What does national strategy mean for QI?

Don't wait for the next step, experts say

The National Strategy for Quality, released to Congress at the end of March, is just the first iteration of reports required by the Patient Protection and Affordable Care Act to outline priorities and areas of focus for healthcare. Last month, HPR talked to health information organizations about its potential impact on quality and safety. This month, we asked for some idea about how it might affect other players.

Conceptually, it is a great thing to have an overarching strategy, says Nancy Foster, vice president of quality at the American Hospital Association (AHA). "This is just the very beginning, and I think there will be a lot of challenges with the detail work."

Hospitals, by and large, are all working very hard to improve safety and quality. However, says Foster, they are all doing different things, and doing them differently. They are also being asked to provide a wide variety of data to a large number of organizations. As an example, Foster mentioned the Washington Hospital Association, which has a list that is some 80 pages long of various items that members are required to report. "When you have so many things and such an onslaught of data, it is hard to figure out the high-value things to focus on."

A common direction

The national strategy will help wade through all of that. "Right now, we are often stepping on each others' toes and actually inhibiting our ability to improve quality. This is a way for stakeholders to come together and come up with a list of what the priorities should be, where there is science that shows that we can do better, and a focus through which we can drive concentrated measurement and reporting to the public on our performance and focus on the strategies that are really effective."

Foster believes this report — and the follow-ups due this fall and beyond — will accelerate QI by getting rid of the din of activity and whittling down to what is important. "That is the intent of this: to get us all working in a common direction. But we do not know how to run fast doing that. We have to walk first. We will have to build an infrastructure that puts all the providers, organizations, and patients — who have not been working collaboratively — on the same path, engaging in that collaborative work."

She had hoped for more specificity in the initial report, but appreciates that a framework has to come first and that the Secretary of Health and Human Services needs to listen to what people have to say.

Right now, Foster says the AHA is working to make suggestions to the Secretary of Health and Human Services on what should come next — a recent meeting of the National Priority Partnership was putting together questions about what they think the secretary should include to address issues like readmissions and hospital-acquired infections. Foster encourages AHA members and other interested parties to be part of the conversation. "To the extent that you have ideas that can drive quality and safety forward and ideas about what the national strategy should focus on, submit them."

Open books are a good thing

We have known for a long time that the health system in this country is "sub-optimal" in terms of safety, says Allan Korn, MD, chief medical officer of the Blue Cross Blue Shield Association in Chicago. "This did not start in 1999 with the Institute of Medicine report. Frankly, not a lot has changed, despite some individual achievements."

Korn says his organization has long believed that focusing on quality and steering people toward it is a good idea. "We have a national commitment for being safer, more compassionate, and more affordable," he says. "That's what the strategy is about."

The solutions, though, aren't in data collection and reporting, but in creating a better delivery system. The first report to Congress is a good start — Korn calls it "substantive in a light way. It sets a stake in the ground that says the federal government will pay attention to this. That matters. Everyone has to be on board."

While the specific document may not be all he hoped, Korn is delighted at the added oomph this push will provide. But he is surprised at the measures included in the initial report. All are things that BCBSA has advocated doing. And what alarmed him was the amount of pushback coming from organizations about the strategy. "I like to remind people that hiring more MBAs will not make accountable care organizations. We have to rethink the model of how we deliver care, how we exchange information, and how we manage the care of complex patients. One thing that really appalled me is that people are talking about how the money isn't right. So if you have a goal to reduce harm by 25% but the money isn't right, should you just let those people die? Or should you start the work and get to the table to figure out the money while you are working to save those lives? Make incremental changes and figure out the money while you do it."

For now, he thinks providers should continue working on improving healthcare — BCBSA is working on a patient safety training course and will continue to roll out its Blue Distinction Centers for organizations that do well on various quality metrics. They are partnering with safety guru Peter Pronovost and hope to replicate Michigan's Keystone project. The organization is also encouraging its CEOs to interact more with hospital trustees to get them interested in issues beyond finances. "Some of them know about other issues, but some do not. Raising awareness is good, and this provides another opportunity for that."

Mimic the great organizations, Korn advises. "Cleveland Clinic, Mayo — they are already re-engineering the way they provide care. It is already safer, and their efforts are multi-disciplinary down to the housekeepers. They may not call themselves accountable care organizations yet, but they are not standing still. None of us should be."

For more information on this topic, contact:

  • Nancy Foster, Vice President of Quality at the American Hospital Association, Washington, DC. Telephone: (202)626-2337. Email: nfoster@aha.org.
  • Allan Korn, MD, chief medical officer, Senior Vice President, Blue Cross Blue Shield Association, Chicago, IL. Email: allan.korn@bcbsa.com.