Outcomes management and continuous quality improvement: the compass and the rudder

The impact of contracting-out on health system performance: A conceptual framework

Despite the increased popularity of contracting-out of health services in developing countries, its effectiveness on overall health system performance is not yet conclusive. Except for substantial evidence of contracting-out's positive effect on access to health services and some evidence on improved equity in access, there is little evidence of contracting-out's impact on quality and efficiency. Most studies on the subject evaluate specific contracting-out projects against narrowly specified project objectives, not against more broadly defined health system goals. For this reason, conclusions of positive effects pertaining to project level may not hold at system level. This paper presents a conceptual framework that is expected to facilitate comprehensive, rigorous, and standardized evaluation of contracting-out at health system level. Specifically, this framework supports: full and standardized description of contracting-out interventions, study of the determinants of effectiveness, examination of provider and purchaser responses, assessment of the impact of contracting-out on all dimensions of health system performance, and cross-project analyses.

The design of evaluations for continuous quality improvement

Many health care organizations are modeling continuous quality improvement activities after designs used in business and industry. This has resulted in a somewhat standardized and possibly limited approach to conducting quality improvement activities. In contrast, the evaluation paradigm provides a broader approach because the design of an evaluation may be based on the questions to be examined, or the design may emerge during the process of conducting the evaluation. This article examines the design of evaluations used for continuous quality improvement activities in health care and human service organizations. Through a case example, the benefits of using alternative evaluation designs are explored. In particular, use of alternative approaches to gather and evaluate information about restrictive treatment interventions in a mental health setting are presented.

The Evolution of a Quality Programme within a Changing Environment

Health care facilities have been forced to re-evaluate traditional methods of quality assurance and consider quality improvement techniques. The Toronto Hospital Occupational Therapy Department has developed a quality programme that incorporates a foundation and supporting structures that can be adapted to accommodate the shift from quality assurance to continuous quality improvement. The foundation consists of a philosophy and principal functions, while the supporting structures include mechanisms to monitor principal functions and for communication. With a shift to continuous quality improvement, the quality programme was expanded to include clinical indicators and greater involvement of front-line staff and consumers. The programme also incorporates a framework that directs the development and implementation of clinical indicators related to occupational performance outcomes. Issues pertaining to the implementation and adaptation of the quality programme are discussed. Although initially developed in an occupational therapy environment, the framework and processes of this quality programme are being applied to multidisciplinary quality programmes in which occupational therapists are taking on leadership roles.

Selecting clinical outcome indicators for monitoring quality of care

Clinical outcome indicators are used to identify opportunities for improvement in patient care processes. This paper focuses on issues specific to the selection of clinical outcome indicators for use in assessing performance within and between hospitals. The issues and examples are based on the experiences of a university research team that worked in collaboration with a group of teaching hospitals to develop and monitor clinical outcome indicators. Four sets of issues are discussed: the intended use, and end users of indicator information; aspects of indicator validity; data quality; and dissemination and use of indicator information. Recommendations are made that apply to individual hospitals, groups of hospitals and health care systems.

Effect of feedback on resource use and morbidity in hip and knee arthroplasty in an integrated group practice setting

OBJECTIVE

To assess the effect of a structured program of feedback about resource utilization and morbidity on resource consumption and complications in an orthopedic surgical practice.

DESIGN

We prospectively analyzed use and outcomes before and after an intervention (departmental data presentation).

MATERIAL AND METHODS

Feedback on resource utilization and morbidity for 2,820 patients who underwent a primary total hip or knee arthroplasty for a diagnosis of osteoarthritis between Jan. 1, 1990, and Dec. 31, 1992, was provided to members of the orthopedic department of an academic medical center. Data were adjusted for severity of disease.

RESULTS

On reassessment 18 months after the beginning of the feedback program, total charges and length of hospital stay for hip or knee arthroplasty were significantly reduced. Interpractitioner variability was also reduced but not significantly. The feedback process was instrumental in identifying a specific complication--pulmonary embolism after bilateral total knee replacement--which was significantly reduced by addition of warfarin prophylaxis.

CONCLUSION

The intervention was successful in reducing resource use (length of hospital stay) and complications (pulmonary embolism). In addition, total charges for hip and knee arthroplasty declined significantly at a time when medical center charges overall were increasing. Efforts to maintain continuous improvement will primarily focus on the development of critical pathways.

