Statement on Quality of Care

Institute of Medicine

National Roundtable on Health Care Quality

Molla S.Donaldson, Editor

Institute of Medicine

2101 Constitution Avenue, N.W.

Washington, DC 20418

telephone: (202) 334–2184

fax: (202) 334–1463

e-mail: mdonalds@nas.edu



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Statement on Quality of Care Statement on Quality of Care Institute of Medicine National Roundtable on Health Care Quality Molla S.Donaldson, Editor Institute of Medicine 2101 Constitution Avenue, N.W. Washington, DC 20418 telephone: (202) 334–2184 fax: (202) 334–1463 e-mail: mdonalds@nas.edu

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Statement on Quality of Care NOTICE: The project that is the subject of this statement was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy’s 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I.Shine is president of the Institute of Medicine. Support for this project was provided by The Agency for Health Care Research and Policy (DHHS), The Commonwealth Fund, the National Research Council, the Department of Defense (Health Affairs), and Pfizer Inc. The views presented in this statement are those of the Members of the National Roundtable on Health Care Quality and are not necessarily those of the funding organizations. For more information about the Institute of Medicine, visit the IOM home page at http://www.nas.edu

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Statement on Quality of Care ROSTER Mark R.Chassin, MD, MPP, MPH, Co-Chair* Professor and Chairman Department of Health Policy The Mount Sinai Medical Center New York, NY Robert W.Galvin, Co-Chair Chairman of Executive Committee Motorola, Inc. Schaumburg, IL Kathleen O.Angel Vice President Benefits and Worldwide Solutions Digital Equipment Corporation Maynard, MA Marcia Angell, MD* Executive Editor The New England Journal of Medicine Boston, MA Robert A.Berenson, MD Vice President The Lewin Group Fairfax, VA Robert H.Brook, MD, ScD* Professor of Medicine and Health Services UCLA Center for Health Sciences Vice President & Director RAND Health The RAND Corporation Santa Monica, CA Ezra C.Davidson, Jr., MD* Associate Dean, Primary Care Professor and Former Chair Department of Obstetrics and Gynecology Charles R.Drew University of Medicine and Science King-Drew Medical Center Los Angeles, CA Arnold Epstein, MD, MA Chief, Section on Health Services and Policy Research Brigham and Women’s Hospital Professor and Chairman Department of Health Policy and Management Harvard School of Public Health Boston, MA Clifton Gaus, Sc.D. (until 04/01/97)† Administrator Agency for Health Care Policy and Research Rockville, MD Charlene A.Harrington, PhD,RN* Professor and Chair Department of Social and Behavioral Sciences School of Nursing University of California San Francisco, CA John K.Iglehart* Editor, Health Affairs Quarterly National Correspondent New England Journal of Medicine Potomac, MD Brent James, MD Executive Director Intermountain Health Care Institute for Health Care Delivery Research Salt Lake City, UT Steven Joseph, M.D., M.P.H. (until 01/15/97)*† Assistant Secretary of Defense for Health Affairs Department of Defense Washington, DC Rhoda Karpatkin, JD President Consumers Union of the United States Yonkers, NY

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Statement on Quality of Care Kenneth W.Kizer, MD, MPH† Under Secretary for Health Department of Veteran Affairs Veterans Health Administration Washington, DC Gerald D.Laubach, PhD* Former CEO Pfizer Inc Essex Fells, NJ David McK. Lawrence, MD, MPH* Chairman and Chief Executive Officer Kaiser Foundation Health Plan, Inc. and Kaiser Foundation Hospitals Oakland, CA William L.Roper, MD, MPH* Dean School of Public Health The University of North Carolina, Chapel Hill Chapel Hill, NC O.David Taunton, MD, FACP Private Practice of Endocrinology Birmingham, AL Bruce Vladeck, Ph.D.*† Administrator Health Care Financing Administration Baltimore, MD *   IOM Member †   These authors are expressing their individual views and not necessarily those of their organization. IOM Staff Molla S.Donaldson, Project Director Kathleen Nolan, Research Assistant Tracy McKay, Project Assistant Evelyn Simeon, Administrative Assistant

