Quality: Where We Have Been Where We Are Going - PowerPoint PPT Presentation


Title: Quality: Where We Have Been Where We Are Going


1
QualityWhere We Have BeenWhere We Are Going
Paul D. Cleary, Ph.D.   Department of Heath Care
Policy 20th Anniversary Celebration April 29, 2008

2
In the Beginning
  • Pure FFS
  • Predominantly solo practitioners and small groups
    for ambulatory care
  • Not-for-profit, poorly run hospitals
  • Only general concern about rising costs and
    proportion of GNP
  • Little awareness of variability, quality, or
    errors Best care in the world!

3
Traditional Approaches to Promote Quality
  • Focus on individuals (e.g., physicians, nurses,
    administrators)
  • Social-psychological-cognitive theories
  • Education (e.g., MM conferences, CME, scientific
    literature)

4
Findings of Early Health Services and Policy
Research
  • The quality of health care is often less than
    optimal
  • There are large regional and inter-organizational
    variations in quality of care
  • There frequently are large racial, ethnic, age,
    and/or gender disparities in care

5
Current Emphases forQuality Improvement
  • Continued measure development and promotion
    Cochrane NQF
  • Systems approaches to quality improvement
  • Consumer choice
  • Pay for performance
  • Electronic medical records

6
Many Strategies for Improving Quality

7
Provider-Focused Strategies
  • Training and certification
  • Feedback
  • Guidelines
  • Decision support
  • Rules and regulations
  • Process and outcome incentives (e.g., HEDIS)

8
Organization-Focused Strategies
  • Feedback to organizations to facilitate quality
    improvement
  • Regulation HIPAA, PROs/QIOs, bill of rights
  • Pubic disclosure (e.g., PA, NY, MA)
  • Management QA QI
  • Accreditation (HEDIS Joint Commission)
  • Contracting
  • Structure incentives (Leapfrog)

9
Market-Based Strategies
  • Feedback to purchasers to facilitate choice and
    to stimulate pressure to improve quality
  • Disclosure (e.g., PA, NY, MA, Medicare)
  • Contracting
  • Promoting types of management strategies (e.g.,
    HMOs)
  • Competition (e.g., Medicare Advantage, Medicare
    Part D)

10
Consumer-Focused Strategies
  • Consumer education
  • Information (e.g., web-based)
  • Disclosure (e.g., PA, NY, MA, Medicare.gov, CAHPS)

11
Provider Feedback
  • Consistent with professional norms and
    expectations
  • Many theoretical arguments to support such an
    approach
  • Widespread frustration with lack of progress

12
Guidelines
  • Theoretically consistent with professional norms
  • Consistent with principles of quality management
  • Generally implemented poorly and seen as
    intrusive and cookie cutter medicine
  • Cannot address complex decision making
  • Widespread resistance and/or ignored

13
Decision Support
  • Consistent with professional norms and cognitive
    theories
  • Consistent with principles of quality management
  • More timely and synthesized data needed
  • Good implementation requires more sophisticated
    and coordinated information systems
  • Very expensive

14
Training and Certification
  • Continuous education (CME) ineffective
  • New efforts to improve certification (ABMS-MOC)
    will have minimal impact for many years
    difficulty even establishing a floor

15
Feedback to Purchasers
  • Some organizations have taken a leadership role
    promoting quality of care
  • Evidence suggests that purchasers decide
    primarily on price
  • It is difficult for purchasers to monitor quality
  • Markets too fragmented for concentrated effects

16
Regulation
  • Regulation is appealing and reassuring
  • Regulation can be slow, inflexible,
    inappropriate, and ineffective
  • Examples
  • Obstetric care
  • Medicare disclosure of financial incentives

17
Accreditation
  • Useful for achieving consensus on standards
  • Little relationship to overall quality
  • May facilitate disclosure and/or internal
    improvement

18
Consumer Education
  • Inherently good
  • Too much information asymmetry to result in much
    quality improvement

19
Managed Care
  • Resisted by public and many clinicians
  • Generally unsuccessful at improving efficiency or
    quality
  • Current forms dramatically diluted from original
    concepts
  • Failures probably cumulative effect of problems
    with specific strategies

20
System Approaches to Quality Improvement
  • Exciting models and dramatic success in industry
  • Results to date in health care mixed

