Health care quality assurance

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Health care quality assurance is "activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps."[1]

Health care quality assurance addresses topics such as medical error, cross infections[2], evidence-based medicine, and patient satisfaction.

Health care quality assurance uses tools such as

Creating quality measures

Creating quality measures from clinical practice guidelines can be problematic.[5][6]

Conflict of interest may influence the creation of measures. The National Committee for Quality Assurance receives money from groups who have financial interests in the components of measures.[7]

Sometimes, quality measures must be discontinued.[8]

Measuring quality

Chart abstraction may underestimate quality.[9]

Regarding measuring quality in primary care, physicians' case loads may be too small to measure the quality of management of individual diseases.[10]

Quality improvement

Study designs include:[11]

  • Stepped Wedge Design
  • Pragmatic Randomized Controlled Trial
  • Interrupted Time Series
  • Controlled Before-After Study
  • Uncontrolled Before-After Study

Improving quality

Guidelines exist for reporting[12] and assessing[11] studies of quality improvement.

More experience, as measured by volume of care, is associated with better quality of care.[13]

Process control charts can be used to identify specific problems that need improvement.[14][15][16] Examples are assessing methods to obtain blood cultures[17], the impact of screening for methicillin resistant Staphylococcus aureus[18] and comparing mortality in surgical units[19].

A healthcare matrix can help assess the quality of an individual episode of care and link to the Institute of Medicine (IOM) and the Accreditation Council of Graduate Medical Education (ACGME) goals.[20]

Surprisingly, hospitals reporting more compliance with the Leapfrog safe practices do not report reduced mortality than other hospitals.[21]

Cultures of quality

The highest quality takes place when all involved constantly reinforce "lessons learned" to one another, in a learning process. The institution performing this research was a United States Air Force hospital at which aviation safety techniques were well known.[22]

Considerable insight from aviation safety appears applicable to health care. [23]

Audit and feedback

Audit and feedback has been systematically reviewed by the Cochrane Collaboration who concluded its "effects are generally small to moderate."[24]

More recently, a factorial, cluster randomized controlled trial of audit and feedback concluded "enhanced feedback of requesting rates and brief educational reminder messages, alone and in combination, are effective strategies ."[25] The feedback in this trial was enhanced with an educational message.

Financial incentives

Medicare has used its payments to health care providers as incentives to achieve health care quality assurance. For example, in the United States, the Centers for Medicare and Medicaid Services (CMS) may withhold a portion of the payments for the care of patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty who have perioperative deep venous thrombosis or [pulmonary embolism]].[26]

While pay for performance targets clinical quality and patient experience criteria may improve health care, targeting productivity and efficiency criteria may have adverse effects.[27]

Physician Quality Reporting Initiative

Per the Medicare website:[28]

"The 2006 Tax Relief and Health Care Act (TRHCA) (P.L. 109-432) required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals (EPs) who satisfactorily report data on quality measures for covered professional services furnished to Medicare beneficiaries during the second half of 2007 (the 2007 reporting period). CMS named this program the Physician Quality Reporting Initiative (PQRI). The PQRI was further modified as a result of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) (Pub. L. 110-275) and the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (Pub. L. 110-275)."

Public reporting of quality measures

A systematic review found that "publicly releasing performance data stimulates quality improvement activity at the hospital level. The effect of public reporting on effectiveness, safety, and patient-centeredness remains uncertain".[29] However, a comparative study found concerns with the quality of data that is publically available.[30] A subsequent cluster randomized controlled trial reported no benefit.[31] Recommendations have been made to improve public reporting.[32]

Research on quality improvement

Guidelines exist for the reporting (http://www.squire-statement.org/)[33][34][12] and reading[11] of studies on quality improvement

