Health care quality assurance

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This editable Main Article is under development and subject to a disclaimer.

[edit intro]

## Contents

* 1 Creating quality measures
* 2 Measuring quality
* 2.1 Statistical methods
* 3 Quality improvement
* 4 Improving quality
* 4.1 Cultures of quality
* 4.2 Audit and feedback
* 4.3 Financial incentives
* 4.3.1 Physician Quality Reporting Initiative
* 5 Public reporting of quality measures
* 6 Research on quality improvement
* 7 Teaching quality improvement to health care personnel
* 8 References

Health care quality assurance is "activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps."[1]

Health care quality assurance addresses topics such as medical error, cross infections[2], evidence-based medicine, and patient satisfaction.

Health care quality assurance uses tools such as

* Clinical practice variation (variability)
* Total quality management
* Product line management
* Critical pathways
* Quality control
* Risk management and Safety management
* Error reporting and root cause analysis[3][4]
* Clinical audit (audit and feedback)
* Utilization Review[5][6]
* Registries and panels[7][8]

## Creating quality measures[edit]

Creating quality measures from clinical practice guidelines can be problematic.[9][10]

Conflict of interest may influence the creation of measures. The National Committee for Quality Assurance receives money from groups who have financial interests in the components of measures.[11]

Sometimes, quality measures must be discontinued.[12]

## Measuring quality[edit]

Chart abstraction may underestimate quality.[13]

Regarding measuring quality in primary care, physicians' case loads may be too small to measure the quality of management of individual diseases.[14]

### Statistical methods[edit]

Interrupted time series studies with segmented regression analysis can be used in studies without concurrent controls.[15][16][17] This method may mimic estimates of effects from cluster trials.[15]

## Quality improvement[edit]

Study designs include:[16]

* Stepped Wedge Design
* Pragmatic Randomized Controlled Trial
* Interrupted Time Series
* Controlled Before-After Study
* Uncontrolled Before-After Study

## Improving quality[edit]

Guidelines exist for reporting[18] and assessing[16] studies of quality improvement.

More experience, as measured by volume of care, is associated with better quality of care.[19]

Process control charts can be used to identify specific problems that need improvement.[20][21][22] Examples are assessing methods to obtain blood cultures[23], the impact of screening for methicillin resistant Staphylococcus aureus[24] and comparing mortality in surgical units[25].

A healthcare matrix can help assess the quality of an individual episode of care and link to the Institute of Medicine (IOM) and the Accreditation Council of Graduate Medical Education (ACGME) goals.[26]

Surprisingly, hospitals reporting more compliance with the Leapfrog safe practices do not report reduced mortality than other hospitals.[27]

### Cultures of quality[edit]

The highest quality takes place when all involved constantly reinforce "lessons learned" to one another, in a learning process. The institution performing this research was a United States Air Force hospital at which aviation safety techniques were well known.[28]

Considerable insight from aviation safety appears applicable to health care. [29]

### Audit and feedback[edit]

Audit and feedback has been systematically reviewed by the Cochrane Collaboration who concluded its "effects are generally small to moderate."[30]

More recently, a factorial, cluster randomized controlled trial of audit and feedback concluded "enhanced feedback of requesting rates and brief educational reminder messages, alone and in combination, are effective strategies ."[31] The feedback in this trial was enhanced with an educational message.

### Financial incentives[edit]

Medicare has used its payments to health care providers as incentives to achieve health care quality assurance. For example, in the United States of America, the Centers for Medicare and Medicaid Services (CMS) may withhold a portion of the payments for the care of patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty who have perioperative deep venous thrombosis or [pulmonary embolism]].[32]

While pay for performance targets clinical quality and patient experience criteria may improve health care, targeting productivity and efficiency criteria may have adverse effects.[33]

#### Physician Quality Reporting Initiative[edit]

Per the Medicare website:[34]

"The 2006 Tax Relief and Health Care Act (TRHCA) (P.L. 109-432) required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals (EPs) who satisfactorily report data on quality measures for covered professional services furnished to Medicare beneficiaries during the second half of 2007 (the 2007 reporting period). CMS named this program the Physician Quality Reporting Initiative (PQRI). The PQRI was further modified as a result of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) (Pub. L. 110-275) and the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (Pub. L. 110-275)."

