Quality of Care
Introduction - What Do We Mean by "Quality of Care"
Quality of care is becoming an increasingly important topic of discussion for researchers and policy advocates. However, its importance as an advocacy tool for obtaining and maintaining services is often less obvious. Such issues are integral to understanding who receives care, the promptness and appropriateness of care, and to understanding systemically the reasons why quality and access problems occur. A focus on quality allows beneficiaries and their advocates to participate in the development of appropriate monitoring and enforcement of quality standards. The Center for Medicare Advocacy focuses on quality not only to raise general consumer awareness of this important topic, but to highlight the use of this growing body of knowledge by advocates to secure and expand services. Racial and ethnic minority populations and the larger disabled community should pay particular attention to these issues because these groups tend to be less supported by the health care community.
The U.S. Institute of Medicine (IOM) defines ‘quality’ 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. What this really means is that each individual consumer should receive the best possible health care available every time services are needed. Health care providers should provide care that meets the needs of each individual patient, including the use of appropriate advances in medical technology. health care should also be non-discriminatory, providing the same quality of service regardless of race, ethnicity, age, sex or health status.
Issue & Concerns
In November 1999, the Institute of Medicine published “To Err is Human,” a groundbreaking study of the U.S. health care system. Their findings indicated that 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. (Institute of Medicine 1999) Since that time, multiple studies have been conducted on various issues and results have repeatedly substantiated the IOM’s claims.
Quality of care remains an area for improvement, despite the increased attention it has received in recent years. Though researchers and survey organizations have focused on safety and quality through public campaigns and quality measurement and reporting, largely of a voluntary nature, little has been done with this information to make changes that would improve quality.
Everyone, nonetheless, has the right to receive in a timely manner care that meets the highest standards for quality health care. It is important that consumers and advocates understand the right to high quality care, and move to assure that quality care becomes universal. The task becomes one of working to translate written standards into practiced norms of treatment and care, including establishing an environment or “culture” that promotes patient safety and care of the highest quality.
Resource Tip: Make sure you are getting safe, quality care. See the Guide to Choosing Quality Care (http://www.jointcommission.org/topics/default.aspx?k=822&b=) from the Agency for Health Care Research and Quality and Speak UpTM from the Joint Commission on Accreditation of health care Organizations’ (JCAHO).
Update: Patient Safety Five Years After To Err Is Human (.pdf)
The "Quality Chasm" - Perception vs. Reality
Repeated studies have shown that substandard care persists in the United States. In a 2003 article published in the New England Journal of Medicine, the RAND Corporation found that “…On average, Americans receive about half of recommended medical care processes….the gap between what we know works and what is actually done is substantial enough to warrant attention.” (McGlynn, Elizabeth, et.al. 2003.) These ‘quality gaps’ are being persistently found as more and more organizations focus on this issue. Recent reports from the IOM produced these indicators:
- Only 55% of patients in a recent random sample of adults received recommended care, with little difference found between care recommended for prevention, to address acute episodes or to treat chronic conditions
- The lag between the discovery of more effective forms of treatment and their incorporation into routine patient care averages 17 years.
- 18,000 Americans die each year from heart attacks because they did not receive preventative medications, although they were eligible for them.
- Medical errors kill more people per year than breast cancer, AIDS, or motor vehicle accidents.
(Institute of Medicine 2003, http://content.nejm.org/cgi/content/full/348/26/2635)
Resource Tip: Take Action to Ensure that You get Quality Care with 20 Tips to Help Prevent Medical Errors from the Agency for health care Research and Quality.
Causes of Sub-Standard Care
The causes of sub-standard care can be broken down into two equally important parts:
- Structural factors in our health care system which result in poor quality care
- Structural factors in our society which result in poor care.
The first category can affect all Americans at random. The second disproportionately affects minority populations such as women, racial and ethnic minorities, elderly persons or disabled persons. Because these two causal categories impact quality of care so strongly, it is imperative that advocates be aware of the unique problems posed by each category as well as how to deal with them to create the best solutions.
America’s health care system, while among the best in the world, faces multiple systemic barriers to providing the best care possible to every patient. In its 2003 State of Health Care Quality Report, the National Committee for Quality Assurance cites six main factors that prevent many Americans from receiving the highest standards of care. They include:
- The slow pace with which new technology, information and guidelines are adopted by the health care industry.
- Current and historical lack of government incentives, standards, or direction.
- Inconsistent care by physicians and other health care professionals.
- Lack of widespread collaboration and information sharing among health care organizations.
- The failure of existing financing and reimbursement mechanisms to provide incentives for excellence.
- The failure of the health care system to measure and report on performance.
(National Committee for Quality Assurance 2003)
These problems are widespread and endemic to the health care system, and need to be addressed on a national level, as well as by each individual facility.
