Closing quality and value gaps

Physician Executive, May-June, 2005 by Sheri Strite, Michael E. Stuart

In Part 1 of this series on evidence-based medicine (The Physician Executive, January/February, 2005, Vol. 31, Issue 1), we described the problem of inappropriate care in the United States and how solutions to cost and quality in health care can be effectively dealt with at the organizational level, and noted that purchasers will be carefully evaluating the details of organizations' quality structures and processes.

In Part II (The Physician Executive, March/April, 2005, Vol. 31, Issue 2) we described in detail how work groups can effectively identify gaps for closing to improve health care quality, cost, satisfaction and uncertainty. We also described the steps involved in critically appraising and synthesizing the medical literature.

We conclude this series by emphasizing the need to analyze both economic and non-economic impacts of proposed changes in the care we deliver and discussing the development of information, decision and action aids. We strongly recommend that professionals working in the quality improvement area develop or acquire useful tools to assist their staff with implementation and measurement.

After examining the published evidence regarding benefits and harms of a potential practice change, the next step in the evidence and value-based clinical improvement process is to assess the possible impacts on cost, quality, satisfaction and other considerations of implementing the change. The sequential steps are outlined in Table 1.

At this point, a value judgment needs to be made. Workgroup leaders or oversight groups are now in an excellent position to decide if the group should proceed with the project, if further modifications should be made or if the project should be stopped.

If the latter, document and summarize your decision, the history of your efforts and your analyses. If the decision is to proceed, the next steps are to create information, decision and action tools that meet the needs of various target groups such as clinicians, patients, leaders and other health care staff. These final steps are outlined in Table 2.

It has been 16 years since Donabedian described the components of quality in terms of people, preferences, systems, effectiveness and the three core elements of evaluating effective clinical improvement work--structure, process and outcomes.

It is now possible to combine leadership with a systematic approach to quality improvement using evidence and value-based methodology and improve the quality of the care we deliver. Medical leaders can now:

* Compare their organization's current performance to optimal care as defined by the best available scientific evidence which can now be accomplished by taking advantage of powerful electronic search technology and the skills and tools of evidence-based medicine

* Create the needed organizational structures, processes and supports to evaluate that evidence in the context of other considerations for value and, combined with effective leadership, successfully implement and measure practice change

* Improve patient care, use their resources more optimally and demonstrate to patients, insurers, accreditors, regulators, purchasers and others that they have an efficient, effective evidence-based system which can achieve desired outcomes.