Quality Measures - General Resources

Data limitations continue to pose challenges for efforts to identify racial and ethnic disparities in health and health care and analyze the underlying causes. Given budget constraints, the most feasible federal strategies to improve national data are those requiring only modest expenditures. Collaborations among private and public stakeholders hold promise for improving estimation methods and assessing disparities among small populations.

In today's healthcare environment, institutions are striving to streamline processes, reduce costs of healthcare, and establish best practice patterns while maintaining and improving the quality of care provided. Various healthcare delivery models are in use including case management and outcomes management. Various tools or structured-care methodologies (SCMs) are incorporated into these different models to support cost reduction and streamline processes while enhancing quality of care. This article discusses the tools frequently used, such as critical pathways, algorithms, and guidelines, as well as how these tools can be used in combination to support each other. This article also addresses the benefits of SCMs, how these tools are developed, and how the data obtained can be used in quality enhancement programs.

BACKGROUND: Previous reviews have shown inconsistent effects of publicly reported performance data on quality of care, but many new studies have become available in the 7 years since the last systematic review.
PURPOSE: To synthesize the evidence for using publicly reported performance data to improve quality.
DATA SOURCES: Web of Science, MEDLINE, EconLit, and Wilson Business Periodicals (1999-2006) and independent review of articles (1986-1999) identified in a previous systematic review. Only sources published in English were included.
STUDY SELECTION: Peer-reviewed articles assessing the effects of public release of performance data on selection of providers, quality improvement activity, clinical outcomes (effectiveness, patient safety, and patient-centeredness), and unintended consequences.
DATA EXTRACTION: Data on study participants, reporting system or level, study design, selection of providers, quality improvement activity, outcomes, and unintended consequences were extracted.
DATA SYNTHESIS: Forty-five articles published since 1986 (27 of which were published since 1999) evaluated the impact of public reporting on quality. Many focus on a select few reporting systems. Synthesis of data from 8 health plan-level studies suggests modest association between public reporting and plan selection. Synthesis of 11 studies, all hospital-level, suggests stimulation of quality improvement activity. Review of 9 hospital-level and 7 individual provider-level studies shows inconsistent association between public reporting and selection of hospitals and individual providers. Synthesis of 11 studies, primarily hospital-level, indicates inconsistent association between public reporting and improved effectiveness. Evidence on the impact of public reporting on patient safety and patient-centeredness is scant.
LIMITATIONS: Heterogeneity made comparisons across studies challenging. Only peer-reviewed, English-language articles were included.
CONCLUSION: Evidence is scant, particularly about individual providers and practices. Rigorous evaluation of many major public reporting systems is lacking. Evidence suggests that publicly releasing performance data stimulates quality improvement activity at the hospital level. The effect of public reporting on effectiveness, safety, and patient-centeredness remains uncertain.

Collaborative practice teams consist of interdisciplinary providers who are charged with the process of implementing and refining an outcomes management program within a targeted population. Collaborative practice teams work under the assumption that clinical quality enhancement through practice standardization decreases care fragmentation, resulting in improved physiologic, psychosocial, and financial outcomes. Collaborative practice team members identify best practice through the implementation and testing of interdisciplinary interventions. Represented on a critical pathway, these practices are evaluated toward achievement of defined population outcomes. In this article, the authors review the process of collaborative practice team formation, expected pitfalls and barriers to effective collaboration, and the work accomplished by a collaborative practice team.

Crisis resource management (CRM) is a team-training program that teaches nontechnical skills such as: collaboration, communication, task management, teamwork, and leadership 1. The purpose of this study was to evaluate improvement in the nontechnical skills of a multidisciplinary team of pediatric residents, anesthesiology residents and pediatric nurses following participation in the CRM educational program. Self-efficacy theory guided the teaching method used in the CRM program. The Collaboration and Satisfaction about Care Decisions instrument 2 and the Anesthetists' Nontechnical Skills System 3 served as outcome measures. Seven multidisciplinary groups were studied with a total of 40 subjects. A significant increase was found in posttest scores for perceived collaboration and satisfaction with care and in numerical ratings of observed team skills following the CRM program. The results suggest multidisciplinary team participation in the CRM program increased perceived team collaboration, satisfaction with care, and observed teamwork skills.

