Quality of Care Measurement To assess the quality o.docx

Quality of Care Measurement
“To assess the quality of medical care one must first unravel a
mystery: the meaning of quality itself. It remains to be seen
whether this can be done by patiently teasing out its several
strands or whether one must, in despair, use a sword to cut the
Gordian knot”.
Avedis Donabedian,1980
The Triple Aim
Proposed by Donald Berwick as the previous Administrator of
the Centers for Medicare and Medicaid Services
An attempt to transform the American healthcare system in
accord with the vision set forth in his 2008 “Triple Aim” Health
Affairs article.
Consists of three overarching goals:
Better care for individuals (described by the six dimensions of
health care performance listed in the Institute of Medicine’s
2001 report “Crossing the Quality Chasm”: safety,
effectiveness, patient-centeredness, timeliness, efficiency, and
equity).
Better health for populations (by addressing “the upstream
causes of so much of our ill health,” such as poor nutrition,
physical inactivity, and substance abuse).
Reduction in per capita healthcare costs

Romano, P.S. (March 1, 2012). Quality Measurement 101 A
Framework for CVEs. CVE Annual Meeting.
Hospital Quality: M&M cases
“Monday Mornings”
Morbidity and mortality (M&M) conferences: recurring
conferences conducted by medical services at academic medical
centers, most large private medical and surgical practices, and
other medical centers
Usually peer reviews of mistakes occurring during the care of
patients
Main objectives: to learn from complications and errors, to
modify behavior and judgment based on previous experiences,
and to prevent repetition of errors leading to complications.
Non-punitive and focus on the goal of improved patient care
Proceedings generally kept confidential by law, occur with
regular frequency (often weekly, biweekly or monthly),
highlight recent cases of concern, and identify areas of
improvement for clinicians involved in the case.
Also important in identifying systems issues (e.g., outdated
policies, changes in patient identification procedures, arithmetic
errors, etc.) which affect patient care
Wikipedia

Case: Right Regimen, Wrong Cancer
A 48-year-old man with a history of metastatic penile cancer
was admitted to an inpatient internal medicine service for his
fourth round of chemotherapy.
He had three previous uncomplicated admissions where he
received a standard protocol of 3 days of paclitaxel, ifosfamide,
and cisplatin.
The patient received this regimen for 3 days with minimal
adverse effects.
On hospital day 4, based on his previous admissions for
chemotherapy, the patient was expecting to go home.
6
6
In the morning his nurse for the day came in and stated that she
would be giving him his fourth day of chemotherapy.
The patient was surprised by this and, before the chemotherapy
was administered, asked to speak with the oncology team who
was directing his care.
After speaking with the patient, the oncology fellow examined
the orders in more detail and realized that the incorrect
chemotherapy regimen had been ordered for the patient.
7

7
Rather than the 3-day regimen for metastatic penile cancer, the
order stipulated a higher dose 5-day regimen of paclitaxel,
ifosfamide, and cisplatin for germ cell cancer
The oncology fellow and the attending oncologist discussed this
with the patient and he was discharged later that day with no
adverse consequences.
8
8
Medication errors
9
Formal review of the case determined that the outpatient
oncologist (a specialist in penile cancers) recommended the
appropriate 3-day regimen to the oncology fellow.
This medical center had a functioning electronic health record
(EHR) and computerized provider order entry (CPOE), but the
chemotherapy order sets still existed on paper.

In choosing the chemotherapy regimen, the oncology fellow
inadvertently chose the wrong paper order set—he saw that the
order set included the correct agents but failed to notice the
higher dose and incorrect duration.
10
10
The inpatient attending oncologist, who had not previously met
the patient and was less familiar with penile cancer, co-signed
the fellow's incorrect orders.
Throughout the hospitalization, the primary internal medicine
team copied and pasted the original oncology outpatient note,
which stated the patient would receive the 3-day course of
chemotherapy, even though this differed from the 5-day regimen
that was ordered.
None of the other safety checks that existed (including the
presence of a chemotherapy pharmacist and chemotherapy nurse
checking the orders) identified the dose and duration error.
Where did the system fail this patient?
What tools can we use to examine the errors?
11
11

One method: Fishbone Analysis
Failure to Recognize the Wrong Regimen
Numerous factors contributed to the error:
Multiple handoffs
Lack of content expertise by the inpatient fellow and inpatient
attending
Lack of supervision by the attending oncologist
Location of the patient on a non-oncology unit for the treatment
of his cancer
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13
RoAnnualMeetingmano, P.S. (March 1, 2012). Quality
Measurement 101 A Framework for CVEs. CVE.
Health care domains: PESTEE
Effectiveness. Relates to providing care processes and
achieving outcomes as supported by scientific evidence.
Efficiency. Relates to maximizing the quality of a comparable

unit of health care delivered or unit of health benefit achieved
for a given unit of health care resources used.
Equity. Relates to providing health care of equal quality to
those who may differ in personal characteristics other than their
clinical condition or preferences for care.
Patient centeredness. Relates to meeting patients' needs and
preferences and providing education and support.
Safety. Relates to actual or potential bodily harm.
Timeliness. Relates to obtaining needed care while minimizing
delays.
15
Improvement of care
Avedis Donabedian (1988)
Structure: Better equipment
Process: Doing the right things better
Outcome: Obtain better results in
- effective services
- costs
- client and employee satisfaction

Mercy Hospital Emergency Department
Cedar Rapids, Iowa
A young family brings their 6-year-old daughter to the
emergency department (ED) at Mercy Medical Center.
The parents suspect the girl suffered a broken finger while
roughhousing with her younger brother, and now they are
hoping for prompt medical attention so they can return home
quickly.
Two potential outcomes to this scenario:
The family experiences a long, frustrating wait, with treatment
for their daughter’s injured finger delayed while ED staff
attended to more serious cases.
The young child receives timely treatment and the family is able
to return home in approximately one hour.
LEAN methodology
During the two-day lean value stream event in the ED, a cross-
functional team mapped the current state, identified non-value-
added processes and issues, and then developed an ideal state
and a future state for the department.
This initial work took place in February 2005.
The team also brainstormed ideas for improvements and created
a list of events, projects, and “do its,” which are items that are
quickly and easily corrected.

