Transcript Defining performance measurement in the health sector

Dr. Mohammed Alahmed
Dr. Mohammed Alahmed
Defining Performance
Measurement in the
Health Sector
http://fac.ksu.edu.sa/alahmed
[email protected]
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• Healthcare accountability mechanisms have
traditionally included: business planning, annual
reporting and contracting.
• In recent years a richer sense of accountability
has emphasized the achievement of goals
effectively and efficiently and has stimulated PM.
• Performance measures for health have been
developed for the three classical components of
care defined by Donabedian (1988) (structure,
process and outcomes) and at all care levels,
from patient to population.
Dr. Mohammed Alahmed
Introduction
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• Aa good place to start when thinking about
implementing performance measurement in
public health is to understand those things that
are unique or different about public health
practice
• These unique things will inform our performance
measurement development and implementation
strategies
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• It is not possible to design, implement, or even
discuss performance measurement systems
without having defined “performance.”
• What is it that health care systems do that
should be measured? Who uses the information
and for what purpose?
• Healthy People 2020 objectives offer public
health practitioners a built-in set of performance
measures!
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Domains of Performance Measurement
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• Several major domains of performance
measurement are common among many existing
measurement systems:
• Quality of Care
1. Utilization/Cost/Efficiency
2. Satisfaction
3. Financial
4. Other
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• This domain focuses on the clinical content of
care provided for defined groups of patients
• There are an infinite number of potential quality
of care measures available
• Quality measures and concepts could be
categorized into three categories:
• Structure
• Process
• outcome
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Quality of Care
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JCAHO: Joint Commission
on Accreditation of
Healthcare Organizations
NCQA: National
Committee for
Quality Assurance
HEDIS: Health
plan Employer Data and
Information Set
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• Structure refers to those characteristics of a hospital,
health plan, or health care system which are relatively
stable, and create the capacity or opportunity for good
quality.
• Most measures in the JCAHO accreditation system or in the
NCQA/HEDIS accreditation system are structural measures
• Does the organization have a patient safety committee?
Does it have a system for reviewing patient deaths? Does it
have policies for handling dangerous chemicals? Does it
have a credentialing committee?
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• Process refers to what the organization does.
• Most utilization measures (length of stay, ER visit
rate, inpatient days per 1,000) are process measures.
• More clinically-specific process measures include
mammography rates, childhood immunization rates,
or rates of use of breast-conserving surgery.
• Process measures are typically selected because
scientific research has shown a particular practice to
be associated with favorable patient outcomes.
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• Outcome refers to a measurable change in the health
status of a person or group of people.
• Mortality is an obvious outcome measure, but there are
many other measures of morbidity, clinical state (e.g.,
change in blood pressure), functional status (e.g., ability
to return to work) and quality of life that have been used
to assess organizational performance.
• Performance measures reflecting organizational
“outcome” (e.g., change in market share) are not
outcome measures from a quality of care perspective.
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• Different categorization of quality measures has
been produced:
• Underuse
• Overuse
• Misuse
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Underuse
• prescribe beta blockers to patients after acute MI;
• provide immunizations to young children or flu shots to older
adults;
• provide regular screening mammograms to women over 50;
• provide adequate doses of antidepressants to newly
diagnosed depressed patient
• These measures are almost always expressed as
rates, and are calculated after having first
identified a target population of eligible patients
or health plan members.
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• Underuse refers to the extent to which
necessary or indicated services are not provided.
• Examples include: failure to:
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• Overuse refers to the extent to which wasteful,
ineffective, or unproven tests and procedures are
provided to patients who don’t need them.
• Examples include:
• MRIs or x-rays for patients with new, uncomplicated
low back pain;
• antibiotics for patients with viral infections;
• elective surgical procedures for patients without clear
indications;
• use of expensive patented medications when an
equivalent generic is available.
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Overuse
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• Misuse refers to the inappropriate use of
procedures that would be beneficial if properly
applied.
• Most instances of “medical errors” fall in this
category – overdose of medications, wrong-limb
surgery, failure to follow up on abnormal test
results, or adverse drug interactions.
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Misuse
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Prioritize measurement activities
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•
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Prevalence of the clinical condition;
Known incidence or severity of quality problems for that condition;
Feasibility of collecting key data elements;
Clarity of interpretation of performance measures (i.e., either more
or less of the thing must be clearly better);
• Ability of the organization to actually use the data to improve
processes or outcomes;
• Importance of the condition or quality problem to purchasers, the
general public, or significant stakeholder groups.
Dr. Mohammed Alahmed
• Within any system for measuring quality of care, there is
an additional need to prioritize measurement activities
• Selection of quality of care measures for inclusion in
performance measurement systems is usually driven by:
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• Utilization measures are measures of clinical
activity that focus on activity per se, rather than
whether the “right” activities are being
performed.
• Length of inpatient stay is an interesting example
of an efficiency measure that is not interpretable
as a quality measure
Dr. Mohammed Alahmed
Utilization/Cost/Efficiency
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• There are a number of utilization measures that are
already in widespread use. They include:
• Inpatient days per 1,000 or admissions per 1,000 for
defined populations (e.g., managed care plan
members);
• Length of stay;
• Cost or charge per admission (or adjusted admission);
• Bed occupancy rate;
• Cost per member per month;
• ER visit rate.
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• Satisfaction is an accepted part of the quality domain (usually
viewed as an outcome measure)
• There are a variety of standardized satisfaction surveys available
and in use; many provided by private vendors
• A distinction should be made between satisfaction surveys and
reports of care surveys
• Satisfaction surveys are just that – patient or family reports of
the extent to which they were satisfied with various aspects of a
health care encounter
• Scores are recorded on 1-5, or 1-10, or perhaps even 1-100
scales
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Satisfaction
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• Reports of care are similar to satisfaction surveys in some
ways, but different in other important ways
• Reports of care may include questions o particular
aspects of a health care encounter;
• The Picker Institute has been at the forefront of the
movement to use patient report of care surveys
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• This domain of performance refers to familiar measures like
net gain (or loss) or operating gain (or loss).
• These measures reflect the most aggregated analysis of the
balance between revenues and expenses.
• Other performance measures like days in accounts receivable,
days cash on hand, etc., reflect the efficiency of financial
management processes.
• Other related measures include FTEs per occupied bed, cost
per adjusted discharge, or revenue per RVU.
• These measures reflect operating efficiency in financial terms.
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Financial
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• There is really no obvious limit to the range of concepts
that might be included in a set of performance measures.
• Some additional concepts are worth noting here, though:
• Cultural and linguistic competence
• refers to the extent to which health care organizations offer
services
• Community Benefit
• refers to the extent to which a hospital or health care
organization offers valuable services to the community
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Other
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• Incorporate Stakeholder Input
• Promote Top Leadership Support
• Create a Mission, Long-Term Goals, and
Objectives
• Formulate Short-Term Goals
• Devise a Simple, Manageable Approach
• Provide Technical Assistance
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Key Components In Developing An Effective
Performance Measurement Process
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1. Use a balanced set of measures
2. Mature what matters to services users and other
stakeholders
3. Involve staff in determining the measures
4. Include both perception measures and performance
indicators.
5. Use combination of outcome and process measures
6. Take account of the cost of measuring performance.
7. Have clear systems for translating feedback from measures
into a strategy for action.
8. Measurement systems need to be focused on continuous
improvement, not a blame culture.
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Essentials of PM
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