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Quality
What Is Quality?
Although there is a consensus that quality is an essential goal in healthcare, there are
many different ideas about how to define quality, how to recognize it, and how to provide
it. In its most general sense, the term quality in the context of a health plan refers to the
plans success in providing healthcare and other services in such a way that plan
members needs and expectations are met.
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100,000 Americans die in hospitals each year as a result of medical errors.3 More
recently (in 2006) IOM issued a report on preventable adverse drug events, which
estimated that in one year there were 380,000-450,000 such events in hospitals,
800,000 in long-term care facilities, and 530,000 among outpatient Medicare patients.4
These large numbers represent people whose physical wellbeing or even lives were put
at risk, and who may have undergone unnecessary suffering. It should also be noted
that medical errors add to the cost of healthcare, as they can worsen patients conditions
and lead to the need for additional treatment. The 1999 IOM study estimated the annual
cost of medical errors at between $17 and $29 billion.5
Medical Errors
What exactly are medical errors?
An error of commission is doing the wrong thing. A wrong treatment or
procedure is performed, as when the wrong medication is administered.
An error of omission is not doing the right thing. A patient does not receive the
appropriate test or treatment, or does not receive it in a timely manner.
An error of execution is doing the right thing in the wrong way. A planned
treatment or procedure is delivered incorrectly, as when a mistake is made in a
surgical operation.
An adverse event is any harm a patient suffers that is caused by something
other than her underlying condition. The cause might be a medical error, some
other deficiency in the patients care, or something else.
A federal Quality Interagency Coordination (QuIC) Task Force, expanding on an earlier
IOM definition, defined a medical error as: "the failure of a planned action to be
completed as intended or the use of a wrong plan to achieve an aim. Errors can include
problems in practice, products, procedures, and systems. A useful, brief definition of a
medical error is that it is a preventable adverse event.6
The Causes of Medical Errors
Medical errors have a number of causes. In some cases an individual practitioner makes
a mistake, but more often there is some breakdown in the healthcare system.
Lack of communication. Communication among healthcare providers is often
limited or faulty, and this is the cause of many errors. To give a simple but
frequent occurrence, doctors often write illegible prescriptions leading to incorrect
medications, or illegible orders resulting in inappropriate procedures. Another
example: an outpatient diagnostic center fails to call a physician about a patients
chest x-ray showing pneumonia, and as a result the patient does not receive
timely treatment for the pneumonia and has to be hospitalized. The problem of
poor communication is compounded by the large numbers of people who may
participate in a patients care.
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In using these measures, a health plan can compare its performance to established
standards and/or its own previous performance.
Healthcare Providers
For healthcare providers, service quality includes:
how easily members can get through to a doctors office by phone;
how long members wait for an appointment;
how long members wait in the office before seeing the doctor;
the attitude, competence, and efficiency of office staff;
the doctors bedside manner. This includes how friendly and understanding the
doctor is, how well she explains clinical findings and treatment options, whether
the patient feels that she listens to his concerns, etc.).
Provider service quality can also be assessed by means of structure measures (such as
the number of primary care physicians), process measures (average wait time for an
appointment), and outcomes measures (results of member surveys).
Assessing Healthcare Quality
Healthcare quality typically refers to:
patient safety (as defined above);
practices consistent with current clinical or scientific knowledge, best practices,
and professionally recognized standards of care; and
care delivered in a timely manner to avoid harmful delays; and
care respectful of and responsive to patient needs, preferences, and values.
Structure Measures
Structure measures of healthcare quality include:
the number of primary care providers in the plans network,
the number of specialists,
the number of providers accepting new patients,
the geographic distribution of providers within the service area,
the percentage of providers who are board-certified,
physician turnover in the plan,
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Misuse of care occurs when the wrong treatment is provided (an error of
commission) or when the correct treatment is delivered incorrectly (an error of
execution).
In many cases appropriate care is codified as professionally recognized standards of
care. A standard of care is a diagnostic and treatment process that a provider should
follow for a certain type of patient, illness, or clinical circumstance. Standards of care are
generally published by medical organizations such as the American Medical Association
(AMA) and others.
