Healthcare quality a janus view
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Healthcare Quality - a Janus view . Rajesh Patel BHF May 2009. Janus. In Roman mythology, Janus (or Ianus) was the god of gates, doors, doorways, beginnings and endings

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Healthcare quality a janus view

Healthcare Quality - a Janus view

Rajesh Patel


May 2009



  • In Roman mythology, Janus (or Ianus) was the god of gates, doors, doorways, beginnings and endings

  • Janus was usually depicted with two heads looking in opposite directions. According to a legend, he had received from the God Saturn, in reward for the hospitality received, the gift to see both future and the past.

Healthcare quality

Healthcare Quality



  • What is quality?

  • Janus view of quality using HQA 2008 report results

  • Message

    • System excellence, weaknesses and cost drivers

    • Some suggestions on risk management

    • Value of HQA report and participation

Healthcare quality a janus view

What is “quality” in Healthcare?

Major attributes of quality noun in healthcare

Major attributes of Quality (noun) in Healthcare

  • Access

    • Transport

    • Benefits

  • Accountability

  • Affordability

  • Continuity of care

  • Efficacy

  • Effectiveness

  • Efficiency

  • Equity

Quality assurance

Quality Assurance

  • Definition

    • Anything done to measure and improve quality of care.

  • 3 dimensions

    • To define

    • To measure

    • To improve

  • Tools

    • Accreditation

    • Provider profiling

    • etc

Quality verb improvement medical audit

Quality (verb) Improvement & Medical Audit

Ncqa diabetes quality improvement it is an ongoing process

NCQA: Diabetes quality improvementIt is an ongoing process!

Healthcare quality implementation and assessment

Healthcare Quality: Implementation and Assessment

  • Structure/ standards

  • Process

  • Outputs including Outcomes

Healthcare quality assessment

Healthcare Quality Assessment

Structure practice guidelines

Structure: Practice Guidelines

  • 52-55% adherance to guidelines1,2

Use of CPGs by 28 Canadian healthcare facilities 3% of respondents

Use CPGs regularly (well-established CPG process/program) 12.7

Use CPGs occasionally (on an ad hoc basis) 23.3

Beginning to explore of develop CPGs 22.8

Never use CPGs 40.7

No response 0.4

  • NCQA

  • Disease Management Network


Structure pmb

Structure: PMB

  • Equity & Access

    • 26 CDL

      • Iniquitous, therefore unconstitutional

      • Technically, not part of PMB!

    • DTP

      • Menopause

      • Life threatening vitamin and mineral deficiency

        • Always late Pathologist

  • Effectiveness

    • Interferon for MS

  • Efficiency

    • At cost, no limitation

  • Affordability

    • Without specification

  • Accountability

Too many inconsistencies!

Good intentions lost through implementation!

Health quality improvement for industry medical aid scheme

Health quality improvement for “Industry Medical Aid Scheme”

  • As seen through the eye of trustee, CEO or health risk manager

  • HQA report

    • 2007 claim data

    • Claims paid from risk and savings benefits

      • Unpaid claims not included

    • Normalised

    • 2 schemes resubmitted data

Medical school humour

Medical School Humour

  • Physician

    • Knows a lot, does little

  • Surgeon

    • Knows a little, does a lot

  • Pathologist

    • Knows a lot, does a lot, always too late!

Maternal health 2005 2007

Maternal Health 2005-2007

  • Contraception

    • ppp

  • Above 30%

    • Inefficiency cost

    • Solutions:

      • Professionalism

      • Clinical governance

      • Financial incentives proposal…

District Health Barometer 2007/08

According to darwin future human race

According to Darwin: “future” human race

Healthcare quality a janus view


DUR intervention to promote benefit

10% of adults

Diabetes 2005 and 2007 is there place for disease management

Diabetes: 2005 and 2007Is there place for disease management?

  • What happened to cholesterol coverage?

  • 2005/2007 difference

  • Podiatry and LL amputation observation?

  • Intervention: In-house or CDE?

Diabetes 2005 2007 and cde not case mix adjusted

Diabetes: 2005, 2007 and CDENot Case-mix adjusted!




CDE: n =13312; 7-10% of FFS Diabetics

Asthma it s about reversibility

Asthma It’s about reversibility!

  • SA

    • 4th highest asthma related death rate in the world

  • 1999: MSO

    • Peak flow for self Mx: 17%

    • World Asthma meeting 2001

Copd too little too late

COPD:Too little, too late!


*MAG conference 2002

Limited treatment options:

What about Spiriva into the future?

Healthcare quality a janus view



*MAG conference 2002

Preventative care and the pmb

Preventative Care and the PMB

  • Screening is not justified when treatment is inaccessible

  • Prostate screening not included!

    • Marketing benefit




  • Under-utilisation and underfunding of essential services that is available in current benefits

  • Avoidable expenditure is being incurred

    (big demand for costly latest and greatest)

Janus peeped into the past what is the view ahead

Janus peeped into the past!What is the view ahead?

Looking forward

Looking forward

  • Structure

    • Benefit design:

      • What are the objectives?

        • PMB: “prevent dumping on the state”

          • Hospital, not “healthcare”, access achieved!

      • Use the needs analysis approach

      • Affordability level?

    • Accreditation

      • Third party: effectiveness of Managed Care can be improved

      • Service provision…

Looking forward1

Looking forward

  • Process

    • “expensive” PMB to cost more (investment) before it will cost less

    • Member access to PMB benefits

      • Lack of awareness of entitlement by members

      • PMB claims identification and assessing issues

        • BHF commenced engagement with schemes/administrators

Looking forward2

Looking forward

  • Opportunities to intervene and make a difference, together with providers of service and other stakeholders

    • Providers are hungry for this type of feedback!

      • They too have an interest in our members well being

  • Provider remuneration (PBR)

    • ?incentives/rewards and ethical considerations

      • Performance based reimbursement using withhold/reward

Looking forward3

Looking forward

  • If you don’t measure, you don’t manage!

    • Need for active and proactive management

  • Minimum reporting standards for schemes

    • Demographic monitoring

    • Public health / health status indicators (BHF 2007)

    • Clinical quality indicators - HQA

    • Utilisation indicators and report

    • Finance & Economic indicators

    • Third party processes report

Healthcare quality a janus view


  • Section 21 Company

  • Established by the industry for the industry

  • Includes Associates

  • Initiative supported by BHF, CMS and Consumer Union

  • Ongoing development for improvement

  • CEO: Louis Botha

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