America's Health in Transition: Protecting and Improving the Quality of Health and Health Care

In America, we are now in the midst of an historic transition in how we seek and receive health care and in how we finance and deliver that care. Some fear that the changes under way will produce long queues for care, limit the availability of effective treatments and technologies, or lessen the personal commitment of health care providers to their patients. As we try to provide adequate access to health care for all Americans and to reduce the future cost of care, we want also to ensure that we preserve and improve the quality of care that the nation now enjoys. By enhancing the quality of health care, we will also gain greater value for our health care expenditures.

Quality-of-care concerns have often been set aside to tackle the seemingly more pressing problems of access and financing. The Council of the Institute of Medicine (IOM) believes that quality-of-care matters must be given the same attention in policy and research as the other problems that have led us to the health care reform path on which the nation is now embarked. In fact, the quality of health care can be measured and quality measurement tools can be used to improve care and to help the health care transition succeed.



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America's Health in Transition: Protecting and Improving Quality America's Health in Transition: Protecting and Improving the Quality of Health and Health Care In America, we are now in the midst of an historic transition in how we seek and receive health care and in how we finance and deliver that care. Some fear that the changes under way will produce long queues for care, limit the availability of effective treatments and technologies, or lessen the personal commitment of health care providers to their patients. As we try to provide adequate access to health care for all Americans and to reduce the future cost of care, we want also to ensure that we preserve and improve the quality of care that the nation now enjoys. By enhancing the quality of health care, we will also gain greater value for our health care expenditures. Quality-of-care concerns have often been set aside to tackle the seemingly more pressing problems of access and financing. The Council of the Institute of Medicine (IOM) believes that quality-of-care matters must be given the same attention in policy and research as the other problems that have led us to the health care reform path on which the nation is now embarked. In fact, the quality of health care can be measured and quality measurement tools can be used to improve care and to help the health care transition succeed.

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America's Health in Transition: Protecting and Improving Quality For almost 25 years, the IOM has contributed to many pivotal health policy issues. As its 1993 monograph, Assessing Health Care Reform, asserts, leaders in both the public and private sectors must ensure that a reformed health care system delivers high-quality care at an affordable price to all and be ever vigilant to the risks to quality of care that change may bring. Those who are responsible for enacting and enforcing public policy and for determining the future shape of health care in the United States must identify the public agencies and private groups that shall be responsible for overseeing quality measurement and specify to whom those organizations shall be accountable. Such policymakers must also: identify the populations for whom quality of care shall be monitored, from individuals and members of health plans to groups with special health needs, communities, and the nation as a whole; confront the full range of quality-of-care problems, including overuse and underuse of services as well as deficiencies in the technical and interpersonal aspects of health care; stipulate that quality measurement include evaluation of structural elements, processes, and outcomes of care; create reliable uniform data systems and collect consistent data from a variety of sources; apply and refine tools and techniques of quality measurement and improvement that will help health care reform succeed; devise means of providing valid, useful information on health care quality to consumers, providers, payers, and policymakers; and promote communication and education among all elements of society about quality of care and the use of quality measures. Concerns about quality of care are no excuse to delay or thwart health reform. They are a compelling reason to confront quality matters with the same vigor and sophistication as will be directed at issues of access and cost.

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America's Health in Transition: Protecting and Improving Quality Improving the quality of health and health care requires attention to the processes and outcomes of health services rendered to individuals, with adequate adjustments for the different disease, risk-factor, and personal characteristics of those individuals. It also demands consideration of these same elements of process, outcome, and risk adjustment for those with special health care needs and for populations. Preventive care, promotion of healthful lifestyles, and broader public health activities are critical components of good health. For example, 10- to 24-year-olds, as a group, are likely to gain much more in improved health and survival from preventive and public-health-oriented actions than from traditional illness care. A separate paper will address the key role that public health could play in a reformed health system through population-based services, links with the medical care system to ensure the provision of quality health care to all, and public policies related to environmental health and other areas. The IOM has demonstrated that many barriers to better health are related to socioeconomic, educational, cultural, and behavioral factors. At times these elements extend far beyond health care or health promotion and disease prevention in the usual sense. In this White Paper, however, the IOM emphasizes the central role that assessing and improving the quality of health care services have in achieving value for health care expenditures. QUALITY OF CARE AND HEALTH CARE REFORM: KEY QUESTIONS Can Quality of Care Be Defined? The answer is “Yes.” The IOM stated in 1990 in Medicare: A Strategy for Quality Assurance that “quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” This definition has been widely accepted and has proven to be a powerful tool in the formulation of practical