## Public reporting of quality measures[edit]

See also: Health care reform

Systematic reviews find 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".[35][36] A comparative study found concerns with the quality of data that is publicly available.[37] A subsequent cluster randomized controlled trial reported no benefit.[38] Recommendations have been made to improve public reporting.[39]

## Research on quality improvement[edit]

Guidelines exist for the reporting (http://www.squire-statement.org/)[40][41][18] and reading[16] of studies on quality improvement.

## Teaching quality improvement to health care personnel[edit]

Knowledge and self-assessed skills can be taught.[42][43][44][45][46][47][48]

Knowledge and attitudes can be measured with the QAIC with agreement as measured by kappa of 0.2 to 0.4[48] to a more recent report by different authors of over 0.8 [44]

Learning quality improvement can be linked to continuing medical education.[49]

## References[edit]

1. ↑ Anonymous (2025), Health care quality assurance (English). Medical Subject Headings. U.S. National Library of Medicine.
2. ↑ Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S et al. (2006). "An intervention to decrease catheter-related bloodstream infections in the ICU.". N Engl J Med 355 (26): 2725-32. DOI:10.1056/NEJMoa061115. PMID 17192537. Research Blogging.
3. ↑ Wu AW, Lipshutz AK, Pronovost PJ (2008). "Effectiveness and efficiency of root cause analysis in medicine.". JAMA 299 (6): 685-7. DOI:10.1001/jama.299.6.685. PMID 18270357. Research Blogging.
4. ↑ Hofer TP, Hayward RA (2002). "Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis.". Ann Intern Med 137 (5 Part 1): 327-33. PMID 12204016. [e]
5. ↑ Rosenberg SN, Allen DR, Handte JS, Jackson TC, Leto L, Rodstein BM et al. (1995). "Effect of utilization review in a fee-for-service health insurance plan.". N Engl J Med 333 (20): 1326-30. DOI:10.1056/NEJM199511163332006. PMID 7566025
6. ↑ Kerr EA, Mittman BS, Hays RD, Siu AL, Leake B, Brook RH (1995). "Managed care and capitation in California: how do physicians at financial risk control their own utilization?". Ann Intern Med 123 (7): 500-4. PMID 7661493.
7. ↑ Leffler DA, Neeman N, Rabb JM, Shin JY, Landon BE, Pallav K et al. (2011). "An alerting system improves adherence to follow-up recommendations from colonoscopy examinations.". Gastroenterology 140 (4): 1166-1173.e1-3. DOI:10.1053/j.gastro.2011.01.003. PMID 21237167. Research Blogging.
8. ↑ Cameron KA, Persell SD, Brown T, Thompson J, Baker DW (2011). "Patient outreach to promote colorectal cancer screening among patients with an expired order for colonoscopy: a randomized controlled trial.". Arch Intern Med 171 (7): 642-6. DOI:10.1001/archinternmed.2010.468. PMID 21149742. Research Blogging.
9. ↑ Walter LC, Davidowitz NP, Heineken PA, Covinsky KE (2004). "Pitfalls of converting practice guidelines into quality measures: lessons learned from a VA performance measure". JAMA 291 (20): 2466–70. DOI:10.1001/jama.291.20.2466. PMID 15161897. Research Blogging.
10. ↑ Fonarow GC, Abraham WT, Albert NM, et al (January 2007). "Association between performance measures and clinical outcomes for patients hospitalized with heart failure". JAMA 297 (1): 61–70. DOI:10.1001/jama.297.1.61. PMID 17200476. Research Blogging.
