Quality in Health Care:Quality in Health Care:Building Systemic CapacityBuilding Systemic Capacity

Sheila LeathermanAdjunct Professor, University of North Carolina

Sr. Associate, University of Cambridge, England

Seminar OutlineSeminar Outline

I. What is the state of quality?

II. Building Systemic Capacity: A Model

III. Change: Strategy and Methods

IV. Accountability and Public Reporting

V. The Way Forward

Ireland Health StrategyIreland Health Strategy

PRINCIPLESPRINCIPLES– Equity– People-centeredness– Quality– Accountability

Ireland Health StrategyIreland Health Strategy

NATIONAL GOALS– Better health for everyone– Fair access– Responsive and appropriate care– High performance

QualityQuality

“the degree to which health services for individuals and

populations increase the likelihood of desired health outcomes and

are consistent with current professional knowledge”

IOM Definition 1999

Concerns Regarding QualityConcerns Regarding Quality

Physician Perceptions (1999-2000) 5 country survey (Australia, NZ, UK,

Canada, and USA)

% saying ability to provide quality care worsened over 5 years

•Australia 38%•Canada 50%•New Zealand 53%•United Kingdom 46%•United States 57%

Concerns Regarding QualityConcerns Regarding Quality

Nurses Perceptions (1998-1999) 5 country survey (Canada, Germany,

Scotland, England and USA) 17-44% reported quality had deteriorated

in last year

Concerns Regarding QualityConcerns Regarding Quality

Public Perception (1998) 5 country survey ( Australia, Canada, NZ,

UK, and USA) Overwhelmingly stated that health care

system needed “fundamental change or complete overhaul”

1998 American Consumer 1998 American Consumer Satisfaction IndexSatisfaction Index

Hospitals ranked between the U.S. Post Office and the Internal Revenue Service (tax agency)

Performance DomainsPerformance Domains

EffectivenessEfficiencyEquity/AccessSafetyResponsiveness/Patient-Centered

Applicable at individual and population level

Concerns Regarding Quality: Concerns Regarding Quality: Hard FactsHard Facts

Inappropriate use of resources – US data indicates overuse and underuse

Unexplained variation/postcode lottery Safety/Adverse events

– Adverse event rate 10% of hospitals (UK and USA)

– Serious errors 2.3%– 16.6% of hospital admissions in Australia

(1995)

Adverse events cost USA 4% of total health expenditures; 1996

Outstanding claims for alleged clinical negligence in UK was £3.9 billion

Suboptimal QualitySuboptimal Quality Poor resource usePoor resource use

Financial riskFinancial risk

What is needed?What is needed?

Incentives

“Will” to address problems Articulated national policy

Priority setting Performance monitoring capability

“Essential infrastructure new organizations legal framework IT

Knowledge aids (protocols, DSS)

Building Systemic Capacity: Building Systemic Capacity: A ModelA Model

Organizing and Integrating PerformanceOrganizing and Integrating Performance

Policy Formulation & Infrastructure

Performance Monitoring Macromanagement

Operations ManagementGovernance

Clinical Service ProvisionIndividual Accountability

Regional

National

Institutional

Individual

Policy Formulation & Infrastructure

Performance Monitoring Macromanagement

Operations ManagementGovernance

Clinical Service ProvisionIndividual Accountability

Organizing and Integrating QualityOrganizing and Integrating Quality

Organizing and Integrating Organizing and Integrating PerformancePerformance

Policy Formulation & Infrastructure

Performance Monitoring Macromanagement

Operations ManagementGovernance

Clinical Service ProvisionIndividual Accountability

Uni

ted

Kin

gdom

United States

Policy Formulation & Infrastructure

Performance Monitoring Macromanagement

Operations ManagementGovernance

Clinical Service ProvisionIndividual Accountability

IrelandIreland

Effecting Change: Effecting Change: Strategy and MethodsStrategy and Methods

Methods for Improving QualityMethods for Improving QualityApplications and Uses of Performance DataApplications and Uses of Performance Data

External Oversight• External review/inspection• Accreditation, licensing and certification • Setting performance targets

Patient engagement/empowering consumers

• Providing performance information• Enacting patient charters/patient rights legislation

Regulations• Government regulations• Professional/self regulation

Incentives• Financial (pay-for-performance)• Non-financial

Knowledge/Skill enhancement of providers

• Peer review and data feedback• Use of guidelines and protocols

External OversightExternal Oversight

External review/inspectionAccreditation, licensing and

certificationSetting performance targets

Patient Engagement/ Patient Engagement/ Empowering ConsumersEmpowering Consumers

Providing performance informationEnacting patient charters/patient

rights legislation

RegulationsRegulations

Government regulationsProfessional/self regulation

IncentivesIncentives

Financial (pay-for-performance)Non-financial

Knowledge/Skill EnhancementKnowledge/Skill Enhancement

Peer review and data feedbackUse of guidelines and protocols

Knowledge/Skill EnhancementKnowledge/Skill Enhancement

Problem– Both WILL and SKILL problems– Impossibility to assimilate new knowledge

• Numbers of articles published from RCTs– 1960 1000 annually– 1990 10,000 annually

Use of Performance Data– Scant evidence that physicians can/will use for behavior change– Evidence that multiple interventions are needed

• Published protocols/guidelines• Computer assisted decision support• Peer review/practice comparisons

Strategy for Improving Strategy for Improving PerformancePerformance

Regulation Purchasing Facilitation ofconsumer choice

Provider/ Systemsbehavior change

Accountability

Public

Providers

Purchasers

Policymakers

Drivers of PerformanceDrivers of PerformanceU.S. U.K.

