Transcript 원문보기 - 서울대학교 의과대학 의료관리학 교실

의료의 질 관리(2):
Performance Measurement
2010. 9. 30.
서울의대 의료관리학교실
김
윤
IF YOU CAN'T MEASURE IT, YOU
CAN'T MANAGE IT ...
Role of Performance Measurement
• Health system to deliver effective health care
and secure population health.
– to secure accountability within the system
– to determine appropriate treatments for patients
– to facilitate patient choice and/or for managerial
control
• Assuring governance of the health system
3
Core component of
quality improvement policy: US
Collaborative
Quality
Improvement
• Pay for
Performance
• Payment denial
for HAC
Value-Based
Purchasing
Performance
Measurement
& Reporting
CMS &
State
Quality
Reporting
4
평가인증제도는 질을 보장하는가?
• 인증결과와 임상질지표 평가결과간에 직접적 상관관계(-)
– Dean Beaulieu and Epstein 2002; Grasso, Rothschild, Jordan and Jayaram 2005;
Griffith, Knutzen and Alexander 2002; Miller et al. 2005
• Dean 등(2002) : NCQA 인증과 질적 수준
– NCQA 인증여부가 최소질적 수준 보장 못함
– HEDIS 질지표를 인증평가기준에 적용 필요
• Chen 등(2003) : JCAHO 인증과 AMI 진료
– 인증받은 병원들간에 커다란 질적 수준 차이
– 질지표 평가결과를 인증 여부 결정에 활용 필요
• Barker 등(2002) : 인증 여부와 투약오류 발생률
– 인증 여부와 투약 오률 발생률 간에 상관관계 없음
임상질지표 기반 질평가 및 질향상 필요
5
EFQM Excellence Model
6
Definition
• Performance measurement evaluates the extent to
which a health system meets its key objectives.
– objectives reflect different historical trajectories, political,
financial and organizational priorities and the power of
interest groups and stakeholders
• The World Health Report 2000 defined three intrinsic
goals of health systems
– improving health
– increasing responsiveness to the legitimate demands of
the population
– ensuring that financial burdens are distributed fairly
7
Definition
• Use of statistical evidence to determine progress toward
specific defined organizational objectives
– Various aspects, methods, and tools
– How well each company performs is dependent on the strategic plan.
– Basic financial ratios such as debt-to-equity ratio
• Performance measurement systems
–
–
–
–
–
Balanced Scorecard (Kaplan and Norton, 1993, 1996, 2001),
Performance Prism (Neely, 2002)
Cambridge Performance Measurement Process (Neely, 1996)
TPM Process (Jones and Schilling, 2000)
7-step TPM Process (Zigon, 1999)
8
Dimensions of Health Performance Measures
9
Dimensions of Health Performance Measures
10
Dimensions of Health Performance Measures
11
Typology
• National Library of • HEDIS
Healthcare Indicators – Quality
(1997): JCAHO
– Satisfaction
– Clinical performance
– Health Status
– Satisfaction
– Administrative/
Financial
– Access to services
– Utilization
– General plan
management
– Financial measure
Context
Scope
• Performance
measurement :
broader scope than
Quality indicator
Target
• Health system
– National
– Regional
• Organization
– Including hospital
13
WHO : Health systems performance
• improving the health of the
population they serve;
• responding to people's nonmedical expectations;
• providing financial protection
against the costs of ill health.
Objectives
Health
Responsiveness
Financial contribution
Level Distribution
x
x
x
x
x
Quality
Equity
미국 : National Healthcare Quality Report
15
미국 : National Healthcare Disparity Report
16
17
질 평가 결과의 공개: CMS
• 폐렴환자에서 항생제 투여 시점의 적절성
18
19
JCAHO Accreditation Report:
National Patient Safety Goals
20
Components of a performance
measurement system
• Standardized performance measures
• Access to patient data
• Data verification and auditing
• Comparative analysis and reporting capability
Components of a performance
measurement system
• Standardized performance measures
– Measures with detailed specifications
• e.g. definitions for the numerator and denominator /
sampling strategy if appropriate
– allowing for “"apples-to-apples”" comparisons
– sometimes requiring effective risk adjustment or
stratification of results across key subgroups
Components of a performance
measurement system
• Access to patient data
– Calculation of many performance measures
requires access to patient-level data from
administrative files and chart reviews
– Other measures require asking patients to
complete surveys that allow assessment of their
perceptions of their care, their quality of life, or
their functional status.
Components of a performance measurement
system
• Data verification and auditing
– Accuracy of data for performance measures
• A key element of a quality measurement and reporting
system
• e.g. self-reported data
– External auditing function often desirable or
mandatory
Components of a performance
measurement system
• Comparative analysis and reporting capability
– To support the decisions of consumers, purchasers,
referring physicians, and other stakeholders in
choosing plans, providers, or treatment options
– Similarly, improvement efforts that draw on
knowledge of best practices benefit from
comparative data.
