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NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

Healthcare Outcome Measures Explained

There are hundreds of outcome measures, ranging from changes in blood pressure in patients with hypertension to patient-reported outcome measures (PROMs). The seven groupings of outcome measures CMS uses to calculate hospital quality are some of the most common in healthcare:NURS 6231 – Healthcare Systems and Quality Outcomes Case Study


#1: Mortality

Mortality is an essential population health outcome measure. For example, Piedmont Health care’s evidence-based care standardization for pneumonia patients, resulted in a 56.5 percent relative reduction in the pneumonia mortality rate.

#2: Safety of Care

Safety of care outcome measures pertain to medical mistakes. Skin breakdown and hospital-acquired infections (HAIs) are common safety of care outcome measures:

Skin breakdown—happens when pressure decreases blood flow to the skin. A skin assessment tool can be used to reduce skin breakdown. Patients with skin breakdown are at a higher risk of infection. Patients’ risk scores go up if they’re diabetic, for example, because their circulation is poor.
HAIs—caused by viral, bacterial, and fungal pathogens. For example, Texas Children’s Hospital identified evidence-based bundles to reduce HAIs in children through their partnership with the Solutions for Patient Safety National Children’s Network. Using an enterprise data warehouse (EDW) and analytics applications to identify vulnerable patients and monitor clinicians’ compliance with best practice bundles, Texas Children’s Hospital decreased HAIs by 35 percent.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

#3: Re admissions

Readmission following hospitalization is a common outcome measure. Readmission is costly (and often preventable). In fact, researchers estimate that in one year, $25 to $45 billion is spent on avoidable complications and unnecessary hospital readmissions. After increasing efforts to reduce their hospital readmission rate, the University of Texas Medical Branch (UTMB) saw a 14.5 percent relative reduction in their 30-day all-cause readmission rate, resulting in $1.9 million in cost avoidance. UTMB reduced their hospital readmission rate by implementing several care coordination programs and leveraging their analytics platform and advanced analytics applications to improve the accuracy and timeliness of data for informing decision making and monitoring performance.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

#4: Patient Experience

Patient-reported outcome measures (PROMs) fall within the patient experience outcome measure category. According to the Agency for Clinical Innovation (ACI), PROMs “assess the patient’s experience and perception of their healthcare. This information can provide a more realistic gauge of patient satisfaction as well as real-time information for local service improvement and to enable a more rapid response to identified issues.” For example, a patient might be asked to complete a satisfaction survey (on a scale of 1-5) about the care they received.

Patient experience may also be used as a balance metric for improvement work. For example, a care delivery process may decrease the LOS, which can be a positive outcome, but result in a decreased patient satisfaction score if patients instead feel they are being pushed out.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

#5: Effectiveness of Care

Effectiveness of care outcome measures evaluate two things:

Compliance with best practice care guidelines.
Achieved outcomes (e.g., lower readmission rates for heart failure patients).

Given the rapid changes that occur within healthcare, making sure best practice care guidelines are current is critical for achieving the best care outcomes. It’s important to track clinician compliance with care guidelines; It’s equally important to monitor treatment outcomes and alert clinicians when care guidelines need to be reviewed.

Failing to adhere to evidence-based care guidelines can have negative consequences for patients. For example, according to The Dartmouth Atlas of Healthcare, “even though it is well established that beta-blockers can reduce the risk of heart attack in patients who have already had one heart attack, many heart attack patients are never prescribed beta-blockers.”NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

#6: Timeliness of Care

Timeliness of care outcome measures assess patient access to care. Overcrowding in the emergency department has been associated with increased inpatient mortality, increased length of stay, and increased costs for admitted patients.

A community hospital system implemented an improvement process to address overcrowding in its ED after determining that approximately 4,000 patients were leaving its ED each year without being seen. They leveraged their analytics platform to develop an ED analytics application that provided actionable, timely ED performance data to focus improvement efforts on four areas: staffing patterns, registration, triage assessment by the registered nurse, and early access to a qualified medical provider. They achieved significant performance improvements, including an 89 percent relative reduction in the rate of patients that left without being seen, with current performance at 0.4 percent.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

The efficient use of medical imaging is an increasingly important outcome measure. According to the European Science Foundation, “Medical imaging plays a central role in the global healthcare system as it contributes to improved patient outcome and more cost-efficient healthcare in all major disease entities.”

