Quality Quiz 2

quality

the degree of excellence of something

health care quality

the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes are are consistent with current professional knowledge

donabedian model of care

structures, processes, outcomes

structures

professional credentials, operational policies

processes

patient counseling, safety monitoring

outcomes

clinical, humanistic, economic

quality control

relies on quality by inspection; focuses on defects found

quality assurance

- retrospective assessment

- programmatic approach to assuring quality

- still relies on inspection but focuses on improvement based on performance to meet a specific standard

quality improvement

- systematic, formal approach to the analysis of practice performance and efforts to improve performance

- based on belief that quality can always be improved

- involves continuous assessment of data to evaluate the appropriateness of the plan

QI approaches

- continuous improvement or total quality improvement

- plan, do, check, act (PDCA) or plan, do, study, act (PDSA)

continuous quality improvement

- proactive and deliberate

- continuous and never ending

- requires organization wide participation

- focuses on preventing and reducing organization wide variations

PDSA

Plan

- goals, measures

Do

- carry out the plan and document

Study

- analyze

Act

- changes and improvements

six sigma concept

assumes defects are responsible for the costs of poor quality

six sigma overall goal

decrease defects in all of the organization's processes

six sigma four major quadrants

improvement process, quality initiatives, quality measurements, improvement tools

lean six sigma

create value for customers by minimizing waste

national academy of medicine

Specific Aims for Improvement

safe

avoid injuries to patients from the care that is intended to help them

effective

match care to science; avoid overuse of ineffective care and underuse of effective care

patient centered

honor the individual and respect choice

timely

reduce waiting for both patients and those who give care

efficient

reduce waste

equitable

close racial and ethnic gaps in health status

accreditation bodies

Joint Commission, National Committee for Quality Assurance

the Joint Commission

- nonprofit founded to continuously improve the safety and quality of healthcare

- required by federal government for Medicare reimbursement

- incorporates quality related delivery issues

National Committee for Quality Assurance

- nonprofit established for managed care

- reviews and accredits managed health care organizations (voluntary, patient centered medical home)

- develops quality standards and measures that are applicable across organizations

government agencies

Centers for Medicare and Medicaid Services, Agency for Healthcare Research and Quality, Food and Drug Administration, Quality Interagency Coordination Task Force

Centers for Medicare and Medicaid Services (CMS)

- largest payor in healthcare

- quality improvement roadmap

CMS and Quality Improvement Organizations

- ensures payment only for medically necessary services

- investigates beneficiary complaints about quality of care

- develops quality improvement programs

Agency for Healthcare Research and Quality (AHRQ)

- lead federal agency for conducting research on health care quality

- National Quality Measures Clearing House, Consumer Assessment of Healthcare Providers and Systems, Patient Safety Organizations

Food and Drug Administration (FDA)

- responsible for assuring safety and efficacy of ALL regulated, marketed, medication products

- MedWatch, Sentinel Initiative

Quality Interagency Coordination Task Force (QuIC)

goal is to assure that all federal agencies that purchase, provide, study, or regulate health services are working in a coordinated manner

5 themes to QuIC's work

- improve patient and consumer information on healthcare quality

- identify opportunities to improve clinical quality

- improve efforts to measure the quality of care

- developing the healthcare workforce to deliver quality

- improve information systems

private organizations

Institute of Medicine (National Academy of Medicine), United States Pharmacopeia, Institute for Safe Medication Practices, Institute for Healthcare Improvement

National Academy of Medicine (NAM)

- private, nonprofit institutions that work outside of government to provide objective advice on matters of science, technology, and health

- best known for defining healthcare quality reports

NAM Quality Reports

- To Err is Human: building a safer healthcare system, focused on number of medical errors occurring annually in US healthcare systems

- Crossing the Quality Chasm: defines 6 aims for care

- Preventing Medication Errors: highlights common medication errors and comprehensive approach to reducing medication errors

United States Pharmacopeia (USP)

