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Summary of Recommendations
Providing Strong Leadership and Clear Aims for Improvement
The President should provide strong, continuous leadership to develop a broad national consensus on improving the quality of health care in the United States. The President should begin this effort by articulating and continuing to emphasize a unifying statement of purpose for the health care system. The President should then work with the Congress and leaders of the public and private sectors to embrace this statement of purpose and to initiate collaborative efforts for improving health care.
The Commission suggests the following statement: "The purpose of the health care system must be to continuously reduce the impact and burden of illness, injury, and disability, and to improve the health and functioning of the people of the United States."
National aims for improvement of health care quality should be established, accompanied by appropriate, specific objectives for improvement. The first step toward improving the quality of health care is the creation of a concise set of national aims for improvement. To encourage the greatest possible gains in the health of the American people, these aims should be based on criteria that include focusing on common and/or costly conditions, areas where wide variability in practices exists, and improvements that have the greatest impact on reducing morbidity and mortality and improving functional capacity. Setting national improvement aims, accompanied by a commitment by all participants to support and practice evidence-based care, can enhance Americans' access to appropriate, affordable health care.
The Commission suggests that an initial set of national aims should include, but not be limited to, the following:
Measurable objectives within each of these aims should be specified and developed, including objectives that focus on the unique needs of local areas, individuals with chronic illness and disability, and other vulnerable populations. These aims and objectives should be revised over time as improvements occur and new concerns arise.
An annual award for excellence in health care quality should be established. The Malcolm Baldrige National Quality Award has served as a tremendous incentive for organizational quality improvement. It should be expanded to include an annual award program for health care quality to increase public awareness of health care excellence, motivate organizations to improve quality, encourage dissemination of best practices, and recognize achievement in areas established as national aims for improvement.
Advancing Quality Measurement and Reporting
Core sets of quality measures should be identified for standardized reporting by each sector of the health care industry. These sets should reflect measurement priorities developed by taking into account both national aims for improvement and the information needs of consumers (especially vulnerable populations), purchasers, providers, health organizations, and public health and policy officials. Pertinent measures developed by the research community, quality oversight organizations, health care organizations, and others should be evaluated for potential inclusion in these reporting sets.
A framework and capacity for quality measurement and reporting should be developed in tandem with the standardization of quality measures for reporting. Specific functions to be undertaken include:
All sectors of the health care industry should support the focused development of quality measures that enhance and improve the ability to evaluate and improve health care. Comprehensive sets of quality measures are needed to reflect the full continuum of health care, but measures currently are lacking in a number of important areas. Types of measures that are needed include:
Quality measurement requirements and the detailed specifications for measurement and reporting should be determined through a stable and predictable mechanism. The Commission's specific recommendations on the creation of such a stable and predictable mechanism—a Forum for Health Care Quality Measurement and Reporting—are described in Chapter 5.
This entity, which would be responsible for designating core sets of measures for reporting for each sector of the health care industry, should:
Steps should be taken to ensure that comparative information on health care quality is valid, reliable, comprehensible, and widely available in the public domain. Specifically:
Creating Public-Private Partnerships
An Advisory Council for Health Care Quality should be created in the public sector to provide ongoing national leadership in promoting and guiding continuous improvement of health care quality. The expert Advisory Council would identify national aims and specific objectives for improvement and would establish goals and objectives for systemwide quality measurement. It also would track and report on the Nation's progress in (1) achieving the national aims for improvement; (2) undertaking related quality measurement and reporting; and (3) implementing the Consumer Bill of Rights and Responsibilities. The Advisory Council's additional responsibilities would be to provide a public forum for to address quality improvement and consumer protection issues, assess relevant policy proposals, make recommendations on strategies for quality improvement, develop and promote an agenda for quality research, track key health system indicators, support and foster approaches to improve the dissemination of effective health care practices, and guide public education and communication efforts pertaining to quality. The Advisory Council would issue an annual public report on the findings from its tracking activities and recommendations for any steps needed to improve.
A Forum for Health Care Quality Measurement and Reporting should be created in the private sector to improve the effectiveness and efficiency of health care quality measurement and reporting. The Forum would define a comprehensive plan for implementing quality measurement, data collection, and reporting standards consistent with the national aims and the goals and objectives for quality measurement put forward by the Advisory Council. The objective of this plan would be to assure the widespread public availability of comparative information on the quality of care furnished by each sector of the health care industry, to be accomplished through the coordinated efforts of existing quality measurement organizations and initiatives. The Forum would be responsible for identifying and updating core sets of quality measures and standardized reporting methods. The Forum's work also would focus on establishing measurement priorities, soliciting the voluntary participation of key organizations, assessing the use of the core sets of measures and the extent of publicly available information generated through reporting efforts, providing input to an agenda for research on quality measurement, developing strategies for quality information dissemination and public education on measurement issues, and fostering development of improved health information systems.
