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THE HEALTHCARE THE HEALTHCARE QUALITY QUALITY
IMPROVEMENT IMPROVEMENT IMPERATIVEIMPERATIVE
Kenneth W. Kizer, M.D., M.P.H.President and CEO
National Quality Forum
April 28, 2005©
Presentation OverviewPresentation Overview
1) Why the increased interest in healthcare quality today? What is driving the quality improvement agenda?
2) The confusing array of QI-related organizations.
3) What is the National Quality Forum and what does it do?
4) What are some of the implications of all this for laboratory medicine?
“If a physician make a large incision with the operating knife and cure it,…, he shall receive ten shekels in money.
If a physician make a large incision with the operating knife, and kill him,…, his hands shall be cut off.”
Code of Hammurabi, 1870 BC
The Quest for Healthcare The Quest for Healthcare QualityQuality
“I would give great praise to the physician
whose mistakes are small for perfect
accuracy is seldom to be seen”
Hippocrates, ca 430 BC
The Quest for Healthcare The Quest for Healthcare QualityQuality
The Quest for Healthcare The Quest for Healthcare QualityQuality
“Grant me the courage to realize my daily mistakes so that
tomorrow I shall be able to see and understand in a better light what I could not comprehend in
the dim light of yesterday”
Maimonides (1135-1204)
Healthcare Quality Healthcare Quality Improvement Driving Improvement Driving
ForcesForces
1. Knowledge of deficiencies2. Rising healthcare
expenditures3. Purchaser activism 4. Consumerism5. Regulation and accreditation
1998 – A Watershed Year 1998 – A Watershed Year for QIfor QI
Quality First: Better Health Care for All Americans, President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry
The Milbank Quarterly, Vol 76 : #4 – esp paper by Schuster, McGlynn and Brook, “How Good is the Quality of Health Care in the United States” pp 517-63
IOM National Roundtable on Health Care Quality. “The Urgent Need to Improve Health Care Quality.” JAMA 1998: 280: 1000-1005
IOM National Roundtable IOM National Roundtable on Health Care Qualityon Health Care Quality
“…Serious and widespread quality problems exist throughout American medicine. These problems….occur in small and large communities alike, in all parts of the country, and with approximately equal frequency in managed care and fee-for-service systems of care. Very large numbers of Americans are harmed as a direct result….” JAMA 1998; 280:1000-
1005
What is the Quality What is the Quality Gap?Gap?
The The quality gapquality gap, or the , or the need for quality need for quality
improvement, is the improvement, is the difference between what is difference between what is
scientifically sound and scientifically sound and possible and the actual possible and the actual practice and delivery of practice and delivery of
health services.health services.
The Four Parts of the Quality The Four Parts of the Quality GapGap
OveruseUnderuseMisuse/errorsWaste
IOM Committee on IOM Committee on Quality of Health Care Quality of Health Care
in Americain America
“Quality problems are everywhere, affecting many patients. Between the health care we have and the care we could have lies not just a gap but a chasm.”
IOM: Crossing the Quality Chasm , 2001
Healthcare Quality Healthcare Quality Improvement Driving ForcesImprovement Driving Forces
1. Knowledge of deficiencies2. Rising healthcare
expenditures3. Purchaser activism 4. Consumerism5. Regulation and accreditation
U.S. Health Care CostsU.S. Health Care Costs
In 2003, total U.S. health care spending reached $1.7 trillion (14% GDP) and $5, 671 per capita
In 2013, total U.S. health care spending will reach $3.4 trillion (18.4% GDP)
1% population accounts for 27% health care spending; 10% for about 69%
15 conditions account for half the growth in health care spending
11.5%10.9%
9.2%
7.2%
4.3%
0.8%
13.0%
6.0%
8.0%
10.0%
12.0%
0.7%
-0.1%
3.2%3.2%3.2%2.8%
1.0%
1.9%1.9%2.3%
2.5%2.6%2.9%
4.1%4.4%
-2.0%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Health Insurance PremiumsGeneral Inflation
Costs Are On The RiseCosts Are On The Rise
Next Act!