- independent, scientific nonprofit organization focused on building trust in the supply of safe, quality medicines

- official public standards setting authority

Institute for Safe Medication Practices

- only nonprofit organization devoted entirely to preventing medication errors

- provides education programs and tools for hospital and retail pharmacies to use to prevent medication errors

Institute for Healthcare Improvement

- independent nonprofit

- provides resources pertaining to improving healthcare quality in healthcare institutions

public-private organizations

National Quality Forum, LEAPFROG group, Hospital Quality Alliance, Pharmacy Quality Alliance

the LEAPFROG group

committed to a set of common purchasing principles to drive leaps in patient safety

Hospital Quality Alliance

goal is to identify set of hospital measures

Pharmacy Quality Alliance

- 5 measures included in Medicaid Part D ratings

- actively developing a set of pharmacy performance measures for pharmacy accountability

- addressing social determinants of health

- collaborates with pharmacists and payers to foster the adoption of pharmacist provided care, a value based care model

state initiatives

State Boards of Pharmacy

- promoting quality improvement programs among members

- payers are mandating quality improvement in pharmacy contracts

Health Reform

- Accountable Care Organizations

- CMC Innovation Center

- Health Insurance Exchanges

- CMS Star Ratings

what is quality in pharmacy?

safety, effectiveness, access

reasons to assess quality in pharmacy practice

- morbidity/mortality

- cost/dollars

- public's perception

- dispensing errors

- regulatory issues

- legal issues

- malpractice claims

assessment of quality in pharmacy

- accuracy of dispensing

- prescribing errors identified and resolved

- accessibility of pharmacist for consultation

- appropriateness of consultaions

- appropriateness of therapy recommendations

- achievement of patient outcomes

performance measures

- provides a benchmark

- often mandated by government programs or payers

quality improvement measures/indicators

- do not provide a benchmark

- allow organizations to implement quality improvement strategies to shift their baseline

- used to better understand the efficiency and outcomes of internal processes

Donabedian's philosophy on quality assessment

structure (government/management) => process (clinical support/functions) => outcomes

criteria for quality measures

- scientifically sound: reliable and valid

- relevant and important to various users

- interpretable and actionable

- feasible

Healthcare Effectiveness Data and Information Set (HEDIS) measures

- effectiveness of care

- access/availability of care

- experience of care

- utilization and risk adjusted utilization

- health plan descriptive information

- measures collected using electronic clinical data systems

PQA Health Plan Quality Measures

adherence, appropriate medication use, safety, medication management services

adherence

proportion of days covered (80%)

appropriate medication use

- statin use in persons with diabetes

- use of medications to prevent major CV events in persons with diabetes

- INR monitoring for individuals on warfarin

- migraine preventative therapy

polypharmacy

use of multiple anticholinergic/CNS medications in older adults

medication management services

- completion rate for comprehensive mediation review

- medication therapy problem resolution

- provision of medication therapy management services host hospital discharge

- readmission of patients provided medication therapy management services post hospital discharge

possible domains in consumer experience surveys

- staff patient interactions

- verbal information about medicine

- written information about medicine

- counseling about new prescriptions

- access to medicines

- pharmacist care

star ratings

adherence, statin use in diabetics, CMR completion

star ratings categories

outcomes, intermediate outcomes, patient experience, access, process

Part C 5 domain ratings

- customer service

- member experience

- member complaints and changes in plan's performance

- staying healthy

- managing chronic conditions

Part D 4 domain ratings

- customer service

- member experience

- member complaints and changes in plan's performance

- drug safety and accuracy of pricing

identifying a new measure

- identify area to evaluate

- conduct literature review

- develop measure and provide specifications on how to measure

- evaluate feedback

- field test measure to ensure validity, reliability, and feasability

measurement challenges

- data sources

- tyranny of small numbers

- case mix/patient factors

- attribution/accountability

benchmarking

process of measuring one's organization's products or service according to specific standards

internal benchmarking

looks to within an organization's own business to determine best practice

external benchmarking

compares performance to other, comparable organizations

functional benchmarking

compares results across different industries

elements of report cards

measures, results, benchmarks

report card measures

- number of visits/procedures

- screening and vaccination rates

- same day appointments

- patient satisfaction scores

- dosing

- drug interactions

- adherence

- readmissions

- mortality

report card results

- measurement at certain point in time

- percentages of total patients meeting measures

- percentile within health system or similar organizations

report card benchmarks

- targets or goals

- may include percent change over time

- may use color coding to display

how to report quality?

