Raising the bar: the use of performance guarantees by the Pacific Business Group on Health.
In 1996 the Pacific Business Group on Health (PBGH) negotiated more than two dozen performance guarantees with thirteen of California's largest health maintenance organizations (HMOs) on behalf the seventeen large employers in its Negotiating Alliance. The negotiations put more than $8 million at risk for meeting performance targets with the goal of improving the performance of all health plans. Nearly $2 million, or 23 percent of the premium at risk, was refunded to the PBGH by the HMOs for missed targets. The majority of plans met their targets for satisfaction with the health plan and physicians, as well as cesarean section, mammography, Pap smear, and prenatal care rates. However, eight of the thirteen plans missed their targets for childhood immunizations, refunding 86 percent of the premium at risk. (+info)
Indicators of the appropriateness of long-term prescribing in general practice in the United Kingdom: consensus development, face and content validity, feasibility, and reliability.
OBJECTIVES: To develop valid, reliable indicators of the appropriateness of long-term prescribing in general practice medical records in the United Kingdom. DESIGN: A nominal group was used to identify potential indicators of appropriateness of prescribing. Their face and content validity were subsequently assessed in a two round Delphi exercise. Feasibility and reliability between raters were evaluated for the indicators for which consensus was reached and were suitable for application. PARTICIPANTS: The nominal group comprised a disciplinary mix of nine opinion leaders and prominent academics in the field of prescribing. The Delphi panel was composed of 100 general practitioners and 100 community pharmacists. RESULTS: The nominal group resulted in 20 items which were refined to produce 34 statements for the Delphi exercise. Consensus was reached on 30, from which 13 indicators suitable for application were produced. These were applied by two independent raters to the records of 49 purposively sampled patients in one general practice. Nine indicators showed acceptable reliability between raters. CONCLUSIONS: 9 indicators of prescribing appropriateness were produced suitable for application to the medical record of any patient on long term medication in United Kingdom general practice. Although the use of the medical record has limitations, this is currently the only available method to assess a patient's drug regimen in its entirety. (+info)
Health authority commissioning for quality in contraception services.
OBJECTIVE: To compare the commissioning of contraception services by London health authorities with accepted models of good practice. DESIGN: Combined interview and postal surveys of all health authorities and National Health Service (NHS) trusts responsible for running family planning clinics in the Greater London area. MAIN OUTCOME MEASURES: Health authority commissioning was assessed on the presence of four key elements of good practice--strategies, coordination, service specifications, and quality standards in contracts--by monitoring activity and quality. RESULTS: Less than half the health authorities surveyed had written strategies or service specifications for contraception services. Arrangements for coordination of services were limited and monitoring was underdeveloped. CONCLUSION: The process of commissioning services for contraception seems to be relatively underdeveloped despite the importance of health problems associated with unplanned pregnancy in London. These findings raise questions about the capacity of health authorities to improve the quality of these services through the commissioning process. (+info)
Trust in performance indicators?
The 1980s and 90s have seen the proliferation of all forms of performance indicators as part of attempts to command and control health services. The latest area to receive attention is health outcomes. Published league tables of mortality and other health outcomes have been available in the United States for some time and in Scotland since the early 1990s; they have now been developed for England and Wales. Publication of these data has proceeded despite warnings as to their limited meaningfulness and usefulness. The time has come to ask whether the remedy is worse than the malady: are published health outcomes contributing to quality efforts or subverting more constructive approaches? This paper argues that attempts to force improvements through publishing health outcomes can be counterproductive, and outlines an alternative approach which involves fostering greater trust in professionalism as a basis for quality enhancements. (+info)
Assessment of management in general practice: validation of a practice visit method.
BACKGROUND: Practice management (PM) in general practice is as yet ill-defined; a systematic description of its domain, as well as a valid method to assess it, are necessary for research and assessment. AIM: To develop and validate a method to assess PM of general practitioners (GPs) and practices. METHOD: Relevant and potentially discriminating indicators were selected from a systematic framework of 2410 elements of PM to be used in an assessment method (VIP = visit instrument PM). The method was first tested in a pilot study and, after revision, was evaluated in order to select discriminating indicators and to determine validity of dimensions (factor and reliability analysis, linear regression). RESULTS: One hundred and ten GPs were assessed with the practice visit method using 249 indicators; 208 of these discriminated sufficiently at practice level or at GP level. Factor analysis resulted in 34 dimensions and in a taxonomy of PM. Dimensions and indicators showed marked variation between GPs and practices. Training practices scored higher on five dimensions; single-handed and dispensing practices scored lower on delegated tasks, but higher on accessibility and availability. CONCLUSION: A visit method to assess PM has been developed and its validity studied systematically. The taxonomy and dimensions of PM were in line with other classifications. Selection of a balanced number of useful and relevant indicators was nevertheless difficult. The dimensions could discriminate between groups of GPs and practices, establishing the value of the method for assessment. The VIP method could be an important contribution to the introduction of continuous quality improvement in the profession. (+info)
Conditional Length of Stay.
