Wednesday, April 8, 2009
quality, not quantity
i feel like one of the main issues for being able to evaluate quality is that people need to be able to standardize quality. every hospital and clinic hold themselves accountable in different ways and i think that there should be a standardized level of quality to hold themselves to. quality is subjective for everyone, and i think that, once again, a standardized level of things that need to be done in order to achieve certain "quality" levels is what should determine quality. money is also a factor in being able to achieve quality. i think that health practices should realize that if they try to attain a certain level of "quality", it will be better for not only their own practice, but the health of the public simultaneously. quality over quantity. i want my health care to last a long time, like a good pair of shoes. i dont want to have to go back over and over again to get my soles replaced.
Quality to me means good level of care where physicians and hospitals implement the most appropriate ways to save the patients life, make a quick diagnosis, reduce morbidity or even effective pain management. It also means delivering services to patients without having them go through gruelling insurance claims.So Quality of care comes not only from people providing direct care but also providers who set up insurance policies and carry them out.
It is true that most patients receive undue services and others get scoffed at. That I think stems from the inequality in the way care is delivered; managed versus public care. Also people with higher end insurance policies are more likely to get appropriate care with good quality rather than those with low end ones. This inequality based on monetary gains is what drives the process of inequitable distribution of quality care.
It seems difficult to improve quality because the way our system is engineered favouring those who have the resources to buy the best care they can afford. When the system is designed to function based on monetary benefits rather than on who needs care most, it is likely that its going to fail, it is likely its going to have quality issues. Also there is no uniformity in processes implemented in hospitals. Providers cater to diverse populations which need different methods of care but that does not mean quality has to be compromised in.
Best practices guidelines could help streamline processes in ensuring standard care. Reporting adverse events, outcomes could make providers accountable. It would also ensure competitiveness. Good team work needs to be encouraged where different health care professionals function effectively with good coordination. Implementing electronic records systems would help.
It is true that most patients receive undue services and others get scoffed at. That I think stems from the inequality in the way care is delivered; managed versus public care. Also people with higher end insurance policies are more likely to get appropriate care with good quality rather than those with low end ones. This inequality based on monetary gains is what drives the process of inequitable distribution of quality care.
It seems difficult to improve quality because the way our system is engineered favouring those who have the resources to buy the best care they can afford. When the system is designed to function based on monetary benefits rather than on who needs care most, it is likely that its going to fail, it is likely its going to have quality issues. Also there is no uniformity in processes implemented in hospitals. Providers cater to diverse populations which need different methods of care but that does not mean quality has to be compromised in.
Best practices guidelines could help streamline processes in ensuring standard care. Reporting adverse events, outcomes could make providers accountable. It would also ensure competitiveness. Good team work needs to be encouraged where different health care professionals function effectively with good coordination. Implementing electronic records systems would help.
Better comprehensive health care
The Health Care system in the US, like in many other countries throughout the world, has its' positive and negative components to it. I think the way health care is evaluated by individuals, in terms of quality, is clearly subjective based on their own experiences. Everyone has had their fair share of negative experiences as well as, hopefully, positive ones but an integral part that is often overlooked and is lacking in our current health care system is the continuous,comprehensive, and consistent component. Many times the quality of health care is interrupted by the major fragmentations within the system. The ability of insurance companies to dictate whether certain services will be rendered for patients has the grave potential to adversely interject with quality of care and thus the quality of life in certain cases. When it comes to physicians, their ability to deliver comprehensive quality care is also key. So many factors come into play when evaluating the level of quality of care in our current system. A thorough health care reform, one that touches on these issues as well as the various other points raised by fellow classmates on this blog is in order so that we may achieve higher standards in achieving more comprehensive and continuous quality of care.
Standardization
The underlying reason for the discrepancy in quality of care is the lack of standardization. There isn't enough regulation of services to standardize when services should and should not be provided. Sadly, the closest we get to a regulating body is insurance companies, who at least stipulate when services should not be provided because they are not proven to be of benefit (the the insurer's pocket book rather than the the insured's health... but still).
Additionally, this is not always an issue of access. Each doctor has their own guidelines and this contributed to why so many patients have such a hard time trusting their doctor, after all another doctor may tell them something different.
We need a governing body that closely regulates the provision of services to all patients, whether insured or not, to advocate for patient health. Therefore doctors that fail to provide necessary services and doctors that provide unnecessary services will be watched over more closely. Rather than punishing doctors we need to provide incentives for a higher standard of care.
The Human Element
What will make healthcare "satisfactory" in the United States? Satisfaction and high quality are subjective terms that yield to several intangibles: physical state; emotional condition; perspectives of the healthcare provider and the patient. Can we ever reach a point in the U.S. where healthcare will be "satisfactory?" The answer is, unfortunately, no. Healthcare itself is an extraordinary process involving a unique marriage of professionalism and intamicy. To this country's credit, I must say, I have met some outstanding "Americans" at various hospitals here in the U.S. that have made healthcare as satisfactory as can be imagined. Putting quality based upon accessibility and cost issues aside, there is much to be proud of the healthcare "system" in this country that is seldom discussed (for many good reasons, by the way). Simply put, healthcare is a human issue - making it difficult for it to ever reach that satisfactory peak in this, or any other country. However, I have one idea for the system that might strive for such a goal: education! Educating preventive measures, in an accessible and seamless fashion, to better help our fellow citizens enjoy a better quality of life, and gain confidence in a system that may provide satisfaction unlike any other.
Quite a ComplicatedTask
The Agency for Healthcare Research and Quality placed it best:
“Getting quality health care can help you stay healthy and recover faster when you become sick. However, we know that often people do not get high-quality care. A 2004 study of 12 large U.S. communities found that just over half (54.9 percent) [substandard care] of people were receiving the care they needed.
What exactly is health care quality? We know that quality means different things to different people. Some people think that getting quality health care means seeing the doctor right away, being treated courteously by the doctor's staff, or having the doctor spend a lot of time with them.
While these things are important to all of us, clinical quality of care is even more important. Think of it like this: getting quality health care is like taking your car to a mechanic. The people in the shop can be friendly and listen to your complaints [like patient satisfaction with the services, facilities, and the outcome], but the most important thing is whether they fix the problem with your car.
