How Do We Define Value and Quality Improvement Initiatives in Healthcare?
The healthcare industry talks a great deal about quality improvement initiatives and increasing the value for patients. But how should we define quality and value? The Agency for Healthcare Research and Quality (AHRQ), a division of the U.S. Department of Health and Human Services, provides, among other resources, tips on patient safety and industry updates on quality improvement initiatives and advancements. Recently, they published a summary of the definition of quality and subsequent quality domains put forth by the Institute of Medicine (IOM). Value is more simply defined and tends to be summarized as providing the best quality care possible to as many people as possible for the best possible price. As Sarh Gentry and Padmanabhan Badrinath put it in their 2017 publication in Cureus entitled Defining Health in the Era of Value-based Care: Lessons from England of Relevance to Other Health Systems:
“Combining the best available evidence with open and honest dialogue between patients, clinicians, and others, whilst requiring considerable time and resources are essential to building a consensus around the value that allows the best use of limited budgets.”
Given that value is defined by high quality and affordability, it stands to reason that quality must be discussed and understood before a definition of value can be agreed upon.
IOM Quality Domains For Quality Improvement Initiatives
The IOM has decided upon six metrics, or domains, that they feel encompass quality. In other words, if an institution or organization, or even the healthcare system as a whole, wishes to implement quality improvement initiatives that result in a higher level of quality across the board, these six domains must be taken into account.
According to the IOM, effectiveness has to do with providing care processes and achieving outcomes as supported by scientific evidence. In other words, there is evidence to suggest that certain processes of healthcare and clinical care will result in better outcomes than others. It’s important for providers to review the science and create evidence-based approaches that will most likely yield the best results. If it’s been proven to work, start there.
The IOM defines efficiency as maximizing the quality of a comparable unit of health care delivered or unit of health benefit achieved for a given unit of health care resources used. So, if you use a unit of healthcare, such as time, in two different situations where a comparable unit of health care was delivered or a comparable benefit was received, you should be able to test the efficiency of what was done in that time. If one process of clinical care produces better results in the same amount of time or results in more “units of healthcare” in the same amount of time, that process is more efficient. Focusing on higher levels of efficiency can greatly impact quality improvement initiatives.
According to the Institute of Medicine, equity means providing health care of equal quality to those who may differ in personal characteristics other than their clinical condition or preferences for care. So, assuming the patient in front of you doesn’t have a preference for a certain manner of care and assuming they have a similar clinical condition, they should receive the same level of care as someone else with the same clinical condition who benefits from more resources, is a member of a different demographic, or differs in some personal way from the first patient. Basically, it’s important that everyone is getting the same level of care regardless of demographic or socioeconomic variables. This is perhaps one area in which quality improvement initiatives could create widespread and lasting change given that lack of access among certain groups is one of the most challenging equity issues facing healthcare today.
Focusing on meeting patients’ needs and preferences and providing education and support is one of the most important functions of the healthcare system. Being able to provide patients with what they need when they need it and supplying them with the information they need in order to make decisions about their care is vital to a functioning and successful healthcare system. Patients should be able to understand their health, their rights, and should have access to a support network if they need it.
This is a rather obvious component of quality in healthcare and relates to the actual or potential bodily harm any given prescription, procedure, or action could cause the patient. While almost all medical procedures and prescriptions can cause a certain level of harm and pose a certain level of risk, it should always be the goal of a quality-focused healthcare system to improve safety and to, as much as possible, ensure that the risk of harm or injury to a patient is the lowest it can be.
Finally, the IOM considers the patient’s ability to obtain the care they need while minimizing delays helps to determine the quality level of the care they received. Of course, timeliness is vital given that many medical situations are time-sensitive and responding quickly can save the patient from going through unnecessary discomfort or injury. In some cases, timeliness can save lives. For this reason, the IOM also considers timeliness when determining whether a patient has obtained quality care.
Value: Profit vs Performance
Value is a hotly contested issue in healthcare. Some are uncomfortable with the notion that profit should play a part in the value discussion and believe, instead, that quality and performance initiatives should focus solely on patient welfare and access. Others acknowledge that the healthcare industry is a business and that without factoring profit into the equation, there would be no healthcare facilities to provide care in the first place.
Add to this already contentious discussion the challenge of providing value in a climate of mass change with which the current system is already struggling to keep up and it’s easy to see why value, while seemingly simple to define, is far more difficult to implement and facilitate in a clinical care context.
The IOM and other institutions like it are conscious of the need to save money, cut wasteful spending, and create a more value-based system, as well. In 2012, the IOM published the following chart to illustrate the missed opportunities, areas of wasteful spending, and fiscal areas where quality improvement initiatives could focus.
The Ever-changing Landscape and Current Quality Improvement Initiatives
Current initiatives designed to improve the quality of healthcare are doing their best to address modern needs. However, as Yuan and Chung put it in Defining Quality in Health Care and Measuring Quality in Surgery:
“Quality in health care has been sluggish to adapt to the changing landscape, leading to lapses in the successful delivering of care. Consequently, quality of care has come under intense scrutiny in the past decade, resulting in the creation of various federally funded and nonprofit organizations aimed at assessing and implementing systematic quality improvement.”
This rings true given programs like “Realising the Value” in the UK. However, without a consensus as to how value should ultimately be defined, debates about whether or not patients are receiving it will continue.
That being said, there are still well-understood (or at least openly acknowledged) challenges that can be addressed using affordable, data-driven solutions. Utilizing AI and machine learning technology to create facility management programs that can provide predictive analysis and precision data on population statistics and disease trajectories, for example, can help address challenges such as the aging nature of our current population and the increasing prevalence of chronic illnesses.
So long as we in the healthcare industry are proactively seeking equity, efficiency, and quality as they relate to patient care, we can use AI and data analytics to create progress. We can also implement quality improvement initiatives based on this data that have the potential to result in substantial change — even in the absence of universally held definitions of quality and value — and offer patients a better healthcare experience.