PREPARING FOR THE 21ST CENTURY


FOCUSING ON QUALITY IN A CHANGING
HEALTH CARE SYSTEM

 


National Academy of Sciences

National Academy of Engineering

Institute of Medicine

National Research Council

Background

Since Abraham Lincoln approved the Congressional charter of the National Academy of Sciences in 1863, the Academy complex—now made up of the National Academy of Sciences, the National Academy of Engineering, the Institute of Medicine, and the National Research Council—has been advising government about the impact of science and technology on society. The Academy complex provides independent advice to government by appointing committees of experts who serve without compensation, asking these committees to prepare draft reports by consensus, and subjecting these drafts to rigorous independent scientific review before release to ensure their quality and integrity. To avoid potential conflict of interest and bias, careful attention is given to the composition and balance of study committees.

As the 21st century approaches with science and technology assuming increasing importance in society, the Governing Board of the National Research Council has synthesized, summarized, and highlighted principal conclusions and recommendations from recent reports to inform decisions in a number of key policy matters. The resulting series of papers do not address all the intersections of science and technology with public policy, but they do address some of the most important. They are directed to federal administrators, members of Congress, corporate and business executives, managers and professionals, leaders of nongovernmental organizations, and all others involved in the development and implementation of public policies involving science and technology.

This paper discusses policies that can improve the quality of the nation's ever-changing health care system. Previous reports from the Academy complex, particularly the Institute of Medicine, have examined the strengths and limitations of health care in the United States and have recommended strategies to evaluate and improve the quality of health care. Those reports have encouraged and influenced both public and private initiatives to define and monitor the quality of care, measure health outcomes, develop better evidence and guidance on the appropriate use of medical services, and organize systems to improve health services and outcomes. The issues summarized in this paper from past reports continue to be relevant to the work of the Academy complex and to the nation.

This document with direct links to the text of all reports cited herein, is available on the Internet at http://www2.nas.edu/21st. A box at the end describes other ways to obtain information on the Academy complex and the topics discussed in this paper.

PREPARING
FOR THE 21st CENTURY

FOCUSING ON QUALITY
IN A CHANGING HEALTH CARE SYSTEM


Concerns about quality could frustrate important changes in health care delivery and financing. Policymakers, payers, managers, and others must confront current and potential quality-of-care problems with the same vigor and sophistication that they are directing to issues of cost. This message applies to public and private sectors alike and to federal, state, and local governments.


 Introduction

At its best, health care in the United States is superb. Such care—including prevention, early diagnosis of illness, and advanced therapeutic services—is not, however, available to millions of Americans who are uninsured or underinsured. Even Americans with insurance, including Medicare and Medicaid, may not always have access to adequate care. At the same time, some Americans may be subjected to inappropriate or unnecessary procedures.

American health care—with its mix of superb and questionable care and its gaps in access—is very expensive. Continued efforts to limit the growth of health care spending are essential if we are to meet other socially important needs, for example, in education, housing, transportation, and economic development. Trying to balance cost-cutting initiatives with efforts to maintain and improve the quality and availability of care is a major challenge and requires good information for policymakers, patients, consumers, and others to use in judging whether we are on the right course.

One prominent, and increasingly common, strategy is managed care, a simple label for a diverse and complex array of financial, administrative, and educational programs and tools that attempt to balance cost, quality, and accessibility. Managed-care approaches, which include health maintenance organizations (HMOs), are increasingly the choice for both the privately insured and those covered by Medicare and Medicaid. Some fear that the shift to managed care will produce long queues for care, reduce the availability of effective treatments and technologies, or lessen the personal commitment of physicians, nurses, and other caregivers to their patients. Others believe that managed care, properly designed and implemented, will provide more rational, effective, and affordable health care.

Several key objectives set forth in reports of the Academy complex can help guide the development and implementation of public policies that will ensure the quality of health care provided to Americans. Among these objectives are the following:


Measuring the Quality of Care is Necessary to
Promote Improvements

Tested approaches already exist for measuring variations in the quality of some types of care. For more than 25 years, experts have been working to create reliable, valid ways to assess the quality of care of a wide range of inpatient and outpatient services given for a broad array of health and medical problems. For some health care fields, well-understood measurement tools can be put to immediate, widespread use; in others, the science of quality measurement is relatively elementary, making the validity of comparative assessments suspect.

