This final chapter captures the insights of key stakeholder groups represented on a Reactor Panel convened to respond to the overarching themes that emerged during the summit. It also integrates comments of participants and the public present in the audience and listening to the proceedings on the web. The chapter ends by returning the focus to communities, emphasizing the importance of collaboration across stakeholder groups at both the local and national levels. Amplifying this point, commitments made by many of the national champions participating in the summit (see Chapter 1) are presented, thus setting the stage for next steps in implementing the many strategies put forth by the summit participants for making real progress in crossing the quality chasm in health care.
SYNOPSIS OF REACTOR PANEL AND AUDIENCE FEEDBACK
After a day and a half of intense work informed by panel discussions, audience interaction, and breakout groups, the Reactor Panel was convened. It included four summit participants and a moderator, who broadly represented consumers, health care systems, purchasers, employers, and community coalitions. The panel’s charge was to frankly assess the strategies put forth during the summit—drawing on their unique perspectives—and to identify areas of strength as well as weakness. Following is a synthesis of the main points made during the panel discussion and the subsequent audience feedback.
The Patient as “True North”
The summit began with a consumer focus, as Martha Whitecotton shared her family’s struggles with the health care system in obtaining high-quality care for her son with major depression (see Chapter 4). The summit ended on this same note, placing the patient’s experience at the center.
Sylvia Drew Ivie from The Help Everyone Clinic in Los Angeles, representing consumers on the panel, provided a reality check drawn from her experience advocating for the poor, who often present with multiple health challenges and are dealing with a myriad of psychosocial issues. She poignantly asked whether the system changes proposed at the summit would actually help improve the quality of care for the patients and families she serves, and offered this as a test for determining the overall effectiveness of the interventions undertaken.
Concern was raised during the audience feedback that the major social and environmental determinants of health had not been fully considered during the summit. Although the summit was convened to address redesign of the care delivery system, public health issues were emphasized as critically important to improving overall health status. However, time constraints did not permit full exploration of these intricately related factors. Additionally, the audience stressed the importance of treating patients holistically and not artificially segmenting them into single disease categories, as most clinicians are treating patients with multiple chronic conditions (Partnership for Prevention, 2002). Caution was directed at the condition-specific working groups to avoid falling into this trap, and it was emphasized that the strategies from these sessions must be integrated.
Integration of Preventive Care
The audience repeatedly emphasized prevention as an essential component of managing chronic disease. Ongoing preventive strategies were cited as necessary to the treatment and provision of high-quality care for patients with chronic conditions—a case in point being blood pressure control, lipid management, and diet and exercise for patients with heart failure. George Isham from HealthPartners, Inc. in Minneapolis, representing health systems on the panel, suggested that attention be focused on three major behaviors that drive illness in this country—tobacco, exercise, and nutrition. He then offered a two-pronged approach: first, incorporate these three areas into the management of diseases and conditions for which they are significant risk factors; and second, look beyond the face-to-face visit and explore alternative sites for the provision of care, while adopting new technologies to extend care beyond its traditional boundaries.
Change in Roles for Public and Private Purchasers
The panel members underscored the importance of galvanizing both public and private purchasers to reorganize and redesign how health care is currently financed. There was general agreement that additional revenue streams from the public sector would not be forthcoming; thus any strategies put forth must be budget neutral, with resources being redistributed to pay for forms of care traditionally not reimbursed. Strong leadership will be required to decide how to reallocate these resources. Helen Darling from the Washington Business Group on Health, representing purchasers on the panel, suggested that payment be tied to evidence-based practices, seeing this as an opportunity to redirect funds from services known not to be effective to those demonstrated to improve care.
