Quality Land

Mª Luisa de la Puente
 

In the world of healthcare, quality is everyone's business and it covers everything. This assertion, generically true but with little operational, is coming in stronger in recent years. This concretion to a specific context is driven by the necessary adaptation to the escalation of healthcare costs, the economic context, the influence of the business world to obtain more performance from resources, the demands of its clients or professional discomfort due to the little recognition of what it is.

Measuring efficiency: is it going well?

Mª Luisa de La Puente

While the concept of efficiency is easy to understand if we consider it as the system that uses resources (inputs) to improve the health of the population, it's not as easy to measure as it appears due to the multiple methodological problems. The relationship between inputs and outcomes in the health sector is influenced by multiple factors external to the control of the health sector itself.

The European Union Health System Performance Assessment (HSPA) expert group has recently published a report on this (1).

It defines efficiency as the quotient between the inputs of the system (equipment, resources) and its outputs (the number of patients treated, for example) or its outcomes (the number of years of life gained, for example). He accepts them both but warns that using outputs as an approximation of outcomes can lead to false interpretations. It also highlights the importance of differentiating efficiency from cost control, since cost control is only concerned with reducing inputs without measuring the outputs/outcomes that that reduction causes.

In a health system, efficiency can arise for two different but related reasons. Efficiency materializes:

 1) When the same result could be produced, or even better, consuming fewer inputs, and

 2) When resources are spent on a mix of services that maximize the health of society as a whole (outcomes). These two typologies of efficiencies are conventionally cited, respectively, as technical efficiency and allocation efficiency. The allocation efficiency can be produced on a macro basis (paying attention to the service with the best cost/effectiveness ratio) and on a micro character (giving the treatment with the best cost/effectiveness ratio). The OECD idea of waste is associated with the notion of technical efficiency (2).

A survey is carried out in the 29 countries that are part of the group of experts, of which 22 answered. The survey only explores technical efficiency, since the assignment would require information on the relative value of the outputs of the services that don't it's available in most of the investigated countries. Half of the respondents state that they don't have a unified system to measure efficiency. Of the other half, approximately 40% respond that they consider the relationship between intermediate inputs and outputs, 40% between inputs and outcomes, and the remaining 20% consider the two previous possibilities. 80% responded that the hospital area is subject to regular measurements, not so much for strategy as for lack of information from other health areas such as primary care, mental health or social and health care. Technical efficiency in hospitals is also measured as it's the functional area with the highest cost. The results show how, although European countries place improving efficiency as their priority, the vast majority have real problems when it comes to having the necessary methodology and instruments to measure it.

The report presents as an example of evaluation of technical efficiency the management of the demand of acute pathology, which requires evaluating three moments of the process: before hospitalization, during the stay and after discharge, expanding the spectrum of the analysis to other areas such as primary care and social health care.

The OECD report insists on the same recommendation to broaden the spectrum when looking at the overuse of hospitals. This is exemplified by the excessive use of emergency services in mild pathologies and the excessive use of emergency and hospital services in chronic pathologies, both of which can be better managed in other devices. It also illustrates this with different examples of how certain OECD countries have made these changes.

The recommendations that emerged after reading the OECD report are:

1. It’s essential to have more homogeneous instruments for measuring and evaluating the efficiency of health systems that serve to guide decision-making.

2. It’s dangerous to make decisions based on comparisons and benchmarks with outputs/outcomes that are not well validated or contextualized.

3. When analyzing efficiency, as opposed to the concept of cost control, it's essential to broaden the spectrum of analysis to all services that address the care process. This formula also allows crossing the border between technical and assigned efficiency.

It seems, therefore, that the measure of efficiency is still at a very early stage. Improving the information that supports efficiency measurement is essential to support change. On the one hand, it will avoid inappropriate policies, on the other, it favours the evaluation of services with greater precision. Also, finally, it will promote the awareness of the population about what it means to obtain appropriate care, a necessary aspect in our country.

Bibliography

1. EU. Report by the Expert Group on Health System Performance Assessment. TOOLS AND METHODOLOGIES TO ASSESS THE EFFICIENCY OF HEALTH CARE SERVICES IN EUROPE. 2019

2. OCDE. Tackling wasteful spending on health. 2017.

Who is responsible for providing quality and safe care?

Mª Luisa de la Puente

Chris Ham and Don Berwick argued that the teams of professionals who care for patients are mainly responsible for providing quality care and safety, placing managers and regulators second.

The health managers’ role is to manage the means of communication, training, resources and the time critical requirements to enable the functioning and constant improvement of the care and safety requirements. They cannot achieve this it if they are not focused on what is happening in the front line and making this their main priority.

While managers have the responsibility to add value to clinical teams surrounding them with the resources necessary for continuous efficiency and safety improvement, the clinical leaders must connect with the managers and the professionals and focus on  detecting the organisational factors that may leave room for improvement and work in the reordering them and in innovation to carry these out. According to this view, the new definition of professionalism assumes that those professionals who work in the first line, with the support of others, must accept the responsibility to identify and remove the obstacles that may get in the way of a high quality of care. Similar recommendations have been proposed by others like Bohmer since 2010, but the authors insist on this fact, given the practical difficulty to carry them out. 

Do we need audits or indicators to control the quality and safety of health centres?

Mª Luisa de la Puente 

Are care indicators useful in detecting the quality problems in hospitals? This question, which seems obvious, has its crumb. Alex Griffiths, of the School of Management at King's College London, has just published the results of a study of the usefulness of health indicators as predictors of the quality of care of English hospitals and the conclusion is that you can’t trust them too much.

The Care Quality Commission (CQC) is responsible for ensuring the quality of health and social services in England (more than 30,000 providers). Due to the scarcity of resources to carry out on-site inspections, the CQC used statistical surveillance through health indicators to prioritize those hospitals that had quality of care problems and subsequently send inspectors to these centres. The inspectors’ mission is to analyze the situation and give support to the suppliers for the orientation of the improvements. What was surprising to see was that the instrument "Intelligent Monitoring" (IM, scale of risk composed of 150 indicators, among others waiting list, mortality, surveys of users and professionals, etc.) is not able to predict which hospitals present quality problems or discern between those that work well and those that need improvements (compared to the classification of sanitary inspectors).

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.