11. ↑ Meier, Barry (August 17, 2009). Diabetes Case Shows Pitfalls of Treatment Rules. The New York Times. Retrieved on 2009-08-18. “the National Committee for Quality Assurance, received about $3 million, or 10 percent of its revenue, last year from drug and medical device makers”
12. ↑ Reeves D, Doran T, Valderas JM, Kontopantelis E, Trueman P, Sutton M et al. (2010). "How to identify when a performance indicator has run its course.". BMJ 340: c1717. DOI:10.1136/bmj.c1717. PMID 20371570. Research Blogging.
13. ↑ How well does chart abstraction measure quality? A...[Am J Med. 2000 \- PubMed Result]. Retrieved on 2008-02-12.
14. ↑ Nyweide DJ, Weeks WB, Gottlieb DJ, Casalino LP, Fisher ES (2009). "Relationship of primary care physicians' patient caseload with measurement of quality and cost performance.". JAMA 302 (22): 2444-50. DOI:10.1001/jama.2009.1810. PMID 19996399. Research Blogging.
15. ↑ 15.0 15.1 Fretheim A, Soumerai SB, Zhang F, Oxman AD, Ross-Degnan D (2013). "Interrupted time-series analysis yielded an effect estimate concordant with the cluster-randomized controlled trial result.". J Clin Epidemiol 66 (8): 883-7. DOI:10.1016/j.jclinepi.2013.03.016. PMID 23810027. Research Blogging.
16. ↑ 16.0 16.1 16.2 16.3 Fan E, Laupacis A, Pronovost PJ, Guyatt GH, Needham DM (2010). "How to use an article about quality improvement.". JAMA 304 (20): 2279-87. DOI:10.1001/jama.2010.1692. PMID 21098772. Research Blogging.
17. ↑ Wagner AK, Soumerai SB, Zhang F, Ross-Degnan D (2002). "Segmented regression analysis of interrupted time series studies in medication use research.". J Clin Pharm Ther 27 (4): 299-309. PMID 12174032. [e]
18. ↑ 18.0 18.1 Davidoff F, Batalden P, Stevens D, Ogrinc G, Mooney SE, SQUIRE development group (2009). "Publication guidelines for quality improvement studies in health care: evolution of the SQUIRE project.". BMJ 338: a3152. DOI:10.1136/bmj.a3152. PMID 19153129. PMC PMC2769030. Research Blogging.
19. ↑ Lin HC, Xirasagar S, Lin HC, Hwang YT (2008). "Does physicians' case volume impact inpatient care costs for pneumonia cases?". J Gen Intern Med 23 (3): 304-9. DOI:10.1007/s11606-007-0462-3. PMID 18043982. Research Blogging.
20. ↑ Nelson EC, Splaine ME, Batalden PB, Plume SK (March 1998). "Building measurement and data collection into medical practice". Ann. Intern. Med. 128 (6): 460–6. PMID 9499330. [e]
21. ↑ Lloyd, Robert M.; Carey, Raymond G. (1995). Measuring quality improvement in healthcare: a guide to statistical process control applications. White Plains, N.Y: Quality Resources. ISBN 0-527-76293-8.
22. ↑ Staker, Larry V.; Carey, Raymond G. (2002). Improving Healthcare with Control Charts: Basic and Advanced SPC Methods and Case Studies. Milwaukee, Wis: ASQ Quality Press. ISBN 0-87389-562-2.
23. ↑ Norberg A, Christopher NC, Ramundo ML, Bower JR, Berman SA (February 2003). "Contamination rates of blood cultures obtained by dedicated phlebotomy vs intravenous catheter". JAMA 289 (6): 726–9. PMID 12585951. [e]
24. ↑ Harbarth S, Fankhauser C, Schrenzel J, et al (March 2008). "Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients". JAMA 299 (10): 1149–57. DOI:10.1001/jama.299.10.1149. PMID 18334690. Research Blogging.