Good ways also exist for improving the quality of health care. In addition to what we know about measuring high- and low-quality care, systems and management research (involving such fields as organizational behavior, statistics, psychology, and learning) can be used to evaluate the outcome of health care decisions and thus influence favorably the institutions and people that provide health services. Organization-wide quality-improvement efforts are beginning to be adopted in the service sectors around the world. Much remains to be learned about linking these concepts and tools, most of which are not yet familiar to clinicians or health administrators, to other, better-known disciplines and approaches in health, such as technology assessment, practice guidelines, clinical evaluation, and medical decision making, as well as to the databases and networks needed to incorporate them into day-to-day operations.

Nursing Homes and Health Care Quality 

Many Americans will one day have to enter nursing homes. What is the quality of care in those nursing homes? Are the horror stories that are occasionally reported accurate depictions of common occurrences? Will increasing the quality of their care make them unaffordable through Medicare and Medicaid?

Despite recent improvements in nursing-home quality and regulatory compliance, the quality of care provided by some nursing facilities leaves much to be desired. Frequently cited problems include inadequate care plans, unsanitary and hazardous environments, and unsanitary food. There is also a failure to maintain the dignity of and respect for patients. Although the use of restraints (which decrease muscle tone and increase the likelihood of falls, incontinence, ulcers, depression, confusion, and mental deterioration) has been decreased, a number of facilities still fail to recognize and promote the independence of residents.

Many residents of nursing homes have serious disabilities and problems that need skilled nursing care. Although a licensed nurse (LN) must be on duty 24 hours per day, current regulations require a registered nurse (RN) to be on duty only 8 hours per day. Nurse assistants constitute 70-90% of the nursing staff in nursing facilities. They provide most of the direct care and spend the most time with residents, but they are the least trained. Yet, in 1993, 48% of all nursing-facility residents were chairbound, and 5% were bedfast; 37% had some severe irreversible psychiatric condition (such as Alzheimer's disease), and another 33% were receiving psychoactive medication for such conditions. This situation indicates the need for careful reviews to determine whether quality of care is adequate.

Greater RN presence on all shifts should lead to higher rates of patient survival, improved ability of residents to function independently, fewer hospitalizations, and earlier discharge from nursing homes. The additional cost of boosting RN coverage from 8 to 24 hours per day might be reduced by the potential long-term savings from better-quality health care.

 For more information:

  • Nursing Staff in Hospitals and Nursing Homes: Is it Adequate?, Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes, 1996
    		•

    Overall, tools for measuring and improving health care must confront three broad kinds of quality-of-care concerns:

     1. Use of unnecessary or inappropriate care. Examples include the excessive or unnecessary use of x-ray and other diagnostic tests, unnecessary hysterectomies and open-heart surgery, and overprescription of antibiotics and some mood-altering drugs. Those practices make patients vulnerable to harmful side effects. They also waste money and resources that could be put to more productive use.

    2. Underuse of needed, effective, and appropriate care. People do not get proper preventive, diagnostic, or therapeutic services if they lack health insurance and if they delay seeking care or receive no care at all. Even those with insurance often face geographic, cultural, organizational, or other barriers that limit their abilities to seek or receive care.

    3. Shortcomings in technical and interpersonal aspects of care. Inferior care results when health care professionals lack full mastery of their clinical-practice fields, do not adequately explain key aspects of care, or cannot communicate effectively with their patients. Cases in point include preventable drug interactions and surgical mishaps, failure to monitor or follow up abnormal laboratory-test results, neglect of appropriate education and information for patients, lack of adequate coordination of care, and insensitivity to ethnic and cultural characteristics of patients. (A-1, A-2)

    For more information on measuring the quality of care:

  • A-1. America's Health in Transition: Protecting and Improving Quality, A Statement of the Council of the Institute of Medicine, 1994
  • A-2. Medicare: A Strategy for Quality Assurance, Vol. I, Committee to Design a Strategy for Quality Review and Assurance in Medicare, 1990

    •  

    Can Quality of Care Be Defined?

    Quality of care can be defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. That definition, formulated by a committee to design a quality strategy for the Medicare program, has been widely accepted and has proved to be a powerful tool in the formulation of practical approaches to quality assessment and improvement.

