opportunities for improvement while simultaneously issuing citations for closures of facilities deemed noncompliant with set measures of quality standards 35 howdy In the United Kingdom Edit In the UK healthcare is publicly funded and delivered through the National Health Service NHS and quality is overseen by a number of different bodies 36 Monitor a non departmental public body sponsored by the Department of Health is the sector regulator for health services in England It works closely with the Care Quality Commission CQC a government funded independent body responsible for overseeing the quality and safety of health and social care services in England including hospitals care homes dental and GPs and other care services The National Institute for Health and Care Research NIHR has a number of infrastructure programmes supporting quality in healthcare including the Collaborations for Leadership in Applied Health Research and Care CLAHRCs 37 Medical professions in the UK have their own membership and regulatory associations These include the General Medical Council GMC the Nursing and Midwifery Council the General Dental Council and the Health and Care Professions Council Other healthcare quality organisations include the Healthcare Quality Improvement Partnership HQIP a charity and limited company established by the Academy of Medical Royal Colleges the Royal College of Nursing National Voices and Healthwatch a statutory national body that works with groups across the country to ensure that patients views are at the heart of decisions about the healthcare system A number of health think tanks including the King s Fund the Nuffield Trust and the Health Foundation offer analysis resources and commentary around healthcare quality In 2013 the Nuffield Trust and the Health Foundation launched QualityWatch an independent research programme tracking how healthcare quality in England is changing in response to rising remand and limited funding 38 In India Edit Healthcare quality efforts in India are beginning to gain strength Some organizations involved in this work include the National Accreditation Board for Hospital amp Healthcare providers NABH Patient Safety Alliance ICHA and National Health Systems Resource Center NHSRC The All India Institute of Medical Sciences is also leading some of the healthcare quality work in India and in the SEARO region See also EditEvaluation amp the Health Professions journal List of international healthcare accreditation organizationsReferences Edit Understanding Quality Measurement www ahrq gov Retrieved 2016 11 21 Carroll Aaron MD MS 2012 10 03 JAMA Forum The Iron Triangle of Health Care Access Cost and Quality news JAMA Retrieved 2016 11 21 Chassin M R 1998 The Urgent Need to Improve Health Care Quality Institute of Medicine National Roundtable on Health Care Quality JAMA The Journal of the American Medical Association 280 11 1000 1005 doi 10 1001 jama 280 11 1000 PMID 9749483 Richardson William C 2000 Crossing the Quality Chasm A New Health System for the 21st Century PDF National Academy of Sciences Archived from the original PDF on August 28 2019 Retrieved November 20 2016 a b Types of Quality Measures www ahrq gov Retrieved 2016 11 21 ASPA Assistant Secretary for Public Affairs 2015 01 29 Laws amp Regulations HHS gov Retrieved 2016 11 21 a b c d e f g h i j k Shi L Singh DA Delivering Health Care in America a Systems Approach 6th ed Sudbury MA Jones and Bartlett 2015 Maxwell R J 1984 05 12 Quality assessment in health British Medical Journal Clinical Research Ed 288 6428 1470 1472 doi 10 1136 bmj 288 6428 1470 ISSN 0267 0623 PMC 1441041 PMID 6426606 Donabedian Avedis 1988 01 01 Quality Assessment and Assurance Unity of Purpose Diversity of Means Inquiry 25 1 173 192 JSTOR 29771941 PMID 2966122 Every NR et al 2000 Pathways A Review AHA Journal Circulation 101 4 461 465 doi 10 1161 01 CIR 101 4 461 PMID 10653841 a b c d Donabedian A 23 September 1988 The quality of care How can it be assessed JAMA The Journal of the American Medical Association 260 12 1743 8 doi 10 1001 jama 1988 03410120089033 PMID 3045356 Lau Rick 1986 The role of surgeon volume on patient outcome in total knee arthroplasty a systematic review of the literature BMC Musculoskelet Disord 20 5 1290 8 PMID 3534547 Neumayer LA 1992 Proficiency of surgeons in inguinal hernia