This is the healthcare delivery providers part of the healthcare market place specialization. This is module 1.3.2, Experience of Care, Clinical Quality. The learning outcomes for this particular lesson are that we will understand some of the metrics for this first trip will aim around patient experience of care, and that would be the clinical quality realm. And then we will understand a high level of quality measure framework in the United States. So this is the Institute for Healthcare Improvement, IHI, triple aim paradigm that we have already discussed, and as we've discussed, the clinical quality falls under the patient experience of care domain. And this is where it sits. So let's start by looking at some of the quality measures that are being looked at in the United States. And I want to begin with the ambulatory quality measures. And these are the ambulatory settings. Or the pre-acute settings that come before the acute care hospital. So, for example, the primary care clinics or other clinics that are out in the community. So, let's look at some of those quality metrics. So, the first reporting system that exists is called the Physician Quality Reporting System. There is another system under the Medicare Shared Savings Program. So this is another paradigm that collects many ambulatory sensitive quality measures. Another paradigm that exists is under the electronic health record or information technology meaningful use. And so there are metrics that need to be looked at and reported as part of that meaningful use program. Another program called the Healthcare Effectiveness Data and Information Set, or HEDIS, is a tool that is used by more than 90% of the U.S. Health plans or the insurance plans to measure performance and important dimensions of a clinical quality. So that's HEDIS. So here sits the clinic, primary care clinic, or the physicians office. And these are the various programs or methodologies through which the various clinical quality metrics are reported. And some of the clinical quality metrics that underlie, or lie under these various programs are, for example, the diabetes measures. Diabetes is a medical condition. So there are clinical quality metrics around that that might lie under some of these reporting systems. There might be measures around smoking. There might be measures around depression, or some of the other cancer screening, for example, or many other quality metrics. Another metric might be around medications. So, are the patients taking any high risk medications? There could be immunization status metrics. So, is the patient being given the correct immunization at the correct time? For example, high blood pressure metric might be another one. So a lot of these metrics are mixed and matched between these various programs. Sometimes they might be collected in more than one program. And there is definitely a move trying to standardize the collection of these metrics through these various programs. And lead to an overall program of simplification so that it's easier for the clinics to collect the metrics, report the metrics, and then afford the federal government or other regulatory bodies to look at these metrics in a meaningful way. To look at what is happening across populations, across states, and across the nation. And finally, after all of these metrics have been collected, then there is a customer-facing interface. So in this case it's called the physician compare. It's a website that the government maintains, and all of these metrics are posted. And so the customer Harland Reeves, or his wife, or his daughter or son, if interested, they could go to this website and look at all of these metrics for their particular clinic. So that's the point of this, to make it very transparent to the end user. A very similar paradigm exists for the hospital quality measures. So here again, here is the hospital. And what might be measured, one program of measurement is called the value based purchasing through the Centers for Medicare and Medicaid services. Another program is how to reduce readmissions. Another program is the hospital acquired infections, or HAI Reduction. Similarly there's a Meaningful Use program which has to do with information technology for the hospitals. So these are all in patient. And then also, for the hospital based outpatient clinic, there's a whole separate quality reporting measure and a program. So here are some of the measures that underlie some of these programs. So, mortality. 30 day readmissions. Here's an infection called a central line associated bloodstream infection. Here's another infection, catheter associated urinary track infection. And there are numerous such clinical quality measures that lie under these various programs. And again, there is simplification and standardization, and a development of an overall plan or a map of what should be collected, what is in stable state and should be retired, what equality improvements are needed, and how can regulatory bodies system themselves start to make sense of these numerous clinical quality measures. So, there are many more electronic health record measures as well, some of them are directly electronically reported. Some of them have to be abstracted from the chart and then reported manually to the various regulatory and federal bodies. And again, after all of these are collected, then there is a customer facing view so that the end customer is able to look at this matrix and judge what their hospital's quality condition or quality control Is like. This time, let's take a short quiz. Let's keep looking at some of the other quality metrics. Now, we've talked about the ambulatory and pre-acute setting. We did talk about the acute care hospital, and let's look quickly at the post acute quality measures. So again, here is the skilled nursing facility or transitional care unit or home health care or hospice, and these are some of the measurement systems that are in place. So nursing home quality reporting, home health quality reporting, hospice quality reporting, inpatient rehabilitation facility quality reporting. And underneath all of these there are various measures, just like in the hospital and the clinics. Sometimes they may or may not align with each other and there's work happening to do that. And all of these metrics then are reported. Now, one of the things that I wanted to draw your attention in each of the previous three slides is what happens after these metrics are reported. So as discussed previously, these metrics are reported, and then through a customer facing website, the nursing home compare, they are visible to the patient and the family. So they can judge what their post acute nursing home, home health quality condition and quality control is like. So here's a very high level look at the quality measurement framework across the US, and it's extremely complicated but I'll try to make it a little simple. So here's one particular system that has a hospital, a primary care clinic, maybe a surgery center, maybe a nursing home. And there is the federal government, so CMS, and the federal government that will be looking at quality metrics that flow from all of these to the federal government. So, here is a central corporate body that collects all of these metrics and sends them on to the federal government. Now there might be another body, for example, a payer, that might be interested in these same quality metrics. So what the system, this particular system could do, is that they could also divert those quality metrics and report them to this particular pair. Now, let's say this is payer one. There could also be another payer, payer two, insurance company that wants to also look at these metrics. So let's say this corporate body also sends it to that particular payer. Now, here is a state agency, or the state government, that also wants to look at some of these quality metrics. So again, this body sends those metrics to the state as well. Now, as you can imagine, the more coherence between these quality metrics there is, the more effective this body will be. So if the metrics for CMS do not align with the metrics for state or the payers that the system is working with, then this particular body over here is going to become quite distraught, and it'll have to start collecting many, many, many hundreds and thousands of metrics. So there's working happening to try to bring coherence, or standardization, across these metrics, so that what the payers, the regulators, the federal government, the state government, are looking at is much more standardized. And much of this work falls under the category of administrative simplification. There's also pay for performance concepts in the US, which means that a quality measurement is done. It is reported to a payer, either governmental, federal, state, or local commercial. And based upon that, there are rewards that are shared with the delivery system, for example, the hospital or the clinic. And both carrots, so there's rewards, or sticks, so there are withholds. So let's say X amount was supposed to be paid in incentive payments to the hospital. They did not meet the quality metrics, so a certain percentage of that money is withheld and the hospital is paid less amount. So that's a stick approach to quality reward and penalties. In summary, clinical quality metrics are one very important component of the experience of care triple aim. And there's an extremely complex system of quality measurement reporting, and also rewards and penalties, that exists in the United States. And it is being continuously looked at for administrative simplification, and to get the most value out of this quality measurement.
