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Overview and Recommendations
Welcome!
This is the 14th annual assessment by the Vermont Program for Quality in Health Care (VPQ) measuring the quality of health care received by Vermonters and highlighting improvements across the state. The Vermont Health Care Quality Report was the first report of its kind in the nation, was recognized for its excellence by the Institute of Medicine[1] and subsequently served as the template for the National Health Care Quality Report, now published by the Agency of Healthcare Research and Quality[2]. The Quality Report remains unique in evaluating the quality of health care in Vermont.
Incorporated in 1989, VPQ has never changed its mission to measure and improve the quality of care the citizens of Vermont receive. And the need for VPQ has never diminished in spite of many years, many technologic advances, many health reform efforts and many different individuals and partners. The Institute of Medicine’s seminal report on the Future of Quality in Rural Health Care[3] highlighted five essential components for change and success. Included among the paramount needs for financial reform, consumer engagement, focus on chronic illness, primary care and information technology was the central role for a quality improvement infrastructure. The Vermont Legislature has wisely continued support for that quality infrastructure with years of investment in building and supporting its own Vermont Program for Quality – VPQ.
The overall construct for this year’s Quality Report is the very construct of quality improvement itself, a continual cycle of analyzing and clarifying the needs for improvement, developing intelligent interventions, implementing those interventions and finally evaluating these efforts and deciding whether we succeeded, could we make further improvements, or should we go back to the planning stage. The overall result of Quality Improvement is interpreting data to create useful information; applying subject matter expertise to the information to create knowledge; and applying that knowledge as actionable interventions. Additionally, it is essential that interventions be coupled with rigorous evaluation. In the current economy it is crucial that limited resources are directed toward success and not wasted on something that sounded good to begin with, but failed to deliver as promised.
Three themes are prominent throughout the various chapters of this year’s Quality Report:
1) Change is just as difficult at the granular level of our primary care practices and rural hospitals as it is at the statewide or national level; and that as a state we need to recognize the importance of supplying quality improvement resources to our frontline care providers;
RECOMMENDATION – Ensure adequate quality improvement
resources and time for our frontline care providers
2) Evaluation of interventions is crucial both on the micro-system level of a primary care clinic and on the macro-system of statewide reform. Quality Improvement is a data-driven process whether at the local or statewide level. Hand in hand with the need to insist on rigorous evaluation is the need for broad access to useable data itself; and
RECOMMENDATION – Increase access to timely and useable data
to support evaluation of Reform at both the micro and macro levels
3) Evaluation in itself can be costly, incomplete and even erroneous. In times of scarce resources, evaluation needs to be intelligently designed to be both efficient and valid. The VPQ Report to the New England Rural Roundtable on the appropriateness of state and federal mandated evaluation of Critical Access Hospitals highlights the need for continual reexamination of the appropriateness of evaluation efforts.
RECOMMENDATION – Evaluation efforts themselves need to be
continually evaluated for both rigor and relevance
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Access and support of quality improvement resources for providers must be part of Health Care reform, and Health Care Reform itself should be based on the continual cycle of improvement. Quality Improvement must be both an internal cog in a reforming delivery system and a key overarching construct for Reform itself.
Figure 1: Components of the Quality Improvement Cycle
Creating Useful Information from Data
The initial chapters of this year’s Report focus on creating information from data. Chapter 1 summarizes original VPQ research based on analysis of Medicare billing data. This work is important because of the unique potential to look at the care that our older citizens receive across care settings and the potential to equate utilization and cost with health outcomes. Chapter 2 makes the case for a coordinated effort across both public and private sectors in Vermont to develop more access to health care data and improvements in the data itself. This need is critical in view of potential new reform efforts and evaluating the success of those in place.
Interpreting Information to Create Knowledge
Chapter 3 is an accessible explanation of some key measurement methods that underlie policy discussions about resource allocation and accountability for health outcomes and costs. VPQ included this section as a resource for policy makers and planners as well as the general public who follow the dialogue on health care reform. Our hope is that more people will be able to understand and participate in the conversations on what’s the best health care for our state.
Using Knowledge to Design Interventions
Chapters 4, 5, and 6 all highlight partnerships between VPQ, health care practitioners and communities that are using knowledge from previous VPQ analyses and their own sources to make change that matters. The quality improvement efforts focus on: Care Coordination across Settings in Randolph; Reducing Potentially Avoidable Hospitalizations in Bennington; and Shared Decision Making between practitioners and patients on Women’s Health Concerns in Springfield.
Chapter 7 celebrates the very successful Medical Home Readiness Collaborative that VPQ hosted this year that is so critical to efforts to sustain and improve primary care in our state.
Did We Make a Difference?
Rutland Regional Medical Center has asked VPQ to formally evaluate their innovative and popular Palliative Care Program that they introduced recently. They are interested in quantifying the difference they have made and, if the results are as good as expected, have their success serve as a model for others around the state.
VPQ also partnered with Bailit Health Purchasing to assess the appropriateness and completeness of the evaluation plans for several state programs designed to address the needs of Vermonters with chronic illness. The study concludes that there are numerous positive features of evaluation methods being used to assess the state’s chronic care programs, but there is also substantial room for improvement. The VPQ Roadmap study makes the recommendation that the state needs a uniform evaluation strategy that arches over all programs and departments in order to best judge what’s working and what’s not.[4]
Comprehensive QI Partnerships
The final chapters put two major VPQ partnerships in the spotlight; both efforts use all the component pieces of the quality improvement cycle. VPQ has partnered with the Department of Health, acute care hospitals and long-term care facilities to combat the emerging problem of antibiotic resistant bacteria in our care facilities and specifically the transfer multi-drug resistant infections from one care setting to another. The effort has caught the interest of the federal Center of Disease Control and Prevention which is adding additional in-kind resources.
Another effort focuses on the quality of care at our eight Critical Access Hospitals. This effort is funded with federal monies through the Vermont Office of Rural Health. This effort has assisted these eight hospitals with their eligibility to receive Medicare and Medicaid reimbursements which are critical to their survival. In the coming year, the partnership is being expanded to include a statewide collaborative effort to improve critical care services in our rural hospital emergency departments. Another related VPQ activity is the creation of a tight network of quality personnel among the various institutions with the intent to leverage the knowledge and quality resources at each hospital.
The Quality Improvement Cycle
Consistent with the overarching construct of this year’s Quality Report, we welcome your feedback regarding this report and VPQ’s improvement activities. VPQ is dedicated to continually improving the manner in which we report and inform our readers about the quality of healthcare in Vermont. Also in the spirit of quality improvement, we hope that you will find inspiration from either the findings and recommendations from the analytic sections of this report or the highlighted quality improvement efforts in other parts of the Report. Quality improvement is principally about learning from our own efforts and those of others to be inspired to try new ways of doing things either from measured success or failure. Quality improvement is based on the scientific model; it is data driven and results oriented.
We invite your feedback on how to continually improve the nascent quality infrastructure we must have in Vermont in order to truly reshape our health care delivery system to provide the best care to all of us, all the time, no matter where we live, or what the circumstances may be.
[3] Institutes of Medicine, Quality Through Collaboration: The Future of Rural Health Care (2005)
[4] VPQ recognizes Joshua Slen of Bailit Health Purchasing for the leadership and hard work he contributed to this study.
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