Issue link: https://beckershealthcare.uberflip.com/i/501108
51 Question: How do you define "high-quality" care? Dr. Stanley Ashley: There have been many efforts to define high- quality care. I think the Institute of Medicine's definition is as use- ful as any — care that is safe, effective, patient-centered, timely, efficient and equitable. Dr. Dennis Lund: Measuring quality is a tricky subject in health- care, as there is no exact definition. There are the givens, like patient satisfaction, accessibility, affordability and, of course, out- comes. And yes, low complications and reasonable costs. All play a role in quality. But there is also a less quantifiable quality mea- surement, one that a patient or patient family knows and feels when their overall patient experience is one of great value. Dr. John Lynch: I think the triple aim that was started about 10 years ago by the Institute for Healthcare Improvement to define high-quality care is still relevant today. It is care that is patient- centered, focused on the patient experience, as well as maximiz- ing the outcomes for individual patients. It is also organized in a way that incorporates population health issues and uses popula- tion health tools to support groups of patients with similar prob- lems. It uses evidence-based guidelines for care across groups of patients and is cost efficient. Dr. Stephen Moore: I begin to look at this from a consumer or patient perspective more than from our own perspective these days. I think three key pieces surround quality. One is access. For people — regardless of whether they have complex issues — can you provide access to educational resources or availability when they need treatment or consultative experience? The second is around customer service and satisfaction. How are you going to treat them, how are you going to explain their treatment and how are you going to engage them in their care? The third piece is affordability. From a health system perspective, we take those is- sues at the core and then add safety and consistency. So, don't under- or over-treat patients, which can result in harm as well. Dr. Suzanne White: I define high-quality care as care that is safe, timely, efficient, evidence-based and patient-centered. As health- care providers, it is our responsibility to continuously work to do research, explore new ways to provide better care, improve wait and recovery times, and ultimately form expansive team-based models to provide comprehensive and innovative care to benefit the patient. Q: Are there any components of high-quality care that cannot be measured with numbers and charts? SA: We have a growing number of surrogate measures for each of the IOM attributes, although some are better measured than oth- ers. For example, in the hospital setting, there are multiple patient safety measures: pressure ulcer incidence, hand hygiene, falls, etc. None in isolation is an adequate measure of overall quality, and many need better mechanisms for risk adjustment before they can be applied for comparative purposes. The relative significance of each of these measures varies. In contrast, efficiency, because of the lack of consistency in our cost accounting practices, is even more difficult to measure. Although imperfect, such measures are useful to help direct quality improvement efforts. DL: Much of high-quality care can't be measured, but I think the surgeons have done the best job at attempts to measure quality by using strategies to do risk stratification. There are limitations in that effort, though, The American College of Surgeons developed a system called the National Surgical Quality Improvement Pro- gram, which uses over 30 risk stratification variables. However, if you look at a specialty like neonatology, one of the best quality databases in the field — called the Vermont Oxford Network — only uses two risk stratification variables. How do you determine what's enough and what's not enough? And when you get a num- ber, what do you do with that number? How can I look at the num- bers that come out of hospital X and compare them to hospital Y to know which is better? Quality is a huge conundrum. JL: The numbers and charts currently used to measure quality are generally focused on the down side of clinical care — complica- tions of care, avoidable readmissions, numbers and ratios of "ex- cess care," etc. The measurement systems are less focused on the outcomes that patient might expect or recognize. For example, if you're having a joint replacement, how well does the new joint function and what activities have you been able to perform in the intermediate term and in the long term after the intervention? Are we able to return people to the highest level of function as defined by the patient? Was the care delivered in a way the respects the patient's cultural norms? Do we display respect, compassion and coordination in a way that reduced the patient's fears and anxiety at the time care delivery? Unfortunately, sometimes the outcomes that are most important to our patients are the hardest to measure. SM: I think we're getting a lot better with it. I would say right at this point — around affordability, customer service satisfaction, access, consistent and safe care — those are all things currently measured with surveys and charts. It's interesting: 10 years ago, the only thing data could tell us about was the bottom performers. Studies were not consistent in identifying people doing the best. I think that is getting much better today with a broader set of tools, and I think it's still a work in progress as we refine those tools. SW: At Detroit Medical Center, we focus a lot on measurement, because it is very hard to improve what you cannot measure. However, some very important aspects of quality are difficult to measure. A good example is safe care transition — moving pa- tients from one stage of care to the next. This period of transition is very high risk for medical errors and contributes to readmis- sions, which can be a marker of low quality. Other areas that are difficult to measure include how well the patient's individual goals are being met, awareness of health disparities, effectiveness of improving the patient's ability to manage his/her own health, or 'disease self-management,' how effectively the patient's ability to cope with illness is improved and how well medical advice is com- prehended. Q: What does high-quality care look like when it is delivered? If you put two physicians in a room, could you tell who is delivering higher quality care? SA: Such comparisons probably have more validity for institutions than they do for individuals. Although it is possible — using a com- posite summary of quality measures to identify outliers at either end of the spectrum — most of us are somewhere in between and the distinctions may be very subtle. DL: No, I don't think you can. From a consumer's perspective, qual- ity should be a given. So if they look at a hospital or a doctor, they can't tell which surgeon ties a better knot, and online reviews can be all over the map. What they can tell is who has good bedside