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					      의료의 질 관리(2):
Performance Measurement

        2010. 9. 30.
    서울의대 의료관리학교실
       김    윤
IF YOU CAN'T MEASURE IT, YOU
CAN'T MANAGE IT ...
   Role of Performance Measurement

• Health system to deliver effective health care
  and secure population health.
  – to secure accountability within the system
  – to determine appropriate treatments for patients
  – to facilitate patient choice and/or for managerial
    control
• Assuring governance of the health system


                                                         3
                  Core component of
            quality improvement policy: US

                                                Collaborative
                                                   Quality
                                                Improvement

• Pay for
  Performance       Value-Based
• Payment denial    Purchasing
  for HAC
                                  Performance
                                                      CMS &
                                  Measurement
                                                       State
                                  & Reporting         Quality
                                                     Reporting


                                                                4
   평가인증제도는 질을 보장하는가?
• 인증결과와 임상질지표 평가결과간에 직접적 상관관계(-)
   – Dean Beaulieu and Epstein 2002; Grasso, Rothschild, Jordan and Jayaram 2005;
     Griffith, Knutzen and Alexander 2002; Miller et al. 2005


• Dean 등(2002) : NCQA 인증과 질적 수준
   – NCQA 인증여부가 최소질적 수준 보장 못함
   – HEDIS 질지표를 인증평가기준에 적용 필요
• Chen 등(2003) : JCAHO 인증과 AMI 진료
   – 인증받은 병원들간에 커다란 질적 수준 차이
   – 질지표 평가결과를 인증 여부 결정에 활용 필요
• Barker 등(2002) : 인증 여부와 투약오류 발생률
   – 인증 여부와 투약 오률 발생률 간에 상관관계 없음


             임상질지표 기반 질평가 및 질향상 필요
                                                                               5
EFQM Excellence Model




                        6
                         Definition
• Performance measurement evaluates the extent to
  which a health system meets its key objectives.
   – objectives reflect different historical trajectories, political,
     financial and organizational priorities and the power of
     interest groups and stakeholders
• The World Health Report 2000 defined three intrinsic
  goals of health systems
   – improving health
   – increasing responsiveness to the legitimate demands of
     the population
   – ensuring that financial burdens are distributed fairly

                                                                        7
                            Definition
• Use of statistical evidence to determine progress toward
  specific defined organizational objectives
   – Various aspects, methods, and tools
   – How well each company performs is dependent on the strategic plan.
   – Basic financial ratios such as debt-to-equity ratio

• Performance measurement systems
   –   Balanced Scorecard (Kaplan and Norton, 1993, 1996, 2001),
   –   Performance Prism (Neely, 2002)
   –   Cambridge Performance Measurement Process (Neely, 1996)
   –   TPM Process (Jones and Schilling, 2000)
   –   7-step TPM Process (Zigon, 1999)



                                                                          8
Dimensions of Health Performance Measures




                                            9
Dimensions of Health Performance Measures




                                            10
Dimensions of Health Performance Measures




                                            11
                    Typology

• National Library of • HEDIS
  Healthcare Indicators – Quality
  (1997): JCAHO         – Satisfaction
  – Clinical performance   – Access to services
  – Health Status          – Utilization
  – Satisfaction           – General plan
  – Administrative/          management
    Financial              – Financial measure
                       Context

Scope                      Target
• Performance              • Health system
  measurement :              – National
  broader scope than         – Regional
  Quality indicator        • Organization
                             – Including hospital




                                                    13
WHO : Health systems performance
            • improving the health of the
              population they serve;
            • responding to people's non-
              medical expectations;
            • providing financial protection
              against the costs of ill health.

                  Objectives           Level Distribution
             Health                      x         x
             Responsiveness              x         x
             Financial contribution      -         x
                                      Quality   Equity
미국 : National Healthcare Quality Report




                                      15
미국 : National Healthcare Disparity Report




                                            16
17
      질 평가 결과의 공개: CMS
• 폐렴환자에서 항생제 투여 시점의 적절성




                          18
19
         JCAHO Accreditation Report:
     National Patient Safety Goals




20
     Components of a performance
        measurement system
• Standardized performance measures
• Access to patient data
• Data verification and auditing
• Comparative analysis and reporting capability
     Components of a performance
        measurement system
• Standardized performance measures
  – Measures with detailed specifications
     • e.g. definitions for the numerator and denominator /
       sampling strategy if appropriate

  – allowing for “"apples-to-apples”" comparisons
  – sometimes requiring effective risk adjustment or
    stratification of results across key subgroups
     Components of a performance
        measurement system
• Access to patient data
  – Calculation of many performance measures
    requires access to patient-level data from
    administrative files and chart reviews
  – Other measures require asking patients to
    complete surveys that allow assessment of their
    perceptions of their care, their quality of life, or
    their functional status.
 Components of a performance measurement
                  system
• Data verification and auditing
  – Accuracy of data for performance measures
     • A key element of a quality measurement and reporting
       system
     • e.g. self-reported data
  – External auditing function often desirable or
    mandatory
     Components of a performance
        measurement system
• Comparative analysis and reporting capability
  – To support the decisions of consumers, purchasers,
    referring physicians, and other stakeholders in
    choosing plans, providers, or treatment options
  – Similarly, improvement efforts that draw on
    knowledge of best practices benefit from
    comparative data.
    STANDARDIZED PERFORMANCE MEASUREMENT: Pioneering
                         effort

•   Efforts under way for more than 15 years
•   Health Plan Employer Data and Information Set (HEDIS)
     – One of the oldest and perhaps most successful quality measurement efforts
     – First released in 1989 by members of The HMO Group and large employers
     – subsequently adapted and refined by NCQA
•   CMS
     – requires health plans participating in the Medicare program to submit data on HEDIS-
       developed measures
     – comparative quality reports available on the CMS Web site
•   Many state governments
     – require plans participating in Medicaid to report HEDIS data
          •   New York State Department of Health
          •   Texas Health and Human Services Commission
          •   Washington State Department of Health and Human Services, 2005

