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Department of Health and Human Services 2005 IQLM Conference Indicators Workgroup April 29, 2005.

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Presentation on theme: "Department of Health and Human Services 2005 IQLM Conference Indicators Workgroup April 29, 2005."— Presentation transcript:

1 Department of Health and Human Services 2005 IQLM Conference Indicators Workgroup April 29, 2005

2 IQLM Thanks The Quality Indicators Workgroup Members Workgroup Members Raj Behal, MD (UHC) Lucia Berte, MA (Consultant) Robert Dufour, MD (VAMC) Diane Feeney, BSN, MSc (NQF) Linda Hanold, MHSA (JCAHO) Alan Hoffman, MD (NCQA) Robert Pendrak, MD (Inservco Insurance Services) Paddy Sundararajan, PhD (Quest Diagnostics) Richard Zarbo, MD, DMD (HFHS) Former Workgroup Members: Merilyn Francis, MPP (NQF) David Sundwall, MD (ACLA) Workgroup Co-Leaders: Lee Hilborne, MD, MPH (UCLA/RAND) Frederick Meier, MD (HFHS) CDC Co-liaisons/Indicator Reviewers: Shahram Shahangian, PhD Susan Snyder, PhD Pamela Thompson, MS CDC Supervision: Joe Boone, PhD Devery Howerton, PhD

3 Consider the following question If Congress wanted to quickly know about America’s laboratories, what information should they have? –Laboratory medicine’s contribution to the nation’s health –What is important to the nation should be important to its laboratories If IQLM goes off by itself, the relevance will be lost

4 But Aren’t Laboratory Tests Relevant To Clinical Monitoring? Consider 24 common clinical outpatient conditions with explicit evidence for a specific course of evaluation or treatment In how many of these common conditions are laboratory tests part of the diagnosis or monitoring? –Involved in Diagnosis:50% –Involved in Treatment Monitoring:38% –Involved in Diagnosis or Treatment:63% No other specialty touches so many clinical situations that frequently impact patients

5 The Indicators Group Was Given A Specific Agenda Define a core indicator set for laboratory practice –IOM quality domains –Cover total testing process –Practice settings Be judicial in selection –Perhaps 3-5 domains, 3-5 measures per domain How should indicators be used? –Surveillance for quality across organizations –Identification of best practices for awards –Ability to monitor through the IQLM Network Review and incorporate existing evidence –Identify evidence gaps related to core indicator set –Determine strategies to fill the gaps

6 And Began Discussion Around IQLM Objectives Promote evidence-based lab practices leading to improvements in quality, effectiveness, safety and appropriateness Support research in the design and delivery of effective lab services –Translate research into practical strategies to improve health care –Be driving force for continuous quality improvement Provide a partner’s forum to improve quality and safety Develop and promote indicators to measure lab service quality Develop sentinel networks that provide regular, factual information on the state of laboratory practice Serve as a trusted source for information on laboratory practices Develop educational programs to promote best laboratory practices Endow fellowship programs to conduct laboratory services research

7 So We Started By Considering The IQLM Mission To promote improvements in laboratory testing and services to benefit the health of the public –This is a bold mission –It cannot happen without a strong partnership –We must be sensitive to all quality domains IOM: Safe, effective, patient-centered, timely, efficient and equitable NQMC: Access, patient experience, structure, process, outcome

8 Indicators Fit Into The Institute Vision Awards National Report Network Laboratory Indicators Identify Issues And Best Practices Awards and Grants Program Develop Network of Laboratories & Partners Indicators to Benchmark And Monitor Progress

9 Our Job Was To Provide Initial Direction Regarding Indicators

10 Quality Indicator Characteristics Should Be Broad and Defensible Evidence-based, practice-tested measures of IOM health care domains Associated with identifiable health care quality problems Objective metrics that can be implemented in a standardized and comparable format –Employ standard methods for evaluation Reliable means of external and internal evaluation of quality performance over time Address a wide range of laboratory tests and testing sites

11 We Considered How To Prioritize Indicator Efforts What is important? Where should we focus? In what testing venues will indicators be applicable? How can we avoid reinventing the wheel? How much can we do at the beginning without biting off too much?

12 Some Important Concepts Emerged Link to National Quality Report Define scope of analysis Information is actionable Data efforts are doable (practicality) –Feasible –Affordable Submissions should be auditable

13 While All Phases Of The Total Testing Process Are Important… Analytic Phase Pre-Analytic Phase Post-Analytic Phase We Concluded Focusing On Pre And Post Analytic Phases Will Have The Greatest Impact

14 IQLM, and Indicators Should Acknowledge All Stakeholders Laboratory professionals Accrediting organizations Standards developers Administrators Diagnostic industry Physicians and others providing direct patient care Patients and public Policy makers Payers and purchasers Delivery systems Proficiency testing (?)

