1. SchusterView Graph # 1 OUTLINE FOR TODAY’S TALK Quality of Care: Definitions Who Uses Quality Assessment Information Quality Measurement Methods Challenges for Measuring Quality for Children Quality Improvement Summary

2. SchusterView Graph # 2 INSTITUTE OF MEDICINE DEFINITION OF QUALITY (1990) The degree to which health services for individuals and populations * increase the likelihood of desired health outcomes and * are consistent with current professional knowledge

3. SchusterView Graph # 3 STEPS IN DEFINING QUALITY Define optimal practice Practice in real world Gap between efficacy and effectiveness Closing the gap Efficacy Effectiveness Quality Assessment Quality Improvement

4. SchusterView Graph # 4 POTENTIAL USERS OF QUALITY ASSESSMENT INFORMATION Consumers CHIP administrators Clinicians Health Plans Policy makers Researchers

5. SchusterView Graph # 5 CONCEPTUAL FRAMEWORK STRUCTUREPROCESSOUTCOMES Technical Excellence Right choices Effective/skillful Interpersonal Excellence Patient-centered Responsive Functional Status Satisfaction Mortality Biological Status Health Care Organization Characteristics Provider Characteristics Community Characteristics Population Characteristics

6. SchusterView Graph # 6 Health Care Organization Characteristics - Ratio of hospital beds to covered population - Weekend and night hours - Accessible to transportation Provider Characteristics - Pediatric subspecialists - Case managers - Translators STRUCTURAL MEASURES

7. SchusterView Graph # 7 CONCEPTUAL FRAMEWORK STRUCTUREPROCESSOUTCOMES Technical Excellence Right choices Effective/skillful Interpersonal Excellence Patient-centered Responsive Functional Status Satisfaction Mortality Biological Status Health Care Organization Characteristics Provider Characteristics Community Characteristics Population Characteristics

8. SchusterView Graph # 8 TECHNICAL PROCESS: ADHERENCE TO PROFESSIONAL STANDARDS OF CARE Process Quality Indicators Describe a Process of Care That Should Occur for a Particular Type of Patient or Clinical Circumstance

9. SchusterView Graph # 9 INDICATORS FOR CHILDREN Well Child Care - The child’s weight should be measured at least four times during the first year of life. This information must either be plotted on a growth curve or recorded with the age/gender percentile. Sickle Cell Disease - Children with a positive sickle cell screen or suspected of being positive for sickle cell disease should be placed on daily penicillin prophylaxis from at least six months of age until at least five years of age.

10. SchusterView Graph # 10 PROCESS QUALITY INDICATORS Sources: Research Literature, Statements of Professional Medical Organizations, Expert Panel Best If Leads to Better Outcomes Performance of Plans/clinicians Is Measured by Rates of Adherence to the Indicator Not Looking for 100% Adherence Generally Aim to Cover a Few Markers of Clinical Care for a Condition Rather Than All Aspects of Care: Canary

11. SchusterView Graph # 11 CONCEPTUAL FRAMEWORK STRUCTUREPROCESSOUTCOMES Technical Excellence Right choices Effective/skillful Interpersonal Excellence Patient-centered Responsive Functional Status Satisfaction Mortality Biological Status Health Care Organization Characteristics Provider Characteristics Community Characteristics Population Characteristics

12. SchusterView Graph # 12 Waiting Time to Get an Appointment The Way Questions Are Answered Ability to Get All the Care a Parent Feels the Child Needs Overall SATISFACTION/CONSUMER ASSESSMENT

13. SchusterView Graph # 13 CONCEPTUAL FRAMEWORK STRUCTUREPROCESSOUTCOMES Technical Excellence Right choices Effective/skillful Interpersonal Excellence Patient-centered Responsive Functional Status Satisfaction Mortality Biological Status Health Care Organization Characteristics Provider Characteristics Community Characteristics Population Characteristics

14. SchusterView Graph # 14 SOURCES OF INFORMATION ON QUALITY Administrative Data - Follow-up for ear infection - Was lab test done Medical Record - Was the ear examined, what did it look like - What are results of lab test, was it addressed Patient Survey - What happened (or what they remember) - What they know (following counseling) - Satisfaction Registries Applications, Reports to CHIP

15. SchusterView Graph # 15 CHALLENGES IN QUALITY ASSESSMENT FOR CHILDREN Children Tend to Be Healthy: Low Incidence and Prevalence of Disease Much of Care Is Preventive Long Term Outcomes: - Assign responsibility, system change Limited Research Base Age-Specific and Developmentally Appropriate Indicators Confidentiality

16. SchusterView Graph # 16 QUALITY IMPROVEMENT Traditional: Outliers, “Bad Apples” - Focus on individual incompetence or irresponsibility Continuous Quality Improvement - Raise the average level of quality by improve quality of all clinicians - Focus on systematic problems - Interdisciplinary teams - Example: medication errors

17. SchusterView Graph # 17 SUMMARY Quality Assessment Can - Help screen out bad providers - Help with improving all providers - Show effects of changes or variations Need to Implement Systems Now - Easier if plan new program and new system together - Will want to compare before and after - Models and indicators are available (e.g., HEDIS) - Opportunity for creativity