•   HEDIS measures are frequently used in the nearly 90 pay for performance
    programs sponsored by private purchasers
     STANDARDIZED PERFORMANCE MEASUREMENT:
         Pioneering effort in Hospital care area

• Phase 1: DHHS and JCAHO – before 1990s
  – CMS released comparative reports on hospital
    mortality (HCFA, 1987).
  – JCAHO developed and field tested six sets of
    standardized performance measures (mid-1980s)
     • perioperative care, obstetrical care, trauma care, oncology
       care, infection control, and medication use
     • intent to require accredited hospitals to submit data on
       these measures
  – Both of these efforts were abandoned
     • strong objections from the hospital sector
       STANDARDIZED PERFORMANCE MEASUREMENT:
           Pioneering effort in Hospital care area

• Phase 2: In 1990s
   – JCAHO allowed great discretion in selecting measures from a
     large menu, and the measure specifications were not
     standardized
       • three of five standardized measure sets
       • acute myocardial infarction, heart failure, pneumonia, pregnancy and
         related conditions, and surgical infection prevention
• Phase 3: 2000s
   – CMS announced a voluntary hospital reporting initiative linking
     a hospital’s payment update under Medicare to the submission
     of data for a set of standardized measures from the JCAHO
     ORYX system (CMS, 2004)
   – In 2005, CMS began publicly reporting hospital comparative
     data based on these measures via its Web-based tool, Hospital
     Compare (CMS, 2005b).
        STANDARDIZED PERFORMANCE MEASUREMENT:
              Pioneering effort in other areas

• Consumer Assessment of Health Plans Survey (CAHPS) instrument
   – AHRQ release in 1997 to capture consumer assessments of care received
   – now required by NCQA for health plan accreditation and many public and private
     purchasers
        • CMS’s Medicare program / many state Medicaid programs / Federal Employees Health Benefit
          Plan
   – expanded to include a survey of behavioral health services

• Long term care : Minimum Data Set (MDS)
   – CMS supported the development of patient assessment instruments used by organ
     transplant centers, nursing homes, and home health agencies (1980s)
   – first implemented by CMS in 1990 for nursing home patients
   – 24 quality indicators based on MDS data had become part of a routinely administered
     nursing home survey (CMS, 1999)
   – Nursing Home Compare (CMS, 2002)
        • Web-based reporting mechanism
        • provide the public and other stakeholders with comparative quality data on nursinghomes
PERFORMANCE MEASURE
DESIGN PRINCIPLES
                     Design principle
• Principle 1: Comprehensive Measurement
• A performance measurement system should advance the core
  purpose of the health care system and foster improvements in all
  six quality aims identified in the Quality Chasm report (IOM,
  2001): safety, effectiveness, patient-centeredness, timeliness,
  efficiency, and equity. The committee endorses the following
  statement of purpose, proposed by the President’'s Advisory
  Committee on Consumer Protection and Quality in the Health
  Care Industry:
• The purpose of the health care system must be to continuously re
  duce the impact and burden of illness, injury, and disability, and to
  improve the health and functioning of the people of the United St
  ates.
                      Design principle
• Principle 2: Evidence-Based Goals and Measures
• A performance measurement system should be guided by a
  comprehensive set of evidence-based goals for improvement,
  where appropriate. The National Quality Coordination Board
  (NQCB) should identify explicit health care goals for the nation,
  assess progress toward achieving these goals; and continually
  update and modify the goals as circumstances, information, and
  needs change. As a starting point, the NQCB should adopt the
  priority areas for quality improvement identified by the Institute
  of Medicine (IOM, 2003), as endorsed and expanded by the
  National Quality Forum (2004), as national goals, and specify
  measures corresponding to these goals that encompass the care
  of patients across the lifespan (e.g., staying healthy, getting better,
  living with chronic illness, and coping with end of life) (FACCT,
  1997).
                 Design principle
• Principle 3: Longitudinal Measurement
• Standardized performance measures should
  characterize health and health care of a patient both
  within and across settings and over time. The NQCB
  should identify standardized measures that
  characterize the health and quality of care received
  by both individuals and populations. In general, the
  measures should not vary by type of health care
  provider or setting, but should characterize care
  across as well as within sites and settings. The set of
  standardized measures should provide the
  information needed to assess progress toward
  achieving the six quality aims and the national goals.
                          Design principle
•   Principle 4: Supportive of Multiple Uses and Stakeholders
•   A national system for performance measurement and reporting should provide
    information for multiple uses, including provider-led improvement efforts, public
    reporting, payment and benefits design, and population health initiatives. This
    system should produce useful information for three purposes:
•   • Accountability—-Information should be available to assist stakeholders in maki
    ng choices about providers, including patients identifying a clinician, hospital, or
    other provider from which to seek services; purchasers and health plans selecting
    providers to include in their health insurance networks; and quality oversight org
    anizations making accreditation and certification decisions.
•   • Quality improvement—-The information provided should be of value to stakeh
    olders responsible for improving the quality of care, including clinicians and admi
    nistrators and governing board members of health care organizations.
•   • Population health—-The information should be useful for stakeholders making
    decisions about access to services (e.g., public insurance benefits and coverage); t
    hose involved in communitywide programs and efforts to address racial and ethn
    ic disparities and promote healthy behaviors; and public officials responsible for
    disease surveillance and health protection.
                       Design principle
• Principle 5: Measurement Intrinsic to Care
• Performance measurement should be intrinsic to the care process. For
  most standardized measures (e.g., health care processes and some
  outcome measures), the data generated to calculate measures should be
  byproducts of the patient care process and should reside within an
  electronic health record system. For example, the data required to
  calculate standardized measures for assessing the quality of patient care
  provided to diabetics (e.g., cholesterol and hemoglobin A1c levels)
  should be captured as a part of patient care encounters. This approach
  has several advantages: (1) it allows for the development of
  computerized decision-support systems (e.g., prompts to providers and
  patients that the patient is due for an annual retinal exam); (2) it enables
  more immediate calculation of measures and feedback to providers on
  performance; and (3) it minimizes the burden associated with special
  data collection processes. These data reflect the health care delivery
  system; in and of themselves they do not adequately address population
  and public health.
                 Design principle
• Principle 6: A Central Role for the Patient’'s Voice
• The performance measurement system should also
  include direct reports and ratings from patients and
  family caregivers. Patients need a voice in the process
  of selecting measures and designing public reports.
  The input of patients and family caregivers should
  reflect their viewpoints on the quality and
  functionality of the care received. Caregivers’'
  perceptions of the quality of care provided should
  also be incorporated into the measurement system.
                      Design principle
• Principle 7: Individual-, Population-, and Systems-Based Measurement
• Measurement and measures should assess the health and health care of
  both individuals and populations and the many systems within which
  care is provided. A national system for performance measurement and
  reporting should include both measures of the quality of care provided
  by the personal health care system and measures of population health,
  health behaviors, and unmet health needs. The measure set should
  include measures of access and unmet service needs for the entire
  population of a community and for specific groups most likely to
  experience access limitations because of an inability to pay; high levels
  of uninsurance or underinsurance; racial, ethnic, class, cultural, and
  linguistic barriers; or geographic impediments. The measure set should
  also include measures of the efficiency of the local health system, such
  as resource use compared with that of other communities.
                 Design principle
• Principle 8: Shared Accountability
• Measurement should not be constrained by the
  absence of a current, identifiable, single responsible
  agent. A national system should measure processes
  and outcomes of care important to patients and
  communities. Measurement should foster individual
  and shared accountability for health system
  performance. When no responsible agent can be
  identified, shared accountability by all agents within
  the health care system should be presumed, and
  responsible stewardship encouraged and induced. In
  many settings, this will require significant
  restructuring of how care is currently delivered.
                 Design principle
• Principle 9: A Learning System
• A performance measurement system should be a learning
  system, continually evaluating its own performance and
  advancing knowledge regarding performance
  measurement. A national system for performance
  measurement and reporting should advance knowledge of
  (1) how environmental levers, such as purchasing, pay for
  performance, and quality oversight can best be used to
  motivate quality improvement; (2) the most effective
  strategies for redesigning care processes, including
  methods for transferring knowledge, implementing
  information technology, and forming effective care teams;
  and (3) the extent to which all quality efforts lead to
  improvements in the six quality aims.
               Design principle
• Principle 10: Independent and Sustainable
• A performance measurement and reporting
  system should be continually enhanced and
  financed in a way that ensures its independence
  and sustainability. This system should be
  dynamic and should evolve based on careful
  evaluation of its impact and advances in the
  science base. It should be adequately supported
  by both public- and private-sector stakeholders.
 병원 질향상을 위한

