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Quality Interagency Coordination (QuIC) Task Force
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Progress of the Quality Interagency Coordination Task Force (QuIC)

Report for the President as of September 21, 1999

In March 1998, the Advisory Commission on Consumer Protection and Quality in the Health Care Industry reported that one of the critical steps in advancing the quality of health care in this country was to unify providers, purchasers, quality oversight and improvement organizations, and the American people in their aims to improve health care quality. The President noted that the Federal agencies with health care responsibilities exert significant power in the health care industry, and could improve the quality of health care for Americans if they had common aims and better coordination. He asked Secretary Donna Shalala to bring these Agencies together in the Quality Interagency Coordination (QuIC) Task Force to work to improve health care quality. The QuIC has provided a significant opportunity for the Agencies to discuss issues of mutual concern. It has made substantial progress on specific projects to improve health care since it first met in May 1998.

Briefly, the Agencies that have been working together in the QuIC are the Departments of Defense, Veterans Affairs, Labor, Commerce, and Health and Human Services, and the Office of Personnel Management, the Office of Management and Budget, the Coast Guard, the Bureau of Prisons, the Federal Trade Commission and the National Highway Transportation and Safety Administration. Dr. John Eisenberg, Administrator of the Agency for Health Care Policy and Research, serves as Operating Chair of the QuIC.

In its initial meetings, the QuIC identified five areas of shared interest:

  1. Providing patients and consumers with information to assist in their choices.
  2. Pursuing key opportunities for clinical quality improvement.
  3. Enhancing quality measurement.
  4. Developing the workforce to provide higher quality care.
  5. Improving information systems.

The QuIC appointed multi-agency work groups in each of these areas and asked them to develop specific projects that would move toward these goals. Key staff were appointed from each of the participating agencies and are working hard to bring these projects to fruition. The health care leaders in each agency meet periodically to steer the actions of the work groups and to ensure appropriate support is available. Its projects include the following.

QuIC Efforts to Improve Current Patient Care Practices

The Work Groups identified several key opportunities to improve the care that is delivered. Some are areas in which there is scientific evidence demonstrating what should be done to diagnose and treat patients, but where common practice does not conform to those scientifically proven methods. Others are areas where research is needed to inform the choices that health care providers and managers make when determining what to do. The QuIC has undertaken efforts in these four specific areas:

  1. Diabetes Care. In 1997, the President launched the Diabetes Quality Improvement Project (DQIP) which brought together the Health Care Financing Administration, The Department of Veterans Affairs (DVA), and private sector partners to identify ways in which diabetes care could be improved. Working from research sponsored by the Agency for Health Care Policy and Research that identified what is most important and effective in treating patients with diabetes, DQIP created a small set of measures to use in judging clinical performance and determining where improvement was needed. The DQIP efforts led to three specific actions under the QuIC.

    • First, before the QuIC was created, the DVA and the Department of Defense (DoD) had created a common guideline for care of diabetes and had planned to use the DQIP measures to assess performance. Under the auspices of the QuIC, other Federal Agencies were invited to participate in the creation of the guideline and to use the guideline to improve the performance of their providers.

    • Second, the DQIP group held a conference aimed at helping providers and community organization to identify successful strategies to improve the quality of diabetes care. The QuIC was able to enrich this conference by bringing to it the Federal Agencies and care teams with successful strategies to share and by bringing together teams who were seeking new ideas that could be tried in their own communities. The conference was highly successful, and its success will be extended through efforts to compile and disseminate the "best practices" that were described at the conference to other providers and community representatives who were unable to attend.

    • Third, the QuIC is seeking a broad agreement among Federal agencies to collect and report the performance of providers on the DQIP measures. The QuIC discussed the importance of Federal Agencies agreeing to use this common set of measures for patients with diabetes, and concluded that it would significantly help to improve patient care. The QuIC has endorsed the idea of asking the Federal Agencies to agree to use the DQIP measures. We are in the process of making that request of all of the participating Federal Agencies and expect to know by mid-October how they have responded and what it will mean to use the DQIP measures in their programs.