25. ↑ Tekkis PP, McCulloch P, Steger AC, Benjamin IS, Poloniecki JD (April 2003). "Mortality control charts for comparing performance of surgical units: validation study using hospital mortality data". BMJ 326 (7393): 786–8. DOI:10.1136/bmj.326.7393.786. PMID 12689973. Research Blogging.
26. ↑ Bingham JW, Quinn DC, Richardson MG, Miles PV, Gabbe SG (2005). "Using a healthcare matrix to assess patient care in terms of aims for improvement and core competencies.". Jt Comm J Qual Patient Saf 31 (2): 98-105. PMID 15791769.
27. ↑ Kernisan, Leslie P.; Sei J. Lee, W. John Boscardin, C. Seth Landefeld, R. Adams Dudley (2009-04-01). "Association Between Hospital-Reported Leapfrog Safe Practices Scores and Inpatient Mortality". JAMA 301 (13): 1341-1348. DOI:10.1001/jama.2009.422. Retrieved on 2009-04-01. Research Blogging.
28. ↑ Timothy J. Hoff, Henry Pohl, Joel Bartfield, Implementing Safety Cultures in Medicine: What We Learn by Watching Physicians, Advances in Patient Safety: From Research to Implementation Volume 1. Research Findings, National Center for Biotechnology Information, National Library of Medicine
29. ↑ Robert L Helmreich (2000 March 18), "On error management: lessons from aviation", British Medical Journal 320(7237): 781–785.
30. ↑ Jamtvedt G, Young JM, Kristoffersen DT, O'Brien MA, Oxman AD (2006). "Audit and feedback: effects on professional practice and health care outcomes". Cochrane Database Syst Rev (2): CD000259. DOI:10.1002/14651858.CD000259.pub2. PMID 16625533. Research Blogging.
31. ↑ Thomas RE, Croal BL, Ramsay C, Eccles M, Grimshaw J (June 2006). "Effect of enhanced feedback and brief educational reminder messages on laboratory test requesting in primary care: a cluster randomised trial". Lancet 367 (9527): 1990–6. DOI:10.1016/S0140-6736(06)68888-0. PMID 16782489. Research Blogging.
32. ↑ Streiff MB, Haut ER (2009). "The CMS ruling on venous thromboembolism after total knee or hip arthroplasty: weighing risks and benefits.". JAMA 301 (10): 1063-5. DOI:10.1001/jama.301.10.1063. PMID 19278950. Research Blogging.
33. ↑ Rodriguez HP, von Glahn T, Elliott MN, Rogers WH, Safran DG (2009). "The Effect of Performance-Based Financial Incentives on Improving Patient Care Experiences: A Statewide Evaluation.". J Gen Intern Med. DOI:10.1007/s11606-009-1122-6. PMID 19826881. Research Blogging.
34. ↑ Physician Quality Reporting Initiative (PQRI)
35. ↑ Fung CH, Lim YW, Mattke S, Damberg C, Shekelle PG (2008). "Systematic review: the evidence that publishing patient care performance data improves quality of care". Ann. Intern. Med. 148 (2): 111–23. PMID 18195336. [e]
36. ↑ Ketelaar NA, Faber MJ, Flottorp S, Rygh LH, Deane KH, Eccles MP (2011). "Public release of performance data in changing the behaviour of healthcare consumers, professionals or organisations.". Cochrane Database Syst Rev 11: CD004538. DOI:10.1002/14651858.CD004538.pub2. PMID 22071813. Research Blogging.
37. ↑ Rothberg, Michael B.; Elizabeth Morsi, Evan M. Benjamin, Penelope S. Pekow, Peter K. Lindenauer (2008-11-01). "Choosing The Best Hospital: The Limitations Of Public Quality Reporting". Health Aff 27 (6): 1680-1687. DOI:10.1377/hlthaff.27.6.1680. Retrieved on 2008-11-10. Research Blogging.
