Measuring the quality of health care

This Issue Brief examines some of the issues involved in defining and measuring the quality of health care and in implementing quality measures. It discusses the importance of measures of health care quality in the evolving health care delivery system, examines some of the conceptual issues involved in defining quality of care, and discusses some of the measures of health care quality and how these measures have been implemented in the health care delivery system. The major impetus for quality assurance programs is cost management: it is an attempt to allocate scarce health care resources efficiently. This requires making choices among alternatives, which may mean that maximizing quality of care for whole populations may not maximize the quality of care for individuals. Quality, in terms of any single good or service, has a number of dimensions. Health care is a complex bundle of services, and each component service within an episode of care affects the other components and the patients differently. Moreover, patients differ in numerous ways, which means that similar symptoms may require different services if care is to be effective. Measuring quality of health care services requires accounting for all of these factors. In attempting to manage health care costs, employers and other private health plans have begun to employ process measures of quality, i.e., evaluating caregivers' activities, the decisions made at each step in an episode of illness, and the appropriateness of the care provided. Process is an important component of quality measures because it focuses directly on the uncertainty in the efficacy of treatment. Given this uncertainty, the logic of medical decision making is an important determinant of quality and cost effectiveness. Examining the process of care involves assembling a panel of physicians who review medical records to determine the appropriateness of the care received. Providers have increasingly found that their medical decision making and practice styles are being monitored by purchasers as new health care delivery systems are being formed. The American Medical Association found that 39 percent of surveyed physicians were subject to clinical profiling.     

Providing nursing leadership in a community residential mental health setting

The worldwide burden of mental illness is increasing. Strong leadership is increasingly emerging as a core component of good mental health nursing. The aim of this article is to demonstrate the ways in which nurses can provide strong and consistent leadership in a values-based practice environment that embodies respect for individuals' dignity and self-determination within a community residential mental health service, which provides a structural foundation for effective action. This is accomplished through the presentation of two vignettes, which highlight how the seemingly impossible becomes possible when an economic paradigm such as agency theory is exchanged for a sociological and psychological paradigm found in leadership as stewardship at the point of service. It is through stronger nursing leadership in mental health that stigma and discrimination can be reduced and better access to treatments and services can be gained by those with mental illness. Nurse leadership in mental health services is not new, but it is still relatively uncommon to see residential services for "high needs" individuals being led by nurses. How nurses meet the challenges faced by mental health services are often at the heart of effective leadership skills and strategies.     

Measuring organizational health in child welfare agencies

In recent years, federal funds have been directed toward programs to improve the organizational health and functioning of public and tribal child welfare agencies. This study introduces a battery of instruments aimed at holistic measurement of organizational health factors in public, private, and tribal child welfare agencies. The Comprehensive Organizational Health Assessment (COHA) was designed as part of a federally funded grant to aid development of organizational interventions in child welfare settings. Assessment results are used diagnostically to identify strengths and challenges and to guide the development of targeted systems-change interventions and to track change over time. This study describes the iterative process of developing and testing the measurement tools, including results from exploratory and confirmatory factor analyses. The final, revised set of measures includes 20 scales and 3 indices measuring aspects of individual, work unit, and organizational functioning.     

Preference for same-race health care providers and perceptions of interpersonal discrimination in health care

This article examines black Americans' preference for black health care providers. Using data from a national survey, we assess how blacks 'perceptions of discrimination are related to preference for same-race health care providers. Overall, the belief that discrimination is frequent in different-race doctor-patient dyads is associated with greater preference for a same-race provider However; the belief that discrimination occurs regardless of a doctor's race reduces preference for a same-race provider Finally, general perceptions of discrimination are distinct from concerns about personally being treated unfairly, and low personal concern about unfair treatment reduces preference for a same-race provider among those who believe that interpersonal discrimination occurs frequently. These results suggest a complex picture of how perceptions of discrimination influence preferred race of health care provider among blacks in the United States.     

Risk management issues in postmenopausal health care

As in other areas of clinical activity, unintended harm to patients may occur in the course of postmenopausal health care, and measures to ensure patient safety should be actively promoted. This paper discusses the application of some basic principles of risk management to postmenopausal health care. To facilitate communication and reduce errors in diagnosis and treatment, risk management should be incorporated in the development of a dedicated menopause service.     

Family health care decision making

How do families choose a health plan when offered the option of insurance or a Health Maintenance Organization (HMO)? Choices are influenced by health consumerism, decision variables, family health needs, family composition, family socioeconomic status, and knowledge about HMOs. Subjects in the research reported here chose insurance or one of four HMOs; control subjects had no HMOs available. The model is estimated with LOGIT regression, yielding a pseudoR ² of.22 for the adjusted model. Participation in the decision process, number of chronic illnesses, and knowledge about HMOs all are significantly and positively associated with choosing an HMO; also, young adults are more likely than older adults to choose HMOs. The consumerism variable fails to attain significance. LOGIT analysis of the adjusted model indicates that the model predicted 72% of plan choices correctly. Suggested research for other family forms, for the poor, and for the elderly's health plan choices are discussed.     

Medicare and health care reform

Although Medicare constitutes one of the most popular programs of the federal government, even its most ardent supporters would likely agree that improvements could be made and likely should be part of any package of comprehensive health care reform. While some changes could be made as stand-alone reforms, it would be better to integrate changes for the under 65-population with those for the Medicare program. For example, cost-containment strategies would work best if they applied to the population as a whole rather than creating differences that lead to cost-shifting and possible discrimination across groups. The generosity of services covered also ought to be balanced between Medicare and whatever happens elsewhere. This would allow Medicare's cost-sharing structure to be less severe in terms of hospital and skilled nursing care, for example. Finally, while it is tempting to use reductions in spending on Medicare as a means for helping to finance other expansions, the impact of such changes needs to be carefully assessed before assuming that they would create no lasting problems. This essay examines some of the options and likely consequences for Medicare as part of comprehensive health reform.