임상질지표의 활용

   2010. 9. 30.
서울의대 의료관리학교실
    김   윤
        차    례


임상질지표의 기본 개념


외국의 임상질지표 : Resource


임상질지표의 개발


                       42
I. 임상질지표 기본 개념
                    의료의 질이란?

                           의료서비스가
바람직한 결과를 달성할 가능성을 높이는 정도
          최신 전문지식에 부합하는 정도


‘the degree to which health services for individuals and populations
       Increase the likelihood of desired health outcomes and
        are consistent with current professional knowledge’


44
                  Lohr KN(ed.) Medicare: A Strategy for Quality Assurance. Vol. I and II. National Academy Press, 1990.
      의료에 질에 대해 무엇을 알고 있는가?

• 치료과정에 대한 체계적인 평가 부족
 Lack of documentation about how major illnesses are treated
• 진료결과에 대한 체계적인 평가 부족
 Lack of systematic outcome assessment
• 진료 질과 관련된 자원 분배에 대한 평가 부족
 Lack of resource evaluation related to quality for specific
 diseases
• 의료제공자들간 지속적인 변이
 Persisting variations among providers in care for similar
 patients
• 공식적인 모니터링 체계 부족
  Few formal monitoring systems in place by health care
  providers or regulators
 45
      • Mainz J. Defining and classifying clinical indicators for quality improvement. IJQHC 2003; 15(6): 523.
                           임상질지표의 정의
• 특정 의료서비스의 과정 또는 결과를 평가하는 방법
     As measures that assess a particular health care process or outcome

• 환자 건강에 영향을 줄 수 있는 관리, 진료 및 진료지원 기능
  의 질을 모니터링하고 평가하는 계량적 측정 방법
     As quantitative measures that can be used to monitor and evaluate the quality
     of important governance, management, clinical, and support functions that
     affect patient outcomes

• 환자 건강에 영향을 줄 수 있는 진료, 진료지원, 조직 기능의
  질을 모니터, 평가, 개선하기 위한 지침으로 사용되는 측정
  도구, 선별도구 또는 신호
     As measurement tools, screens, or flags that are used as guides to monitor,
     evaluate, and improve the quality of patient care, clinical support services, and
     organizational function that affect patient outcomes



46
         • Mainz J. Defining and classifying clinical indicators for quality improvement. IJQHC 2003; 15(6): 523.
                            임상질지표: 바람직한 특성

   1. 합의된 정의에 근거                                                 5.      높은 변별력
         Based on agreed definitions                                     Discriminates well