Encouraging Action by Group Purchasers
Group purchasers, to the extent feasible, should provide their individual members with a choice of plans. Where group purchasers are not able to offer a choice of health plans, they should provide for adequate input from employees in the development of the criteria and selection of the health plan to be offered.
State and Federal governments should create further opportunities for small employers to participate in larger purchasing pools that, to the extent feasible, make a commitment to individual choice of plans. State and Federal policymakers should take action to foster the creation of more group purchasing coalitions for small purchasers by examining insurance rating rules and Federal tax policies that serve as disincentives to the formation of coalitions. State and Federal governments, foundations, and others should explore the option of providing "seed money" to groups of small purchasers to foster the creation of larger, gateway.html consumer-choice purchasing coalitions. State and Federal governments also should explore opening public employee health benefit programs to participation by small group purchasers. Opening public employee programs should be carefully studied and analyzed, including the results of previous such efforts, prior to implementation to assess feasibility, cost implications, risk selection issues, and unintended consequences.
All public and private group purchasers should use quality as a factor in selecting the plans they will offer to their individual members, employees, or beneficiaries. Significant strides have been made by leading group purchasers in the pursuit of value-based purchasing, but further efforts should be made to encourage widespread adoption of best practices throughout the industry. It is critically important that information on quality and cost be considered and acted upon when making purchasing decisions. Group purchasers should share with their individual members/ beneficiaries/employees the information on quality, cost, and other factors that led to their decision to offer certain health plans. Consideration should be given to providing the Medicare program with greater flexibility to selectively contract on the basis of quality after full exploration of implications for quality of care and unintended consequences.
Group purchasers should implement strategies to stimulate ongoing improvements in health care quality. Large purchasers, in particular, will need to continue to exercise leadership by undertaking such initiatives, which often are resource intensive but lead to improvements in quality for all recipients of health care. Such approaches include: using financial incentives to encourage exemplary performance; undertaking collaborative activities with their contractors; and participation in local, State or national health care quality improvement efforts.
Strengthening the Hand of Consumers
A widespread and ongoing consumer education strategy should be developed to deliver accurate and reliable information about health care quality to consumers and encourage them to consider information on quality when choosing health plans, providers, and treatments. Education should address how health care experts define and identify good quality health care; how quality can vary across plans, facilities, health care organizations, and providers; why quality should be an important factor in making health care purchasing decisions; how to obtain comparative information on quality, their rights and responsibilities as health care purchasers and patients, and how they can play a role in improving health care quality.
Information on health care quality should be developed to meet the needs of consumers. Entities promulgating quality measures should obtain consumer input on issues consumers value and on the design of information reports that are intended, in part or in whole, for consumer use. Quality measures should be developed that are of interest to consumers in general, as well as consumers with particular health concerns (e.g., those with chronic or terminal illness, those receiving home care, those living with physical or mental disabilities, and those concerned with care of children).
Credible and stable programs are needed to produce and disseminate information for consumers. Current consumer information initiatives are carried out by numerous organizations including employee benefit managers, labor unions, health care organizations, and ombuds programs. Such diversity is to be encouraged as are public and private sector partnerships in producing such information. Public and private group purchasers, health care organizations and governmental agencies are encouraged to provide stable and ongoing funding for such initiatives. Grant-making institutions (both foundations and governmental organizations providing research and demonstration funding) are encouraged to provide seed money for local consumer information initiatives.
Some consumers require assistance in making informed health care decisions about their health plans, professionals, and facilities. This assistance can come from a variety of sources including employee benefit managers, unions, public programs, health care organizations, and independent ombuds programs. Certain vulnerable individuals (e.g. those with low literacy, complex chronic conditions, or language or other cultural barriers) will require more intensive and specialized forms of assistance. Foundations, other research and grant-making institutions, Federal and State governments, group purchasers and other public and private coalitions should fund consumer information and assistance demonstration programs with strong evaluation components.
Further research addressing use of information by consumers is needed. Public and private grant- making institutions and researchers should pursue a vigorous research agenda to enhance understanding of how information on quality is and can be used by consumers in their purchasing decisions; how consumers value and use different types of quality information; differences in values among populations (e.g., with different educational, cultural, socioeconomic and health status); and effective dissemination strategies for consumer information.