21
Limits to Systems Approaches
  • Contextual and inter-organizational issues often
    critical
  • Fixing micro processes may not affect overall
    quality if other issues are not addressed (e.g.,
    leadership, professional attitudes)
  • Need new models of care (e.g., true teams)

22
Financial Incentives
  • Revenue maximization is a high priority for
    individuals and organizations
  • Incentives are most effective when motivation is
    a limiting factor and there is excess capacity
  • Organizational incentives can target
    infrastructure deficits
  • Any incentives are limited by coherence and
    awareness

23
Problem with Many MechanismsLack of Coherent
Structures
24
Disclosure
  • Great interest in transparency and
    accountability, but
  • Information must be valid
  • Information must be salient to decisions
  • Information must be presented in a useful format
  • Information must be read and understood
  • Information must influence decisions or be
    perceived as influencing decisions
  • A sufficient number of providers must participate
  • Poor providers must fail and/or improve in
    response
  • Sunshine effect may be more important than
    consumer choice

25
The Current Situation
  • Dramatic improvements in research methods and
    commitment
  • Many care improvements
  • Improvements have been slower than almost
    everyone wanted and expected
  • Systems, infrastructure, policy, science, data,
    and care continue to be fragmented and
    uncoordinated
  • Medical care continues to be craft work
  • Physicians, purchasers, and consumers all
    frustrated

26
What is needed for a medicalindustrial
revolution?
  • More coordinated, timely data on treatments and
    for decision support
  • Information infrastructure
  • Simplified, integrated structures for purchasers,
    regulators, and providers
  • Support and incentives for infrastructure
  • New models of care coordination that leverage
    physician expertise
  • New manpower policies

27
Most Dramatic Changes in Health CareSystem-Wide
Change
  • 1965 - Medicaid and Medicare
  • 1980s - Health Maintenance Organizations
  • 1990s - VA transformation
  • 2000s - CMS focus on quality (e.g., never events,
    value purchasing)

28
Conclusion
  • Closing the chasm between what is done and what
    is possible will require better use of existing
    data and bold new thinking about data standards,
    systems, and providers
  • More consolidation or coordination of oversight
    and improvement functions necessary
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Quality: Where We Have Been Where We Are Going

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Findings of Early Health Services and Policy Research ... New manpower policies. Most Dramatic Changes in Health Care: System-Wide Change ... – PowerPoint PPT presentation

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Transcript and Presenter's Notes

Title: Quality: Where We Have Been Where We Are Going


1
QualityWhere We Have BeenWhere We Are Going
Paul D. Cleary, Ph.D.   Department of Heath Care
Policy 20th Anniversary Celebration April 29, 2008

2
In the Beginning
  • Pure FFS
  • Predominantly solo practitioners and small groups
    for ambulatory care
  • Not-for-profit, poorly run hospitals
  • Only general concern about rising costs and
    proportion of GNP
  • Little awareness of variability, quality, or
    errors Best care in the world!

3
Traditional Approaches to Promote Quality
  • Focus on individuals (e.g., physicians, nurses,
    administrators)
  • Social-psychological-cognitive theories
  • Education (e.g., MM conferences, CME, scientific
    literature)

4
Findings of Early Health Services and Policy
Research
  • The quality of health care is often less than
    optimal
  • There are large regional and inter-organizational
    variations in quality of care
  • There frequently are large racial, ethnic, age,
    and/or gender disparities in care

5
Current Emphases forQuality Improvement
  • Continued measure development and promotion
    Cochrane NQF
  • Systems approaches to quality improvement
  • Consumer choice
  • Pay for performance
  • Electronic medical records

6
Many Strategies for Improving Quality

7
Provider-Focused Strategies
  • Training and certification
  • Feedback
  • Guidelines
  • Decision support
  • Rules and regulations
  • Process and outcome incentives (e.g., HEDIS)

8
Organization-Focused Strategies
  • Feedback to organizations to facilitate quality
    improvement
  • Regulation HIPAA, PROs/QIOs, bill of rights
  • Pubic disclosure (e.g., PA, NY, MA)
  • Management QA QI
  • Accreditation (HEDIS Joint Commission)
  • Contracting
  • Structure incentives (Leapfrog)

9
Market-Based Strategies
  • Feedback to purchasers to facilitate choice and
    to stimulate pressure to improve quality
  • Disclosure (e.g., PA, NY, MA, Medicare)
  • Contracting
  • Promoting types of management strategies (e.g.,
    HMOs)
  • Competition (e.g., Medicare Advantage, Medicare
    Part D)