Health care providers, the government, and many other groups are working hard to improve health care quality. You also have a role to play to make sure you and your family members receive the best quality care possible.”
How should we address these issues?
Expand on the importance of having a health society over money. Therefore, understanding the needs of our diverse populations and meeting the health needs of these populations. There have been cultural competence models developed in order to target race and have better understanding of culture as a factor to health outcomes. Such models should be developed to outreach to larger communities.
Why does it seem so difficult to improve quality?
Diversity and lack of resources between different groups.
What do you think makes for “good” quality of care?
A concern for the individual and not for compensation. In order to provide quality care, we understand that there is a need to treat the patient like an individual, but also provide the access to care (both treatment and preventive) to all.
“Getting quality health care can help you stay healthy and recover faster when you become sick. However, we know that often people do not get high-quality care. A 2004 study of 12 large U.S. communities found that just over half (54.9 percent) [substandard care] of people were receiving the care they needed.
What exactly is health care quality? We know that quality means different things to different people. Some people think that getting quality health care means seeing the doctor right away, being treated courteously by the doctor's staff, or having the doctor spend a lot of time with them.
While these things are important to all of us, clinical quality of care is even more important. Think of it like this: getting quality health care is like taking your car to a mechanic. The people in the shop can be friendly and listen to your complaints [like patient satisfaction with the services, facilities, and the outcome], but the most important thing is whether they fix the problem with your car.
Health care providers, the government, and many other groups are working hard to improve health care quality. You also have a role to play to make sure you and your family members receive the best quality care possible.”
How should we address these issues?
Expand on the importance of having a health society over money. Therefore, understanding the needs of our diverse populations and meeting the health needs of these populations. There have been cultural competence models developed in order to target race and have better understanding of culture as a factor to health outcomes. Such models should be developed to outreach to larger communities.
Why does it seem so difficult to improve quality?
Diversity and lack of resources between different groups.
What do you think makes for “good” quality of care?
A concern for the individual and not for compensation. In order to provide quality care, we understand that there is a need to treat the patient like an individual, but also provide the access to care (both treatment and preventive) to all.
Tuesday, April 7, 2009
Health Care Quality
I think that one of the major reasons that quality of care is at such a substandard level is because it is not the main priority when patients walk in the door. For many health care providers, simply providing adequate care (at whatever quality that may be) is their primary concern. It's easy for many providers to think "I have a huge case load of patients today, so it's more important I see each and every one of them as opposed to making sure I spend a good amount of time with them, because at least I will have seen them all." But, as we can all imagine, this opens the door wide open for mistakes and due to the lack of thoroughness with each patient, the opportunity to miss crucial elements to the diagnosis process. One of the ways I think this can be remedied is by reducing the case load for these health care providers by hiring more staff. Some physicians have been forced to take on a huge amount of patients every day just to be able to make a decent enough living after having such low reimbursement rates for Medicare and Medicaid as well as having to pay malpractice insurance premiums that continue to rise each year. Understandably, with the economy as bad as it is right now, I only foresee this as happening some time in the future once our economy has taken an upward turn. Another way these issues can be dealt with is to hold the providers more responsible for their actions. If they are penalized for inefficiencies such as putting patients through unnecessary and expensive tests, they are more likely to think twice about what they recommend to each patient. However, this can also have negative effects since providers may be less likely to recommend certain services that could potentially improve the patient's health or even save their life.
I understand good quality of care to be whether or not everything that could have possibly been done for each patient was actually done to improve their health status. I feel that outcome is an unfair measure because even poor outcomes could have been treated with the best quality of care. There is only so much that providers can do and as long as all possible options have been exhausted in each patient's case, they should be able to consider themselves as having been treated with the best quality of care.
I understand good quality of care to be whether or not everything that could have possibly been done for each patient was actually done to improve their health status. I feel that outcome is an unfair measure because even poor outcomes could have been treated with the best quality of care. There is only so much that providers can do and as long as all possible options have been exhausted in each patient's case, they should be able to consider themselves as having been treated with the best quality of care.
Health Care Quality
For a physician to deliver "good" quality care they must have more than just medical knowledge. They need to be culturally competent, provide preventive care, have good personal skills, etc. Quality care involves delivering medical care in an effective way, always having the patients best interests. Quality care is difficult to accomplish because every case/patient is different, and its difficult to standardize care. Its subjective..."good"quality care for one patient, may be something very different for another. However, one way to help tackle this complex issue, is for hospitals to enforcing clinical practicing guidelines (CPGs). These guidelines offer a suggested course of action/treatment for the physician to follow. By having guidelines, it standardizes care and guarantees patients quality/appropriate medical treatment while eliminating extra costs and unnecessary services. Physicians can use these guidelines as a foundation and adapt their form of delivery according to the patient.
health care quality
I think that the only way to actually solve the problem is to reform our health care system. It needs to be less fragmented. In addition, insurance companies should not give physicians a rate at which they see patients (5 patients an hour or 10-15 mins with each patient). This may cause the physician or health care provider to rush a diagnosis or line of treatment. I feel like there are so many problems that contribute to this issue. I also think that SES plays a factor in how effective and efficient treatment and services are. It may be difficult to improve quality because every physician has different standards and methods for treating patients. Even if there was a standard…it would be difficult to regulate this amongst health care providers world wide. Good quality of care is comprehensive care which allows the health care provider to get to know the patient on a personal level. I think that this would increase the quality of care because the provider would be developing a stronger relationship with the patient.
using patient satisfaction as a measurement of quality
I think customer satisfaction is a good measurement of quality of service when you're at Nordstrom, but when you're rating medical care it's hard to get a subjective response from patients. I don't disagree that health care in the country needs improvement, however I don't think we focus all of our efforts solely on raising patient's individual satisfaction of health care. In class we've learned that the majority of healthcare spending in this country is spent on a minority of the population, namely the elderly. In addition, we saw that the elderly have historically had strong grassroots efforts lobbying on their behalf for health care rights. We've also learned that in the UK the government highly regulates what treatments or medications are approved for the elderly which helps control costs and spreads out the resources more evenly. In their case, they are obviously not going to be happy with the treatment, or lack thereof, received. I think since the elderly population has a large voice too much of our healthcare dollars are spent trying to appease them, which isn't to say they don't deserve it but a system more on par with the UK's may be more beneficial to everyone rather than the uneven allotment of resources we now have, which isn't even producing ideal results for the target population.
