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: 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 (Institute of Medicine, 1990)
The interest profile of agencies sponsoring QA Components Consumers Providers Health authorities Effectiveness Efficiency Adequacy Technical competence
B (efficacy) (B) A (effectiveness) (A) (efficiency)
The interest profile of agencies sponsoring QA Components Consumers Providers Health authorities Effectiveness ++ + - Efficiency - - +++ Adequacy +++ - ++ Technical competence + +++ -
: Absolutist definition the nature of the health problem the state of the science, technology, and art of medicine & allied discipline Individualized definition considering patient s wishes, expectations, valuations, and means Social definition the aggregate net benefit for an entire population the social distribution of that benefit within the population
: Technical aspect: the application of medical science and technology in a manner that maximizes its benefits to health without correspondingly increasing its risks. Interpersonal aspect: must meet socially defined values and norms that govern the interaction of individuals in general and in particular situations. Amenities
Performance What How well Results Health outcomes Costs Satisfaction Judgment Quality Value
(JCAHO) What is done (efficacy) (appropriateness) How it is done (availability) (timeliness) (effectiveness) (continuity) (safety) (efficiency) (respect and caring)
Benefit Cost - Benefit - Cost (optimum) A B (social optimum, A) (medical optimum, B)
Structure: the relatively stable characteristics of the providers of care, of the tools and resources they have at their disposal, and of the physical and organizational settings in which they work. Process: whether certain procedures, which are clearly associated with good results, are used in specified situations or not. Outcome: a change in patient s current and future health status that can be attributed to antecedent health care.
AHRQ Quality Indicators Prevention QI Ambulatory care sensitive conditions Inpatient QI Inpatient mortality for medical cond n/procedures Utilization of procedures Volume of procedures Patient Safety QI Surgical complications and other iatrogenic events
Hospital Performance Report by PHC4 73 DRGs: 22 public documents + 51 additional Measures reported: risk-adjusted In-hospital mortality Average Hospital charge Average LOS Readmission rate Transfer-out to acute care % Notation of status as provider of advanced cardiac care
Actual to Expected Mortality by, Cardiac Surgeons, 1994-1995
Classification of Quality Problems Overuse Underuse Misuse From JAMA 1998;280:1000-1005
Some Examples from Medical Literatures - Overuse & Underuse - Unnecessary surgery: 8-86%(Leape, 1992) No regular HbA 1 c & retinal exam. for many D.M. patients(weiner et al., 1995) Only14% of pt. with CV Ds. achieved recommended lipid level(mcbride et al., 1998). Failure to treat effectively AMI leads to 18,000 preventable deaths/yr(chassin & Galvin, 1998).
Some Examples from Medical Literatures - Misuse - In US 180,000 deaths/yr partly as a result of iatrogenic injuries(leape, 1994) In US 106,000 deaths/yr by fatal ADR among inpatietns(lazarou et al., 1998) Fatal medication errors in US doubled among outpatients btw. 1983 & 1993(Phillips et al, 1998). Lower quality of care within hospitals for black & the uninsured(kahn et al., 1994; Burstin et al, 1992)
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QI Implicit case review Medical audit Problem-oriented studies Ongoing monitoring of departmental indicators Systems thinking Practice guidelines Outcomes management TQM/CQI Organization-wide continuous improvement in performance
Principles of TQM/CQI Customer focus: internal/external customer Total involvement Measurement Systematic support Continuous improvement
: : I II
Cycle for Improving Performance Design Measurement Assessment Improvement Re-design
QI FOCUS-PDCA FOCUS Find a process improvement opportunity Organize a team that knows a process Clarify the current knowledge of the process Understand causes of process variation Select the process improvement PDCA Plan - Do - Check - Act
QI FOCUS-PDCA FOCUS Find, Organize, Clarify, Understand, Select PDCA Plan the process improvement Do the improvement, data collection & analysis Check the results and lessons learned Act by adopting, adjusting, or abandoning the change
QI Assessment QI: FOCUS Improvement :, QI: PDCA
: Find, Organize Clarify : 11.8 ( 9.1 ) Understand (+) Select
: Plan Do (2nd) : 120 ml/day 3ml/Kg/day 4 Check : 9.1 6.1 : 0/19 0/18 : 11.8 10.1 Act
(1910) (1919) JCAH (1951) PSRO UR (1972) JCAHO PRO (1963) (1981) (2000) (1995) 80