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Overview
Along with other aspects of the US health-care system, we are now witnessing rapid change in the area of health-care performance improvement. Accordingly, this chapter reviews the history and current state of health-care performance improvement. The key sections of this chapter include:
Developments in the history of health-care performance improvement
Main approaches to performance improvement
Key organizations promoting performance improvement and their products
Evolving incentives for performance improvement and participation in quality measurement and reporting programs
The role of health information technology
Details on key organizations
A prominent 2012 article by Blumenthal provides a valuable framework for this chapter:
The guiding vision should also be based on the understanding that performance improvement requires that clinicians and patients be enabled to make better health care decisions by giving them the best available information when and where they need it and making it easy to do the right thing. Clinicians and patients need information about patients’ personal health and health care and about medical evidence relevant to their decisions. Clinicians need environmental supports and financial incentives to choose diagnostic and therapeutic pathways that maximize the value of care. Organizational arrangements must support collaboration, teamwork, and coordination of care.[1]
Accordingly, this chapter will highlight the two levers identified by Blumenthal: environmental supports and financial incentives.
Key developments in the history of health-care performance improvement
Although a comprehensive review of the history of health-care performance improvement is beyond the scope of this chapter, reviewing some key developments will be instructive.
Donabedian: structure, process, and outcome
Donabedian’s model sees health care quality as having three components: structure, process, and outcomes.[2, 3] Structure refers to the context in which care is delivered (i.e., buildings and equipment, staff and organization, and financing). Process refers to transactions between patients and providers, especially services provided. Outcomes refer to the effects of health care on the health of patients and populations. While other frameworks have been developed since Donabedian’s time, his model remains a key paradigm for assessing health care quality.
Institute of Medicine reports
Two key publications by the Institute of Medicine (IOM) helped to produce a paradigm shift in public perception of the quality and safety of US health care. In 1999, the first, “To Err is Human: Building a Safer Health System” opened with this striking paragraph:
Health care in the United States is not as safe as it should be–and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies. Even using the lower estimate, preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS.[4]
In 2001, the IOM followed up with “Crossing the Quality Chasm: A New Health System for the 21st Century,” which began with a similarly bleak picture and stern warning:
The U.S. health care delivery system does not provide consistent, high-quality medical care to all people. Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge–yet there is strong evidence that this frequently is not the case. Health care harms patients too frequently and routinely fails to deliver its potential benefits. Indeed, between the health care that we now have and the health care that we could have lies not just a gap, but a chasm.[5]
Main approaches and methodologies of performance improvement
The plan-do-study-act cycle
The plan-do-study-act cycle (PDSA cycle) is a series of steps for gaining knowledge for the continual improvement of a process. Logically enough, the steps are as follows:
Plan: This step involves identifying a goal or purpose, formulating a theory, defining success metrics and putting a plan into action.
Do: Implementation of the plan.
Study: In this step, outcomes are assessed to validate the plan, specifically identifying good-versus-bad outcomes and/or areas for improvement.