STANDARDIZED PERFORMANCE MEASUREMENT: Pioneering
effort
•
Efforts under way for more than 15 years
•
Health Plan Employer Data and Information Set (HEDIS)
– One of the oldest and perhaps most successful quality measurement efforts
– First released in 1989 by members of The HMO Group and large employers
– subsequently adapted and refined by NCQA
•
CMS
– requires health plans participating in the Medicare program to submit data on HEDISdeveloped measures
– comparative quality reports available on the CMS Web site
•
Many state governments
– require plans participating in Medicaid to report HEDIS data
•
•
•
•
New York State Department of Health
Texas Health and Human Services Commission
Washington State Department of Health and Human Services, 2005
HEDIS measures are frequently used in the nearly 90 pay for performance
programs sponsored by private purchasers
STANDARDIZED PERFORMANCE MEASUREMENT:
Pioneering effort in Hospital care area
• Phase 1: DHHS and JCAHO – before 1990s
– CMS released comparative reports on hospital
mortality (HCFA, 1987).
– JCAHO developed and field tested six sets of
standardized performance measures (mid-1980s)
• perioperative care, obstetrical care, trauma care, oncology
care, infection control, and medication use
• intent to require accredited hospitals to submit data on
these measures
– Both of these efforts were abandoned
• strong objections from the hospital sector
STANDARDIZED PERFORMANCE MEASUREMENT:
Pioneering effort in Hospital care area
• Phase 2: In 1990s
– JCAHO allowed great discretion in selecting measures from a
large menu, and the measure specifications were not
standardized
• three of five standardized measure sets
• acute myocardial infarction, heart failure, pneumonia, pregnancy and
related conditions, and surgical infection prevention
• Phase 3: 2000s
– CMS announced a voluntary hospital reporting initiative linking
a hospital’s payment update under Medicare to the submission
of data for a set of standardized measures from the JCAHO
ORYX system (CMS, 2004)
– In 2005, CMS began publicly reporting hospital comparative
data based on these measures via its Web-based tool, Hospital
Compare (CMS, 2005b).
STANDARDIZED PERFORMANCE MEASUREMENT:
Pioneering effort in other areas
• Consumer Assessment of Health Plans Survey (CAHPS) instrument
– AHRQ release in 1997 to capture consumer assessments of care received
– now required by NCQA for health plan accreditation and many public and private
purchasers
• CMS’s Medicare program / many state Medicaid programs / Federal Employees Health Benefit
Plan
– expanded to include a survey of behavioral health services
• Long term care : Minimum Data Set (MDS)
– CMS supported the development of patient assessment instruments used by organ
transplant centers, nursing homes, and home health agencies (1980s)
– first implemented by CMS in 1990 for nursing home patients
– 24 quality indicators based on MDS data had become part of a routinely administered
nursing home survey (CMS, 1999)
– Nursing Home Compare (CMS, 2002)
• Web-based reporting mechanism
• provide the public and other stakeholders with comparative quality data on nursinghomes
PERFORMANCE MEASURE
DESIGN PRINCIPLES
Design principle
• Principle 1: Comprehensive Measurement
• A performance measurement system should advance the core
purpose of the health care system and foster improvements in all
six quality aims identified in the Quality Chasm report (IOM,
2001): safety, effectiveness, patient-centeredness, timeliness,
efficiency, and equity. The committee endorses the following
statement of purpose, proposed by the President’'s Advisory
Committee on Consumer Protection and Quality in the Health
Care Industry:
• The purpose of the health care system must be to continuously re
duce the impact and burden of illness, injury, and disability, and to
improve the health and functioning of the people of the United St
ates.
Design principle
• Principle 2: Evidence-Based Goals and Measures
• A performance measurement system should be guided by a
comprehensive set of evidence-based goals for improvement,
where appropriate. The National Quality Coordination Board
(NQCB) should identify explicit health care goals for the nation,
assess progress toward achieving these goals; and continually
update and modify the goals as circumstances, information, and
needs change. As a starting point, the NQCB should adopt the
priority areas for quality improvement identified by the Institute
of Medicine (IOM, 2003), as endorsed and expanded by the
National Quality Forum (2004), as national goals, and specify
measures corresponding to these goals that encompass the care
of patients across the lifespan (e.g., staying healthy, getting better,
living with chronic illness, and coping with end of life) (FACCT,
1997).
Design principle
• Principle 3: Longitudinal Measurement
• Standardized performance measures should
characterize health and health care of a patient both
within and across settings and over time. The NQCB
should identify standardized measures that
characterize the health and quality of care received
by both individuals and populations. In general, the
measures should not vary by type of health care
provider or setting, but should characterize care
across as well as within sites and settings. The set of
standardized measures should provide the
information needed to assess progress toward
achieving the six quality aims and the national goals.
Design principle
•
Principle 4: Supportive of Multiple Uses and Stakeholders
•
A national system for performance measurement and reporting should provide
information for multiple uses, including provider-led improvement efforts, public
reporting, payment and benefits design, and population health initiatives. This
system should produce useful information for three purposes:
•
• Accountability—-Information should be available to assist stakeholders in maki
ng choices about providers, including patients identifying a clinician, hospital, or
other provider from which to seek services; purchasers and health plans selecting
providers to include in their health insurance networks; and quality oversight org
anizations making accreditation and certification decisions.
•
• Quality improvement—-The information provided should be of value to stakeh
olders responsible for improving the quality of care, including clinicians and admi
nistrators and governing board members of health care organizations.
•
• Population health—-The information should be useful for stakeholders making
decisions about access to services (e.g., public insurance benefits and coverage); t
hose involved in communitywide programs and efforts to address racial and ethn
ic disparities and promote healthy behaviors; and public officials responsible for
disease surveillance and health protection.