There is no argument that the quality of care in the United States is less than ideal. Although we have great care in certain times, there are also those instances where patients are receiving less than "good" care. As mentioned by other people, improving the quality of care is extremely difficult in the current system. This is a result of the vast complexities, specialities and differences in the health care that is delivered from state to state. It is extremely difficult to obtain a measure of the level of care being delivered when it is not uniform and consistent across the board. I think the greatest way to achieve these improvements in quality of care would be to implement a "standard of care". For instance, in the emergency medical field (both in the ER and prehospital setting) there is a standard of care that clinicians must abide by and deliver to all patients. The reason this field has a consistent way of delivering care is because emergent situations open the flood gates to mistakes and missed diagnoses. With all of the rushing around and immediate thinking/decision making, it is imperative that health professionals have a routine pattern of dealing with these cases.
Now I know that even the ERs have differences and disparities in care, however, as a whole, they are much more consistent than other areas. If the entire health care system could figure out a way to be more continuous in its efforts, I think we would see a vast improvement in the quality to which our patients receive care.
Finally, I think a big problem that is contributing to the low quality in care is the record keeping and hastiness of clinicians. I have personally seen numerous cases where patients were given wrong procedures, in which some resulted in permanent damage and death. There really is no excuse that a patient's chart should have wrong information on it or have tests ordered on their chart that were really supposed to go to another patient. Therefore, I feel as though the whole process of chart taking/reviews needs to be improved; maybe nationwide EMRs would do the trick.
Regardless of all these things, it is evident that something needs to be done to improve the quality of care being delivered in our nation. Perhaps this will come with reform and maybe it won't; however, this time around it needs to be a monumental change and not just incremental differences.
bad healthcare system = bad quality of life.
When we think of quality in terms of health care, we typically think of patient satisfaction with the services, facilities, and the outcome. However, we’ve all heard stories of how the quality of care in the United States is simply substandard with some getting care (ie. treatments/tests) that they don’t need and others not getting the care they do need. How should we address these issues? Why does it seem so difficult to improve quality? What do you think makes for “good” quality of care?
I think quality of care comes to the last, meaning it is the result of our healthcare system. We all know that our healthcare system has big problems with multiple issues, therefore, it causes the quality of care not so great. So, back to the original issue, we need to find ways to improve our health care system before even thinking how kind our quality of care is so bad. I think the first step to change the system is to provide more primary care and use more public health resources. Like Dr. Stevens said, the U.S healthcare system spends most of funding on "last 3 months of a person's life", we should change gear toward spend most of funding on "first 3 months of a person's life". Prenantal care is essential since we have learned that childhood is very critical for a person's life both mentally and physically. I think we can start our "healthcare system" reform in this new generation (the newborns and children under 8 year-old). We can do a longititude study and see if have better quality of care in 20 years, and I am confident that our quality of care will improve if we focus on primary and pediatric care.
I think quality of care comes to the last, meaning it is the result of our healthcare system. We all know that our healthcare system has big problems with multiple issues, therefore, it causes the quality of care not so great. So, back to the original issue, we need to find ways to improve our health care system before even thinking how kind our quality of care is so bad. I think the first step to change the system is to provide more primary care and use more public health resources. Like Dr. Stevens said, the U.S healthcare system spends most of funding on "last 3 months of a person's life", we should change gear toward spend most of funding on "first 3 months of a person's life". Prenantal care is essential since we have learned that childhood is very critical for a person's life both mentally and physically. I think we can start our "healthcare system" reform in this new generation (the newborns and children under 8 year-old). We can do a longititude study and see if have better quality of care in 20 years, and I am confident that our quality of care will improve if we focus on primary and pediatric care.
Three Solutions
Issue: Good health care quality starts from getting a quicker diagnosis.
Solution1: Remove the pressure for doctors to use all applicable technology. They might do this to rule out every possibility before diagnosing, to avoid lawsuits, if a patient is hurt from a bad diagnosis.
Solution2:
Decrease paper work or give each doctor his own "clinical scribe." A clinical scribe would be legally responsible for doing a doctors paperwork for each patient and their diagnosis.
Solution3: According to, "Doctor Autonomy Linked to Medical Errors," integrate doctor autonomy with standardized guidelines because "To err is human," and we cannot rely a doctor to be on target every time.
Conclusion: These are my recommendations for improving a doctors ability to conclude a diagnosis, improving health care.
Solution1: Remove the pressure for doctors to use all applicable technology. They might do this to rule out every possibility before diagnosing, to avoid lawsuits, if a patient is hurt from a bad diagnosis.
Solution2:
Decrease paper work or give each doctor his own "clinical scribe." A clinical scribe would be legally responsible for doing a doctors paperwork for each patient and their diagnosis.
Solution3: According to, "Doctor Autonomy Linked to Medical Errors," integrate doctor autonomy with standardized guidelines because "To err is human," and we cannot rely a doctor to be on target every time.
Conclusion: These are my recommendations for improving a doctors ability to conclude a diagnosis, improving health care.
Quality of Care
In an ideal health care system, all patients would receive equal, affordable, and sensible quality of care. Certainly not all systems are ideal, and many would argue the United States' health care system isn't either. But it definitely gets complicated when one tries to define an appropriate way to ascertain quality of care. Sure you can measure the number of successful cardiopulmonary surgeries or the number of people who recover from various infectious diseases once administered medical care, but I think it becomes difficult to really grasp the bigger picture about the quality of health care as a whole.
Health care can be a rather lucrative business for medical executives who wish to exploit patients for unnecessary, expensive treatments that do not improve the health status of an individual. For instance, patients who are almost certainly going to die may be given pointless medications for money making purposes. This sort of reckless and careless decision needs to be closely monitored and reprimanded. In a decent health care system, no one's life should be subject to manipulation and profit.