For example, during Texas Children’s Hospital’s efforts to improve asthma care it discovered a high volume of chest X-rays being administered to asthma patients. Using its EDW to examine real-time X-ray data, it realized clinicians were ordering chest X-rays for 65 percent of their asthma patients—evidence-based practice calls for X-rays in only five percent of cases. Texas Children’s Hospital’s IT team traced the problem to a faulty order set within the hospital’s EHR, and rewrote the order set to reflect the evidence-based best practice.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

Process Measures Are Equally Important

Achieving outcomes is important, but the process by which health systems achieve outcomes is equally important. Process measures capture provider productivity and adherence to standards of recommended care. For example, if a health system wants to reduce the incidence of skin breakdown, then it might implement the process measure of performing a risk assessment using the Barden Scale for reducing pressure ulcer risk in all the appropriate units in the hospital. If health systems are too focused on an outcome, then they lose sight of the process.

The following outcome and process measures illustrate how systems can improve healthcare outcomes by improving processes:NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

Conducting a medication reconciliation system check with heart failure patients at the time of discharge (process measure) can reduce heart failure readmission rates (outcome measure).
Performing a fall risk assessment on a patient at the time of admission (process measure) can reduce fall rates (outcome measure).
Using a skin assessment tool (process measure) can prevent skin breakdown (outcome measure).

Three Essentials for Successful Healthcare Outcomes Measurement

Among every health system’s goals is to improve patient outcomes. But outcomes improvement can’t happen without effective outcomes measurement. As health systems work diligently to achieve the Quadruple Aim, they need to prioritize three outcomes measurement essentials: transparency, integrated care, and interoperability.

Used in tandem, these essentials improve and sustain outcomes measurement efforts by creating a data-driven culture that embraces data transparency, an integrated care environment that treats the whole patient and improves critical care transitions, and interoperable systems that enable the seamless exchange of outcomes measurement data between clinicians, departments, and hospitals.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study


#1: Data Transparency

Healthcare is on a journey to outcomes transparency. Patients rely on outcomes data to make educated decisions about their healthcare. Quality reporting organizations, such as The Leap Frog Group, evaluate and report on U.S. hospital safety and quality performance. Patients want reassurance that they’re receiving the best care for the lowest cost. Publicly reported healthcare outcomes help do just that.

#2: Integrated Care and Transitions of Care

The industry is also shifting toward integrated care—hospitals aren’t just treating a hip anymore; they’re treating the whole person. A key component of integrated care is helping patients with transitions: easing patient transitions from the ER, to surgery, to inpatient care, to rehab, and, ultimately, back to a steady, normal state. Transitional points of care are critical for managing consistency of care and providing the right care in the right setting at the lowest cost.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

#3: Data Interoperability

Sharing data between departments within an integrated system is another important component. Outcomes measurement and improvement depends on the system’s ability to share data across clinicians, labs, hospitals, clinics, pharmacies, and other staff, departments, and settings. EDWs improve interoperability by integrating data and providing a single source of truth.

Improving critical care transitions through integrated care and seamlessly exchanging data through interoperability are essential ingredients for better outcomes measurement. For example, as heart failure patients are discharged (depending on the risk stratification), it’s critical for them to see a cardiologist or primary care physician as quickly as possible. Otherwise, they have a higher risk of being readmitted.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

The Quadruple Aim: The Goal of Outcomes Measurement

Outcomes measurement should always tie back to the Quadruple Aim, so healthcare organizations aren’t just reporting numbers. Health systems shouldn’t become so obsessed with numbers that they forget their Quadruple Aim goal. Instead, they should focus on quality and improving the care experience at the most efficient cost. 

Health systems measure outcomes to ensure they are delivering the best care for patients and providing a transparent, efficient, and accessible environment for all healthcare providers. That is outcomes nirvana.

