Report to Congress gives structure to healthcare reform requirements

HHS report outlines priorities, goals, and sample strategies

Some states have highly developed quality improvement organizations (QIOs) that have for years worked with healthcare organizations to improve quality, share information, and tackle problems. But those states that have not made it a priority will have to in order to meet requirements set out by the National Quality for Strategy, released late in March by the Department of Health and Human Services.

The report to Congress aims to give structure to health care reform's requirement to promote higher-quality and lower-cost healthcare (it is available online at http://www.healthcare.gov/center/reports/quality03212011a.html#container) and focuses on three aims: providing quality care, promoting healthy communities, and reducing costs associated with health care. The first of those aims directly affects quality professionals, with a stated goal of making care better, more patient- and family-centered, and safer.

The report also lists six priorities:

  • making care safer by reducing harm caused in the delivery of care;
  • ensuring that people and families are engaged as partners in their care;
  • promoting effective communication and coordination of care;
  • promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease;
  • working with communities to promote wide use of best practices to enable healthy living;
  • making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.

It is the first four of these that have the most impact for hospital QI departments.

Among the specific tasks for QIOs working closely with providers at all levels is to create QI programs that meet specific goals outlined in the strategy — for example, reducing deaths from cardiovascular disease. Another task set out for QIOs is to "drive quality improvement through collaboratives at the State level..." while also noting that local-level efforts are a vital resource.

"I noticed right away that they didn't mention any tactics in the report," says Jonathan Sugarman, MD, MPH, chief executive officer of Qualis Health, which serves as the QIO in Washington state and Idaho. "I think it's by design that they don't have a lot of measures in this initial report. This is just a high-level framework that is open to discussion right now."

He does find it interesting that this came out just as many QIO contracts were coming up for bid, and requests for proposal — called a statement of work — have been released. "The Centers for Medicare & Medicaid Services (CMS) have let it be known that they want to make the scope of work we are tasked with highly aligned with this strategy," says Sugarman.

The appendix and the list of priority areas (see chart below) offers a glimpse at how connected QIO work, CMS goals, and strategy goals will be. For instance, one goal is to eliminate preventable healthcare-acquired infections (HAIs). CMS, meanwhile, has called for a reduction in central-line infections. The statement of work for the QIOs also mentions catheter-associated urinary tract infections (UTIs). Sugarman says that it is clear that all parts of government related to healthcare seem to be converging on similar issues of import.

While this may mean that some QIOs have to merely continue on the paths they are already walking, for others it will mean new work, Sugarman says. Some states haven't jumped on the QIO bandwagon. Legislatures haven't had it on their radar and, with money tight, it's not something they look forward to implementing now. "There are states that have robust reporting and some where politically, they haven't demanded it," he says.

Similarly, there are QIOs that exist and are strong, but haven't been as collaborative with local organizations as the strategy implies is going to be necessary. In Washington, there have been nearly six years of collaboration between Qualis and local health departments on issues related to antibiotics. Other places may not be used to working together at that level. Some hospitals, likewise, will have to learn to work with their competitors in ways that are new and different from the way they are used to working.

Healthcare providers and facilities will also have to get used to providing more information for consumers, Sugarman says. "We are used to federal reporting, but attention is going to be increased and become much more universal than it is now. Payment approaches are also going to bring more emphasis to this."

May you live in interesting times

Sugarman says he'll be watching how local and federal priorities intermingle. "We want local priorities to include nationally significant issues," he notes. "The interesting devil in the detail is that some communities have the infrastructure to do this. It will be of note to see how well QIO contractors are able to align what they are doing at the federal level and how they can combine activities to ensure they are not doing two processes to work on the same thing. And how it will be measured isn't clear yet.

Here's an example: the National Healthcare Safety Network requires infection rates as the measure for central-line associated bloodstream infections. That may not jibe with what works on a local level, depending on the processes used. Purchasers may want some other method of measurement. What do you do to make sure you don't have to do the same thing twice over? Another area of confusion might be on reducing readmissions. But how do you define what is preventable and what isn't? How do you note what is a planned readmission and what is because you left a sponge in someone? "I don't think anyone will say that every readmission is a bad thing," Sugarman says.