The quality of care has really seemed to be polarized where certain hospitals and clinics provide quality that is second to none, whereas others provide care that is substandard and often unfair. Not having health insurance in many situations is the deciding factor between good and poor quality of care, and certainly this needs to be addressed. I think there is definitely a lot of room for improvement, and one place we might start is by ensuring that the health care that is administered is more equal and certainly not profit-centric.
Health care can be a rather lucrative business for medical executives who wish to exploit patients for unnecessary, expensive treatments that do not improve the health status of an individual. For instance, patients who are almost certainly going to die may be given pointless medications for money making purposes. This sort of reckless and careless decision needs to be closely monitored and reprimanded. In a decent health care system, no one's life should be subject to manipulation and profit.
The quality of care has really seemed to be polarized where certain hospitals and clinics provide quality that is second to none, whereas others provide care that is substandard and often unfair. Not having health insurance in many situations is the deciding factor between good and poor quality of care, and certainly this needs to be addressed. I think there is definitely a lot of room for improvement, and one place we might start is by ensuring that the health care that is administered is more equal and certainly not profit-centric.
Quality in Health Care
Quality can be measured in different ways: expertise of physicians and staff, attitude and manners of providers, availability of physician, concern for patients health, services provided in a timely manner, etc. etc. Quality is so difficult to measure because every health care program has a different set of standards, regulations, and funds that the services it delivers highly reflects the prices individuals must pay. Expense should not determine quality of health care, but from my experience, it seems that the more expensive the premium in a private insurance the better the quality of care. However, this is not to say that all those expensive insurances have great quality because that is not the case either. From my experience with all insurances (private and government), appointment waiting periods have always been long. I hate the co payments and premiums in insurances, but I love their health care facilities and staff. I hate the long waits in free clinics (Healthy Families), but I love the free service and prescriptions. Everyone has a different idea of what quality they look for in a health care insurance. However, I think that most importantly, people would like an emphasis on patients well being overall the other factors. I think that if a program did not have to worry so much about the costs (because of complex administration and clerical work), more emphasis would be placed on the quality of service.
Quality = level of excellence.
If we walk down the supermarket isle and look at the meat selection we will notice that some brands are marketed with a quality sticker. This infers that the meat must meet specific criteria in order for it to reach the supermarket. The marketed quality sticker most likely has to meet specified criteria such as: the animal grown and fed in a specific way, the meat is only a few days old prior to reaching consumers, and it’s the tenderest part on the animal. As we can see, most items marketed in the U.S. have to meet specific criteria prior to being sold to public otherwise there would be a public outcry. However, this is not the case for our frail health care system especially if your one of the unfortunate souls that does not have health insurance. So why does this seem to be the case for goods and not for our health care? Well, one thing is for sure, we know where to look if we get sick from eating the meat. However, do we know where to look if we receive bad care? Is it the doctor’s fault? Is it the system’s fault? Where do we pin the blame if a patient receives a wrong medication? Is it the pharmacist fault for filling the medication, the doctor for prescribing the wrong medication, the system for not catching the human error or our own fault for not demanding more? It’s a very complicated system as we have heard first hand from the representative of LA Care Health Plan. So first things first, we need to do away with bad habits, and start implementing new changes that define what a quality system entails. Yet, before this happens, markers must be in place to define what quality means. Quality means-patients are not dying needlessly because of medication errors, diagnosis are accurate, unnecessary test are not performed, a patient has a chart that follows him/her through his/her lifetime, doctors servicing a specific population are specialized in that area, and lastly money is spent effectively to put a patient on the right track. These are but a few criteria that can define quality of care. Yet one thing is certain, we all need to come together and define what quality medical care means to us so that we can start taking the steps to improving our broken health care system.
If we walk down the supermarket isle and look at the meat selection we will notice that some brands are marketed with a quality sticker. This infers that the meat must meet specific criteria in order for it to reach the supermarket. The marketed quality sticker most likely has to meet specified criteria such as: the animal grown and fed in a specific way, the meat is only a few days old prior to reaching consumers, and it’s the tenderest part on the animal. As we can see, most items marketed in the U.S. have to meet specific criteria prior to being sold to public otherwise there would be a public outcry. However, this is not the case for our frail health care system especially if your one of the unfortunate souls that does not have health insurance. So why does this seem to be the case for goods and not for our health care? Well, one thing is for sure, we know where to look if we get sick from eating the meat. However, do we know where to look if we receive bad care? Is it the doctor’s fault? Is it the system’s fault? Where do we pin the blame if a patient receives a wrong medication? Is it the pharmacist fault for filling the medication, the doctor for prescribing the wrong medication, the system for not catching the human error or our own fault for not demanding more? It’s a very complicated system as we have heard first hand from the representative of LA Care Health Plan. So first things first, we need to do away with bad habits, and start implementing new changes that define what a quality system entails. Yet, before this happens, markers must be in place to define what quality means. Quality means-patients are not dying needlessly because of medication errors, diagnosis are accurate, unnecessary test are not performed, a patient has a chart that follows him/her through his/her lifetime, doctors servicing a specific population are specialized in that area, and lastly money is spent effectively to put a patient on the right track. These are but a few criteria that can define quality of care. Yet one thing is certain, we all need to come together and define what quality medical care means to us so that we can start taking the steps to improving our broken health care system.
By quality do you mean coverage?
I think the issue described in the question above becomes a coverage issue. The quality mentioned is based on the "quality" of coverage you have. People with more comprehensive coverage are sometimes given test/treatments that may not be necessary, but since it is "covered" they don't see any reason not to provide these services. On the other hand, people with coverage that is not as comprehensive have to pay out of pocket expenses to obtain the same test/treatments that may actually be necessary for their course of treatment. I don't think that this issue can be simply addressed. There are to many factors that affect quality in this respect. I think good quality of care is defined as comprehensive care that includes all and any test/treatments that are needed to maintain and improve one's health.
Absurdity
And on the note of quality improvement, here's what a simple checklist accomplished in an age of face transplants, quadruple coronary bypasses, and robotic surgery:
From the Independent
And:
From the Harvard School of Public Health
And NOBODY managed to get this done until 2008? Way to go, team. I don't know whether this makes me want to cheer or burst into tears.