Policies to improve population health have often focused exclusively on the expansion of access to basic health services, to the neglect of quality of care. Efforts to increase the demand for priority interventions have implicitly assumed that the care available is of sufficient quality or that, with the expansion of coverage, quality will naturally improve.1 However, such assumptions may be incorrect. There is growing recognition that people may be acting in a perfectly rational way when they avoid using health services of poor quality and that poor quality of care can be a barrier to universal health coverage independent of access.2NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

The aim of many strategies to improve health-care quality has been to ensure that essential inputs – e.g. technology, operational facilities, pharmaceutical supplies and trained health workers – are in place.3 Many such strategies have focused on the supply side and been designed to support the provision of services according to clinical guidelines.4 The acknowledgement that quality improvement approaches should be applied within patient-centered models of care is relatively recent.5

In this paper we seek to unpack complexities around quality of care and identify strategies for improving the measurement of such quality. An understanding of these issues could inform pragmatic strategies for the analysis and measurement of quality of care. We draw on research conducted in a variety of low- and middle-income countries and identify areas of inherent complexity that require further in-depth research. In doing so, we reflect on what is meant by quality of care and how perceptions and understanding of quality of care influence health systems and effect the measurement of quality.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

We have identified and structured our discussion around six conceptual and measurement challenges. First is the recognition that, even though they may not reflect actual quality, perceptions of the quality of care are an important driver of care utilization. Second, a patient’s experience of quality must be conceptualized as occurring over time. Third, responsiveness to the patient is a key attribute of quality. Fourth, so-called upstream factors – e.g. management at facility and higher levels – are likely to be important for quality. Fifth, quality can be considered as a social construct co-produced by different actors. Finally, there are substantial measurement challenges that require the adaptation and improvement of current approaches.

The classic framework on quality of care developed by Donabedian makes the distinction between structure, process and outcomes.6 More recently, the Institute of Medicine in the United States of America (USA) has unpacked the concept further and suggested that efforts to improve care quality should be focused around six aims: effectiveness, efficiency, equity, patient-cent redness, safety and timeliness. We do not seek to propose a new framework for understanding quality. Rather, we highlight some key issues that deserve more consideration in debates about enhancing the accessibility and quality of care. Building on our experiences of doing empirical research in low- and middle-income countries, we present several insights that are complementary to existing, comprehensive frameworks of quality of care and may be absent from current debates.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

Clinical quality

Clinical quality of care relates to the interaction between health-care providers and patients and the ways in which inputs from the health system are transformed into health outcomes. The care provided should be effective, evidence-based and neither underused nor overused.7 The concept of clinical effectiveness tends to shift attention away from inputs such as drugs and equipment and towards the process of care.6,8 While relatively easy to measure, the availability of inputs cannot generally be used in isolation to determine if a patient’s health is likely to improve as a result of the care received.9 Clinical processes are directly attributable to the behaviour of health-care providers and their measurement can provide a critical starting point in the development of methods to improve care received by patients. Although health outcomes can be informative, they are only likely to be a crude measure of quality because of the inherent unpredictability in patients’ responses to health care.9NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

Assessment of the clinical quality of care poses several conceptual and practical challenges. It requires a strong evidence base that can act as a benchmark against which to evaluate interventions. In high-income countries, treatments received can be compared with the treatments recommended in national guidelines. In many low- and middle-income countries, however, such guidelines are either not available or poorly enforced. Even when such guidelines are present, the evaluation of what constitutes the over provision of care is not clear-cut and requires careful judgement. Although harmful care should be distinguished from unnecessary care, such categorization can be difficult in practice. Care for a single patient may be provided over the course of numerous interactions by a large team of health professionals. In such circumstances, measurement of the quality of care often focuses on a small number of distinct interventions with proven efficacy.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

There are several well-known practical challenges to the assessment of the clinical quality of care. For example, it may not be possible to observe the interactions between patients and their physicians and, when they are possible, such observations can generate bias through the Hawthorne effect, i.e. health-care providers change their behaviour when observed.10 In low- and middle-income countries, medical records are often poorly maintained and may not reflect actual practice. The use of so-called undercover or standardized patients in the assessment of clinical care may raise ethical concerns,11 is generally limited to non-invasive conditions12 and is not a practical solution to the routine measurement of quality.9 Despite these challenges, an influential literature on the clinical quality of care in low- and middle-income countries is emerging.2,13NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

Perceived quality

Attempts to improve the quality of care have often been underpinned by a biomedical understanding of quality – i.e. the conceptualization of a gold standard of quality guided by clinical guidelines – that can lead to a narrow focus. Provider practices tend to vary despite the existence of accountability procedures and guidelines.14 Interventions may not be implemented as intended or easily accommodated within established models of care.15 Clinical quality is important for patient outcomes but perceptions of the quality of care – which may not correlate with actual quality – are likely to be the key drivers of utilization.16,17 Patients may also find it difficult to evaluate the quality of care because they lack their physician’s medical expertise and training.18,19