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America's Health in Transition: Protecting and Improving Quality approaches to quality assessment and improvement. Several ideas in this definition deserve elaboration. The term “health services” refers to a broad range of services that affect health, including those for physical and mental illnesses. Furthermore, the definition applies to many types of health care providers (physicians, nurses, dentists, therapists, and various other health professionals) and to all settings of care (from hospitals and nursing homes to physicians ' offices, community sites, and even private homes). Including “populations” as well as “individuals” draws attention to the different perspectives that need to be addressed. On the one hand, we are concerned with the quality of care that individual plans and providers deliver; this is a traditional, familiar area of assessing and improving the care that individual patients and persons enrolled in specific health programs receive and the outcomes they experience. On the other hand, we must direct attention to the quality of care across the entire system; in particular, we must ask whether all parts of the population have access to needed and appropriate services and whether health status is improving. That focus embraces all groups, whether or not they receive care and whether they are defined by cultural heritage, sociodemographic characteristics, geography (e.g., a state or region), or diagnosis, and it recognizes that such individuals will include the most vulnerable and frail among us. The phrase “desired health outcomes” highlights the crucial link between the processes and outcomes of health care. It underscores the importance of being mindful of people 's well-being and welfare and of keeping patients and their families well informed about alternative health care interventions and their expected outcomes. Focusing on outcomes requires clinicians to take their patients' preferences and values into account as together they make health care decisions. “Current professional knowledge” emphasizes that health professionals must stay abreast of the dynamic knowledge base within their professions and take responsibility for explaining to their patients the

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America's Health in Transition: Protecting and Improving Quality processes and expected outcomes of care. It involves maintaining high standards for licensure, certification, and recertification for all individuals and institutions that provide health care. Finally, it highlights the need for clinicians to contribute to the knowledge base by participating in biomedical and health services research and by developing and using clinical practice guidelines. Where Do the Quality-of-Care Concerns Lie Today? The answer is “In many different areas of health care.” In accordance with the IOM definition, a reformed health care system must be able to address three fundamental quality-of-care issues: Use of unnecessary or inappropriate care. Examples include excessive use of cesarean section, hysterectomy, and open-heart surgery, and overprescription of antibiotics and certain mood-altering drugs. These practices make patients vulnerable to harmful side effects. They also waste money and resources that could be put to more productive use. Underuse of needed, effective, andappropriate care. People do not get proper preventive, diagnostic, or therapeutic services if they lack health insurance and delay seeking care or receive no care at all. Even those with insurance often face geographic, cultural, attitudinal, organizational, or other barriers that limit their abilities to seek or receive such care. For instance, mammography and immunizations are not as widely provided as most experts believe is appropriate, and many conditions, including serious depression, are often not diagnosed. Shortcomings in technical and interpersonalaspects of care. Inferior care results when health care professionals lack full mastery of their clinical areas, cannot adequately explain key aspects of care to their patients, or cannot communicate effectively and with compassion. Cases in point include preventable medical injuries such as drug

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America's Health in Transition: Protecting and Improving Quality interactions, surgical mishaps, failure to monitor or follow up abnormal laboratory tests, neglecting to provide appropriate education and information to patients, lack of adequate coordination of care, and insensitivity to ethnic and cultural characteristics of patients. Most quality-of-care issues today are brought to light in the context of personal health care services for individuals, but many critical problems relate to the population as a whole. Public health contributes to the health of the public through assessment of health and health needs, policy formulation, and assurance of the availability of services. This role was clearly stated in 1988 in The Future of Public Health and must be reaffirmed. Furthermore, those concerned with the success of health reform must be able to know how reform efforts may differentially affect certain groups of people, especially vulnerable or disadvantaged persons who are most at risk from poor care or inadequate access to care, and they must devise ways to protect such groups from any unanticipated negative effects. These tasks call for applying population-based quality measures to all types of providers in both the private and the public sectors. Thus, although success in health care reform calls for attention to the quality of care that individual plans, clinics, and institutions deliver, it also demands monitoring of the quality of care across the entire system. It is imperative that the nation guard against significantly different levels of performance among the states or among markedly different populations—there are some criteria for quality that should be satisfied everywhere. Policymakers must be clear about the extent to which national bodies and organizations have responsibilities to protect the quality of care for all populations and plans, to ensure that no particular group falls below acceptable thresholds, and to ove everyone up the quality scale.

