Summary

In this presentation, we talked about the standards of care as defined for medical, legal, and ethical purposes. Generally, standards of care are developed through review of evidence and graded for strength of evidence supported medical care direction in specific conditions. Standards of care can cover services and products that may be used to produce the best outcomes at the least cost. Legally, standards of care may be used to assist in the judgement regarding legal challenges to practice of individuals or groups in providing patient care. Ethically, standards of care may be used to help in promoting and protecting patient well-being through four guiding principles, including beneficence, autonomy, non-maleficence, and justice.

Standards of care are used to with other markers to provide benchmarks and measurement of appropriateness, cost effectiveness, and positive outcomes. Standards of care are generally based on the strength of evidence and experience in providing care for specific conditions.

The performance measures developed for HEDIS have been culled from best practices for various procedures and treatment guidelines from across the country. These best practices are derived from the standards of care for that particular condition, and standardized for all patients who present similarly. More than 90 percent of the health plans in the U.S. use HEDIS to measure performance on important dimensions of care and service.

To ensure that HEDIS guidelines stay current, each year the National Committee for Quality Assurance (NCQA) determines if each particular guideline needs to evolve. The NCQA’s Committee on Performance Measurement, a broad-based group representing employers, consumers, health plans and others, discusses the current content and makes collective decisions as to how each standard should change for the coming year. Individual standards are field tested to assure appropriateness and accuracy, and then implemented. It’s also important to note that HEDIS includes the Consumer Assessment of Healthcare Providers and Systems or CAHPS 5.0 survey which measures health plan member’s satisfaction with claims processing, customer service and the perceived speed of getting care when needed.

Patient satisfaction surveys are the main qualitative measure from the patient’s perspective. And while there are pros and cons to the weight given to patient perspective and satisfaction measures, much is dependent on maintaining and improving on survey scores, including reimbursement and bonuses to maintain financial solvency and success.

The establishment of standards of care gives us an opportunity to organize and formalize the process of learning about and implementing evidence-based and patient-centered medical care, protecting and promoting patient well-being, and considering patient expectations and satisfaction with care. Evaluating and improving measures of each of these factors is crucial to assuring that the best possible care is provided at the lowest cost, while still achieving the highest patient satisfaction.