The critical examination of clinical practice should be an integral part of patient care. It includes the development and implementation of guidelines, together with continuous evaluation of clinical process and outcomes to improve the quality of care provided. Clinical audit has not been successful in achieving this. The use of Integrated Care Pathways facilitates the introduction of guidelines and the continuous evaluation of clinical practice. Improvements are achieved by frequently revising the pathways to reflect current, local best practice. Integrated Care Pathways define the expected course of events in the care of a patient with a particular condition, within a set time-scale. A pathway is divided into time intervals during which specific goals and expected progress are defined, together with appropriate investigations and treatment. A pathway reflects the activities of a multidisciplinary team and can incorporate established guidelines and evidence-based medicine. It is usually unique to the institution in which it was developed. The pathway forms part of the clinical record of every patient. All variations from the pathway are documented, and the reasons for the variations analysed. Solutions are developed to address the causes of potentially avoidable variation, and the pathway is revised to incorporate these improvements. Integrated Care Pathways provide a powerful audit tool, as all aspects of the process and outcome of clinical practice can be constantly monitored. Variations from set standards are minimized, and improvements are rapidly incorporated into routine practice and subsequently re-evaluated.

Team performance measurement is a critical and frequently overlooked component of an effective simulation-based training system designed to build teamwork competencies. Quality team performance measurement is essential for systematically diagnosing team performance and subsequently making decisions concerning feedback and remediation. However, the complexities of team performance pose a challenge to effectively measuring team performance. This article synthesizes the scientific literature on this topic and provides a set of best practices for designing and implementing team performance measurement systems in simulation-based training.

In this article, the authors draw on the disciplines of sociology and environmental and social epidemiology to further understanding of mechanisms through which social factors contribute to disparate environmental exposures and health inequalities. They propose a conceptual framework for environmental health promotion that considers dynamic social processes through which social and environmental inequalities--and associated health disparities--are produced, reproduced, and potentially transformed. Using empirical evidence from the published literature, as well as their own practical experiences in conducting community-based participatory research in Detroit and Harlem, the authors examine health promotion interventions at various levels (community-wide, regional, and national) that aim to improve population health by addressing various aspects of social processes and/or physical environments. Finally, they recommend moving beyond environmental remediation strategies toward environmental health promotion efforts that are sustainable and explicitly designed to reduce social, environmental, and health inequalities.

OBJECTIVE: The objective was to develop, validate, and recommend a scaling model for a discriminative obstetric outcome measure named the Morbidity Assessment Index for Newborns. The purpose of this tool is to allow comparison of obstetric therapeutic strategies on neonatal morbidity, particularly in the mild to moderate morbidity range. STUDY DESIGN: A list of 66 check-mark (yes or no) items of readily available clinical and laboratory data from the early neonatal period was compiled by a panel of obstetric and neonatal experts. These data were collected on 411 neonates born at ≥28 weeks’ gestation and representing all grades of morbidity. Detailed psychometric testing included dimensionality testing and item analysis with the item response theory. The scores obtained with this new assessment tool were correlated with newborn and maternal disease conditions or events and with other measures of newborn morbidity. RESULTS: The Morbidity Assessment Index for Newborns is easy to apply in prospective or retrospective studies. Detailed psychometric evaluation resulted in modification of the list to 47 items, each item with a relative scale value according to severity of morbidity. The test was demonstrated to be a reliable and generalizable scaled index that performs optimally for the mild to moderate neonatal morbidity range. CONCLUSION: The Morbidity Assessment Index for Newborns is a validated outcome measurement scale of neonatal morbidity. This new tool may facilitate the conduct of obstetric clinical trials or epidemiologic population- based studies in obstetrics.