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- Oral and Written Testimony from the Public Hearings lo Harris-Wehling The Institute of Medicine (IOM) committee for the Study to Design a Strategy for Quality Review and Assurance in Medicare convened two pub- lic hearings and sought additional written testimony from a large and di- verse group of interested organizations. The two public hearing forums provided opportunities for dialogue between the committee and the present- ers; the format also allowed several panel members to respond to common questions of relevance for which consensus was questionable or unknown. Groups were able to use the written testimony procedure to provide details on their concerns about and experiences with quality assurance. Having this information during the early phase of the study was helpful for guiding the committee's activities as the study progressed. Because of the diversity and breadth of the information, staff prepared several working papers on the submissions for the committee. This chapter describes the public hearing process used for this study and summarizes the main themes raised by the written submissions. METHODS Invitations to Submit Testimony The invitahona1 package included a transmittal letter, a set of guidelines for written testimony (see Appendix A), and general information items about the IOM and the study. The guidelines asked the submitting groups to respond to 12 key questions about: (1) their definition of quality of care; (2) their views on who should be responsible for quality of care and quality assurance; (3) their own activities as sponsors or subjects of quality assur- ance programs; and (4) their recommendations about strengthening quality assurance, including research and development.

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8 JO HARRIS-WEHLING The 574 groups or individuals invited to testify fell into 10 broadly defined categories. Table 2.1 identifies, by category, the number asked to provide testimony and the number and percentage of those responding. By far the greatest number of invitations was sent to professional associations (238~; about one-quarter responded. Respondents to the Invitations We convened two formal public hearings. The first was in San Fran- cisco, California, on June 23, 1988; the second was in the Washington, D.C. area on October 21, 1988. We asked 59 groups to appear at one or the other of these hearings. Sixteen groups participated with oral and written state- ments for the first hearing, and 26 groups participated for the second. Appendix B identifies these organizations and an additional 97 groups that provided only written testimonial documents. About 30 groups that received an invitational package informed the study office they would not be submitting testimony. Among the reasons given for declining were the following: (1) lack of staff resources to develop a response; (2) internal policies not to take positions on the types of issues the study addressed; and (3) lack of expertise on the subject despite interest in the issues. Some groups asked to receive the committee's final report. Types of Documents Submitted The documents submitted by the 139 respondents to our inquiry varied greatly in size and content. They ranged from a one-page letter with no attachments to a three-ring 1/-inch notebook accompanied by 3 inches of publications. A typical document was about 10 single-spaced pages. About one-quarter of the submissions were accompanied by some type of publica- tion, such as a set of clinical guidelines or a brochure about the organiza- t~on. The information contained in these documents was quite diverse. Some of this diversity relates to the varying interests and experiences of the groups submitting testimony; a state peer review organization of Medicare's Utili- zation and Quality Control Peer Review Organization (PRO) program, for instance, would be expected to provide different information than a con- sumer advocacy group. Furthermore, even though the guidelines were sent to all invitees, invitees were free to address any quality issues they wished, not just the topics identified in the guidelines. About one-quarter of the respondents organized their submissions around the key questions in the guidelines. Some in this group elected to respond in a question-by-question format and others focused on one or two of the key questions without making any comments on the others. The remaining

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ORAL AND WRITTEN TESTIMONY TABLE 2.1 Number and Percentages of Invitees and Respondents for the Public Hearing Process Classified by Type of Interest Group 9 Number Percentage Type of NumberSubmitting Submitting Interest Group InvitedTestimony Testimony Professional associations 23861 26 Provider groups 5419 35 Peer review organizations (PROs) 479 19 Business groups and unions 408 20 Elderly and consumer interest groups 3311 33 Disease-specific voluntary and professional groups 306 20 Foundations and research groups 30 ~27 Government agencies 239 39 Insurers 154 27 All other 644 6 Total 574139 24 three-quarters of the submissions varied widely in content and format. In some cases, respondents provided information only on research studies under way or completed; some studies are in the quality assessment and assurance field and others are not. Some respondents addressed only the broad issue of access to health care. Some took up the majority of key questions but confined their comments to only one area of health care (such as home health care) or to only one particular professional practice (such as critical care nursing, enterostomal therapy, or occupational therapy). Development and Testing of Abstract Form Staff developed a form to record key information abstracted from each testimonial document. An extensive amount of time was spent in develop- ing the abstract form and building a high level of inter-abstractor reliability. Four drafts were tested by staff before the final version of the form was adopted. Three staff members were involved in reading the documents and ab- stracting the information. One staff member reviewed about 75 percent of the documents; a second staff member reviewed the remaining 25 percent. The third staff member participated in the joint review of six documents and also monitored about 20 additional reviews for consistency and thor- oughness.