An audience member asked the panel what strategies might be implemented now in the absence of comprehensive finance reform. Examples of system-level approaches that have progressed despite the lack of such a major transformation include implementation of automated health records, integration of evidence-based guidelines into clinical practice settings, and the use of multidisciplinary care teams. However, finance reform was cited as essential to provide momentum for these interventions, now scattered across the country as demonstrated by the communities represented at the summit. It was suggested that small-scale demonstration projects and multilevel collaborations across health systems,
states, communities, and others could promote the diffusion of best practices and innovations.
Quality Improvement and Measurement
To implement the changes to the health care finance system recommended by summit participants, transparency and accountability at the results level were stressed as crucial. The panel echoed the point discussed in Chapter 8 that if more emphasis were placed on outcomes, such as patients being healthier and more satisfied with their care, more flexibility might be afforded to cover alternative treatment modalities, such as telephone or e-mail follow-up with patients, as long as they produced better results. Likewise, the panel reiterated the need for outcome measures for all levels of the health care system—patient, clinician, group practice, health plan, home health, nursing home, and hospital.
Roles of National Organizations and Communities
As demonstrated by the 15 communities participating in the summit, health care consumers are often well served by local strategies that bring together many different players through collaborative efforts. Al Charbonneau from the Rochester Health Commission, representing communities on the panel, made an appeal for leadership at the national level to support the ongoing work in these communities and others across the nation. Public–private partnerships could accelerate progress in all the cross-cutting areas addressed at the summit for helping the care team better meet the needs of patients—measurement, information and communications technology, care coordination, patient self-management support, finance, and community coalition building. Many of these communities have made great strides in improving the quality of care for their constituents; however, they require national-level support to overcome many of the barriers discussed at the summit and sustain their laudable efforts.
COMMITMENTS OF NATIONAL CHAMPIONS
Despite the gallant efforts of individuals, communities, and national leadership, a deplorable quality chasm persists between the abundance of evidence-based interventions established by clinical research and the routine practice of medicine in the United States. Recognizing that no individual or organization can overcome all the barriers to providing high-quality care discussed at the summit, participants identified collaboration across the private and public sectors as a critical success factor for change. In response, 24 representatives from national champions participating in the summit publicly declared their commitment to furthering community efforts. They channeled their support in response to key strategies identified at the summit for effecting the needed changes: instituting finance reform to reward evidence-based care, including care coordination and patient self-management; simplifying measurement to facilitate assessing and providing continuous feedback on quality of care; improving information and communications technology infrastructure and interoperability; and marshaling community resources for collaboration and coalition building.
There are many champions of health care redesign around the nation. Some play on a national stage in the scope of their work, while some are regional and others are located in communities. The national champions whose commitments are presented below are among the key players at the national level. Some of them, as well as others not listed, make an impact at the international level as well. It is hoped that others will join this list, and we emphasize that any omissions are unintentional.
Agency for Healthcare Research and Quality (AHRQ)
AHRQ is a component of the U.S. Department of Health and Human Services (DHHS) whose mission is to improve the quality, safety, effectiveness, and efficiency of health care. In December 2003, AHRQ released the first annual National Healthcare Quality and Disparities Reports (www.qualitytools.ahrq.gov/qualityreport), providing the first comprehensive picture of the state of quality for the population at large and for racial, ethnic, and other subgroups. The reports provide a roadmap for communities to follow in addressing the quality challenge. Although these are national reports, similar reports could be produced at the community or provider level, and indeed their production would be consistent with the goal of harmonizing measurement and reporting efforts. AHRQ also maintains a clearinghouse of practical, ready-to-use tools for measuring and improving the quality of health care (www.qualitytools.ahrq.gov). In the coming months, AHRQ will be releasing a series of evidence-based reports synthesizing scientific knowledge pertaining to each of the 20 priority areas identified by the IOM (IOM, 2003) and, when possible, pointing to best practices in care delivery. AHRQ will also work with other agencies in DHHS and private-sector foundations to support an evaluation of the improvement efforts of the IOM summit communities.