There is also likely to be a greater emphasis on giving patients a role in QI projects. "Best practices in patient safety all have patients involved — and not at a distance. This is familiar to staff at some hospitals, but unfamiliar at others. What are the implications of that?" There are hospitals that fear that close engagement, while others — like Virginia Mason in Seattle — have become committed to putting patients at the table "at every level," Sugarman says. "This isn't explicit in the strategy document, but the priority on developing the capacity to act on patient-reported information means I think you have to think about integrating more patient feedback into your QI."

This and other details still have to be worked out — the initial report is just a starting place, designed "to begin a dialogue that will continue" throughout this year, the report notes. Future versions will include more specifics, as well as long-and short-term goals.

In future issues of HPR, look for stories that further outline how the National Strategy for Quality will impact QI departments and what you can do now to be ready.

For more information on this topic contact: CEO Jonathan Sugarman, MD, MPH, Qualis Health, Seattle, WA. Telephone: (206) 288-2458.

National Quality Strategy Priorities and Goals, With Illustrative Measures

Priority

Initial Goals, Opportunities for Success, and Illustrative Measures

#1
Safer Care

Goal:
Eliminate preventable health care-acquired conditions

Opportunities for success:

  • Eliminate hospital-acquired infections
  • Reduce the number of serious adverse medication events

Illustrative measures:

  • Standardized infection ratio for central line-associated blood stream infection as reported by CDC's National Healthcare Safety Network
  • Incidence of serious adverse medication events

#2
Effective Care Coordination

Goal:
Create a delivery system that is less fragmented and more coordinated, where handoffs are clear, and patients and clinicians have the information they need to optimize the patient-clinician partnership

Opportunities for success:

  • Reduce preventable hospital admissions and readmissions
  • Prevent and manage chronic illness and disability
  • Ensure secure information exchange to facilitate efficient care delivery

Illustrative measures:

  • All-cause readmissions within 30 days of discharge
  • Percentage of providers who provide a summary record of care for transitions and referrals

#3 Person- and Family-Centered Care

Goal:
Build a system that has the capacity to capture and act on patient-reported information, including preferences, desired outcomes, and experiences with health care

Opportunities for success:

  • Integrate patient feedback on preferences, functional outcomes, and experiences of care into all care settings and care delivery
  • Increase use of EHRs that capture the voice of the patient by integrating patient-generated data in EHRs
  • Routinely measure patient engagement and self-management, shared decision-making, and patient-reported outcomes

Illustrative measures:

  • Percentage of patients asked for feedback

#4
Prevention and Treatment of Leading Causes of Mortality

Goal:
Prevent and reduce the harm caused by cardiovascular disease

Opportunities for success:

  • Increase blood pressure control in adults
  • Reduce high cholesterol levels in adults
  • Increase the use of aspirin to prevent cardiovascular disease
  • Decrease smoking among adults and adolescents

Illustrative measures:

  • Percentage of patients ages 18 years and older with ischemic vascular disease whose most recent blood pressure during the measurement year is <140/90 mm Hg
  • Percentage of patients with ischemic vascular disease whose most recent low-density cholesterol is <100
  • Percentage of patients with ischemic vascular disease who have documentation of use of aspirin or other antithrombotic during the 12-month measurement period
  • Percentage of patients who received evidence-based smoking cessation services (e.g., medications)

#5
Supporting Better Health in Communities

Goal:
Support every U.S. community as it pursues its local health priorities

Opportunities for success:

  • Increase the provision of clinical preventive services for children and adults
  • Increase the adoption of evidence-based interventions to improve health

Illustrative measures:

  • Percentage of children and adults screened for depression and receiving a documented follow-up plan
  • Percentage of adults screened for risky alcohol use and if positive, received brief counseling
  • Percentage of children and adults who use the oral health care system each year
  • Proportion of U.S. population served by community water systems with optimally fluoridated water

#6
Making Care More Affordable

Goal:
Identify and apply measures that can serve as effective indicators of progress in reducing costs

Opportunities for success:

  • Build cost and resource use measurement into payment reforms
  • Establish common measures to assess the cost impacts of new programs and payment systems
  • Reduce amount of health care spending that goes to administrative burden
  • Make costs and quality more transparent to consumers

Illustrative measures:

  • To be developed

SOURCE: US Department of Health and Human Services