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10 JO HARRIS-WEHLING Data Base System Both hardcopy and database management procedures were set up within the study office to log in basic information as documents arrived. Each testimonial document was assigned a number to facilitate the tracking of documents, the storage of data, software report generation, and the report- ing of findings in staff reports. Data on the abstract forms were entered into two database management files to facilitate the analysis. WordPerfect's secondary file was used for most text-type items on the abstract form. The Paradox database manage- ment system was used for the checklist-type sections on the abstract form. Limitations of the Analysis Efforts were made to build a high level of inter-abstractor and intra- abs~actor reliability. Given the diversity of the documents, however, some errors in abstracting the information undoubtedly have occurred. The major errors are likely to be ones of omission or interpretation. For example, abs~actors may have missed some of the "primary concerns about health care" that a respondent addressed or alluded to in the testimony because the respondent may have dispersed comments throughout the document that related to concerns about health care rather than stating them in one identi- fiable section of the document. Many respondents have both a parochial interest and a societal interest in quality assessment and assurance of health care; views on specific issues in quality assurance may differ depending on which perspective is being taken at any one time by a given organization. This chapter makes no attempt to differentiate between these interests. FINDINGS This section summarizes the content of the testimony received through the public hearing process. The first part comments on major themes that emerged through our analysis of the testimony. Following that are brief synopses of findings keyed to the main topic areas highlighted in the guide- lines. In addition to the information summarized in this chapter, many groups provided descriptive information on tools for quality assessment or assurance (such as manuals and guides), on research projects under way, and on leads for additional follow-up. In some cases this information was used to plan the study committee's site visits and as input into the sampler of quality assessment and assurance methods reported in Chapter 6 of this volume.

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ORAL AND WRITIEW TESI IMONY 11 Main Themes Several themes or topics appeared in many of the documents, although we did not tally the precise frequency the subjects were mentioned. This section briefly reviews these themes. Later sections elaborate on these topics as they relate to the key questions from the guidelines. Gaps in Information The majority of respondents believed that gaps exist in the knowledge base for effective quality assessment and assurance. A few respondents, however, were adamant in stating that no gaps exist in quality assessment. They acknowledged that the quality of health care is less than desired but attributed this to problems with attitudes, implementation, and communica- tion rather than to a lack of specific instruments to measure quality. Peer Review The term "peer review" was used by a large percentage of respondents, most of whom indicated their support for the concept. However, the re- ported effectiveness of peer review differed, depending in part on the type of sponsor for peer review, such as Medicare's PRO program, specialty practices, and internal institutional review committees. Some respondents consider peer review to be a formal process and others view it as a very informal process. Some respondents were adamant about the ineffectiveness of peer review as practiced by PROs, but some of these same respondents stated that the most effective mechanism for assuring quality is peer review. Access Issues Access was mentioned frequently as a concern at the San Francisco hear- ing. It was also mentioned in many of the written documents as a necessary condition for improving the quality of care. Patient-Physician Relationship Many respondents noted that the relationship between the patient and the physician is a significant element of the quality of health care. They rarely elaborated the point, however. A few respondents implied that the quality of care would be high if only the patient and physician dyed were not subject to outside influences.

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12 JO HARRIS-WEHLING Role of the Elderly in Quality Assessment and Assurance and Health Care Decision Making There seemed to be general agreement that the elderly consumer does not have a significant role in existing quality assessment and assurance sys- tems. Many respondents indicated the need for more participation of the elderly in health care decision making. They also expressed concern about how to involve the more-frail, the less-informed, and those having multiple psychosocial problems. Interrelationship of Oualitv. Costs. and Financing -A -, ~-if, ~ According to many respondents, a relationship exists between the cost of health care and its quality. Respondents expressed concern that pressure to contain costs results in pressure to provide lower-quality health care. Some respondents stated that, given the limitations of the Medicare financing structure, the elderly do not receive quality care because they cannot afford to purchase needed health care. The major barriers identified were services that are presently not covered and the Medicare beneficiary's out-of-pocket expenditures for charges in excess of the amount reimbursed by Medicare. Patient-Centered Quality Assurance System Some respondents believed that an effective quality assessment and as- surance system must be structured in a manner that follows the patient through episodes of illness across the multiple settings and providers of care. Clinical Guidelines, Specialty Board Certification, and Credentialing Views varied among the respondents as to the value and effectiveness of existing clinical guidelines, board certification and recertification, and cre- dentialing by hospital-based medical staffs as quality assurance methods. Some professional groups emphasized their professional guidelines, certifi- cation requirements, and procedure manuals and claimed or implied that these are adequate to assure high-quality care. Other groups pointed out limitations of existing standards, measurement tools, and the like. Need to Measure, Demonstrate, and Prove Performance Competency A few practitioner groups explicitly cited the need for new methods to assess competency using performance measures such as chart audits or ob- servations rather than simply fulfilling continuing medical education requirements. Two respondents implied that new, reliable, and visible per

