must earn the trust and respect of all stakeholders, but especially the provider and patient communities. As noted above, the board’s decision making must be grounded in scientific evidence. Auditing mechanisms must be established to ensure data quality. Adequate data protections must be in place to ensure patient confidentiality. Public reports must provide fair comparisons.

Finally, in any complex system, the change process produces both intended and unintended consequences. An early warning system will be needed to identify unintended consequences of the NQCB and take mitigating action. The unintended consequences of the goal-setting and standardized measurement and reporting processes of the NQCB might include the following:

  • Adverse selection—In the absence of adequate risk-adjustment techniques, providers who care for some of those patients most in need may appear to be poor performers compared with their peers who treat healthier patients (Werner and Asch, 2005). Some providers may try to improve their performance scores by engaging in adverse selection. As a consequence, patients most likely to experience poor health outcomes, such as those most severely ill or with poor health behaviors, may experience difficulty in gaining access to the health system.

  • Data manipulation—Providers may engage in data recording and coding practices designed to inflate their performance ratings. For example, if performance measures are adjusted for a patient’s complicating and comorbid conditions, providers may inflate the list of secondary diagnoses to include conditions that are inactive or those yet to be confirmed.

  • Stifled innovation—There is always the potential for innovation to be stifled through the imposition of a more structured process for setting goals and focusing quality improvement efforts. As provider attention becomes focused on the national goals and measurement requirements established by the NQCB, providers may divert resources from other promising quality measurement and improvement activities that could yield even greater returns. Private-sector organizations may reduce investments in the development of new quality measures, survey instruments, and tools, some of which could represent breakthrough technologies.

Recognizing the potential for undesirable consequences such as those described above, the committee included efforts to identify solutions to these problems in the comprehensive research agenda proposed in Chapter 5. That research agenda places particular emphasis on the need to address methodological issues, such as risk adjustment, and to perform an impact assessment to monitor and correct for unintended consequences.

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