   2. 측정에 필요한 요소 기술                                              6.      사용자와 명확한 관련성
      Described exhaustively and                                         (의사 : 임상진료 관련 지표)
         exclusively                                                     Relates to clearly identifiable
                                                                         events for the user
   3. 높은 민감도와 특이도
         Highly specific and sensitive                           7.      비교 가능성
         = few false (+) and false (-)                                   Permits useful comparisons

   4. 타당도와 신뢰도                                                   8.      근거 기반
         Valid and reliable                                              Evidence-based




                                                                                                           47
• Mainz J. Defining and classifying clinical indicators for quality improvement. IJQHC 2003; 15(6): 523.
                                  임상질지표: 분류
  • Rate-based(비율) 지표 vs.                                    • 기능
    sentinel(적신호 사건) 지표                                             –   스크리닝 지표
  • 구조(Structure), 과정(Process),                                     –   진단 진표
    결과(Outcome)                                                     –   치료 지표
  • 일반(Generic) 지표 vs.                                              –   Follow up 지표
    질병 특이(disease-specific)                                  • Modality
  • 서비스의 형태(type of care)                                           –   병력
         – 예방 관련 지표                                                 –   신체계측(Physical examination)
         – 급성 관련지표                                                  –   임상병리/방사선 검사
         – 만성 관련 지표                                                 –   투약 관련
                                                                    –   다른 시술(Other interventions)




                                                                                                           48
• Mainz J. Defining and classifying clinical indicators for quality improvement. IJQHC 2003; 15(6): 523.
           비율 지표 vs. 적신호 지표
• 비율 지표 (Rate-based indicators)
  – 빈도를 담고 있는 자료를 사용하여 지표를 생성
  – 표본 집단의 평균값, 비율(proportion), 비(ratio)로 표현됨
  – 위험에 노출된 집단의 분모와 실제 발생한 수로 표현되는 분자가 필요
    함
• 적신호 지표 (Sentinel indicators)
  – 낮은 성과 수준(poor performance)으로 표현됨
  – 위험관리 대상을 골라내는 데 사용됨
  – 심층 조사나 분석을 하게 하는 계기가 되는 지표임
                비율(rate based) 지표                                               적신호(sentinel) 지표
창상 감염
   분자: 수술 5일 이후 창상감염 환자 수                                               수술 중 사망한 환자 수
   분모: 수술 후 5일 이상 병원에 입원한 수술 받은 환자 수
병원성 감염
   분자: 감염자수                                                             주산기 동안 사망한 환자 수
   분모: 연구 기간동안 병원입원 환자 수

 49       • Mainz J. Defining and classifying clinical indicators for quality improvement. IJQHC 2003; 15(6): 523.
          구조(structure), 과정(process),
             결과(outcome) 지표
• 구조 지표
     – 물적 자원(병원들, 장비, 재정)
     – 인적자원(질, 양)
     – 조직의 구조(의사 수, 조직, 동료 심사 방법, 상환방법)
• 과정 지표
     – 환자의 치료 과정이 잘 이루어졌는가를 의미함
     – 예: 진단과정에서 의사의 활동, 치료의 적정성, 환자와 의사의 관계
• 결과 지표
     – 환자 및 집단의 건강상태에 대한 치료의 효과를 의미함
     – 예: 환자의 지식 및 행태 변화, 환자의 만족도



50
              구조-과정-결과 지표의 예
           • 전문의 비율
           • MRI 접근성
     구조    • 뇌졸중 치료센터 접근도
           • 임상 가이드라인 2년 마다 갱신
           • 물리치료사 수
           • 당뇨 환자 중 규칙적인 발 관리를 받는 환자의 비율
           • 급성심근경색환자 중 혈전용해제를 사용한 환자의 비율
     과정
           • 의뢰 24시간 이내 의사에게 평가 받은 환자 비율
           • 임상 가이드라인에 의해 치료 받는 환자 비율
           • 당뇨환자에서 HbA1c
      중간
           • 고지질혈증 환자에서 Lipid profile
      결과
           • 고혈압 환자에서 혈압
           • 치명률 (Mortality)
결과         • 유병률 (Morbidity)
           • 기능상태
      최종
           • 건강상태측정 (Health status measurement)
      결과
           • 작업을 할 수 있는 정도
           • 삶의 질(Quality of life)
51         • 환자 만족도(Patient satisfaction)
                   과정 지표의 특징 및 유용성
  •    결과가 입증된(Outcome-validated) 과정 지표
         – 진료결과와 진료과정 사이의 관계가 확립되어 있음
         – 질적 수준을 직접적으로 나타내는 지표임
         – 예: 특정 환자에게 어떤 특정 시술을 하는 것이 좋은 건강결과로 이어진다면, 특정
           상황에서 특정 시술의 부재는 의료의 질이 '나쁨'을 의미함
  •    과정 지표의 유용성
         –   질 개선이 목적인 경우
         –   특정 의료제공자가 특정한 결과를 달성하고 싶을 때
         –   단기간 측정틀(frame)이 필요할 때
         –   낮은 시술량 의료제공자의 performance에 관심이 있을 때
         –   환자 요인을 보정하거나 층화할 수 없을 때
  •    결과지표에 비하여 질 차이를 잘 구분해 낼 수 있고 해석하기가 쉬움
         – 뇌졸중 환자의 적절한 투약 여부(과정 지표)
         – 뇌졸중 환자의 30일간 치명률(결과 지표)


  52
• Mainz J. Defining and classifying clinical indicators for quality improvement. IJQHC 2003; 15(6): 523.
           결과 지표의 장점 및 제한점
• 결과 지표의 유용성
     –   보건의료의 영향을 측정할 수 있음
     –   장기 측정틀(frame)로 사용할 수 있음
     –   전체 시스템의 performance를 측정할 때
     –   시술량이 많은 경우

