Medicare: New Directions in Quality Assurance Proceedings (1991)

Edward W. Hook

I, too, wish to congratulate the Institute of Medicine (IOM, 1990) committee on this carefully constructed proposal designed to improve the quality of the health of our people. Because of its magnitude and the many unknowns, I see the committee's 10-year implementation plan as a very wise decision. Like others, I have learned much in reviewing the proposal and have gained more than I could possibly give in commenting on the report.

My charge was to review the section on capacity building, focusing principally on training and on education. Having just indicated that I am very positive overall about the report, I can state my main criticism: the report has very little information, insufficient information in my opinion, on who will do the job and how they will be trained. For example, there is no assessment of our present capacity to implement the recommendations of the report, although it was emphasized that our present capacity was inadequate. There is no assessment of the requirements for new personnel or the magnitude of the retraining and educational effort that will be required. Considering the detail given to structure and function of the program, and the emphasis placed on specific research needed to correct information deficits, I found the lack of emphasis on manpower development and training programs inconsistent.

The types of personnel that will be needed fall into two major categories. The first includes persons required to staff and operate the quality assurance program—that is, from top to bottom, from the oversight to the provider

organizations, especially in the MQROs¹. The second consists of investigators who will carry out the research. The investigators themselves fall into two main groups: those who would work to strengthen the weak knowledge base of the methods and the impact of quality assurance, and those who do the research that will provide data on effectiveness and outcomes of various interventions or alternatives that constitute the information base for much of the quality assurance process.

Regarding the operation of the program, the report appropriately emphasizes the fundamental importance of a core of professionals prepared to provide both technical skills and leadership. There seems to be general agreement in the committee that at present we lack an adequate number of professionals to staff a nationwide program and that establishing training programs to prepare these professionals should be a high-priority item. The committee apparently envisioned that these educational programs would require a year of study—I see the period of training as very variable—and that such programs could be built on existing programs in epidemiology, health care research, and biostatistics. Re-education of existing staffs and senior professionals already working in the area will facilitate implementation of the program until organized training programs that would include field experience could be developed to prepare this new cadre of health workers with the tools needed to collect and apply information for quality assurance.

The professional staff required for the program will require a diverse group of individuals with many different skills, including persons trained for leadership roles, as managers, in data acquisition and analysis, evaluation, record abstraction, information science, questionnaire development, ethics, and so forth. Much work remains to be done in identifying the types and numbers of such persons who will be needed to establish a nationwide network for quality assurance.

Because of the diversity of the group, it seems inevitable that the type and duration of training will vary greatly. Curriculum development for the types of personnel that will be required is a high priority. Some experimentation through demonstration projects might be advisable to define the optimum staff for the MQROs and other components of the system. I very much like

Dr. Relman's ideas (Relman, 1991) as well as the committee's views about incremental implementation before going big.

In the report and the other conference presentations, two related messages recur. First is the need for research—and then more and more research. The research is required to fill extensive knowledge gaps and to define what works and what does not, what people want and what they need. Second is the need for research specifically in quality-of-care issues—how to measure it, how to apply such measures efficiently, how to address deficiencies, and how to evaluate the effort.

The training of researchers who will focus on quality assurance, outcome, and related issues will require that they gain varying levels of proficiency in experimental design, biostatistics, clinical epidemiology, decision analysis, and perhaps other nonbiological disciplines. Those planning a research career in the area would probably be M.D.s, Ph.D.s, or degree nurses, and they would need a period of study of no less than two years, perhaps even three. For the M.D.s this would come after clinical training of sufficient duration to achieve board eligibility. The characteristics of training sites would need to be carefully defined and would certainly have to include adequate faculty to cover all of the disciplines or areas that I mentioned earlier. The training site should also be an active site for research in quality assurance and technology assessment, outcomes research, and health services research broadly defined.

