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25
Where Do We Go From Here?

Ceylon S. Lewis, Jr.

The Institute of Medicine (IOM, 1990) report Medicare: A Strategy for Quality Assurance is a challenging and, in my opinion, excellent analysis of the current state of the art of quality monitoring, evaluation, and improvement in the delivery of health care. It is a timely subject that represents a concern of many people in our country. The positions taken in the report that the quality of health care has been, and may continue to be, negatively influenced by cost containment pressures and that, therefore, quality should be addressed in a positive manner are an excellent beginning.

I would like to review briefly the major mechanisms that are in place at present in the private sector and to some degree in the public sector to address the issue of maintenance of high quality of care. I would then like to comment on the ten recommendations in the IOM report.

CURRENT MECHANISMS FOR ASSURING QUALITY CARE

Medical Education and Board Certification

The medical profession has in place a number of mechanisms to assure appropriate training and clinical competence of physicians. Other health professions have similar programs in place. Webster's Third International Dictionary defines a profession as

a calling requiring specialized knowledge and often long and intensive preparation, including instruction in skills and methods, as well as in the scientific, historical or scholarly principles underlying such skills and methods, maintaining by force of organization or concerted opinion high standards of achievement and conduct and committing its members to continued study of a kind of work which has for its prime purpose the rendering of public service.



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Medicare: New Directions in Quality Assurance 25 Where Do We Go From Here? Ceylon S. Lewis, Jr. The Institute of Medicine (IOM, 1990) report Medicare: A Strategy for Quality Assurance is a challenging and, in my opinion, excellent analysis of the current state of the art of quality monitoring, evaluation, and improvement in the delivery of health care. It is a timely subject that represents a concern of many people in our country. The positions taken in the report that the quality of health care has been, and may continue to be, negatively influenced by cost containment pressures and that, therefore, quality should be addressed in a positive manner are an excellent beginning. I would like to review briefly the major mechanisms that are in place at present in the private sector and to some degree in the public sector to address the issue of maintenance of high quality of care. I would then like to comment on the ten recommendations in the IOM report. CURRENT MECHANISMS FOR ASSURING QUALITY CARE Medical Education and Board Certification The medical profession has in place a number of mechanisms to assure appropriate training and clinical competence of physicians. Other health professions have similar programs in place. Webster's Third International Dictionary defines a profession as a calling requiring specialized knowledge and often long and intensive preparation, including instruction in skills and methods, as well as in the scientific, historical or scholarly principles underlying such skills and methods, maintaining by force of organization or concerted opinion high standards of achievement and conduct and committing its members to continued study of a kind of work which has for its prime purpose the rendering of public service.

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Medicare: New Directions in Quality Assurance The Liaison Committee on Medical Education (LCME) oversees the standards for curriculum in medical schools and for the maintenance of adequate resources and environment for medical student education. The Accreditation Council for Graduate Medical Education (ACGME) coordinates the activity of the 24 Residency Review Committees that oversee and approve curriculum, resources, and faculty for residency education and carry out an accreditation program based on periodic survey. The American Board of Medical Specialties (ABMS) oversees the 24 specialty boards that are members of the ABMS, and each specialty board oversees the training requirements for eligibility to sit for the examination by the board and for certification by the board. The ongoing stimuli for maintenance of quality of physicians in terms of clinical competence and knowledge consists of time-limited certification, professional organizations that stress continuing medical education, and the availability of high-quality continuing medical education. These mechanisms do not guarantee cost containment. However, a large amount of data supports the thesis that high-quality care is more cost-effective than low-quality care. Continuing effort to increase and update medical information for health professionals is one of the most potent means of assuring continual improvement in quality of care per se, but society will have to make the difficult decisions on the apportionment of resources to care for our citizens in the future, such as prenatal care compared to terminal care. Hospital Accreditation The environment for providing medical care, particularly for the hospitalized patient, is monitored and accredited primarily by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). In addition to monitoring quality of care through quality assurance and quality improvement mechanisms, the JCAHO is in the process of revamping the standards and monitoring capabilities through a series of approaches under the general term "Agenda for Change." The JCAHO is reducing the complexity of standards and focusing them on key governance, management, patient care, and support functions within the hospital organization. Standards are being created to provide a foundation for continual improvement in quality of care. To monitor performance capabilities more effectively, a method has been created to develop useful performance measures. This method is now being used to formulate sets of indicators related to performance of key functions that will be measured in each institution. The data will be transmitted to the JCAHO for analysis and feedback. This will form the basis for a national data base that incorporates standards, compliance information, and performance data. One important aspect of the Agenda for Change is to develop an attitude of seeking continual improvement in the quality of care through cooperative