Design principle
• Principle 5: Measurement Intrinsic to Care
• Performance measurement should be intrinsic to the care process. For
most standardized measures (e.g., health care processes and some
outcome measures), the data generated to calculate measures should be
byproducts of the patient care process and should reside within an
electronic health record system. For example, the data required to
calculate standardized measures for assessing the quality of patient care
provided to diabetics (e.g., cholesterol and hemoglobin A1c levels)
should be captured as a part of patient care encounters. This approach
has several advantages: (1) it allows for the development of
computerized decision-support systems (e.g., prompts to providers and
patients that the patient is due for an annual retinal exam); (2) it enables
more immediate calculation of measures and feedback to providers on
performance; and (3) it minimizes the burden associated with special
data collection processes. These data reflect the health care delivery
system; in and of themselves they do not adequately address population
and public health.
Design principle
• Principle 6: A Central Role for the Patient’'s Voice
• The performance measurement system should also
include direct reports and ratings from patients and
family caregivers. Patients need a voice in the process
of selecting measures and designing public reports.
The input of patients and family caregivers should
reflect their viewpoints on the quality and
functionality of the care received. Caregivers’'
perceptions of the quality of care provided should
also be incorporated into the measurement system.
Design principle
• Principle 7: Individual-, Population-, and Systems-Based Measurement
• Measurement and measures should assess the health and health care of
both individuals and populations and the many systems within which
care is provided. A national system for performance measurement and
reporting should include both measures of the quality of care provided
by the personal health care system and measures of population health,
health behaviors, and unmet health needs. The measure set should
include measures of access and unmet service needs for the entire
population of a community and for specific groups most likely to
experience access limitations because of an inability to pay; high levels
of uninsurance or underinsurance; racial, ethnic, class, cultural, and
linguistic barriers; or geographic impediments. The measure set should
also include measures of the efficiency of the local health system, such
as resource use compared with that of other communities.
Design principle
• Principle 8: Shared Accountability
• Measurement should not be constrained by the
absence of a current, identifiable, single responsible
agent. A national system should measure processes
and outcomes of care important to patients and
communities. Measurement should foster individual
and shared accountability for health system
performance. When no responsible agent can be
identified, shared accountability by all agents within
the health care system should be presumed, and
responsible stewardship encouraged and induced. In
many settings, this will require significant
restructuring of how care is currently delivered.
Design principle
• Principle 9: A Learning System
• A performance measurement system should be a learning
system, continually evaluating its own performance and
advancing knowledge regarding performance
measurement. A national system for performance
measurement and reporting should advance knowledge of
(1) how environmental levers, such as purchasing, pay for
performance, and quality oversight can best be used to
motivate quality improvement; (2) the most effective
strategies for redesigning care processes, including
methods for transferring knowledge, implementing
information technology, and forming effective care teams;
and (3) the extent to which all quality efforts lead to
improvements in the six quality aims.
Design principle
• Principle 10: Independent and Sustainable
• A performance measurement and reporting
system should be continually enhanced and
financed in a way that ensures its independence
and sustainability. This system should be
dynamic and should evolve based on careful
evaluation of its impact and advances in the
science base. It should be adequately supported
by both public- and private-sector stakeholders.
병원 질향상을 위한
임상질지표의 활용
2010. 9. 30.
서울의대 의료관리학교실
김
윤
차
례
임상질지표의 기본 개념
외국의 임상질지표 : Resource
임상질지표의 개발
42
I. 임상질지표 기본 개념
의료의 질이란?
의료서비스가
바람직한 결과를 달성할 가능성을 높이는 정도
최신 전문지식에 부합하는 정도
‘the degree to which health services for individuals and populations
Increase the likelihood of desired health outcomes and
are consistent with current professional knowledge’
44
Lohr KN(ed.) Medicare: A Strategy for Quality Assurance. Vol. I and II. National Academy Press, 1990.
의료에 질에 대해 무엇을 알고 있는가?
• 치료과정에 대한 체계적인 평가 부족
Lack of documentation about how major illnesses are treated
• 진료결과에 대한 체계적인 평가 부족
Lack of systematic outcome assessment
• 진료 질과 관련된 자원 분배에 대한 평가 부족
Lack of resource evaluation related to quality for specific
diseases
• 의료제공자들간 지속적인 변이
Persisting variations among providers in care for similar
patients
• 공식적인 모니터링 체계 부족
Few formal monitoring systems in place by health care
providers or regulators
45
• Mainz J. Defining and classifying clinical indicators for quality improvement. IJQHC 2003; 15(6): 523.
임상질지표의 정의
• 특정 의료서비스의 과정 또는 결과를 평가하는 방법
As measures that assess a particular health care process or outcome
• 환자 건강에 영향을 줄 수 있는 관리, 진료 및 진료지원 기
능의 질을 모니터링하고 평가하는 계량적 측정 방법
As quantitative measures that can be used to monitor and evaluate the quality
of important governance, management, clinical, and support functions that
affect patient outcomes
• 환자 건강에 영향을 줄 수 있는 진료, 진료지원, 조직 기능
의 질을 모니터, 평가, 개선하기 위한 지침으로 사용되는
측정 도구, 선별도구 또는 신호
As measurement tools, screens, or flags that are used as guides to monitor,
evaluate, and improve the quality of patient care, clinical support services, and
organizational function that affect patient outcomes
46
• Mainz J. Defining and classifying clinical indicators for quality improvement. IJQHC 2003; 15(6): 523.