References

  1. ↑ Anonymous (2024), Health care quality assurance (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S et al. (2006). "An intervention to decrease catheter-related bloodstream infections in the ICU.". N Engl J Med 355 (26): 2725-32. DOI:10.1056/NEJMoa061115. PMID 17192537. Research Blogging.
  3. ↑ Leffler DA, Neeman N, Rabb JM, Shin JY, Landon BE, Pallav K et al. (2011). "An alerting system improves adherence to follow-up recommendations from colonoscopy examinations.". Gastroenterology 140 (4): 1166-1173.e1-3. DOI:10.1053/j.gastro.2011.01.003. PMID 21237167. Research Blogging.
  4. ↑ Cameron KA, Persell SD, Brown T, Thompson J, Baker DW (2011). "Patient outreach to promote colorectal cancer screening among patients with an expired order for colonoscopy: a randomized controlled trial.". Arch Intern Med 171 (7): 642-6. DOI:10.1001/archinternmed.2010.468. PMID 21149742. Research Blogging.
  5. ↑ Walter LC, Davidowitz NP, Heineken PA, Covinsky KE (2004). "Pitfalls of converting practice guidelines into quality measures: lessons learned from a VA performance measure". JAMA 291 (20): 2466–70. DOI:10.1001/jama.291.20.2466. PMID 15161897. Research Blogging.
  6. ↑ Fonarow GC, Abraham WT, Albert NM, et al (January 2007). "Association between performance measures and clinical outcomes for patients hospitalized with heart failure". JAMA 297 (1): 61–70. DOI:10.1001/jama.297.1.61. PMID 17200476. Research Blogging.
  7. ↑ Meier, Barry (August 17, 2009). Diabetes Case Shows Pitfalls of Treatment Rules. The New York Times. Retrieved on 2009-08-18. “the National Committee for Quality Assurance, received about $3 million, or 10 percent of its revenue, last year from drug and medical device makers”
  8. ↑ Reeves D, Doran T, Valderas JM, Kontopantelis E, Trueman P, Sutton M et al. (2010). "How to identify when a performance indicator has run its course.". BMJ 340: c1717. DOI:10.1136/bmj.c1717. PMID 20371570. Research Blogging.
  9. ↑ How well does chart abstraction measure quality? A...[Am J Med. 2000 - PubMed Result]. Retrieved on 2008-02-12.
  10. ↑ Nyweide DJ, Weeks WB, Gottlieb DJ, Casalino LP, Fisher ES (2009). "Relationship of primary care physicians' patient caseload with measurement of quality and cost performance.". JAMA 302 (22): 2444-50. DOI:10.1001/jama.2009.1810. PMID 19996399. Research Blogging.
  11. ↑ 11.0 11.1 11.2 Fan E, Laupacis A, Pronovost PJ, Guyatt GH, Needham DM (2010). "How to use an article about quality improvement.". JAMA 304 (20): 2279-87. DOI:10.1001/jama.2010.1692. PMID 21098772. Research Blogging.
  12. ↑ 12.0 12.1 Davidoff F, Batalden P, Stevens D, Ogrinc G, Mooney SE, SQUIRE development group (2009). "Publication guidelines for quality improvement studies in health care: evolution of the SQUIRE project.". BMJ 338: a3152. DOI:10.1136/bmj.a3152. PMID 19153129. PMC PMC2769030. Research Blogging. Cite error: Invalid <ref> tag; name "pmid19153129" defined multiple times with different content
  13. ↑ Lin HC, Xirasagar S, Lin HC, Hwang YT (2008). "Does physicians' case volume impact inpatient care costs for pneumonia cases?". J Gen Intern Med 23 (3): 304-9. DOI:10.1007/s11606-007-0462-3. PMID 18043982. Research Blogging.
  14. ↑ Nelson EC, Splaine ME, Batalden PB, Plume SK (March 1998). "Building measurement and data collection into medical practice". Ann. Intern. Med. 128 (6): 460–6. PMID 9499330. [e]
  15. ↑ Lloyd, Robert M.; Carey, Raymond G. (1995). Measuring quality improvement in healthcare: a guide to statistical process control applications. White Plains, N.Y: Quality Resources. ISBN 0-527-76293-8. 
  16. ↑ Staker, Larry V.; Carey, Raymond G. (2002). Improving Healthcare with Control Charts: Basic and Advanced SPC Methods and Case Studies. Milwaukee, Wis: ASQ Quality Press. ISBN 0-87389-562-2. 
  17. ↑ Norberg A, Christopher NC, Ramundo ML, Bower JR, Berman SA (February 2003). "Contamination rates of blood cultures obtained by dedicated phlebotomy vs intravenous catheter". JAMA 289 (6): 726–9. PMID 12585951. [e]
  18. ↑ Harbarth S, Fankhauser C, Schrenzel J, et al (March 2008). "Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients". JAMA 299 (10): 1149–57. DOI:10.1001/jama.299.10.1149. PMID 18334690. Research Blogging.