In South Africa, a key motivating factor in patients’ travel to access health services – including travel across borders – was found to be the patients’ perceptions of the quality of health services.20 Patients may sometimes believe an ineffective and unsafe treatment to be good, even when they have access to effective and safe treatments. In Malaysia, for example, many people with hypertension seek potentially ineffective and unsafe treatments from traditional practitioners.21 Perceptions of the quality of care are based on a mix of individual experience, processed information and rumor. In Uganda, perceptions of the quality of the care that was locally available were found to have persuaded many women to seek maternal care away from their local area – apparently regardless of the availability of transportation and the distances involved.22 In Bangladesh, despite a nationwide expansion in the network of health facilities, facility-based deliveries remained rare and most women still attempted to give birth at home or, in the case of complications, at distant periurban health cent res that the women believed to offer care of higher quality than that available at the community facilities closest to their homes.23,24 Patients’ trust in services has been shown to be an important element of perceived quality.25NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

Perceptions of the quality of care may relate entirely to non-clinical factors. For example, criminalized or marginalized populations – e.g. some ethnic or sexual minorities – may judge the quality of care only according to the extent that the care environment is non-discriminatory or supportive.26 In Zambia, many patients considered public-sector clinics supported by one particular nongovernmental organization to be better than other public-sector facilities that apparently provided the same standardized package of care.27

The effect of perceived quality is not limited to delivery models. Among remote rural populations in Armenia, there was disappointingly low participation in community-based health-insurance schemes because the quality of the care provided by the schemes was perceived to be low. Despite the often high out-of-pocket costs, most people in the communities covered by the schemes preferred to use district-based clinics and hospitals – where they believed the quality of care to be higher than in the facilities covered by the schemes.28 Although quality is a construct largely based on individual subjective perceptions, such perceptions are shaped by collective and traditional beliefs and peer influences. While improving or, at least, maintaining the actual quality of the care they provide, health systems need to address – and ultimately close – the gap between perceived and actual quality.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

Quality as a process

There is a temporal dimension to both clinical and perceived quality. Although the Donabedian framework recognizes the importance of understanding the process of care,6,8 the quality of care may often be assessed in just a single encounter or illness episode. However, individual treatment for most diseases is not a one-off event but a succession of treatment episodes. Patients’ perceptions of quality may develop over time, as the different attributes of the services available and their outcomes are revealed. Waiting times and staff attitudes may be perceived rapidly. However the patient’s experience of clinical treatment, e.g. surgery, and its implications for subsequent care, e.g. frequent check-ups, and health outcomes, e.g. potential complications, may carry on developing over months or years. Patients may only become sensitized to the benefits of having a dedicated provider and effective follow-up after they experience the absence of such benefits. Easy-to-navigate pathways to care and continuity are critical to how patients perceive the quality of care and choose whether to continue treatment or not.29 Long-term compliance is only likely if the patients involved consider their care to be of good quality. Such compliance is a particular challenge in the monitoring and treatment of chronic noncommunicable diseases and human immunodeficiency virus, especially for the under-resourced health systems of low- and middle-income countries.30–33NURS 6231 – Healthcare Systems and Quality Outcomes Case Study


While The World health report 2000. Health systems: improving performance34 defined responsiveness to people’s non-medical expectations as a key health-systems goal, the relationship between responsiveness and quality has rarely been discussed. Although ability to book an appointment, confidentiality, privacy, respect shown by staff and waiting times are not service attributes that are clinically necessary, they may all influence patients’ perceptions and their willingness to return for – or adhere to – treatment. At a broader level, responsiveness involves respect for cultural needs and the preferences of specific patient groups – e.g. ethnic, gender and sexual minorities and migrants. The relationship between health workers and their patients often develops over time and multiple episodes of care. As levels of trust and mutual understanding increase, responsiveness and the patients’ perceptions of the quality of their care often improve.35

Although responsiveness to need is often consistent with good clinical practice, it represents an added layer in the patients’ perceptions of quality. In one South African study, women appeared to have been given greater access to public maternity wards but it was the verbal abuse that the women often suffered on such wards that largely shaped the women’s poor perceptions of the care that they had received.36NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

