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Health
Care Today
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The Quality of Health Care
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Health Care Today
Health Care Today is a forum for District
Board members to openly discuss health care topics currently facing
the District.
Periodically, we will
update the page with new information and points of view. Please
note that the opinions of the individual Board members are those
of the author, and may or may not represent the views of other Board
members.
If you would like to comment or give suggestions
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The
Quality of Health Care
By Daniel J. Ullyot, M.D., Vice Chair,
Peninsula Health Care District Board
Of course, we want our health care to be of high quality. Just as
we demand quality education for our children, and insist on quality
for a myriad of public and private services we enjoy and purchase
with our taxes and hard-earned money, quality health care is at or
near the top of our list of priorities.
Americans pay more for health care per capita than those in any
other country. In recent years health policy has focused on whether
we are getting our money's worth in terms of quality, which, in
turn, has led to a national discussion on defining what is meant
by quality and how best to measure it.
There are a variety of means to assess health care quality: patient
satisfaction surveys, site visits looking at processes of care,
external and internal peer review, and monitoring of patient outcomes,
to name several.
For example, efforts have being made to define quality standards
in order to "Pay for Performance". In other words, payment
for health care services will be made not simply for services performed,
but will take into account whether evolving quality standards are
met in the delivery of these services. These standards are derived
from "evidence based" studies looking at clinical outcomes
of health care, and from expert consensus. Two such examples are
the prescribing of specific medications (aspirin, Beta blockers,
and cholesterol lowering agents) for heart attack patients, and
periodic testing (Hemoglobin A1C, and blood glucose) for diabetics.
These examples are rather simple measures of quality care in which
the data in hospitalized patients with these conditions can be derived
from hospital discharge data and chart review, and represent early
attempts to introduce quality measures into payment for performance.
A more complex example is seen at state level. Several states require
public disclosure of clinical outcomes data for coronary bypass
surgery in an attempt to identify quality programs providing this
service, and by extrapolation to suggest quality performance in
treating heart disease generally. In California the Office of Statewide
Health Planning and Development (OSHPD) and the Pacific Business
Group on Health (PBGH), a public/private collaboration, developed
a means of assessing clinical outcomes in coronary artery bypass
surgery (CABG) which became state law (SB 680) mandating reporting
of surgical outcomes (risk-stratified mortality data) by all 120
California hospitals performing this service. Early attempts to
evaluate quality used raw mortality data on Medicare patients and
led to misleading inferences about quality, because patient risk
factors such as age, gender, previous heart damage and concurrent
medical conditions, factors which contribute to surgical mortality,
were not taken into account. In other words, surgical programs which
treated a higher proportion of older, sicker, more complex patients,
might have experienced a higher surgical mortality, but may, nonetheless,
be providing a high quality service. This example of quality measurement
of a complex surgical intervention illustrates the fact that quality
assessment is neither simple nor inexpensive. Accurate clinical
data must be collected, analyzed according to a complex formula,
and reported at intervals. And the process must be audited to assure
comparability and fairness. Efforts are ongoing to extend this reporting
system to include other cardiac interventions (eg. coronary angioplasty
and stenting) and to report physician-specific performance.
On a local level questions have been raised recently about the
quality of health care provided by Sutter Health, a non-profit hospital
chain of some 26 hospitals in Northern California, of which one
is Mills-Peninsula Health Services (MPHS), our community hospital
in this District. These questions about quality impact the negotiations
presently taking place between the Peninsula District Health Board
(PDHB) and MPHS, especially given the call to include quality standards
in the lease arrangements between the District and MPHS.
Criticism of the health care quality provided by Sutter Health
is, in effect, criticism of the physicians practicing at the individual
hospitals comprising the Sutter system. Hospitals don't practice
medicine, doctors do. The basic unit of health care is the interaction
between a patient in need, and a physician with the education, training,
and clinical experience to help, in a context guided by medical
ethics which place the interests of the patient above all others
(beneficence). The need for hospitalization defines those patients
whose care is more demanding and requires the space, equipment,
personnel (nurses and technicians), and administrative management
provided by the hospital. The physician directs the care of the
hospitalized patient using the technology and human resources available,
and takes ultimate responsibility for the outcomes of care.
The members of the medical staff are independent of, and are not
employees of Sutter. The medical staff leadership consists of representatives
of the various medical specialties (surgery, medicine, pediatrics,
obstetrics, radiology, emergency medicine, etc.), each responsible
for policies and procedures within their respective specialties.
It is here, under physician leadership, where quality of health
care is given great emphasis. Admission of physicians to the hospital
staff, credentialing (deciding whether a physician has the training
and qualifications to perform specific services and procedures),
disciplinary actions, patient safety standards, recommendations
for the purchase of medical technology and equipment, regular meetings
to monitor clinical outcomes, and programs for "continuous
quality improvement", are all activities of the professional
staff with the purpose of improving and achieving quality health
care. Each department (medical or surgical specialty) is influenced
by national specialty organizations which promulgate quality standards
(eg. Clinical Practice Guidelines), continuing medical education,
and ethical norms.
In other words, the attainment of quality health care is to a large
extent a function of the activities and commitment of the physicians
on the medical staff, which is autonomous with respect to the hospital.
This is not to say that we should not hold the hospital to account.
Acute care hospitals in California must satisfy multiple legal and
regulatory requirements. Hospitals must meet licensing requirements
(renewed annually) and must report on a wide spectrum of activities
to the State of California Department of Health Services (DHS).
Perhaps the most important, universally accepted "Good Housekeeping
Seal of Approval" for hospitals is the formerly every-three-year,
scheduled inspection (and now, inspections are unannounced and occur
at various intervals as determined by the Commission) by the Joint
Commission on Accreditation of Healthcare Organizations (JCAHO)
which looks at processes of care and certifies that standards are
met. It is reassuring that MPHS consistently meets these standards,
and continues to bear the "Fully Accredited" status, the
highest category awarded by JCAHO. And we want our District hospital
to be clean, well equipped, well staffed, well run and to provide
suitable amenities. Periodic patient surveys give us a barometer
of whether these expectations are being met.
The point is that that there is great emphasis today, at national,
state, and local levels, on quality of health care. The measurement
of quality is evolving and is both complex and expensive. Nonetheless
it must be, and is being done. Health policy in respect to quality
emphasizes accurate measurement of clinical outcomes, transparency
(public disclosure), and systems of continuous quality improvement,
the latter led by physicians and their specialty societies. And
let us not fail to mention the nurses, who are employed by the hospital,
and who care deeply about quality as shown by their commitment to
adequate patient/nurse staffing ratios here in California, and in
their everyday care of patients.
It is obvious that we must continue to demand quality health care.
It is equally obvious that quality can not be assured in a lease
arrangement. The complex and evolving attempts to define quality
defy simple formulae, and are not sufficiently developed for general
acceptance, much less to be written into a lease. An increasingly
sophisticated and informed public, better tools, methods and resources
for quality assessment, and a continued commitment by doctors and
nurses to improved quality is our best guarantee that we will be
successful in providing high quality health care for the people
of our District.
Daniel J. Ullyot, M.D.
Vice Chair, Peninsula Health Care District Board
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