Department of Family Medicine
Quality Assurance
Quality of Care is the degree to which Health Services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
Healthcare is Constantly Evolving (or "Stop the World, I Want to Get Off")
Physicians, Nurses, other healthcare personnel, healthcare systems (Clinics, Hospitals, Labs, etc.), national and state healthcare organizations, insurance and managed care plans are all in a state of evolution. They share the strain of development in a larger world that is changing at incredible speed. The changes can be dizzying and frustrating--every part of the system is feeling this today.
Attention to quality is an Important Element in the Evolution of Healthcare
Nearly everyone involved in the practice of Medicine is highly trained, is
usually very well educated, and is, for the most part, committed to providing
high quality of care. Because of all the changes in healthcare, the ways in
which quality is perceived, pursued, and insured continues to develop.
Historically, much of what has driven the changes in healthcare has been the
need for insuring quality across the entire healthcare system. For an historical
overview of the development of quality, see the Quality
Evaluation Timeline.
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Quality in Healthcare
What is Driving Attention to Quality Today?
- Limited Resources
- Changes in Insurance Coverage
- Shift from paternalism to participation / decision making by patient
- Patient demands and expectations
OK, So What Exactly is "Quality"?
- The Institute of Medicine defines Quality of Care as:
"the degree to which Health Services for individuals and populations
(1) increase the likelihood of desired health outcomes and are
(2) consistent with current professional knowledge."
- "Quality" is one of the major cornerstones of healthcare along with "Access to Services" and "Cost." Quality has a major influence on Access and Cost.
- Putting it all together, Quality is achieved when:
accessible
services are provided in an
efficient, cost-effective and acceptable manner
that can be controlled by the ones providing it.
You Mean "Control by Others"—What Power Do I Have Anymore?
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Traditional patient care has been a very individual and private affair conducted solely by the MD.
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MDs often feel powerless in this evolving system, and because quality assessment and assurance (and Total Quality–we'll get to that later) feel invasive and intrusive, it can produce resistance. While that is understandable, it is not in an MD's (or healthcare's) best interest to stay stuck in resistance.
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While many still long for the traditional practice of medicine, the changes happening in healthcare mean that only about 15% of healthcare quality is attributable to performance of individual MDs (or other) and 85% is due to performance of systems (Deming on Total Quality).
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These new realities in healthcare require a new paradigm: Team vs. Individual approach (traditional MD model). "Team" concept is new to MDs.
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An MD has power in the developing healthcare system to the extent to which s/he has knowledge (Knowledge = Power). The knowledge is of his/her performance and of increases in his/her performance quality (for him/herself and with respect to externally codified guidelines). This is the 15% of the overall quality that s/he can actually do something about.
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The power is to do what?
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Constantly increase the quality of the patient care s/he delivers.
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Gain greater certainty over economic stability.
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Maintain sufficient freedom to deal with uncertainties of patient care.
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Gain a greater sense of participation and proactive influence in institutional development in the future.
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Restore a lost sense of the social value of an MD's work.
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- FOCUS: Power allows an MD, within his/her own arena, to proactively increase quality of patient care and to share positive outcomes with influential Managed Care plans.
Making Sense Out of the "Quality" Talk—What is Involved in Insuring Quality?
Over 30 years ago (1966), Avedis Donabedian, MD, looked at both the historical development of quality in healthcare and at what was needed. He suggested that quality had been, and needs to be, insured in three key aspects of healthcare:
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Structure (First assessed by Flexner, MD in 1910: The Flexner Report)
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Process
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Outcomes (First assessed by Nightingale, RN in 1855)
| Structure | The stable elements of the Health Care Delivery System in a
community that facilitate or inhibit access to and provision of services.
|
| Process | The interaction between the patient and a provider depends
on:
1. Technical Excellence
2. Interpersonal Excellence |
| Outcomes | Results of efforts to prevent, diagnose, and treat various
health problems. Some possible outcomes:
|
Structure, Process, and Outcomes are measured at the levels of:
- Health Service Delivery Systems (Systemic Level)
- Specific Health Conditions or Services (Clinical Level).
Each of these levels, in turn, has both an Internal and an External Focus:
Some Examples:
WHOA! This is Too Much!
What Can My Small Team Alone do to Improve Our Quality of Healthcare Delivery?
