Can JCAHO, NCQA, AMAP pull joint effort off?

Accreditors promise action, but it'll take a while

A super report card, a single set of quality information required for accreditation, no more redundant or irrelevant requests. If you've seen these ideas in your dreams since you heard about the new joint effort between the nation's leading accreditation organizations, you might as well turn over and go back to sleep. At least for a few years, while the new Performance Measurement Coordinating Council (PMCC) tackles a long list of data reporting problems that will take quite a feat of coordination to resolve.

The council, made up of five members each from The American Medical Accreditation Program of the American Medical Association (AMAP), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA), will meet for the first time on Sept. 25, says Al Buck, MD, executive vice president for performance measures and research at JCAHO in Oakbrook Terrace, IL.

The first issue to be addressed is achieving consensus on how the group will work, and the second issue will be prioritizing which area to tackle first. A likely priority is risk adjustment. Just that much might take a while, since the PMCC is taking on the huge goal of making assessment processes efficient, consistent, and useful. The group wants to make performance measurement less burdensome to providers and more meaningful to the public.

"What we're talking about here, as big and important as it is, is still just a part of an even larger national challenge in data management that even with optimism is going to take several years to resolve," Buck says. "Part of the problem is consensus, part of it is a question of building appropriate infrastructure, part of it is resources."

No 'super report card'

There's one dream you can let go of now: There won't be an attempt to create a super report card that would let you report the same data to each organization. "It's unlikely, as seductive as it is, that there will be a single report card of any workable size that is going to provide meaningful feedback," Buck says. "The emphasis on report cards has been primarily on patients, but as important as patients are, they are really only one constituency among all the participants in health care that really have to get feedback."

Brian Schilling, spokesman for the NCQA in Washington, DC, agrees that a super report card won't be on the table. "We're not proposing that AMAP, NCQA, and JCAHO scrap their existing performance measurement tools," he says. "What we are proposing is sitting down and looking at ways to make those tools work better together. Right now, they don't work together. Providers are required to collect data that's really similar but in several different ways to satisfy different measurement efforts. We could get at the same question much more efficiently all at once."

For example, for ear infection treatment, NCQA measures the appropriate use of antibiotics, while JCAHO looks at the use of tubes to drain inner-ear fluid. "It gives a contradictory signal on what's important," Schilling says.

Buck names the main goal "convergence." Many plans, he says, use HEDIS measures but typically don't have a standardized automation infrastructure to produce those data. "That's a source of many of the data quality issues, and the other side is that the plans may not have the data at all," he says. "The data they need actually comes from other sites of care."

Data quality, especially in the area of case mix adjustment, is a big issue that must be addressed if performance measures are to have any credibility, says Dennis Scanlon, assistant professor of health policy and administration at The Pennsylvania State University in University Park, PA. Scanlon had a study published recently that found HMO ratings send mixed signals to consumers because of the variation in evaluation methods.1 The study compared report cards for seven health plans and found conflicting results. One plan, for example, received an overall rating of excellent from one report card while receiving the worst possible rating from another.

"Plans get bombarded with requests for information, and there's such a cost involved in reporting the data that it only makes sense to try to standardize the measures," he says. "Maybe three heads will be better than one, and they'll be able to make some progress."

One potential positive impact could be a trickle-down effect from standardized performance improvement to standardized patient care, Scanlon says. "Where there tends to be agreement on issues like using peak flow meters for asthma, having a core set of measures will make it more difficult for physicians to ignore practice guidelines."

If providers sat down with the PMCC, they would plead a case for practicality and thrift in quality measurement. Robert Klint, MD, president and CEO of Swedish American Health System in Rockford, IL, says that while nobody is trying to avoid quality improvement, reporting requirements can detract from the patient care goal. He's concerned that excessive standards will reduce health care providers to automatons so compliance-driven that patient care gets lost.

"We need a common severity adjustment system," he says. "Our data should be as current as possible, and it should be benchmarked with other organizations. Data on its own is fairly useless." He also would like to see the ability to send data to the accrediting agencies via the Internet.

Ellen Gaucher, MPH, MSN, vice president for Quality and Customer Satisfaction at Wellmark Inc. Blue Cross/Blue Shield of Iowa and South Dakota in Des Moines, says she would advise the coordinating council to ask itself what it is trying to help health care organizations achieve. The group needs to decide whether to refine the existing minimum accreditation standards or set stretch goals. "We also need to be asking what's the best way to achieve the right results so we can produce better quality with fewer resources."

[For more information, contact:

· Joint Commission on Accreditation of Healthcare Organizations, Performance Measures and Research Department, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5000. World Wide Web:

· National Committee on Quality Assurance, 2000 L St. NW, Suite 500, Washington, DC 20036. Telephone: (202) 955-3500.]


1. Scanlon et al. Health plan report cards: Exploring differences in plan ratings. J Qual Improve 1998; 24:9-20.