NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

NURS 6231 – Healthcare Systems and Quality Outcomes Case Study NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Healthcare Outcome Measures Explained There are hundreds of outcome measures, ranging from changes in blood pressure in patients with hypertension to patient-reported outcome measures (PROMs). The seven groupings of outcome measures CMS uses to calculate hospital quality are some of the most common in healthcare:NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Permalink: nurs-6231-health…comes-case-study / #1: Mortality Mortality is an essential population health outcome measure. For example, Piedmont Health care’s evidence-based care standardization for pneumonia patients, resulted in a 56.5 percent relative reduction in the pneumonia mortality rate. #2: Safety of Care Safety of care outcome measures pertain to medical mistakes. Skin breakdown and hospital-acquired infections (HAIs) are common safety of care outcome measures: Skin breakdown—happens when pressure decreases blood flow to the skin. A skin assessment tool can be used to reduce skin breakdown. Patients with skin breakdown are at a higher risk of infection. Patients’ risk scores go up if they’re diabetic, for example, because their circulation is poor. HAIs—caused by viral, bacterial, and fungal pathogens. For example, Texas Children’s Hospital identified evidence-based bundles to reduce HAIs in children through their partnership with the Solutions for Patient Safety National Children’s Network. Using an enterprise data warehouse (EDW) and analytics applications to identify vulnerable patients and monitor clinicians’ compliance with best practice bundles, Texas Children’s Hospital decreased HAIs by 35 percent.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study #3: Re admissions Readmission following hospitalization is a common outcome measure. Readmission is costly (and often preventable). In fact, researchers estimate that in one year, $25 to $45 billion is spent on avoidable complications and unnecessary hospital readmissions. After increasing efforts to reduce their hospital readmission rate, the University of Texas Medical Branch (UTMB) saw a 14.5 percent relative reduction in their 30-day all-cause readmission rate, resulting in $1.9 million in cost avoidance. UTMB reduced their hospital readmission rate by implementing several care coordination programs and leveraging their analytics platform and advanced analytics applications to improve the accuracy and timeliness of data for informing decision making and monitoring performance.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study #4: Patient Experience Patient-reported outcome measures (PROMs) fall within the patient experience outcome measure category. According to the Agency for Clinical Innovation (ACI), PROMs “assess the patient’s experience and perception of their healthcare. This information can provide a more realistic gauge of patient satisfaction as well as real-time information for local service improvement and to enable a more rapid response to identified issues.” For example, a patient might be asked to complete a satisfaction survey (on a scale of 1-5) about the care they received. Patient experience may also be used as a balance metric for improvement work. For example, a care delivery process may decrease the LOS, which can be a positive outcome, but result in a decreased patient satisfaction score if patients instead feel they are being pushed out.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study #5: Effectiveness of Care Effectiveness of care outcome measures evaluate two things: Compliance with best practice care guidelines. Achieved outcomes (e.g., lower readmission rates for heart failure patients). Given the rapid changes that occur within healthcare, making sure best practice care guidelines are current is critical for achieving the best care outcomes. It’s important to track clinician compliance with care guidelines; It’s equally important to monitor treatment outcomes and alert clinicians when care guidelines need to be reviewed. Failing to adhere to evidence-based care guidelines can have negative consequences for patients. For example, according to The Dartmouth Atlas of Healthcare, “even though it is well established that beta-blockers can reduce the risk of heart attack in patients who have already had one heart attack, many heart attack patients are never prescribed beta-blockers.”NURS 6231 – Healthcare Systems and Quality Outcomes Case Study #6: Timeliness of Care Timeliness of care outcome measures assess patient access to care. Overcrowding in the emergency department has been associated with increased inpatient mortality, increased length of stay, and increased costs for admitted patients. A community hospital system implemented an improvement process to address overcrowding in its ED after determining that approximately 4,000 patients were leaving its ED each year without being seen. They leveraged their analytics platform to develop an ED analytics application that provided actionable, timely ED performance data to focus improvement efforts on four areas: staffing patterns, registration, triage assessment by the registered nurse, and early access to a qualified medical provider. They achieved significant performance improvements, including an 89 percent relative reduction in the rate of patients that left without being seen, with current performance at 0.4 percent.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study The efficient use of medical imaging is an increasingly important outcome measure. According to the European Science Foundation, “Medical imaging plays a central role in the global healthcare system as it contributes to improved patient outcome and more cost-efficient healthcare in all major disease entities.” For example, during Texas Children’s Hospital’s efforts to improve asthma care it discovered a high volume of chest X-rays being administered to asthma patients. Using its EDW to examine real-time X-ray data, it realized clinicians were ordering chest X-rays for 65 percent of their asthma patients—evidence-based practice calls for X-rays in only five percent of cases. Texas Children’s Hospital’s IT team traced the problem to a faulty order set within the hospital’s EHR, and rewrote the order set to reflect the evidence-based best practice.