Upstream factors

The patient–provider interaction is likely to be influenced by governance and management practices at national, sub national and facility levels. The results of studies in the United Kingdom of Great Britain and Northern Ireland and the USA have demonstrated the key importance of management in ensuring care of high quality.37 In low- and middle-income countries, however, there appears to have been little consideration of the role of management practices – especially at district or facility level – in influencing the quality of care. There is increasing recognition that health professionals do not act in isolation and that governance, management and structural factors also determine the performance of health systems.38,39NURS 6231 – Healthcare Systems and Quality Outcomes Case Study


Even when front line providers do have substantial discretion in their interpretation of regulations and freedom to adapt treatment protocols, their actions may still largely depend on upstream factors related to institutional capacity, legal sanctions and professional norms. A study of tuberculosis cases in Samara, in the Russian Federation, revealed that while entry to the care system was relatively easy and formally free and pharmaceuticals were highly subsidized, some cases from marginalized groups – e.g. former prisoners, migrants and people not registered with the authorities – still avoided treatment because of perceived discrimination, loss of social status and stigma.40 Both behavioral and structural factors can be important when assessing perceived quality of care.

Quality as a social construct

Assessment of quality of care in low- and middle-income countries is frequently conducted at the individual level by using various tools – e.g. clinical observations, exit and in-depth interviews, extraction of medical records, role-playing vignettes and standardized patients, designed to assess both patients’ experiences and technical quality. However, social networks influence perceptions relating to both health services and illness.41 Therefore, for a comprehensive investigation of the development of the general public’s and patients’ perceptions of the quality of care, we need to examine community and family values.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

In many situations, patients may have responses to a health provider’s actions and, similarly, providers may adapt their responses to patients to suit social norms.42 For example, a patient may be recommended a clinical investigation and they may either agree to be investigated – e.g. if the proposed investigation is offered by a provider trusted by the patient’s social network – or they may exit the system and seek care elsewhere, e.g. from a more trusted traditional practitioner. Such responses may be considered as a social relationship that can happen in formal care settings, or elsewhere.

Perception of quality can also be shaped by power relationships in society. In a study in the Russian Federation, the women most likely to undergo pregnancy-related procedures were found to be the relatively young and poorly educated. Although such women were relatively poor and therefore found it particularly hard to pay for their care, they appeared to be given little choice – possibly because of their relatively low social status and inability to negotiate care that was commensurate to their needs.43 Similar discrepancies between what health professionals felt would improve the quality of care for non-compliant patients and those patients’ preferences and wishes were observed in a study of tuberculosis cases in India. In that study, the number of treatment choices offered was found to be positively correlated with social status.44NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

Measurement challenges

In light of the above discussion, there is a case for taking a broader perspective when measuring quality of care. Although this has been recognized by the World Health Organization’s monitoring framework for universal health coverage45 – which considers effectiveness of treatment, patient safety, people-cent redness and the level of integration of health services as key dimensions – the focus of recent assessments of the quality of care has been on indicators of health-service coverage.45,46

We suggest that, for a comprehensive and detailed assessment of the quality of health services, both clinical and perceived quality of care need to be evaluated and then compared (Box 1). Alongside technical measures of quality, attention should be given to manifestations of quality – e.g. acceptability, cultural appropriateness and responsiveness. Strategies to improve clinical quality only have the potential to increase demand for care if the general public’s perceptions of the quality of the care available also improve.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

Box 1. Principles for measuring the quality of health care

Measure aspects of care that go beyond technical quality, e.g. responsiveness, acceptability and trust.
Measure perceived quality and compare with clinical quality.
Measure quality at different points in the patient pathway through the health system.
Measure the immediate and upstream drivers of quality of care.
Measure collective and individually assessed quality and its relationship to power, social norms, trust and values.

Any evaluation of the overall quality of care needs to consider a patient’s experience of quality as a cumulative process. Changing patterns of illness and increasing numbers of treatment options mean that an increasing amount of health care involves a sequence of interlinked contacts – with a range of health professionals at different levels of the health system – over a lengthy period.47 A patient’s perceptions may vary widely as treatment follows diagnosis and follow-up follows treatment, with each stage potentially affecting the patient’s subsequent choices. By measuring clinical and perceived quality at each key step in this continuum of care, it should be possible to generate a better, more nuanced understanding of how patients interact with health systems.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

A growing body of work focusing on measures of patients’ perceptions now exists. To understand these perceptions more holistically, qualitative methods need to become an integral part of quality assessments. In such assessments, theory-driven hierarchical models can be useful in generating propositions to guide empirical research or help deepen interpretation.48 Mid-range program me theories48 and open-box evaluations49 have also been useful in examining why and how particular health program mes work. Although the measurement of indicators that are rapidly observed by patients seeking care – e.g. staff attitudes and waiting times – can be useful, it is important to delve deeper and study how upstream factors, such as management practices, matter – e.g. by influencing staff morale. Use of carefully selected proxies for quality of care and comparison of findings generated through different methods may help to inform pragmatic intervention strategies.