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ORAL AND WR17TEN TESTIMONY 13 formance measures are needed to reassure the more sophisticated, inquisi- tive, and educated consumer or purchaser. Assessing the Heeds of the Elderly Five respondents, in their discussion on the needs of the elderly, tended not to distinguish any differences in the methods and purposes of quality assessment from those of needs assessment and health status assessment. Other respondents, however, logically linked the process of assessing the needs of the elderly (medical, social, economical, and functional) with the process of assessing quality of service and quality of care. Some respon- dents discussed the uniqueness of elderly individuals, the importance of the quality of life, the limitations of the Medicare reimbursement system for a population that experiences chronic illnesses, and the need for tools that measure the health status of an individual beyond the scope of the medical model. Continuous Quality Improvement A few respondents wrote about the effectiveness of the continuous qual- ity improvement model, and some incorporated its concepts in their defini- tions of quality. Continuous quality improvement was explicitly mentioned more frequently by researchers and by the Colleges, Academies, and Boards of specialty practices. Responses to Specific Questions Defining Quality of Care In response to key question no. 1, we received about 55 statements (40 percent of all respondents) explicitly defining quality of care. In about 25 additional submissions, the respondents offered parameters by which qual- ity might be defined or evaluated but did not give a definition per se. Many respondents included structure, process, and outcome dimensions in their definitions. Several definitions included an active role for the patient in decision making, an emphasis on health care beyond the medical model, and a focus on the patient-physician relationship. Some definitions mentioned resource availability as a consideration for defining quality. Chapter 5 of this volume gives a more detailed discussion of the dimensions used by the respondents to define quality of care. Assessment of Contemporary Health Care Key question nos. 2 and 3 sought information on respondents' views

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14 JO HARRIS-WEHLING about the level of quality of care now provided. Most of the concerns expressed were about costs, access, and quality-of-life factors. About 25 percent of all respondents (32 of 139) believed that health care is good to excellent. Within this subgroup of respondents, however, a large percentage indicated some concern about the quality of health care for a particular subpopulation, such as the rural elderly, poor elderly, elderly women, minority elderly, or nursing home patients. Some respondents ad- dressed quality of health care only from their own perspective as providers. Examples (paraphrased in some instances) of comments relating to this topic are as follows: . . . is the best health care system in the world. If there is a quality problem, the elderly are at greatest risk. . . . excellent. Physicians are delivering quality care with excellent outcome and patient satisfaction, despite HCFA's administratively burdensome and . . . pnmltlve system. Serious deficiencies exist in the quality of health care available to the Medi care consumer. The quality of care provided through the state's hospital systems has never been better. Cost containment and quality health care. Most respondents identified more than one concern about the quality of health care today. For many the major issue is the perceived inverse relationship between cost containment measures and quality of care. Nearly 50 percent of the respondents (68) expressed uneasiness that the quality of health care would decrease as a result of cost containment efforts. Premature discharges, utilization review, financial incentives for underuse, and health care decisions being made by the (alleged) wrong people (fiscal intermediaries, PROs, utilization review staff of third-party payers) are examples of the cost containment concerns mentioned. Only 11 percent of the respondents identified overuse as a quality-of-care issue. Medicare benefits. Over 37 percent of the respondents (52) believed that the quality of care for the elderly is less than desired because Medicare does not cover several health services needed by the elderly population. Access to a broader range of services was seen as necessary to improve the quality of care now provided. The most frequently mentioned problem with access to benefits was the lack of coverage of services needed by the chroni- cally ill elderly. Some respondents asserted that a higher quantity of a covered service, such as home health care, is needed to improve quality. Other respondents stressed that the Medicare reimbursement system does not take into account the health needs of the elderly that relate to their quality of life.

