Health care quality assurance

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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

Creating quality measures

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

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

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

Study designs include:[16]

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

Improving quality

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

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

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

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

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

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

Guidelines exist for the reporting ([40][41][18] and reading[16] of studies on quality improvement.

Teaching quality improvement to health care personnel

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]


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