Institute of Medicine Committee onthe Committee on the National Quality Report on Health Care Delivery Funding: Agency for Healthcare Research and Quality.

Institute of MedicineInstitute of Medicine

Committee onCommittee on the the National Quality Report National Quality Report on Health Care Deliveryon Health Care Delivery

Funding:Funding:Agency for Healthcare Research Agency for Healthcare Research

and Quality and Quality

Study Period:Study Period:October 1999 to March 2001October 1999 to March 2001

Margarita Hurtado, Ph.D.Margarita Hurtado, Ph.D.American Institutes for ResearchAmerican Institutes for Research

www.nap.edu/catalog/10073.htmlwww.nap.edu/catalog/10073.html

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Committee MembersCommittee Members

WILLIAM L. ROPER (Chair) Dean, School of Public Health, University of North Carolina at Chapel Hill

ARNOLD M. EPSTEIN (Vice Chair) John H. Foster Professor and Chair, Department of Health Policy and Management, Harvard School of Public Health

BECKY CHERNEY President and CEO, Central Florida Health Care Coalition

DAVID C. CLASSEN Associate Professor of Medicine, University of Utah and Vice President,

First Consulting Group

JOHN M. COLMERS Program Officer, Milbank Memorial Fund

ALAIN ENTHOVEN Marriner S. Eccles Professor of Public and Private Management,

Graduate School of Business, Stanford University

JOSÉ J. ESCARCE Senior Natural Scientist, The RAND Corporation

SHELDON GREENFIELD Director, Primary Care Outcomes Research Institute, New

England Medical Center

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Committee Members Committee Members (continued)(continued)

JUDITH HIBBARD Professor, Department of Planning, Public Policy and Management,

University of Oregon

HAROLD S. LUFT Caldwell B. Esselstyn Professor of Health Policy and Health

Economics and Director, Institute for Health Policy Studies, University of California, San Francisco

ELIZABETH McGLYNN Senior Researcher, The Rand Corporation (served until July

2000)

SCOTT C. RATZAN Senior Technical Advisor and Population Leadership Fellow,

Center for Population, Health, and Nutrition, U.S. Agency for International Development

MARK D. SM ITH President and CEO, California HealthCare Foundation

WILLIAM W. STEAD Associate Vice Chancellor for Health Affairs and Director,

Informatics Center, Vanderbilt University Medical Center

ALAN M. ZASLAVSKY Associate Professor of Statistics, Department of Health Care

Policy, Harvard Medical School

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Why a National Health Care Quality Why a National Health Care Quality Report?Report?

• To inform Congress, the Administration and other policy makers. To identify actionable areas to improve health care quality and monitor the effects of policies.

• To serve as a barometer of quality & systematically assess progress in meeting specific aims or national goals.

• To raise public awareness about the state and progress of quality of health care delivery in the country.

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The Committee’s TaskThe Committee’s Task

• Most important questions need to answer to be able to evaluate

the level & change in quality of care

• Major aspects of quality or categories that should be included

• Examples of specific measures in each category

• Recommendations on the production of the report

The committee was asked to define:The committee was asked to define:

National National Health Care Health Care Quality Quality ReportsReports

National Health Care Quality Framework(Chapter 2)

MeasureSelection Criteria and Guidelines

(Chapter 3)

Review of Data Sources

(Chapter 4)

Categories of Measures

Measure Set

National Health Care Quality

Data Set

Audience- Centered Reporting Criteria

(Chapter 5)

Process ProductFROM THE FRAMEWORK TO THE NATIONAL HEALTH CARE QUALITY

REPORT(S)

RecommendationsRecommendations

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Framework and CategoriesFramework and Categories::Recommendation 1Recommendation 1

The conceptual framework should address two dimensions two dimensions

• Components of Health Care QualityComponents of Health Care Quality

– Safety– Effectiveness– Patient Centeredness– Timeliness

• Consumer Perspectives on Health Care NeedsConsumer Perspectives on Health Care Needs

– Staying Healthy– Getting Better– Living with Illness or Disability– Coping with the End of Life

The conceptual framework should also analyze EquityEquity as an issue that cuts across both dimensions.

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The Framework as a MatrixThe Framework as a Matrix

Components of Health Care QualityConsumerPerspectivesonHealth CareNeeds

Safety EffectivenessPatient

CenterednessTimeliness

Staying healthy

Getting better

Living withillnessor disability

Coping with theend of life

Rec. 1

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Components of Health Care Components of Health Care QualityQuality

Safety refers to “avoiding injuries to patients from care that is intended to help them” (Institute of Medicine, 2001).

