Measuring performance is key to identifying problems in the health care system and thus to improving quality. Congress advanced the use of standardized performance measures by authorizing a stable source of adequate funding to the National Quality Forum.
Disparities in care—research has documented significant disparities in health care, including preventive services. These disparities persist regardless of income and health insurance status.
Measuring and addressing disparities in health care is an integral component of performance assessment and requires consistent and uniform data collection on a range of factors including race, ethnicity, sex, age, primary language, socioeconomic status, sexual orientation, and gender identity. The National Healthcare Quality and Disparities Report by the Agency for Healthcare Research and Quality (AHRQ) documents the inequities that pervade the U.S. health care system. Without a consistent and uniform method of data collection, we cannot assess where and why disparities exist. For example, enabling access to knowledgeable and sensitive providers as well as recognizing and eliminating treatment barriers that arise from social stigma are important approaches to ensuring equity for the lesbian, gay, bisexual, and transgender community. A first step toward eliminating these disparities is a systematic approach to collecting these data, which would facilitate monitoring health care processes and outcomes for different population groups and help target initiatives to eliminate gaps in care. In addition, it is important to recognize and respond to the goals and preferences of all individuals for their care.
Safety—safety is a critical component of quality and is a core attribute of a well-performing health care system. In the current system, preventable errors often needlessly endanger patients. In its landmark 1999 study, To Err Is Human: Building a Safer Health System, the Institute of Medicine estimated that thousands of Americans die each year in hospitals due to medical errors. The Patient Safety and Quality Improvement Act of 2005 authorized a system for hospitals, physicians, and other health professionals to voluntarily and confidentially report medical errors to patient safety organizations. The health care delivery system’s organization and system-level failures are major contributors to medical errors and threats to patient safety. Many experts recommend expanding the Centers for Disease Control and Prevention’s system for tracking health care-acquired infections to also track other types of patient harm. Others propose a national patient-safety monitoring board to provide regulatory oversight that would help ensure patient safety. Reducing patient harm requires monitoring, greater transparency, and penalties for failure to address recognized safety issues.
Public reports—performance measures should be publicly reported to drive resources to high performers. The measures used must reflect evidence-based practice guidelines and reported data must be in a format that is easily accessible and useful for consumers, providers, purchasers, and regulators.
Measures for public and private sectors should be aligned to ensure consistent provider and consumer incentives in all parts of the health care system and reflect the priorities of the National Quality Strategy.
The Institute of Medicine has recommended a “full performance measurement system that is purposeful, comprehensive, efficient, and transparent.”
The assessment of resource use and efficiency along with a corresponding quality appraisal of physicians, hospitals, and other providers would offer patients and purchasers useful information about the cost and quality of care and would provide information about the value of care provided.
The ACA has several provisions that address system reform and health care quality. The legislation created the infrastructure for a national strategy to improve health care services and align the related efforts of public and private payers. It established the National Quality Strategy (NQS), a public-private initiative (i.e., not solely a federal effort) with three aims: better care, healthy people and communities, and affordable care.
The NQS calls for collaboration by public and private health care stakeholders and has six priorities.
- Make care safer.
- Ensure patient- and family-centered care.
- Promote effective communication and coordination.
- Promote effective prevention of and treatment for the leading causes of mortality, starting with cardiovascular disease.
- Work with communities to promote healthy living.
- Implement new delivery models to make care more affordable for individuals, families, employers, and governments.
MEASURING AND IMPROVING HEALTH CARE QUALITY: Policy
Funding for measurement and quality improvement
States and the federal government should fund the development of quality measures, quality oversight, and technical assistance to help all health professionals and institutions develop the capacity to collect, aggregate, report, and use data to improve the care they deliver. Measures should focus on high-priority areas that have been agreed upon by all stakeholders.
Congress should advance the use of standardized performance measures by ensuring a stable source of adequate funding for the development and implementation of valid and reliable standardized performance measures.
Consumers should be adequately represented at the governance and policymaking levels on all multi-stakeholder entities, such as those advising the Department of Health and Human Services on health care priorities and goals, measure selection, and other issues for quality improvement and public reporting.
Policymakers should support efforts to eliminate preventable medical injuries and accidents from procedural errors or preventable adverse events.