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ORAL AND WR17TEN TESTIMONY 15 Supply and training of health care practitioners. About 40 percent of the respondents (57) were concerned about the availability and supply of health care practitioners. The nursing shortage was mentioned frequently, as was the shortage in specific subspecialties. Concern was also expressed about the need for health care providers to be better trained in aging-specific issues. Training and supervision was a concern of about 25 percent of the respondents (34~. Related to the general issue of the supply of certain health professionals is a question of geographic distribution. About 15 percent (20 respondents) believed that lower-quality care is provided in some geographic locations such as inner cities and rural areas. Humaneness and continuity. Among those respondents who thought that the health care system is not responsive to the unique characteristics of the elderly population, many cited the need for a more humane relationship between the elderly consumer and the provider. Some comments focused on the fragmentation of the health care system, the increase in subspecialty practices, and a decrease in the role of the primary physician. Over 25 percent called for increased continuity of care among delivery settings as well as among various providers within a given setting; some proposed case management as a solution to the lack of continuity. About 16 percent (22) perceived a current or emerging decrease in the humane aspects of health care. Eight respondents explicitly distinguished quality of service from quality of care; for example, one respondent stated that the elderly ". . . want to be cared about, not just cared for." Ethical dimensions. Seven respondents explicitly voiced a concern about the ethical implications of the health care system and the Medicare program in particular. Equity issues within the context of rationing health care and the prolongation of life through technology without consideration for the quality of the extended life are examples mentioned by these respondents. Strengths and weaknesses of Medicare. Responses to key question no. 3 varied, depending in part on the respondent's perception of the meaning of the term "Medicare." Some respondents (within the context of their testi- mony) treated Medicare as equivalent to the PRO system. Others viewed Medicare as a system for financing and reimbursing specific health care expenditures of beneficiaries. Still others saw Medicare as a public com- mitment or responsibility to provide high-quality health care to the elderly in accordance with all health care needs, where health is defined broadly. Responses that relate to assessing the adequacy of quality assessment and assurance of the Medicare program are summarized in a later section. The following comments (paraphrased) summarize the strengths of the Medicare program mentioned by the respondents.

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16 JO HARRIS-WEHLING Medicare's emphasis on cost containment and access stimulates an open dia- logue between the patient and provider in decision making. A better informed consumer is talking a more active role in making decisions. Medicare's emphasis on quality has served as a catalyst and an incentive to other payers as well as to hospitals to accept the need for quality assessment and assurance. There is also an increased awareness among health profession- als of the need for developing performance standards. Private sector funding of quality assessment and assurance research has increased. Quality of care has improved overall because of the sentinel effect of the PRO system. Medicare is a statement of a national commitment to provide quality health care for all elderly; it is non-stigmatizing for the consumer and the provider. Data collection efforts have stimulated advanced computer technology. The data bases create a potential for further advancement in assessment tools such as small area analysis and risk adjustments that are acceptable to physicians. Respondents identified the following (paraphrased) as weaknesses of the Medicare program: The program provides inadequate reimbursement, creates disincentives to physicians to care for Medicare beneficiaries, and places limitations on pro- viding marginal or experimental procedures and services. Medicare does not promote quality nor is it the best buy. Medicare's cost containment emphasis has shifted the power from the physi- cian to employers and businesses who are ill equipped to ask the right kinds of questions about quality. Costs of Quality Assessment and Assurance Activities Very few respondents provided information on the costs of their quality assessment and assurance activities. When information was provided, vari- ations in the cost units used by the respondents limited generalization. The following give a sense of the way various groups describe their costs. Professional associations: "100 percent of annual budget" "not less than 50 percent of annual budget" "significant resources" Provider groups: "six staff members at an annual cost of approximately $155,000" "$2-$5 per case per reviewer or $20-$30 an hour" "approximately 2 percent of annual budget" "the amount indicated in the budget is a small portion of the total amount spent"