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Statement on Quality of Care PREFACE AND ACKNOWLEDGMENTS The National Roundtable on Health Care Quality was established in 1995 by the Institute of Medicine. The Roundtable consists of experts formally appointed through procedures of the National Research Council (NRC) who represent both public and private sector perspectives and appropriate areas of substantive expertise (not organizations). From the public sector, heads of appropriate Federal programs serve. It offers a unique, nonadversarial environment to explore ongoing rapid changes in the medical marketplace and the implications of these changes for the quality of health and health care in this nation. The Roundtable convenes nationally prominent representatives of the private and public sector (regional, state and federal), academia, patients, and the health media to analyze unfolding issues concerning quality, to hold workshops and commission papers on significant topics, and when appropriate, to produce periodic statements for the nation on quality of care matters. By providing a structured opportunity for regular communication and interaction, the Roundtable fosters candid discussion among individuals who represent various sides of a given issue. Biographical sketches of each member of the Roundtable are included at the end of this statement. Additional Contributors to the Roundtable In addition to appointed members of the Roundtable, several individuals from government programs provided special assistance to the Roundtable. They are: from the Agency for Health Care Policy and Research, Lisa Simpson, M.B., B.ch., F.A.A.P., Deputy Administrator; Sandy Robinson, Acting Director, Center for Quality Measurement and Improvement; and Irene Fraser, Director, Center for Organization and Delivery Studies; from the Health Care Financing Administration, Helen Smits, M.D., Deputy Administrator and Peter Bouxsein, J.D., Acting Director, Office of Clinical Standards and Quality; from the Department of Defense (Health Affairs) Colonels David Shutt and William Strampel, Directors of Quality Management OSD/Clinical Services; and from the Department of Veterans Affairs, Nancy J.Wilson, M.D., M.P.H., Department for Quality Management. In addition to stepping in for the program head on occasion, all the individuals provided helpful information about their program’s work. Although the Roundtable does not provide advice or make recommendations on any specific issue or policy pending before any government agency or other entity, it can make public statements on the state of health and the quality of health care in the nation. Such documents are subject to the formal report review procedures of the National Research Council and distill what is known on key issues, promote public awareness of these issues, and serves as a credible source of information on the “quality” of quality measurement and improvement. The charge to the Roundtable was: To identify important issues related to the quality of health care in the United States, including its measurement, assessment, and improvement.

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Statement on Quality of Care To identify important strengths and weaknesses in the current healthcare system that affect the quality of health care and options for improvement that might be considered by the public or private sector. To identify issues related to the quality of health care that should be recommended for formal Institute of Medicine studies through the various Boards of the Institute. To identify issues related to the quality of health care that should be clarified by workshops, symposia, invited presentation, or commissioned papers. To provide representation to the Quality Coordinating Committee leading to that committee’s peer-reviewed assessment of the quality of health care and resulting in periodic reports, including specific recommendations for action. To identify other roles of the Roundtable consistent with Institute of Medicine and National Research Council policies that would lead to enhanced quality of health care in the United States. The Roundtable met six times in formal plenary sessions between February, 1996 and January, 1998. It invited presentations from experts, convened two conferences, and commissioned papers. Individuals who made presentations at meetings of the Roundtable were: Jo Ivey Boufford, M.D., Dean, Wagner Graduate School of Public Service, New York University; Janet Corrigan, Ph.D., Executive Director, Advisory Commission on Consumer Protection and Quality in the Health Care Industry; James E.Jensen, Director, Office of Congressional and Government Affairs, National Academy of Sciences; Stanley B.Jones Director, Health Insurance Reform Project George Washington University and Chair, IOM Committee on Choice and Managed Care); Charles Kahn, J.D., (then) Majority staff, House Ways and Means Subcommittee on Health; Lawrence Lewin, M.B.A. Chief Executive Officer, The Lewin Group; and Harold S.Luft, Ph.D., Caldwell B.Esselstyn Professor of Health Policy and Economics Director, Institute for Health Policy Studies, University of California, San Francisco. CONTEXT OF THIS STATEMENT Based on its deliberations over a two-year period, two major conferences, guest presentations, and commissioned papers, the Roundtable members determined that a statement outlining its conclusions was warranted. The statement presented here has been reviewed by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the authors and the IOM in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their participation in the review of this report: Paul Griner, M.D., Vice President and Director, Center for the Assessment and Management of Change in Academic Medicine, Association of American Medical Colleges; John Ludden, M.D., Senior Vice President for Medical Affairs, Harvard Pilgrim Health Care; Arnold Milstein, M.D., M.P.H., Managing

