Using Utilization Measures to Improve Quality of Care in Health Systems

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Using Utilization Measures to Improve Quality of
Care in Health Systems

• Stephen M. Davidson, Ph.D.
• Boston University School of Management
• Presentation to CHMR Industry Advisory Board
• Phoenix, AZ
• October 7, 2005

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The Problem

• It is widely recognized that safety and quality
  are not high enough or consistent enough.
• Therefore, there is much interest in trying to
  improve the level of safety and quality.

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First Step

• Leaders of health care organizations and health
  plans need to know the state of quality in their
  systems
• The extent to which care provided meets
  established criteria.
• When it does not meet those criteria, where in
  the process of care are improvements needed?

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• Knowing the state of care in their systems will
  help leaders
• To set specific improvement goals.
• To engage clinical professionals in improvement
  efforts.
• To measure progress.

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Organization of the Presentation

• The suitability of utilization measures to assess
  quality of care.
• Define quality and its measurement.
• Examine 2 sources of utilization data medical
  records and claims.
• 2. Using utilization measures in a
  quality-improvement strategy.

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Quality of Care

• the degree to which health services increase
  the likelihood of desired health outcomes and are
  consistent with current professional knowledge.
• K. Lohr
• Selecting services.
• Delivering service with skill.
• Producing improved health.

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Implications

• Ultimate criterion the impact of services on
  health outcomes.
• Other factors besides health services affect a
  persons health status.

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• Since quality of care cannot be recognized by
  observing a team of clinicians providing
  services,
• To measure quality of care for a health plan,
  studies are needed that compare the care received
  by groups of similar patients.
• The test the probability of good outcomes in
  the two groups.

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Questions about Measurement

• What do we count?
• How do we know it is related to quality?
• How do we distinguish between good quality and
  lesser quality?

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Donabedians Conceptualization

• Chances that care is of good quality improve if
• Good structural conditions are in place.
• Processes of care meet certain standards.
• Outcomes improve after receiving care.

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• Utilization is a measure of process.
• Studies need to relate utilization (process) to
  outcomes.

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Sources of Utilization Data

• Medical records.
• Claims for services rendered.

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Factors Affecting Adequacy

• CONTENT
• Completeness
• Accuracy
• USEABILITY BURDEN
• Retrievability
• Confidentiality
• Suitability for Analysis

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What Utilization Data Can Do

• Show what services were provided.
• Identify patterns of services provided.
• Determine whether indicated follow-up services
  were provided.
• Include details of patient visits
• Values from tests.
• Progress notes.

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Caveats

• Understand the datas limitations.
• Use care in transcribing to an analysis file.
• Understand the nature of the sample.
• Do not over-interpret the results.

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Using Utilization Measures to Improve Quality of
Care

• Key Fact
• To change the way care is delivered in order to
  improve quality and outcomes requires the active
  participation of clinicians.

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Doctors must believe 3 things to be willing to
participate

• Whatever the level of quality and safety in the
  organization, they can be improved.
• The consequences of not improving quality will
  affect not just the organization, but also
  themselves.
• Even though they are not to blame, what they do
  as individuals can help improve care.

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Other Obstacles

• Managers doctors have different orientations.
• They have different connections to the
  organization.
• Doctors tend to assume managers want to constrain
  their autonomy.
• Managers are reluctant to engage doctors on
  clinical issues.
• Doctors consider non-clinical activity to be a
  diversion from seeing patients.

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Assets

• Information is the major asset in the process.
• Payoff from success Patients who are more
  appreciative of their doctors.
• Opportunity to ease the pain, especially through
  financial compensation and other benefits.
• An intangible benefit sense of accomplishment
  for all participants.

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The Process

• Step One Organizational Assessment.
• Step Two Picking a Place to Start.
• Step Three Choosing a Target for Change.

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The Process 2

• Put together a multi-disciplinary group to lead.
• State objectives clearly invite comment be
  willing to modify.
• Share information.
• Do not work uphill pick projects that are real
  and likely to succeed.
• Set milestones so expectations are clear.

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Conclusion

• Stakes are high quality, cost.
• Change is hard but unavoidable.
• Utilization information can be a major asset it
  shows the problems are real they are systemic
  and therefore, the system needs to change.
• The process does not end but significant
  milestones can be achieved.