Focus on Clinical, Internal Quality Assurance, paying attention to the following Medical Conditions:
- Highly prevalent conditions with significant effects on Morbidity and Mortality. Focusing on prevalent conditions provides for a greater number of cases to be available for review so there is adequate statistical power to draw conclusions.
- Primary prevention (prevent disease from happening)
- Secondary Treatment (stop progression, accomplish cure)
- Tertiary Treatment (reduce impairment)
- Conditions in which improving quality of service delivery will be efficacious, i.e., will enhance population health (spend effort in the wisest manner)
- Conditions for which interventions are cost effective (spend money in the wisest manner)
- Conditions for which interventions are under control of health plan or provider or for which variation can be controlled (a matter of the non-contamination of the independent variable: the medical or systemic intervention. That is, it is easier to control how my team performs a treatment than it is to control patient compliance).
A Paradigm Shift: From "Quality Assurance" to "Total Quality"
Traditionally, Quality Assurance programs have focused on physicians (alone) and changing physicians' behavior by:
Assessing or measuring performance.
Determining whether the performance conformed to standards (HEDIS, Clinical Practice Guidelines, HMO, etc.: see below)
Improving performance when standards are not met.
Underlying this approach is the "Bad Apples" view: "find the bad apple and get rid of it." Such an approach to measuring and insuring quality has, understandably, led to much resentment and focuses on meeting minimal standards (then stopping the assessment) rather than on improvement of quality as a continuous activity and "ethic."
A more mature and developed approach than Quality Assurance (QA) alone is Total Quality Management (TQM). It uses QA as its first step and seeks to implement the results of QA into a more comprehensive and continuous effort to improve Quality.
Total Quality |
| Quality improvement is a continuous effort by all the members of an organization to meet and exceed the needs and expectations of the patients and other customers. The goal is to not merely meet standards of care or to see them as limits (ceilings) to which we strive, but to exceed these standards. Performance assessment or measurement (QA) is a necessary step but it is not the end–it is the first step in a continuous cycle of improving quality (Continuous Quality Improvement: CQI). |
Total Quality is founded upon these principles:
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Senior administrative and clinical leaders should explicitly and actively pursue an ethic of continuous improvement in the quality of care and service
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Processes, not just individuals, should be the objects of quality improvement. Quality measurement examines variation in structures, processes, and outcomes and seeks to eliminate detrimental variation. Processes are complex and are frequently characterized by unnecessary rework and waste.
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Revise personnel management strategy to treat employees and professionals as valuable resources with a central role in quality improvement:
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Increase training in multiple areas: supervision, optimal strategies for procedures, concepts of Total Quality (TQ), communication skills, elementary statistics and simple analytic, and graphic techniques.
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Eliminate work standards and numerical goals (these stimulate behavior narrowly directed solely at their achievement and are perceived as maximal attainable levels of performance discouraging appropriate risk-taking and creativity essential for quality improvement)
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new approaches to employee evaluation are facilitative (based on assumption that people want to do their best and that variations are process not people problems).
What are Some Techniques I Can Use to Diagnose Quality Problems and Focus Quality Improvement Strategies?
From the Hospital Corporation of America: FOCUS PDCA:
What About Practice Guidelines, Standards, and "Indicators"?
Clinical Practice Guidelines & Standards of Care
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Are systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.
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Rely on qualitative reasoning and emphasize clinical content
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Are written to influence practitioner behavior
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Are like "expert opinion"
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Require examination of "evidence" and "values"
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Must deal with the lack of "best evidence" (for lack of good studies)
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Should include patient preferences (how values were agreed upon, dates of most recent evidence, and final recommendations)
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Should be "graded" according to:
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Strength of evidence in the overview
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Magnitude of effect
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Precision of the estimate (how much does it work?)
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Note: The material contained herein is a combination of original text
and information
quoted and/or modified from:
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Al-Assaf, A.F., Schmele, J.A. (1993). The textbook of total quality in healthcare. Delray Beach, FL: St. Lucie Press
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McGlynn, E.A., ; Brook, R.H. (1996). Ensuring quality of care. In R.M. Andersen, T.H. Rice, G.F. Kominski, Eds., Changing the U.S. health care system (pp. 142-179). San Francisco: Jossey-Bass.