Suggested areas for improvement
Cross-training of ED technicians
Making changes to the software used during the discharge
process
Updating procedures so that some tests are conducted in the ED
rather than transferring the patient to another department
Registering patients at the bedside
Initiating teamwork activities to promote a culture change in the
department
Renovating the department’s front entrance and triage areas for
smoother patient flow
Implementing bedside registration and rapid triage
Allowing patients to bypass the waiting room and go directly to
exam rooms when available
Creating protocols that allow nurses to begin some treatments
before a physician sees the patient
Installing an electronic documentation system to improve the
discharge process
Restructuring the department’s leadership team to promote

consistency and teamwork
Appointing a medical director for the ED and building
administrative time into his schedule
The results
The Bottom Line

The demand for transparency:
http://www.healthgrades.com/
Agency for Healthcare Research and Quality: AHRQ
Prevention Quality Indicators: identify hospital admissions in
geographic areas that evidence suggests may have been avoided
through access to high-quality outpatient care
Inpatient Quality Indicators: reflect quality of care inside
hospitals, as well as across geographic areas, including
inpatient mortality for medical conditions and surgical
procedures.
AHRQ: continued
Patient Safety Indicators: reflect quality of care inside
hospitals, as well as geographic areas, to focus on potentially
avoidable complications and iatrogenic events
Pediatric Quality Indicators: use indicators from the other three
modules with adaptations for use among children and neonates
to reflect quality of care inside hospitals, as well as geographic
areas, and identify potentially avoidable hospitalizations

Outcomes Measures in Use by CMS
Measure Summary:
74 total current CMS outcome measures in use (approximately)
28 Inpatient
8 Physician
12 Home Health
14 Nursing Home
4 End-stage renal disease
8 Medicare Advantage
Hospital Inpatient Outcome Measures:
Mortality, Complications, Readmissions
Mortality (Medical Conditions)
30 day mortality AMI, HF, PNE, (CMS) *
Selected Medical Conditions (AHRQ) *
Mortality (Surgical Conditions/Procedures)
AAA, Hip Fractures (AHRQ) *
Selected Surgical Conditions (AHRQ) *
Death of surgical patients with treatable serious complications*
Complication/patient safety for selected indicators *
Complications (Medical and Surgical)
Post op wound dehiscence in abdominal-pelvic surgery *
Accidental puncture or laceration *
Iatrogenic pneumothorax *
MRSA Infection Rate; Transmission Rate (CMS-QIO)

Hospital Acquired Pressure Ulcers (CMS-QIO)
Readmission (Medical Conditions)
AMI, HF, PNE (CMS) *
All patient Readmission Rate (CMS-QIO)
Intermediate Outcome
Cardiac Surgery Patient Controlled 6 AM Glucose
Barbara Starfield, MD
Johns Hopkins
JAMA, 2000
Headline:
Central Florida hospitals among worst in state for infections
related
to patient stays
June 4, 2011| by Linda Shrieves, Orlando Sentinel
Several Central Florida hospitals were among the worst in the
state for life-threatening infections and conditions related to
patient stays, according to recently released data from the
federal government.
Many had rates for falls, blood infections, even bedsores that
were several times the national average.
Orlando Health, for instance, had the highest rate of life-
threatening blood infections in the state of Florida: four times
the national average.
South Lake Hospital's rate of falls among seniors was almost
three times the national average, as was Bert Fish Medical
Center's in Volusia County.

Continued:
In Daytona Beach, Florida Hospital Memorial Medical Center
had a rate nearly seven times higher than the national average
for foreign objects left in patients.
Leesburg Regional's rate in that category was about five times
the national average
In the category of bedsores, Winter Haven Hospital had the
second-worst rate in the state and was five times higher than the
national average.
Headline:
Central Florida hospitals among worst in state for infections
related
to patient stays
June 4, 2011| by Linda Shrieves, Orlando Sentinel
Several Central Florida hospitals were among the worst in the
state for life-threatening infections and conditions related to
patient stays, according to recently released data from the
federal government.
Many had rates for falls, blood infections, even bedsores that
were several times the national average.
Orlando Health, for instance, had the highest rate of life-
threatening blood infections in the state of Florida: four times
the national average.
South Lake Hospital's rate of falls among seniors was almost

three times the national average, as was Bert Fish Medical
Center's in Volusia County.
Headline: Hospitals haven't cut readmission rates
February 11, 2013 Marni Jameson, Orlando Sentinel
While Florida, with a surgical readmission rate of 12.6 percent,
came close to the national average of 12.4 percent, rates varied
widely among regions and hospitals in the Sunshine State.
Miami had the highest readmission rates: 15.1 percent of
surgical patients were readmitted within 30 days of discharge.
Meanwhile, Sarasota had the lowest rate at 9.7 percent.
At 13.2 percent, Orlando's surgical-readmission rates were
higher than the nation's.
In Orlando, the region's two largest hospitals had rates on the
higher end of the spectrum: At Orlando Regional Medical
Center, 15.7 percent of surgical patients were readmitted in
2010, and 14.9 percent had to check back into Florida Hospital.
Studies of Rehospitalizations
Nearly 20% of Medicare hospitalizations are followed by
readmission within 30 days.
90% of rehospitalizations within 30 days appear to be
unplanned, the result of clinical deterioration.
75% of readmissions are preventable, adding $12 Bn/yr to
Medicare spending.
Only half of the patients rehospitalized within 30 days had a
physician visit before readmission.