There are many people who do not receive quality care because of their race, ethnicity, gender, socio-economic status, age or health status. As evidenced in the current national debates over universal health care, not everyone has insurance, or access to health care. Beyond that, there are many specific groups that often find themselves unable to access the same quality of care as the general population. Some of these groups include: women, children, elderly, racial and ethnic minority groups, residents of rural areas, disabled or mentally handicapped persons, people in need of long-term-care, and others with special needs. In the 2003 National health care Disparities Report, the Agency for health care Research and Quality cite four factors that are key barriers to the provision of quality care. These include:
- Entry into the Health care system; the accessibility of care.
- Structural Barriers; the ease of navigating through the system to receive the best care.
- Patients’ Perceptions; cultural and socio-economic relationship problems between patients and providers.
- Utilization of care; accessing appropriate care at the appropriate time.
(Agency for health care Research and Quality 2003)
These factors result in sometimes severe disparities in the quality of health care provided to the general population and care received by minority populations. It is important for both consumers and advocates to be aware of the multiple factors causing such disparities of care, and to learn how to combat them.
Resource Tip: Learn what providers can do to avoid health care disparities in the Provider’s Guide to Quality and Culture.
The Beneficiary Quality of Care Complaint Process
What can a beneficiary do if he or she believes that the medical care that the doctor prescribed was inadequate or incorrect in some way? In Medicare, beneficiaries may request a “quality of care review” and question the level or kind of services provided by their practitioner or provider.
The Centers for Medicare & Medicaid Services (CMS) oversees the Quality Improvement Organization (QIO) program, which is responsible for working with both providers and beneficiaries to improve the quality of health care delivered to Medicare beneficiaries. The program is a network of 43 contractors – some for-profit, most not-for-profit – with each one representing one or more of the 50 states, the District of Columbia, Puerto Rico, and the Virgin Islands.
As part of its overall mission to improve the quality of health care for Medicare beneficiaries, the Social Security Act places the responsibility for investigating and resolving “quality of care” complaints from Medicare beneficiaries with the QIOs. A quality review is defined as “a review focused on determining whether the quality of the services meets professionally recognized standards of care.” Complaints triggering review can be about the quality of medical care, including concerns about the receipt of poor or inadequate treatment from health care workers, incorrect or inadequate medication, inappropriate or failed surgeries and procedures, or the premature discharge from a hospital.
Generally, beneficiary concerns about non-medical services that are ancillary to the care that they received are not considered to be reviewable by QIOs. For instance, during a hospital stay if a patient feels that he or she did not receive enough food or that the room temperature was uncomfortable, these issues are not considered to be “quality of care” complaints that the QIOs can review. Matters of this sort should be addressed through the health care provider’s grievance process.
The Business Case for Quality
Although the incentives to provide quality care seem obvious, for many looking at the profit margins, there is a need to make a ‘business case’ for quality improvement. Many health care providers, focused on the “bottom line” profit margin, fail to take measures to improve quality because the improvements will cost money. Indeed, many quality improvements, while they may have a positive impact on patients, provide only marginal savings or profits to the health care facilities themselves. Without proof that there are indeed economic incentives to improve quality, it is unlikely that the private sector will move with any speed towards adopting proven quality improvements. (Leatherman, Shelia, et. al.,”The Business Case for Quality: Case Studies and an Analysis” Health Affairs, Vol 22, No. 2, March/April 2003, p. 18.) This lack of economic impetus provides a strong case for a working federal regulatory system that would ensure compliance with quality standards regardless of the economic consequences to the facility.
The structure of payment systems is one of the largest factors affecting the business case for quality. In many cases, because of the way our insurance system is structured, payment is unrelated to quality of care and consumers have little or no choice of health care providers. As many Americans rely on health benefits received from their employers, their choices of plans and providers are limited to those covered in the employer’s plan. Similarly, the cost of medical procedures or care is determined independently between the employer’s plan and the health care provider before care is ever received. The payment is completely independent of the quality of care given. Therefore, care providers have no incentive to provide quality care; the consumer cannot leave to choose another care giver, and cannot refuse to pay for bad care.
According to a study by the Agency for health care Research, “almost half (45%) of respondents with employer-based coverage say they are offered only one health plan through their work, leaving them with no selection of plans to compare and, understandably, less interested in comparative information.” (“Americans as Health Care Consumers: The Role of Quality Information,” 1/26/2003 www.ahrq.gov/qual/kffhigh.htm) There is a great need to change the system to both educate consumers to be sensitive to changes in quality of service, and to align payment with quality of care provided.
Insurance companies, large corporations providing health benefits to their employees, Medicare, and other health care purchasers are looking to improve the quality of health care and control costs by changing the way they pay for health care – paying doctors, hospitals, and other providers more for high quality care, and less for poor quality care. This approach is often called pay-for-performance or value-based purchasing and is gaining widespread popularity among private and public payers, despite the fact that no systematic study of the effectiveness of such programs exists. Varying payment based on quality is an attempt to address the persistent and well documented “quality chasm” in our health care system, but details of the efficacy of such programs require further study.