임상질지표: 바람직한 특성
1. 합의된 정의에 근거
5.
Based on agreed definitions
2. 측정에 필요한 요소 기술
Described exhaustively and
Discriminates well
6.
사용자와 명확한 관련성
7.
비교 가능성
exclusively
3. 높은 민감도와 특이도
Highly specific and sensitive
= few false (+) and false (-)
4. 타당도와 신뢰도
Valid and reliable
높은 변별력
(의사 : 임상진료 관련 지표)
Relates to clearly identifiable
events for the user
Permits useful comparisons
8.
근거 기반
Evidence-based
• Mainz J. Defining and classifying clinical indicators for quality improvement. IJQHC 2003; 15(6): 523.
47
임상질지표: 분류
• Rate-based(비율) 지표 vs.
sentinel(적신호 사건) 지표
• 구조(Structure), 과정(Process),
결과(Outcome)
• 일반(Generic) 지표 vs.
질병 특이(disease-specific)
• 서비스의 형태(type of care)
– 예방 관련 지표
– 급성 관련지표
– 만성 관련 지표
• 기능
–
–
–
–
스크리닝 지표
진단 진표
치료 지표
Follow up 지표
• Modality
–
–
–
–
–
병력
신체계측(Physical examination)
임상병리/방사선 검사
투약 관련
다른 시술(Other interventions)
• Mainz J. Defining and classifying clinical indicators for quality improvement. IJQHC 2003; 15(6): 523.
48
비율 지표 vs. 적신호 지표
• 비율 지표 (Rate-based indicators)
– 빈도를 담고 있는 자료를 사용하여 지표를 생성
– 표본 집단의 평균값, 비율(proportion), 비(ratio)로 표현됨
– 위험에 노출된 집단의 분모와 실제 발생한 수로 표현되는 분자가 필요
함
• 적신호 지표 (Sentinel indicators)
– 낮은 성과 수준(poor performance)으로 표현됨
– 위험관리 대상을 골라내는 데 사용됨
– 심층 조사나 분석을 하게 하는 계기가 되는 지표임
비율(rate based) 지표
적신호(sentinel) 지표
창상 감염
분자: 수술 5일 이후 창상감염 환자 수
분모: 수술 후 5일 이상 병원에 입원한 수술 받은 환자 수
수술 중 사망한 환자 수
병원성 감염
분자: 감염자수
분모: 연구 기간동안 병원입원 환자 수
주산기 동안 사망한 환자 수
49
• Mainz J. Defining and classifying clinical indicators for quality improvement. IJQHC 2003; 15(6): 523.
구조(structure), 과정(process),
결과(outcome) 지표
• 구조 지표
– 물적 자원(병원들, 장비, 재정)
– 인적자원(질, 양)
– 조직의 구조(의사 수, 조직, 동료 심사 방법, 상환방법)
• 과정 지표
– 환자의 치료 과정이 잘 이루어졌는가를 의미함
– 예: 진단과정에서 의사의 활동, 치료의 적정성, 환자와 의사의 관계
• 결과 지표
– 환자 및 집단의 건강상태에 대한 치료의 효과를 의미함
– 예: 환자의 지식 및 행태 변화, 환자의 만족도
50
구조-과정-결과 지표의 예
구조
•
•
•
•
•
전문의 비율
MRI 접근성
뇌졸중 치료센터 접근도
임상 가이드라인 2년 마다 갱신
물리치료사 수
과정
•
•
•
•
당뇨 환자 중 규칙적인 발 관리를 받는 환자의 비율
급성심근경색환자 중 혈전용해제를 사용한 환자의 비율
의뢰 24시간 이내 의사에게 평가 받은 환자 비율
임상 가이드라인에 의해 치료 받는 환자 비율
중간
결과
• 당뇨환자에서 HbA1c
• 고지질혈증 환자에서 Lipid profile
• 고혈압 환자에서 혈압
최종
결과
•
•
•
•
•
•
•
결과
51
치명률 (Mortality)
유병률 (Morbidity)
기능상태
건강상태측정 (Health status measurement)
작업을 할 수 있는 정도
삶의 질(Quality of life)
환자 만족도(Patient satisfaction)
과정 지표의 특징 및 유용성
•
결과가 입증된(Outcome-validated) 과정 지표
– 진료결과와 진료과정 사이의 관계가 확립되어 있음
– 질적 수준을 직접적으로 나타내는 지표임
– 예: 특정 환자에게 어떤 특정 시술을 하는 것이 좋은 건강결과로 이어진다면, 특정
상황에서 특정 시술의 부재는 의료의 질이 '나쁨'을 의미함
•
과정 지표의 유용성
–
–
–
–
–
•
질 개선이 목적인 경우
특정 의료제공자가 특정한 결과를 달성하고 싶을 때
단기간 측정틀(frame)이 필요할 때
낮은 시술량 의료제공자의 performance에 관심이 있을 때
환자 요인을 보정하거나 층화할 수 없을 때
결과지표에 비하여 질 차이를 잘 구분해 낼 수 있고 해석하기가 쉬움
– 뇌졸중 환자의 적절한 투약 여부(과정 지표)
– 뇌졸중 환자의 30일간 치명률(결과 지표)
52
• Mainz J. Defining and classifying clinical indicators for quality improvement. IJQHC 2003; 15(6): 523.