A balanced scorecard for Canadian hospitals

Managing a health care organization on the basis of one set of information alone (e.g., financial information) does not give a full view of the impact of changes on the organization. A balanced scorecard approach can provide management with a comprehensive framework that turns an organization's strategic objectives into a coherent set of performance measures. This approach has been used extensively in industry, but seldom in health care organizations. By developing a scorecard approach, these organizations could obtain feedback providing a balanced view of organizational performance, letting them see if improvements in one area may have been achieved at the expense of another. It also demands that managers translate their general mission statement on customer service into specific measures that reflect the factors that really matter to customers.

Improving patient quality of life with feedback to physicians about functional status

OBJECTIVE

To improve functional status among primary care patients.

INTERVENTION

1) Computer-generated feedback to physicians about the patient's functional status, the patient's self-reported "chief complaint," and problem-specific resource and management suggestions; and 2) two brief interactive educational sessions for physicians.

DESIGN

Randomized controlled trial.

SETTING

University primary care clinic.

PARTICIPANTS

All 73 internal medicine house officers and 557 of their new primary care patients.

MEASURES

1) Change in patient functional status from enrollment until six months later, using the Functional Status Questionnaire (FSQ); 2) management plans and additional information about functional status abstracted from the medical record; and 3) physician attitude about whether internists should address functional status problems.

RESULTS

Emotional well-being scores improved significantly for the patients of the experimental group physicians compared with those of the control group physicians (p < 0.03). Limitations in social activities indicated as "due to health" decreased among the elderly (> or = 70 years of age) individuals in the experimental group compared with the control group (p < 0.03). The experimental group physicians diagnosed more symptoms of stress or anxiety than did the control group physicians (p < 0.001) and took more actions recommended by the feedback form (p < 0.02).

CONCLUSIONS

Computer-generated feedback of functional status screening results accompanied by resource and management suggestions can increase physician diagnoses of impaired emotional well-being, can influence physician management of functional status problems, and can assist physicians in improving emotional well-being and social functioning among their patients.

Pursuing quality improvement: a social work perspective

The multidisciplinary approach to the treatment of patients with chronic renal failure has existed since the inception of the Medicare end-stage renal disease (ESRD) Program. Social workers as team members in the various renal outpatient treatment settings have contributed to the planning and assessment of patient needs with the goal of achieving the optimal quality of life available to each individual. Nephrology social workers have also participated in the evolution of quality management through their professional organization. The eight clinical indicators jointly developed by the Council of Nephrology Social Workers and the National Association of Social Workers provide a basis for the implementation of continuous quality improvement concepts. The Health Care Financing Administration, the administrative agency of the ESRD Program, has shifted its quality management approach from quality assurance to the broader concepts of continuous quality improvement. The Health Care Quality Improvement Program provides the structure for all professionals to develop a facility-based system for quality management. By using strategies of quality control and quality improvement, social workers will be able to demonstrate the positive benefit of social service intervention. Identification of useful psychological and functional assessment tools must be incorporated into social work practice to measure outcome. Social workers have the necessary expertise in conflict resolution and group dynamics, which are skills needed for team facilitators used within the conceptual framework of continuous quality improvement. The challenge is to learn these concepts and incorporate them into the daily operation of social work practice.

Outcome evaluations as measures of quality in pediatric intensive care

In recent years, interest in assessing quality of care has blossomed. Quality care may be defined as providing the most appropriate treatment and providing it with great technical and managerial skill and proficiency in a manner that gains patient acceptance. For assessment purposes, variation in risk-adjusted outcomes between providers should be attributable to quality of care differences. Some methods for measuring outcomes and risk-adjustment for pediatric intensive care populations have been developed, but additional tools are needed for applications in outcomes management, continuous quality improvement, and outcomes research.

Deming meets Braverman: toward a progressive analysis of the continuous quality improvement paradigm

The continuous quality improvement (CQI) model has rapidly become the dominant management paradigm in U.S. industrial and health care leadership circles. Despite its widespread corporate acceptance and its relevance to public sector policy issues, there has been a paucity of progressive analysis of CQI. The authors begin by noting remarkable similarities between CQI critiques of Taylorism (so-called scientific management of work) with those made by Braverman, a leading Marxist analyst of the work process. Each of the 14 principles of CQI pioneer W. E. Deming are explained and analyzed for their progressive content. These pluses are then contrasted with 18 problematic issues in an attempt to challenge and go beyond the constraints of CQI as it is currently being applied in health care and other sectors. These issues include (1) mismatch between rhetoric and reality, (2) public sector issues, and (3) broader contradictions. The authors emphasize the genuine need for improving health care quality and the relevance of CQI for addressing this need. They challenge progressives to grapple with the profound contradictions by the CQI paradigm inviting a broader dialogue on CQI's meaning for improving the public's health.