How to Measure Quality of Care: Guide for Healthcare Organizations

Quality control in the provision of medical services is an important stage in the development of a modern clinic. Historically, several approaches have evolved for assessing quality based on different indicators, formulas, and metrics.

Today, we will discuss the main methods of measuring the quality of medical services with examples.

Why is Healthcare Quality Measurement Important?

Measuring quality in healthcare plays a crucial role for several reasons.

Ensuring effective treatment

Measurement of quality allows assessing how effective the provision of healthcare services is. This helps identify strengths and weaknesses in the clinical practice and implement improvements to ensure more effective patient care.

Optimizing resources

Quality assessment helps determine which treatment methods are more resource-efficient. This enables organizing expenditures in a way that maximizes value for patients with minimal costs.

Enhancing patient safety

Measuring quality in health services contributes to identifying errors in the system, thereby improving patient safety. This includes monitoring the accuracy of diagnoses, conducting procedures, and dispensing medications.

Evaluating programme and method effectiveness

Quality measurement allows evaluating the outcomes of NHS programmes, such as preventive campaigns and educational initiatives. This helps determine how effective such programmes are in achieving their goals.

Improving patient engagement

The quality of healthcare also involves assessing patient satisfaction and their involvement in the treatment process. This is important for creating a more centralized and people-centred healthcare system.

3 Approaches to Medical Care Assessment

Structural approach

From this perspective, the assessment involves examining individual structural components of medical care. This includes studying compliance with licensing requirements and conditions by healthcare institutions, as well as certification and accreditation requirements for clinicians.

The main idea of this approach is that if a healthcare institution does not meet the legally established structural requirements for the process of medical care, quality medical services cannot be provided there by default.

The main drawback of the structural approach is the questionable notion that formal compliance with legal requirements for healthcare institutions ensures a high-quality therapeutic and diagnostic process.

Outcome approach

Quality indicators focus primarily on evaluating the results achieved by the doctor rather than the process itself. To do this, models of expected outcomes of care are first constructed and then compared with actual results. In addition to expert-driven comparisons and model building, statistical methods are also applied in this case.

The outcome approach has its limitations. When evaluating the quality of medical care using this approach, the focus is on the actual results, and it occurs when influencing the process of providing medical care is no longer feasible. The outcome and process approaches frequently intersect, making it difficult to practically separate the therapeutic and diagnostic processes from their outcomes.

Process approach

The process approach to quality measurement in healthcare involves systematically evaluating and improving the various stages and activities within the healthcare delivery system. This methodology focuses on understanding, managing, and optimizing the processes involved in providing medical services.

The key aspects are:

• Identification of processes and creating process maps.
• Comparing performance against established benchmarks to identify areas for improvement.
• Developing measurable metrics and indicators to assess the performance of each process.
• Implementing systems for real-time monitoring of processes and establishing feedback loops to involve stakeholders in the ongoing evaluation.
• Conducting thorough analyses to identify the root causes of any deviations from standards.
• Involving patients in decision-making processes related to their care.
• Implementing integrated health information systems to facilitate seamless data flow and communication between different stages of healthcare delivery.
  
  

Evaluation Criteria and Quality Metrics

Examining the issues of assessing the quality of medical care, H.V. Vuory proposed four evaluation criteria:

1. Adequacy corresponds to the patient's needs.
2. Technological appropriateness: provision of services in line with contemporary scientific and technical standards.
3. Effectiveness is the degree of achievement of planned results.
4. Economy: the ratio of the achieved result to the costs incurred to obtain it.

A. Donabedian, when considering the quality of care, suggests a similar set of evaluation criteria: efficacy, optimality, acceptability, productivity, efficiency, legality, and justice.

Donabedian relies on three main parameters:

Resources – medical personnel, equipment and technology, material and technical conditions that determine the quality of patient stays, and working conditions for medical staff.

Processes – activity technologies in providing care (prevention, diagnosis, and treatment).

Outcomes – achieved indicators of providing care.

This model, named the "Donabedian Triad," takes into account the resource support of medical organizations, the compliance of therapeutic and diagnostic procedures with established standards, and the ultimate result of activity, evaluated from the perspective of social and economic efficiency.

Representatives of the Harvard T.H. Chan School of Public Health in the United States note:

"One of the themes that we increasingly address lately is what is changing in the United States in the field of medical care. The focus of attention is shifting from the medical organization to the patient; moreover, we are trying to extend this focus and concentrate not only on the patient but also on their family."

Cost-of-illness methodology

In the United States, a method has been suggested to evaluate the societal impact of diseases, known as the "cost-of-illness methodology." Under this approach, the overall cost of illness (COI) is calculated by combining direct costs (DC), indirect costs (IC), and intangible costs (IntC).

COI=DC+IC+IntC

Direct costs are directly related to the disease and its causes, and without this level of expenditure, the provision of medical care would be impossible. This category includes both medical costs (diagnosis, therapy, and medications) and non-medical costs (hospitalization, food, and transportation).

Indirect costs are non-medical expenses associated with treatment, including production losses resulting from the illness. Examples of such costs include expenses (payments) for social insurance and a reduction in an individual's income due to disability.

Intangible costs are non-material costs associated with pain, suffering, and discomfort experienced by the patient. These costs do not exist as a financial resource and cannot be compared, for example, with expenditures on medical care. This type of cost does not represent resources that can be available to others and therefore is rarely included in assessments of the socio-economic consequences of diseases.