10
Consumer-Focused Strategies
  • Consumer education
  • Information (e.g., web-based)
  • Disclosure (e.g., PA, NY, MA, Medicare.gov, CAHPS)

11
Provider Feedback
  • Consistent with professional norms and
    expectations
  • Many theoretical arguments to support such an
    approach
  • Widespread frustration with lack of progress

12
Guidelines
  • Theoretically consistent with professional norms
  • Consistent with principles of quality management
  • Generally implemented poorly and seen as
    intrusive and cookie cutter medicine
  • Cannot address complex decision making
  • Widespread resistance and/or ignored

13
Decision Support
  • Consistent with professional norms and cognitive
    theories
  • Consistent with principles of quality management
  • More timely and synthesized data needed
  • Good implementation requires more sophisticated
    and coordinated information systems
  • Very expensive

14
Training and Certification
  • Continuous education (CME) ineffective
  • New efforts to improve certification (ABMS-MOC)
    will have minimal impact for many years
    difficulty even establishing a floor

15
Feedback to Purchasers
  • Some organizations have taken a leadership role
    promoting quality of care
  • Evidence suggests that purchasers decide
    primarily on price
  • It is difficult for purchasers to monitor quality
  • Markets too fragmented for concentrated effects

16
Regulation
  • Regulation is appealing and reassuring
  • Regulation can be slow, inflexible,
    inappropriate, and ineffective
  • Examples
  • Obstetric care
  • Medicare disclosure of financial incentives

17
Accreditation
  • Useful for achieving consensus on standards
  • Little relationship to overall quality
  • May facilitate disclosure and/or internal
    improvement

18
Consumer Education
  • Inherently good
  • Too much information asymmetry to result in much
    quality improvement

19
Managed Care
  • Resisted by public and many clinicians
  • Generally unsuccessful at improving efficiency or
    quality
  • Current forms dramatically diluted from original
    concepts
  • Failures probably cumulative effect of problems
    with specific strategies

20
System Approaches to Quality Improvement
  • Exciting models and dramatic success in industry
  • Results to date in health care mixed

21
Limits to Systems Approaches
  • Contextual and inter-organizational issues often
    critical
  • Fixing micro processes may not affect overall
    quality if other issues are not addressed (e.g.,
    leadership, professional attitudes)
  • Need new models of care (e.g., true teams)

22
Financial Incentives
  • Revenue maximization is a high priority for
    individuals and organizations
  • Incentives are most effective when motivation is
    a limiting factor and there is excess capacity
  • Organizational incentives can target
    infrastructure deficits
  • Any incentives are limited by coherence and
    awareness

23
Problem with Many MechanismsLack of Coherent
Structures
24
Disclosure
  • Great interest in transparency and
    accountability, but
  • Information must be valid
  • Information must be salient to decisions
  • Information must be presented in a useful format
  • Information must be read and understood
  • Information must influence decisions or be
    perceived as influencing decisions
  • A sufficient number of providers must participate
  • Poor providers must fail and/or improve in
    response
  • Sunshine effect may be more important than
    consumer choice

25
The Current Situation
  • Dramatic improvements in research methods and
    commitment
  • Many care improvements
  • Improvements have been slower than almost
    everyone wanted and expected
  • Systems, infrastructure, policy, science, data,
    and care continue to be fragmented and
    uncoordinated
  • Medical care continues to be craft work
  • Physicians, purchasers, and consumers all
    frustrated

26
What is needed for a medicalindustrial
revolution?
  • More coordinated, timely data on treatments and
    for decision support
  • Information infrastructure
  • Simplified, integrated structures for purchasers,
    regulators, and providers
  • Support and incentives for infrastructure
  • New models of care coordination that leverage
    physician expertise
  • New manpower policies

27
Most Dramatic Changes in Health CareSystem-Wide
Change
  • 1965 - Medicaid and Medicare
  • 1980s - Health Maintenance Organizations
  • 1990s - VA transformation
  • 2000s - CMS focus on quality (e.g., never events,
    value purchasing)

28
Conclusion
  • Closing the chasm between what is done and what
    is possible will require better use of existing
    data and bold new thinking about data standards,
    systems, and providers
  • More consolidation or coordination of oversight
    and improvement functions necessary
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