  19. ↑ Tekkis PP, McCulloch P, Steger AC, Benjamin IS, Poloniecki JD (April 2003). "Mortality control charts for comparing performance of surgical units: validation study using hospital mortality data". BMJ 326 (7393): 786–8. DOI:10.1136/bmj.326.7393.786. PMID 12689973. Research Blogging.
  20. ↑ Bingham JW, Quinn DC, Richardson MG, Miles PV, Gabbe SG (2005). "Using a healthcare matrix to assess patient care in terms of aims for improvement and core competencies.". Jt Comm J Qual Patient Saf 31 (2): 98-105. PMID 15791769.
  21. ↑ Kernisan, Leslie P.; Sei J. Lee, W. John Boscardin, C. Seth Landefeld, R. Adams Dudley (2009-04-01). "Association Between Hospital-Reported Leapfrog Safe Practices Scores and Inpatient Mortality". JAMA 301 (13): 1341-1348. DOI:10.1001/jama.2009.422. Retrieved on 2009-04-01. Research Blogging.
  22. ↑ {{citation | title = Advances in Patient Safety: From Research to Implementation Volume 1. Research Findings | contribution = Implementing Safety Cultures in Medicine: What We Learn by Watching Physicians | author = Timothy J. Hoff, Henry Pohl, Joel Bartfield | url = http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=aps.section.65 | publisher = National Center for Biotechnology Information, [[National Library of Medicine}}
  23. ↑ Robert L Helmreich (2000 March 18), British Medical Journal title = On error management: lessons from aviation 320(7237): 781–785.
  24. ↑ Jamtvedt G, Young JM, Kristoffersen DT, O'Brien MA, Oxman AD (2006). "Audit and feedback: effects on professional practice and health care outcomes". Cochrane Database Syst Rev (2): CD000259. DOI:10.1002/14651858.CD000259.pub2. PMID 16625533. Research Blogging.
  25. ↑ Thomas RE, Croal BL, Ramsay C, Eccles M, Grimshaw J (June 2006). "Effect of enhanced feedback and brief educational reminder messages on laboratory test requesting in primary care: a cluster randomised trial". Lancet 367 (9527): 1990–6. DOI:10.1016/S0140-6736(06)68888-0. PMID 16782489. Research Blogging.
  26. ↑ Streiff MB, Haut ER (2009). "The CMS ruling on venous thromboembolism after total knee or hip arthroplasty: weighing risks and benefits.". JAMA 301 (10): 1063-5. DOI:10.1001/jama.301.10.1063. PMID 19278950. Research Blogging.
  27. ↑ Rodriguez HP, von Glahn T, Elliott MN, Rogers WH, Safran DG (2009). "The Effect of Performance-Based Financial Incentives on Improving Patient Care Experiences: A Statewide Evaluation.". J Gen Intern Med. DOI:10.1007/s11606-009-1122-6. PMID 19826881. Research Blogging.
  28. ↑ Physician Quality Reporting Initiative (PQRI)
  29. ↑ Fung CH, Lim YW, Mattke S, Damberg C, Shekelle PG (2008). "Systematic review: the evidence that publishing patient care performance data improves quality of care". Ann. Intern. Med. 148 (2): 111–23. PMID 18195336. [e]
  30. ↑ Rothberg, Michael B.; Elizabeth Morsi, Evan M. Benjamin, Penelope S. Pekow, Peter K. Lindenauer (2008-11-01). "Choosing The Best Hospital: The Limitations Of Public Quality Reporting". Health Aff 27 (6): 1680-1687. DOI:10.1377/hlthaff.27.6.1680. Retrieved on 2008-11-10. Research Blogging.
  31. ↑ Tu, Jack V.; Linda R. Donovan, Douglas S. Lee, Julie T. Wang, Peter C. Austin, David A. Alter, Dennis T. Ko (2009-11-18). "Effectiveness of Public Report Cards for Improving the Quality of Cardiac Care: The EFFECT Study: A Randomized Trial". JAMA: 2009.1731. DOI:10.1001/jama.2009.1731. Retrieved on 2009-11-18. Research Blogging.
  32. ↑ Rothberg MB, Benjamin EM, Lindenauer PK (2009). "Public reporting of hospital quality: Recommendations to benefit patients and hospitals.". J Hosp Med. DOI:10.1002/jhm.481. PMID 19514092. Research Blogging.
  33. ↑ Davidoff, Frank; Paul Batalden, David Stevens, Greg Ogrinc, Susan Mooney, for the SQUIRE development group (2008-12-01). "Publication Guidelines for Quality Improvement Studies in Health Care: Evolution of the SQUIRE Project". Journal of General Internal Medicine 23 (12): 2125-2130. DOI:10.1007/s11606-008-0797-4. Retrieved on 2008-12-18. Research Blogging.
  34. ↑ Davidoff F, Batalden P, Stevens D, Ogrinc G, Mooney S (November 2008). "Publication guidelines for improvement studies in health care: evolution of the SQUIRE Project". Ann. Intern. Med. 149 (9): 670–6. PMID 18981488. [e]

External links

Quality measures

Measuring quality improvement

Reporting studies of quality improvement

  1. ↑ Iglehart JK (1996). "The National Committee for Quality Assurance". N. Engl. J. Med. 335 (13): 995-9. PMID 8786789. [e]
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