    Several ideas in the definition deserve elaboration. The term health services refers to a wide array of services that affect health, including those for physical and mental illnesses. Furthermore, the definition applies to many types of health care practitioners (physicians, nurses, dentists, therapists, and various other health professionals) and to all settings of care (from hospitals and nursing homes to physicians' offices, community sites, and even private homes).

    Including both populations and individuals draws attention to the different perspectives that need to be addressed. On the one hand, we are concerned with the quality of care that individual plans and clinicians deliver. On the other hand, we must direct attention to the quality of care across the entire system. In particular, we must ask whether all parts of the population have access to needed and appropriate services and whether health status is improving.

    The phrase desired health outcomes highlights the crucial link between how care is provided and its effects on health. It underscores the importance of being mindful of people's well-being and welfare and of keeping patients and their families well informed about alternative health care interventions and their expected outcomes. Current professional knowledge emphasizes that health professionals must stay abreast of the dynamic knowledge base in their professions and take responsibility for explaining to their patients the processes and expected outcomes of care.

     For more information:

  • Medicare: A Strategy for Quality Assurance, Vol. I, Committee to Design a Strategy for Quality Review and Assurance in Medicine, 1990

    •  

    Accountability for Quality of Care Under
    Medicare Should Be Strengthened

    What is Medicare's responsibility for quality of care?

    The quality-assurance strategy of the Medicare program (the federal program providing health insurance to elderly people and some people with disabilities) has done much, but accountability for quality remains a concern. Medicare's quality-assurance strategy should focus on health care decision making and patient-health outcomes, enhance professional responsibility and capacity for improving care, use clinical practice as a source of information to improve quality of care, and be able to demonstrate positive effects on the public's health.

    Although both public and private programs have moved in those directions, the Medicare program's responsibility for the quality of care can be strengthened. Congress should expand the mission of Medicare to include an explicit responsibility for ensuring the quality of care of Medicare enrollees. (B-1)

    To help to meet that responsibility, Congress should establish a Quality Program Advisory Commission (QualPAC) to oversee Medicare activities and report to Congress. (B-1) QualPAC would guide and advise on quality in ways similar to those used by the commissions that have advised Congress on physician and hospital payment.


    Does managed care present any quality
    concerns for Medicare?

    All those providing care to Medicare beneficiaries should be accountable for the quality of care. Managed care presents two key quality concerns for Medicare beneficiaries: health plans need to be more accountable to and understandable by elderly patients, and the necessary protections need to be built into the system to help Medicare beneficiaries to move through the health care system effectively, safely, and confidently in an environment of greater health-plan choice.

    Information from a neutral source (neither purchaser nor health plan) relevant to patient and consumer concerns should be much more widely and easily available. (B-2) It will require substantial efforts to build the needed consumer-oriented information infrastructure for Medicare beneficiaries at the national, state, and local levels.

    Enrollment and disenrollment guidelines, appeals and grievance procedures, and marketing rules should reflect Medicare beneficiaries' vulnerability and lack of understanding of traditional Medicare and Medigap insurance, as well as their current mistrust of important aspects of alternative health plans. (B-2)

    Payment incentives, gag rules, and other practices that might motivate providers to evade their ethical responsibility to give complete information to their patients about their illness, treatment options, and plan coverage should be abolished or prohibited as a condition of plan participation in Medicare. (B-2)

    For more information on quality of care under Medicare:

  • B-1. Medicare: A Strategy for Quality Assurance, Vol. I, Committee to Design a Strategy for Quality Review and Assurance in Medicare, 1990
  • B-2. Improving the Medicare Market: Adding Choice and Protections, Committee on Choice and Managed Care: Assuring Public Accountability and Information for Informed Purchasing by and on Behalf of Medicare Beneficiaries, 1996



    • A Carefully-Constructed Knowledge
    Base Is Needed to Improve the Quality
    of Medical Practice

    Why is knowledge so important?

    Quality assessment and improvement are knowledge-driven enterprises. We know far more today than in the past. Yet we still do not know enough about what works in medicine and health care, for what conditions, under what circumstances, and at what cost to improve the quality of health care to the greatest extent possible. Effectively functioning markets require that patients, employers, and other consumers have good information for decision making, including knowledge about the performance of health plans and the efficacy, effectiveness, and cost-effectiveness of health services, both new and established.

