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Using Utilization Measures to Improve Quality in Health Systems

Stephen M. Davidson, PhD, Boston University School of Management

Utilization data are essential tools for assessing the state of quality in a health care organization and developing a strategy to improve it.

Many health systems are committed to improving the quality and consistency of the care they provide to their patients.  However, before their leaders can devise and implement effective strategies to improve the quality of care they deliver, they must:

  • know the extent to which the care their system provides meets established criteria for good quality care, and
  • be able to identify deficits that can act as targets for improvement.

In this paper, Dr. Davidson presents a new approach to defining and measuring up to five levels of quality using claims data.  It has practical value because it

  • is relatively easy to calculate;
  • permits managers to identify specific gaps that can be targeted for action; and
  • enables them to track step-by-step progress toward eliminating those gaps.

Quality is a complex concept, encompassing the extent to which appropriate services are used, the skill with which those services are provided, and the relationship of those services to achieving desired clinical outcomes.  Although, ultimately, quality of care is most clearly defined by the outcomes it produces, most quality-improvement actions focus on care processes.  Utilization data are essential tools in such efforts in any health care organization.

Two principal sources of utilization measures are claims for services rendered and medical records.  The adequacy for assessing quality of care are affected by their completeness and accuracy and by issues of usability, including how readily data can be retrieved, how effectively confidentiality can be preserved, and how suitable the data are for analysis.  Utilization data can yield valuable information in key areas and, based on that information, important issues about an organization’s quality of care can be identified.  Among the uses for which these data can be employed are determining whether or not indicated individual services were provided; identifying patterns of services provided (so that levels of quality can be calculated); comparing services to condition-specific standards of care; and determining whether indicated follow-up services were provided.

Davidson points out that utilization data—like all other data—have limitations.  As a result, a careful analyst must be aware of important caveats when using utilization it. Analysts should:

  • Understand the data’s limitations, including the potential for systematic inaccuracies resulting from their primary uses.
  • Exercise care when transcribing data to an analysis file:  The quality of the source data is predetermined and cannot be changed, but entering it accurately for use in the study of quality is critical.  Electronic data may eliminate the need for transcription as a separate step, and computer algorithms can be created to test for inconsistencies and identify the most egregious errors.
  • Understand the nature of the sample.  Know how the groups are defined; how large and representative the samples are and the statistical power associated with them; and what conclusions are reasonable.
  • Avoid over-interpreting the results.

Once accurate measures of the current state of quality are obtained from utilization data, they can be used to improve quality and safety within a health care system.  Below is a condensation of Davidson’s three practical steps for achieving change through the use of utilization measures.

Step One—Organizational Assessment

The change effort can begin by analyzing utilization data to help define specific problems.  Start with several diagnoses and determine the extent to which care provided in the organization meets evidence-based standards.  Try to identify those elements of the care process that are the most problematic.  (Data from several diagnoses that show similar patterns may provide important clues.)  If possible, advance some hypotheses or tentative suggestions regarding changes that can be made.

The organizational assessment should also include an appraisal of the state of relations between clinicians and management as well as a fundamental understanding of the processes used to deliver care to patients with the target diagnoses.

Step Two—Picking a Place to Start

From among the problems identified by the utilization analysis, choose a specific focus (or two or three) for action.  (Remember to keep goals manageable.)  Define the processes of care in detail.  Identify hypotheses to explain why an unacceptable number of patients do not receive the services that are indicated by their condition or why an episode of care takes longer than necessary.  Consider reasons that patients do not come in for services when they should.

Step Three—Choosing a Direction for Change

Identify particular targets for change and involve key stakeholders in developing detailed action plans.  Some guidelines for leading change include:

  • putting together a multi-disciplinary group to lead the effort.
  • clearly explaining the objectives of the change initiative, then inviting feedback from affected parties.  Be willing to modify goals.
  • selecting projects that are real and that are likely to succeed.
  • using leaders who are respected by large numbers of participants and providing those leaders with training and/or consultation in group problem-solving.
  • setting a timetable for achieving milestones so that expectations are clear and the group feels some pressure to achieve results.

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