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ORAL AND WRITTEN TESTIMONY PROs: "$103 per review, the equivalent of 38 percent of total annual budget" "$38-$39 per case reviewed" "sixty percent of budget" Assessment of Adequacy of Qualiry Assessment and Assurance 17 The responses to key question no. 4 on the adequacy of the current quality assessment and assurance programs reflected a broad mix of experi- ences and roles. A few direct health care providers, such as health mainte- nance organizations (HMOs), described the effectiveness of their internal quality assessment and assurance system and provided comments on the external quality assessment and assurance systems to which they are sub- ject. The nine PROs and two SuperPRO contractors (National Medical Audit; SysteMetrics) that submitted testimony and 16 other respondents (e.g., the Joint Commission, American Psychiatric Association, Aetna, Ameri- can Association of Homes for the Aging, and Paralyzed Veterans of Amer- ica) have either major or limited roles in conducting external quality assess- ment and assurance activities. Other respondents are actively developing tools for assessment and assurance processes; examples included the Ameri- can College of Physicians through their Clinical Privileges Project and the Nahona1 Association of Boards of Examiners for Nursing Home Adminis- trators through their national examination for nursing home administrators. Comments of PROB. Five of the nine PROs submitting testimony identified some problems they have encountered in quality assessment and assurance. Their comments are paraphrased as follows: The use of generic screens results in too many false-positives and misses a lot of problems. Generic screens applied across the board are not cost-effective. A better method to focus reviews should be found. The lack of clearly defined standards for judging quality of care creates prob- lems, in particular, inconsistency among the physician advisor reviewers. Even though it is difficult to have uniform standards for judging quality, the lack of a clear understanding and agreement about national standards creates a disad- vantage for the SuperPRO program. It is difficult to institute corrective action plans, improve clinical perform- ance, and resolve existing quality problems because of the limited information available about linking the process of therapy to outcomes. No mechanism is available to monitor the performance of providers of serv- ices covered under Part B Medicare who "go underground" and calmot be monitored through Part A claims.

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24 JO HARRIS-WEHLING e. Increase Medicare reimbursement levels. f. Establish equal pay scales. 2. Increase the competitive environment (4~. 3. Promote greater attention to geriatrics (10~. a. Implement a nationwide geriatric evaluation unit, provide incen tives or require practitioners to have geriatric or gerontology training, and require case management in managed care. 4. Develop strategies to prevent unnecessary transfers to and from skilled nursing facilities at the end of life (19. 5. Provide incentives to practice in rural areas (1~. Recommendations concerning broad quality-of-care topics. 1. Broaden the scope of quality assessment and assurance activities. a. Expand the efforts to other settings and services (22~. b. Include nonmedical disciplines that affect the health of the elderly (12~. c. Increase the attention given to system and program factors (7~. d. Promote or require continuing education for all health care provid ers (4~. e. Address underutilization (3~. f. Examine the bioethical issues involved in decisions about the allo cation of resources (2~. 2. Improve the accountability to the elderly population. a. Include consumer (elderly and nonelderly; users and nonusers) inter ests in quality assurance systems (271. b. Make the system more accountable to the elderly consumer, involve the elderly in decision making, and provide more information to the pub- lic to allow for informed decision making (17~. 3. Promote increased support for quality assurance among practitioners . .. . . .... . ~ . (12~. 4. Increase coordination of quality assurance efforts. a. Improve coordination among assessors, eliminate duplication, and promote sharing of information (12~. b. Require PROs to work more closely with hospital medical staff and professional associations and shift corrective action responsibility away from PROs to local groups such as medical staff (8~. c. Establish a national organization to work with professional socie- ties in developing their own quality assurance activities or systems (3~. d. Standardize quality assurance activities among PROs (2~. e. Promote more interactive relationships of the research community with PROs and with providers (1~. 5. Maintain flexibility and plurality of approaches (7~. 6. Increase the financing for monitoring and review activities (61.

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ORAL AND WRITTEN TESTIMONY 25 7. Conduct reviews in an open atmosphere with due process, provide legal protection to whistle blowers, and increase legal protection to those involved in the peer review process (4) . 8. Improve the record keeping and documentation of care (4~. 9. Implement widescale consumer education programs on consumer re- sponsibility for self-care, on consumer's rights in the health care system, and on the Medicare program (3~. r - = Recommendations concerning quality assessment methods. 1. Establish concrete, precise, acceptable, and standardized definitions of terms (10~. 2. Define and refine norms, criteria, and standards. a. Develop explicit and uniform national standards and criteria (99. b. Establish routine procedures for updating norms, criteria, and stan dards (2~. 3. Focus on significant deviations from norms or criteria and standards (6~. 4. Use peers who (8) a. Are trained in specialties. b. Are treating minority and poor elderly. c. Are practicing in rural areas. 5. Require better trained and experienced surveyors, auditors, reviewers, and physician advisors (71. 6. Conduct retrospective reviews of patterns of care (14~. 7. Conduct timely reviews, that is, closer to the time the service is deliv- ered (2~. Recommendations concerning specific quality assurance activities. 1. Provide financial incentives to reward providers for achieving stan- dards of excellence (12~. 2. Improve the approaches to staffing and training. a. Establish minimal staffing levels in care settings such as nursing homes and hospitals, require more certification for home care techni cians, and require career ladders in the nursing field (10~. 3. Maintain and improve the quality of home health care. a. Prohibit contracting with individuals directly (rather than agencies) for home health care if public monies are involved and regulate nursing registries (2~. b. Develop a model state licensure law and a single set of conditions of participation for home health care (4~. c. Support deemed status for home health agencies (and nursing homes) (2~.