• 고려할 점
     – 위험 보정(risk adjustment)을 반드시 해야 함
     – 측정의 용이성은 항상 고려해야 할 점임
     – 발생 빈도가 너무 낮을 경우 유용한 지표로 사용하기 곤
       란

53
          근거 기반 지표 vs. 합의 기반 지표
  • 과학적 근거 기반 지표 (Evidence-based indicators)
         – 과학적 근거를 가지는 지표
               • Cochrane Collaboration literature syntheses
               • Meta-analyses
               • RCT


  • 전문가 합의 기반 지표 (Consensus-based indicators)
         – 보건의료 전문가 패널을 통해 결정함
         – 과학적인 증거가 부족할 경우 합의 과정을 통해 결정함



  55
• Mainz J. Defining and classifying clinical indicators for quality improvement. IJQHC 2003; 15(6): 523.
인증평가제도에서는
임상질지표를 어떻게 활용하나요?
의료기관 인증평가와 임상질지표




                    56
   질향상 두 경로: 자발적 질향상 vs. 사회적 책임

•Supportive             질향상 활동 지원
 Clinical Indicator



                       평가시행     자발적
     자발적
                        및       질향상
     질향상
                      결과 피드백   노력 유도
                                       의료
                                       질 향상
   의료의                         소비자의
                      평가결과
  질에 대한                        의료기관
                       공개       선택
 사회적 책임

•Summative
                                            57
 Clinical Indicator
                           질평가 시스템의 분류
                                               Nature of expected action

  •Clinical indicators
   - 호주: ACHS                            Formative                               Punitive
   - 캐나다: CCHSA                          supportive                             summative

                                 Continuous quality                      Internal evaluation
                internal         improvement
                                                            A                                     C
Source
  Of
Control                          Accreditation                        External
                                                                      accountability
               External
                                                           B                                      D
                                                                          •   미국 JCAHO Core measure
                                                                          •   미국 CMS Hospital Public Reporting
                                                                          •   미국 CMS pay for performance
                                                                          •   미국 Leapfrog Group
                                                                          •   미국 AHRQ patient safety indicators
 Veillard et al., A performance assessment framework for hospitals: the WHO regional office for Europe PATH
                                                                                                                  58
 project. International Journal for Quality in Health Care 2005; volume 17, number 6; pp. 487-496
                       질평가 시스템의 분류

                                              평가결과의 활용


                         의료기관 질향상 활동                         결과 공개 및 유인 제공


                        인증제                                    Internal evaluation
         내부             임상질지표
         평가
                                                   A                                   C
                                                                                       C


                        Accreditation                        과거 의평
         외부                                                  임상질지표 평가
         평가                                       BB                                   D
                                                                                       D
                                                                                       C



Veillard et al., A performance assessment framework for hospitals: the WHO regional office for Europe PATH
project. International Journal for Quality in Health Care 2005; volume 17, number 6; pp. 487-496             59
        Supportive vs. Summative
Supportive    • 외래수술(day surgery)후 입원율
                – 백내장 수술, 무릎 관절경, 서혜부 탈장
              • 재입원율
                – AMI(30일 이내), 폐렴(30일 이내), 천식(72시간 이내)
              • 재수술률


Summative:      Aspirin at arrival
                Aspirin prescribed at discharge
   Acute        ACEI for LVSD
 Myocardial     Smoking cessation advice/counseling
 Infarction     Beta blocker prescribed at discharge
                Beta blocker at arrival
                Thrombolytic received within 30 minutes of
                hospital arrival
                PCI received within 120 minutes of hospital
                arrival
 60
                Inpatient mortality rate
       중요한 것과 측정가능한 것 : 무엇을 측정?

 한 남자가 땅바닥에서 무엇인가를 찾고 있는 것을 보고 지나가던 행인이 물
   었다. (Shah, 1972)
      행인: 뭘 잃어 버렸나요?
      남자: 내 차 열쇠를…
      행인: 어디 쯤에서 잃어 버렸나요?
      남자: 우리 집에서요
      행인: 그런데, 왜 여기에서 찾고 있나요?
      남자: 아~~~ 여기가 우리 집보다 밝아서요
• 성과 측정: 중요한 것이 아니라, 측정 가능한 것을 측정하는 경향
      – 중요한 진료결과를 측정할 수 있는 도구가 부족
      – 중요한 것과 측정할 수 있는 것들 사이에 타협점을 찾는 것이 중요
• 성과 측정 지표: 누구를 위한 것인가에 따라 지표가 달라짐
      – 의료진: immediate outcome - 예: 병원감염률
      – 환 자: ultimate outcome – 예: 실제 건강수준 향상
 61
II. 외국 임상질지표: Resource
            외국의 임상질지표(1)
• WHO (2003): Performance Assessment Tool for
  Quality Improvement in Hospitals (PATH)
• ACHS (1989): Australian council on health care
  standards (ACHS) Indicator project, Australia
• Germany (2000): BQS-Bundesauswertungen
• Scotland (2000): Clinical Indicators support team
  (CIST), NHS Quality Improvement
• France (2003): COMPAQH


                                                      63
            외국의 임상질지표(2)
• JCAHO (1997): ORYX, USA
• Ontario Hospital Association (1997): Hospital
  reports, Canada
• [International] Quality Indicator Project (1984): USA
• The National Indicator project (2000), Denmark
• Reporting of performance in Dutch hospitals (2003),
  The Netherlands
• Verein Outcome (2000): Switzerland