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Process Measures Are Equally Important Achieving outcomes is important, but the process by which health systems achieve outcomes is equally important. Process measures capture provider productivity and adherence to standards of recommended care. For example, if a health system wants to reduce the incidence of skin breakdown, then it might implement the process measure of performing a risk assessment using the Barden Scale for reducing pressure ulcer risk in all the appropriate units in the hospital. If health systems are too focused on an outcome, then they lose sight of the process. The following outcome and process measures illustrate how systems can improve healthcare outcomes by improving processes:NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Conducting a medication reconciliation system check with heart failure patients at the time of discharge (process measure) can reduce heart failure readmission rates (outcome measure). Performing a fall risk assessment on a patient at the time of admission (process measure) can reduce fall rates (outcome measure). Using a skin assessment tool (process measure) can prevent skin breakdown (outcome measure). Three Essentials for Successful Healthcare Outcomes Measurement Among every health system’s goals is to improve patient outcomes. But outcomes improvement can’t happen without effective outcomes measurement. As health systems work diligently to achieve the Quadruple Aim, they need to prioritize three outcomes measurement essentials: transparency, integrated care, and interoperability. Used in tandem, these essentials improve and sustain outcomes measurement efforts by creating a data-driven culture that embraces data transparency, an integrated care environment that treats the whole patient and improves critical care transitions, and interoperable systems that enable the seamless exchange of outcomes measurement data between clinicians, departments, and hospitals.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study #1: Data Transparency Healthcare is on a journey to outcomes transparency. Patients rely on outcomes data to make educated decisions about their healthcare. Quality reporting organizations, such as The Leap Frog Group, evaluate and report on U.S. hospital safety and quality performance. Patients want reassurance that they’re receiving the best care for the lowest cost. Publicly reported healthcare outcomes help do just that. #2: Integrated Care and Transitions of Care The industry is also shifting toward integrated care—hospitals aren’t just treating a hip anymore; they’re treating the whole person. A key component of integrated care is helping patients with transitions: easing patient transitions from the ER, to surgery, to inpatient care, to rehab, and, ultimately, back to a steady, normal state. Transitional points of care are critical for managing consistency of care and providing the right care in the right setting at the lowest cost.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study #3: Data Interoperability Sharing data between departments within an integrated system is another important component. Outcomes measurement and improvement depends on the system’s ability to share data across clinicians, labs, hospitals, clinics, pharmacies, and other staff, departments, and settings. EDWs improve interoperability by integrating data and providing a single source of truth. Improving critical care transitions through integrated care and seamlessly exchanging data through interoperability are essential ingredients for better outcomes measurement. For example, as heart failure patients are discharged (depending on the risk stratification), it’s critical for them to see a cardiologist or primary care physician as quickly as possible. Otherwise, they have a higher risk of being readmitted.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study The Quadruple Aim: The Goal of Outcomes Measurement Outcomes measurement should always tie back to the Quadruple Aim, so healthcare organizations aren’t just reporting numbers. Health systems shouldn’t become so obsessed with numbers that they forget their Quadruple Aim goal. Instead, they should focus on quality and improving the care experience at the most efficient cost. Health systems measure outcomes to ensure they are delivering the best care for patients and providing a transparent, efficient, and accessible environment for all healthcare providers. That is outcomes nirvana. Policies to improve population health have often focused exclusively on the expansion of access to basic health services, to the neglect of quality of care. Efforts to increase the demand for priority interventions have implicitly assumed that the care available is of sufficient quality or that, with the expansion of coverage, quality will naturally improve.1 However, such assumptions may be incorrect. There is growing recognition that people may be acting in a perfectly rational way when they avoid using health services of poor quality and that poor quality of care can be a barrier to universal health coverage independent of access.2NURS 6231 – Healthcare Systems and Quality Outcomes Case Study The aim of many strategies to improve health-care quality has been to ensure that essential inputs – e.g. technology, operational facilities, pharmaceutical supplies and trained health workers – are in place.3 Many such strategies have focused on the supply side and been designed to support the provision of services according to clinical guidelines.4 The acknowledgement that quality improvement approaches should be applied within patient-centered models of care is relatively recent.5 In this paper we seek to unpack complexities around quality of care and identify strategies for improving the measurement of such quality. An understanding of these issues could inform pragmatic strategies for the analysis and measurement of quality of care. We draw on research conducted in a variety of low- and middle-income countries and identify areas of inherent complexity that require further in-depth research. In doing so, we reflect on what is meant by quality of care and how perceptions and understanding of quality of care influence health systems and effect the measurement of quality.