5.4 What would a MediCaring Community monitor to guide decision-making?
The Community Board must become an active learning organization, aiming for continuous quality improvement (CQI). The concept of CQI derives from the work of W. Edwards Deming and colleagues, who first showed the potential of guiding reform with rapidly informative statistics and ongoing testing in his quality improvement work with the Japanese automotive industry. Deming exhorted reformers to consider the whole of the system they aim to optimize: “A system consists of components. Any company, any industry, consists of components that are different activities. All the components of the system must contribute to the system, not exist for their individual gains.”[158] In general, he said, successful quality improvement efforts require five elements:
- Foster and sustain a culture of change and safety.
- Develop and clarify an understanding of the problem.
- Engage key stakeholders.
- Test change strategies.
- Conduct continuous monitoring of performance and reporting of findings to sustain the change.
In a Medicaring Community, the Community Board will be ultimately responsible for delivering on these requirements, so success requires a comprehensive and appropriate monitoring system that assures timely knowledge of implementation, service supply and quality, and system efficiency. These elements form the nucleus of a community dashboard that will serve to manage and share information about the local system. In addition to tracking progress, the community will need to establish a cost and quality baseline for each important metric, against which to measure system improvement. Monitoring will serve several specific and overlapping goals, as follows:
- Providing rapid and actionable feedback on utilization and costs
- Ensuring quality of care by external standards
- Functional limitations, symptoms, mortality
- Medication appropriateness and management
- Workforce skills and adequate numbers
- Ensuring quality of care from the perspective of the frail elderly person and his or her family
- Assessing supply and distribution of services
- Assessing the effects of elder care and improvements upon the community, including confidence and civic pride.
The strategies to accomplish these ends are numerous, and the ones chosen will depend in part on the availability of timely data in each MediCaring Community. Data will come from the conventional sources of administrative records of claims and payments, questionnaires from the client and/or family representative, and review of the records kept by service providers. These will generate a number of conventional metrics: 30-day readmissions, pressure ulcers, falls, location at the time of death, hospice use, and more. The records will be enriched with comprehensive assessments and care plans, which will anchor new measures of quality and utilization, including adherence to the elderly person’s goals and confidence in the care system. The MediCaring Community’s Community Board will need to monitor total costs of care, including out-of-pocket costs from patients and families, Medicare, Medicaid, Older Americans Act, local revenues, long-term care insurance, and veteran’s benefits.
A characterization of the community’s outcome from a sample of case studies that tallied the patient and family experiences and the services provided in the last couple of years before death could help MediCaring Communities estimate baseline performance and costs more accurately. This technique may prove to be an efficient approach for measuring quality of care during the last years of life, and an inexpensive method for auditing the care of all of a community’s frail elderly persons. The stories collected would also be very helpful in outreach and education efforts in the community (with family consent to make the information public).
To orient care systems around frail elders’ needs and goals, MediCaring Communities need frequent feedback on how frail elderly persons and their families and caregivers experience the delivery system. These elder and family surveys could be very short, consisting of only a few questions, using various rating approaches. They would be designed to generate reports about how often the frail elderly person’s situation seemed out of control or frightening, recent health and LTSS use, and how well (global self-rating) the care is meeting their priorities and goals.
Some aspects of care will require assessing the perceptions of key provider stakeholders, e.g., the medical director of the emergency department, emergency transport staff, a funeral director, local hospice leaders, and intervention leaders. The themes and trends in these interviews should illuminate how substantially practices have changed in the community, what shortcomings participants are seeing, and the general level of enthusiasm for ongoing change.
Some events are so distressing that the MediCaring Community should require reporting and investigating them. Major treatment errors and many hospital-acquired problems are already reported to public officials for all patients, and these could be publicly reported separately for a subset of frail elders. Other errors that especially affect this population should be reported and analyzed within a MediCaring Community: e.g., medication errors with harms, falls with injury, failure to follow an explicit and appropriate advance directive, onset of a new stage III or IV pressure ulcer, family caregiver quitting or self-harm, inadequate supply of an important service, and enrollee or caregiver distress with services.
The Community Board will need an appropriate staff and internal and technical support capabilities to manage data and public display quickly and efficiently.
[158] (Deming 1994)