Alliance of Community Health Plans (ACHP)
The Alliance of Community Health Plans (ACHP) represents 12 leading health plans and provider organizations. ACHP is sponsoring an initiative called Advancing Better Care that includes eight projects. Of these eight, three provide patients and clinicians with on-line access to electronic health records. Two are focused on communitywide efforts to measure performance at the provider group level (one in Minnesota, the other in Massachusetts). The remaining three projects involve on-line health risk assessments with referrals, a “know your numbers” campaign initially targeting heart disease and expanding to other chronic illnesses, and a tool to engage women more actively in managing their own health needs and those of their family. The knowledge and experience gained from the Advancing Better Care initiative should be highly useful to all of the summit communities, as well as to the broader health care community. ACHP is making descriptive information, measurement tools, and evaluative material available on its website (www.achp.org).
American Board of Internal Medicine (ABIM)
Internal medicine is the largest medical specialty. ABIM is a member of the American Board of Medical Specialties, which represents all 24 of the recognized board-certified specialties. Over the last few years, many specialty boards have started to require maintenance of certification of their diplomats, but in 2002 more than 24 boards agreed that all certificates would now be “time-limited,” requiring that all board-certified physicians maintain certification continuously over the life of their practice. The certification process will require not only tests of cognitive knowledge, but also practice performance assessment and improvement.
In support of this transition, ABIM has started developing practice assessment and improvement modules (PIMs), which include measures of technical performance and surveys of patient perceptions. PIMs have already been developed for three of the five priority areas that were the focus of the summit—congestive heart failure, diabetes, and asthma—and modules for depression and pain management are under
development. In collaboration with the American Academy of Family Practice and the American Academy of Pediatrics, ABIM is now launching the Improving Performance in Practice project. This project will work with innovative provider practices in various communities to pilot test and refine the PIMs. ABIM is prepared to develop a teleconference for the IOM summit communities to discuss the Improving Performance in Practice project and identify ways in which innovative practices from these communities might participate in this effort. The intent is to allow the summit communities to benefit from the knowledge, technical resources, and momentum associated with this program.
American Cancer Society (ACS)
ACS is the largest volunteer health organization in the world. It is nationwide and community based with 14 divisions, 3,400 units, more than 2 million volunteers, and 6,555 staff. Relative to the summit, ACS makes the following commitments:
ACS supports the recommendations of the pain control group within the scope of its organizational objectives and the capacity of its budget. The organization is committed to improving the quality of life for cancer patients, with improved pain control one of the primary goals.
ACS supports evidence-based practice through the use of regularly updated, evidence-based quality guidelines. In collaboration with the National Comprehensive Cancer Network (NCCN), ACS has translated NCCN’s continuously updated physician practice guidelines for patient utility (available in English and Spanish) and made them available through the ACS website (www.cancer.org) and call center (1-800-ACS-2345). These patient guidelines have been widely distributed (50,000+) and assist patients in understanding and evaluating treatment options, thus making patients advocates for their own quality care.
In collaboration with the American College of Surgeons Commission on Cancer (CoC), ACS is developing standardized performance measures for quality cancer management. ACS sponsors, within the CoC hospital approved cancer program (1,500 hospitals), reportable criteria and measures for quality pain control. Further, ACS sponsors the CoC National Cancer Database (NCDB), containing long-term analytic data on more than 10 million cancer patients.
ACS is considering sponsorship of a national public media campaign on a patient’s right to pain relief, consistent with the NCCN practice guidelines. This project is subject to budgetary limitations.
ACS has developed a pain advocacy toolkit now being piloted in 15 states. Pain control advocacy is carried out at the state and national levels.
A sizable portion of the ACS research budget is devoted to cancer pain research.
The ACS Behavioral Research Center is presently conducting longitudinal and cross-sectional research on quality of life among 100,000 cancer survivors.