Focusing on Vulnerable Populations
Additional investment should be provided for developing, evaluating, and supporting effective health care delivery models designed to meet the specific needs of vulnerable populations. The lack of evidence of effective approaches to enhance the health and functional status of persons with chronic illness or disabilities suggests the need for significant additional investment in research and innovation for health care and rehabilitation programs serving these patients. In addition, telemedicine and similar innovations, incentives for health care professionals to practice in underserved areas, and enhanced availability of prehospital emergency services should be assessed as approaches for improving the access to care of those facing geographic barriers to appropriate care.
Development and evaluation of health care quality measures and measurement methods for vulnerable populations should be supported. A focus on vulnerable populations in the design of quality measurement initiatives is valuable, in part, because their experiences may provide new insight on systemwide problems. Attention to vulnerable populations should be integrated within general quality measurement strategies, recognizing that quality measures and measurement methods tailored to vulnerable groups will, in some cases, be required.
Payments to health plans and providers should promote quality health care and improved health and functional status for all patients, including vulnerable populations. Adjusting payments for differences in health or functional status is especially important for Medicare, Medicaid, and other payers that have significant enrollment of individuals with chronic illness or disability so that health plans and providers have an incentive for developing innovative models of care that best serve these individuals. Risk-adjusted payments are also critical to sustaining the safety-net mission of certain providers that provide a disproportionate amount of care to vulnerable populations, such as community health centers, rural health clinics, and academic health centers. The Federal Government should convene high-level stakeholders to determine how best to implement risk-adjusted payments for Medicare. Payment systems also can be better aligned with quality care for vulnerable populations by being broadly based across groups of providers and related health care services to encourage multidisciplinary, coordinated care; providing coverage for health care delivery approaches that have been demonstrated to improve outcomes, functional status, and satisfaction; and rewarding quality performance through financial incentives.
Public and private sector Quality Oversight Organizations (QOOs) and group purchasers should incorporate the provisions of the Consumer Bill of Rights and Responsibilities into their contractual and oversight requirements. The Advisory Council on Health Care Quality should: annually report on the extent to which public and private quality oversight organizations and group purchasers have incorporated the provisions of the Consumer Bill of Rights and Responsibilities into contractual and oversight requirements, issue a comprehensive evaluation in the year 2000 on the extent of compliance with the Consumer Bill of Rights and Responsibilities and, if necessary, make recommendations for enhancing compliance.
Quality Oversight Organizations should make a commitment to participate in the work of the Advisory Council on Health Care Quality and the Forum for Health Care Quality Measurement and Reporting. The Forum is a voluntary, private sector approach intended to produce an efficient and comprehensive approach to quality measurement and reporting by promoting collaboration across existing QOOs. The Council, in its annual reports, should evaluate the success of this approach in obtaining the cooperation of QOOs.
Quality Oversight Organizations should take steps to increase public confidence in their oversight processes. QOOs can accomplish this by: expanding the representation of consumers on governing boards and committees that establish oversight standards and make determinations; providing for public review of and deliberation on existing and proposed standards; making standards and survey protocols used to reach licensing, certification, and accreditation decisions (as well as results of oversight processes) available to the public at little or no cost; and fully disclosing all funding sources. Alternative funding mechanisms for accreditation processes should be explored to further minimize conflicts of interest and equitably spread the costs of oversight across all health care organizations. QOOs also should assure adequate input from health care workers into their oversight processes and enhance mechanisms to assess the care of vulnerable populations.
Quality Oversight Organizations should take steps to move to a common set of quality standards for each sector of the health care industry (i.e., health plans, facilities, and other health care entities). These standards should be strongly oriented to quality improvement and should be required of all entities within each sector of the industry.
Quality Oversight Organizations should coordinate their quality oversight processes within the health care industry. Once common standards are agreed upon, use of one oversight organization's findings to satisfy another oversight organization's need for assurance on the same standard(s) (i.e., "deeming") should be pursued so long as standards to ensure public confidence in, and the integrity of, oversight processes and accountability to the public are in place.
Reducing Errors and Increasing Safety in Health Care
Interested parties should work together to develop a health care error reporting system to identify errors and prevent their recurrence. The Federal Aviation Administration's Aviation Safety Reporting System (ASRS) may provide a useful model for a blame-free system of error reporting.
Internal and external appeals processes should be enhanced to assure compliance with the Consumer Bill of Rights and Responsibilities. The Department of Labor should expedite its review of options to assure a timely internal process for consumer complaints and appeals to help reduce the incidence of injury. Public and private purchasers should work quickly to implement complaint and appeal processes consistent with the Consumer Bill of Rights and Responsibilities.