While care quality, unfortunately, varies by location, population, and procedure, the United States nevertheless spends unprecedented amounts on health care regardless of quality or consistency. Most payment systems today reimburse hospitals, doctors, and other providers based on the quantity of services, with little review of appropriateness or whether the procedure resulted in the desired outcomes. Many believe that this system is one of the primary contributors to skyrocketing health care costs. In 2003, $1.7 trillion was spent on health care, representing 15.3% of Gross Domestic Product and a near 150% increase in spending since 1990. This disconnect between the cost of care and the quality of that care has moved both private and public health care purchasers to leverage their position as payers to force providers to make quality improvements. At present, programs tend tooffer annual reward or bonus payments on top of the provider’s regular income, representing an increase of up to 5%, to those who simply report quality data. In the future, these programs will condition payment on quality improvement and achievement.
Pay-for-performance is designed to respond to criticisms of the current payment structure, which rewards providers based on the quantity of services provided, regardless of quality. In the current system, a provider who makes investments in quality, resulting in fewer visits with the patient, for example, will save the health care system money. Yet the provider will actually lose income because he or she is providing fewer actual services. Pay-for-performance, proponents argue, would correct this disincentive by passing on a portion of those savings realized from higher quality care to the providers who help implement quality improvementMeasuring quality as a function of quantity of services delivered however, whether it involves more and fewer services, is not in isolation a measure of quality. Other factors such as the appropriateness of care and the patient’s preferences must be considered to make such a system practicable and reliable.
While large employers and purchasers across the country move to incorporate pay-for-performance into their payment structures, Medicare and Medicaid are forging ahead with demonstration projects. Whether an experimental program or a full-fledged reimbursement structure, the evaluation of pay-for-performance as a quality assurance tool should consider:
1. Available and agreed upon standardized quality data: Most pay-for-performance programs seek to measure quality through standardized clinical measures. Measures might rate, for example, whether a heart-attack patient received beta-blockers upon release from the hospital. Payers such as Medicare decide which quality measures facilities and physicians must follow in order to receive bonus payments. Providers who wish to receive bonus payments must collect and report data that show how well they performed on those measures.
Though pay-for-performance may seem straightforward, complexities arise when deciding precisely how to measure quality. There are quality measures upon which there is agreement in the medical community, yet there are an equal number, if not more, upon which there is much uncertainty. Uncertainty may arise when there is not enough research, when research results require interpretation, or when there are multiple, equally effective treatment options available. In addition, there is no single clearinghouse for the development of quality measurements on which bonuses are based. Purchasers are therefore permitted to select quality measurements of their choosing. Indeed, there is much variation in the sets of quality measurements purchasers use for performance incentive programs, and in the way it is presented and explained. One purchaser may, for instance, require hospitals to report on whether they followed recommended guidelines for the treatment of a heart attack patient, while another may provide bonuses to hospitals that implement computerized patient records.
It is also important to remember that medicine evolves. The scientific community is constantly discovering new treatments and refining old guidelines. What is considered “good medicine” today may be improved upon, or conversely considered inappropriate or harmful, tomorrow. A study published in the New England Journal of Medicine highlights this issue in relation to guidelines for cardiac care. The study revealed that while guidelines recommend giving beta blockers to patients at high risk for heart complications who are entering into non-cardiac surgery, hospitals often give them to cardiac patients at low risk as well. A review of patient records revealed that this practice actually increased the risk of mortality for low risk patients by 43 percent. While most pay-for-performance programs rely only on the most accepted evidence-based measures, it is important to note that even trusted standards may need adjustment. Any viable pay-for-performance program must allow for such contingencies while maintaining consistent program principles and guidelines.
2. Evaluating and weighing self-reported quality data: No national quality reporting system currently exists for many categories of health care providers. Pay-for-performance therefore relies on providers to record and submit their own data. By making payment contingent on “good” data, providers may be inclined to inflate their numbers in order to receive payment. Further, to assure quality improvement, Medicare’s Quality Improvement Organizations (QIOs) are charged with helping hospitals implement pay-for-performance. Indeed, payment to the QIOs is contingent on their getting hospitals to achieve higher quality for particular indicators. This duplicate system is not only costly (QIOs have a budget of over $1 billion over three years, while Medicare is setting aside $21 million over three years for bonuses in its Premier, Inc. demonstration project), it also provides perverse incentives to both the providers and to the agencies responsible for oversight to game the system in order to receive bonuses.
