Profiling of Clinical audits and practices are gaining momentum as a popular tool in its attempt to make a change in the behavior of physician for the improvement of quality of care, in each passing day. It is a pity that the increasing need for the information pertaining to quality of care is dodging the development of the standardized, valid and trustworthy approaches for using these tools. The studies related to performance measurement, as are being published in these date portray varying impact in the matter of improvement of clinical care, some of them are randomized at the same time controlled trials.
Emory Health Care is the health care facility center of Robert W. Woodruff Health Sciences Center (WHSC) of Emory University. The hospital renders the services of patient care, health professionals’ education, undertakes researches in the subjects of illness and health in addition to undertaking the policies related to the treatment and prevention of illness and health. The institute is under the control of Emory University School of Medicine, Atlanta, USA. The hospital is a major partner of Atlanta Clinical & translational Science Institute (ACTSI) for the collaborative research studies by the researchers and doctors of Emory Health Care for the rapid and effective translation of scientific discoveries pertaining to the health care of the entire Atlanta population.
It is a known fact that measurement of performance is commonly practiced in these days, but the science of this field is in its infancy, nevertheless, it seems that it will come of age, but till then it should be considered as experimental in its true sense so far these two issues are studied:
(1) Quality of Care and (2) data Information set of Health Plan Employer
During the periods ranging from 1980 to onset of 1990, these studies helped in indicating about the important differences pertaining to medical care quality focusing on the misuse, under use and/or overuse of medical interventions. The eventuality of it, the medical care system has started evolving to find the avenues of using this information so that it can influence the changes towards improving in the medical care.
The Potential areas of Improvements, observed in the Emory Health Care
The methods and tools pertaining to performance improvements in the Emory health care have proven to be effective. That is why it is widely used not only in the America it is also used in Europe and in many parts in Asia. An increased interest was seen while the experience was also noticed in the last five years.
The emerging trends were the result of the recognition of the successes in the processes of the performance improvements that of course required tailoring and adaptations in any situation.
The current trend does tell upon the underlying principles pertaining to performances.
Example:
A substantial growth is being seen in the collaborative and intersection and integration, which has widened open the expectation in which stakeholders of border range get involved in the planning and decision making.
The positive reactions of it are noticed among the patients, the members of their families plus their communities. The consumers, here the patients exerts their rights that ultimately improve the health care quality.
As the financial and administrative authorities are decentralized for the sake of service delivery, an environment is created where service managers and stakeholders are accountable.
The trends not only have created fertile ground for the improvements in performances, challenges too have come in place in this situation. It is suffice to say, that the frame work pertaining to performance improvement as designed by the USAID is the most favored and powerful tool too, as on date.
USE of DATA
Using the clinical data for improving the outcomes is a regular feature. It is the decades old practice of the hospitals to use the data from the surgical morbidity as well from the reviews of mortality rate which can ultimately become the sources of experience. In the recent time a shift in focus has been observed in the review of clinical data which comprises multiple setting involving different types of groups.
The present paper discusses about the use of clinical practice/audit feedback, and also the practice benchmarking/profiling in addition to regulatory oversight, behaving as tools to affect the behavior of physician for improving the outcomes.
A few basic concepts which relate to performance measurement needs to be reviewed before these different tools can be explored.
Population vs. Individual performance measurement
Reviewing of individual cases can give varied data from the reviews which base population, and both of these reviews have their own Ps and Qs. Principally, individual review of cases are meant for exploring the concern which are although rare events but sentinel. While approach of population based review is the aggregated experiences gained after studying multiple cases that ultimately focuses on the clinical behavior pattern in common conditionalities that may affect a large number of patients.
Identify and describe at least three data collection tools you can use to collect performance information.
1. What types of information does each tool collect?
2. What are the strengths and weaknesses of each tool for each area?
3. How are the data collection tools similar? How are they different?
4. Research at least two tools that measure and display the QI data that can be gathered with the data collection tools.
5. What types of information does each tool measure and display?
6. What are each tool’s strengths and weaknesses?
7. How are the tools similar? How are they different? How are these tools helpful for health care organizations?
Tools of quality measurements 1) Structure, followed by 2) Process and ends with 3) Outcomes
Based upon the concept of Donabedian, quality is measured by basing on the structure, followed by process and ending with its outcome.
Structure: The domain of structure is physical factors like building, professionals and finally the institutional factors which are related to financing and regularity environments where health care is looked after.
Process: The actions of the providers of health care in the matters of medical care delivery that relates to medical examination performance, prescribing tests and medication.
Outcome: This is the end of the interventional process, which ultimately tells upon the health as well as the well being of a patient.
Structure relates to the measurement of health care quality, exploring the clinical process takes its following position, and the final part is seen as the outcomes.
Patient outcomes, although, are the ultimate parameters for judging the health care quality, but using process also helps in measuring performance of the health care quality in place of outcome measures. It is seen to be easier for physician or health providers of other categories for accepting their action-taken responsibility in the matter of care given to the patients rather than the outcomes, as because many factors stand between the care given and the outcomes, which can not be claimed to be under the control of care providers.
Example: A concerted effort can be made to ensure about the fact that a patient has been
offered the vaccine for flu remedy but the patient may decline to take it and the fallout is seen as the attack of influenza on the patient. The performance evaluation result will show paradoxical result in this situation, the conflict will remain between the process of providing vaccination and the outcomes as influenza.
The importance of the Demonstration Project of The Ambulatory Care Medical Audit
The importance of the Demonstration Project of The Ambulatory Care Medical Audit is highly recognized study for the formal investigation in the matter of auditing in the health performance in the US. The project was instituted for the controlled trial in the clinical affairs in a randomized way, so that quality of clinical performance can be improved through this technique, especially in the areas of primary care. Of course, it is the single elements in the affairs of multidimensional areas of medical intervention. Yet, the study proved that there are the possibilities of improvements in the matters of health care with the help of the feedback of information through this audit.
Nevertheless, the paradox of the fact is that there is no concrete synthesis of the study for affecting the performance of clinical practices. It was also found that many of the studies could not done with well control, nor they could include the strategy the randomizing the health practitioners who were supplied with the feedback. In contrast, most of them were post-evaluation / pre-evaluation design based, or sometimes based on a single institution with the meager number of practices. So, decisively, clinical audit with feedback is a better step for the changes in the medical practitioners’ behavior, while its profoundness is unclear.
Conclusion:
Process measures are useful tools for evaluating the quality conditions of common chronic diseases, the outcomes of which are not easily derived, it takes years together for the ultimate outcomes.
Example:- Stroke, hypertension, complications of diabetes, glycemic control are the examples. That is why process measure is ideal for measuring the performances instead of outcomes measures. Nevertheless, patient outcomes are considered as the best measure for the health care performances.
References:
1. Wennberg, J, Gittelsohn, A (1973) Small area variations in health care delivery. Science 182,1102-1108
2. Wennberg, DE Variation in the delivery of health care: the stakes are high. Ann Intern Med 1998;128,866-868
3. Detsky, AS Regional variation in medical care. N Engl J Med 1995;333,589-590