Policymakers should support:
- the multifaceted work of the Agency for Healthcare, Research, and Quality (AHRQ) to improve quality and safety; and
- greater transparency regarding safety lapses, including nationwide mandatory reporting to enable states to collect standardized data on adverse events that result in serious injury or death—Congress should provide funds and technical expertise to help states establish or adapt their current reporting systems to collect and analyze the data and follow up with health care practitioners and providers.
The AHRQ should:
- ensure that information and expertise on best practices for implementation are disseminated;
- assess the impact of state programs, and analyze aggregate reports from the states to identify persistent safety issues that require more intensive responses;
- encourage voluntary reporting efforts that include reports of hazards with the potential to cause patient injury as well as cases in which injuries have occurred;
- develop performance standards that focus on patient safety—the standards should require regulators and accreditors to implement meaningful patient safety programs. Public and private health care purchasers should provide incentives to organizations to demonstrate ongoing improvement in patient safety;
- facilitate action by health care organizations and affiliated professionals to make patient safety a declared priority—organizations should make quality improvement and safety a defined responsibility at the governance level and institute measures, including developing and implementing no punitive systems, for reporting errors and proven medication safety practices;
- develop medical-error data collection methods that are consistent with patients’ legal rights; and
- encourage states to develop effective systems to protect the public by removing from practice those health care professionals who fail to provide consistently safe and effective care.
Reporting of preventable events
The federal and state governments should require individual providers and health care facilities (including hospitals, nursing homes, rehabilitation centers, medical centers or offices, outpatient dialysis centers, ambulatory surgical centers, urgent care centers, and dental practices) to report serious, preventable adverse events as identified by the National Quality Forum. Policymakers should require that facility-specific reports be publicly disseminated.
The federal and state governments should prohibit facilities responsible for serious, preventable, reportable adverse events from passing the cost of treating related complications either to the federal government, states, other payers, or patients.
Assessing performance and improving quality
Performance measures should be developed from evidence-based guidelines. Priorities, goals, and standards to guide measure development should be national to ensure standardization, with local implementation to permit innovation and a focus on community needs.
Quality measures should focus on high-priority areas identified by the consensus of a multi-stakeholder group that includes adequate consumer representation.
A core set of quality and performance measures in the Institute of Medicine’s six domains of quality should be developed, at least in part with public funds, and collected from all providers and practitioners across all care setting.
The NQS should serve as the basis for national priority-setting to improve quality, safety, and efficiency.
States and the federal government should identify a consistent and uniform method of collecting information on an individual’s race, ethnicity, sex, age, socioeconomic status, and primary language and require health plans, public and private insurers, and other appropriate entities to collect and use the data to reduce or eliminate inappropriate disparities. These data should be reported to the public.
States and the federal government should identify gaps in access to care and care quality for vulnerable populations, including people with multiple chronic physical and mental illnesses.
States and the federal government should implement measures to assess resource use and efficiency in conjunction with quality so that physicians, hospitals, and other providers are fairly evaluated, and patients and purchasers have useful information about the value of care they receive.
Public reports about quality
All public reports should present information that is grounded in evidence, clinically important, and useful and meaningful to the end-users: consumers, providers, purchasers, and regulators.
The federal government and states should ensure that valid, accurate, objective, and standardized information is available to consumers to help inform their health care decisions.
Information for consumer decision-making should include, but not be limited to, data on treatment options; plan benefits and procedures; plan, provider, and practitioner performance; consumer experience; patient outcomes; and cost.
To the extent possible, public reports should permit consumers to compare the performance of competing types and models of plans, such as health maintenance organizations, preferred-provider organizations, conventional fee-for-service plans, and those with integrated delivery systems, among others. Comparative data on medical groups, physicians, and institutions (including hospitals) also should be provided.
Quality information should include patient-reported outcomes and should, to the extent possible, be paired with information about the cost of care to help consumers and others make informed decisions about where to receive care.
Information should be presented in formats that promote understanding and correct interpretation of data. Processes known to reduce the cognitive and physical difficulty of using information should be employed, and users’ literacy levels should be considered when information is developed and reported. Consumer information should be evaluated to assess its usefulness and relevance.
Education programs should promote the public’s understanding of the health care system, the need to improve health care quality, the role individual consumers can play in maintaining their health and improving their care, and how to make the best and most efficient use of health care services.
Governments should encourage the use of shared decision aids in collaborative treatment planning. These decision aids should be made available in multiple languages and at appropriate literacy levels.