결과 지표의 장점 및 제한점
• 결과 지표의 유용성
–
–
–
–
보건의료의 영향을 측정할 수 있음
장기 측정틀(frame)로 사용할 수 있음
전체 시스템의 performance를 측정할 때
시술량이 많은 경우
• 고려할 점
– 위험 보정(risk adjustment)을 반드시 해야 함
– 측정의 용이성은 항상 고려해야 할 점임
– 발생 빈도가 너무 낮을 경우 유용한 지표로 사용하기 곤
란
53
근거 기반 지표 vs. 합의 기반 지표
• 과학적 근거 기반 지표 (Evidence-based indicators)
– 과학적 근거를 가지는 지표
• Cochrane Collaboration literature syntheses
• Meta-analyses
• RCT
• 전문가 합의 기반 지표 (Consensus-based
indicators)
– 보건의료 전문가 패널을 통해 결정함
– 과학적인 증거가 부족할 경우 합의 과정을 통해 결정함
55
• Mainz J. Defining and classifying clinical indicators for quality improvement. IJQHC 2003; 15(6): 523.
인증평가제도에서는
임상질지표를 어떻게 활용하나요?
의료기관 인증평가와 임상질지표
56
질향상 두 경로: 자발적 질향상 vs. 사회적 책임
•Supportive
Clinical Indicator
자발적
질향상
질향상 활동 지원
평가시행
및
결과 피드백
자발적
질향상
노력 유도
의료
질 향상
의료의
질에 대한
사회적 책임
•Summative
Clinical Indicator
평가결과
공개
소비자의
의료기관
선택
57
질평가 시스템의 분류
Nature of expected action
•Clinical indicators
- 호주: ACHS
- 캐나다: CCHSA
internal
Formative
supportive
Punitive
summative
Internal evaluation
Continuous quality
improvement
A
Source
Of
Control
C
External
accountability
Accreditation
External
B
•
•
•
•
•
D
미국 JCAHO Core measure
미국 CMS Hospital Public Reporting
미국 CMS pay for performance
미국 Leapfrog Group
미국 AHRQ patient safety indicators
Veillard et al., A performance assessment framework for hospitals: the WHO regional office for Europe PATH
project. International Journal for Quality in Health Care 2005; volume 17, number 6; pp. 487-496
58
질평가 시스템의 분류
평가결과의 활용
의료기관 질향상 활동
내부
평가
결과 공개 및 유인 제공
인증제
임상질지표
Internal evaluation
A
과거 의평
임상질지표 평가
Accreditation
외부
평가
C
C
BB
D
D
C
Veillard et al., A performance assessment framework for hospitals: the WHO regional office for Europe PATH
project. International Journal for Quality in Health Care 2005; volume 17, number 6; pp. 487-496
59
Supportive vs. Summative
Supportive
• 외래수술(day surgery)후 입원율
– 백내장 수술, 무릎 관절경, 서혜부 탈장
• 재입원율
– AMI(30일 이내), 폐렴(30일 이내), 천식(72시간 이내)
• 재수술률
Summative:
Acute
Myocardial
Infarction
60
Aspirin at arrival
Aspirin prescribed at discharge
ACEI for LVSD
Smoking cessation advice/counseling
Beta blocker prescribed at discharge
Beta blocker at arrival
Thrombolytic received within 30 minutes of
hospital arrival
PCI received within 120 minutes of hospital
arrival
Inpatient mortality rate
중요한 것과 측정가능한 것 : 무엇을 측정?
한 남자가 땅바닥에서 무엇인가를 찾고 있는 것을 보고 지나가던 행인이 물
었다. (Shah, 1972)






행인: 뭘 잃어 버렸나요?
남자: 내 차 열쇠를…
행인: 어디 쯤에서 잃어 버렸나요?
남자: 우리 집에서요
행인: 그런데, 왜 여기에서 찾고 있나요?
