Measuring Quality of Care

By: Stacie Sutter

HCA 540: Healthcare Organization and Management

Research Paper for Dr. Frank Fan

Fall 2010 Semester

 Measuring Quality of Care

Abstract

Measuring quality of care is an extremely complex concept. Various organizations have

their own viewpoints on what quality should be and the standards they follow. When analyzing

quality of care there are three distinct perspectives to consider: Patients, Physicians, and Payers.

They each have their own interpretation of quality along with their individual needs. There are

endless measures and key performance indicators used to determine quality such as the

numerous organizations that offer accreditation to healthcare facilities. There are also multiple

players whom affect the quality of care from the physician to the patient. Timely patient

feedback is a key that many healthcare organizations do not currently take advantage of. What

an organization does with the results is just an important as conducting the surveys. Peer review

is a key concept and a great place to start on the road to quality improvement initiatives.

Topic Introduction

By making short and long term goals toward quality improvement an organization can

make great strides toward improving their quality. Small things such as listening to their patients

and evaluating their current processes can make all the difference. Accreditation organizations

are great but can be very costly. For example, the Accreditation Association for Ambulatory

Healthcare charges $25,000 for their review services and an organization must renew every two

to three years to remain accredited. Accreditation organizations offer a lot of key concepts but

their services come with a price. Finding what best fits for an organization and its members will

go a long way toward improving the quality of care. Quality is a journey. During this journey

there are unlimited ways to get there and not one path is necessarily superior over another. It’s

all about the journey and what you learn along the way.

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Quality Perceptions

The quality of care can be defined in many ways. The quality of care is often in the eye

of the beholder. Quality is complex and there are three main groups (patients, physicians, and

payers) who define quality differently. Each group has their own expectations for healthcare

quality and each group defines those expectations differently. Defining and measuring quality of

care is complex and comes with many challenges.

Patients

Quality is frequently based on patient perception and their desired outcome for the given

situation. For example, a physician can be abrupt and to the point but at the same time a very

precise and efficient physician. One patient can view that as rude and arrogant after a visit.

They may feel their quality of care was lacking due to the physicians lack of bedside manner.

Another patient may feel the same physician is quick and efficient and doesn’t waste time on

small talk. This patient may also appreciate the physician being bluntly honest and direct. That

was the same qualities the first patient viewed as rude and uncaring. Every patient is has their

own expectations and perception based on their need and experiences. A provider should also be

willing to adjust their approach when a situation calls for it and treat patients different based on

the reaction or non-verbal queues different patients omit. Some physicians are great at this and

others are not. It’s a balancing act.

Physicians

Elizabeth McGlynn, a RAND health policy analyst and an expert in quality issues

expresses the following regarding physician’s perception on quality.

Physicians are caught between efforts to control costs, their own judgment about the

best course of treatment for a patient, and demands that patients’ values be reflected

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 in making treatment choices. These three influences do not always lead to the same

conclusion. Cost control frequently is achieved as third parties make decisions about

what services will be covered and what types of providers can offer those services.

The involvement of third parties in decision-making may diminish the importance of

physician judgment and autonomy, which may lead physicians to conclude that the

technical quality of care is suffering. (McGlynn, 1997)

One key thing a physician can rely on is the outcome of the medical care they provide a patient.

However, that outcome is based on the physician in conjunction with the patient. If a patient

takes their medication and follows the physician’s recommendations then a physician can

measure their success. If a patient does not follow the physician’s recommendations, they can

skew the quality of care a physician provides. Patient cooperation is also instrumental when it

comes to measuring quality of care for a physician.

Payers

Payers have a large focus on cost and cost containment. Most insurance companies are

for profit so they need to pay close attention to their bottom line. They want to know how their

premium dollars are being spent. They often contract or employ physicians to review claims to

ensure there is a medical need for the variety of services provided. They will sometimes audit a

patient’s medical chart to ensure the test or procedures performed were medically necessary prior

to issuing payment to a physician or hospital. Payers are also ensuring quality of care when they

perform medical chart reviews.

Healthcare reform is moving toward a more preventative approach than in the past.

There will be little or no cost incurred by an insured patient moving forward with healthcare

reform when it comes to preventative visits or tests. Payers will continue paying for preventative

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care with no co-pay for the patient. This may lower cost since many conditions may be

diagnosed earlier and help prevent soaring costs to the payers since it was caught in the early

stages where treatment will be less invasive. Time will tell a how healthcare reform impacts all

areas of quality.

Quality and Accreditation

There are numerous organizations that accredit healthcare organizations. Below are just

a few of the most popular organizations.

• Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

• National Committee for Quality Assurance (NCQA)

• Accreditation Association for Ambulatory Healthcare (AAAHC)

Each organization utilizes their own set of standards they have deemed necessary to ensure the

best practices for quality. The U.S Department of Health and Human Services describes

accreditation as “a conformity-assessment process whereby industry experts first define the

standards (explicit criteria) that organizations must meet in order to be accredited and then

systematically review the organizations’ performances against those standards.” (Health and

Human Services, 2009)

Keep in mind that an organizations accreditation does not guarantee their quality of

above all others. Accreditation means an organization has been certified by an accrediting

body’s standards.

AAAHC and Quality

Accreditation Association for Ambulatory Healthcare (AAAHC) has been around for

over 30 years and they have accredited over 4,700 ambulatory care organizations. Their mission

is “to maintain its position as the preeminent leader in developing standards to advance and

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promote patient safety, quality, value, and measurement of performance for ambulatory

healthcare through peer-based accreditation processes, education and research” (Accreditation

Associations for Ambulatory Healthcare, 2010).

For an ambulatory organization to receive AAAHC accreditation, they must meet the

requirements of a handbook that is 220 pages long with 27 chapters. Eight of the 27 chapters are

considered ‘core chapters’ and have many more details than the other ones. AAAHC puts the

most emphasis on the following eight chapters: Rights of Patients, Governance, Administration,

Quality of Care Provided, Quality Management and Improvement, Clinical Records and Health

Information, Infection Prevention and Control and Safety, Facilities and Environment

(Accreditation Associations for Ambulatory Healthcare, 2010). Once an organization receives

accreditation, they must become re-accredited every one, two, three, or five years to maintain

their accreditation status.

The key with many of the accreditation organizations is helping to develop standards of

care and peer based review. Another key they look for is evidence based decision-making. They

want healthcare providers to step back and analyze why they are doing what they are doing.

When a healthcare provider takes some time out to reflect and analyze what they are doing,

better decisions can be made. While accreditation does assist with quality of care measurements,

accreditation cannot improve and sustain quality alone.

Quality Measurements

There is not one common set of measurements that define the quality of care. According

to the Merriam-Webster Dictionary quality assurance is a program for the systematic monitoring

and evaluation of the various aspects of a project, service, or facility to ensure that standards of

quality are being met. The Institute of Medicine has defined quality as “the degree to which

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health services for individuals and populations increase the likelihood of desired health outcomes

and are consistent with current professional knowledge” (McGlynn, 1997). Again, quality is in

the eye of the beholder or accrediting body.

Decision-makers need to agree on a common set of measurements that accurately

represent quality of care at an institutional or individual level. Neither the federal government

nor national institutes collect or measure patient’s experience, rates of medical error, hospital-

acquired infections, surgical outcomes or complications (Hebert, 2010).

In healthcare something as simple as evidence-based decision-making could increase

quality and enhance patient outcomes. When a provider takes the time to research similar patient

scenarios or they utilize the research from a clinical informationist, decisions can be made based

on similar desired results. Anytime standards are utilized and patient outcomes are improved,

quality increases. These are small steps but can have an enormous impact on the quality of care.

Patient-Centered Care and Quality

A healthcare system should not solely focus on the needs of institutions or providers. A

healthcare system should first focus on the needs of their patients before anything else.

Typically the needs of the institution or provider come before the patient. For the most part, the

U.S. does not track outcomes nor do we consider obtaining feedback from the patients regarding

the care they receive. The feedback from the patient must be timely to have an accurate impact

on quality (Hebert, 2010).

On the other hand, many hospitals and ambulatory care setting are conducting patient

satisfaction surveys. Many of these surveys are marketed during the time of the visit on paper.

Others are conducted over the web or by phone. The surveys need to be reviewed timely and

appropriate changes need to be implemented based upon patient feedback and perception. There

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will be negative and positive feedback as with any survey. Decisions should be based on the

average response and not focused on the minority ones. Analysis of key areas should be done

prior to implementing any changes. Surveys should also start basic and built upon as changes

are implemented based on previous surveys. This is not a national approach but it is a start for

those provider and hospitals that want to adjust their approach based on feedback from their

patients. Patient survey results could be shared with other healthcare providers as they work

toward a more collaborative approach of improving quality of care.

Some physicians in Bowling Green, Kentucky have implemented their own patient

satisfaction surveys to assist with quality improvement initiatives. PrimeCare Medicine

Associates sends an e-mail surveys to patients after their most recent visit to solicit feedback.

Dr. John Cowan, dermatologist, has paper surveys available for his patients during check-out.

The completed surveys are kept in a basket at the check-out desk. The Medical Center is a not-

for-profit hospital which contracts with a third party company to conduct patient phone surveys.

The phone calls are generated a few weeks after the patient is discharged. Western Kentucky

University Health Services conducts on-line patient surveys from a kiosk located by their check-

out. Health Services reviews their survey results once per month with an internal quality

committee. Any areas ranking low are discussed with the key managers and disseminated as

necessary. Positive results are also shared with managers and team members.

Patient complaints and incident reviews are another area that often goes unnoticed.