Example: Diabetes

1. Direct Costs (DC):

• Medical expenses related to diabetes treatment include doctor visits, medications, insulin, hospital stays, and laboratory tests.
• Example: $5,000 per year per diabetic patient.

1. Indirect Costs (IC):

• Productivity losses due to disability, absenteeism, or premature mortality associated with diabetes.
• Example: $2,000 per year per diabetic patient.

1. Intangible Costs (IntC):

• Factors that are challenging to quantify, such as pain, emotional distress, and the impact on the overall quality of life.
• Example: Assumed to be $1,000 per year per diabetic patient.

1. Calculation of the Total Cost of Illness (COI):

• COI=DC+IC+IntC
• COI = $5,000 + $2,000 + $1,000 = $8,000 per year per diabetic patient

This total represents the economic burden imposed by diabetes on society per affected individual.

Cost-Effectiveness Ratio

The “Cost-Effectiveness Ratio” (CER) is the ratio of the cost of treatment to the effectiveness achieved as a result of the treatment.

CER = (DC + IC) / Ef.

Example: Hypothetical Drug for Hypertension

1. Total Cost of Intervention:

• The cost of developing, manufacturing, and administering a new antihypertensive drug.
• Example: $10 million.

1. Benefit or Effectiveness of Intervention:

• The reduction in blood pressure achieved by the drug is measured in terms of Quality-Adjusted Life Years (QALYs) gained.
• Example: 1 QALY per patient.

1. Calculation of Cost-Effectiveness Ratio (CER):

• CER=1QALY / $10,000,000​=$10,000,000 per QALY

This means that for each Quality-Adjusted Life Year gained, the cost of the intervention is $10 million.

As a measure of effectiveness (Ef), any of the criteria describing the patient's health status can be adopted. Typically, the "Cost-Effectiveness Ratio" (CER) is applied to compare methodologies or treatment outcomes. A limitation of this approach is the inability to compare treatment results with different outcomes, and it also does not take into account the value of treatment for the client. The value of medical service for the client, essentially its effectiveness, can be assessed using the indicator of quality-adjusted life years (QALY).

Quality-adjusted life years (QALY)

QALY = Duration of life × Quality of life

Steps to Calculate QALY:

1. Determine the duration of life:

• This involves estimating how long the individual is expected to live after a particular medical intervention or treatment.

1. Quality of life assessment:

• Assess the quality of life during the remaining time. This is often done on a scale from 0 to 1, where 0 represents a state equivalent to death and 1 represents perfect health.

1. Multiply duration by quality:

• Multiply the estimated duration of life by the assessed quality of life during that period.

1. Repeat for different time periods:

• If the quality of life changes over time (due to the nature of the medical condition or treatment effects), calculate QALY for different time periods and sum them up.

Example:

Let's say a patient is expected to live for 10 years after a medical intervention, and the assessed quality of life during this period is 0.8.

QALY=10years×0.8(quality of life)=8QALYs.

Summing Up

Measuring quality in healthcare involves a comprehensive approach that considers various aspects of patient care and outcomes. Here are some common methods and indicators used to measure healthcare quality.

Clinical indicators

• Outcome measures: Evaluate the results of medical interventions and treatments, such as mortality rates, complication rates, and patient recovery.
• Process measures: Assess adherence to established clinical guidelines and best practices during patient care, including timely diagnosis, appropriate treatments, and follow-up procedures.

Patient experience and satisfaction

• Surveys and feedback: Collect feedback from patients through surveys to understand their experiences, satisfaction levels, and perceived quality of care.
• Patient-centred care: Assess the extent to which healthcare providers involve patients in decision-making, respect their preferences, and provide clear communication.

Access to care

• Timeliness: Evaluate how quickly patients can access healthcare services, including appointment scheduling, waiting times, and response to emergencies.
• Geographic accessibility: Assess the availability of healthcare services in different geographic areas to ensure equitable access.

Efficiency

• Resource utilization: Measure the efficient use of resources, including time, personnel, and equipment, to deliver high-quality care while minimizing waste.
• Wait times: Evaluate waiting times for appointments, tests, and procedures to ensure timely access to care.

Safety

• Adverse event rates: Monitor and assess the occurrence of adverse events, including medical errors, infections, and complications, to enhance patient safety.
• Medication safety: Evaluate the accuracy of medication administration and monitor for adverse drug reactions.

Care coordination

• Communication and information transfer: Assess how well healthcare teams communicate and share information to ensure seamless transitions between different levels of care.
• Follow-up care: Evaluate the effectiveness of post-discharge care and coordination to prevent readmissions.

Population health management

• Preventive care measures: Assess the effectiveness of preventive care initiatives, such as vaccination rates and cancer screenings, to promote population health.
• Chronic disease management: Monitor the management of chronic conditions to prevent complications and improve overall health outcomes.

Cost-effectiveness

• Cost per Quality-Adjusted Life Year (QALY): Evaluate the cost-effectiveness of healthcare interventions by considering both the cost and the impact on the patient's quality of life.

Continuous monitoring, data collection, and feedback mechanisms are essential for an ongoing quality improvement process in healthcare. Combining quantitative data with qualitative insights helps provide a holistic view of healthcare quality.

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