From the Independent
And:
From the Harvard School of Public Health
And NOBODY managed to get this done until 2008? Way to go, team. I don't know whether this makes me want to cheer or burst into tears.
Quality
"No comprehensive nationwide system exists for patient safety..." (Leape & Berwick, JAMA 2005)
What?! There isn't a federal regulation on health care?! Of all things. We regulate so many other things, but the health of our nation isn't one of them? How can this be? And why hasn't it changed?
Usually, I think fairly highly of the way this country is organized, with all of the different states having a say in their state's laws, because it makes some sense - California is worlds apart from West Virginia or North Dakota, as is New York from Texas. But sometimes, I really question why something like regulating health care for the safety of patients would be left alone.
Quality, I think, shouldn't just focus on the errors of clinicians, but should also focus on the over- and under-use of medical care, because these are very serious problems facing our nation. Quality should follow a certain standard of best-practices as decided upon by the physicians and specialists of this country. No matter the geographic location, every American should be entitled to the same standard of care. Nosocomial infections are widely preventable, so there should be a reevaluation of hospital standards to prevent more of these. Chronic diseases are widely preventable, or at least manageable to a greater extent than they are, so success, and therefore quality of care should be measured by how well chronic diseases are cared for. Certain tests like lipid panels and blood chemistry panels can tell so much about the health of a patient, and yet the frequency with which some patients receive these tests is much lower than others - usually traceable to insurance status, and frequency of visits. My point is that "quality of care" encompasses so many different branches of health care, that unless there is a nationwide standard, how could we possibly make sure that health care is equal across and within state lines?
I think it is and always will be difficult to improve quality because within our current system, there isn't much flexibility in terms of time, money and effort to make sure that every patient gets absolutely everything they need, no more no less. That is why all these incremental changes haven't affected the big picture very much. Unless we have one giant widespread reform to health care, it probably won't change very much - and with that reform, let's please make sure there is some federal regulation on health care!
Quality
These issues need attention now. I think that the health care system needs to first address that there is a problem with the quality. I think that quality is that very subjective to the person and to the status that you hold in their eyes. When you walk into a health care clinic you are summed up by the employees and it determines the quality that you will receive. The quality is based on underlined prejudices that all health care providers have. Earlier this week I had to take an older family friend from church to the county hospital. The way that I was treated as a patient was very different then when I went as a USC student. I felt that I was constantly discriminated and spoken to as if I was dumb. I feel that the quality that I received was very different when I was just a Latino girl that was coming in to county for care as opposed to a USC student that may one work here.
I think that for “good” quality of care people need to be treated equally as humans and be given the same care and treatment regardless of other external factors. This is difficult because whether we would like to admit it or not we all have some sort of bias that we can not get rid of.
I think that for “good” quality of care people need to be treated equally as humans and be given the same care and treatment regardless of other external factors. This is difficult because whether we would like to admit it or not we all have some sort of bias that we can not get rid of.
Pay for Performance
In our reading for this week, Leape and Berwick note (with a hint of exasperation, perhaps?) that, "despite the widely disseminated message from the IOM that systems failures cause most injuries, most individuals still believe that the major cause of bad care is bad physicians." In other words, while people tend to blame the healthcare system as a whole when it comes to problems with cost or access, they tend to blame individuals when it comes to problems with quality of care.
And why shouldn't they? After all, the doctor-patient relationship is at the core of the "quality" concept. And I'm not talking about all the other myriad forms of "quality" here; I'm just talking about the quality of medical care, not quality of access or coverage or portability or what have you. Quality of care is clearly determined by some sort of concensus between doctors and patients. It is essentially defined (or rather, undefined) by the tension between these two populations: does "quality" mean patient satisfaction or desirable medical outcomes? Is the patient's perception or the physician's a better measure of quality? Or, to put it another way: if the patient is happy, has the doctor done his or her job? Is the doctor's job to make a patient happy? Or is his job to make a patient healthy?
Patient satisfaction and patient health are obviously two very different things, but the fact that they're also very much related makes determining the minimal standards for "quality" very difficult. For instance, I strongly believe that the pay-for-performance (P4P) payment system is the right approach to improving quality of care. Since the doctor-patient relationship is what essentially determines quality, it makes sense to tackle the problem from the ground-up by changing physician incentives, rather than from the top-down by imposing systemic restrictions. However, creating incentives under P4P is very tricky. Do you pay doctors more for better medical outcomes for their patients, or for better patient satisfaction? Neither is objective, but you can't have quality care plus the PERCEPTION of quality care (an arguably more powerful political force) unless both agree. So do we award doctors for lower blood sugar levels, or for making patients feel better able to manage their diabetes? Ideally, we would do both, but which should take precedent in case the two measures disagree?
This is all the more difficult to figure out on a policy level because the US has paradoxically the most advanced, well-equipped, and cutting edge medical facilities of any nation (a physician-side "quality" measure) but also the worst continuity of care (a patient-side "quality" measure). US patients are not happy with their doctors, as this graph plainly shows:
Yikes. But for those of you who think more preventative medicine is the answer, here's a graph from the year before:
So even though US patients are plainly GETTING their primary or preventative care (if we understand that to be breast cancer screenings, blood pressure checks, etc.), they still FEEL that their primary care (or "regular") doctors aren't talking to them enough about what's going on.
I'm not posting this to be critical of either the doctors giving the care or the patients recieving it, but simply to illustrate that it is entirely possible for one group to say that the first graph is inevitable and the second wonderful, and for the other group to say that the first graph is terrible and the second inconsequential.
And why shouldn't they? After all, the doctor-patient relationship is at the core of the "quality" concept. And I'm not talking about all the other myriad forms of "quality" here; I'm just talking about the quality of medical care, not quality of access or coverage or portability or what have you. Quality of care is clearly determined by some sort of concensus between doctors and patients. It is essentially defined (or rather, undefined) by the tension between these two populations: does "quality" mean patient satisfaction or desirable medical outcomes? Is the patient's perception or the physician's a better measure of quality? Or, to put it another way: if the patient is happy, has the doctor done his or her job? Is the doctor's job to make a patient happy? Or is his job to make a patient healthy?
