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Flashcards in SPR L2 Quality Services Deck (31)
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1

Learning outcomes (for general perusal)

  1. Apply a systems approach to health and social care policy and service provision.
  2. Apply frameworks for service quality measurement and assessment.
  3. Interpret measures of service utilisation and performance appropriately.

2

Why assess quality?

  • Identify poor performance
  • Demonstrate good performance
  • Duty of quality - clinical governance
  • Continuous improvement - quality cycle

  • Responsive to patient/client needs

  • Track effects of changes

  • Funding

3

For what sort of things is assessing quality important?

  • Improve standards
  • Identify cost-effective activities
  • Demonstrate work to outside agencies
  • Ensure activities meet shareholder requirements

4

Outline the WHO health system framework

System Building Blocks

  • Service Delivery
  • Health Workforce
  • Information 
  • Medical Products, Vaccinations and Technologies 
  • Financing
  • Leadership/Governance 

Access, Coverage, Quality, Safety, 

Overall Goals/Outcomes

  • Improved health (level and equity)
  • Responsiveness
  • Social and Financial Risk Protection
  • Improved Efficiency

5

What is 

  1. Quality Assurance?
  2. Evaluation?

  1. ongoing process (continual assessment and improvement of practice). Setting standards which specify acceptable quality and ensures consistency.

  2. focuses on outcomes at a specific point in time

6

NI Health and Social Care Structure and Drivers (for general perusal)

NI Health and Social Care Planning and Commissioning  (for general perusal)

7

Understanding Systems

“Every system is perfectly designed to get the results it gets. If we want better outcomes, we must change something in the system. To do this we need to understand our systems.”

  1. Outline a systems approach
  2. What is involved in this?

  1. examines complex interrelationships rather than linear pathways, and processes rather than single elements.

  2. measurement of performance, comparisons, predictions of impact on the ‘whole system’ resulting from a change in an element, innovation and improvement.

    1. Complex systems such as structures (attributes, infrastructures), Processes (sequence of events, flows, pathways) and Patterns (decision making, relationships, behaviour) can lead to Complex decisions with uncertainty, multiple competing objectives, unavoidable trade-offs and different perspectives lead to different conclusions

8

Outline the simple logic model

9

Complex Systems

Give examples of

  1. Structures 
  2. Processes
  3. Patterns

  1. attributes, infrastructure

  2.  

10

What is Quality?

degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

11

Outline some of the generic quality concerns

  • Wide variations in quantity of care received by similar populations - no apparent relationship with quality.
  • Growing complexity - ability to deliver cannot keep pace with health technology advances and innovations.
  • Chronic Disease - consume majority of health resources in developed countries.
  • Delivery system designed to deal with acute health problems - lack of effective chronic care models; and
  • Constraints on exploiting revolution in information technology.

12

What are Maxwell's Criteria?

 

  • Effectiveness
  • Efficiency 
  • Access
  • Equity 
  • Acceptibility
  • Relevance

13

Maxwell's Criteria 

Explain the following 

  1. Effectiveness
  2. Efficiency 
  3. Access
  4. Equity 
  5. Acceptibility
  6. Relevance

  1. Does a service work (beneficial effect on health status in the routine usual context of the health service?)

  2. Can we produce the same outcomes with fewer inputs or resources? (Efficiency is only achieved if the saved resources can be put to other effective uses)

  3. Complex trade-offs - local services may be less effective and efficient due to lack of relevant skilled staff or economies of scale

  4. Is service provision is 'fair‘ and “proportionate”? There may be inequalities of access; inequality of process; or inequality of outcome.

  5. is the degree to which a service meets the ethical, social, psychological and cultural needs and standards of the  target population

  6. of the service to the identified and prioritised needs of the population

14

Standard Setting

What is a standard?

 

What are the 5 high level quality themes in NI?

a level of quality against which performance can be measured. 

 

  • Corporate Leadership and Accountability of Organisations;
  • Safe and Effective Care;
  • Accessible, Flexible and Responsive Services;
  • Promoting, Protecting and Improving Health and Social Well-being; and
  • Effective Communication and Information.

15

Quality Improvement and Safety

 

Outline the mechanisms

  • Setting Standards (linking with national standard setting and patient safety bodies)
  • Regulation, Inspection and Review of services
  • Clinical and Social Care Governance arrangements (Risk Management; Evidence Based Care; Training and CPD; Clinical Audit; Patient Involvement; Staff management) 
  • Regulating the workforce, and promoting development through life-long learning and continuous professional development
  • Performance management and accountability arrangements

16

What are the quality concerns in the health system?

