Monday, 29 January 2018

The old is not an enemy of the new: quality standards for health institutions

Mª Luisa de la Puente

This provocative title intends to join the debate that appeared in JAMA this year on what are the quality results that an institution should establish and publish. Common objectives among institutions, from one or different countries for certain diseases selected by international agencies? Or specific objectives of each institution established according to their priorities and the preferences of their professionals?

Professionals from Kaiser Permanente (KP) and from the Department of Veterans Affairs Center (VA) and the Joint Commission Accreditation Agency (JC) disagree. The authors of KP/VA recognize that the measurement and publication of the results of certain prioritized diseases have undoubtedly contributed to the improvement of quality, but they believe that, while continuing to focus on the performance of accounts, it’s necessary to establish innovative formulas for measuring results.

The experts defend more ad hoc indicators, adapted to the circumstances that really are a problem for the institution and that reach other health problems not measured to date. They propose that institutions that have reached an optimal level in standard measures, innovate in three main areas: a) new ways of measuring in clinical areas, such as using continuous versus dichotomous measures in hypertension, b) development of measures in clinic areas unmonitored to date; and c) testing new methods of measuring compliance (for example, new incentives). These more clinical strategies would achieve greater involvement of professionals when working for goals that they have prioritized and not other agents.

Measuring quality requires significant resources and in addition, some indicators are accompanied by economic incentives. To do this, it’s necessary to ceaselessly put effort into maintaining the standards already achieved, to continuously focus on the development of new measurement areas, observing whether the expected benefits are gained. Joint Commission defends that its objectives are directed to health problems with a significant weight of illness and/or causing a high consumption of resources. It also notes that, thanks to the established priorities, a significant improvement in results has been achieved (in 2002 when the project began with 8 measures, only 7% of hospitals reached more than 95% compliance, in 2014 with 49 measures, more than 80% reached it). Joint Commission defends that the quality standards established at the country level are more successful when they are shared among clinicians, institutions, health systems, society and accreditation agencies. In their opinion, without this external visibility among several entities, it’s much more difficult to achieve it.

Behind this debate, in my opinion, KP/VA defend the importance of "quality improvement", which together with "quality planning" and "quality control" constitute Juran's trilogy (see graphic). The continuous improvement of quality aims to work on small or large improvements based on the impulse and motivation of professionals to improve practices and innovate (see in this sense the video of the East London NHS Foundation Trust).

These improvements usually fall in second place along with other control measures and, therefore, don’t have the strong institutional and technical support (management of scientific knowledge, professional leadership, and process management and information technology) that they need to succeed.

The one is not an enemy of the other and in our country we need both: to have well-defined standards to deal with diseases and processes in all health care lines and, at the same time, we have to know how to look for innovative mechanisms to support professionals who want carry out changes in practice (to treat or not to treat diseases with more weight!).

[ii] David W. Baker, MD, MPH; Mark R. Chassin, MD, MPP, MPH. Measuring and Improving Quality. JAMA. 2016; 315(24):2733. doi:10.1001/jama.2016.4613.

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