Health Care System Performance
Assessing Care Quality
A review of the current methods for assessing the quality of medical care also points out issues and problems raised by these approaches. The author concludes that the process of evaluation requires much further study. In addition, a more complete exploration of the conceptual meaning of quality and the associated dimensions of care and values is needed. A. Donabedian (2005) Evaluating the Quality of Medical Care. The Milbank Quarterly 83, 691–729.
Health Outcome Assessments
A longitudinal study of 31,823 patients at 22 Veterans Health Administration integrated service networks examined whether a clinically credible risk adjustment methodology for the outcome of change in health status could be developed for assessing system performance. Physical and mental component scales from the Veterans Rand 36-items Health Survey and mortality were used to measure outcomes. The authors found that it was feasible to develop models for outcomes of decline but, without adequate case-mix controls, they could not determine whether poor outcomes reflect poor performance, sicker patients, or other factors. A. J. Selim et al. (2006) Use of Risk-Adjusted Change in Health Status to Assess the Performance of Integrated Service Networks in the Veterans Health Administration. International Journal for Quality in Health Care 18, 43–50.
Quality Tools in Practice
QI in Medicaid Managed Care
An assessment of the Best Clinical and Administrative Practices initiative, operated by the Center for Health Care Strategies as part of its Medicaid Managed Care Program, found that participation led most plans to make sustainable changes in their delivery of care. In addition to changing the way Medicaid plans think about quality improvement, the authors conclude that the initiative's ultimate impact could be greater once the plans become more sophisticated in their approaches. M. Gold et al. (2006) Quality Improvement in Medicaid Managed Care: Experience of the Best Clinical and Administrative Practices Initiative. Joint Commission Journal on Quality and Patient Safety 32, 81–91.
Learning From Defects Tool
This "tool tutorial" summarizes the use of the Learning From Defects (LFD) tool, which was developed by a team of quality and safety researchers at the Johns Hopkins Medical Institutions. Described as a "lighter" version of root cause analysis, the LFD tool provides a structured approach to identifying systems that contribute to defects and a mechanism to ensure that safety improvements are achieved. Barriers to its use include the need to understand systems analysis and a culture that emphasizes work organization over personal performance. P. J. Pronovost et al. (2006) A Practical Tool to Learn From Defects in Patient Care. Joint Commission Journal on Quality and Patient Safety 32, 102–108.
Improving Dementia Care
This article introduces a special issue focused on improving dementia care and outcomes through physician education, diffusing innovations, care management, consumer "self-management," and serving older adults. M. G. Austrom and D. Gallagher-Thompson (2005) Educating Physicians in the Detection of Alzheimer's Disease and Other Dementias. Clinical Gerontologist 29, 1–2.
Error Identification and Prevention
Surrogate Outcomes Measures
According to the authors, adopting objective measures for quality of care and outcomes would be easier if the health care field were open to surrogate measures of important outcomes, as it is neither necessary nor feasible to focus only on rigorously confirmed adverse events. The authors point to surrogate measures for hospital-associated infections that are used to provide useful information about an organization's infection rate. The surgical site infection rate following coronary artery bypass, for example, appears to correlate closely enough with the proportion of patients who receive extended courses of inpatient antibiotics to be a useful indicator of a hospital's outcomes for the procedure. R. P. Gaynes and R. Platt (2006) Monitoring Patient Safety in Health Care: Building the Case for Surrogate Measures. Joint Commission Journal on Quality and Patient Safety 32, 95–101.
Hospital's Medication Dispensing Errors
A direct observational study found that even a low rate of drug distribution can translate into a large number of errors with potential to harm patients due to the volume of medication doses dispensed by hospitals. In this case, 3.6 percent—or 5,075 of 140,755 medications filled over a seven-month period at a tertiary academic medical center—contained errors, and the hospital pharmacist identified only 79 percent of them. Of the undetected errors, 23.5 percent were serious and 0.8 percent were life threatening. J. L. Cina et al. (2006) How Many Hospital Pharmacy Medication Dispensing Errors Go Undetected? Joint Commission Journal on Quality and Patient Safety 32, 73–80.
Pay-for-Performance
P4P Supplement
This foreword introduces a supplement with five articles and three commentaries focused on pay-for-performance. Supported by the Agency for Healthcare Research and Quality, the articles examine the impact of pay-for-performance on: Health Plan Employer Data and Information Set measures in an integrated delivery network, the quality of care delivery, and the care of chronically ill patients. They also evaluate its cost-effectiveness in hospitals and incentives for implementation in physician practices. P. McNamara (2006) Foreword: Payment Matters? The Next Chapter. Medical Care Research and Review 63, 5S–10S.