Finally, assessment of individual perceptions of the quality of care and examination of how such perceptions are rooted in community, family and societal expectations, norms and values may offer a promising way forward. Perceived quality may correlate closely with the expectations and social status of the users themselves, the circumstances in which the users obtain care and/or the levels of community cohesion and resources that enable collective action. Although the inclusion of contextual variables and appropriate units of observation for studying community and social group-level characteristics may be methodologically challenging, it is important for understanding individual choices and perceptions.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study


Recognition of the multifaceted nature of the quality of care is critical for scaling up priority health interventions. If uptake of health services is to be increased, we require not only better technical quality but also better acceptability and patient-cent redness – across the continuum of care. Perceptions of quality are shaped by interconnected community, health-system and individual factors. Moreover, quality of care cannot be understood fully without some appreciation of the social norms, relationships and values and trust within the communities and societies where care is provided.

What is Quality of Care and why is it important?

Due to focused global advocacy, many countries have made progress in increasing the proportion of pregnant women who give birth in a health facility. However, this increase in coverage often has not translated in the expected reduction of maternal and newborn mortality and stillbirths. This is due to inadequacies in the quality of care provided in health facilities.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

Quality of care vital for further reductions in mortality

Health facilities often struggle to provide the rapid emergency care needed to manage maternal complications and care for small and sick newborns. Common causes include inadequate or unhygienic infrastructure; lack of competent, motivated staff; lack of availability or poor quality of medicines; poor compliance to evidence-based clinical interventions and practices; and poor documentation and use of information. Improving quality of care and patient safety are therefore critical if we want to accelerate reductions in maternal and newborn mortality.

Quality of care is also a key component of the right to health, and the route to equity and dignity for women and children. In order to achieve universal health coverage, it is essential to deliver health services that meet quality criteria.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

How do we define quality of care?

On the basis of several definitions in the literature, the WHO definition of quality of care is “the extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centered.”

Safe. Delivering health care that minimizes risks and harm to service users, including avoiding preventable injuries and reducing medical errors.

Effective. Providing services based on scientific knowledge and evidence-based guidelines.

Timely. Reducing delays in providing and receiving health care.

Efficient. Delivering health care in a manner that maximizes resource use and avoids waste.


Equitable. Delivering health care that does not differ in quality according to personal characteristics such as gender, race, ethnicity, geographical location or socioeconomic status.

People-centered. Providing care that takes into account the preferences and aspirations of individual service users and the culture of their community.

Types of Health Care Quality Measures

Measures used to assess and compare the quality of health care organizations are classified as either a structure, process, or outcome measure. Known as the Donabedian model, this classification system was named after the physician and researcher who formulated it.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

Structural Measures

Structural measures give consumers a sense of a health care provider’s capacity, systems, and processes to provide high-quality care. For example:

Whether the health care organization uses electronic medical records or medication order entry systems.
The number or proportion of board-certified physicians.
The ratio of providers to patients.

Process Measures

Process measures indicate what a provider does to maintain or improve health, either for healthy people or for those diagnosed with a health care condition. These measures typically reflect generally accepted recommendations for clinical practice. For example:

The percentage of people receiving preventive services (such as mammograms or immunizations).
The percentage of people with diabetes who had their blood sugar tested and controlled.

Process measures can inform consumers about medical care they may expect to receive for a given condition or disease, and can contribute toward improving health outcomes. The majority of health care quality measures used for public reporting are process measures.

Outcome Measures

Outcome measures reflect the impact of the health care service or intervention on the health status of patients. For example:

The percentage of patients who died as a result of surgery (surgical mortality rates).
The rate of surgical complications or hospital-acquired infections.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

Outcome measures may seem to represent the “gold standard” in measuring quality, but an outcome is the result of numerous factors, many beyond providers’ control. Risk-adjustment methods—mathematical models that correct for differing characteristics within a population, such as patient health status—can help account for these factors. However, the science of risk adjustment is still evolving. Experts acknowledge that better risk-adjustment methods are needed to minimize the reporting of misleading or even inaccurate information about health care quality.