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Statement on Quality of Care Director, William M.Mercer, Inc.; David Nash, M.D., M.B.A., Associate Dean and Director, Health Policy, Thomas Jefferson University; and Gail Warden, President & Chief Executive Officer, Henry Ford Health System. Although the individuals listed above have provided many constructive comments and suggestions, responsibility for the final content of this statement rests solely with the authoring committee and the IOM The contributions of many other individuals to the work and conclusions of the Roundtable are gratefully acknowledged. In addition to those mentioned above the roles of these people are described below. ACTIVITIES OF THE ROUNDTABLE Conferences Two conferences sponsored by the Roundtable contributed significantly to the conclusions expressed in this statement. These conferences were “State of the Art of Quality Measurement,” September, 1996. This conference was summarized in IOM. Measuring the Quality of Health Care—State of the Art. Summary of a Conference, MS Donaldson and KN Nolan, eds. April, 1997. (available online at http://www2.nas.edu/quality/212a.html) and Donaldson, M.S. and Nolan, K. Conference. Measuring the Quality of Health Care: State of the Art. Journal on Quality Improvement 23:283–292, 1997; and “Integrating Strategies for Health Care Quality Improvement,” Airlie House, Va, October, 1997. The conference included presentations of commissioned papers, panels of respondents, a rapporteur, and a synthesis session. The papers and commentaries on the conference topic will be published in a forthcoming issue of The Milbank Quarterly. Authors who wrote papers for presentation at this conference were: “A Report Card on Continuous Quality Improvement.” David Blumenthal, M.D., M.P.P., Chief of Health Research Policy and Development, Massachusetts General Hospital and Charles M.Kilo, M.D., M.P.H., Institute for Healthcare Improvement. “Accelerating the Impact of Continuous Quality Improvement on Clinical Practice: Assessing the Evidence and Recommendations for ‘Improvement.’” Stephen M.Shortell, Ph.D., Professor of Health Services Management, Professor of Organization Behavior, Northwestern University, Charles L.Bennett, M.D., Ph.D., Associate Professor of Medicine, Northwestern University Medical Center, VA Chicago Health Care System-Lakeside Division and Gayle R.Byck, M.P.H., Research Associate Institute for Health Services Research and Policy Studies, Northwestern University. “The Impact of Financial Incentives on Quality of Health Care.” R.Adams Dudley, M.D., M.B.A., Assistant Professor, Department of Medicine, Institute for Health Policy Studies, University of California, San Francisco, Harold S.Luft, Ph.D. (IOM), Caldwell B.Esselstyn Professor of Health Policy and Economics, Director, Institute for Health Policy Studies, University of California, San Francisco and Robert H.Miller, Ph.D., Institute for Health Policy Studies, University of California, San Francisco.