Policy makers and other stakeholders should engage in a national dialogue regarding the current state of existing remedies for individuals in public or private plans who are injured as a result of inappropriate health care decisions. They should carefully consider the cost and intended and unintended consequences of both the status quo as well as any revisions to existing policy.
Fostering Evidence-Based Practice and Innovation
Federal funding for health care research, including basic, clinical, prevention, and health services research, should be increased and the necessary research infrastructure supported. Strong Federal funding and support for sustaining the network of research centers through the National Institutes of Health, the Agency for Health Care Policy and Research, the Centers for Disease Control and Prevention, and other agencies is the cornerstone of a robust health care research enterprise and, in turn, a high quality health care system.
Collaborative arrangements between researchers and public and private sector organizations supporting research should be developed to provide additional funding for research, make patients available for approved clinical trials, and provide training opportunities. Private sources, including pharmaceutical and health care supply manufacturers, health plans, and foundations are increasingly important for funding health care research. A summit meeting of key leaders in research, including academic health centers, government, health plans, health care professionals, pharmaceutical and equipment manufacturers, and not-for-profit foundations is a positive first step in furthering collaborative relationships. In addition, the NIH Clinical Research Panel's interim recommendations provide a strong starting point for enhancing training and career opportunities for researchers.
Research should be targeted to address areas where the greatest improvements in health and functional status of the population can occur and where gaps in knowledge exist. The establishment of national aims for improvement can provide guidance in setting an appropriate research agenda. Research should be focused on preventing, diagnosing, and treating conditions that are prevalent, costly, and where needed improvements are most likely to occur.
Public and private sector organizations should pursue greater collaboration in conducting health care technology assessments. The current pluralistic approach to technology assessment can be improved through developing an online directory of existing and ongoing technology assessments and developing a process for organizations relying on technology assessments to provide feedback to researchers regarding areas where additional research is needed to evaluate the effectiveness of health care practices.
More complete and rapid dissemination of effective health care practices should be supported by encouraging public and private organizations to collaboratively share knowledge of innovations, synthesize evidence on effective health care practices, develop practice protocols, disseminate this information, and provide technical assistance to practitioners. Synthesizing the existing clinical literature and developing practice guidelines are essential steps in support of evidence-based health care practices. To encourage their acceptance, practice guidelines should be developed by credible sources, allow for local adaptation, actively involve local clinical leaders, and enable practitioners to use clinical judgment in determining their applicability to particular patients. Because merely disseminating information has proven insufficient to ensure the widespread diffusion of effective health care practices, these efforts should be accompanied by technical assistance and implementation programs that encourage the adoption of effective health care practices.
Adapting Organizations for Change
Health care organizations should provide strong leadership to confront quality challenges. Organizations should develop a culture that is supportive of leadership, innovation, and risk taking. They should strive to attract, reward, and retain strong leaders while providing mentoring opportunities for new generations of leaders. Educational institutions should build organizational leadership into their curriculum. Professional associations and labor unions should establish aims for improvement of their professions and make quality improvement an integral part of their agendas.
Organizations should establish and pursue aims for improvement. Organizations should be supportive of national efforts to establish aims for improvement and provide local leadership in their communities to achieve those aims (see Chapter 3).
Organizations should become skilled at using and learning from quantitative information to measure progress toward quality improvement. The key goal should be to improve the performance of systems of care as a whole rather than improving parts of the system at the expense of the whole. There should be a commitment to evidence-based health care with processes put in place to systematically reevaluate established practices.
Organizations should commit themselves to continuous improvement and the elimination of waste. Health care organizations should recognize that most quality problems are due to faulty processes not individuals' failings. A clear link should be established between quality improvement and the elimination of wasteful processes.
Organizations should make a commitment to reduce error and increase safety. The health care industry should examine the possibility of establishing a national system for reporting and tracking errors. Changes in medical malpractice, tort, and quality oversight systems are also needed to create a climate in which errors can be more readily reported, analyzed, and prevented, while still providing fair and equitable compensation to victims of error (see Chapter 10).
Organizations should build long-term relationships with all stakeholders. Contracts with suppliers and other vendors should build quality improvement into long-term planning.
Organizations should commit themselves to fundamental change in their work environment, involving and empowering all employees. Employees should feel free to report errors and instances of improper care, as well as suggest innovations, regardless of their position within an organization.