repair effect of experience and age Scand J Work Environ Health 18 Suppl 1 27 30 PMID 1357742 Birkmeyer JD 27 November 2003 Surgeon volume and operative mortality in the United States N Engl J Med 349 22 2117 27 doi 10 1056 nejmsa035205 PMID 14645640 S2CID 15548566 Doctors Do Better when They Do Procedures Often Retrieved 12 December 2014 Arditi Chantal Rege Walther Myriam Durieux Pierre Burnand Bernard 2017 07 06 Computer generated reminders delivered on paper to healthcare professionals effects on professional practice and healthcare outcomes Cochrane Database of Systematic Reviews 2017 7 CD001175 doi 10 1002 14651858 cd001175 pub4 PMC 6483307 PMID 28681432 a b Studdert DM Mello MM Sage WM DesRoches CM Peugh J Zapert K Brennan TA 2005 Defensive Medicine Among High Risk Specialist Physicians in a Volatile Malpractice Environment JAMA 293 21 2609 2617 doi 10 1001 jama 293 21 2609 PMID 15928282 Asadi Lari Mohsen Tamburini Marcello Gray David 2004 01 01 Patients needs satisfaction and health related quality of life Towards a comprehensive model Health and Quality of Life Outcomes 2 32 doi 10 1186 1477 7525 2 32 ISSN 1477 7525 PMC 471563 PMID 15225377 Al Abri Rashid Al Balushi Amina 2016 11 21 Patient Satisfaction Survey as a Tool Towards Quality Improvement Oman Medical Journal 29 1 3 7 doi 10 5001 omj 2014 02 ISSN 1999 768X PMC 3910415 PMID 24501659 White Brandi Measuring Patient Satisfaction How to Do It and Why to Bother Family Practice Management www aafp org Retrieved 2016 11 21 HCAHPS Hospital Survey www hcahpsonline org Retrieved 2016 11 21 Robbins Alexandra The Problem With Satisfied Patients The Atlantic Retrieved 2016 11 21 Kisekka Victoria Giboney Justin 2018 The Effectiveness of Health Care Information Technologies Evaluation of Trust Security Beliefs and Privacy as Determinants of Health Care Outcomes Journal of Medical Internet Research April 4 e107 doi 10 2196 jmir 9014 PMC 5917085 PMID 29643052 Marjoua Youssra Bozic Kevin J 2012 09 09 Brief history of quality movement in US healthcare Current Reviews in Musculoskeletal Medicine 5 4 265 273 doi 10 1007 s12178 012 9137 8 ISSN 1935 973X PMC 3702754 PMID 22961204 a b c d e The Evolution of Quality and Safety in Healthcare patientsafetyed duhs duke edu Retrieved 2016 11 21 a b The Joint Commission Over a century of quality and safety PDF Retrieved November 20 2016 National Committee for Quality Assurance NCQA healthfinder gov Retrieved 2016 11 21 Chassin Mark R Loeb Jerod M 2011 04 01 The Ongoing Quality Improvement Journey Next Stop High Reliability Health Affairs 30 4 559 568 doi 10 1377 hlthaff 2011 0076 ISSN 0278 2715 PMID 21471473 a b Cleary P D 1997 Health Care Quality Incorporating Consumer Perspectives JAMA The Journal of the American Medical Association 278 19 1608 1612 doi 10 1001 jama 1997 03550190072047 PMID 9370508 a b Centers for Medicare and Medicaid Services www cms gov 2016 11 18 Retrieved 2016 11 21 Quality Initiatives General Information www cms gov 2016 02 08 Retrieved 2016 11 27 HospitalCompare www cms gov 2016 10 19 Retrieved 2016 11 27 AHRQ Mission amp Budget www ahrq gov Retrieved 2016 11 21 AHRQ 2014 About CAHPS cahps ahrq gov cahps ahrq gov Retrieved 13 June 2014 Top Performer on Key Quality Measures Joint Commission www jointcommission org Retrieved 2016 11 21 Health watchdogs explained NHS Choices UK government Retrieved 19 February 2015 NIHR infrastructure www nihr ac uk Archived from the original on 2019 04 08 Retrieved 2017 11 07 QualityWatch www qualitywatch org uk Nuffield Trust and Health Foundation Retrieved 19 February 2015 Further reading EditMays N Pope C 2000 Qualitative research in health care Assessing quality in qualitative research BMJ 320 7226 50 52 doi 10 1136 bmj 320 7226 50 PMC 1117321 PMID 10617534 Lytle R S Mokwa M P 1992 Evaluating health care quality The moderating role of outcomes Journal of Health Care Marketing 12 1 4 14 PMID 10116754 Downs S H Black N 1998 The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non randomised studies of health care interventions Journal of Epidemiology amp Community Health 52 6 377 384 doi 10 1136 jech 52 6 377 PMC 1756728 PMID 9764259 Retrieved from https en wikipedia org w index php title Health care quality amp oldid 1125538157, wikipedia, wiki, book, books, library,

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