15 Indicators Must Be Sensitive To Different Testing Venues Hospital Laboratories Physician Office Laboratories Reference Laboratories Public Health Laboratories And Consider Different Perspectives –What the laboratory needs to know –What laboratory users need to know –What patients and consumers need to know to select a laboratory

16 Look To Partners Who Have Considered Questions Before College of American Pathologists –Q-Probes and Q-Tracks National Committee on Quality Assurance –HEDIS Joint Commission on Accreditation of Health Care Organizations –ORYX –National Patient Safety Goals Veterans Administration Agency for Healthcare Research and Quality –National Healthcare Quality Report –Natl Quality Measures Clearinghouse/Ntl Guideline Clearinghouse US Preventive Services Task Force Centers for Disease Control and Prevention (e.g., MMWR) Published work (Medline, data mining, others)

17 We Reviewed The Literature And Found Many Potential Indicators

18 Then Focused Down Using Some Guiding Principles A limited number of indicators relevant to the quality agenda –No more than about 8-12 –If there are too many, the process won’t be deemed credible Should cover various laboratory venues If at all possible, use existing, validated indicators –Develop new or test obscure indicators only if absolutely necessary

19 We Identified Two Main Indicator Categories Systems Indicators –Involve interactions between the laboratory and laboratory customers Laboratory Quality Indicators –Primary impact is on the provision of care by the laboratory –Specific total testing process subsets Pre, intra and post analytic components

20 The Following List Encompasses The Highest Priority Items Diabetes monitoring (system) Hyperlipidemia screening(system) Patient identification (preanalytic) Test order accuracy (preanalytic) Blood culture contamination (preanalytic) Adequacy of specimen information (preanalytic) Accuracy of Point of Care Testing (analytic) Cervical Cytology/Biopsy Correlation (analytic) Critical value reporting (postanalytic) Turnaround time (infrastructure) Clinician satisfaction (infrastructure) Clinician follow up (system/general)

21 IQLM’s Initial List Closely Parallels That Recommended by Dr. Howanitz last year MeasureDisciplinePhaseFrequency Customer SatisfactionAllPre, Intra, PostAnnual Turnaround TimeChemistry, Hematology Pre, Intra, PostMonthly Patient IdentificationAllPreanalyticalMonthly Specimen AcceptabilityChemistry, Hematology PreanalyticalMonthly Proficiency TestingAllAnalytical6-20 specimens/ analyte per year Critical Value ReportingAllPostanalyticalMonthly Blood Product WastageTransfusion MedicinePostanalyticalMonthly Blood Culture Contamination MicrobiologyPreanalyticalMonthly Presented at CAP 04

22 There Are Some Key Dimensions That Remain To Be Addressed We’ve covered issues of underuse and access in several measures We need to consider a focus on –Overuse (appropriateness) –Misuse

23 We Started By Reviewing The Twelve Selected Indicators Summarize and describe the evidence so practical healthcare decisions are feasible Use defined recognized methods for reviews and desirable quality measure attributes Maintain a practical perspective consistent with the constraints imposed by the limited availability and quality of evidence, producing a comprehensive, objective and reproducible evaluation

24 Indicators Were Evaluated Using A Structured Process Formulate the problem –Conceptual framework Search strategy Quality and validity assessment of studies –Inclusion criteria Collect and analyze findings –Evaluation criteria/template Interpret findings and present results Update findings Cochrane Handbook for Systematic Reviews of Interventions, 3/05

25 Proximate, Associated w/ desired Health Outcomes Evaluation Was Approached With This Conceptual Framework Problem Specification Indicator Definition Potential Interventions Intermediate Outcomes Health Outcomes Issue The Indicator Addresses Specific Metric Properties Actions To Change Outcome Morbidity, Mortality, DALY, QALY, Cost

26 Evaluation Criteria Followed Four Primary Dimensions Importance Scientific acceptability Feasibility Usefulness

27 Evaluation Criteria: Importance Health importance –Ability to meaningfully impact populations –Measures an important quality aspect(s) Common: high prevalence/incidence Impact: serious impact on health outcomes Potential for improvement –Need supported by quality variation or substandard quality –Literature or expert opinion support (e.g., effective interventions)