남자: 아~~~ 여기가 우리 집보다 밝아서요
• 성과 측정: 중요한 것이 아니라, 측정 가능한 것을 측정하는 경향
– 중요한 진료결과를 측정할 수 있는 도구가 부족
– 중요한 것과 측정할 수 있는 것들 사이에 타협점을 찾는 것이 중요
• 성과 측정 지표: 누구를 위한 것인가에 따라 지표가 달라짐
– 의료진: immediate outcome - 예: 병원감염률
– 환 자: ultimate outcome – 예: 실제 건강수준 향상
61
II. 외국 임상질지표:
Resource
외국의 임상질지표(1)
• WHO (2003): Performance Assessment Tool for
Quality Improvement in Hospitals (PATH)
• ACHS (1989): Australian council on health care
standards (ACHS) Indicator project, Australia
• Germany (2000): BQS-Bundesauswertungen
• Scotland (2000): Clinical Indicators support team
(CIST), NHS Quality Improvement
• France (2003): COMPAQH
63
외국의 임상질지표(2)
• JCAHO (1997): ORYX, USA
• Ontario Hospital Association (1997): Hospital
reports, Canada
• [International] Quality Indicator Project (1984): USA
• The National Indicator project (2000), Denmark
• Reporting of performance in Dutch hospitals (2003),
The Netherlands
• Verein Outcome (2000): Switzerland
64
외국의 임상질지표 : Overview
임상질지표
영역
지표 수
WHO PATH
CE/ EF/ SO/ RG/ SF/ PC
호주 ACHS
CE/ EF
독일 BQS
31: 95 tracers
참여 방식
자발적
308: 22 영역
자발적
CE
169: 17 영역
의무적
스코틀랜드CIST
CE
64: 7 영역
의무적
프랑스 COMPAQH
CE
43: 8 Nat’l priority
자발적
미국 JCAHO
CE/ EF
/ SF/ PC
36: 5 영역
의무적
캐나다 OHA
EF
/ PC
47: 4 영역
자발적
미국 QIP
CE/ EF
/ SF/ PC
47: 4 영역
자발적
덴마크 NIP
CE/ EF
/ SF/ PC
87: 7 영역
의무적
네델란드 Dutch
CE/ EF
/ SF/ PC
39: 3 영역
의무적
스위스VereinOutcome
CE/ EF
/ RG/ SF/ PC
118: 19 영역
의무적
/ SF
/ SO
/ PC
/ RG
CE clinical effectiveness/ EF efficiency/ SO Staff orientation/ RG responsive
governance/ SF safety / PC patient centeredness
65
Acute Care Indicators (including Ambulatory indicators)
Psychiatric Care Indicators (both adult and adolescent units)
Long Term Care Indicators
Home Care Indicators
66
In-patient Quality Indicators
1. Hospital-acquired
infections
2. Surgical site infections1
3. In-patient mortality
4. Neonatal mortality
5. Perioperative mortality
6. Management of labour
7. Unplanned
readmissions
8. Unplanned admissions
following day case
procedures
9. Unplanned returns to
ICU
10. Unplanned returns to
the operating theatre
11. CABG perioperative
mortality
12. Use of restraint
13. Sedation and analgesia
67
14. Falls
• AC Indicator 9: Unscheduled Returns to
Intensive Care Units (ICU)
– Unscheduled returns to ICU
– Unscheduled returns to ICU
for the following durations:
•
•
•
•
Within 24 hours
> 24 but <= 48 hours
> 48 but <= 72 hours
> 72 hours
– Unscheduled returns to intensive care units for
patients with the following primary diagnoses:
• Acute myocardial infarction
• Heart failure
• Pneumonia
68
69
70
Case studies
Hospital-acquired infections
• A hospital that had very low levels of wound infections for
hip replacements observed a sudden and dramatic increase
in post-operative infections, from a low baseline to ∼10%
over three consecutive data points.
• The increase was found to coincide with a change in
operating theatre cleaning contractors. The new contract
was discontinued and the infections fell back to previous low
levels.
• This shows the value of monitoring indicators over time and
also re-emphasizes that understanding and explaining a
particular indicator rate depends upon local
audit/investigation.
71
Resource : 우리나라
72
QI 사업과 임상질지표를
어떻게 선정할까?
73
우리 병원에서
어떤 QI 사업을 하면 좋을까요?
74
질향상 사업과 임상질지표
병원
감염
Deep Post-Op
Wound Infection
UTI
Pneumonia
Bacteremia
Other
Prevention
Prevention
Patient
Preparation
Prophylaxis
Patient
Selection
Detection
Prophylactic
Antibiotics
Antibiotic
Selection
Surgery
- Duration
- Sterile Technique
- Operative Findings
Treatment
Delivery
Post-Op
Wound Care
- Timing
75
Opportunity summary
Dollars
$2MM
$3MM
acute
sprain
allergic
rhinitis
Adult
Acute
Self-Ltd
CPMs
Peds
Acute
Self - Ltd
CPMs
$4MM
$7MM
sinusitis
other eye
problem
Legend
Cardiovascular
adult
abd. general exam
pain
otitis media
Peripheral neuropathy /
neuralgia
peds general exam
Musculoskeletal
diabetes
psychotic depression
non-psychotic
depression
lipid
disorder
pneumonia
Sleep disorder
Adult
Amb CPMs
Elective
$6MM
other skin disorder
Adult
Medical
CPMs
Peds
Medical
CPMs
$5MM
Behavioral Health
Infectious Disease
GI tract disease
headache
Pulmo/Allergy
hypertension
other neuro.
disorder
neck
kidney problem
stone
bursitis/
Ischemic
synovitis
Nephrology
other joint &
disc disease
low back pain
GI biliary tract
Ophthalmology
Dermatology
Primary Care
osteoarthritis
Ischemic
other joint &
disc disease
low back pain
Endocrinology
Neurology
non-ulcer peptic
disease
Adult
Ind/Guidelines
Elective
Gastroenterology
X-Axis = Total Cost
Bubble size = Variation
76
Priority Areas for Transforming Health Care:
Inpatient/Surgical Care
• Care coordination
• Self-management/health literacy
• End of life with advanced organ
system failure
• Ischemic heart disease
• Medication management
• Medication errors
• Overuse of antibiotics
• Nosocomial infections
• Pain control in advanced cancer
• Pregnancy and childbirth
• Severe mental illness
• Stroke
77
IHI Improvement Map
• Open resource
– Available free of charge for anyone
• Tool for identifying the key
processes for
– Improving hospital quality
– Organizing your improvement efforts
– Getting the information you need to
get started
– Containing 70 patient care and
organizational processes
78
79
외국에서 개발된 지표를
우리 병원에서 적용할 수 있을까?