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26 JO HARRIS-WEHLING 4. Retain strong regulatory activities (4~. a. Maintain a strong sanction process for PROB. b. Be more aggressive in enforcing current survey standards and con- ditions of participation. 5. Increase the use of remedial medical education (2~. Recommendations for research and development. 1. Research in quality assessment. a. Develop national and specialized data bases, improve the analyses of existing data, and determine future data base needs (27~. b. Conduct consensus development activities on standards of care (case-mix and severity of illness were mentioned frequently) (22~. c. Develop elderly-specific quality assessment concepts and instru ments (e.g., norms, intervention protocols, outcome measures, needs as- sessment instruments) (18~. d. Assess the relationship between quality and different delivery settings (14) access to care (both covered and non-covered services) (13) cost containment efforts (~) Medicare payment levels (7) patient-provider relationship (2~. e. Examine and clarify process-outcome relationships (11~. I. Improve measurement tools to make them more reliable, valid, and practical (11~. g. Conduct research on disease-specific quality of care concepts and tools (9~. h. Develop methods for measuring and assessing performance compe tency (6~. Increase resources for developing outcome measures (51. j. Develop standards of excellence (4~. k. Define rural-specific quality assessment measures (2~. 2. Research in quality assurance. a. Evaluate current quality assurance programs including both the PRO program and other efforts (12~. b. Investigate effective approaches for changing behavior, such as continuing and remedial medical education (7~. c. Examine the cost-benefit ratios of different quality assurance meth ods (4~. 3. Develop methods to assist the elderly to participate in the health care delivery system (10~. 4. Increase research on technology development and assessment (8), including cost-benefit of health care interventions (2~. 5. Examine methods to synthesize, transmit, and motivate timely utiliza- tion of new information (7~. 1.

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ORAL AND WRITTEN TESIllf ONY 6. Increase involvement of specialties in quality-of-care research (4) 7. Increase research in the decision-making process (3~. 8. Fund PRO-sponsored research (3~. 9. Increase research on the aging process, causes of disability, and early detection and prevention of occupational diseases (3~. 10. Study the impact of the current legal system on cost, quality, and appropriateness of care (3~. 27 . CONCLUDING REMARKS The information provided by the participants in the public hearings vastly enriched this study, particularly given the diversity of the groups and the wide range of roles and responsibilities in quality assessment and assurance they reflected. Respondents who in many cases were constrained in staff resources and time limitations generously provided thoughtful recommen- dations for improving the health care system, the Medicare program, and the Medicare quality assurance system. Testimony varied by source (from, for example, a statewide advocacy group operating with only volunteers to a national health care professional membership organization) and by length and complexity (from the single- page document to the testimony that arrived at the study office in two boxes). The contributions of the participants at the two formal public hear- ings who gave willingly of their time at their own expense and of the groups that generously provided publications filled with methods and ideas on quality assessment and assurance were especially valuable. Conflicting views and contradictory recommendations were heard through- out the public hearings. One theme prevailed, however: No one method or group can assure the quality of health care and a cooperative effort toward improving quality is desired by all. APPENDIX A GUIDELINES FOR WRITTEN TESTIMONY A SI-UDY TO DESIGN A STRATEGY FOR QUALITY REVIEW ED ASSURANCE IN MEDICARE PART A. BACKGROUND The IOM Study Committee is interested in a broad set of issues relating to the quality of health care delivered in all major settings in which the elderly receive care, for instance, hospitals, free-standing clinics, physi- cians' offices, and health maintenance organizations. We are also inter- ested in the quality of home health care and medical or hospital care re- ceived by residents of nursing homes. In line with our Congressional man -

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28 JO HARRIS-WEHLING date to "design a strategy," we are particularly interested in your judgment of the crucial elements of a successful quality review and assurance system. Among the topics the Study Committee will address during the project are the following: . . different perspectives and definitions of quality of care; the current levels of quality of health care; potential or emerging problems with quality of care; current or future methods to use in assessing quality of care; organizations that now engage in various quality assurance activities; possible strategies for assuring the quality of health care; leadership and coordination of quality assurance programs; and needs for further research. We are seeking the views of a wide range of patient groups, consumer agencies, provider groups and associations, institutional administrators, fed- eral and state governments, and other interested parties on these and other issues related to the quality of health care for the elderly Medicare popula- tion. Materials provided by representatives of these groups in written or oral form will be compiled and considered by the Study Committee in its deliberations and preparation of the study's final report. PART B. KEY QUESTIONS Please address any or all items listed below that apply to you and your organization. Your written statement may be as long as you choose. Sup- plementary materials (such as brochures or other publications) are also wel come. mean? 1. What does your organization understand "quality of health care" to 2. What are your views about the level of quality of care now provided to the elderly? (a) Does your evaluation differ by the type of care, setting of care, or other factors? (b) Does it differ for different groups within the elderly population? 3. If you believe that quality is a key issue for Medicare today, what do you believe are the major existing or emerging problems? the major strengths? 4. To what extent do you believe that quality of health care is being adequately monitored or assessed today? That is, do you believe quality assessment of the care Medicare beneficiaries receive is too extensive, ade- quate, or too little to protect the quality of patient care now and in the future?