Reviewing incident or near misses along with patient complaints on a frequent and pro-active

basis can prevent future similar events from occurring. When reviewing these answering the

following questions might be helpful:

 What caused this event and how can it be prevented going forward?

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  Is additional training needed?

 What additional review of existing processes may help?

Reviewing these and making necessary changes will help improve quality along with prevention

of possible adverse outcomes.

The Donabedian Model

Avedis Donabedian, MD, MPH developed a familiar model to assist with defining and

measuring quality which has three domains: structure, process, and outcomes. All three domains

are proportionately significant and complement one another (Shi, 2008).

Structure

Structure is where the quality of healthcare begins. Structure has been defined as “the

relatively stable characteristics of the providers of care, of the tools and resources they have at

their disposal and of the physical and organization setting in which they work” (Shi, 2008).

Structure defines the resource inputs such as facilities along with licensing and accreditation as

well as equipment, staffing levels along with their qualifications. Structure is also important

because it indicates the potential an organization has to provide adequate levels of quality care.

For example, well-trained, licensed, and credentialed employees have the potential for better

outcomes than others who do not possess those characteristics (Shi, 2008).

Process

The way in which care is provided is the process. The process can be made up of many

components such as diagnosis, treatment, accurate prescription and drug administration, waiting

times, and costs. Peer review is also an important component and it serves two purposes; ensures

quality does not suffer and controls costs. Over the years, healthcare processes have evolved

into critical pathways, clinical practice guidelines, cost-efficiency, and risk management (Shi,

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2008).

According to Leiyu Shi and Douglas Shingh clinical practice guidelines are explicit

descriptions representing preferred clinical processes for specific conditions. For clinical

problems it creates a plan based on evidence to manage the problem. Cost-efficiency for a

service occurs when the benefit received is greater than the cost of providing the service.

Critical pathways are used as a timeline, which identifies planned medical intervention along

with expected outcomes for patients. Critical pathways are often defined by a specific diagnosis

or a group of cases. A proactive effort to prevent adverse events related to facility operations

and clinical care is known as risk management (Shi, 2008)

Outcome

Outcomes are also known as the final result in healthcare delivery. Outcomes can consist

of patient satisfaction, health status, recovery, improvement, re-hospitalization, and mortality.

Outcomes are not always consistent. They help determine what structure and process to utilize

depending on the desired outcome (Shi, 2008).

Benchmarking and Quality

Benchmarking began in 1983 when the healthcare industry tried to meet the growing

needs of their patients by attempting to improve their performance. Benchmarking is commonly

known as peer comparison. It occurs when one provider, practice, or hospital attempt to see how

their services rate in relation to others in the market (Ozcan, 2008).

Medical Group Management Association (MGMA) is currently one of the leaders in

benchmarking services. MGMA conducts many of the benchmarking surveys for various

healthcare entities. They send out monthly and quarterly reports that contain many standards for

care which others can rank themselves against. Benchmark surveys can also help define some of

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the standards of care, which play a vital role in the quality of care.

Conclusion

The measurement of quality is not easy but it is possible. Healthcare providers should at

the very least make the start to define, measure, and improve their quality. If something cannot

be defined or measured, then don’t waste time trying to improve it. Utilizing accreditation

groups or MGMA can assist a healthcare provider in ranking themselves against other similar

practices. Once baselines are determined benchmarks can be obtained with quality improvement

initiative. One of the key factors that often get overlooked is listening to the patients. They are

one of the most valuable sources of information a healthcare provider can obtain. Quality

improvement takes buy-in from the providers and their staff in order to be successful. The

willingness to improve along with the desire and motivation can make great strides toward

quality improvement.

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Works Cited

Accreditation Associations for Ambulatory Healthcare. (2010). Accreditation Handbook for

Ambulatory Healthcare. Skokie, IL: Accreditation Associations for Ambulatory Healthcare.

Health and Human Services. (2009). Health and Human Services. Retrieved November 20th,
2010, from Policy 26: http://www.hhs.gov/ociio/index.html

Hebert, P. C. (2010, February 23rd). PubMed. Retrieved November 19th, 2010, from Measuring
Performance is Essential to Patient-Centered Care:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2826460/

McGlynn, E. (1997, May/June). Health Affairs. Retrieved November 15th, 2010, from Six
Challenges in Measuring the Quality of Healthcare:
http://content.healthaffairs.org/cgi/reprint/16/3/7.pdf

Merriam-Webster Dictionary. (n.d.). Retrieved November 21st, 2010, from http://www.merriam-

webster.com/

Ozcan, Y. (2008). Healthcare Benchmarking and Performance Evaluation. Stanford, CA:

Springer Science + Business Media LLC.

Shi, L. S. (2008). Delivering Healthcare in America A Systems Approach. Sudbury, MA: Jones
and Bartlett Publishers.

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