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America's Health in Transition: Protecting and Improving Quality Can Quality of Care Be Measured and Improved? The answer is “Yes, to varying degrees.” Tested approaches already exist for measuring quality of care. Experts have been engaged, for more than 25 years, in creating reliable, valid ways to assess the quality of care for inpatient and ambulatory settings and across a wide range of health services and concerns. In a few areas, well-understood measurement tools can be put to immediate, widespread use. In others, however, the science of quality measurement is relatively elementary, making the validity of comparative assessments suspect. One conspicuous need is to develop and apply widely accepted standards and criteria for quality measurement tools and instruments that take into consideration factors such as patient age, severity of illness, and the statistical implications of the size of the patient population. Health care reform means that Americans' concerns about quality of care, and people's ability to gather and use data, will evolve over time. Thus, even as existing quality-of-care instruments are applied, new and enhanced measurement tools must be developed. Good ways also exist for improving the quality of health care. In addition to what we know about good and bad quality care, a “science” of systems and management (involving fields such as organizational behavior, statistics, psychology, and learning) can be used to influence positively the institutions and people who provide health services. Organization-wide quality improvement efforts are just beginning to be adopted in the service sectors worldwide. Promising work is currently under way in health care settings in the United States. Much remains to be learned about linking these concepts and tools, most of which are not yet familiar to clinicians or health administrators, to other, betterknown disciplines and approaches in health, such as technology assessment, practice guidelines, clinical evaluation, and medical decisionmaking.

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America's Health in Transition: Protecting and Improving Quality None of today's approaches to quality assurance and management can serve all the aims of reform simultaneously. Reform goals include changing provider behaviors and improving the processes of care at the health plan and practitioner levels; informing consumers about local health matters of interest so they can make better choices; providing useful, comparable data by region or across the nation as a whole; ensuring that all who need care receive it; and promoting good health outcomes for all Americans. The challenge is to learn more about the strengths and limitations of current quality improvement approaches in relation to the goals of health reform. This will not be easy or without cost. Health care providers have special respousibilities for ensuring quality of care—now and as health care reform proceeds. These responsibilities involve continuing education and training, expanded health services research, and active involvement in quality improvement programs. No current reform proposals tackle these issues head on, and no single organization or institution in the private sector has fully addressed them either. Formal linkages between quality review and improvement organizations and the nation's academic health institutions may prove instrumental in fostering greater leadership and participation by all the nation's health professionals in quality-of-care activities. Internalquality improvement and management efforts to develop and design care and to monitor quality of care areessential—both health plans and provider groups must act on their own to measure andimprove their performance and their patients' outcomes. Reform efforts must reinforce the steps that physicians and other health care professionals can take now toward improving the performance of local health care institutions and health plans, so that intrusive programs to micromanage care from the outside can be avoided. A correlate to this idea is strengthening the performance of the system as a whole by rewarding exemplary performance and promoting continuous improvement of all plans and providers. Finally, for quality improvement to succeed at the local level, clinicians and patients need

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America's Health in Transition: Protecting and Improving Quality to have easy-to-use knowledge and tools, and these are increasingly available. We also need to relate retrospective measures of performance (e.g., “report cards”) to actions that should be taken to guide the delivery of high-quality care. External monitoring of quality of care will be necessary, however, to ensure the integrity of the quality management procedures used by plans and providers and the quality-of-care information they report and to make assessments from a broader population perspective. It is imperative that the impact of reform on the quality of health care and the health status of the entire population be tracked. The absolute necessity of having a dual approach—internal and external quality monitoring and improvement—as a way of understanding the effects of reform on quality of care is not well understood by the health care community, policymakers, or consumers; thus, these issues must be explained more carefully and fully to all these audiences. Can We Gather and Disseminate the Data We Need? The answer is “We can in principle but current data are inadequate.” Improving the performance of this society's health system and the health status and well-being of all its members —the touchstone of reform efforts—will require the collection of better, more consistent, and more comprehensive health data from a variety of sources. The uses for more and better data were recently catalogued in Health Data in the Information Age: Use, Disclosure, and Privacy. These are to: assess the health of the public and patterns of illness and injury; identify unmet regional health needs; document patterns of health care expenditures on inappropriate, wasteful, or potentially harmful services; identify cost-effective care providers; and provide information to improve the quality of care in hospitals, practitioners' offices, clinics, and other health care settings.