valid, reliable, evidence based, relevant, standardized, tailored to community

quality reporting best practices

- account for differences in the user audiences

- make accessible through various media

- trend data over time rather than periodic snapshots

- include transparent and available measures

- provide contextual information

challenges to reporting quality

- rapidly changing healthcare setting and best practices

- consistent definitions, calculations, and reporting formats

- no formal consensus

- prioritizing measures

- context for consumer

- confidentiality

key takeaways for quality reporting

- public reporting associated with quality improvement

- public reporting does not necessarily drive patients to higher quality healthcare providers

- employers rarely use quality data when selecting health plans

pay for reporting

- medicare driven

- public reporting for hospitals focusing on risk adjusted quality of care

- voluntary program

- nonparticipating hospitals receive reduced medicare payments

- physician quality reporting system

pay for performance

- reimbursement is tied to quality measures that exceed certain benchmarks, improve from year to year

- aim to incentivize high quality care

Agency for Healthcare Research and Quality

- collection of healthcare report cards

- provide information to the public about the quality of hospitals, physician groups, clinics, health plans

- does not contain report cards for pharmacy services

benefits of pharmacy quality reporting

- encourages continuous performance improvement

- provides benchmarks as a basis for comparisons with other pharmacies

- generates external pressure to have performance meet or exceed that of competitors

- identifies best practices as outstanding performance is recognized

outcomes MTM

- comprehensive medication review

- adherence: inhalers, statins, BP meds, diabetes meds

- needs drug therapy: statins, rescue inhalers

EQuIPP initiative targets

- use of high risk medications in elderly

- appropriate treatment of diabetes

- drug-drug interactions

- adherence: diabetes, blood pressure, cholesterol

J.D. power

- offers consumer insights, advisory services and data and analytics

- the US Pharmacy Study

J.D. Power key findings

- brick and mortar losing ground to mail orders

- retail pharmacies excel in communication but do not foster trust

- online pharmacies should prioritize ease of use of digital ordering

- confusion over insurance remains barrier for digital pharmacies

quality report cards

- consist of measures, results, and benchmarks

- used by patients, healthcare professionals, health systems, health plans, legislators

aim of quality report cards

drive quality improvement

medication error

any preventable event that may cause or lead to inappropriate medication use or patient harm

error of commission

doing something wrong

error of omission

failing to do the right thing

side effect

expected, well known reaction resulting in little or no change in management

adverse drug reaction

unexpected response that requires some type of medical response or results in a negative outcome

sentinel event

unexpected occurrence involving actual or potential death or serious injury; requires immediate investigation and response

Free from Harm approach

- realization that safety issues are far more complex and pervasive than initially appreciated

- patient safety is more than just mortality

- need for total systems approach

med error stats

- 3rd leading cause of death

- high cost burden

- 7000 deaths were preventable

high reliability organizations (HRO)

organizations that operate in complex, high hazard domains for extended periods without serious accidents or catastrophic failures

- aviation, nuclear power, wildfire operations, healthcare

high reliability

a condition of persistent mindfulness within an organization

5 principles of HRO

- preoccupation with failure

- reluctance to simplify explanations for operations, successes, and failures

- sensitivity to operations (situational awareness)

- deference to frontline expertise

- commitment to resilience

preoccupation with failure

everyone is aware of an thinking about the potential for failure or a breakdown

reluctance to simplify explanations for operations, successes, and failures

people resist simplifying their understanding of work processes and how and why things succeed or fail in their environment