28 Evaluation Criteria: Scientific Acceptability Strength of evidence based on peer reviewed literature –Quality problem is explicitly defined –Indicator links specifically to the problem –Indicators must be reliable and valid Findings are consistent among raters Accurately measures desired attributes Other sources for future consideration –Professional organizations –? Expert opinion

29 Evaluation Criteria: Feasibility Data definitions are sufficiently clear –Abstraction tools can be developed –Data abstraction quality easily standardized Manual: Trained individuals for consistency Electronic: Clear data fields easily extractable Ability to broadly implement indicators –Across multiple similar laboratories –Across different laboratory types Benefits of measurement exceed financial and administrative burdens –Burdens: need to collect new data, abstraction time, analysis time, health impact of erroneous results –Benefits: health improvement, reduced rework, reduced cost

30 Evaluation Criteria: Usefulness Relevant –Stakeholder(s) find the indicator useful –Acceptance by laboratories, clinicians and other stakeholders –Relevance extends to the healthcare system (beyond the laboratory) Opportunity to impact health system –Interventions within stakeholders’ sphere of influence –Actionable findings to guide organizational decisionmaking and inform public policy

31 Here’s An Example of Indicator Evaluation Specimens w/ inaccurate or inadequate info % of specimens w/ inaccurate or inadequate info Specimen rejection policy CPOE system Label bar coding Reporting/treatment error or delay Patient satisfaction Cost of Error Morbidity Mortality Cost

32 Accuracy And Adequacy Of Specimen Information Definition: Percent of specimens sent to laboratory with inaccurate or inadequate information –No label, illegible, no patient information –No tissue source or clinical information when needed Population: Specimens sent to laboratory Providers: Locations where specimens are collected IOM domains: Safety, timeliness, efficiency

33 The Degree Of Support For Criteria Domains Is Variable Current information supporting evaluation criteria appears adequate Current information supporting evaluation criteria is equivocal/uncertain Current information supporting evaluation criteria is limited or does not exist

34 Accuracy And Adequacy Of Specimen Information: Importance= Prevalence/incidence: –Surgical specimens: 1.2-2.2% (CAP) –Clinical lab specimens 0.015-0.030% (CAP) Impact: –Limited data available regarding impact on outcome Potential for improvement –Variation suggests opportunities –Monitoring and feedback insufficient

35 Accuracy And Adequacy Of Specimen Information: Acceptability= Strength of evidence: –Quality problem defined: –Indicator linked to quality problem: –Professional society acceptance: Reliability and validity: –Validity: No explicit information: –Reliability: CAP studies suggest consistency:

36 Accuracy And Adequacy Of Specimen Information: Feasibility= Clear data definitions: –Standardization of data definitions remains an opportunity –JCAHO has developed standard definitions Implementable: –Many studies have been done in multiple institutions Reasonable Cost: –No data specifically documenting cost to study –Multiple studies suggest cost is not excessive

37 Accuracy And Adequacy Of Specimen Information: Usefulness= Relevance to users, stakeholders: –Useful for performance improvement –Not explicitly on any national metric Operationalizable: –No specific data on operationalizing this metric –Findings suggest strategies can be developed improve performance Specimen rejection policy dissemination and enforcement Bar codes on specimen labels

38 What Do We Currently Know About The First Indictors Evaluated? =Pending Review

39 The Workgroup Raised As Many Challenges As Solutions Laboratory indicators are limited Strength of evidence linking laboratory indicators to health outcomes is weak –Lack of evidence for health outcomes Literature does not directly address many defined quality problems or review questions Lack of standard definitions limits comparability of findings Quality of evidence, generalizability and applicability not evaluated Many laboratory indicators have limited relevance to national health priorities

40 Some General Themes Emerge System indicators likely are better supported by the evidence on health outcomes –Selected because of their impact on patient outcome –Results are linked to evidence supported specific care interventions Laboratory indicators are less frequently supported by ties to health outcomes –Most of the work has been done by CAP –Definitions for many are clear or could be standardized –Linked to intermediate outcomes but links to health outcomes are generally inferential

41 Issues For The New IQLM To Consider Solidify a definition of quality as it relates to laboratory practice Assure selected/future indicators map to laboratory quality definitions Focus on test utilization: overuse, underuse and misuse of testing services Consider whether intermediate outcomes should be sufficient –Identify direct and indirect ways to link intermediate processes to health outcomes –Accept intermediate outcomes as final outcomes for most laboratory services

42 Logical Next Steps for Indicators Once IQLM Direction Is Clear Begin a broader discussion of indicators with key stakeholders Link indicators to awards and network groups Determine the extent to which indicator validation will be studied Select one or two for more in depth exploration

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