When the committee or other responsible group comes to grips with designing the goals, the objectives, and the characteristics of the research training program, it might profit by calling on the experience of the Robert Wood Johnson Foundation's Clinical Scholars Program. This program has been the country's premier program in producing qualified clinician investigators in health services research, technology assessment, and the like. The program was designed to allow young physicians from all clinical specialties to undertake two years of graduate-level study and research to acquire competence in one or more of a number of nonbiological disciplines that bear on medicine and health affairs. These disciplines include epidemiology, biostatistics, economics, management sciences, ethics, anthropology, and occasionally others. To date there have been more that 500 graduates of this highly successful program, many of them in full-time investigative roles and many of them working on problems related to quality assurance, outcomes of care, and the like.

The IOM report, by design, did not address technology assessment, health services research, or research into access to care and continuity of care. Nevertheless, as the committee emphasized, these areas are critical to qual-

ity assurance. The number of persons properly trained to carry out research in these areas, and especially those with satisfactory clinical backgrounds, is inadequate despite increasing interest in the field in recent years and the current prospects for increased funding in the new Agency for Health Care Policy and Research. I am disappointed, however, by the apparently limited research training capabilities of that agency; at least that is my interpretation of the emphasis on research reflected in the remarks by Dr. Demlo (Demlo, 1991) at the conference. Thus, I see the serious need for expanded opportunities for research training, not only for those professionals who will focus on research specifically on quality-of-care measurement and quality assurance, but also for those who will do health services research, technology assessment, and other research providing data on effectiveness and outcome—the information base for much of quality assurance.

Finally, let me comment briefly on the issue of patient education. I accept completely the recommendation that we educate the public and our patients about matters of health and, of course, I respect the right of the public and patients to be involved in decisionmaking about their health. Yet what we decide to communicate to the public might be quite different from what we communicate to our patients. First things should come first. Before communicating morbidity and mortality figures of uncertain value to the public, I would like to use our resources in an educational effort extolling the virtues and the importance of having a primary care physician or providing more information on preventive practices of known value.

In contrast to this type of broad public education, there is interaction between the patient with a significant problem and his or her physician. In this interaction, balancing the alternatives with morbidity and mortality data and any other information that is available becomes more meaningful and very helpful in the decisionmaking process. Of course the model that we discuss so much is Dr. Wennberg's prostatic hypertrophy model, which I think is an extremely good one (Mulley, 1991; Wennberg, 1991).

In terms of capacity building, the question becomes who is going to make this patient and public educational effort and by what means? Newsletters, video disks, television programs, and tapes were all mentioned in the report, but priorities were not defined. Obviously, appropriately trained educators are central to this effort, and experimentation in this area is certainly in order.

The goals of the program proposed by the IOM offer exciting possibilities for the continued, even continuous, improvement of the health of our

people. Adequately trained professionals are a prerequisite for success. Specific, detailed plans for training of these professionals should be initiated as a high-priority item early in the development of the program.

Demlo, L.K. An Administration Response to the Institute of Medicine Report From the Agency for Health Care Policy and Research. Pp. 174-178 in Medicare: New Directions in Quality Assurance. Donaldson, M.S., Harris-Wehling, J., and Lohr, K.N., eds. Washington, D.C.: National Academy Press, 1991.

Institute of Medicine. Medicare: A Strategy for Quality Assurance. Lohr, K.N., ed. Washington, D.C.: National Academy Press, 1990. (See especially Volume I, Chapters 11 and 12,)

Mulley, A.G. A Patient Outcomes Orientation: The Committee View. Pp. 63-72 in Medicare: New Directions in Quality Assurance. Donaldson, M.S., Harris-Wehling, J., and Lohr, K.N., eds. Washington, D.C.: National Academy Press, 1991.

Relman, A.S. A Physician's Resonse to the Institute of Medicine Report. Pp. 167-173 in Medicare: New Directions in Quality Assurance. Donaldson, M.S., Harris-Wehling, J., and Lohr, K.N., eds. Washington, D.C.: National Academy Press, 1991.

Wennberg, J.E. A Patient Outcomes Orientation: A Response. Pp. 73-78 in Medicare: New Directions in Quality Assurance. Donaldson, M.S., Harris-Wehling, J., and Lohr, K.N., eds. Washington, D.C.: National Academy Press, 1991.