Chapter 6

1. CHAPTER 6:
HEALTHCARE SYSTEM
PERFORMANCE

2. Introduction
• Healthcare systems are evaluated on 3 criteria:
1. Quality of healthcare
2. Equity of healthcare
3. Efficiency
• Can be assessed at the Micro or Macro levels
• Performance can be evaluated by gold standards, best
possible performance, benchmark

3. Quality of Healthcare
• Assessed in terms of structure, process and outcomes
• Structure-the condition under which care is provided
• Includes material resources, equipment, facility, human
resources, number and qualities of professional resources
• Process- is taken to mean activities that constitute healthcare-
diagnosis, treatment, rehab, prevention, and patient education
• Structure and process help influence the outcomes or
effectiveness of healthcare
• Outcomes are taken to mean changes in individuals and
populations (good or bad) that can be attributed to healthcare
• Two types: patient outcomes and population outcomes-
people who have and have not received healthcare

4. Population Health Outcomes
• Population mortality and morbidity rates-number of deaths
in a given population per year
• IMR (infant mortality rate)
• YPLL (years of potential life lost)-# of yrs expected in a
given population
• HALE (healthy life expectancy)-avg # of yrs to live in full
health
• QALY (quality adjusted life years)-perceived health status
as the indicator of quality of life
• DALY (disability-adjusted life years)
• YHL (years of healthy life)

5. Clinical Outcomes
• Health outcomes that are specific to the persons who
receive care are often called clinical outcomes
• Examples: Readmissions to hospital after a surgical
procedure, functional capacity after medical intervention,
long-term pain and discomfort after medical treatment,
infection acquired after a hospital stay (nosocomial)
Micro Level/Clinical Outcomes: 2 aspects of Quality:
Effectiveness: whether care produces the desired outcome
• Evidence-based-scientifically valid and, empirical
research
• Standards against which quality is measured is based on
clinical research

6. Clinical Effectiveness
Effectiveness: whether care produces the desired outcome
• Evidence-based-scientifically valid and, empirical
research
• Standards against which quality is measured is based on
clinical research
• Clinical outcomes research is the foundation of quality
improvement efforts at the micro level
• Published clinical outcome studies have been synthesized
by experts in the field and are translated into clinical
practice guidelines or evidence-based “best practices”
• AHRQ, CDC, and NIH

7. Patient Safety
• Improving the quality of healthcare through the application
of methods borrowed from other industries
• Deming was an American statistician, father of modern
quality-TQM:
• Freedom from accidental injury; ensuring patient safety
involves the establishment of operational systems and
processes that minimizes the likelihood of errors and
maximizes the likelihood of intercepting them when they
occur

8. The Joint Commission & Other HC
Accrediting Organizations
• In order for a hc organization to participate in and receive
reimbursement from Medicare/Medicaid, they must be
certified as complying with the Conditions of Participation
• Based on a survey conducted by a state agency on behalf
of CMS
• If a national accrediting organization, such ad the TJC
enforces standards that meet the federal guidelines of
participation, CMS may grant the organization “deeming”
authority and “deem” each accredited hc organization as
meeting the CMS certification requirements
• Other accrediting bodies p. 184

9. Public/Private Partnerships
Providers of hc performance information:
• For consumers and purchasers
• NQF-National Quality Forum and the Leapfrog Group
• Developing standard measures of hospital quality and
disseminating to purchasers and consumers
• IHI-Institute for Healthcare Improvement-not for profit
organization that focuses on the mission and goals set
forth by IOM’s six improvement aims: safety,
effectiveness, patient centeredness, timeliness, efficiency,
and equity
• State legislators have passed laws for hospitals to
disclose infection rates

10. Equity of Healthcare
• 2nd criterion used to evaluate performance of HC systems
• Fair allocation of benefits and burdens among those that are
deserving of care and those who are in a position to pay for it
• Inequities in access to hc as well as inequities in the quality of
hc
• Factors associated with inequities:
• SES, race and ethnicity, and geographic location
• Low income, low education, rural or inner cities
• Leads to fewer preventive medicine procedures
• Studies suggest that that the gap in disparities of care may be
closing and it is not as much of an issue as the overall quality
of care for all groups

11. Equity and Access
• People without health insurance have reduced access to
hc
• Patchwork system of employer-based insurance, public
insurance programs and CMS leave 46.1 million people
without health insurance
• Millions underinsured
• Do not have usual place to go and more likely to use
safety net providers such as emergency rooms and
community health centers
• Some choose not to have it or cannot afford it or there are
no local resources

12. Efficiency
• 3rd criterion for judging a hc system
• Create the combination of goods and services with the
highest attainable total value, given limited resources and
technology
• Allocative efficiency-attaining the most valued mix of hc
services, ex: how much to invest in preventive vs curable
medical services
• Production efficiency-producing a given level of hc
services at minimum cost , ex: sub low-cost RNs for
higher-cost physicians

13. National Scorecard
• Ability to evaluate the US hc system comprehensively
• Commonwealth Fund developed a scorecard that
evaluates on quality, access, equity and efficiency
• Macro level evaluation of hc comparing national scores to
benchmarks (top performing groups)
• 42 performance indicators and 5 broad domains
• Domains: health outcomes, quality, access, efficiency, and
equity

14. Data and Information Technology
• Organizations recognize need for better data in order to
benchmark current situation and determine if improvements
have occurred in quality, access and equity, and cost and
efficiency
• Proper functioning of hc requires an advanced health
information network that supports clinical care, personal health
mngt, population health, and research-does not yet exist!
• Health information systems need to evaluate performance
internally and externally (between organizations)-latter
Regional Health Info Organizations
• EHR is major sources of data for internal health info and
RHIOs
• Data included: used for clinical outcome studies, population
health outcomes (morbidity & mortality), design and evaluate
interventions to improve clinical practice, and increase access,
equity and efficiency

15. ONC
• Office of National Coordinator for Health Information
Technology
• Part of DHHS
• 4 goals: informing clinicians, interconnecting clinicians,
personalizing hc, and improving population healt
1. Informing Clinicians-slow adoption of EHRs attributed to
cost of hardware/software and training and disruption of
the current workflow, access to ehrs in rural areas and
develop incentives-MU
2. Interconnecting Clinicians-provide access to patient
health info in any healthcare setting, any place in the
US-a network that can be accessed by any health care
provider, common set of communication standards

16. ONC
• Personalizing HC
• 3rd goal-equip patients to participate actively in their own
health care and in decision making through the
development of a national health info system
• Use of PHRs-electronic application through which
individuals can maintain and manage their health info in a
private, secure, confidential manner
• 4th goal-Population Health-improve through Nat’l
Healthcare Information system-unify public health
surveillance, streamline quality and health status
monitoring of populations
• React early or prevent issues

17. Conclusions
• 3 criteria pf performance: quality of hc, equity of hc, and
efficiency of hc
• Quality-over last 20 yrs increased effort has developed to
measure and improve quality at the micro-level
• Evaluations of clinical effectiveness and patient safety are
based on empirical studies that provide evidence about
best practices and are foundations of clinical practice
guidelines
• EHR standard for all hc providers
• Health information systems will affect the work and future
of all healthcare professionals