3. The incentive to “score well” limits patient access to care: Pay-for-performance programs may provide perverse incentives for providers to limit access patients have to needed care. When performance measures are not adequate or do not exist for particular conditions, providers may be hesitant to accept patients with those conditions for fear of unfairly lowering their quality score. This problem was highlighted in a study published in the Journal of the American Medical Association, which reported the inadequacy of certain clinical practice guidelines, especially when used for performance measurement purposes, for patients with multiple chronic conditions. The study concluded that there would likely be adverse drug interactions and disease complications for persons with multiple chronic conditions if the guidelines for each specific condition were followed. In a pay-for-performance system, a doctor who recognizes the need to properly manage multiple conditions to avoid adverse reactions would not necessarily obtain high scores based on the clinical or performance guidelines. Such a system might therefore limit a provider’s willingness to accept certain patients. A separate study on skilled nursing facilities by the Inspector General shows that reimbursement rates indeed affect providers’ willingness to treat certain patients in a timely manner. In that report, the Inspector General concluded that patients whose conditions required expensive medications, treatments, or which were not adequately reimbursed experienced delays in accessing appropriate care. These studies underscore the danger in oversimplifying performance measurement, as well as the complexities that arise in developing a performance measurement or variable payment system that does not discriminate against patients based on payment issues or health status.
4. Developing an appropriate balance between cost-control or cost-containment and quality: Though initially promoted as a quality improvement tool, pay-for-performance is increasingly discussed as a tool for cost-containment. Many health care plans believe rising health care costs are the result of over-utilization. In their view, pay-for-performance provides an effective method to limit unnecessary services. Caution is appropriate however, as past experience has shown that access barriers such as co-payments also lower use of necessary services. Using pay-for-performance to lower utilization by limiting access is an inappropriate and potentially more expensive use of a quality improvement tool.
Tips for Advocates and Institutions
- Advocates may wish to work with local hospitals to implement a system-wide protocol for staff interaction with patients. The protocol might include some simple but meaningful steps that providers can take to promote dignity:
- Knock before entering a patient’s room and ask permission to enter;
- Give your name verbally and have it visibly displayed on your jacket in readable type;
- Before any procedure, ask for the patient’s consent. Explain what the procedure is, why you are performing it, and how it will feel.
- Inform patients any time their care plan is altered and explain the reasons behind the changes.
- Hospitals should have an appropriate redress mechanism to document patient grievances regarding inappropriate behavior from staff. This may involve a wider effort to document patient satisfaction, an aspect Medicare should incorporate into its conditions for reimbursement or its certification requirements. Such grievance procedures should include:
- The provision of information to patients about their right to report a grievance, including how to initiate the process;
- The ability to initiate a grievance without feeling intimidated or disparaged by facility staff;
- The ability to have the grievance recorded in the patient record by someone other than the staff member in question;
- The serious review of complaints by institution administrators, with the goal of amending or implementing protocols to improve patient satisfaction and dignity.
Tips for Patients
- Ask questions. It is okay to ask the doctor to repeat or explain information that is not clear. Ask the doctor to write instructions if you feel they are complicated or that you will forget them. The instructions should be legible and make sense to you.
- When possible, have a trusted family member or friend with you at all times who is willing to speak up and ask questions on your behalf.
- Ask to see physician orders for procedures being carried out by other staff. This duplicate process can make you feel more in control, and forces staff to review orders, which can reduce medical errors.
- Ask staff to explain the procedures they are performing, why they are performing them, how it will feel, and how long it will take.
These few steps can make a significant difference in a patient’s health care experience. Patient-provider communication is crucial at every step of the process, from entry into a facility to discharge, and through recovery. Some of the steps outlined will not only improve patient dignity, but will also help assure patient safety.
- Find the Quality Improvement Organization (QIO) covering the area in which the hospital is located – http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1144767874793
- Quality of care complaint form: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms10287.pdf.
- General Medicare information about quality of care complaints: http://www.medicare.gov/claims-and-appeals/file-a-complaint/complaints.html.
- Check out the accreditation status of health care facilities online at the JCHAO’s Quality Check site.
- Resource tip: The Agency for health care Research and Quality now has a website to help consumers choose the best health care provider for them. It can be found at www.ahrq.gov/consumer/qnt/.
- For a more in depth look into this issue, take a look at NCQA’s site on The Business Case for Quality.
- See the American Medical Association (www.ama-assn.org/ama/pub/category/14416.html#ama), the Johns Hopkins Outcomes Evaluations Program in conjunction with American Healthways “Outcomes-Based Compensations: Pay-for-Performance Design Principles” at http://www.healthleadersmedia.com/content/145150.pdf.
- Find out what others are doing that is working! Some statewide or regional organizations include: California’s Health Scope; The Texas Business Group on Health, and the Massachusetts Health Quality Partners.
- Resource sheets for some states are available at: http://www.informedpatientinstitute.org/media.php#tip.
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