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ORAL AND WR17TE~ TESTIMONY 29 5. What agencies, institutions, associations, or individuals do you be- lieve should be responsible for assessing and assuring the quality of health care as you have defined it above? 6. In what ways is your organization involved in assessing or assuring the quality of health care? For instance, do you (a) promulgate regulations, (b) license, certify, or accredit individual practitioners or institutions, (c) conduct quality assurance programs within your own institution or for other organizations, (d) conduct training or technical assistance programs, (e) compile information for your members or for public use, (f) participate in research projects or medical technology assessment, or (g) conduct other such activities? Please describe your activities as fully as possible or include separate explanatory materials. (a) What kinds of problems do you encounter in conducting qualit assessments or in resolving quality-of-care problems? (b) What would improve the effectiveness of your efforts-for in- stance, better measurement tools? expanded financing? greater sup- port from management, providers, or patients? greater integration of quality assurance into the organization's other activities? or other fac- tors? (c) What do you estimate is the cost of your assessment and assur- ance activities-for instance, dollars spent per case reviewed, or per- centage of your total annual budget spent on quality-related activities? 7. How should quality assurance programs be coordinated among the following groups: (a) among local, state, and federal agencies? (b) among private accrediting and review organizations? and (c) between the public and private sectors? 8. If you are subject to quality assessment and assurance activities: (a) what kinds of problems do you experience with those efforts? (b) what do you believe would improve the effectiveness of those efforts? 9. What kinds of activities are the most effective and what are the least effective in improving quality of health care? 10. What do you believe are the primary gaps in our knowledge of how to implement cost-effective quality assessment and assurance strategies? 11. What would your recommendations be for the highest priority areas for research and development in this area? 12. If the above items have not included issues of special interest to you, please tell us what additional topics related to quality of health care for the elderly you believe the Study Committee should pursue.

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30 PART C. FORMAT JO HARRIS-WEHLING Your submission should include information about your organization or agency. Materials already developed, such as a flyer or brochure, would be adequate. All submissions should have a one-page Executive Summary for direct use by the Study Committee. A cover letter should include the name, position or title, and telephone number of a contact person, should IOM staff need to follow up. Written testimony should be submitted in duplicate. IOM would appre- ciate receiving testimony no later than July 29, 1988. If you are among those who have been requested to submit written documents to the IOM office by a specific date, you should follow the specific instructions you received. Address for mailing testimony: Telephone contact Quality Assurance in Medicare Study for assistance: Institute of Medicine Jo Harris-Wehling Molla S. Donaldson 202/334-2165 National Academy of Sciences 2101 Constitution Avenue, NW Washington, DC 20418 APPENDIX B ORGANIZATIONS SUBMITTING TESTIMONY Name of Organization Presented Testimony at Public Hearinga ARA Living Centers Academy for Health Services Marketing Administration on Aging, Department of Health and Human Service Aetna Life Insurance Corporation American Academy of Facial Plastic and Reconstructive Surgery American Academy of Family Physicians American Academy of Home Care Physicians American Academy of Orthopaedic Surgeons American Academy of Otolaryngology-Head and Neck Surgery American Academy of Physical Medicine and Rehabilitation DC

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ORAL AND WRIITE;N TESTIMONY Name of Organization 31 Presented Testimony at Public Hearinga American Association of Critical Care Nurses American Association of Homes for Aging American Association of Retired Persons (AARP) American Board of Medical Specialties American Board of Nutrition American Board of Otolaryngology American Board of Pathology American College of Emergency Physicians American College of Physicians American College of Radiology American College of Surgeons American Congress of Rehabilitation Medicine American Diabetes Association American Dietetic Association American Federation of State, County and Municipal Employees American Foundation for the Blind American Gastroenterological Association American Geriatrics Society American Health Care Association American Health Care Institute American Hospital Association American Medical Association American Medical Peer Review Association American Nurses Association t;ounc~ on computer Application in Nursing American Nurses Association, Inc. American Occupational Therapy Association American Pharmaceutical Association American Physical Therapy Association ~ . . . .. ~ American Podiatric Medical Associates, Inc. American Psychiatric Association American Psychological Association American Red Cross American Society for Gastrointestinal Endoscopy American Society for Parenteral & Enteral Nutrition SF DC DC DC DC DC DC DC DC