    Health-services researchers, government agencies, health plans, purchaser coalitions, and others have done much to improve ways of measuring health outcomes, comparing the outcomes of different health care practices, evaluating the performance of health care providers and practitioners, and developing credible and useful guidance for patients and clinicians in making medical decisions. It is important that Congress and private organizations continue to support this knowledge-building work with the joint goals of improving average performance, and correcting substandard practices. (C-1)

    Guidelines for clinical practice and tools for assessing clinical performance vary substantially. Several attributes of practice guidelines and medical-review criteria are important for quality health care and public trust:

    How Should Accountability Be Assigned
    for the Quality of Health Care?

    Both internal accountability and external accountability are essential in ensuring the quality of health care.

    Internal quality-improvement and quality-management efforts to develop and design care and to monitor quality of care are essential. They involve health plans and health systems acting on their own initiative to measure and improve their performance and their patients' outcomes. Such efforts will also reinforce the steps that physicians and other health care professionals can take now to improve the performance of local health care institutions and health plans.

    External monitoring of quality of care will also be necessary to ensure the integrity of the quality-of-care information that plans report and to make assessments from a broader population perspective. It is imperative that the impact of health-system changes on the quality of health care and the health status of the entire population be tracked. Both public and private organizations are involved—often cooperatively—in work to devise valid, reliable, and practical ways to measure and compare the quality of care provided by health plans, institutions, and clinicians.

    These dual accountabilities—internal and external quality monitoring and improvements—are not well understood by the health care community, policymakers, or consumers. They need to be continually refined and reinforced.

    The multiplicity of public agencies at federal and state levels with oversight responsibility and the range of private organizations that accredit health care organizations and review care, as well as internal quality-improvement efforts of health plans, would lead some to believe that assurance of quality is well in hand. Unfortunately, duplication of effort and gaps in measurement coexist.

    For example, methods for adjusting health-outcome and performance measures to reflect differences in the age, health status, and other characteristics of health-plan members or other populations are improving but are still inadequate. Without appropriately adjusted comparisons, we can misjudge how well health plans protect and serve their members.

    The problem of "severity-adjusting" outcome measures parallels the problem of "risk-adjusting" government, employer, or other payments to health plans (in ways that do not rely on those who are ill to pay higher premiums). Without appropriately adjusted payments, we might penalize plans that attract less-healthy and more-costly members (the plans that experience adverse selection). Such financial incentives could undermine efforts to improve quality and hold health plans accountable for their actions. Thus, sound methods to adjust payments to health plans and comparisons of health plan performance for differences in members' characteristics are essential.

     For more information:

  • Medicare: A Strategy for Quality Assurance, Vol. I, Committee to Design a Strategy for Quality Review and Assurance in Medicare, 1990
  • Employment and Health Benefits: A Connection at Risk, Committee on Employer-Based Health Benefits, 1993
    		•


    What is the role of the computer-based
    patient record?

    Computer-based patient record (CPR) technology is essential for health care. This role begins in the care process as the CPR provides patient information when needed to support clinical decisions and continues as a key information source for quality review and improvement. It can be linked to clinical-practice guidelines, clinical alerts, and up-to-date research findings to help patients and clinicians in making choices. The desire to improve the quality and usefulness of health care data is shared by patients, practitioners, administrators, researchers, and policymakers throughout the nation.

    Widespread CPR use should be achievable within a decade. Progress has been made, but the goal is elusive. Health care professionals and organizations should adopt the computer-based patient record as the standard for medical and all other records related to health care. (C-3)

    What Do Privacy and Confidentiality
    Have to Do with the Quality of Care?

    Privacy and confidentiality are key elements of ensuring quality in the health care system. To the extent that people worry about the confidentiality of the information that they provide to physicians and others, they might withhold information, thus compromising the quality of their own care, undermining the quality of data used for other purposes, and contributing to a deterioration in trust between patient and physician and between patient and health plan. If people fear that seeking particular kinds of medical services will make their medical history available to employers, credit organizations, and others, they may even avoid seeking needed medical care.

    Current state protections often apply duties of confidentiality to the recordkeeper (such as a hospital), but these protections are no longer in effect once the data have left the recordkeeper's control. It is important to note that video-rental records, for example, have more federal privacy protection than medical records. Despite much debate and discussion, several prominent efforts to secure national privacy safeguards have not yet succeeded, although recent legislation may change that.