OBJECTIVE: To develop and test a new outcome measure, Conditional Length of Stay (CLOS), to assess hospital performance when deaths are rare and complication data are not available. DATA SOURCES: The 1991 and 1992 MedisGroups National Comparative Data Base. STUDY DESIGN: We use engineering reliability theory traditionally applied to estimate mechanical failure rates to construct a CLOS measure. Specifically, we use the Hollander-Proschan statistic to test if LOS distributions display an "extended" pattern of decreasing hazards after a transition point, suggesting that "the longer a patient has stayed in the hospital, the longer a patient will likely stay in the hospital" versus an alternative possibility that "the longer a patient has stayed in the hospital, the faster a patient will likely be discharged from the hospital." DATA COLLECTION/EXTRACTION METHODS: Abstracted records from 7,777 pediatric pneumonia cases and 3,413 pediatric appendectomy cases were available for analysis. PRINCIPAL FINDINGS: For both conditions, the Hollander-Proschan statistic strongly displays an "extended" pattern of LOS by day 3 (p<.0001) associated with declining rates of discharge. This extended pattern coincides with increasing patient complication rates. Worse admission severity and chronic disease contribute to lower rates of discharge after day 3. CONCLUSIONS: Patient stays tend to become prolonged after complications. By studying CLOS, one can determine when the rate of hospital discharge begins to diminish--without the need to directly observe complications. Policymakers looking for an objective outcome measure may find that CLOS aids in the analysis of a hospital's management of complicated patients without requiring complication data, thereby facilitating analyses concerning the management of patients whose care has become complicated. (+info)
Developing quality measures for adolescent care: validity of adolescents' self-reported receipt of preventive services.
OBJECTIVE: To demonstrate the feasibility of directly surveying adolescents about the content of preventive health services they have received and to assess the validity of adolescent self-reported recall. DATA SOURCES/SETTING: Audiotaped encounters, telephone interviews, and chart reviews with 14-21 year olds being seen for preventive care visits at 15 pediatric and family medicine private practices, teaching hospital clinics, and health centers. DESIGN: 537 adolescents presenting for well visits were approached, 400 (75 percent) consented, 374 (94 percent) were audiotaped, and 354 (89 percent) completed telephone interviews either two to four weeks or five to seven months after their visits. Audiotapes were coded for screening and counseling across 34 preventive service content areas. Intraobserver reliability (Cohen's kappa) ranged from 0.45 for talking about peers to 0.94 for discussing tobacco. The sensitivity and specificity of the adolescent self-reports were assessed using the audiotape coding as the gold standard. RESULTS: Almost all adolescents surveyed (94 percent) remembered having had a preventive care visit, 93 percent identified the site of care, and most (84 percent) identified the clinician they had seen. There was wide variation in the prevalence of screening, based on the tape coding. Adolescent self-report was moderately or highly sensitive and specific at two weeks and six months for 24 of 34 screening and counseling items, including having discussed: weight, diet, body image, exercise, seatbelts, bike helmet use, cigarettes/smoking, smokeless tobacco, alcohol, drugs, steroids, sex, sexual orientation, birth control, condoms, HIV, STDs, school, family, future plans, emotions, suicidality, and abuse. Self-report was least accurate for blood pressure/cholesterol screening, immunizations, or for having discussed fighting, violence, weapon carrying, sleep, dental care, friends, or over-the-counter drug use. CONCLUSION: Adolescents' self-report of the care they have received is a valid method of determining the content of preventive health service delivery. Although recall of screening and counseling is more accurate within two to four weeks after preventive care visits, adolescents can report accurately on the care they had received five to seven months after the preventive health care visits occurred. (+info)
The development of a quality information system: a case study of Mexico.
One of the primary obstacles in the implementation of continuous quality improvement (CQI) programmes in developing countries is the lack of timely and appropriate information for decentralized decision-making. The integrated quality information system (QIS) described herein demonstrates Mexico's unique effort to package four separate, yet mutually reinforcing, tools for the generation and use of quality-related information at all levels of the Mexican national health care system. The QIS is one element of the continuous quality improvement programme administered by the Secretariat of Health in Mexico. Mexico's QIS was designed to be flexible and capable of adapting to local needs, while at the same time allowing for the standardization of health care quality assurance indicators, and subsequent ability to measure and compare the quality performance of health facilities nationwide. The flexibility of the system extends to permit the optimal use of available data by health care managers at all levels of the health care system, as well as the generation of new information in important areas often neglected in more traditional information systems. Mexico's QIS consists of four integrated components: 1) a set of client and provider surveys, to assess specific issues in the quality of health services delivered; 2) client and provider national satisfaction surveys; 3) a sentinel health events strategy; and 4) a national Comparative Performance Evaluation System, for use by the Secretariate of Health for the quality assessment of state and provincial health care services (internal benchmarking). The QIS represents another step in Mexico's ongoing effort to use data for effective decision-making in the planning, monitoring and evaluation of services delivered by the national health care system. The design and application of Mexico's QIS provides a model for decentralized decision-making that could prove useful for developing countries, where the effective use of quality indicators is often limited. Further, the system could serve as a mechanism for motivating positive change in the way information is collected and used in the process of ensuring high quality health care service delivery. (+info)