                                                      64
            외국의 임상질지표 : Overview
    임상질지표                            영역                     지표 수                  참여 방식
WHO PATH                CE/ EF/ SO/ RG/ SF/ PC       31: 95 tracers               자발적
호주 ACHS                 CE/ EF            / SF       308: 22 영역                   자발적
독일 BQS                  CE                           169: 17 영역                   의무적
스코틀랜드CIST               CE                           64: 7 영역                     의무적
프랑스 COMPAQH             CE    / SO           / PC    43: 8 Nat’l priority         자발적
미국 JCAHO                CE/ EF            / SF/ PC   36: 5 영역                     의무적
캐나다 OHA                 EF        / RG       / PC    47: 4 영역                     자발적
미국 QIP                  CE/ EF            / SF/ PC   47: 4 영역                     자발적
덴마크 NIP                 CE/ EF            / SF/ PC   87: 7 영역                     의무적
네델란드 Dutch              CE/ EF            / SF/ PC   39: 3 영역                     의무적
스위스VereinOutcome        CE/ EF       / RG/ SF/ PC    118: 19 영역                   의무적
  CE clinical effectiveness/ EF efficiency/ SO Staff orientation/ RG responsive
  governance/ SF safety / PC patient centeredness                                    65
Acute Care Indicators (including Ambulatory indicators)
Psychiatric Care Indicators (both adult and adolescent units)
Long Term Care Indicators
Home Care Indicators                                            66
        In-patient Quality Indicators
1. Hospital-acquired           8. Unplanned admissions
    infections                     following day case
2. Surgical site infections1       procedures
3. In-patient mortality        9. Unplanned returns to
4. Neonatal mortality              ICU
5. Perioperative mortality     10. Unplanned returns to
                                   the operating theatre
6. Management of labour
                               11. CABG perioperative
7. Unplanned                       mortality
    readmissions
                               12. Use of restraint
                               13. Sedation and analgesia
                               14. Falls                 67
• AC Indicator 9: Unscheduled Returns to
  Intensive Care Units (ICU)
  – Unscheduled returns to ICU
  – Unscheduled returns to ICU
    for the following durations:
     •   Within 24 hours
     •   > 24 but <= 48 hours
     •   > 48 but <= 72 hours
     •   > 72 hours
  – Unscheduled returns to intensive care units for
    patients with the following primary diagnoses:
     • Acute myocardial infarction
     • Heart failure
     • Pneumonia
                                                      68
69
70
                Case studies
         Hospital-acquired infections
• A hospital that had very low levels of wound infections for
  hip replacements observed a sudden and dramatic increase
  in post-operative infections, from a low baseline to ∼10%
  over three consecutive data points.
• The increase was found to coincide with a change in
  operating theatre cleaning contractors. The new contract
  was discontinued and the infections fell back to previous low
  levels.
• This shows the value of monitoring indicators over time and
  also re-emphasizes that understanding and explaining a
  particular indicator rate depends upon local
  audit/investigation.
                                                                71
Resource : 우리나라




                  72
QI 사업과 임상질지표를
어떻게 선정할까?



                73
      우리 병원에서
어떤 QI 사업을 하면 좋을까요?




                     74
     질향상 사업과 임상질지표
병원   Deep Post-Op        UTI             Pneumonia    Bacteremia       Other
감염   Wound Infection

                               Prevention

                                                        Prophylaxis
                                  Patient
            Prevention          Preparation
                                                          Patient
                                                         Selection
                                Prophylactic
                                 Antibiotics
            Detection                                    Antibiotic
                                                         Selection
                                                          - Duration
                                   Surgery
                               - Sterile Technique
                               - Operative Findings
            Treatment
                                                         Delivery
                                                           - Timing
                                Post-Op
                               Wound Care

                                                                         75
                                         Opportunity summary
                                                                   Dollars
              $2MM                $3MM                    $4MM                     $5MM                    $6MM                     $7MM
                 acute        allergic
                 sprain       rhinitis
                                                       sinusitis
  Adult
                                                                     other skin disorder
  Acute                                                                                                                                        Legend
 Self-Ltd
  CPMs                                       adult                                                                                            Cardiovascular
                      other eye      abd. general exam                                                peds general exam
  Peds                problem        pain                                                                                                    Musculoskeletal
                                                  otitis media
  Acute
 Self - Ltd                                                                                                                                  Gastroenterology
                  Peripheral neuropathy /                                                                                   diabetes
  CPMs                  neuralgia                                                                  psychotic depression
                                                                   non-psychotic                                                             Behavioral Health
                                              lipid                depression
  Adult                                     disorder
 Medical                                                                                                                                     Infectious Disease
 CPMs                                                                           GI tract disease                                             Pulmo/Allergy
                                             pneumonia          headache
                  Sleep disorder                                                                            hypertension
                                other neuro.                                                                                                 Endocrinology
  Peds                            disorder
 Medical                                                                                                                                     Neurology
 CPMs                             neck
                         kidney problem
                 Ischemic
                          stone
                                     bursitis/
                                                                                    other joint &                                            Nephrology
                                                                                    disc disease
   Adult                             synovitis         GI biliary tract                                  low back pain                       Ophthalmology
 Amb CPMs
  Elective                                                                                                                                   Dermatology
                                    non-ulcer peptic
                                        disease                                                                                              Primary Care
    Adult                         osteoarthritis
                                                                                                                         Ischemic          X-Axis = Total Cost
Ind/Guidelines
   Elective                                                                other joint &                                                   Bubble size = Variation
                                                                           disc disease
                      low back pain
                                                                                                                                                         76
Priority Areas for Transforming Health Care:
           Inpatient/Surgical Care
                     • Care coordination
                     • Self-management/health literacy
                     • End of life with advanced organ
                       system failure
                     • Ischemic heart disease
                     • Medication management
                     • Medication errors
                     • Overuse of antibiotics
                     • Nosocomial infections
                     • Pain control in advanced cancer
                     • Pregnancy and childbirth
                     • Severe mental illness
                     • Stroke
                                                         77
             IHI Improvement Map

• Open resource
   – Available free of charge for anyone
• Tool for identifying the key
  processes for
   – Improving hospital quality
   – Organizing your improvement efforts
   – Getting the information you need to
     get started
   – Containing 70 patient care and
     organizational processes

                                           78
79
외국에서 개발된 지표를
우리 병원에서 적용할 수 있을까?