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study We have identified and structured our discussion around six conceptual and measurement challenges. First is the recognition that, even though they may not reflect actual quality, perceptions of the quality of care are an important driver of care utilization. Second, a patient’s experience of quality must be conceptualized as occurring over time. Third, responsiveness to the patient is a key attribute of quality. Fourth, so-called upstream factors – e.g. management at facility and higher levels – are likely to be important for quality. Fifth, quality can be considered as a social construct co-produced by different actors. Finally, there are substantial measurement challenges that require the adaptation and improvement of current approaches. The classic framework on quality of care developed by Donabedian makes the distinction between structure, process and outcomes.6 More recently, the Institute of Medicine in the United States of America (USA) has unpacked the concept further and suggested that efforts to improve care quality should be focused around six aims: effectiveness, efficiency, equity, patient-cent redness, safety and timeliness. We do not seek to propose a new framework for understanding quality. Rather, we highlight some key issues that deserve more consideration in debates about enhancing the accessibility and quality of care. Building on our experiences of doing empirical research in low- and middle-income countries, we present several insights that are complementary to existing, comprehensive frameworks of quality of care and may be absent from current debates.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Clinical quality Clinical quality of care relates to the interaction between health-care providers and patients and the ways in which inputs from the health system are transformed into health outcomes. The care provided should be effective, evidence-based and neither underused nor overused.7 The concept of clinical effectiveness tends to shift attention away from inputs such as drugs and equipment and towards the process of care.6,8 While relatively easy to measure, the availability of inputs cannot generally be used in isolation to determine if a patient’s health is likely to improve as a result of the care received.9 Clinical processes are directly attributable to the behaviour of health-care providers and their measurement can provide a critical starting point in the development of methods to improve care received by patients. Although health outcomes can be informative, they are only likely to be a crude measure of quality because of the inherent unpredictability in patients’ responses to health care.9NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Assessment of the clinical quality of care poses several conceptual and practical challenges. It requires a strong evidence base that can act as a benchmark against which to evaluate interventions. In high-income countries, treatments received can be compared with the treatments recommended in national guidelines. In many low- and middle-income countries, however, such guidelines are either not available or poorly enforced. Even when such guidelines are present, the evaluation of what constitutes the over provision of care is not clear-cut and requires careful judgement. Although harmful care should be distinguished from unnecessary care, such categorization can be difficult in practice. Care for a single patient may be provided over the course of numerous interactions by a large team of health professionals. In such circumstances, measurement of the quality of care often focuses on a small number of distinct interventions with proven efficacy.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study There are several well-known practical challenges to the assessment of the clinical quality of care. For example, it may not be possible to observe the interactions between patients and their physicians and, when they are possible, such observations can generate bias through the Hawthorne effect, i.e. health-care providers change their behaviour when observed.10 In low- and middle-income countries, medical records are often poorly maintained and may not reflect actual practice. The use of so-called undercover or standardized patients in the assessment of clinical care may raise ethical concerns,11 is generally limited to non-invasive conditions12 and is not a practical solution to the routine measurement of quality.9 Despite these challenges, an influential literature on the clinical quality of care in low- and middle-income countries is emerging.2,13NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Perceived quality Attempts to improve the quality of care have often been underpinned by a biomedical understanding of quality – i.e. the conceptualization of a gold standard of quality guided by clinical guidelines – that can lead to a narrow focus. Provider practices tend to vary despite the existence of accountability procedures and guidelines.14 Interventions may not be implemented as intended or easily accommodated within established models of care.15 Clinical quality is important for patient outcomes but perceptions of the quality of care – which may not correlate with actual quality – are likely to be the key drivers of utilization.16,17 Patients may also find it difficult to evaluate the quality of care because they lack their physician’s medical expertise and training.18,19 In South Africa, a key motivating factor in patients’ travel to access health services – including travel across borders – was found to be the patients’ perceptions of the quality of health services.20 Patients may sometimes believe an ineffective and unsafe treatment to be good, even when they have access to effective and safe treatments. In Malaysia, for example, many people with hypertension seek potentially ineffective and unsafe treatments from traditional practitioners.21 Perceptions of the quality of care are based on a mix of individual experience, processed information and rumor. In Uganda, perceptions of the quality of the care that was locally available were found to have persuaded many women to seek maternal care away from their local area – apparently regardless of the availability of transportation and the distances involved.22 In Bangladesh, despite a nationwide expansion in the network of health facilities, facility-based deliveries remained rare and most women still attempted to give birth at home or, in the case of complications, at distant periurban health cent res that the women believed to offer care of higher quality than that available at the community facilities closest to their homes.23,24 Patients’ trust in services has been