38. ↑ Tu, Jack V.; Linda R. Donovan, Douglas S. Lee, Julie T. Wang, Peter C. Austin, David A. Alter, Dennis T. Ko (2009-11-18). "Effectiveness of Public Report Cards for Improving the Quality of Cardiac Care: The EFFECT Study: A Randomized Trial". JAMA: 2009.1731. DOI:10.1001/jama.2009.1731. Retrieved on 2009-11-18. Research Blogging.
39. ↑ Rothberg MB, Benjamin EM, Lindenauer PK (2009). "Public reporting of hospital quality: Recommendations to benefit patients and hospitals.". J Hosp Med. DOI:10.1002/jhm.481. PMID 19514092. Research Blogging.
40. ↑ Davidoff, Frank; Paul Batalden, David Stevens, Greg Ogrinc, Susan Mooney, for the SQUIRE development group (2008-12-01). "Publication Guidelines for Quality Improvement Studies in Health Care: Evolution of the SQUIRE Project". Journal of General Internal Medicine 23 (12): 2125-2130. DOI:10.1007/s11606-008-0797-4. Retrieved on 2008-12-18. Research Blogging.
41. ↑ Davidoff F, Batalden P, Stevens D, Ogrinc G, Mooney S (November 2008). "Publication guidelines for improvement studies in health care: evolution of the SQUIRE Project". Ann. Intern. Med. 149 (9): 670–6. PMID 18981488. [e]
42. ↑ Wong BM, Levinson W, Shojania KG (2012). "Quality improvement in medical education: current state and future directions.". Med Educ 46 (1): 107-19. DOI:10.1111/j.1365-2923.2011.04154.x. PMID 22150202. Research Blogging.
43. ↑ Wong BM, Etchells EE, Kuper A, Levinson W, Shojania KG (2010). "Teaching quality improvement and patient safety to trainees: a systematic review.". Acad Med 85 (9): 1425-39. DOI:10.1097/ACM.0b013e3181e2d0c6. PMID 20543652. Research Blogging.
44. ↑ 44.0 44.1 Vinci LM, Oyler J, Johnson JK, Arora VM (2010). "Effect of a quality improvement curriculum on resident knowledge and skills in improvement.". Qual Saf Health Care 19 (4): 351-4. DOI:10.1136/qshc.2009.033829. PMID 20513793. Research Blogging.
45. ↑ Boonyasai RT, Windish DM, Chakraborti C, Feldman LS, Rubin HR, Bass EB (2007). "Effectiveness of teaching quality improvement to clinicians: a systematic review.". JAMA 298 (9): 1023-37. DOI:10.1001/jama.298.9.1023. PMID 17785647. Research Blogging.
46. ↑ Oyler J, Vinci L, Johnson JK, Arora VM (2011). "Teaching internal medicine residents to sustain their improvement through the quality assessment and improvement curriculum.". J Gen Intern Med 26 (2): 221-5. DOI:10.1007/s11606-010-1547-y. PMID 21053089. PMC PMC3019318. Research Blogging.
47. ↑ Oyler J, Vinci L, Arora V, Johnson J (2008). "Teaching internal medicine residents quality improvement techniques using the ABIM's practice improvement modules.". J Gen Intern Med 23 (7): 927-30. DOI:10.1007/s11606-008-0549-5. PMID 18449612. PMC PMC2517947. Research Blogging.
48. ↑ 48.0 48.1 Ogrinc G, Headrick LA, Morrison LJ, Foster T (2004). "Teaching and assessing resident competence in practice-based learning and improvement.". J Gen Intern Med 19 (5 Pt 2): 496-500. DOI:10.1111/j.1525-1497.2004.30102.x. PMID 15109311. PMC PMC1492328. Research Blogging.
49. ↑ Shojania KG, Silver I, Levinson W (2012). "Continuing medical education and quality improvement: a match made in heaven?". Ann Intern Med 156 (4): 305-8. DOI:10.1059/0003-4819-156-4-201202210-00008. PMID 22351715. Research Blogging.