  2. Depression Diagnosis and Care. As with diabetes, there is substantial research showing that the diagnosis and treatment of people with mild to moderate depression could be greatly improved. The DVA and DoD identified this as an area in which they wished to create a guideline to improve the care of their populations. Through the QuIC, their efforts were expanded in two significant ways. First, other Federal agencies were invited to participate in developing and using the guideline. Second, the research agencies, such as the National Institutes of Health, the Agency for Health Care Policy and Research, and the Substance Abuse and Mental Health Administration, were involved and able to bring the latest and most compelling evidence from their research to the effort. A guideline that will enhance the care of depressed individuals will be completed by the end of October and disseminated to Federal providers and made available to the public. One of the final steps needed is to marry performance measures to the guideline to ensure that the care for people with depression is getting better. Unfortunately, there is no clearly generally accepted superior set of depression care measures like the DQIP measures were for diabetes. Therefore, the QuIC organized a conference of experts in depression and measurement at the end of September and will produce not only the best measures available currently for monitoring performance, but also a research agenda for creating a more enduring set of critical measures.

  3. Reducing Errors. As indicated in the Advisory Commission's report, there is currently an unacceptable level of errors in health care. The QuIC is working with the Institute for Healthcare Improvement (IHI) to create an initiative that will test several strategies for rapidly reducing the number of errors committed. Our effort will be targeted specifically at health care delivery settings where patients are in need of urgent assistance and decisions have to be made rapidly, which we are calling "high hazard environments." These would include emergency rooms, operating rooms, intensive care units, and on-site rescue operations. This is the first such initiative targeted at error reduction in these high hazard environments. Based on the results of previous IHI initiatives, we hope that some sites will be able to achieve reductions of 25 percent to 30 percent in the number of errors within 12 to 15 months. The QuIC endorsed this effort at its meeting on September 21, and we are in the process of asking the agencies to decide if they wish to participate and how many teams they would like to have participate in the effort. Whatever is learned through this Federal effort will be shared broadly to help others reduce errors in their own health care delivery settings.

  4. Effect of Working Conditions on Quality of Care. From studies in other industries, we know that the conditions under which people work can dramatically affect their productivity and the quality of work that they do, but little research has been done on this issue in health care. Recent changes occurring nationwide in the levels of staffing in hospitals and nursing homes, as well as questions about how the organizational structure and physical environment affect the quality of care delivered, have made this an important topic in health care quality. These questions prompted the QuIC to look for research that could inform provider organizations about working conditions within their control that could influence the quality of care they deliver, but little research was available. Therefore, the QuIC elected to organize an expert meeting that will identify what is known about how working conditions affect the quality of care in health care and, more importantly, to identify the critical questions to be explored about the effect of working conditions on quality of care. We are collaborating in this effort with health care provider organizations, unions and other representatives of health care workers, and experts in facility design, art, organizational design, and quality improvement. This conference will provide a framework for Federal and private research efforts.

Future efforts to improve patient care will be developed based on the priorities of the Agencies involved and are likely to continue to expand on efforts to improve mental health care and move into cardiac disease, cancer, and other major diseases. For example, the QuIC can take advantage of the National Cancer Instituteís Quality of Cancer Care Initiative to affect the quality of cancer care delivered in ways that the NCI can not do solely through research efforts.

QuIC Efforts to Create Quality Improvement Tools

One of the major benefits of the collaboration occurring under the QuIC is the ability to develop and share tools that enable the Federal agencies and others to improve the quality of care. The QuIC Work Groups identified several tools that were needed. By ensuring collective use of these tools, the QuIC will help to minimize the confusion that health care providers encounter in dealing with the various Federal agencies and improve the efficiency of the agenciesí work. These include:

  • A Common Credentialing Effort. Currently, each Federal agency separately credentials the health care professionals who work for them. When professionals seek joint appointments from more than one agency, move from one agency to the other, or are called upon in times of national need, such as the Gulf War, to fill in for their colleagues who are serving abroad, the credentialing effort must begin again at the new agency. To prevent such duplication of effort and to improve the rigor of the initial credentialing process, the Federal agencies are working on a joint credentialing program that would allow electronic sharing of information across the agencies. This process began with an effort between the DVA and the Health Resources and Services Administration to test the feasibility of creating such a credentialing process for physicians and dentists. It has been judged successful, and the QuIC is working to expand both the number of Federal agencies that will use the process and the types of professionals who can be credentialed through the program. We expect this effort will take many more months of effort, but it is progressing.

  • Information on Measures. A goal of the QuIC is to ensure that the Federal agencies are using common measures and risk adjustment methods when possible. These steps will help to reduce reporting burden for health care providers and increase our ability to compare performance across providers. Initial steps have been taken to enable us to move toward this goal.