Unknown if lack of physician visit causes readmissions—but
poor continuity of care is a factor, especially among chronically
ill patients.
19% of Medicare discharges are followed by an adverse event
within 30 days - 2/3 are drug events, the kind most often judged
“preventable.”
Steve Hines, PhD Vice President, Research Health Research and
Educational Trust June 4, 2010
Florida Hospital Association Meeting
Sources and Credits
AHRQ WebM&M Spotlight Case May 2013
See the full article at http://webmm.ahrq.gov
Commentary by: Joseph O. Jacobson, MD, MSc, and Saul N.
Weingart, MD, PhD, Harvard Medical School
Editor, AHRQ WebM&M: Robert M. Wachter, MD
Spotlight Editor: Bradley A. Sharpe, MD
Managing Editor: Erin Hartman, MS
Steve Hines, PhD
Vice President, Research
Health Research and Educational Trust
June 4, 2010
Florida Hospital Association Meeting
48
48

The Value of Investment in Health Care
Better Care, Better Lives
The increase in health spending is a frequent topic of debate…
U.S. Health Care Expenditures per Person (2000 U.S. $)
Source: Health United States 2002, Consumer Price Index (All
Items)
…but the value of this investment
is seldom part of the discussion.
CBO Issues Warning on Rising Health Care Costs
Senate Republicans in Albany Eye Big Medicaid Cuts
Medicare Revamp Fails to Cure Angst Over Costs

New evidence finds our nation’s
health care dollars are well spent.Overall, each additional health
dollar spent produced a return of $2.40-$3.00 in:Deaths
avoidedIncreased longevityAdvances in care have improved
outcomes and quality of life in common diseasesHeart
attackType-2 DiabetesStrokeBreast cancer
Experienced Research TeamMEDTAP International – global
health services research firmBryan R. Luce, Ph.D.,
M.B.AFounder, Chairman, MEDTAP InternationalFormer
Director, Office of Research and Demonstrations, US Health
Care Financing AdministrationFrank Sloan, Ph.D.Director,
Center for Health Policy, Law and Management, Duke
UniversityJosephine Mauskopf, Ph.D.Global Director of Health
Economics, RTI Health

Solution
s
Multi-faceted Research ApproachOverall value of investment
1980 to 2000Dollar value of gains in annual population health
outcomes versus……the increase in annual health care
expendituresFocus on four common diseases: Heart attack, type
2 diabetes, stroke, and breast cancerAdvances in
careImprovements in outcomesOverall value of investment for
the Medicare populationValue of specific medical
breakthroughs
Conservative EstimatesEstimates of value:Value of gain of 1
year of life = $100,000*Value of less disability and increased
productivity not in overall estimateBenefits and harms of non-
health care changes even out**

*Source: Nordhaus (2002), Blomquist (2001)
**e.g. smoking, obesity, exercise, environment
Overall Value of Investment:
Findings
Since 1980, per capita expenses are up $2,254, but:Overall
death rate is down 16%Life expectancy from birth is up by 3.2
yearsDisability rates are down 25% for people over 65*56%
fewer days are spent in the hospital
Health gains of $2.40 to $3.00 per dollar invested
*Value of this improvement not quantified.
Overall Value of Investment:
Findings
$2254 per

capita
in
savings
470,000
more
deaths
2.3
million
more
disabled
persons
206
million
more
days in
hospital
Where would we be in 2000 without healthcare advances?
Findings: Four Common Diseases
Heart attack Type 2 Diabetes StrokeBreast Cancer

Why these four?Common conditions High disability and death
ratesNearly all at risk for one of these diseasesMedical
breakthroughs have improved outcomesValue of investment not
documented
U.S. Population Affected by Conditions Studied,
in millions, 2003
Source: American Heart Association; www.diabetes.org;
www.cdc.gov/nchs
Heart Attack
Heart Attack:
Advances in CareImprovements in drug therapyBlood flow
restored more quickly (clot-busters)Blockages better prevented
(anti-platelets, cholesterol lowering drugs)Advances in surgical
techniquesPTCA reopens arteries—more effective, less
invasiveStents keep blood vessels openAdvances in diagnostic
technologiesElectrocardiograms and diagnostic imaging provide
more rapid, precise diagnoses

Heart Attack:
Advances in Care
In the 1970s…5-7 days in critical care; 3-4 weeks in general
wardComplete bed rest for several weeksMinimal understanding
of risk factors/ preventive measures
Today…Total hospital stay of 5-7 days
People up and around within daysKey risk factors like
cholesterol and hypertension are routinely managed
Heart Attack:
Improvement in OutcomesMortality cut nearly in halfDeath
within 30 days cut from 1 in 4 to 1 in 8
Death Rate Due to
Heart Attack
(Age-adjusted, per 100,000)
Source: www.cdc.gov/nchs