American Heart Association
The American Heart Association is a national voluntary health agency whose mission is to reduce disability and death from cardiovascular disease and stroke. Working collaboratively with the American College of Cardiology, the association is committed to the availability of up-to-date practice guidelines (www.acc.org/clinical/statements.htm). Through its Guidelines Applied in Practice program, the association maps guidelines to “teachable moments” when patients and physicians will be most receptive to applying specific aspects of the guidelines. The association also maintains patient information portals, such as the Heart
Profiler, which provides patients with information on their disease and helps them identify the types of questions they should ask their physician. The American Heart Association is working with the American Medical Association on the development of standardized physician-level performance measures for heart disease and on a recognition program for physicians who practice in office settings. It is also collaborating with the American Diabetes Association and the American Cancer Society to develop and implement measures related to smoking, diet, and exercise, patient behaviors that influence the course of many chronic conditions.
American Hospital Association (AHA)
AHA’s quality agenda is directly aligned with the six aims of the Quality Chasm report. In 2002, AHA and two other hospital associations—the Federation of American Hospitals and the Association of Academic Medical Centers—undertook the National Voluntary Hospital Reporting Initiative in collaboration with the Centers for Medicare and Medicaid Services (CMS), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the American Medical Association, the National Quality Forum, and others. The initiative includes public reporting on acute myocardial infarction, community-acquired pneumonia, and congestive heart failure. In the future, other clinical measures addressing the 20 priority areas identified by the IOM (IOM, 2003) will be added. In the near future, the initiative will also pilot test a new instrument on patient experience of care developed by AHRQ and CMS.
AHA is also addressing some of the cross-cutting issues discussed at the summit. To encourage and maximize the return on investment in information and communications technology, AHA was instrumental in establishing the National Alliance for Health Information Technology, a public–private partnership focused on standards for electronic health records and medication bar coding. In 2004, projects addressing patient-centered health care delivery and patient self-management of chronic conditions will be initiated. Lastly, AHA’s research arm, the Hospital Research and Education Trust, would welcome working with the summit communities to develop coalitions for health care improvement.
America’s Health Insurance Plans (AHIP)
AHIP’s member organizations provide health care coverage to about 200 million people. Its health plans operate in every state, and AHIP will be pleased to serve as a gateway for communities to come together with health plans. AHIP is also prepared to arrange for community representatives to enter into a dialogue with the chief medical officers of the health plans, perhaps as a part of its executive leadership program. AHIP is involved in numerous collaboratives around the country on diabetes, asthma, women’s health, depression, domestic violence, and other health issues (see www.ahip.com), and is prepared to share detailed information on these efforts with the IOM summit communities. Member health plans are working to design and implement pay-for-performance programs, and AHIP is tracking and making information available on these efforts so others can learn from them. On the policy front, AHIP’s board of directors wants to make this the year for improving quality and access, and one effort in this area will be to encourage greater investment in applied research aimed at translating clinical knowledge into practice. Lastly, AHIP concurs with and will support the efforts of the many national champions who are working toward the adoption of a uniform strategy for measuring and reporting on performance.
Blue Cross and Blue Shield Association (BCBSA)
The member health plans of BCBSA insure nearly 91 million people in the United States, and can be of help in many ways in addressing the country’s health care challenges. First, the Blues are an enormous resource with respect to data on the health needs of communities and information about the resources available to meet those needs. They also have information on successful efforts by various BCBS plans to improve health, such as the efforts of the Blues plan in Kansas City to improve asthma management, and would be glad to share that information. Second, the BCBS plans have established communication channels with their business communities, health professionals, pharmacies, and others and can share this resource on behalf of efforts to improve health in communities. Lastly, BCBSA will work collaboratively with others to ensure that there are nationally endorsed guidelines for clinical practice that can be used to report provider performance. BCBSA views this is a very powerful way to help patients navigate a highly complex health care environment.