  • Variation in quantity of care received by similar populations
    • No apparent relationship with quality.
  • Growing complexity
    • Ability to deliver can’t keep pace with health technology advances & innovations.
  • Chronic Disease
    • Consume majority of health resources in developed countries.
  • Delivery system designed to deal with acute health problems
    • Lack of effective chronic care models
  • Constraints on exploiting revolution in information technology.

17

Quality Assessment

Outline the Donabedian Framework

(S, P, O)

Structure : “settings in which medical care takes place and instrumentalities of which it is a product"

Process : “set of activities that go on between practitioners and patients"

Outcome : “consequences to the health and welfare of individuals and society"

18

Maxwell's Criteria

Outline all of Maxwell's Criteria

  • Effectiveness - Does a service work?
    • Beneficial effect on health status in routine usual context of the health service.
  • Efficiency - Can we produce the same outcomes with fewer inputs/resources?
    • Only really achieved if resources saved can be put to other effective uses
  • Access - Complex trade-offs
    • Local services may be less effective/efficient due to lack of skilled staff or economies of scale
  • Equity - Is service provision is 'fair‘ & “proportionate”?
    • There may be inequalities of access; process; or outcome.
  • Acceptability - The degree to which a service meets the ethical, social, psychological and cultural needs and standards of the  target population
  • Relevance - of the service to the identified and prioritised needs of the population

19

What does Quality Improvement and Safety involve?

  • Setting of Standards;
  • Regulation, Inspection and Review of services;
  • Linking with national standard setting and patient safety bodies;
  • Clinical and Social Care Governance arrangements;
  • Regulation of the workforce, and promoting staff development through life-long learning and continuous professional development;
  • Performance management and accountability arrangements;

20

How can quality improvement come about?

Clinical Audit - “… a quality improvement process seeking to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change.” (NICE)

PDSA Cycles - Plan, Do, Study, Act

21

L03 - Use of Health Outcomes Data

  1. How can data be recorded?
  2. Evaluate the health outcome itself as a marker for quality care?
  3. What may variability relate to?

  1. patient-rated (satisfaction and QoL) or recorded by an external party (mortality and morbidity).
  2. neither a sensitive nor a specific marker

  3. definitions/data quality, patient case-mix, play of chance.

22

Use of process measures

​Outline the following characteristics of process measures

  1. Routine data sources
  2. Comparisons
  3. Composite indicators

  1. most provide info on processes of care, not outcomes
  2. process measures may be the only measures with the statistical power to assess variations in quality.
  3. (e.g. complication/readmission rates) - can be used to convert a group of process measures into more meaningful indicators of quality.  

23

What can Time Series Data provide?

may provide an ‘early warning’ of substandard care and support quality improvement activities.

 

(Delay interval - GP referral to Outpatient appointment)

24

Performance indicators

  1. What should these do?
  2. What questions need to be asked?
  3. Give an example
    1. What is the value of these?
    2. Should they be made available to the public?

  1. Should measure parts of casual pathway that are understood and they should identify elements that are amenable to change. Often complex, composite or summary measures.

  2. What is being measured?

    Why it is being measured?

    How it is being measured?

  3. Surgical League Tables                                            

    Case-mix adjustment - some surgeons may deal with more complicated cases.

    Adverse outcome rates - based on small numbers lack precision

    Play of chance / regression to mean

    Variation - ideally taking the approach of Statistical Process Control         

    May produce a “gaming response” -  avoidance of certain types of case

     

25

Variation

What is

  1. Common Cause Variation 
  2. Specific Cause Variation 

  1. inevitable random variation observed in any process (characteristic of the whole system.)
  2. departure from the norm due to a particular characteristic of the outlier. (not due to characteristic of whole system.) 

26

Variation in System Activity 

How may this be explained?

  • Data errors / artefact?
  • Differences in Need?
  • Inappropriate care?
  • Uncertainty?
  • Medical errors?
  • System issues?
  • Different preferences?
  • Supply issues?

27

Performance 

Outline the issue with 'averages'

“If I stick my right foot in a bucket of boiling water and my left foot in a bucket of ice water, on the average, I’m pretty comfortable.”

28

Control Charts

What are the control limits usually?

Three standard deviations from the mean

29

Summar (for general perusal)

Quality assurance is an important part of our health system. It is an ongoing process to help improve practice by helping set standards and to ensure standards are to be met.

There are numerous component parts to quality assurance. Including standard setting, Regulation, Inspection and Review of services, audit, promotion of continuous professional development within the workforce etc. 

30

Discussion Forum Questions