Costs and Outcomes for Medicare Heart Attack Patients
*Five-year costs 1985-1989 versus 1995-1999, Medicare plus
out-of-pocket
Source: Analysis of Medicare Part A and Part B and National
Long-Term Care Survey data (1982-2000)
Value of improved outcomes:
(12% gain in life expectancy)
--minus--
Increase in treatment costs*:
(Medicare plus out-of-pocket)
Net benefit in dollars:
$28,632
$26,093
$2539
Value of $1.10 per dollar invested

Heart Attack:
Value of Specific Medical BreakthroughsBeta-blockersMobile
coronary care unitsStatin therapyAngiographyRt-PA
Angioplasty w/stenting
Breakthroughs vs. Current Standard Treatment
Range in Value per Dollar Invested
Source: Published literature
$38.44
Type 2 Diabetes
Type 2 Diabetes:
Advances in CareImprovements in drug therapyInsulin therapy

lasts longer and is more convenientNew classes of drugs with
fewer side effectsAdvances in diagnostic
technologiesHemoglobin A1c testing and glucose monitoring
kits allow more accurate, less invasive readingsAdvances in
surgical techniquesLaser surgery and vitrectomy procedures
treat eye diseaseDialysis and transplant surgery lengthen and
improve life
Type 2 Diabetes:
Advances in Care
In the 1970s…Insulin agents short-acting; inconvenient dosing
schedulesFrequent needles sticks to test glucose levelsLimited
understanding of need to control blood pressure and cholesterol
Limited treatment options for complications
Today…More effective options for insulin; long acting and
more convenientGlucose tests without puncturing the skinBetter
management of all aspects of disease reduces chances of
complicationsSurgical options for diabetic eye and kidney
disease improve quality of life

Type 2 Diabetes:
Improvement in Outcomes
Advances support tight management of disease; better
outcomes**Tight glucose control decreases mortality by 10%,
complications** by 25%Tight blood pressure control decreases
mortality by 32%, heart failure by 56%, stroke by 44%Gains in
employment and productivity with drug therapy to manage
disease
*Higher incidence—linked to increased rates of obesity—has
led to increased mortality rates (up 39%)
**eye, kidney, and nerve disease
Costs and Outcomes for Medicare
Type 2 Diabetes Patients
out-of-pocket
--minus--

$16,930
$11,337
$5,593
Type 2 Diabetes:
Value of Specific Medical BreakthroughsTight control of
glucose, blood pressure, and cholesterolStatinsAce
inhibitorsScreening and treatment of diabetic retinopathy
$36.00

Stroke
Stroke:
Advances in CareImprovements in drug therapyBlood flow
restored more quickly (clot-busters)Better-tolerated, more
effective drugs to control blood pressureAdvances in surgical
techniquesPTCA reopens arteries—more effective, less
invasiveCarotid endarterectomy clears plaque in carotid
arteriesAdvances in diagnostic technologiesImprovements in
brain imaging, such as weighted imaging, magnetic resonance
angiography

Stroke:
Advances in care
In the 1970s…Treatment options limited; disability rates
highTypical discharge to nursing home
Limited diagnostic technologies
Limited surgical options for prevention
Today…With rt-PA more stroke victims resume normal
lifeAcute and subacute rehabilitation widely availableNew
imaging technologies offer faster more precise diagnosisCarotid
endarterectomy and implanted microcoil devices can prevent
stroke
Stroke:
Improvement in OutcomesMortality cut by 37 percentFaster
diagnosis Stroke-related disability after 3 months reduced by up
to 30 percent with rt-PA
Death Rate Due to Stroke
Source: www.cdc.gov/nchs

Costs and Outcomes for Medicare Stroke Patients
out-of-pocket
--minus--
$24,903
$16,035
$8,868

Stroke:
Value of Specific Medical Breakthroughs
Source: Published literatureClopidogrelTiclopidinert-
PA*Carotid endarterectomy*
*Yields a savings in treatment costs
Breast Cancer
Breast Cancer:
Advances in CareImprovements in drug therapyAdjuvant
chemotherapy – more tolerant, less toxicBetter-tolerated
hormonal treatmentsAdvances in surgical techniquesBreast-
conserving surgeryLess-invasive biopsyAdvances in diagnostic

technologiesEarlier diagnosis
Breast Cancer:
Advances in Care
In the 1970s…Chemotherapy required
hospitalizationChemotherapy poorly toleratedMastectomies
were the norm
Few drug therapies existed
Mammography not in widespread use
Today…90% of chemotherapy is outpatientNew drugs reduce
nausea
Breast conserving surgery performed with reconstructionNew
drugs offer higher cure rates and less toxicityRoutine
mammography leads to earlier diagnosis
Breast Cancer:
Improvement in OutcomesMortality cut by 21 percentFive-year
overall survival rates increased from 76.9% to 86.6% Risk of
developing metastatic disease declined from 40% to 15%

Death Rate Due to
Breast Cancer
Costs and Outcomes for Medicare Breast Cancer Patients
out-of-pocket
--minus--
$22,341
$4,676

$17,665
Breast Cancer:
Value of Specific Medical BreakthroughsLetrozoleBreast-
conserving surgeryBiennial mammographyAdjuvant
chemotherapyStereotactic core biopsy
$36.81
Policy RecommendationsHHS should include a measure of
health benefits gained in its annual report on health care

spendingFurther study is needed on the role of innovation in
improving healthEmployers and health care providers should
account for the benefits of a healthier workforceDiscussions of
coverage for uninsured should consider value of investing in
health care for all Americans—not just the costs
$2,207
$3,541
$4,461
1980
1990
2000
17
2.2
4.7
7.6
Heart
Attack
Type 2
Diabetes
Stroke
Breast
Cancer
$1.42
At LeastAs Much As

