Transcript Lecture 5 : Reach and impact

Leadership and Governance: The
Quality Assurance System
Unit 5: Reach and Impact
Outline
1. Identifying quality in health system
2. Locating units, agents, institutions
responsible for governing quality
3. Classify incentives for units and agents
positions
4. Syndromes in governance and quality
5. Spillovers from quality to service delivery
Part 1: Quality in the Health System
Where does quality matter
Aspects of Quality
Primary health services
Workforce
Supply chain
Finance
Information systems
Household
How to Define Health System Quality
• Donabedian’s Trinity
– Structure
• Who does what?
• What certifications and qualifications?
– Process
• What gets done?
• Did so and so do this or that?
– Outcome
• What happened to the patient’s health?
• Deaths, complications, satisfaction
Measurement
• The invisibility of quality is the root of
countless problems in health systems
• Measuring quality and informing agents
about quality is the solution
– Measurement and information flow:
• Costs money
• Threatens some important agents
Structure Measurement
• Document review
– What are credentials of staff
– What are written policies for operations
– Do staff seem to know the policies
– Dust, dirt, rodents?
Process Measurement
• What percent of patients were immunized?
– Counseled?
– Got timely treatment?
• Did staff wash hands?
• Do staff take temperatures properly?
Outcome measures
• Deaths while in treatment
• For acute conditions:
– Cure rates
– Readmission rates
– Nosocomial infection rates
• For chronic conditions:
– Numbers of flare ups, ER visits
– Quality of Life Measures
Part 2: Agents Units and Institutions
Public Goods
• Problem because quality is a public
good
• Pure public goods defined as nonrival and non-excludable
– Non-rival goods: consumption by A does not
effect consumption by B
– Non-excludable goods: goods where one
cannot exclude persons who want to enjoy
the product
Facts about public goods
• Public goods are always in shortage
– Free riders always assume someone else will
provide the public good
• Examples:
– Throwing litter in the public park
– Keeping street lights on at night
– Agents not fully incentivized to deliver these
goods
Principals and Agents
• Ultimate principals (the ones who
“contract” with agents to receive quality)
are the patients
• Agents are:
– Health providers
– Drug vendors and suppliers
– Financiers
Leading examples of public goods
from health
• Controlling contagious disease
• Controlling environmental health threats
– Air, Water, Rats, Mosquitoes
– Regulating dangerous consumer products
– Safe roads
• Ensuring the quality of health services in a
country
• Protecting vulnerable populations
Taxonomy
Rival
Excludable
Non-Excludable
Private
Goods
Common Pool
Resources
Cheeseburgers
Trout streams
Merit goods
(maybe?)
Haircuts
Personal trainers
NonRival
Club Goods Pure Public Goods
Cable TV
HMO quality
National Defense
Quality of all the clinical services in a
country
Part 3: Incentives
Incentives for Providers
• Why would they have low quality?
– It takes effort to do the right thing
• Extra time to counsel patients
• Extra time to look up drug doses and clinical
records
– Time spent on quality could be used to see
more patients in private practice
• Quantity and quality are in conflict
Institutions and Incentives
• There are institutions that affect the trade-off between
doing a lot for each patient and seeing more patients
• Example 1: The Medical Student
– Immediately presenting patient case to their supervisor
– Supervisor rates student for thoroughness and quality
– Student not paid for seeing extra patients
• Example 2: The Drug Seller
–
–
–
–
3 drugs on their shelf
no supervisor
income depends on moving product off the shelf
Only potential loss of reputation might reign in profit seeking
Typical government health worker
• Govt health worker paid a low level salary
not tied to number of patients
– Some supervision via patient flow log
– Inconsistent oversight of the log
• Income can be supplemented by referral
to income-generating activity
– “Come see me in my evening clinic”
Private healer paid cash for service
• Patients expect to leave with something in
the hand: piece of paper, drugs
• Potential profit from marking up drugs
– Japan: doctors expected to sell and dispense
Professionalism and Empathy
• Professionalism goes beyond incentives
• Admission process tries to select ‘moral’
people into health care professions.
– Health workers join the profession because
they are concerned for their patients
– They are also motivated by knowing how they
are they performing relative to peers
• Sometimes just telling providers how they
are doing is enough to trigger change
Part 4: Syndromes in Quality
Syndrome 1: Insufficient training
• Health workers lacked pre-service training
• Lacked in-service training to keep up with
new technology
• Underlying difficulty is shortage of training
resources
Cure for lack of training
• More Units that training
• More institutions that emphasize training
– Specialty societies
– Specialty boards
– Peer credentialling
Syndrome 2: Insufficient oversight
• Training alone is never enough
• Post-training supervision
• Underlying difficulty is lack of resources for
the supervision
• Lack of information flows about health
worker quality
• Lack of measurement tools
Cure for lack of oversight
• Units that oversee
• Institutions that incentivize oversight
– Quality oversight is a public good
– Quality oversight can become a “club good”
• Example 1) The staff model HMO
– Combines financing like vouchers with quality
regulation
• Example 2) Social franchises
– Franchise membership fees paid to quality regulator
Syndrome 3: Uninformed Patients
• Patients can’t distinguished effective from
ineffective technical quality of care
• Patients often can’t take action (even if
poor quality is recognized)
Cure for Uninformed Patients
• Need units that inform patients
• Need units that help patients act on
information about quality
• Example 1) A health care services report
card by independent rating agency
– How financed? How to maintain independent?
– How to maintain trust?
• Example 2) Malpractice legislation
Part 5 Spillover Effects
Primary Health Care and Quality
• Public vs. Private affects Quality Strategy
– Supply led strategies for public sector
• Government command and control
• Regulation
– Demand side strategies for private sector
• Tying vouchers to quality providers
Supply chain and Quality
• Supply is an aspect of healthcare quality
that consumers can observe ‘
• They will respond by increases in demand
– Empty shelves are an obvious mark of low
quality
– Full shelves are necessary but not sufficient
Financing and Quality
• Staff model HMO is one option
• So is a Preferred Provider Organization
• Many contractual options that can tie
finance to quality
Summary
1. Identified 3 aspects of quality in health
system
2. Located units, agents, institutions
responsible for governing quality and
defined “Public Goods”
3. Classified incentives for units and agents
positions
4. Syndromes in governance and quality
5. Spillovers from quality to service delivery