Quality of Care

Background

Access to healthcare does not guarantee individuals will receive high quality care that will produce improved health outcomes. High quality health care is timely, safe, effective, and affordable–the right care for the right person at the right time [1]. Quality care in clinical settings can help protect and improve population health and reduce costs from eliminating unnecessary or inappropriate care.  

Quality is defined as the degree or level of excellence of health care and can be determined in by assessing technical competency, need for the service provided, and appropriateness. In other words, quality is the degree to which the services provided are properly matched to the needs of the population, are technically correct, and achieve beneficial impact. The higher the quality of health care services, the better the associated health outcomes [2].

Quality is demonstrated in three domains: 
1. infrastructure and resources,
2. the process of delivering services, and
3. the outcomes resulting from service delivery.

The DC Healthy People 2020 goal for this topic area is: 

1. Every District resident has access to affordable, person-centric, and quality health care services in an appropriate setting.

National Healthcare Quality and Disparities Report, District of Columbia Snapshot, 2016-2017 [3]

Our challenge is providing the right care for the right patient at the right time, every time.

—Carolyn Clancy, former Director of the Agency for Healthcare Research and Quality (AHQR)

According to the Agency for Healthcare Research and Quality (AHRQ), in 2016 the strongest measures in the District included post-stroke care for patients at the time of hospital discharge, smoking cessation counseling in clinical visits, and survivorship of Medicare dialysis patients.

States report on the same set of standardized quality measures and are evaluated against established quality benchmarks. According to the most recent data for the District, 28 of the quality measures have achieved less than 50% of the benchmark, 37 measures are close to achieving the benchmark, and 49 have achieved or exceeded the benchmark [3, 4]. The areas for improvement at this time included perception of patient-centered care quality, substance abuse, and the HIV care continuum [3].

Healthcare quality can be improved through:

• Making care safer by reducing harm caused in the delivery of care;

• Ensuring that each person and family are engaged as partners in their care;

• Promoting effective communication and coordination of care;

• Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease;

• Working with communities to promote wide use of best practices to enable healthy living; and

• Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models [5].

Wait times in emergency rooms are a marker not only of quality of the care in healthcare facilities, but of the larger system that includes emergency management and administrative functions that can slow down processes. In addition, a culture of care access that relies more heavily on emergency departments for non-emergencies will affect quality of care for those experiencing true emergencies. 

Healthcare-Associated Infections

Healthcare-associated infections (HAIs) are infections that are acquired by patients within a healthcare setting while they are receiving care. These infections may occur in all types of healthcare facilities, including hospitals, outpatient surgery centers, nursing homes, or rehabilitation facilities. HAIs are largely preventable, yet are the most common complication of healthcare and can cause significant morbidity and mortality. 

DC Health conducts routine surveillance for a wide range of infectious diseases and related health outcomes. Healthcare facilities in the District are required to report certain HAIs to the DC Health using the National Healthcare Safety Network (NHSN). To monitor HAI prevention and progress over time, the Centers for Disease Control and Prevention (CDC) uses the standardized infection ratio (SIR) as a summary statistic showing how often infections occur divided by what would be expected given certain criteria particular to the facility. Lower SIRs indicate better outcomes or a positive change . In 2017, the SIRs for the acute care hospitals in the District were comparable to the national average of SIRs for central line-associated bloodstream infections. The District showed significant improvement compared to the national baseline for catheter associated urinary tract infections  [4, 6].

Resident Perspective

In the 2019 DC Community Health Needs Assessment survey, residents were asked about the quality of clinical care received in District hospitals and clinics. One in five respondents either disagreed or expressed indifference as to their satisfaction with their current healthcare providers. When asked if they receive poorer service than others when receiving medical care, 27.6% of respondents reported that they experience this in clinical settings. Among the residents who reported they feel they receive poorer service when receiving medical care, the main reasons they identified for these experiences included: race, gender, age, ethnicity, and weight. 

There are still a lot of healthcare providers who are ignorant and will not take the time to learn how to deal with diverse groups of people and their healthcare needs.
My neurologist and gynecologist recently disagreed with each other about my treatment - it was frustrating and hard to navigate, especially when getting an appointment with either provider was so difficult to begin with.
My experience with prenatal care was that providers have an approach that differs person to person and were unwilling to discuss evidence based alternatives.
I have had a doctor say I was a difficult patient just because I challenged their opinion on my treatment and got a second opinion. A physician should never bad-mouth a patient who is just trying to do what is best for him/herself.
Doctors don't always respect that I know my body. I experienced mental health side effects from my IUD and had to convince multiple clinicians at the same facility that I should have it removed. They kept asking questions like, “Are you going through something? Have you had a bad break up?” instead of trusting that I knew my body. 
I got a kidney infection once because I had a UTI and was menstruating so they couldn’t perform a point-of-care urine test. They suggested it was likely a yeast infection. By the time my test results came back, the infection had already progressed to my kidney. I understand that a lot of people are susceptible to hypochondria in the age of WebMD but these clinicians were disrespectful, dismissive, and ultimately, wrong.

Assets & Resources

 • Information for patients & persons who  may get care in the future

 • Patient Resources

 • Hospital Compare

 • Nursing Home Compare

 • Infection Prevention Updates for Professionals n Infection Control & Epidemiology

 • Types of HAIs

Diseases and Organisms in Healthcare Settings

Antibiotic/Antimicrobial Resistance

Get Smart: Know When Antibiotics Work

Hand Hygiene

Nursing Homes and Assisted Living

Promising Practices & Policies:

• DC Health is supporting training for primary care providers around implicit bias and cultural competence to improve patient experience. 

The DC Healthcare Associated Infections Advisory Committee is a public-private partnership with representatives and stakeholders representing, hospitals, long-term care centers, primary care practices, dialysis centers, academic institutions and coalitions, and other governmental and non-governmental partners to makes recommendations to the District government on the prevention, surveillance and public reporting of healthcare-associated infections.