shown to be an important element of perceived quality.25NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Perceptions of the quality of care may relate entirely to non-clinical factors. For example, criminalized or marginalized populations – e.g. some ethnic or sexual minorities – may judge the quality of care only according to the extent that the care environment is non-discriminatory or supportive.26 In Zambia, many patients considered public-sector clinics supported by one particular nongovernmental organization to be better than other public-sector facilities that apparently provided the same standardized package of care.27 The effect of perceived quality is not limited to delivery models. Among remote rural populations in Armenia, there was disappointingly low participation in community-based health-insurance schemes because the quality of the care provided by the schemes was perceived to be low. Despite the often high out-of-pocket costs, most people in the communities covered by the schemes preferred to use district-based clinics and hospitals – where they believed the quality of care to be higher than in the facilities covered by the schemes.28 Although quality is a construct largely based on individual subjective perceptions, such perceptions are shaped by collective and traditional beliefs and peer influences. While improving or, at least, maintaining the actual quality of the care they provide, health systems need to address – and ultimately close – the gap between perceived and actual quality.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Quality as a process There is a temporal dimension to both clinical and perceived quality. Although the Donabedian framework recognizes the importance of understanding the process of care,6,8 the quality of care may often be assessed in just a single encounter or illness episode. However, individual treatment for most diseases is not a one-off event but a succession of treatment episodes. Patients’ perceptions of quality may develop over time, as the different attributes of the services available and their outcomes are revealed. Waiting times and staff attitudes may be perceived rapidly. However the patient’s experience of clinical treatment, e.g. surgery, and its implications for subsequent care, e.g. frequent check-ups, and health outcomes, e.g. potential complications, may carry on developing over months or years. Patients may only become sensitized to the benefits of having a dedicated provider and effective follow-up after they experience the absence of such benefits. Easy-to-navigate pathways to care and continuity are critical to how patients perceive the quality of care and choose whether to continue treatment or not.29 Long-term compliance is only likely if the patients involved consider their care to be of good quality. Such compliance is a particular challenge in the monitoring and treatment of chronic noncommunicable diseases and human immunodeficiency virus, especially for the under-resourced health systems of low- and middle-income countries.30–33NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Responsiveness While The World health report 2000. Health systems: improving performance34 defined responsiveness to people’s non-medical expectations as a key health-systems goal, the relationship between responsiveness and quality has rarely been discussed. Although ability to book an appointment, confidentiality, privacy, respect shown by staff and waiting times are not service attributes that are clinically necessary, they may all influence patients’ perceptions and their willingness to return for – or adhere to – treatment. At a broader level, responsiveness involves respect for cultural needs and the preferences of specific patient groups – e.g. ethnic, gender and sexual minorities and migrants. The relationship between health workers and their patients often develops over time and multiple episodes of care. As levels of trust and mutual understanding increase, responsiveness and the patients’ perceptions of the quality of their care often improve.35 Although responsiveness to need is often consistent with good clinical practice, it represents an added layer in the patients’ perceptions of quality. In one South African study, women appeared to have been given greater access to public maternity wards but it was the verbal abuse that the women often suffered on such wards that largely shaped the women’s poor perceptions of the care that they had received.36NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Upstream factors The patient–provider interaction is likely to be influenced by governance and management practices at national, sub national and facility levels. The results of studies in the United Kingdom of Great Britain and Northern Ireland and the USA have demonstrated the key importance of management in ensuring care of high quality.37 In low- and middle-income countries, however, there appears to have been little consideration of the role of management practices – especially at district or facility level – in influencing the quality of care. There is increasing recognition that health professionals do not act in isolation and that governance, management and structural factors also determine the performance of health systems.38,39NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Even when front line providers do have substantial discretion in their interpretation of regulations and freedom to adapt treatment protocols, their actions may still largely depend on upstream factors related to institutional capacity, legal sanctions and professional norms. A study of tuberculosis cases in Samara, in the Russian Federation, revealed that while entry to the care system was relatively easy and formally free and pharmaceuticals were highly subsidized, some cases from marginalized groups – e.g. former prisoners, migrants and people not registered with the authorities – still avoided treatment because of perceived discrimination, loss of social status and stigma.40 Both behavioral and structural factors can be important when assessing perceived quality of care. Quality as a social construct Assessment of quality of care in low- and middle-income countries is frequently conducted at the individual level by using various tools – e.g. clinical observations, exit and in-depth interviews, extraction of medical records, role-playing vignettes and standardized patients, designed to assess both patients’ experiences and technical quality. However, social networks influence perceptions relating to both health services and illness.41 Therefore, for a comprehensive investigation of the development of the general public’s and patients’ perceptions of the quality of care, we need to examine community and family values.