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Statement on Quality of Care “Increased Competition and the Quality of Health Care.” Jane Sisk, Ph.D., Professor, Columbia University, School of Public Health. “The Role of Regulation in Quality Improvement.” Troy Brennan, M.D., J.D., Executive Director, Brigham and Women’s Hospital Many other invited participants at the two conferences sponsored by the Roundtable provided information about their work as well as valuable insights about quality of care, how it can be measured and improved. They include: Irma Arispe, Ph.D., Projector Officer, AHCPR; John R.Ball, M.D., J.D., President and CEO Pennsylvania Hospital, Philadelphia, PA; Catherine Borbas, Ph.D., Executive Director Health Care Education and Research Foundation, Alan Bredt, M.D., Assistant to Associate Medical Director, Southern California Permanente Medical Group; Peter Budetti, M.D., J.D., Professor of Health Services, Management, Preventive Medicine and Law and Director, Institute for Health Services Research and Policy Studies Northwestern University; Charles R.Buck, Sc.D.Leader, Health Care Quality and Strategy Initiatives, General Electric Co.; David Classen, M.D., Latter Day Saints Hospital, Intermountain Health System, Molly Joel Coye, M.D., M.P.H., Director, West Coast Office, The Lewin Group; Charles Darby, Co-Project Officer, AHCPR, Thomas J.Davies, J.D., M.P.A., Manager of Managed Care, GTE Services Corporation; Don E.Detmer, M.D., Senior Vice President, University of Virginia; Mary L. Durham, Ph.D., Vice President and Director, Center for Health Research, Kaiser Permanente; Susan Edgman-Levitan, P.A., Executive Director, Picker Institute, Lynn Etheredge, Ph.D., Consultant, Paul B. Ginsburg, Ph.D., President, Center for Health System Change, Sheldon S.Greenfield, M.D., Director, Primary Care Outcomes Research Institute, New England Medical Center; Jerome H.Grossman, M.D., Chairman and CEO, Health Quality; David H.Gustafson, Ph.D., Professor, Department of Industrial Engineering, University of Wisconsin; Jack Hadley, Ph.D., Director, Institute for Health Policy and Research, Georgetown University; Clark C.Havighurst, J.D., Wm. Neal Reynolds Professor of Law, Duke University School of Law; Lisa I.Iezzoni, M.D., M.Sc., Associate Professor of Medicine, Division of General Internal Medicine, Beth Israel Hospital, Jacqueline Kosecoff, Ph.D., President and Co-Chief Executive Officer, Value Health Sciences, Inc.; Lucian Leape, M.D., Professor of Health Policy, Harvard School of Public Health, Arthur Levin, M.P.H., Director, Center for Medical Consumers; Jarod M.Loeb, Ph.D., Director, Research and Evaluation and Chief Scientific Officer, Joint Commission on Accreditation of Healthcare Organizations; Kathleen N.Lohr, Ph.D., Director, Health Services Policy and Research, Research Triangle Institute; Patrick Mattingly, M.D., Senior Vice President Planning and Development, Harvard Pilgrim Health Care, Catherine McDermott, Ph.D., President and CEO, National Committee on Quality Health Care; Catherine G.McLaughlin, Ph.D., Associate Professor, University of Michigan, School of Public Health; Barbara McNeil, M.D., Head, Department of Health Care Policy, Harvard Medical School; Josephine Musser, M.B.A., (then) Commissioner, Office of the Commissioner of Insurance State of Wisconsin; Alan R.Nelson, M.D., Executive Vice President, American Society of Internal Medicine; Mark V.Pauly, Ph.D., Bendheim Professor, Wharton School, University of Pennsylvania; James S.Roberts, M.D., Senior Vice President, Voluntary Hospitals of America; Marc Rodwin, Ph.D., Associate Professor of Law and Public Policy, School of Public and Environmental Affairs, Indiana University; Gary E.Rosenthal, M.D., Associate Professor of Medicine, Case Western Reserve University Cleveland VA Medical Center; Neil Schlackman, M.D., Senior Corporate Medical Director, AETNA U.S. Healthcare; Col. David C.Schutt, M.D., (then) Director, Quality Management Division, Health Affairs, Department of Defense; Gary Sennett, M.D., Vice President for Performance Measurement National Committee for Quality Assurance; Hugh Straley, M.D., Medical Director, Group Health Cooperative-Puget Sound; James R.Tallon, Jr., President, United Hospital Fund of New York; Robert O.Valdez, Ph.D., M.H.S.A., Professor, Department of Health Services, School of Public Health, University of California, Los Angeles; and Alan Zwerner, M.D., J.D., President and Chief Executive Officer, The Medical Quality Commission.

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Statement on Quality of Care Sponsors The Roundtable wishes to acknowledge the generous funding provided for this project by the Agency for Health Care Policy and Research (U.S. Department of Health and Human Services), The Commonwealth Fund, and the National Research Council. Additional funding was provided by the Department of Defense (Health Affairs) and Pfizer Inc. Several members of the staffs of these organizations graciously provided help to the Roundtable. They include Margaret Keyes, Project Officer, Center for Quality Measurement and Improvement, AHCPR; Brian Biles, M.D., Senior Vice President and David Sandman, M.P.H., Program Associate of the Commonwealth Fund; and at Pfizer Inc Frederick Telling, Ph.D., Vice President, Corporate Strategic Planning and Policy and Alison Keith, Ph.D., Director, Economic Policy Analysis. Support to the Roundtable by the Institute of Medicine The Roundtable also wishes to acknowledge the officers and staff of the Institute of Medicine. They include Kenneth I.Shine, M.D., President; Karen Hein, M.D., Executive Officer; Clyde J.Behney, Deputy Executive Officer; Molla S.Donaldson, Project Director; Kay Harris, Financial Analyst; Kathleen Nolan, Research Assistant; Evelyn Simeon, Administrative Assistant; and Tracy McKay, Project Assistant.