Patient satisfaction and patient health are obviously two very different things, but the fact that they're also very much related makes determining the minimal standards for "quality" very difficult. For instance, I strongly believe that the pay-for-performance (P4P) payment system is the right approach to improving quality of care. Since the doctor-patient relationship is what essentially determines quality, it makes sense to tackle the problem from the ground-up by changing physician incentives, rather than from the top-down by imposing systemic restrictions. However, creating incentives under P4P is very tricky. Do you pay doctors more for better medical outcomes for their patients, or for better patient satisfaction? Neither is objective, but you can't have quality care plus the PERCEPTION of quality care (an arguably more powerful political force) unless both agree. So do we award doctors for lower blood sugar levels, or for making patients feel better able to manage their diabetes? Ideally, we would do both, but which should take precedent in case the two measures disagree?
This is all the more difficult to figure out on a policy level because the US has paradoxically the most advanced, well-equipped, and cutting edge medical facilities of any nation (a physician-side "quality" measure) but also the worst continuity of care (a patient-side "quality" measure). US patients are not happy with their doctors, as this graph plainly shows:
Yikes. But for those of you who think more preventative medicine is the answer, here's a graph from the year before:So even though US patients are plainly GETTING their primary or preventative care (if we understand that to be breast cancer screenings, blood pressure checks, etc.), they still FEEL that their primary care (or "regular") doctors aren't talking to them enough about what's going on.
I'm not posting this to be critical of either the doctors giving the care or the patients recieving it, but simply to illustrate that it is entirely possible for one group to say that the first graph is inevitable and the second wonderful, and for the other group to say that the first graph is terrible and the second inconsequential.
HIT....
A comment to “structural organization” and quality care.The issue of structural organization really hits home for me since my group project focusd on the implementation of Health Information Technology (HIT). HIT is a stepping stone in the re-structuring and re-organizing of the way the U.S. healthcare system works. Before we can begin to see drastic changes in outcomes, specifically improved health behaviors of patients, we do need to alter our current “reactive” model of healthcare definitely towards more of a “proactive” model. According to Obama’s administration and health experts, HIT will assist in improving quality of care for patients through the creation electronic medical records. These records will not only be accessible to providers, but to patients as well. Thus, both patients and providers will have the ability to manage and coordinate healthcare together. HIT systems are also expected to improved quallity of care for patients and help them modify their health behaviors through better disease surveillance and chronic illness maintenance through HIT. HIT is indeed a prime example of the re-structuring the U.S. healthcare system.
But quality of care should not just be viewed in a macro level. Quality of care is measured through individual patient outcomes, for instance if their health has improved, health quality can also be measured through the consumer’s experience with their provider.
Although HIT is highly expected to make out healthcare system more efficient, I do not think it is the sole savior of our flawed health care network. It is again one stepping stone. I think HIT will improve orgarnizational processes and will further encourage research with all the data being eletronically saved, but other factos of our healthcare system is in need of alteration such as the our ideology of what healthcare is, here in the U.S.it is a commodity you can purchase, or is it an essential human right? Other factors to consider include the training of our providers…..Are U.S. institutions really gearing our doctors with the correct tools to deal with such diverse populations?
But quality of care should not just be viewed in a macro level. Quality of care is measured through individual patient outcomes, for instance if their health has improved, health quality can also be measured through the consumer’s experience with their provider.
Although HIT is highly expected to make out healthcare system more efficient, I do not think it is the sole savior of our flawed health care network. It is again one stepping stone. I think HIT will improve orgarnizational processes and will further encourage research with all the data being eletronically saved, but other factos of our healthcare system is in need of alteration such as the our ideology of what healthcare is, here in the U.S.it is a commodity you can purchase, or is it an essential human right? Other factors to consider include the training of our providers…..Are U.S. institutions really gearing our doctors with the correct tools to deal with such diverse populations?
3 aspects of quality
Quality can be evaluated based on structure, process, and outcomes (Donabedian 1980). Structural quality evaluates health system characteristics, process quality assesses interactions between clinicians and patients, and outcomes offer evidence about changes in patients’ health status.
An example of structural quality problem is the Medicare program, which is blamed to be "reactive, rather than proactive". It focuses mainly on treating patients when sick with little or no emphasis on prevention and coordination. I think poor quality of care such as too much care, too little care, wrong care are mainly because of structural problems.
Process quality are relatively individual, due to different physicians. Outcome quality is closely related with physicians' professional knowledge and technology.
We can see that among these 3 levels of quality, structural quality is most difficult to change, but a better structure will definitely bring us more benefits.
Monday, April 6, 2009
Health Care Quality
We should address these issues by first acknowledging that there is a problem, but we should also recognize changing quality of care will be much harder since there is not just one hospital/clinic involved, but hundreds of thousands. A national movement should be initiated to make Americans aware that our healthcare system is ranked 72nd in population health according to the World Health Organization and that something must be done. Surveillance for medical errors should be increased and standard care should be enforced so individuals are not getting various treatments when they have the same illness (of course there will be some variation which will be determined on a case by case basis). Good quality of care includes emphasis on preventive medicine, seeing the same physician, monitoring healthcare workers’ performance, minimizing medical errors, and enforcing reporting of these errors so medical sites can prevent future mistakes.
Health Care Quality
I agree that "quality" is subjective. We might not all define quality by the same standards. In my opinion good quality should mean that the patient is getting what they need to stay healthy and happy. If patients are unhealthy then quality of care is low. With the current obesity trends and increase in disease I would venture to say that this is a strong indication that our quality of care is very low indeed. Simply by looking at health trends, we can determine (on a basic scale) where our quality of care falls. We don't necessarily need surveys and questionnaires to determine that. I think we can all agree that one thing we do need is better record keeping and for health care to be more accessible to the public. Without these things, quality is really a secondary issue in my opinion.