Knowledge:Standardsperformancedata

Competition

Regulation

Accountability

Professionalethos

Incentives

Accountability and Public Accountability and Public ReportingReporting

What?What?

The systematic standardized measurement of performance and public disclosure of data

Performance Domains (individual and/or population level)•Effectiveness•Efficiency•Responsiveness•Equity•Safety

Performance Reporting: Why?Performance Reporting: Why?

Unjustified variation/ “postcode lottery” Accountability a growing movement Performance monitoring needed for

regulation “The Information Age” Public confidence eroding

Principle Purposes for Public Principle Purposes for Public DisclosureDisclosure

Regulation (include public accountability) Purchasing or commissioning decisions Facilitation of consumer selection/choice Provider/systems behavior change

Performance ReportingPerformance Reporting

National Quality Reports“Report Cards”League TablesProvider profiling

Current StatusCurrent Status

Measurement and public reporting inevitable

Inadequate evaluation research - what works?

Challenge: How to move ahead responsibly

Evidence of Effectiveness of Evidence of Effectiveness of Performance Reporting: USAPerformance Reporting: USA

PublicProviderPurchaser/payersPolicymakers

The PublicThe PublicEvidence from the USAEvidence from the USA

Performance data used minimally Not meaningful to “the public” Most data designed for other purposes Not easily comprehended or actionable Not salient (example: CABG mortality

rates) Not motivated - individuals believe their

care/provider is “good”

The ProvidersThe ProvidersEvidence from the USAEvidence from the USA

Institutions (hospitals, systems) do pay attention and use:– To improve appropriateness of care– To identify poor performers– To alter processes responsive to complaints

Individual providers less responsive to data

Major QuestionMajor Question: : Public or Confidential Reporting of Performance DataPublic or Confidential Reporting of Performance DataCase StudyCase Study: : Reporting System in New York Reporting System in New York

Publicly reported risk-adjusted mortality past CABG

New York had the lowest risk-adjusted mortality rate in the USA after 4 years.

First 3 years mortality rate fell 41% Rate of decline in New York was twice the

average national rate of decline in first 5 years

Major Question: Major Question: Public or Confidential Reporting of Performance DataPublic or Confidential Reporting of Performance DataCase Study: Case Study: Reporting System in New YorkReporting System in New York

New York CRS: What drove the improvement?

Improvement driven through actions taken by hospital staff– Changes in leadership– curtailment of operating privileges– Intensive peer review

Consumer or market force: minimal action

BUT ….WAS PUBLIC DISCLOSURE THE DRIVER?

Purchasers/Payers/CommissionersPurchasers/Payers/CommissionersEvidence from the USAEvidence from the USA

Little evidence of performance to exercise “market clout”

Two large studies (15,000 employers nation wide)– Data used minimally– Price still main selection factor– Data suffers as not designed for buyer

decision-makers. Reliance on purchasers and payers to use

performance data not a reliable strategy

PolicymakersPolicymakers

Some evidence that policymakers do use comparative performance indicators

New national initiatives in Australia, United Kingdom and United States for national performance reporting

Risks and ChallengesRisks and Challenges

Methodologic issues Manipulation of data “Tunnel vision” Unintended effects on access Erode patient trust Jeopardize QI environment

Adapted from Emanuel and EmanuelAnnals of Internal Medicine, Jan 15, 1996

Conception Domain Methodsof patients of accountability

Professional Recipient of Patient, physician Licensure, Certificationprof. services Prof. Association Malpractice suit

Economic Consumer of Marketplace and Choice and “exit”health care regulationCommodity

Political Citizen Government “Voice” and receivingreforms and government pressurepublic good actions

Accountability: ModelsAccountability: Models

The Way Forward: The Way Forward: Common PitfallsCommon Pitfalls

Common PitfallsCommon Pitfalls Confusion

– Role of government regulation and self-regulation Too Ambitious

– Too many new initiatives– Too many goals/targets– Lack of coherence

Inadequate resources– “Will”– “Skill”– Infrastructure

• IT• Workforce• Infrastructure/capacity

Rhetoric exceeds reality– Cynicism, – Failure to deliver

Knowing is not enough, we must applyWilling is not enough, we must do.

Goethe

Adapted from Emanuel and EmanuelAnnals of Internal Medicine, Jan 15, 1996

Conception Domain Methodsof patients of accountability

Professional Recipient of Patient, physician Licensure, Certificationprof. services Prof. Association Malpractice suit

Economic Consumer of Marketplace and Choice and “exit”health care regulationCommodity

Political Citizen Government “Voice” and receivingreforms and government pressurepublic good actions

Accountability: ModelsAccountability: Models

Policy Formulation & Infrastructure

Performance Monitoring Macromanagement

Operations ManagementGovernance

Clinical Service ProvisionIndividual Accountability

Key StrategiesKey Strategies

Key Strategies for Change

Targets forPerformance

Change

PerformanceReporting

Accreditationand Inspection

Incentives PatientEmpowerment

Regulation Knowledge/Skill

EnhancementProviders X X X X X

ProfessionalBodies

X X X

Public X X X X

Payers andContractorPurchasers

X X X

Policy makers X

Drivers of PerformanceDrivers of PerformanceU.S. U.K.

Knowledge:Standardsperformancedata

Competition

Regulation

Accountability

Professionalethos

Incentives

Strategy for Improving Strategy for Improving PerformancePerformance

Regulation Purchasing Facilitation ofconsumer choice

Provider/ Systemsbehavior change

Accountability

Public

Providers

Purchasers

Policymakers