Centers for Medicare and Medicaid Services (CMS)
CMS is committed to working with communities, national partners, and the National Quality Forum on the development of standardized performance measure sets for the five priority areas addressed at the summit and for many other conditions as well. CMS and JCAHO have agreed to use the same measures for hospitals, and hope that this sets a precedent for collaborative efforts in other areas. CMS is also committed to publishing performance data on health plans, hospitals, nursing homes, group practices, and other providers (see www.Medicare.gov). A secure data warehouse has been created for data on quality, including both Medicare and non-Medicare data.
CMS hopes that the summit communities will continue to put substantial pressure on the national champions and the IOM to keep working together, and CMS will host and participate in future meetings. The quality improvement organizations (QIOs) will be working even harder in the future to engage in community collaborations, and communities are encouraged to contact the QIO in their state (http://www.medqic.org/content/qio/qio.jsp?pageID=4). There is also a website created for QIOs and providers of services to Medicare beneficiaries that contains literature, tools, and other information by clinical setting and priority topics (www.medqic.org).
CMS will soon be sponsoring two new demonstration projects that may prove helpful to the summit communities. The first is a pay-for-performance demonstration in office settings that will provide strong incentives for providers to invest in electronic health records to capture and report the necessary performance data. The second is a population-based disease management demonstration.
General Electric Company (GE)
Francois de Brantes
Health care purchasers, both large and small, influence the health care marketplace through two mechanisms—the design of health insurance benefits and the selection of health plans. In addition, many purchasers, through their participation in the Leapfrog Group and the Bridges to Excellence program, are involved in efforts to directly reward physicians and hospitals for better performance.
As a large purchaser and active participant in the broader purchaser community, GE makes several commitments. First, GE will pursue the design of benefit packages that encourage consumers to be sensitive to both the quality and cost of health care services and to engage in
better self-management. Second, it is imperative that all employers support the use of standardized performance measures, specifically ones approved by the National Quality Forum, in efforts to link payment to performance. Third, GE will contract with health plans that do the best job of rewarding better performance by physicians and hospitals. In support of this third point, GE encourages AHIP and BCBSA to focus on the design of new provider compensation systems that reward value, and encourages the National Business Group on Health to promote the use of best practices by benefits consultants and health plans to diffuse market change.
Grantmakers in Health (GH)
GH is an educational resource to foundations that fund in health. It identifies important issues, clarifies the role of philanthropy in addressing these issues, and provides information and connections to grant makers to help them use their resources wisely.
GH makes two commitments. The first is to forge connections between foundations and community coalitions. Foundations may be able to provide financial support to a community, but they can also do more. They can serve as conveners to bring together stakeholders in a community and help them work across sectors, make connections between communities and other grantees that may be able to share expertise and provide technical assistance, raise public awareness and inform policy makers, and help with leadership development and dissemination of community work.
GH’s second commitment is to stimulate broader foundation interest and involvement in the key issues identified at the summit by using these issues as organizing principles or cross-cutting themes for national meetings. For example, GH’s annual meeting in February 2004 will focus on system redesign, and some of these issues will be integrated into that program.
Institute for Healthcare Improvement (IHI)
IHI can provide the summit communities with access to knowledge and opportunities to work together. For tools and approaches to improving quality, communities are encouraged to consult the IHI websites (www.qualityhealthcare.org and www.ihi.org). IHI will also set up a managed list serve where communities can talk to each other, share experiences, and work together to solve problems. Communities are also invited to attend IHI’s national meeting in December 2004. Since this is just 3 months after the national meeting of Improving Chronic Illness Care, sidebar meetings of the summit communities will be arranged at both of these events. If IHI is able to mobilize the necessary resources, it will organize a formal community collaborative.