Act: In this final step, the team integrates learning generated by the process in order to adjust goals, change methods, and/or even reformulate the theory itself. There is not necessarily just one cycle; ideally, the steps are repeated as needed to promote continuous improvement.[6]
Six Sigma
Six Sigma is another methodology for process improvement, originally developed and elaborated in industry, but recently adopted to promote health care quality and safety as well. Six Sigma seeks to improve the quality of process outputs by identifying and removing the causes of defects (errors) and minimizing variability in manufacturing and business processes. It uses a set of quality management methods, including statistical methods, and creates a special infrastructure of people within the organization (“champions,” “black belts,” etc.) who are experts in these methods. Each Six Sigma project carried out within an organization follows a defined sequence of steps and has quantified value targets (e.g., reduce process cycle time and/or costs, increase customer satisfaction, increase profits). The term “Six Sigma” originated in statistical modeling of manufacturing processes, and the maturity of a manufacturing process can be described by a sigma rating reflecting the percentage of defect-free products it creates.[7]
Lean
Lean manufacturing, or simply “lean,” is a systematic method for the elimination of waste within a manufacturing process. Lean also takes into account waste created through overburden and waste created through unevenness in workloads. Working from the perspective of the client who consumes a product or service, “value” is any action or process for which the consumer is willing to pay. Essentially, lean is centered on making obvious what adds value by reducing everything else.[8]
Key organizations promoting performance improvement, and their products
Public sector organizations
Agency for Healthcare Research and Quality
The Agency for Healthcare Research and Quality (AHRQ) provides “tools, recommendations, and resources for clinicians and providers and hospitals and health systems.”[9] Specifically regarding quality and patient safety, AHRQ provides “tips for preventing medical errors and promoting patient safety, measuring health care quality, consumer assessment of health plans, evaluation software, report tools, and case studies.”[9] The following are some of the AHRQ programs and tools:
AHRQ’s Healthcare-Associated Infection Program
Comprehensive Unit-based Safety Program (CUSP)
Patient Safety Measure Tools & Resources
Pharmacy Health Literacy Center
Surveys on Patient Safety Culture
Quality Measure Tools & Resources [9]
Among the most important AHRQ quality measure tools and resources is its National Quality Measures Clearinghouse (NQMC), “a public resource for evidence-based quality measures and measure sets.”[10] NQMC also hosts the HHS Measure Inventory.”[11] The HHS Measure Inventory is a repository of measures separate from the NQMC which are currently being used by the agencies of the US Department of Health and Human Services (DHHS) for quality measurement, improvement, and reporting. Not all measures in the HHS Measure Inventory meet criteria for inclusion in the NQMC.[11]
An AHRQ initiative parallel to the NQMC is its National Guideline Clearinghouse™, “a publicly available database of evidence-based clinical practice guidelines and related documents. Updated weekly with new content, the NGC provides physicians and other health professionals, health care providers, health plans, integrated delivery systems, purchasers, and others an accessible mechanism for obtaining objective, detailed information on clinical practice guidelines and to further their dissemination, implementation, and use.”[12]
Centers for Medicare and Medicaid Services
The Centers for Medicare and Medicaid Services (CMS), despite its long history of implicitly rewarding volume rather than quality or value, has recently developed a new strategy to reward value, including two key programs, among others, the Physician Quality Reporting System (PQRS) and Meaningful Use (MU). The PQRS program is described briefly in the next section, whereas the description of the Meaningful Use program follows under “Meaningful Use Incentives” in the section on health IT and performance improvement. As will be discussed in more detail under “Evolving Incentives for Performance Improvement by Providers,” CMS has developed PQRS, “a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals.”[13]
Private sector organizations
Institute for Healthcare Improvement
As it states on its website, the Institute for Healthcare Improvement (IHI) “is a nonprofit organization focused on motivating and building the will for change, partnering with patients and health care professionals to test new models of care, and ensuring the broadest adoption of best practices and effective innovations.”[14] IHI was officially founded in 1991, but its groundwork began in the late 1980s as part of the National Demonstration Project on Quality Improvement in Health Care, led by Dr. Don Berwick and a group of individuals committed to redesigning health care to become a system without errors, waste, delay, and unsustainable costs. Originally supported by a collection of grant-supported programs, it is now a self-sustaining organization with worldwide influence. IHI believes there is a need to view health care as a complete social, geopolitical enterprise.[15] In order to establish better models of health care, IHI created the Triple Aim, a framework for optimizing health system performance by simultaneously focusing on improving both the health of a population, and the experience of care for individuals within that population, and reducing the per capita cost of providing that care. A goal of IHI has been to use their framework to develop specific, practical initiatives to bring about change. The process of accomplishing this usually combines components focused on the individuals, families, and the population served; the restructuring of primary care services; cost control; and system integration and execution.[16]