Effectiveness refers to “providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit (avoiding overuse and underuse)” (Institute of Medicine, 2001).

Patient centeredness refers to health care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they require to make decisions and participate in their own care.

Timeliness refers to obtaining needed care and minimizing unnecessary delays in getting that care.

Rec. 1

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Consumer Perspectives on Consumer Perspectives on Health Care NeedsHealth Care Needs

• Staying healthy refers to getting help to avoid illness and remain well.

• Getting better refers to getting help to recover from an illness or injury.

• Living with illness or disability refers to getting help with managing an ongoing, chronic condition or dealing with a disability that affects function.

• Coping with the end of life refers to getting help to deal with a terminal illness.

Rec. 1

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Measure Criteria & Guidelines:Measure Criteria & Guidelines: Recommendation 2Recommendation 2

• General Criteria for Individual MeasuresGeneral Criteria for Individual Measures– Importance– Scientific Soundness– Feasibility

• Criteria for Measure SetsCriteria for Measure Sets– Balance– Comprehensiveness– Robustness

AHRQ should apply criteria to assess the desirable attributes of potential quality measures and measure sets for inclusion in the Quality Report.

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Measure Criteria & Guidelines:Measure Criteria & Guidelines: Recommendation 3Recommendation 3

The Agency for Healthcare Research and Quality should have an ongoing independent committee or advisory body to help assess and guide improvements over time in the National Health Care Quality Report.

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Measure Criteria & Guidelines:Measure Criteria & Guidelines: Recommendation 4Recommendation 4

The Agency for Healthcare Research and Quality should set the long-term goal of using a comprehensive approach to the assessment and measurement of quality of care as a basis for the National Health Care Quality Data Set.

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MMeasure Criteria & Guidelines:easure Criteria & Guidelines: Recommendation 5Recommendation 5

When possible and appropriate, and to enhance robustness, facilitate detection of trends, and simplify presentation of the measures in the National Health Care Quality Report, AHRQ should consider combining related individual measures into summary measures of specific aspects of quality.

AHRQ should also make available to the public information on the individual measures included in any summary measure, as well as the procedures used to construct them.

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Measure Criteria and Guidelines:Measure Criteria and Guidelines:Recommendation 6Recommendation 6

Data Set should reflect a balance of outcome-validated process measures and condition- or procedure-specific outcome measures.

Given the weak links between most structures and outcomes of care and interests of consumers and providers in practice-related aspects as well as outcome measures, structural measures should be avoided.

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Data Sources, Collection & Data Sources, Collection & Analysis:Analysis:

Recommendation 7Recommendation 7AHRQ should assess potential data sources for the National

Health Care Quality Data Set according to the following

Criteria for Individual Data SourcesCriteria for Individual Data Sources• Credibility and Validity of the Data • National Scope and Potential to Provide State-level Detail• Availability and Consistency of the Data Over Time and Across Sources• Timeliness of the Data• Ability to Support Population Subgroup and Condition-specific Analyses• Public Accessibility of the Data

Criterion for Ensemble of Data SourcesCriterion for Ensemble of Data Sources • Comprehensive

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Data Sources, Collection & Data Sources, Collection & Analysis: Analysis:

Recommendation 8Recommendation 8To obtain the data for the Quality Report, AHRQ needs to

In the short term:

• Draw on a MOSAIC of public and private data sources for the National Health Care Quality Data Set

• Complement existent data sources by new ones to address all aspects proposed

In the medium and long term:

• Encourage development of a comprehensive health information infrastructure (including standardized, electronic clinical data systems) to support the vision of the data set for the Quality Report

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Data Sources, Collection & Data Sources, Collection & Analysis: Analysis:

Recommendation 9Recommendation 9The data for the National Health Care Quality Report should be nationally representative and, in the long term, reportable at the state level.

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Designing the Report:Designing the Report:Recommendation 10Recommendation 10

The National Health Care Quality Report should be

• Produced in several versions tailored to key audiences– policy makers– consumers– purchasers– providers– researchers

• Feature limited number of key findings and minimum number of measures needed to support these findings

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Some Reporting GuidelinesSome Reporting Guidelines

Select 3 to 5 key findings for attention in the report

Make report available in print and on the Web

Use benchmarks or standards for comparisons

Choose findings that have strong statistical evidence

Rec. 10

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ChallengesChallenges

• Populating the framework matrix with sufficient measures by selecting from existing ones and defining new ones where needed

• Establishing a comprehensive quality data set accessible to the public and to researchers

• Keeping the report focus narrow (3-5 key findings) despite complexity, visibility and importance of the subject

• Defining useful summary measures where appropriate