Institute of Medicine (IOM)
IOM is committed to continuing its quality initiative. During the last 6 years, about a dozen reports have been produced in the Quality Chasm Series. Over the next 3 years, IOM will focus its attention on producing several reports that address key environmental levers—payment processes, performance improvement programs, and benefits design. The first report, which is congressionally mandated, will provide guidance on linking Medicare fee-for-service and capitated payment systems to performance. The IOM committee for this study will identify specific performance measures to be used and evaluate alternative approaches for adjusting payments based on performance. The second report is also congressionally mandated, and will focus on strengthening Medicare’s performance improvement processes, most
notably the QIOs. The third report in this series will be on quality-based benefit design. In summary, IOM is committed to addressing each of the major environmental forces identified by the summit participants.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
JCAHO accredits more than 16,000 organizations across all major settings of care in the United States and around the world. Its stock in trade is its accreditation standards and performance measurement capabilities. JCAHO, in collaboration with others, has promulgated pain management standards, as well as measures for heart failure, diabetes, and pediatric asthma. Collaborative efforts with the National Committee for Quality Assurance (NCQA) and the American Medical Association to develop pain management measures are continuing, as are efforts to work with the psychiatric hospital community to develop measures for depression and other mental health conditions. JCAHO is committed to working with key players on the ongoing development and maintenance of measure sets and the adaptation of these measures to various practice settings and communities to accommodate changing accountabilities. Beginning in July 2004, JCAHO will publicly report all of the performance measurement data it collects.
More must be done, however, to support the efforts of communities to achieve the IOM’s quality goals. The nation lacks key elements of a quality infrastructure. First, there are no clearly defined, measurable national quality goals, and no agreed-upon authority that could proclaim such goals. In 1998, the President’s Commission on Consumer Protection and Quality recommended that a National Quality Council be established; Congress’s failure to act on that recommendation was a missed opportunity. Second, there is no national strategic plan for the development of a health information infrastructure.1 The lack of electronic health records clearly limits the ability to measure and improve quality. Third, there is no process for the prioritized identification of condition-specific measure sets to systematically address quality goals. One way to identify the work that needs to be done is to develop a matrix with the IOM’s six quality aims on one axis and priority conditions on the other, and to populate the resulting matrix with appropriate measures to create relevant measure sets. Lastly, we need carefully thought-out pay-for-performance models that will both reward desired behaviors and provide incentives for performance improvement. This work must be accomplished over the next 3 to 5 years to give the necessary support to community initiatives and, it may be hoped, enable thousands more such efforts to blossom.
MacColl Institute for Healthcare Innovation at Group Health Cooperative (MIHI)
For 6 years, MIHI has served as the national program office for The Robert Wood Johnson Foundation’s program on Improving Chronic Illness Care. The institute has established a website (www.improvingchroniccare.org) that serves as a repository for information on the Chronic Care Model, including tools and best practices. MIHI also serves nationally as a resource for those interested in improved care for chronic illness, and encourages anyone seeking to identify individuals who have addressed or are currently working on similar challenges to contact the institute. Lastly, the institute sponsors a national meeting each year, and this year’s meeting, to be held in September 2004, will focus on community-based innovations. Each of the summit communities is invited to participate in this meeting. Information about the conference is available on the above website.
Note: Following the Summit, on May 6, 2004, David J. Brailer was appointed as the first Health Information Technology Coordinator for the DHHS (http://www.hhs.gov/news/speech/2004/040506.html).
National Association of Community Health Centers
Community health centers are the family doctor for nearly 15 million Americans in more than 3,500 communities across the country. Virtually all of these people are low-income, and more than one-third are uninsured. During the last few years, more than 500 health centers have participated in “health disparities collaboratives” supported by the Health Resources and Services Administration. Health centers, consistent with their founding purpose as both agents of care and agents of change in their communities, are ready and willing to serve as “foot soldiers” in the campaign to improve health care quality, and to work with other community and national stakeholders to achieve that goal.
National Business Group on Health
The National Business Group on Health will work with IOM and other national partners to accelerate the dissemination of effective methods for achieving major improvements in the quality of health care. The group will continue, as in the last 2 years, to aggressively promote (1) transparency in health care among purchasers, national legislators, and executive and regulatory agencies; and (2) fundamental payment and finance reform tied to high-quality performance and evidence-based practice.