81
82
Sometimes limited transferability
83
지표 자체개발 OR 외국지표 도입 ?
84
병원 자체개발 OR 외국지표 도입 ?
• 병원 자체 개발
– Ownership
[우리 병원이 개발한 지표]
– 이해당사자 참여 유도
– 한국/우리 병원에 중요한
지표 개발 가능
cf) AMI vs. Stroke
– 많은 시간과 노력
[잘 만들려면…]
– 적은 노력으로 개발 가능
[대충 만들면…]
• 외국지표 도입
– 손쉽게 도입 가능
– 우리나라/병원에 활용가
능한 중요지표 존재
– 한국/우리 병원 상황
반영한 Modification 필수
– Ownership 부재
[특히 의사들…]
[우리 나라/병원은 특수…]
– 충분히 이해하지 못한
상태에서 적용할 우려
85
질향상 활동: 의사 참여 유도 전략
• 비효과적 전략
– 수동적 교육
passive = lecture style
– 한가지 중재
• 효과적 전략
– 능동적 교육 interactive
– 다양한 중재
– 의료계 지도자에 의한 교육
• 효과적 / 심한 편차
• Grimshaw et al (2001)
의사 대상 진료행태 변화
1.
2.
3.
강의
강의 + 진료지침 reminder
강의 + 환자 맞춤형 피드백
• 결과
1.
효과 (-)
2와 3. 효과 (+)
86
Model for Improvement:
Four key elements of successful process improvement
1. 구체적 목표
2. 지표: 개선 정도 측정
3. 목표 달성할 수 있는
질향상 활동
4. 여러 차례 질향상 활동
사이클 반복
임상질지표는
질향상 활동의 일부
87
Plsek PE. Improving care through collaboration. Pediatrics. 1999;103(1 Suppl E):384-93.
III. 임상질지표 개발
임상질지표 개발 과정
Selecting Topics
• 주제 선정
Reviewing
Clinical Evidence
• 의학적 근거 찾기
Identifying
Clinical Indicators
• 지표 만들기
Constructing Measures
Creating
Scoring Methods
• 지표 정의하기
• 측정방법 개발하기
89
주제 선정 : 기준
• 가장 중요한 단계
• 건강에 중요한 영향
– 흔함/중증/개선가능성
– 건강수준지표: 사망률/이환률/기능상태/삶의 질
• 병원 전략계획과 연관된 주제
• 고려사항
– 자료수집 노력/가능성
–
90
의학적 근거 찾기: 질문 작성
• What is known about effective interventions
[구체적인 질문 작성]
• Continuum of care
–
–
–
–
–
효과적인 예방법
집단검진의 효과성
효과적 진단 도구
효과적 치료 방법
효과적 지속적 관리 방법
 비효과적인 집단검진/진단/치료/관리
 Underuse vs. Overuse
91
의학적 근거 찾기: 문헌 검색
• Cochrane Collaboration
– Structure of a Cochrane Review
http://www2.cochrane.org/reviews/revstruc.htm
• AHRQ Evidence-based Practice Center
– http://www.effectivehealthcare.ahrq.gov/
• National Institute for Health and Clinical Excellence
– http://www.nice.org.uk/guidance/index.jsp
92
의학적 근거 찾기: 임상진료지침 활용
• 임상진료지침 활용
– 일반적으로 Continuum of care에 대한 진료지침 포함
• http://guideline.gov/
• 2천개 이상의 임상진료지침 포함
• 다양한 지침 개발원
• WHO
• 유럽 임상학회들
93
지표 만들기
Identifying Clinical Indicators
• 예> 지표(안) : 당뇨병 환자 매년 HbA1c 측정
• RAND/UCLA Appropriateness Method
[http://www.rand.org/pubs/reprints/RP395/]
– Established indicator selection process
– Combining a evidence review with formal expert
panel process
• 9 명 전문가 패널 : 지표와 근거 검토
• 1~9점 척도 평가
• 전문가 합의 도출 : Modified Delphi method
94
지표 정의하기
Constructing Measures
• 일반사항
– 지표 : 지표 및 하위 지표
– 지표 설명
– 지표 개발 근거
• 측정
– 분모 / 분자 / 포함 및 제외기준
– 자료 항목 / 수집방법 / 정확도
– 중증도 보정 필요성
• 참고문헌
95
Measure Information Set (1)
• Measure Set: Acute Myocardial Infarction
• Set Measure ID #: AMI-1
• Performance Measure Name: Aspirin at Arrival
• Description: Acute myocardial infarction (AMI) patients
without aspirin contraindications who received aspirin
within 24 hours before or after hospital arrival.
• Rationale: The early use of aspirin in patients with acute
myocardial infarction results in a significant reduction in
adverse events and subsequent mortality. Aspirin therapy
provides a percent reduction in mortality that is
comparable to thrombolytic therapy and the combination
provides additive benefit (ISIS-2,1988). National
guidelines strongly recommend early aspirin for patients
hospitalized with AMI (Braunwald, 2000 and Ryan, 1999).