$3.00
At LeastAs Much As
96.2
60.8
19802000
$2.00
$6.00
At LeastAs Much As
32.3
25.4
1980
2000
$3.27
At LeastAs Much As
345.2
186.9
19802000
ATTACHMENT D: Project Case Scenario
TURNROUND AT THE PORTLAND PLANT1

Introduction
“Before the crisis the quality department was just for looks, we
certainly weren’t used much
for problem solving, the most we did was inspection. Data from
the quality department was
brought to the production meeting and they would all look at it,
but no one was looking
behind it”. (Quality Manager, Portland Plant)
The Portland plant of Rexam Graphics was located in Portland,
Oregon, across the continent
from their headquarters in Massachusetts. The plant had been
bought from the James River
Corporation by Rexam in March 1998. Precision coated papers
for ink-jet printers accounted for
the majority of the plant’s output, especially paper for specialist
uses. Ink-jet products had a
particularly tighter production specification, especially in terms
of coat weight variation. The
plant’s process technology consisted of coating machines that

allowed precise coatings to be
applied. After coating, the conversion department slit and then
cut the coated rolls to shape.
The curl problem
In late 1996 Hewlett Packard (the plant’s main customer for
ink-jet paper) informed the plant of
some problems it had encountered with paper curling under
conditions of low humidity. There
had been no customer complaints to HP, but their own personnel
had noticed the problem.
Nevertheless HP took the curl problem seriously. Over the next
seven or eight months a team at
the plant worked on a series of design experiments to try and
isolate the cause of the problem.
Finally, in October of 1997 the team made recommendations for
a revised and considerably
improved coating formulation. By January 1998 the process was
producing product that HP
regarded as acceptable. However, 1997 had not been a good
year for the plant. Although sales
were reasonably buoyant the plant was making a loss of around
$1 million for the year. In

October 97, Tom Bickford, previously account manager for the
Hewlett Packard business, was
appointed as Managing Director.
Slipping out of control
By spring of 1998 the curl project was completed. Nevertheless,
productivity, scrap and re-work
levels were poor. In response to this the operations management
team increased the speed of the
line and made a number of changes to operating practice in
order to raise productivity.
1 Case reproduced with the permission of Dr. Nigel Slack,
Warwick College, where the case originated, 2007.
“Looking back, changes were made without any proper
discipline, there was no real concept
of control and the process was allowed to drift. The perception

was that we were always
meeting specification. Yet we didn’t fully understand how close
we really were to not being
able to make it. The culture here said, “If it’s within
specification then it’s OK” and we were
very diligent in making sure that the product which was shipped
was in specification.
However, Hewlett Packard gets ‘process data’ which enables
them to see more or less exactly
what is happening right inside your operation. Of course we
were also getting all the reports
but none of them were being internalized. We were using them
just to satisfy outsiders. By
contrast, HP have very much a statistical and technical
mentality which says to itself, “You
might be capable of making this product but we are thinking
two or three product generations
forward and asking ourselves, will you have the capability then,
and do we want to invest in
this relationship for the future?” (Tom Bickford)
The spring of 1998 also saw two significant events. First,
Hewlett Packard asked the plant to
carry out preliminary work for a new paper to supply the next

generation of HP ink-jet platform,
known as the Viper project. If won, the Viper contract would
secure healthy orders for the next
two or three years. The second event was that the plant was
acquired by Rexam.
“What did Rexam see when they bought us? They saw a small
plant on the West Coast of
America losing lots of money”. (Finance Manager, Portland
Plant)
Indeed Rexam were not over impressed by what they found at
the Portland plant. It had been
making a loss for at least two years and had only just escaped
from incurring a major customer’s
disapproval over the curl issue. They made it clear that, if the
plant did not get the Viper
contract, its future looked bleak. The plant’s engineers fully
understood the importance of Viper
and were working hard to develop the new product. Meanwhile,
out in the plant, the chief
concern continued to be centered around productivity issues.
But also, once again, Hewlett
Packard were starting to make occasional complaints to the

plant’s operations management about
quality levels. However HP’s attitude caused some
bewilderment to the operations management
team.
“When HP asked questions about our process the operations
guys would say, “Look we’re
making roll after roll of paper, it’s within specification (as seen
in Exhibit 1) and we’ve got
97 per cent up-time. What’s the problem?” (Quality Manager,
Portland Plant)
But it was not until summer that the full extent of Hewlett
Packard’s disquiet was made clear to
the plant’s senior management.
“The key milestone date for me, and I will never forget it, was
in June of ‘98. I was at a
meeting with HP in Chicago. It was not even about quality. But
during the meeting one of
their engineers handed me some SPC run data. This was data
that we had to supply with

every batch of product, and said “Here’s your latest run data.
We think you’re out of control
and you don’t know that you’re out of control and we think that
HP is looking at this data
more than you are.” He was absolutely right and there was
nothing I could say except that we
would do something about it. This was when I fully understood
how serious the position was.
We had our most important customer telling us we couldn’t run
our processes just at the time
we were trying to persuade them to give us the Viper contract”.
(Tom Bickford)
The Crisis
“At one point in May of ‘98 we had to throw away 64 jumbo
rolls of out-of-specification
product. That’s over $100,000 of product scrapped in one run.
Basically that was because
they had been afraid to shut the line down. If they failed to

keep the machines running we
would flog them and say, “You’ve got to keep productivity up”.
If they kept the machines
running but had quality problems as a result, we flogged them
for making garbage. Now you
get into far more trouble for violating process procedures than
you do for not meeting
productivity targets”. (Engineer, Portland Plant)
Returning from the Chicago meeting Tom immediately set about
the task of bringing the plant
back under control. Knowing that you had taken an operations
management class, Tom asked
for your help to help identify problem areas and make
recommendations to fix the problems.
Exhibit 1
Typical process control charts
May 1998