Which Type of Outcome Measure Do You Need?

I was recently in a conversation about the measurement tools used to determine a patient’s functional ability. Mark Werneke shared an article that was published a few years ago to help me better understand the types of measurements available.

I’ve decided that when it comes to learning the outcomes of your care, you first need to know what it is that you plan on doing with the data.

Let’s say you need to know what seems to improve quality of life more: surgical intervention or rehabilitation services? Or do you want to compare quality of life improvement of a community based program to an outpatient service? General health related quality of life measures  will be your first choice. Now there is a down-side to this kind of measure. Based on the name of this measure, realize it is very general in nature.  The improvement that you see through your services may not actually be fully captured by this type of measure. Typically this measure has multiple components of health. The measure may include physical function, mental status, social well-being, pain, co-morbidity and emotional status. In other words it considers aspects within the various entities defined in “health.”NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

If you need to compare options based on what changes for the patient in terms of quality of life and the length of life, then you need a health utility measure. A health utility measure seems quite broad in nature and from my perspective provides a snap shot of the patient’s life. It seems bare minimum when thinking about all the things a body can potentially do. In other words, it seems to focus on the bare minimum requirements of function. The goal of a health utility measure is to calculate the cost associated with various procedures and to compare the quality-adjusted life years from an economical perspective.

In the musculoskeletal world, you can choose an outcome measure for a defined joint. In the below article, the focus is on the shoulder. Although the article mentions the measurements as “general,” to me they are joint specific measurements. The joint specific measurements mentioned are not wholly focused on functional ability. The measurements shared may include some objective examination findings along with capturing pain level and even satisfaction. Because these measurements include more than just a patient’s self-report of function, the tools really aren’t completely focused on functional ability. The measures are used to capture change. If you need an outcome measure to capture the change that occurred, when you choose the measure, you also need to know the psychometric properties. You want to know the validity, reliability and the responsiveness to change. Another important factor to know is the minimum clinically important difference (MCID). This is important because a change in score outside of the MCID indicates change that is relevant to the patient (positively or even negatively).NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

The last type of outcome measure to consider in the musculoskeletal world is a condition specific measure. Examples of condition specific measures for the knee are the Western Ontario and Master Universities Osteoarthritis Index and  Lysholm Knee Scoring Scale. The abstract shares a few specific to the shoulder. The condition specific measures may not be completely focused on function. The condition specific measures may bring the special symptoms or patient complaints into the measure. It seems the majority of condition specific musculoskeletal measures were designed with surgeons in mind – to capture the before and after patient presentation. In other words, it seems to me the condition specific measures help answer the question of whether the surgical intervention resolved the patient’s symptoms and complaints. I don’t know if the measure is better than a joint specific measure or not.

The abstract introduced the concept of computer adaptive testing (CAT) as the final option. The example provided was Patient-Reported Outcomes Measurement Information System (PROMIS). You can try the PROMIS  CAT here. Although the article mentions an upper extremity CAT, the demo page does not have that as an option and only has the physical function CAT. This CAT is a general CAT, meaning it is not joint specific and is focused on general physical function. Take the CAT and you’ll see.NURS 6231 – Healthcare Systems and Quality Outcomes Case Study

FOTO has research supporting its shoulder functional status items and computer adaptive testing.  In 2006, the number of items originally tested was 60.  Factor analysis only supported 42 of the items.  The item pool was decreased to 37 items to fit the item response theory model.  Pretend you have a shoulder problem and take FOTO’s shoulder CAT. You can compare and see the difference between the general PROMIS CAT and the joint specific shoulder CAT that FOTO offers.


Health outcomes are changes in health that result from measures or specific health care investments or interventions.

Health outcomes include

Preventing death after a heart attack through in-hospital care NURS 6231 – Healthcare Systems and Quality Outcomes Case Study
Improvements in a patient’s quality of life following surgery for a specific health issue; for example, improved eye sight following cataract surgery

CIHI gathers and analyzes health care data and information so that we can effectively report on health outcomes following care. We also look for opportunities to increase our knowledge and understanding of health outcomes through enhanced availability of health outcomes data and information. NURS 6231 – Healthcare Systems and Quality Outcomes Case Studyy

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