Despite these recommendations, aspirin remains
96
underutilized in older patients hospitalized with AMI
Measure Information Set (2)
• Type of Measure: Process
• Improvement Noted As: An increase in the rate
• Numerator Statement: AMI patients who received
aspirin within 24 hours before or after hospital
arrival
– Included Populations: Not Applicable
– Excluded Populations: None
– Data Elements: Aspirin Received Within 24 Hours Before or After
Hospital Arrival
• Denominator Statement: AMI patients without aspirin
contraindications
– Included Populations: Discharges with an ICD-9-CM Principal
Diagnosis Code for AMI as defined in Appendix A, Table 1.1
97
Measure Information Set (3)
•
98
Excluded Populations:
– Patients less than 18 years of age
– Patients transferred to another acute care hospital or federal hospital on
day of arrival
– Patients received in transfer from another acute care hospital, including
another emergency department
– Patients discharged on day of arrival
– Patients who expired on day of arrival
– Patients who left against medical advice on day of arrival
– Patients with one or more of the following aspirin
contraindications/reasons for not prescribing aspirin documented in the
medical record:
• Active bleeding on arrival or within 24 hours after arrival
• Aspirin allergy
• Coumadin/warfarin as pre-arrival medication
• Other reasons documented by a physician, nurse practitioner, or
physician assistant for not giving aspirin within 24 hours before or
after hospital arrival
Measure Information Set (4)
• Data Elements:
– Admission Date, Admission Source, Arrival Date, Birthdate,
Contraindication to Aspirin on Arrival, Discharge Date, ICD-9-CM
Principal Diagnosis Code, Transfer From Another ED
• Risk Adjustment: No
• Data Collection Approach: Retrospective data sources for
required data elements include administrative data and medical
records.
• Data Accuracy: Variation may exist in the assignment of ICD-9CM codes; therefore, coding practices may require evaluation
to ensure consistency.
• Measure Analysis Suggestions: None
• Sampling: Yes, for additional information see the Sampling
section
• Data Reported As: Aggregate rate generated from count data
99 reported as a proportion
Measure Information Set (5)
•
Selected References:
–
–
–
–
–
–
100
Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, Jones RH,
Kereiakes D, Kupersmith J, Levin TN, Pepine CJ, Schaeffer JW, Smith EE III, Steward DE,
Theroux P. ACC/AHA guidelines for the management of patients with unstable angina and
non-ST-segment elevation myocardial infarction: a report of the American College of
Specifications Manual for National AMI-1-3 Hospital Quality Measures
Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on
the Management of Patients with Unstable Angina). J Am Coll Cardiol 2000;36:970-1062.
Available at http://www.acc.org and http://www.americanheart.org.
Randomised trial of intravenous streptokinase, oral aspirin, both or neither among 17,187
cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of
Infarct Survival) Collaborative Group. Lancet. 1988 Aug 13;2(8607):349-60.
Jencks SJ, Cuerdon T, Burwen DR, Fleming B, Houck PM, Kussmaul AE, Nilasena DS,
Ordin DL, Arday DR. Quality of medical care delivered to Medicare beneficiaries: a profile at
state and national levels. JAMA. 2000;284:1670-1676.
Ryan TJ, Antman EM, Brooks NH, Califf RM, Hillis LD, Hiratzka LF, Rapaport E, Riegel B,
Russell RO, Smith EE III, Weaver WD. 1999 update: ACC/AHA guidelines for the
management of patients with acute myocardial infarction: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on
Management of Acute Myocardial Infarction). J Am Coll Cardiol 1999;34:890-911. Available
at http://www.acc.org and http://www.americanheart.org.
Ryan, TJ, Anderson, JL, Antman, EM, Braniff, BA, Brooks NH, Califf, RM, Hillis LD, Hiratzka
L F, Rapaport E, Riegel BJ, Russell RO, Smith EE III, Weaver WD. ACC/AHA guidelines for
the management of patients with acute myocardial infarction: a report of the American
College of Cardiology/American Heart Association Task Force on Practice Guidelines
(Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol
1996;28:1328-1428. Available at http://www.acc.org and http://www.americanheart.org.
분자 - 기준충족환자 기준 예:
당뇨병 환자에서 매년 HbA1c 측정
 제외 기준
 포함 기준
 모든 연령층 OR 어린이/노
인 제외 ?
 Type 1 & Type 2 당뇨병 ?
 신규 환자 vs. 모든 환자
 당뇨병 임산부 포함 ?
 합병증 존재 시 제외?
 당뇨병 환자 정의 기준
– 어떤 합병증 ? 예를 들어 암
환자 – 암치료 우선
– Reason for visit = DM
– Medication order : DM 부합
– 당뇨병에 대한 의무기록
 자료수집 대상 기간 제한
 과거 자료가 부정확한 경우
 일정 시점 이후 자료만 포함
101
측정방법정의하기
Creating Scoring Methods
• 일반사항
– 지표 : 지표 및 하위 지표
– 지표 설명
– 지표 개발 근거
• 측정
– 분모 / 분자 / 포함 및 제외기준
– 자료 항목 / 수집방법 / 정확도
– 중증도 보정 필요성
• 참고문헌
102
요약
• 질향상 : 의료기관 인증평가만으로 “질향상” 곤란
– 주요 임상진료의 질 모니터링
– 임상질지표 기반 질향상 사업
• 외국의 임상질지표 Resource 활용
– 하지만 개발할 수도…
• 원하는 지표가 없거나
• 의료진[의사]들의 ownership 중요할 때
• 임상질지표 개발
– 개발 절차 충실히 지켜서
– 질향상 사업의 일부로서 임상질지표
103
감사합니다
[email protected]