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32 Name of Organization JO HARRIS-WEHLING Presented Testimony at Public Hearings American Society of Anesthesiologists American Society of Plastic and Reconstructive Surgeons American Society on Aging American Urological Association Arkansas Foundation for Medical Care Asociacion Nacional Pro Personas Mayores Association for Advancement of Higher Education Bay Area Health Resources Center Blue Choice (Rochester, N.Y.) Blue Cross and Blue Shield Association Blue Cross and Blue Shield of Arizona Blue Cross and Blue Shield of Kansas Blue Shield of California Bureau of Heals Professions, Health Resources Services Administration, Public Health Service California Medical Association California Medical Review, Inc. Center for Study of Drug Development, Tufts University SF SF SF DC DC SF SF Colorado Foundation for Medical Care Commission on Legal Problems of the Elderly, American Bar Association DC Community Health Care Plan (New Haven, Conn.) DC Community Home Health, Inc. (Boise, Idaho) Department of Defense, Office of Assistant Secretary Empire State Medical, Scientific and Educational Foundation (New York PRO) Federation of American Health Systems Georgetown University School of Nursing Gray Panthers of San Francisco Group Health Association of America, Inc. Health Care Purchasers Association Health Data Institute, Baxter Hewlett Packard Home Health Review - Erie County (New York) Hospital Association of New York State (HANYS) SF DC SF SF

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ORAL AND WRI l -1 EN TESTIMONY Name of Organization 33 Presented Testimony at Public Hearings Illinois Council of Home Health Services Independent Health Association (Buffalo, N.Y.) Institute for Health and Aging, University of California San Francisco InterStudy International Association for Enterostomal Therapy, Inc. International Union, United Auto Workers Joint Commission on Accreditation of Healthcare DC Organizations Kaiser Foundation Health Plan, Inc. Kansans for Improvement of Nursing Homes Keystone Peer Review Organization (KePRO) Kentucky Association of Health Care Facilities Kentucky Medical Association SF DC Levindale Hebrew Geriatric Center and American Medical Directors Association Massachusetts Peer Review Organization (MassPRO) Mathemaiica Policy Research Mt. Zion Medical Center, Institute on Aging National Association of Healthcare Providers, Inc. National Association of Board of Examiners For Nursing Home Administrators National Alliance of Senior Citizens National Association for Home Care National Association of Private Psychiatric Hospitals National Association of Quality Assurance Professionals National Association of Retired Federal Employees National Association of Social Workers National Center for Nursing Research, National Institutes of Health National Council on the Aging, Inc. (NCOA) National Hospice Organization National Institute on Adult Day Care, NCOA National Institute on Aging, National Institutes of Health National League for Nursing National Medical Association DC DC DC SF DC DC DC DC

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34 Name of Organization JO HAR~S-WEHLING Presented Testimony at Public Hearinga National Medical Audit National Multiple Sclerosis Society National Rural Health Association National Senior Citizens Law Center Nursing Home Advisory and Research Council Office of Technology Assessment, Congress of the United States Older Women's League (OWL) Omaha Visiting Nurse Association OnLok Senior Health Services Over 60 Health Clinic PEERVIEW (PRO for Indiana) Professional Review Organization for Washington Professional Review Organization for Washington, Alaska Division Pacific Telesis Paralyzed Veterans of America Pharmaceutical Manufacturers Association Prospective Payment Assessment Commission Providence Hospital (Anchorage, Alaska) Public Citizens Health Research Group Sanford Feldman, M.D. (Consultant) Service Employees International Union Sisters of Mercy Health System Society of General Internal Medicine SysteMetrics Thompson, Mohr and Associates, Inc. University of Washington School of Nursing Visiting Nurses Association of Washington, D.C. Veterans Administration W.K. Kellogg Foundation Washington State Aging and Adult Services Wellspring Gerontological Services (Evergreen Park, Ill.) Windermere Senior Health Center (Chicago, Ill.) SF SF DC SF SF DC DC DC aDC, presented testimony at Washington, D.C. Public Hearing; SF, pre- sented testimony at San Francisco Public Hearing.