                     81
82
Sometimes limited transferability




                                    83
지표 자체개발 OR 외국지표 도입 ?



                       84
  병원 자체개발 OR 외국지표 도입 ?

• 병원 자체 개발              • 외국지표 도입
 – Ownership             – 손쉽게 도입 가능
   [우리 병원이 개발한 지표]       – 우리나라/병원에 활용가
 – 이해당사자 참여 유도             능한 중요지표 존재
 – 한국/우리 병원에 중요한         – 한국/우리 병원 상황
   지표 개발 가능                반영한 Modification 필수
   cf) AMI vs. Stroke
                         – Ownership 부재
 – 많은 시간과 노력               [특히 의사들…]
   [잘 만들려면…]               [우리 나라/병원은 특수
 – 적은 노력으로 개발 가능           …]
   [대충 만들면…]             – 충분히 이해하지 못한
                           상태에서 적용할 우려 85
  질향상 활동: 의사 참여 유도 전략
• 비효과적 전략                    • Grimshaw et al (2001)
 – 수동적 교육                      의사 대상 진료행태 변화
   passive = lecture style     1.   강의
 – 한가지 중재                      2.   강의 + 진료지침 reminder
                               3.   강의 + 환자 맞춤형 피드백
• 효과적 전략
 – 능동적 교육 interactive        • 결과
 – 다양한 중재                      1.    효과 (-)
 – 의료계 지도자에 의한 교육              2와 3. 효과 (+)
     • 효과적 / 심한 편차




                                                       86
        Model for Improvement:
Four key elements of successful process improvement
1. 구체적 목표
2. 지표: 개선 정도 측정
3. 목표 달성할 수 있는
   질향상 활동
4. 여러 차례 질향상 활동
   사이클 반복


     임상질지표는
   질향상 활동의 일부

                                                                                                     87
                Plsek PE. Improving care through collaboration. Pediatrics. 1999;103(1 Suppl E):384-93.
III. 임상질지표 개발
     임상질지표 개발 과정
   Selecting Topics     • 주제 선정


      Reviewing         • 의학적 근거 찾기
  Clinical Evidence

      Identifying       • 지표 만들기
  Clinical Indicators

Constructing Measures   • 지표 정의하기

      Creating          • 측정방법 개발하기
  Scoring Methods
                                      89
         주제 선정 : 기준
• 가장 중요한 단계

• 건강에 중요한 영향
 – 흔함/중증/개선가능성
 – 건강수준지표: 사망률/이환률/기능상태/삶의 질

• 병원 전략계획과 연관된 주제

• 고려사항
 – 자료수집 노력/가능성
 –
                               90
        의학적 근거 찾기: 질문 작성
• What is known about effective interventions
  [구체적인 질문 작성]
• Continuum of care
  –   효과적인 예방법
  –   집단검진의 효과성
  –   효과적 진단 도구
  –   효과적 치료 방법
  –   효과적 지속적 관리 방법

   비효과적인 집단검진/진단/치료/관리
   Underuse vs. Overuse
                                                91
         의학적 근거 찾기: 문헌 검색
• Cochrane Collaboration
   – Structure of a Cochrane Review
     http://www2.cochrane.org/reviews/revstruc.htm

• AHRQ Evidence-based Practice Center
   – http://www.effectivehealthcare.ahrq.gov/


• National Institute for Health and Clinical Excellence
   – http://www.nice.org.uk/guidance/index.jsp


                                                          92
 의학적 근거 찾기: 임상진료지침 활용
• 임상진료지침 활용
 – 일반적으로 Continuum of care에 대한 진료지침 포함




            • http://guideline.gov/
            • 2천개 이상의 임상진료지침 포함
            • 다양한 지침 개발원
                 • WHO
                 • 유럽 임상학회들
                                         93
                      지표 만들기
           Identifying Clinical Indicators
• 예> 지표(안) : 당뇨병 환자 매년 HbA1c 측정

• RAND/UCLA Appropriateness Method
 [http://www.rand.org/pubs/reprints/RP395/]
  – Established indicator selection process
  – Combining a evidence review with formal expert
    panel process
     • 9 명 전문가 패널 : 지표와 근거 검토
     • 1~9점 척도 평가
     • 전문가 합의 도출 : Modified Delphi method
                                                     94
           지표 정의하기
         Constructing Measures
• 일반사항
 – 지표 : 지표 및 하위 지표
 – 지표 설명
 – 지표 개발 근거