Engaging the Health Care Workforce
The training of physicians, nurses, and other health care workers must change to meet the demands of a changing health care industry. Education and training of health workers should provide those individuals with greater experience in working in interdisciplinary teams, the provision of care in nonhospital settings, the effective use of clinical information to promote evidence-based practice, the measurement and improvement of quality and satisfaction, the conducting of small-scale experiments of new ideas, and the reporting and reduction of error.
Minimum standards for education, training, and supervision of unlicensed paraprofessionals should be established. Current oversight of paraprofessional health care workers is very uneven especially among multiskilled paraprofessionals. There is a clear need for greater research into the type of training such individuals require, the kinds of tasks they are assigned, and the relationship of those factors to quality. Such research should pay special attention to rapidly expanding sectors of the industry, including home care and community-based care, where unevenness of quality, training and supervision appear to be matters of some urgency.
Further steps must be taken to improve the diversity and the cultural competence of the health care workforce, as well as to provide training in the treatment of chronic conditions and disabilities. Despite the strong efforts of many educational institutions, the health care workforce is still not fully representative of the broad diversity of the American people. Differences in cultural experience between caregivers and the people they care for can give rise to miscommunication and problems in health care quality. Educational institutions, supported by public and private entities where necessary, should continue their efforts to diversify the health care workforce and make cultural competence an important part of the educational experience of all health care workers.
Health care workers must be encouraged to identify and report clinical errors and instances of improper or dangerous care. Health care organizations should ensure that they have appropriate internal processes and support to obtain workers' input and respond to concerns in a timely fashion. Accreditation organizations should provide greater opportunities for health care workers to provide input on quality-of-care issues. Health care workers who report improper, illegal, or dangerous care to management, accreditation organizations, public agencies, or others must be protected against retaliatory action.
Action must be taken to reduce the unacceptably high rate of injury in the health care workplace. The Occupational Safety and Health Administration's special emphasis program in the nursing home industry should be used as a model for additional collaborative approaches to identifying and abating occupational hazards in the health care workplace.
Efforts must be taken to address the serious morale problems that exist among health care workers in many sectors of the industry. Health care organizations should acknowledge morale problems by taking steps to address the concerns of physicians, nurses, and other health care workers regarding professional autonomy, rising workloads, nonproductive paperwork, and employment security. Organizations undergoing restructuring should involve their employees in the planning and implementation of such changes. Federal and State governments should make funds available to retrain health care workers at risk of dislocation, conduct research into workforce trends, and disseminate information on model workplace partnerships.
Further research should be conducted into how changes in the roles and responsibilities of health care workers are affecting quality. Federal and State governments as well as private foundations should make funds available to conduct such research. Health care organizations should be open to participating in such research.
Investing in Information Systems
Purchasers of health care services should insist that providers and plans be able to produce quantitative evidence of quality as a means of encouraging investment in information systems. Under the auspices of the Forum for Health Care Quality Measurement and Reporting, group purchasers should work with health plans, providers, quality oversight organizations, and other stakeholders to implement ever-increasing standards for information systems capacity.
Standards used by Quality Oversight Organizations (see Chapter 9) for health care organizations should address health care information systems, including the automation of clinical information, improvement of data quality, and participation in regional and/or national health information networks.
National standards for the structure, content, definition, and coding of health information should be established to support improvements in information systems. The Federal Government should consult with public and private stakeholders to assess what additional standards may be necessary to support such improvements. Whenever possible, this effort should encourage the widespread adoption of existing standards and build on the work of existing public and private entities rather than creating additional layers of oversight. The need also exists to consider standards as they are developing in the international marketplace to facilitate the global exchange of medical and health care information and to drive the development of international standards.
Solo practitioners in rural areas, small group practices, and some safety net providers may face significant financial barriers to making necessary investments in information systems. This is an area where government action (e.g., subsidies, purchasing cooperatives, tax credits) may be needed, although the specific form of such action may well vary between localities.
Private and public health care organizations should protect the confidentiality of individually identifiable health care information by implementing comprehensive security programs that include employee training, security audits, and well-defined policies regarding access to different types of information.
The training of health care professionals should include the use of information technology in clinical settings. Graduates of professional schools should be experienced in the use of automated patient records and computerized decision-support tools. Education programs for paraprofessionals and other health care workers should also incorporate training in the use of information technology. There is a need for continuing education programs to train the existing health care workforce in the use of these systems.
The health care industry and the public sector should provide support to demonstration projects that can support information system improvement and create linkages between various sources of health care information at both the local and national level. The success of community health information networks in California, Wisconsin, Utah and other States suggests that this is a fertile area for additional research and action. Care needs to be taken to model success factors of community health information networks because there have also been numerous failures.
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