Quality Improvement in Neurology: Dementia Management
Quality Measures
Germaine Odenheimer, MD,a Soo Borson, MD,b Amy E.
Sanders, MD, MS,c Rebecca J. Swain-Eng, MS,d

Helen H. Kyomen, MD, MS,e Samantha Tierney, MPH,f Laura
Gitlin, PhD,g,h
Mary Ann Forciea, MD,i John Absher, MD,j Joseph Shega,
MD,k and Jerry Johnson, MDi
Professional and advocacy organizations have long urged
that dementia should be recognized and properly diag-
nosed.1,2 With the passage of the National Alzheimer’s
Project Act3 in 2011, an Advisory Council for Alzheimer’s
Research, Care, and Services was convened to advise the
Department of Health and Human Services. In May 2012,
the Council produced the first National Plan to address
Alzheimer’s disease, and prominent in its recommendations
is a call for quality measures suitable for evaluating and
tracking dementia care in clinical settings.4 Although other
efforts have been made to set dementia care quality stan-
dards, such as those pioneered by RAND in its series
Assessing Care of Vulnerable Elders (ACOVE),5 practition-
ers, healthcare systems, and insurers have not widely
embraced implementation. This executive summary (full
manuscript available at www.neurology.org) reports on a
new measurement set for dementia management developed
by an interdisciplinary Dementia Measures Work Group
(DWG) representing the major national organizations and

advocacy organizations concerned with the care of individ-
uals with dementia. The American Academy of Neurology
(AAN), the American Geriatrics Society, the American
Medical Directors Association, the American Psychiatric
Association, and the American Medical Association–
convened Physician Consortium for Performance Improve-
ment led this effort. The ACOVE measures and the
measurement set described here apply to individuals whose
dementia has already been identified and properly diag-
nosed. Although similar in concept to ACOVE, the DWG
measurement set differs in several important ways; it
includes all stages of dementia in a single measure set, calls
for the use of functional staging in planning care, prompts
the use of validated instruments in patient and caregiver
assessment and intervention, highlights the relevance of
using palliative care concepts to guide care before the
advanced stages of illness, and provides evidence-based
support for its recommendations and guidance on the
selection of instruments useful in tracking patient-centered
outcomes. It also specifies annual reassessment and updat-
ing of interventions and care plans for dementia-related
problems that affect families and other caregivers as well
as individuals with dementia. Here, a brief synopsis of
why major reforms in healthcare design and delivery are

needed to achieve substantive improvements in the quality
of care is first provided, and then the final measures
approved for publication, dissemination, and implementa-
tion are listed. J Am Geriatr Soc 62:558–561, 2013.
Key words: dementia; dementia management; quality
measures
OPPORTUNITIES FOR IMPROVEMENT
Health Care for Persons with Dementia Is Inconsistent,
Often Suboptimal, and Largely Unplanned
Peer-reviewed studies of dementia care document incon-sistency
in outpatient care,6,7 high rates of potentially
preventable episodes of acute care,8,9 and large numbers of
locus-of-care transitions.10 These findings suggest that
much of health care for individuals with dementia is
From the aDepartment of Geriatric Medicine, College of
Medicine,
University of Oklahoma, Oklahoma City Veterans Affairs
Medical Center,
Oklahoma City, Oklahoma; bDepartment of Psychiatry and
Behavioral

Sciences, School of Medicine, University of Washington,
Seattle,
Washington; cDepartment of Neurology, Albert Einstein
College of
Medicine, Bronx, New York; dAmerican Academy of
Neurology,
Minneapolis, Minnesota; eDepartment of Psychiatry, McLean
Hospital
and Harvard Medical School, Boston, Massachusetts; fAmerican
Medical
Association, Chicago, Illinois; gCommunity Public Health,
Center for
Innovative Care in Aging, Johns Hopkins University, hDivision
of
Geriatrics and Gerontology, School of Nursing and Department
of
Psychiatry, School of Medicine, Johns Hopkins University,
Baltimore,
Maryland; iDivision of Geriatric Medicine, Perelman School of
Medicine,
University of Pennsylvania, Philadelphia, Pennsylvania;
jAbsher
Neurology, Greenville, South Carolina; and kDepartment of
Geriatrics and
Palliative Medicine, University of Chicago, Chicago, Illinois.

Address correspondence to Rebecca J. Swain-Eng, American
Academy of
Neurology, 201 Chicago Avenue, Minneapolis, MN 55415. E-
mail:
[email protected]
DOI: 10.1111/jgs.12630
JAGS 62:558–561, 2013
© 2013, Copyright the Authors
Journal compilation © 2013, The American Geriatrics Society
0002-8614/14/$15.00
reactive and unsystematic. Chronic conditions, for which
prevention, early recognition, and timely treatment can be
delayed in the setting of dementia, leading to exacerba-
tions of other chronic conditions, largely drive ambulatory
care. Proactive outpatient care and care coordination could
reduce avoidable emergency department visits and hospital
admissions and potentially avert negative effects on indi-
viduals with dementia and caregivers that arise from pre-
ventable health crises.