National Committee for Quality Assurance and the Healthcare Effectiveness Data and Information Set
According to its website, “The National Committee for Quality Assurance [NCQA] is a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality. Since its founding in 1990, NCQA has been a central figure in driving improvement throughout the health care system, helping to elevate the issue of health care quality to the top of the national agenda.”[17]
A major function of NCQA is the management of voluntary accreditation programs for individual physicians, health plans, and medical groups. It also offers dedicated programs targeting vendor certification, software certification, and compliance auditing, and it provides an evidence-based program for case-management accreditation for payer, provider, and community-based organizations.[17]
Two major tools used by NCQA to evaluate health plans seeking accreditation are the Healthcare Effectiveness Data and Information Set (HEDIS) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. More than 90% of America’s health plans use HEDIS to measure their performance on important dimensions of care and service, (81 measures across 5 domains of care). Because this set of standard, tightly defined measures is collected by the vast majority of health plans in the United States, HEDIS provides a means of comparing the performance of health plans on an “apples-to-apples” basis. The CAHPS surveys were developed to provide useful information from patients’ perspectives on their experiences and satisfaction with health care received. There are four versions that can be administered to adults and children in commercial and Medicaid plans. The surveys include a core set of questions; composite or summary scores developed from sets of these questions are used to evaluate key areas of care and service.[18]
The Leapfrog Group
Rapidly increasing health insurance costs were the major factor influencing several large US companies to meet in 1998 to explore ways to influence quality and affordability. The Leapfrog Group was formed and its members agreed to base their purchase of health care on principles that “encourage provider quality improvement and consumer involvement.”[19] The group was officially launched in November 2000 with the initial focus provided by the 1999 Institute of Medicine report.[4] That initial focus was on reducing preventable medical mistakes by having members leverage their purchasing. The concept was to encourage large advances by rewarding hospitals that show significant improvements. The group selected practices that offered computerized physician order entry (CPOE), evidence-based hospital referral, intensive care unit (ICU) staffing by physicians experienced in critical care medicine, and use of a “Leapfrog Safe Practices Score,” based on the National Quality Forum–endorsed Safe Practices.[20] More recent initiatives include public reporting of health care quality and outcomes to influence consumers’ choices. Originally funded by the Business Roundtable, Leapfrog is now supported by its members and major corporations, business coalitions, public agencies that purchase health care benefits, and from products and services it provides to support value-based purchasing.
Quality improvement organizations
According to the CMS website, a quality improvement organization (QIO) is a group of health quality experts, clinicians, and consumers organized to improve the care delivered to people with Medicare.[21] QIOs work under the direction of CMS to assist Medicare providers with quality improvement and to review quality concerns for the protection of beneficiaries and the Medicare Trust Fund. The QIO program is one of the largest federal programs dedicated to improving health care quality for Medicare beneficiaries and is an integral part of the US DHHS’ National Quality Strategy for providing better care and better health at lower cost. The mission of the QIO program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. “CMS identifies the core functions of the QIO Program as:
1. Improving quality of care for beneficiaries;
2. Protecting the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting; and
3. Protecting beneficiaries by addressing individual complaints, such as beneficiary complaints; provider-based notice appeals; violations of the Emergency Medical Treatment and Labor Act (EMTALA); and other related responsibilities as articulated in QIO-related law.”[21]
American Medical Association Physician Consortium for Performance Improvement
The American Medical Association (AMA) Physician Consortium for Performance Improvement® (PCPI®) is a national, physician-led program dedicated to enhancing quality and patient safety. Its ongoing mission is to align patient-centered care, performance measurement, and quality improvement. It develops evidence-based performance measures that are clinically meaningful, meet the current and future needs of the PCPI membership, and are used in national accountability and quality improvement programs.[22] PCPI measures (encompassing structure, process, and outcome) can be used for evaluating quality of care for a wide range of clinical topics. The current performance measures portfolio includes measurement sets in 47 clinical areas and preventive care and more than 300 individual measures (www.ama-assn.org/apps/listserv/x-check/qmeasure.cgi?submit=PCPI).[23]
