Health care quality can be defined as safe and effective care that improves outcome, optimizes health, and results in high patient satisfaction and quality of life. In the current environment of health care reform in the United States, the focus has shifted from the fee-for-service model, in which the volume of health care services rendered was rewarded, to emphasis on quality, safety, and outcome as top priorities. This chapter discusses health care quality, evidence-based medicine (EBM), clinical practice guidelines (CPGs), outcome and performance measures, practice improvement, patient safety, and accreditation.
Access, affordability, and high quality in health care are the main objectives of the Patient Protection and Affordable Care Act of 2010. To accomplish these goals, the U.S. Department of Health and Human Services (HHS) has outlined a National Quality Strategy (NQS) that was developed through a collaborative and participatory process, including input from a wide variety of stakeholders from all over the health care industry (eSlide 7.1) .
Quality of care is a measure of performance in the six specified health care aims of the Institute of Medicine (IOM): safety, timeliness, effectiveness, equity, efficiency, and patient centeredness. On the basis of performance metrics, providers, individuals, organizations, and health plans are incentivized to improve quality through accountability (eSlide 7.2) . The ultimate objective is to deliver high-quality health care and rehabilitation and improve the health of the population we serve (eSlide 7.3) .
Outcome Measures
In health care, an outcome is the health consequence that results from the health care provided. An outcome measure is the assessment of clinical outcomes by qualitative or quantitative means.
Types of Outcome Measures
In 1966, Donabedian conceptualized how the information regarding health care quality may be gathered and modeled three dimensions of health care: structure, process, and outcome (eSlide 7.4) . Because attribution of outcomes to particular processes is challenging, many providers and hospitals prefer to measure processes instead of outcomes. When selecting a process measure, it is important to determine that there is strong scientific evidence that links the process to the outcome. One must adjust for risk factors or stratify the population when using outcome measures because it is challenging to account for all factors that may influence health outcomes.
International Classification of Functioning, Disability, and Health
The physical medicine and rehabilitation (PM&R) community is well versed in outcome measurement, especially as it relates to functional outcome and pain reduction. The International Classification of Functioning, Disability and Health (ICF) was released in 2001 as an update by the World Health Organization to their International Classification of Impairments, Disabilities, and Handicaps. In the ICF, function occurs at three levels: (1) level of the body part or system, (2) level of the person (activities), and (3) level of the person in society (participation). Functional outcomes can be measured at each of the levels described in the ICF, and interventions may be geared at any one or more of these levels.
Functional Independence Measure
The aggregation of individual patient outcome measurements allows providers and hospitals to benchmark and helps identify areas for improvement in health care delivery. Most inpatient rehabilitation programs submit their patients’ Functional Independence Measure (FIM) scores to the Uniform Data System (UDS) (eSlide 7.5) . Tracking functional progress is a key activity in inpatient rehabilitation, and aggregate data can speak volumes about what the facility and providers are doing to promote function. The UDS provides report cards that detail FIM change (discharge FIM–admission FIM) and FIM efficiency (FIM change/length of stay) for patients by impairment grouping. It also tracks the percentage of patients successfully discharged to home.
Choosing Outcome Measures
Several factors must be considered when choosing an outcome measure to use (eSlide 7.6) . The Rehabilitation Measures Database has numerous measures listed that can be used to track outcomes in a patient population of interest. This database intends to provide clinicians with a list of instruments that can be used to screen and monitor patient progress (eSlide 7.7) .
Evidence and Guidelines
Definitions of Evidence-Based Medicine
In 1992, the Evidence-Based Medicine Working Group published a treatise on EBM, calling it a “new paradigm for medical practice.” EBM has been defined as “the integration of best research evidence with clinical expertise and patient values.” Using EBM, physicians can address clinical questions by assessing the quality of evidence in medical information available in both basic science and clinical research.
Assessing, Evaluating, and Applying Evidence
Sackett et al. recommend the application of EBM with a simple and straightforward approach to answer any clinical question: (1) define a clinical question, (2) find the evidence that will help answer the question, (3) assess whether this evidence is valid and important, and (4) apply the evidence to the patient (eSlide 7.8) .
In general, the level of evidence provided by a published article can be determined from the level of evidence hierarchy (eSlide 7.9) . One can also appraise the level of evidence of a research article using evidence tables such as the one produced by The Oxford Center for Evidence-Based Medicine or the criteria adopted by the American Academy of Physical Medicine and Rehabilitation (AAPMR). Other potentially useful EBM concepts are the “evidence-based triad” discussed by Glasziou et al. (eSlide 7.10) and patient-oriented evidence that matters (POEM).
Clinical Practice Guidelines
CPGs are systematically developed written statements, made after a systematic evaluation of available evidence, and are intended to assist practitioners and patients in making appropriate decisions about health care in specific conditions or circumstances (eSlide 7.11) . The IOM’s eight standards for developing CPGs are considered the “gold standard” that every CPG aims to achieve (eSlide 7.12) . The National Guideline Clearinghouse is a useful website to find relevant CPGs to suit one’s needs. It is a public resource that is published online by the Agency for Healthcare Research and Quality.