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America's Health in Transition: Protecting and Improving Quality Numerous barriers keep us from realizing the goals of adequate data acquisition and informationdissemination. Contemporary databases cannot reliably provide information that is dependable, accurate, complete, and appropriate for the quality-of-care and “comparative” report card tasks at hand. In addition, databases that may yield good information for policymakers at a state or national level may not provide useful information for health care professionals or consumers at a local level—and the reverse is also true. Furthermore, the collection of data, especially in clinical settings, should not be allowed to impede the delivery of optimal care. Strategies for carrying out quality assurance and improvement are evolving rapidly, but all rely on having more and better data and data systems. Many people advocate using report cards to give consumers comparative information about individual health plans, hospitals, physicians, and other providers. We must learn more about the appropriate content of such report cards, and we must also gain more experience with making information consistent and comparable across regions and states and across health plans and providers. How consumers could use such information to make safe and appropriate choices and find high-quality care at reasonable prices is not well understood, and there has been little systematic examination of the effects of information disclosure to the public. Thus, we need to know whether public disclosure of quality-related information on health plans, providers, or practitioners will materially influence individuals' decisions about health care or demonstrably improve the processes and outcomes of their health care. We also need to determine what influence public disclosure of such information may have on the quality of data in various databases, and whether it will improve or contaminate certain kinds of information (e.g., on malpractice actions). Furthermore, different audiences will need different types of information for different purposes. What administrators or public officials may want to know may be quite distinct from what patients or their families may want to know, and the information

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America's Health in Transition: Protecting and Improving Quality that various people or groups find useful today may not be what they will need tomorrow. We must avoid the simplistic assumption that a single set of measures will meet the needs of all interested parties. Regardless of the direction that reform takes, the problems associated with obtaining and using comparative data for conducting health policy, making health care decisions, and improving quality of care must be surmounted. These challenges will require significant health services research efforts as well as a national commitment to improving a wide variety of data sources such as consumer surveys, computer-based patient records, and administrative data files. Who Needs to Be Well-Informed About Quality of Care? The answer is “Everyone.” The audiences for information about quality of care are numerous: patients and their families; consumer agents and advocates; health professionals; administrators of health plans and facilities; payers for and purchasers of health care services; and policymakers at the national, state, and local levels. A considerable amount of public outreach, education, and communication will be required for the nation to track quality-of-care issues over the long term and for the American people to know whether the health care systems that emerge are working or breaking down. The twin messages that quality can be measured and improved are the most important ideas to reinforce. Doing this means: (a) making sure that quality-of-care issues stay on the reform agenda; (b) stating clearly what risks and opportunities reform poses; (c) indicating how health plans and providers can be accountable to patients and society and, conversely, how individuals can take responsibility, where appropriate, for their own health; and (d) fostering multiway communications among all these groups. Such educational and communication endeavors, involving all interested parties to a degree not yet seen in the quality-of-care field, must be a

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America's Health in Transition: Protecting and Improving Quality high priority as health reform moves forward, and they must be diverse enough to reach groups with particular social, economic, and health needs. These are significant challenges and responsibilities for public agencies and private health plans that engage in reform efforts at the state and local levels, as well as for the federal government. THE IOM SPECIAL INITIATIVE The challenges and questions raised in this White Paper call for considerable investments of time, money, and effort from many different constituencies. To respond to this need the IOM is pursuing its existing quality-of-care agenda and applying it aggressively to the points raised in this White Paper through a special initiative, designated “America's Health in Transition: Protecting and Improving the Quality of Health and Health Care." This IOM-wide, 3-year effort will be coordinated, focused examination of quality-of-care issues. The IOM has more than 20 years of experience in drawing attention to problems of inadequate systems of care and deficiencies in health services, as well as in devising approaches to measuring and assuring quality (see the Bibliography). This past work will be a solid starting point. In addition, the IOM will undertake further activities as the direction of health reform evolves, with special attention to the health of the public and to that of specific vulnerable populations. This program will involve both analytic studies and convening activities such as forums and workshops. Through this initiative, the IOM will remind policymakers and the public of the need for continuing efforts to monitor and improve the health and well-being of Americans and the quality of care that they receive during this period of potentially rapid and unpredictable change.