The National Business Group on Health will also create a special website that highlights outstanding examples of business groups working with other stakeholders to advance quality and bridge the quality chasm. This effort will begin immediately with posting of the exemplary work done in Kansas City, highlighted at the summit, involving leadership by group member Sprint.
National Cancer Institute (NCI)
Molla Sloane Donaldson
NCI has several efforts under way to improve cancer care, and specifically pain management. First, NCI has issued a request for proposals aimed at overcoming system, provider, and patient barriers to effective palliative care. Communities interested in applying for one of these grants should consult http://grants.nih.gov/grants/guide/rfa-files/RFA-CA-05-013.html. The NCI Outcomes Research Branch (http://outcomes.cancer.gov/) has a particular focus on patient-reported outcomes, such as health-related quality of life, patient experience and satisfaction with care, and economic burden. A complete portfolio of NCI funding opportunities in the palliative care arena can be found at http://www.cancer.gov/researchandfunding/announcements/symptommanagement.
Second, as a part of NCI’s Quality of Care Initiative, numerous public- and private-sector collaborative efforts are under way to improve the quality of cancer care, including work on assessing and improving palliative care for patients with cancer. Work has begun on a public–private project aimed at redesigning cancer care, spanning the cancer continuum from suspicion to end of life. Finally, in terms of quality measurement, NCI and its federal partners AHRQ, CMS, and the Centers for Disease Control and Prevention are supporting the National Quality Forum in identifying a set of consensus measures of cancer quality (http://outcomes.cancer.gov/translation/canqual/). That effort includes both tumor-specific and cross-cutting measures.
National Center for Healthcare Leadership (NCHL)
NCHL, founded 2 years ago, is dedicated to the development of health care leaders who will be capable of implementing the summit’s
aggressive agenda for health system change. NCHL is identifying the core competencies leaders must possess to carry out that agenda, sponsoring educational programs, and conducting evaluation research to ensure that these competencies will be obtained. A national database on leadership best practices and critical success factors will soon be available on the NCHL website. The center welcomes the opportunity to work directly with the summit communities on cultural change and leadership development.
National Committee for Quality Assurance (NCQA)
L. Gregory Pawlson
NCQA makes three commitments: (1) continuing its work with multiple stakeholder groups to populate the full spectrum of performance measures related to the six aims of the Quality Chasm report, striving to reduce duplication and redundancy; (2) working with the 15 summit communities in a number of areas related to measurement, from helping to choose appropriate measures to implementing measures for a specific project; and (3) adapting current NCQA evaluation programs to focus more on cross-cutting areas, such as consumer–patient education and support, care management, and means of enhancing provider performance. Additionally, NCQA has developed several tools and resources that are available to communities:
Quality Compass®, a database derived from the population of nearly 90 million Americans enrolled in health plans, compiled over the last 9 years, which includes patient surveys and clinical performance measures related to depression, asthma, diabetes, heart disease, and some other chronic illnesses.
Quality Dividend Calculator, an on-line tool that allows purchasers and others to see how improvements in quality of care for the major chronic diseases can enhance productivity and reduce absenteeism in the workplace.
Quality Profiles®, a compendium of best-practice examples providing tips on how to implement quality improvement projects in about 12 different disease areas, as well as some cross-cutting areas.
Practice Systems Assessment Survey, an assessment tool patterned after the Chronic Care Model, that measures the degree to which physician practices incorporate such systems as registries, reminders, and feedback, as well as the use of nurses and other health professionals in extended roles.