Performance Measures and Metrics
Performance measurement is a way to compute whether and how often the health care system does what it should. The result of a measure is a ratio or percentage that helps to compare providers and benchmark local and national performances. Development of performance metrics helps in transforming health care quality by measuring sustained gains obtained with improvement methodologies to create data-driven processes in organizations. Stakeholders who support and drive this change by reporting on quality and patient safety culture in hospitals include local and regional purchasers, payers, consumer representatives, and communities.
Measure Development
Development of performance metrics needs finance, labor, technology, education, and a learning environment over long timelines to reduce variation in care delivery across the United States. Because of the increase in people born with disabilities and those who acquire disabilities, particularly in the context of multiple chronic conditions and disparities in care, there is a continuous need to develop methods to measure performance toward the NQS. In addition, the Centers for Medicare and Medicaid Services (CMS) uses different criteria, such as lack of applicability across specialties, to remove measures, further compelling the development of new performance metrics.
Challenges in Measure Development
Desirable Attributes of a Measure Are Complex
By consensus from the American Medical Association (AMA), The Joint Commission (TJC), and the National Committee for Quality Assurance (NCQA), a performance measure must have the following characteristics: (1) address a topic area that is of high priority to maximize the health of people or populations, be financially important, and demonstrate a variation in care and/or potential improvement; (2) be useful in improving patient outcomes based on established clinical recommendations and be potentially actionable, meaningful to, and interpretable by the user; and (3) have a measure design with well-defined specifications and documented reliability and validity and allow risk adjustment while being feasible, confidential, and publicly available.
Measure Testing That Is Critical to the Process of Its Development Is Elaborate
Measure testing requires the involvement of all stakeholders, patients, and providers, including insurers, technology providers, individual or groups of clinicians, and health care organizations.
Measures Are Tested by Different Agencies Before Being Vetted
The AMA’s Physician Consortium for Performance Improvement (PCPI) is one agency that recommends that performance measures must be tested in the areas of needs assessment, feasibility and implementation, reliability, validity, unintended consequences, and applications.
Measure Development Involves Extensive Costs Through the Life Cycle of the Measure
For example, the life cycle of a measure endorsed by the National Quality Forum (NQF), which sets priorities for performance measurement, entails the following: (1) studying evidence-based data on disease prevalence, (2) using an assessment tool to study disease severity, (3) applying a local initiative to measure improvement with the process, (4) leading change toward improvement locally, (5) public reporting on local performance, (6) endorsing the measure as a national consensus standard, (7) retooling the measure for use in electronic health care records, and (8) including the meaningful use program of CMS so that measure adoption is widespread and leads to better patient care.
Risk Adjustment
Risk factors are patient characteristics associated with a statistically significant level of variance to allow valid comparisons across providers and organizations.
Privacy, Security, and Databases
Because public reporting is done with multiple systems and methods for transparency, with measures collected in databases or registries, training and monitoring of providers are required to keep patient information secure from external threats (particularly in this era of transition to electronic health care records across providers).
Strategically Improving Health Care Quality With Performance Measurement
Despite the various challenges, performance measurement is imperative because it helps provide quality at a lower cost. Performance measurement aligns providers to the six priorities of the NQS (eSlide 7.13) .
Safety and Accreditation
Health plan accreditation standards are used to ensure that plans are performing on par with industry standards by measuring their performance with respect to quality. Consumers use these data to compare plans. Other purchasers, such as employers and state and federal regulators, also use these metrics to pay for performance. The NCQA, Utilization Review Accreditation Commission, and TJC are examples of such agencies.
Public reporting by the CMS on nursing homes and measuring the performance of home-based and community-based services with financial incentives are steps that have been taken toward improving health care quality in the long term and in postacute care arenas. In addition, physician performance metrics are gathered using the Physician Quality Reporting System, which are coupled to financial incentives and penalties. Public reporting of performance metrics is a driver of health care quality because it encourages transparency and accountability.
Maintenance of Certification and Quality Improvement
The American Board of Physical Medicine and Rehabilitation’s (ABPMR) Maintenance of Certification (MOC) program is designed to verify a diplomate’s credentials, licensure, professional standing, and practice performance. ABPMR diplomates demonstrate the ability to investigate and evaluate the care of patients, appraise and assimilate scientific evidence, and continuously improve patient care based on constant self-evaluation and lifelong learning through the practice improvement project (PIP) requirement (eSlide 7.14) .
Summary
We are in a state of turbulent transition from volume-based health care to value-based health care. The two main drivers of this change are increasing costs and decreasing or stagnant quality. For this transition to succeed and eventually lead to efficient, safe, effective, and valuable health care, all rehabilitation professionals, including physiatrists, must work together with a unified focus on better quality and outcomes for our patients. Practicing safe medicine and EBM, with unchanging focus on values and outcomes, can help us get there. A fair, transparent, valid, and objective measurement of quality and safety can be embraced by everyone. Together, we can evolve as an accessible, affordable, and high-quality health care system that can be valuable and sustainable over the long term.
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