Ethnic and Socioeconomic Disparities Are Important
Influences on the Quality of Dementia Care
Ethnic and socioeconomic disparities influence the rate and
quality of dementia diagnoses, the stage of decline at
which diagnosis occurs, the use of antidementia medica-
tions, the quality and type of end-of-life care, and the use
of community-based supportive services.11 Although beliefs
about dementia’s origins and significance may contribute
to some of these healthcare disparities, many quality prob-
lems affect minority and mainstream populations alike: a
lack of knowledge of what constitutes good dementia care,
inadequate resources, insufficient insurance coverage, lack
of access to knowledgeable professionals, and institutional
barriers. All contribute to the need for improvements in
healthcare design.
Partnership with Caregivers Is Integral to Improving
Care
Several different models of integrated care for dementia
have been described and have been shown to improve use
of community-based services, reduce the use of central ner-
vous system–active medications that may worsen cogni-

tion, increase family caregivers’ competence and reduce
their stress, and enhance the capacity of practice environ-
ments to provide dementia-specific care.6,10,12–16 Focus is
increasingly turning toward nonpharmacological modes of
management for mood and behavioral problems because
of the newly questioned value of antidepressant medica-
tions for depression in dementia,17–19 the modest efficacy
of antipsychotic medications for behavioral problems20
and the risks of cardiovascular events and mortality associ-
ated with their use, the cognitive toxicity of anticholinergic
medications,21 and recognition of the risks of falls and
other adverse outcomes associated with use of benzodiaze-
pines in elderly adults.22 Caregivers are essential partners
in healthcare management, as well as implementation of
nonpharmacological interventions that complement health
care; their knowledge, well-being, and sustained engage-
ment with healthcare providers are critical to the success
of medical and psychosocial components of care.
The Well-Being of Their Caregivers Strongly Influences
the Well-Being and Behavioral Stability of Individuals
with Dementia
Caregivers for individuals with dementia require individu-

alized attention and assistance to function their best.
Unmanaged caregiving stress adversely affects health,22–24
increases caregiver mortality risk,25 and promotes behav-
ioral decompensation in individuals with dementia, but
models for providing integrated care for caregivers and
individuals with dementia together have not gained trac-
tion outside specialized settings. Interventions targeted at
helping caregivers address dementia-related behaviors and
functional deficits can be effective,12,26–29 but these inter-
ventions are not typically covered under Medicare and
other insurance plans, and when such interventions are
locally available and caregivers use them, their effects may
not be apparent to medical providers, integrated into the
overall care plan, or tracked as components of quality of
care.
Comprehensive, Integrated Care and Quality
Improvement Initiatives Must Be Explicit and Practical
Despite the quality promise of comprehensive dementia
management, provider productivity standards and current
billing and reimbursement systems discourage its adoption
and undermine its consistency. Although much dementia

care is done through work with caregivers, the individual
with dementia must be present for most physician services
to be reimbursed under Medicare, regardless of whether
the individual is able to participate actively in his or her
own care. Moreover, there may be different handling of
neurological and psychiatric codes for the same dementing
condition; International Classification of Diseases, Ninth
Revision, code 331.0 identifies Alzheimer’s disease and is
reimbursed as a medical code, whereas code 294.1 denotes
senile dementia and is a psychiatric code reimbursed by
some plans under a mental health benefit, for which cover-
age may be more limited. Measuring dementia care activi-
ties of providers and health systems will create a solid
data resource for redesigning payment and coding struc-
tures so that they reflect the work providers need to, and
actually, do to provide high quality of care for persons
with dementia.
DEMENTIA MANAGEMENT QUALITY
MEASURES
In dementia care, desired outcomes include preserving, to
the maximum possible extent, cognitive and functional
abilities; reducing the frequency, severity, and adverse
effect of neuropsychiatric and behavioral symptoms; sus-

taining the best achievable general health; reducing risks to
health and safety; and enhancing caregiver well-being,
skill, and comfort with managing the individual with
dementia in partnership with healthcare providers. Clinical
performance measures would ideally include patient-level
outcomes as well as processes of care, although the pro-
gressive nature of most dementing diseases, the heterogene-
ity of comorbid conditions and the medical and other
management requirements, and the multiplicity of factors
that influence outcomes in dementia make development of
reliable self-reported outcome measures impracticable. In
their place, assessing the quality of dementia care must
rely on measuring care processes that have been associated
with positive outcomes in a rapidly evolving evidence base.
The DWG measurement set consists of 10 separate, audit-
able quality measures. These measures are inclusive of the
multiple stages of illness and can be viewed in five catego-
ries relevant to therapeutic decision making: assessment of
JAGS MARCH 2014–VOL. 62, NO. 3 QUALITY
IMPROVEMENT IN NEUROLOGY 559
the person with dementia after diagnosis (measures 1–4