    The QuIC has created a compendium of all of the measures currently in use by Federal agencies. It is available to all who are seeking information on the measures currently available for use in assessing quality. The information also will be available through a National Measures Clearinghouse Web site that is under development by the Agency for Health Care Policy and Research. The QuIC members are sharing and testing the most advanced risk adjustment methods available. Comparisons will be made on the results, the relative costs of each method, and their effectiveness. A workshop is planned to discuss which measures and risk adjustment methods work best for particular purposes, and to agree on which are best.

  • Formulary Guidance. Several Federal organizations maintain formularies for their beneficiaries. Others, such as the Health Care Financing Administration, must oversee organizations that provide care to their beneficiaries and need a method by which they can ensure that the formularies of provider organizations are adequate to meet the expected needs of the populations they serve. A team of individuals is working to determine how to provide guidance based on scientific evidence that will help provider organizations determine what a formulary must contain to be adequate to meeting these expected needs.

  • A Taxonomy of Quality Improvement Methods. A tool that is essential if the nation is to learn which quality improvement strategies work best in various situations is a common method and language for identifying and describing quality improvement interventions. The QuIC Agencies conducted an expert meeting and are in the process of finalizing a taxonomy that will allow us to describe and compare the quality improvement strategies used in Federally sponsored research, and in projects of the DVA, DoD and HCFA's peer review organizations. This taxonomy will be published in a professional journal for broad use, and will be put to work immediately upon completion by the Federal agencies in their solicitations for research proposals, descriptions of on-going projects, and instructions to their provider organizations.

  • Improved Information Exchange across Agencies. Common information is used by the Federal agencies, but much of it is not exchanged electronically in a format that can be used by all agencies. The information systems experts have been studying methods to improve the efficiency and completeness of the data that are used in many agencies. They have started with the "exclusions list," which is the list of individuals and organizations to which the Federal agencies can not make health care payments. Individuals and organizations appear on this list after they have committed fraud or other similar actions in the delivery of health care goods and services. Agencies have noted that they are not sure they have accurate and up to date information on this list, or that they are missing information, such as the individualís or organizationís unique identifier code, and must make inquiries to verify identities before paying for services. Work is underway to determine if a single, searchable list that has the complete information needed by the agencies can be maintained and shared electronically. Further projects to explore the impact that information systems improvement can have on quality are being discussed.

  • Strategies for Ensuring Patientsí Rights. In November 1997, the President directed the Federal agencies to bring their programs into compliance with the Patientsí Bill of Rights that was developed by the Advisory Commission. As part of the efforts to bring our programs into compliance, key agency staff have been discussing their approaches and the challenges. They have been able to share ideas and strategies for bringing about compliance with the Bill of Rights to the extent that current legislation permits. These discussions have proven useful for all of the agencies.

QuIC Efforts to Help Inform Americans About Health Care

The QuIC agencies share responsibility for communicating with the American people about their health care choices and are developing three products that will greatly enhance our ability to do so. These are:

  • A Gateway to Consumer Information Available from Federal Agencies. The QuIC has aided the Federal Trade Commission in augmenting its Web site to include information on health care quality. Through this gateway, the QuIC now links to all of the Federal sites that provide information to assist people in making choices about their health care plans and providers, including information on the quality of health plans for Medicare beneficiaries, Federal employees, and participants in the DoD Tricare plans. There are also links to the Department of Labor's health benefits education campaign to help people understand what they are getting and what their rights are.

  • A Glossary of Commonly Used Terms. The QuIC agencies realized that there could be great benefit to the American people if we could agree to reduce the chance of confusion by using the same terms to mean the same things in our public communications. A set of terms has been developed and is being circulated to the Federal Agencies to solicit their agreement to use the terms. We expect to have that agreement in October.

  • Guidance for Producing Report Cards. Many organizations, including several Federal agencies, large purchasers, and employers, are attempting to help patients make better choices about their health care by providing "report cards" on provider and plan performance to the American people. There are scientific studies that show what is effective in providing these report cards to various types of people, and there are many organizations with experiences that can help others who are attempting to provide high quality report cards. To inform report card producers, the QuIC agencies have brought together researchers and report card producers to develop guidance based on the science and reported experiences. This information will be made available through a Web site that is currently under development. It is expected to be available this spring.

Current as of September 21, 1999

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