• 측정
 – 분모 / 분자 / 포함 및 제외기준
 – 자료 항목 / 수집방법 / 정확도
 – 중증도 보정 필요성

• 참고문헌
                                 95
         Measure Information Set (1)
• Measure Set: Acute Myocardial Infarction
• Set Measure ID #: AMI-1
• Performance Measure Name: Aspirin at Arrival
• Description: Acute myocardial infarction (AMI) patients
  without aspirin contraindications who received aspirin
  within 24 hours before or after hospital arrival.
• Rationale: The early use of aspirin in patients with acute
   myocardial infarction results in a significant reduction in
   adverse events and subsequent mortality. Aspirin therapy
   provides a percent reduction in mortality that is
   comparable to thrombolytic therapy and the combination
   provides additive benefit (ISIS-2,1988). National
   guidelines strongly recommend early aspirin for patients
   hospitalized with AMI (Braunwald, 2000 and Ryan, 1999).
   Despite these recommendations, aspirin remains
96
   underutilized in older patients hospitalized with AMI
           Measure Information Set (2)
• Type of Measure: Process
• Improvement Noted As: An increase in the rate
• Numerator Statement: AMI patients who received
  aspirin within 24 hours before or after hospital
  arrival
     – Included Populations: Not Applicable
     – Excluded Populations: None
     – Data Elements: Aspirin Received Within 24 Hours Before or After
       Hospital Arrival
• Denominator Statement: AMI patients without aspirin
  contraindications
     – Included Populations: Discharges with an ICD-9-CM Principal
       Diagnosis Code for AMI as defined in Appendix A, Table 1.1
97
             Measure Information Set (3)
•    Excluded Populations:
      – Patients less than 18 years of age
      – Patients transferred to another acute care hospital or federal hospital on
        day of arrival
      – Patients received in transfer from another acute care hospital, including
        another emergency department
      – Patients discharged on day of arrival
      – Patients who expired on day of arrival
      – Patients who left against medical advice on day of arrival
      – Patients with one or more of the following aspirin
        contraindications/reasons for not prescribing aspirin documented in the
        medical record:
          • Active bleeding on arrival or within 24 hours after arrival
          • Aspirin allergy
          • Coumadin/warfarin as pre-arrival medication
          • Other reasons documented by a physician, nurse practitioner, or
            physician assistant for not giving aspirin within 24 hours before or
            after hospital arrival

98
         Measure Information Set (4)
• Data Elements:
   – Admission Date, Admission Source, Arrival Date, Birthdate,
     Contraindication to Aspirin on Arrival, Discharge Date, ICD-9-CM
     Principal Diagnosis Code, Transfer From Another ED
• Risk Adjustment: No
• Data Collection Approach: Retrospective data sources for
  required data elements include administrative data and medical
  records.
• Data Accuracy: Variation may exist in the assignment of ICD-9-
  CM codes; therefore, coding practices may require evaluation
  to ensure consistency.
• Measure Analysis Suggestions: None
• Sampling: Yes, for additional information see the Sampling
  section
• Data Reported As: Aggregate rate generated from count data
99 reported as a proportion
                Measure Information Set (5)
•     Selected References:
       –   Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, Jones RH,
           Kereiakes D, Kupersmith J, Levin TN, Pepine CJ, Schaeffer JW, Smith EE III, Steward DE,
           Theroux P. ACC/AHA guidelines for the management of patients with unstable angina and
           non-ST-segment elevation myocardial infarction: a report of the American College of
           Specifications Manual for National AMI-1-3 Hospital Quality Measures
       –   Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on
           the Management of Patients with Unstable Angina). J Am Coll Cardiol 2000;36:970-1062.
           Available at http://www.acc.org and http://www.americanheart.org.
       –   Randomised trial of intravenous streptokinase, oral aspirin, both or neither among 17,187
           cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of
           Infarct Survival) Collaborative Group. Lancet. 1988 Aug 13;2(8607):349-60.
       –   Jencks SJ, Cuerdon T, Burwen DR, Fleming B, Houck PM, Kussmaul AE, Nilasena DS,
           Ordin DL, Arday DR. Quality of medical care delivered to Medicare beneficiaries: a profile at
           state and national levels. JAMA. 2000;284:1670-1676.
       –   Ryan TJ, Antman EM, Brooks NH, Califf RM, Hillis LD, Hiratzka LF, Rapaport E, Riegel B,
           Russell RO, Smith EE III, Weaver WD. 1999 update: ACC/AHA guidelines for the
           management of patients with acute myocardial infarction: a report of the American College of
           Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on
           Management of Acute Myocardial Infarction). J Am Coll Cardiol 1999;34:890-911. Available
           at http://www.acc.org and http://www.americanheart.org.
       –   Ryan, TJ, Anderson, JL, Antman, EM, Braniff, BA, Brooks NH, Califf, RM, Hillis LD, Hiratzka
           L F, Rapaport E, Riegel BJ, Russell RO, Smith EE III, Weaver WD. ACC/AHA guidelines for
           the management of patients with acute myocardial infarction: a report of the American
           College of Cardiology/American Heart Association Task Force on Practice Guidelines
           (Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol
           1996;28:1328-1428. Available at http://www.acc.org and http://www.americanheart.org.
100
       분자 - 기준충족환자 기준 예:
        당뇨병 환자에서 매년 HbA1c 측정
 제외 기준                    포함 기준

 모든 연령층 OR 어린이/노          당뇨병 환자 정의 기준
  인 제외 ?                   – Reason for visit = DM
 Type 1 & Type 2 당뇨병 ?    – Medication order : DM 부합
                           – 당뇨병에 대한 의무기록
 신규 환자 vs. 모든 환자
 당뇨병 임산부 포함 ?             자료수집 대상 기간 제한
 합병증 존재 시 제외?              과거 자료가 부정확한 경우
  – 어떤 합병증 ? 예를 들어 암        일정 시점 이후 자료만 포함
    환자 – 암치료 우선



                                                    101
          측정방법정의하기
         Creating Scoring Methods
• 일반사항
 – 지표 : 지표 및 하위 지표
 – 지표 설명
 – 지표 개발 근거

• 측정
 – 분모 / 분자 / 포함 및 제외기준
 – 자료 항목 / 수집방법 / 정확도
 – 중증도 보정 필요성

• 참고문헌
                                    102
                   요약
• 질향상 : 의료기관 인증평가만으로 “질향상” 곤란
 – 주요 임상진료의 질 모니터링
 – 임상질지표 기반 질향상 사업

• 외국의 임상질지표 Resource 활용
 – 하지만 개발할 수도…
   • 원하는 지표가 없거나
   • 의료진[의사]들의 ownership 중요할 때

• 임상질지표 개발
 – 개발 절차 충실히 지켜서
 – 질향상 사업의 일부로서 임상질지표
                                 103
감사합니다


yoonkim@snu.ac.kr

				
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