and 6), management of neuropsychiatric symptoms (mea-
sure 5), patient safety (measures 7 and 8), palliative care
and end of life concerns (measure 9), and caregiver con-
cerns (measure 10)). For most measures, the proportion of
eligible individuals whose documented care meets the iden-
tified goal indicate care quality. Situations in which the
use of a particular quality measure may not be appropriate
for a particular individual (e.g., counseling regarding risks
of driving for an individual who does not drive) are speci-
fied with an exception to the measure. A brief summary of
each measure is found in Table 1. For the full measure
specifications, visit the Physician Consortium for Perfor-
mance Improvement Web site (www.physicianconsortium.
org). Readers interested in examples of how to meet indi-
vidual measures are referred to this Web site.
CONCLUSION
The DWG measures have the potential to dramatically
affect practice and improve the quality of care provided to
individuals with dementia. All of these measures except
measure 9 were selected for the 2012 and 2013 Physician
Quality Reporting System measures list,30 which provides
an incentive payment to eligible professionals who demon-
strate provision of high-quality care for specified condi-

tions and can accelerate adoption of dementia care quality
standards across all types of practice organizations and all
clinical disciplines providing health care for affected indi-
viduals. In addition, measure 2, Cognitive Assessment, is
included in the clinical quality measure list for Meaningful
Use 2, a Centers for Medicare and Medicaid Services Elec-
tronic Health Record incentive program designed to offer
financial incentives for the “meaningful use” of certified
electronic health record technology to improve patient
care.31
The emphasis on dementia management in this mea-
surement set recognizes the enormous challenge dementia
presents to individuals with dementia and their caregivers,
healthcare providers, public health agencies, and govern-
ment and private insurers. Although individuals with
dementia, caregivers, and health professionals await more-
effective disease-modifying treatments for individuals with
dementia, adherence to the measures outlined here will
improve the quality of life for individuals with dementia
and their caregivers.
ACKNOWLEDGMENTS

The AAN Board of Directors approved the dementia mea-
surement set on October 31, 2011, and the full membership
of the American Medical Association–convened Physician
Consortium for Performance Improvement approved it on
October 31, 2011.
Table 1. Final 10 Dementia Measures
Measure Description
1. Staging of dementia Patients, regardless of age, with a
diagnosis of dementia whose severity of dementia was classified
as mild, moderate, or severe at least once within a 12-month
period
2. Cognitive assessment Patients, regardless of age, with a
diagnosis of dementia for whom an assessment of cognition is
performed and the results are reviewed at least once within a
12-month period
3. Functional status assessment Patients, regardless of age, with
a diagnosis of dementia for whom an assessment of functional
status is performed and the results are reviewed at least once
within a 12-month period

4. Neuropsychiatric symptom
assessment
Patients, regardless of age, with a diagnosis of dementia and for
whom an assessment of
neuropsychiatric symptoms is performed and the results
reviewed at least once in a 12-month
period
5. Management of neuropsychiatric
symptoms
Patients, regardless of age, with a diagnosis of dementia who
have one or more neuropsychiatric
symptoms who received or were recommended to receive an
intervention for neuropsychiatric
symptoms within a 12-month period
6. Screening for depressive symptoms Patients, regardless of
age, with a diagnosis of dementia who were screened for
depressive
symptoms within a 12-month period
7. Counseling regarding safety
concerns

Patients, regardless of age, with a diagnosis of dementia, or
their caregiver(s), who were
counseled or referred for counseling regarding safety concerns
within in a 12-month period
8. Counseling regarding risks of driving Patients, regardless of
age, with a diagnosis of dementia, or their caregiver(s), who
were
counseled regarding the risks of driving and the alternatives to
driving at least once within a
12-month period
9. Palliative care counseling and
advance care planning
Patients, regardless of age, with a diagnosis of dementia, or
their caregiver(s), who received
comprehensive counseling regarding ongoing palliation and
symptom management and end of
life decisions AND have an advance care plan or surrogate
decision-maker in the medical record
or documentation in the medical record that the patient did not
wish or was not able to name a
surrogate decision-maker or provide an advance care plan

within 2 years of initial diagnosis or
assumption of care
10. Caregiver education and
support
Patients, regardless of age, with a diagnosis of dementia whose
caregiver(s) were provided with
education on dementia disease management and health behavior
changes AND were referred to
additional resources for support within a 12 month period
Full specifications are available on the Physician Consortium
for Performance Improvement Web site at
www.physicianconsortium.org. Readers interested
in examples of how to meet the measurement requirements are
referred to this document. Readers are also referred to the full
version for this article at
www.neurology.org in appendix e-1.
Copyright American Medical Association, 2012.
560 ODENHEIMER ET AL. MARCH 2014–VOL. 62, NO. 3

JAGS
Conflict of Interest: Dr. Sanders receives salary and
research support from the Einstein Clinical and Transla-
tional Science Awards Grant UL1 RR025750 and Grants
KL2 RR025749 and TL1 RR025748 from the National
Center for Research Resources (NCRR), a component of
the National Institutes of Health (NIH), and NIH road-
map for Medical Research; loan repayment support from
the National Institute on Aging (NIA) Loan Repayment
Program; has received pilot funds from the Resnick
Gerontology Center; has reviewed for the NIH/NIA, the
Centers for Medicare and Medicaid Innovation (CMMI),
the Patient-Centered Outcomes Research Institute (PCORI),
and the Alzheimer’s Association; has received honoraria for
serving on peer-review panels from the CMMI and PCORI;
and is a member of Medicare Evidence Development and
Coverage Advisory Committee. The contents of this manu-
script are solely the responsibility of the authors and do not
necessarily represent the official view of the NCRR, NIA, or
NIH. Dr. Absher serves on the South Carolina Alzheimer’s
disease Board of Directors.

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IMPROVEMENT IN NEUROLOGY 561
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property of Wiley-Blackwell
and its content may not be copied or emailed to multiple sites or
posted to a listserv without
the copyright holder's express written permission. However,
users may print, download, or
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