Pacific Business Group on Health (PBGH)
One of the many wise observations in the Quality Chasm report is the importance of focusing on a few strategic interventions to improve health system performance. As a participant in the leadership of both the Leapfrog Group and the Disclosure Project, I commit to three strategic interventions. The first is to accelerate national consensus on the public reporting of measures of quality, efficiency, and care redesign at multiple levels, including individual physician office teams, hospitals, larger health care organizations, and communities. The second is to coordinate local and national provider-focused initiatives on pay for performance, including private-sector coordination with CMS. The third, to ambitious aims; specifically of no less than a “30/30” gain within 10 years: a 30 percentage point offset of projected per capita U.S. health care spending and a 30 percent average improvement in standardized measures of quality.
Substance Abuse and Mental Health Services Administration (SAMHSA)
In 2003, the President’s Commission on Mental Health issued a report that addressed transforming the mental health system in ways consistent with the agenda for change set forth in the Quality Chasm report, thus affording a real opportunity for collaboration. To this end, SAMHSA has provided support to IOM for convening a workshop and producing a report on how best to apply the conceptual framework and principles of the Quality Chasm report to the area of mental health and substance abuse. This ongoing IOM project provides an excellent vehicle for continuation of the summit’s work in the area of depression. In the near future, SAMSHA will also be announcing the creation of a new center on policy in mental health and primary care. Lastly, SAMSHA is prepared to commit financial resources to convening the summit communities and helping them address key issues such as quality measurement, and invites others to join in this activity.
The Robert Wood Johnson Foundation (RWJF)
RWJF sponsored the summit as a way to further the agenda set forth in the Quality Chasm report, and what was accomplished far exceeded its expectations. The foundation is committed to following up on the summit in some very specific ways. First, RWJF supports 15 national programs focused on improving chronic illness care or promoting healthy behaviors. Within 2 weeks, the foundation will provide IOM with a list of these programs, the contact individuals, and the types of assistance they can provide. Second, RWJF will make available a list of its grantees in the summit communities that are working on relevant issues and can serve as valuable allies. Third, the foundation is committed to working with IOM to continue the kind of unique gathering that occurred at the summit, and specifically to continuing the convening of the national champions. Finally, RWJF is investing in a number of projects directed at the harmonization and standardization of quality measures for outpatient chronic care and will keep IOM abreast of these efforts.
URAC is a national accreditation organization that has developed standards for functions within health care systems, including disease management, utilization management, and case management, as well as for health plans, preferred provider organizations, and health websites. Over the next 2 years, URAC will be revising its accreditation standards to bring them into closer alignment with the six aims specified in the Quality Chasm report. As part of this process, efforts will be made to identify ways in which the accreditation process can encourage collaborative efforts across all stakeholders, such as those that the summit communities are trying to involve.
The 1st Annual Crossing the Quality Chasm Summit was the beginning of what we may hope will become an ongoing dialogue among local and national individuals, communities, and organizations committed to improving the quality of health care in America. Many of the strategies proposed by the participants are actionable now, and can be hastened by cross-fertilization and cooperation among the diverse stakeholders represented at the summit. These include:
Aligning financial incentives to encourage and reward evidence-based care—including care coordination and patient self-management support.
Establishing a core set of valid and reliable standardized measures for the five priority areas featured at the summit—subsequently expanded to the other 15 priority areas.
Giving patients access to electronic copies or versions of their health record.
Creating national data standards to facilitate the electronic transfer of health information across multiple providers and health care settings.
The action plans that emerged from the summit will need to be further refined and modified for different settings, but the message is clear that change is possible—as illustrated by the work already being done in the communities featured at the summit. The outcomes from the summit can serve as a guide for tackling some of the major barriers to the diffusion of these best practices. The IOM hopes to convene future summits focused on implementaitn of the vision of the Quality Chasm, and looks forward to hearing about the progress of the community participants.
IOM (Institute of Medicine). 2003. Priority Areas for National Action: Transforming Health Care Quality. Adams K, Corrigan JM, eds. Washington, DC: National Academy Press.
Partnership for Prevention. 2002. Better Lives for People with Chronic Conditions. Baltimore, MD: John Hopkins University, Robert Wood Johnson Foundation.