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study In many situations, patients may have responses to a health provider’s actions and, similarly, providers may adapt their responses to patients to suit social norms.42 For example, a patient may be recommended a clinical investigation and they may either agree to be investigated – e.g. if the proposed investigation is offered by a provider trusted by the patient’s social network – or they may exit the system and seek care elsewhere, e.g. from a more trusted traditional practitioner. Such responses may be considered as a social relationship that can happen in formal care settings, or elsewhere. Perception of quality can also be shaped by power relationships in society. In a study in the Russian Federation, the women most likely to undergo pregnancy-related procedures were found to be the relatively young and poorly educated. Although such women were relatively poor and therefore found it particularly hard to pay for their care, they appeared to be given little choice – possibly because of their relatively low social status and inability to negotiate care that was commensurate to their needs.43 Similar discrepancies between what health professionals felt would improve the quality of care for non-compliant patients and those patients’ preferences and wishes were observed in a study of tuberculosis cases in India. In that study, the number of treatment choices offered was found to be positively correlated with social status.44NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Measurement challenges In light of the above discussion, there is a case for taking a broader perspective when measuring quality of care. Although this has been recognized by the World Health Organization’s monitoring framework for universal health coverage45 – which considers effectiveness of treatment, patient safety, people-cent redness and the level of integration of health services as key dimensions – the focus of recent assessments of the quality of care has been on indicators of health-service coverage.45,46 We suggest that, for a comprehensive and detailed assessment of the quality of health services, both clinical and perceived quality of care need to be evaluated and then compared (Box 1). Alongside technical measures of quality, attention should be given to manifestations of quality – e.g. acceptability, cultural appropriateness and responsiveness. Strategies to improve clinical quality only have the potential to increase demand for care if the general public’s perceptions of the quality of the care available also improve.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Box 1. Principles for measuring the quality of health care Measure aspects of care that go beyond technical quality, e.g. responsiveness, acceptability and trust. Measure perceived quality and compare with clinical quality. Measure quality at different points in the patient pathway through the health system. Measure the immediate and upstream drivers of quality of care. Measure collective and individually assessed quality and its relationship to power, social norms, trust and values. Any evaluation of the overall quality of care needs to consider a patient’s experience of quality as a cumulative process. Changing patterns of illness and increasing numbers of treatment options mean that an increasing amount of health care involves a sequence of interlinked contacts – with a range of health professionals at different levels of the health system – over a lengthy period.47 A patient’s perceptions may vary widely as treatment follows diagnosis and follow-up follows treatment, with each stage potentially affecting the patient’s subsequent choices. By measuring clinical and perceived quality at each key step in this continuum of care, it should be possible to generate a better, more nuanced understanding of how patients interact with health systems.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study A growing body of work focusing on measures of patients’ perceptions now exists. To understand these perceptions more holistically, qualitative methods need to become an integral part of quality assessments. In such assessments, theory-driven hierarchical models can be useful in generating propositions to guide empirical research or help deepen interpretation.48 Mid-range program me theories48 and open-box evaluations49 have also been useful in examining why and how particular health program mes work. Although the measurement of indicators that are rapidly observed by patients seeking care – e.g. staff attitudes and waiting times – can be useful, it is important to delve deeper and study how upstream factors, such as management practices, matter – e.g. by influencing staff morale. Use of carefully selected proxies for quality of care and comparison of findings generated through different methods may help to inform pragmatic intervention strategies. Finally, assessment of individual perceptions of the quality of care and examination of how such perceptions are rooted in community, family and societal expectations, norms and values may offer a promising way forward. Perceived quality may correlate closely with the expectations and social status of the users themselves, the circumstances in which the users obtain care and/or the levels of community cohesion and resources that enable collective action. Although the inclusion of contextual variables and appropriate units of observation for studying community and social group-level characteristics may be methodologically challenging, it is important for understanding individual choices and perceptions.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study Conclusion Recognition of the multifaceted nature of the quality of care is critical for scaling up priority health interventions. If uptake of health services is to be increased, we require not only better technical quality but also better acceptability and patient-cent redness – across the continuum of care. Perceptions of quality are shaped by interconnected community, health-system and individual factors. Moreover, quality of care cannot be understood f

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