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Medicare: New Directions in Quality Assurance activities of the medical staff, the administration, and the trustees of each health care organization. Greater emphasis will be placed on the role of leaders within each of these components to ensure continued improvement. Performance indicators that are being developed will be used in measuring results of patient care activities, to identify potential problem areas, and thereby lay a foundation for correcting any problems that may be present. Two groups of indicators—for obstetrics and for anesthesia—have been field-tested for over a year. Later in 1990 they will be field tested in 400 hospitals in the country, with data collection, feedback, and evaluation procedures being tested for general application to all institutions. In addition to these measures, pilot testing is being started this year on indicators for oncology care, cardiovascular care, and trauma care. In summary, the JCAHO is refocusing standards on key processes to include medication usage, infection control, systematic monitoring by using key indicators, and matching individual credentials with demonstrated performance. The traditional assessment of compliance with specific standards will continue and will be complemented by the collection, analysis, and feedback of data that reflect the actual performance of accredited organizations in undertaking key activities. COMMENTS ON THE INSTITUTE OF MEDICINE RECOMMENDATIONS Recommendation No. 1 in the IOM report calls for an expansion of the mission of Medicare to include an explicit responsibility for assuring the quality of care for Medicare enrollees. One means of doing this might well be by deemed status or by other types of cooperative efforts between government and the private sector. Deemed status is now applied to hospitals that are accredited by the JCAHO and are therefore deemed to have met the Medicare requirements. The IOM report strongly endorses deemed status. Recommendation No. 2 in the IOM report calls for continuous improvement in the quality of health care and strengthening the ability of the organization and practitioners to assess and improve their performance, to identify barriers, and to generate options to overcome these barriers. This, again, is an excellent recommendation and could be well covered by a deemed status mechanism as noted above. Recommendation No. 3 calls for restructuring the Medicare Peer Review Organization program to shift the responsibility of the program to monitoring quality of care rather than cost containment. This would be an excellent development, in my opinion, because I think it would do much more to enhance improved quality of care than the current censuring program that has been mandated. Efforts should be made to better coordinate this activity with accreditation.

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Medicare: New Directions in Quality Assurance Recommendations Nos. 4,5,6, and 7 in the IOM report call for structuring the agencies to oversee a program of continued improvement; this certainly appears to be necessary. Recommendations Nos. 8 and 9 call for adequate resources through the office of the Secretary of the Department of Health and Human Services to provide research funds to support development of clinical practice guidelines and adequate educational activities to enhance the nation's capacity for improved quality of care. Funds are urgently needed at this time to support the development and testing of performance indicators. Recommendation No. 10 calls for appropriate funds to carry out the recommendations. The primary suggestion that I have is to develop a strategy to encourage government agencies and private agencies, such as the JCAHO, to work together—much as the Health Care Financing Administration and the JCAHO work together at present with a deemed status mechanism or as the LCME, the Residency Review Committees, and the specialty boards in the private sector carry out the quality assurance functions in medical education. I believe this would produce better results than government working alone. The patients cared for in hospitals that are not currently accredited by the JCAHO represent a special problem. It may best be addressed as suggested in the report with cooperative efforts, particularly between the private sector JCAHO and government agencies, to develop and utilize a mechanism for nonaccredited institutions to be monitored through performance standards that employ clinical indicators. SUMMARY I think this is an excellent report and believe it points in the right direction: improvement on a continuing basis by using clinical indicators and monitoring methods to provide for our citizens the highest quality of health care that is possible. The next steps should be (1) to develop a strategy to enable adequate funding for development and testing of performance; (2) to develop a strategy for utilizing the private sector initiatives (e.g., JCAHO, ABMS, ACGME) in a combined effort to maintain and improve the quality of care; and (3) to develop a strategy to address the societal issues of resource application in health care. REFERENCE Institute of Medicine. Medicare: A Strategy for Quality Assurance. Lohr, K.N., ed. Washington, D.C.: National Academy Press, 1990. (See especially Volume I, Chapter 5 for a discussion of the Joint Commission's accreditation activities and Volume I, Chapter 12 for an explication of the IOM committee's recommendations.)