In my personal experience, I've seen incredible differences in care. On our 10 hour drive home from a trip, my mom got sick. We stopped in the emergency room of a small university affiliated hospital. My mom had to stay in the hospital for 3 days to stabilize her condition. In those three days she got top notch care. Everyone was friendly and even went out of their way to be culturally competent. The doctors were attentive and kind and all of her nurse calls were answered immediately. It was, as weird as it is to say, an great hospital experience. However, her condition required her to have surgery and because the hospital was so small, they stabilized her condition and sent her home (about a 3 hour drive). Upon getting home she was admitted to a much large county hospital for her surgery. In short, they were horrible. Her doctors and nurses were cold and disinterested. They were not at all accommodating or friendly. I could see immediately the change in her. She felt worse, she was in more pain and she had a grim outlook on her condition. This was a much bigger hospital, much newer with many more facilities and newer, better technology but the way the medical staff behaved made most of that not matter. My moms attitude toward her condition and her recovery were completely changed by her interactions with the medical staff.
Quality is relative, but we need better record keeping!
As mentioned by Han in a prior post, quality merely reflects the fulfillment of care or lack thereof. As such, measuring quality seems entirely subjective and can only be understood in a given context. For example, measuring quality of care requires a relative benchmark. The US system is leaps and bounds ahead of third world and developing countries but compared to many of the developed world (i.e much of Western Europe) our "quality" is lacking.
That being said I believe that the most significant change to improve quality of care in the United States is BETTER MEDICAL RECORD KEEPING. We have consistently mentioned medical records as one of the more glaring differences between our health care system and others of the developed world. A priori logic would suggest having our medical records on file, would initially cause sluggishness of the system as doctors would then be forced to manually input data into computers. This might initially be the case.
But after the initial input of data into a nationalized record keeping system, the efficiency with which physicians could implement care would dramatically improve. This would mean that each and every time we visit new doctors, our records would be easily accessed meaning less paperwork, and more patient to doctor time. Having prior records would also help physicians diagnose health related issues as many new problems are often complications of older health problems. All drugs that have been prescribed would be on file as well to minimize risks associated with drug interactions, complications, and side effects. Many people fail or forget to self-report medications they are taking dramatically increasing risks of drug complications or even death...this problem needs immediate remedy.
In addition, the US should look to increasing quality of care by establishing an independent efficiency and quality review board of health care. They should monitor, report, and explain the public the state of health care in the country with full TRANSPARENCY. The FDA currently lacks the power, money, or staff to execute such a complex task.
I have spoken with numerous successful doctors on the issue of more advanced record keeping. The consensus I have gotten (albeit from a sample size of 3) is all negative. A neurologist, plastic surgeon, and ear nose and throat doctors have all told me that in their own experience, record keeping has only slowed down their ability to see more patients. While this might be the case initially, once the rudimentary data is input, the speed and efficiency with which our health care system would skyrocket.
Saturday, April 4, 2009
USC’s student health insurance plan
I have USC’s student health insurance plan. If you go to this website:
http://web-app.usc.edu/scampus/health-insurance/
It explains the cost for the student health insurance. Part of the explanation includes:
“The health insurance plan works in conjunction with the university’s student health centers. For this reason, all students enrolled in the insurance plan are required to pay the student health fee and access their primary care at the student health center on their campus. Blue Cross of California is the insurer of this supplemental insurance plan. The cost for coverage is $319 for the fall semester (August 18, 2008 to January 11, 2009) and $606 for the spring semester and summer session (January 12, 2009 to August 16, 2009).”
What do you get for paying this type of money? In my personal experience, I feel that the USC student health insurance plan is of good quality. I have no problems scheduling an appointment with my primary care doctor. Prescription medications are sent electronically to the USC pharmacy at the University Park Campus. My primary care doctor can easily assist me in referring me to a specialist.
I feel as if one of the reasons why the USC student health plan is of good quality is because the physicians and administrators get and use the patient’s feedback. Most of the times I’ve gone to the USC hospitals or student health center, I would get a questionnaire sheet to fill out. I feel as if the doctors and nurses really read the questionnaire and try to improve upon patient service and decrease wait times for example.
http://web-app.usc.edu/scampus/health-insurance/
It explains the cost for the student health insurance. Part of the explanation includes:
“The health insurance plan works in conjunction with the university’s student health centers. For this reason, all students enrolled in the insurance plan are required to pay the student health fee and access their primary care at the student health center on their campus. Blue Cross of California is the insurer of this supplemental insurance plan. The cost for coverage is $319 for the fall semester (August 18, 2008 to January 11, 2009) and $606 for the spring semester and summer session (January 12, 2009 to August 16, 2009).”
What do you get for paying this type of money? In my personal experience, I feel that the USC student health insurance plan is of good quality. I have no problems scheduling an appointment with my primary care doctor. Prescription medications are sent electronically to the USC pharmacy at the University Park Campus. My primary care doctor can easily assist me in referring me to a specialist.
I feel as if one of the reasons why the USC student health plan is of good quality is because the physicians and administrators get and use the patient’s feedback. Most of the times I’ve gone to the USC hospitals or student health center, I would get a questionnaire sheet to fill out. I feel as if the doctors and nurses really read the questionnaire and try to improve upon patient service and decrease wait times for example.
Friday, April 3, 2009
Health Care Quality Crisis in America
I think "good" quality care means getting the right kind of treatment at the right time: no more or no less. As one report from Robert Wood Johnson Foundation mentioned, when we analyze further, there are 3 key dimensions that can conceptually describe the quality crisis we are facing in health care: “underuse,” “overuse” and “misuse” of care.
Neither of them will bring about the "good quality of care".
• “Underuse” of care means having less than what is recommended. Eg. Not getting enough medication for proper treatment of a disease.
• “Overuse” of care means prescribing advanced antibiotics for simple infections. In one study published by Dartmouth Atlas of Health Care in 2006, it was found that Medicare reimburses about $50,000 more for health care services during the lifetime of a 65-year-old living in Miami than it does for a 65-year-old in Minneapolis, simply because Miami has more acute care resources—including hospital beds and specialists—relative to the size of its Medicare population. The health care outcomes of those patients in Miami are not better.
• “Misuse” of care can be either failure to properly carry out appropriate treatment protocols or the use of inappropriate ones. Eg. Medical errors like adverse reactions to drugs, surgical injuries and other serious harms to patients.