    Health data should be protected. Legislation should be enacted to establish the confidentiality of person-identifiable data as an attribute of data elements themselves, regardless of who holds the data. (C-4) The US Congress should enact privacy legislation. Such legislation should

    • Establish a uniform requirement for the assurance of confidentiality and protection of privacy rights for person-identifiable health data.
    • Specify a Code of Fair Health Information Practices that ensures a proper balance among required disclosures, use of data, and patient privacy.
    • Impose penalties for violations of the act.

    In addition, the Employee Retirement Income Security Act of 1974 (ERISA) should be changed to strengthen protections for employees whose employers have access to personal medical information through health-insurance plans. Employers or their agents have legitimate interests in this information, so Congress should amend ERISA (through provisions analogous to those in the Americans with Disabilities Act), so as to regulate employer access to individual medical information collected in connection with employment-based health benefits. (C-5)

    ERISA is also a major barrier to legal claims of corporate negligence, no matter how clear the fault and how serious the injury (including death) to patients and families. As a result, one of the ultimate tools to discourage and compensate for low-quality care is denied to many workers and their families. This situation underscores the need for efforts aimed at protecting and improving the quality of health care to be broadly focused in identifying problems and promoting agreement on solutions.

     For more information:

  • Health Data in the Information Age: Use, Disclosure, and Privacy, Committee on Regional Health Data Networks, 1994
  • Employment and Health Benefits: A Connection at Risk, Committee on Employer-Based Health Benefits, 1993

    		•

     

    What are the responsibilities of organizations
    that collect health data?

    Organizations that hold health databases or are part of networks of health databases have the responsibility to ensure the quality and security of health data. Such health database organizations can be created by business coalitions, built by entities supported with private funds, mandated by state health legislation, or established by federal action. Characteristics of such databases include their linkage of patient events over time, timeliness of data, accuracy and completeness for the uses intended, ownership and oversight, and the use of unique person-identifiers. Health-database organizations should take responsibility for maintaining data quality continuously and take steps to ensure the completeness and accuracy of the data in the databases for which they are responsible, as well as the validity of data for the analytic purposes for which they are used. (C-4)

    In addition to their benefits, the electronic recording, storage, transmission, and retrieval of patient information have in some respects increased the possibility of infringement on the confidentiality of personal medical information. Such medical information extends beyond the written word to include still images, audio records, and videos of patients, and many more people now have or potentially have access to this information than in the past.

    These developments require continuing reassessment of the tradeoffs between privacy concerns and other values, such as convenient and quick access to information, and of the practical realities of enforcing an agreed-on balance of competing objectives. 

    For more information on the knowledge base and health care quality:

  • C-1. Guidelines for Clinical Practice: From Development to Use, Committee on Clinical Practice Guidelines, 1992
  • C-2. Controlling Costs And Changing Patient Care? The Role of Utilization Management, Committee on Utilization Management By Third Parties, 1989
  • C-3. The Computer-Based Patient Record: An Essential Technology for Health Care, Committee on Improving the Patient Record in Response to Increasing Functional Requirements and Technological Advances, 1991
  • C-4. Health Data in the Information Age: Use, Disclosure, and Privacy, Committee on Regional Health Data Networks, 1994
  • C-5. Employment and Health Benefits: A Connection at Risk, Committee on Employer-Based Health Benefits, 1993



    • Conclusion

    Who needs to be well informed and concerned
    about quality of care?

    Everyone needs to be well informed and concerned about the quality of care. Everyone means patients and their families, consumer agents and advocates, health professionals, administrators of health plans and facilities, purchasers of health care services, and policymakers at all levels. The messages to these audiences are 1) that the quality of care can be measured and improved and 2) that quality of care should not be ignored in pursuit of cost control. Reinforcing these messages means making sure that quality of care stays on the health care-delivery agenda, with clear identification of the risks and opportunities that are posed by the changes in health care in the United States. It also means describing how health plans, health care organizations, and clinicians should be accountable to patients and society and, conversely, how individuals can take appropriate responsibility for their own health.

    For Further Information:

    The World Wide Web site http://www2.nas.edu/21st includes up-to-date versions of all the documents in this series and on-line versions of the reports referred to in this document.

    Internet Address: jjensen@nas.edu
    Phone: (202) 334-1601
    Fax: (202) 334-2419
    Address:

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    © 1997 by the National Academy of Sciences. All rights reserved. This document may be reproduced solely for individual, non-commercial, and educational purposes without the written permission of the National Academy of Sciences.