National Quality Forum
The National Quality Forum (NQF) is a nonprofit organization based in Washington, DC, dedicated to improving the quality of health care in the United States.[24] The NQF has a three-part mission: to set goals for performance improvement, to endorse standards for measuring and reporting on performance, and to promote educational and outreach programs. NQF members include purchasers, physicians, nurses, hospitals, certification bodies and fellow quality improvement organizations. The NQF is known for having developed a list of 28 medical errors it deemed serious reportable events, more commonly referred to as “never events” (www.qualityforum.org/Topics/SREs/List_of_SREs.aspx) because they are largely preventable medical events and, as such, should never happen. The NQF classifies these events according to six categories: surgical, product or device, patient protection, care management, environment, or criminal. Examples include operating on the wrong patient, leaving a foreign object in a patient after surgery, and sending a newborn home with the wrong parents.[25] One of the criteria for the meaningful use of electronic health record (EHR) technology is the ability to report health quality measures to the CMS. To that end, the NQF has introduced several health IT initiatives, such as “The Critical Paths for Creating Data Platforms” project to assess the readiness of electronic data to support selected innovative measurement concepts and others (www.qualityforum.org/HealthIT) to develop the infrastructure to support this reporting requirement.[26]
Evolving incentives for performance improvement by providers
The National Strategy for Quality Improvement in Healthcare (National Quality Strategy) unites federal agencies, health-care payers, providers, consumers, and other stakeholders in a common pursuit of improved health through quality health care for all Americans.[27] Originally published in March 2011, the National Quality Strategy specified three aims: better care, healthy people/healthy communities, and affordable care. These three aims were accompanied by six priorities: making care safer, engaging patients and families as partners in care, promoting coordination of care, implementing the most effective preventive and treatment practices, collaboration with communities to enable healthy living, and expanding access to affordable quality care through new health-care delivery models.[27] Numerous reporting initiatives and accompanying quality measures are presently in use across the public and private health-care domain, representing a concentrated effort to strengthen infrastructure for performance evaluation and improvement. In the context of a complex and evolving quality environment, the US DHHS has recognized the importance of measure harmonization to ensure consistent and meaningful reporting. Specifically, the National Quality Strategy emphasizes “an aligned focus on outcomes for children, adolescents, and adults and for the retirement of unnecessary, redundant measures that will reduce the reporting burden and will allow the remaining quality measures to send a stronger signal about where and how better care is achieved.”[28]
Participation in quality measurement and reporting systems: CMS
The CMS has taken a central role in the initiation and proliferation of incentivized quality reporting and measurement programs. Several of CMS’s most influential programs include value-based purchasing (VBP),[29] PQRS,[30] and the Meaningful Use initiatives.[31] Each program is composed of multiple components or levels which provide flexibility to reporting providers or institutions, with incremental parallel incentives for achieving advanced reporting or performance capabilities. The VBP program is used by CMS to hold institutions accountable for the quality of care provided, rewarding hospitals providing high-quality care with increased payments, and adjusting payments for underperforming hospitals.[29] These initiatives have undergone multiple revisions and updates to optimize effective implementation and continued performance improvement.
The EHR Incentive Program: meaningful use
The Electronic Health Record (EHR) Incentive Program provides payments to eligible providers who utilize EHR technology in ways that positively impact patient care.[31] The program also provides payments to eligible hospitals and critical access hospitals meeting criteria for meaningful use of EHR technology.[31] The program does not make funds directly available to practitioners for purchase of an EHR, but instead provides incentive payments if specified requirements are met. Incentive programs exist for both Medicare and Medicaid, with non-overlapping requirements for each and differential eligibility criteria for participation.[32, 33] (See Table 57.1.) Although certain providers may be eligible for participation in both programs, providers must select and participate in only one. Hospital-based professionals providing greater than 90% of services in the inpatient setting are not eligible for either program. The maximum cumulative EHR incentive payments available to first-year participating providers is greater for Medicaid ($63,750); the maximum amount available to Medicare participants has gradually decreased from $44,000 for participating providers who began in 2011, the first implementation year, to $24,000 for providers initiating in the last incentivized year, 2014. Penalties will begin in 2015 for eligible Medicare providers who choose not to participate.[32]