I think it is difficult to improve quality because, the health care costs are already very high and different stakeholders—patients, health care professionals, health insurance companies etc—perceive these problems with quality in different ways. More importantly, quality is associated with other interrelated elements like cost and access. We can't just focus on one and ignore the others when addressing the quality crisis in health care.
According to former Secretary of Health and Human Service nominee, Tom Daschle, we need to be more transparent as well when it comes to quality issues in health care. He said that we are eager to put forward things, related to quality issues in other sectors almost instantaneously; like how many people died because of the jet engine failure for example. But, we seldom see how many people die because of medical errors or negligence in frontline pages.
Why doesn’t they are in the frontline pages? It’s because we have very little transparency when it comes to quality in health care and we don’t have enough infrastructure to address it. So, unless we have the kind of health infrastructure that can reflect the problems in health care sectors better and become more transparent about medical "abuses", the goal of providing “quality health care” will still be a far-fetched dream.
Neither of them will bring about the "good quality of care".
• “Underuse” of care means having less than what is recommended. Eg. Not getting enough medication for proper treatment of a disease.
• “Overuse” of care means prescribing advanced antibiotics for simple infections. In one study published by Dartmouth Atlas of Health Care in 2006, it was found that Medicare reimburses about $50,000 more for health care services during the lifetime of a 65-year-old living in Miami than it does for a 65-year-old in Minneapolis, simply because Miami has more acute care resources—including hospital beds and specialists—relative to the size of its Medicare population. The health care outcomes of those patients in Miami are not better.
• “Misuse” of care can be either failure to properly carry out appropriate treatment protocols or the use of inappropriate ones. Eg. Medical errors like adverse reactions to drugs, surgical injuries and other serious harms to patients.
I think it is difficult to improve quality because, the health care costs are already very high and different stakeholders—patients, health care professionals, health insurance companies etc—perceive these problems with quality in different ways. More importantly, quality is associated with other interrelated elements like cost and access. We can't just focus on one and ignore the others when addressing the quality crisis in health care.
According to former Secretary of Health and Human Service nominee, Tom Daschle, we need to be more transparent as well when it comes to quality issues in health care. He said that we are eager to put forward things, related to quality issues in other sectors almost instantaneously; like how many people died because of the jet engine failure for example. But, we seldom see how many people die because of medical errors or negligence in frontline pages.
Why doesn’t they are in the frontline pages? It’s because we have very little transparency when it comes to quality in health care and we don’t have enough infrastructure to address it. So, unless we have the kind of health infrastructure that can reflect the problems in health care sectors better and become more transparent about medical "abuses", the goal of providing “quality health care” will still be a far-fetched dream.
This is a problem I am currently experiencing. Right now, I'm on a clerkship trip in southern China, and we see about 50-60 patients with chronic heart diseases each day. Oftentimes, because there are simply too many people to see and not enough time to see them all, we end up rushing through the less severe cases. Obviously, then, the quality of care we offer to those people goes down. But at the same time, it is better to have seen everyone and have made sure to have given them a treatment plan than nothing at all, so time is of the essence, and we have no choice but to go through everything speedily.
Another common thing I've noticed here is patient anxiety. Frequently, there is absolutely nothing wrong with them, although they insist that they have heart problems, gastrointestinal problems, etc. But a physical exam reveals no inconsistencies. When you tell them that they are fine, they refuse to believe it...they almost DEMAND you tell them that something is seriously wrong with them, and expect to be given medication for it. But if there's nothing wrong with them, there's nothing we can do, and then the patient leaves unsatisfied. So to the patient, the quality of care they received was probably perceived as subpar, even though we did everything in our power to treat them.
In the ideal situation, if we were all smart about allocating resources and personnel, everyone would be able to receive good quality care. But that's very difficult to achieve, especially in a system as flawed as ours. It would be prudent, though, in redesigning/improving US healthcare, to always keep quality as a major priority.
Another common thing I've noticed here is patient anxiety. Frequently, there is absolutely nothing wrong with them, although they insist that they have heart problems, gastrointestinal problems, etc. But a physical exam reveals no inconsistencies. When you tell them that they are fine, they refuse to believe it...they almost DEMAND you tell them that something is seriously wrong with them, and expect to be given medication for it. But if there's nothing wrong with them, there's nothing we can do, and then the patient leaves unsatisfied. So to the patient, the quality of care they received was probably perceived as subpar, even though we did everything in our power to treat them.
In the ideal situation, if we were all smart about allocating resources and personnel, everyone would be able to receive good quality care. But that's very difficult to achieve, especially in a system as flawed as ours. It would be prudent, though, in redesigning/improving US healthcare, to always keep quality as a major priority.
It's all about money
Almost a year and a half ago my mom had to have surgery to remove a tumor that was found in her colon. She had to stay in the hospital for 4 days while she recovered after her surgery. After she got discharged she told us how much she hated it in the hospital because the nurses and doctors made her feel like she was a burden and their service was horrible. I even witnessed it myself. I went to visit her one day in the hospital and she needed the nurse for something so she buzzed for her to come. We were waiting for about 15 minutes and the nurse still hadn't come so my mom asked me to go look for the nurse. When I went out into the lobby I found my mom's nurse busy on the computer...on Myspace. My mom told us that every time she buzzed for the nurses they would take at least 15 minutes to get to her and that her doctor only checked up on her once after the surgery.
I think the main issue here is money. We don't have enough money to address the quality of care and it's the money that makes doctors and nurses act the way they do. Because a doctor or nurse is one of the higher paying jobs in the country, many people go into these professions not because they truly care about people, but because they want the money. This results in many hospital professionals not treating their patients the way they deserve to be treated. They are only there to get paid, not to make a difference.
Gawande on better health care
An interesting article regarding quality of care in surgery...
http://www.harvardscience.harvard.edu/medicine-health/articles/surgical-safety-checklist-drops-deaths-and-complications-more-one-thirdThe most fascinating thing is that the most hard thing for people to do to improve quality of care was to communicate with each other and even in surgery to just introduce each other and collectively come up with a solution.
Here is a link to NPR of a talk buy Atul Gawande who wrote the above article...
What Practitioners know VS what Practitioners Actually Do.
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