The advantage of process measures is the same as for structure measuresthey are
relatively easy to determine and report. But while links have been established between
some process measures and positive health outcomes, for others they have not.
Outcomes Measures
Outcomes measures can be divided into three types: clinical status, functional status,
and patient perception.
Clinical status relates to biological health outcomes, either for an individual or
for a population served, such as the following:
o
the five-year survival rate for cancer patients (the percentage still living
five years after treatment),
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Quality Assurance (NCQA) and the new star system for rating Medicare Advantage
plans.
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Quality Improvement
Quality improvement consists of producing better healthcare outcomes (clinical,
functional, and perception/satisfaction). Health plans can accomplish this by changing
the structures and processes that underlie their clinical and administrative services. In
other words, a health plan can improve its services by increasing or improving its
resources and by changing the ways it performs services. For example, a health plan
could improve access to care by expanding its provider network (a structure change) or
by changing its authorization procedures (a process change).
Elements of Quality Improvement
To be effective, changes to structures and processes must include the following
elements:
Planning. Before taking any action, a health plan must identify where
improvement is needed, define desired outcomes, identify causes of problems
and barriers to change, and decide what actions are most likely to achieve the
desired outcomes.
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providers consistently deliver services that will improve their patients health and reduce
unnecessary variations in patient care.
Clinical practice guidelines can be developed in-house by joint health plan-provider
committees. Or they can be obtained from outside sources such as the National
Guideline Clearinghouse (NGC), a joint venture of the AMA, the federal Agency for
Healthcare Research and Quality (AHRQ), and America's Health Insurance Plans
(AHIP). Other sources are professional associations such as the AMA, the American
Academy of Pediatrics (AAP), and the many associations of medical specialists. Like
best practices, clinical practice guidelines are generally accepted and supported by
providers.
Provider Profiling
Provider profiling involves collecting and analyzing information about the practice
patterns of individual providers. It is used during credentialing and recredentialing to
determine how well a provider meets a health plans standards. Profiling also identifies
providers whose practices vary significantly from the normthey may use substantially
more or fewer resources than other providers, or they may use them differently. By
analyzing providers practice patterns, the health plan can sometimes determine whether
an individuals patterns produce better or worse outcomes and whether they are costeffective.
Provider profiling can be useful, but it can also be controversial. It is commonly used to
educate providersfor instance, a plan might inform a pediatrician that his immunization
rates for children are much lower than his peers, and this should encourage him to
assess his practices. But some health plans have acted punitively toward providers
based solely on utilization rates or have posted such information publicly, and they have
found themselves involved in class action lawsuits. As discussed above under
outcomes, comparing providers statistically can be complex and difficult, requiring
adequate risk adjustment, and consequently it may be difficult to demonstrate that
comparisons are valid and fair and defend a punitive or public action.
Peer Review
In peer review a panel of medical professionals evaluates the care delivered by a
provider. Unlike profiling, peer review is not based primarily on statistics. Peer review
can focus on a single episode of care or take a broader look at a providers practices.
The appropriateness and timeliness of the services delivered are reviewed, as well as
outcomes and in some cases patient perceptions (as when a member complaint or
negative responses to satisfaction surveys have been received). Results can be used to
educate a provider and identify opportunities for improvement or to provide a measure of
quality.
One advantage of peer review is that a physician is likely to more receptive to education
and recommendations offered by other physicians than by health plan administrators.
And should a health plan have to take disciplinary action against a provider (such as
termination of his contract), that action will be easier to defend if it is based on the
recommendation of a committee of his peers.
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Notes
1
Landon, Bruce E.; Zaslavsky, Alan M.; Bernard, Shulamit L.; Cioffi, Matthew J.; and Cleary, Paul
D. 2004. Comparison of Performance of Traditional Medicare vs. Medicare Managed Care,
Journal of the American Medical Association (JAMA), 2004, 291(14):1744-1752.
2
Kohn, Linda T.; Corrigan, Janet M.; and Donaldson, Molla S., editors. 1999. To Err Is Human:
Building a Safer Health System. Institute of Medicine. www.iom.edu/reports.
4
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