Managed Care
Health Care Will Grow Far in Excess of CPI . . . Gap Leads to Payer Actions (Leapfrog Group 2003)
BBA
Why are Healthcare Costs Why are Healthcare Costs Rising?*Rising?*
1. Uncontrolled proliferation of technology
2. Population growth (esp elderly)3. Increasing chronic care needs 4. Direct to consumer marketing of
healthcare products and services5. Legislated healthcare service
mandates6. Consolidation of healthcare
providers7. Rising liability insurance costs8. Excessive or inappropriate
demand 9. Restriction of managed care
practices10.Widely variable medical practice*not priority ranked
Healthcare Quality Healthcare Quality Improvement Driving ForcesImprovement Driving Forces
1. Knowledge of deficiencies2. Rising healthcare
expenditures3. Purchaser activism 4. Consumerism5. Regulation and accreditation
Purchaser Activism Has Purchaser Activism Has Resulted From Resulted From
Rising health care costs Rising healthcare costs Rising healthcare costs Growing understanding that
health care quality can be: Accurately measured Routinely assessed Systematically improved
Recognition that overall health status is declining as health care costs are rising
Some Manifestations ofSome Manifestations ofPurchaser Activism Purchaser Activism
The Leapfrog Group Medicare –Hospital Quality Incentive
Demonstration Project Pittsburgh Regional Health Initiative Central Florida Employers Coalition Pacific Business Group on Health National Business Coalition on Health General Electric’s Bridges to
Excellence General Motors Performance
Incentives California’s Pay for Performance
Initiative
THE COST OF POOR THE COST OF POOR QUALITY*QUALITY*
Healthcare error rates are orders of magnitude higher than in other industries
Poor quality care accounts for 35-45% of healthcare expenditures ($585B in 2000)
Poor quality care costs employers about $2000 per covered employee/yr
*Midwest Business Group on Health & The Juran
Institute, 2002
Healthcare Costs and Healthcare Costs and QualityQuality
Improved processes of care generally produce:
Better health outcomesMore satisfied patientsMore satisfied caregiversReduced cost
But the payment system neither rewards nor provides incentives for improvement
Healthcare Payment Reform Healthcare Payment Reform GoalsGoals
1. Payment will provide incentives and rewards for higher quality/better value
2. Payment will provide incentives for process redesign resulting in better coordination and continuity of care
3. Payment will provide incentives for cost-effective care (including the cost-benefit of new technology)
Healthcare Quality Healthcare Quality Improvement Driving Forces Improvement Driving Forces
1. Knowledge of deficiencies2. Rising healthcare
expenditures3. Purchaser activism4. Consumerism5. Regulation and accreditation
What is “healthcare consumerism”?
…the collective demand for more responsive care and service by a growing
mass of educated and empowered consumers
Reasons for Healthcare Reasons for Healthcare ConsumerismConsumerism
Baby boom becomes elder boom Increased interest in healthcare
Increased longevity Increased chronic conditions Patient safety concerns
Population better educated Economic prosperity Cross-industry experience Greater availability of
information The Internet
Healthcare Quality Healthcare Quality Improvement Driving Forces Improvement Driving Forces
1. Knowledge of deficiencies2. Rising healthcare
expenditures3. Purchaser activism4. Consumerism5. Regulation and accreditation
Regulation and Regulation and AccreditationAccreditation
1. Quality Assurance and Performance Improvement programs made a CMS Condition of Participation
2. OIG and DOJ make quality of care a top priority under the False Claims Act
3. MedPAC recommends linking hospital payment to quality of care (2003) and “pay for performance” (2004)
4. State regulations (e.g., CA nurse-patient ratios)
5. JCAHO Patient Safety Goals
WHO ARE THE “MAJOR WHO ARE THE “MAJOR PLAYERS” IN QUALITY PLAYERS” IN QUALITY
IMPROVEMENT?IMPROVEMENT?
The Alphabet Soup of QI-Related Organizations
JCAHO NCQA IOMCMS AHRQ FDA IHI CDC QIOsQUIC GAO OIGOPM NBCH PCPILeapfrog MedPAC FACCT NQF PBGH NBCHWBGH CPDG MBGH
We Are Concerned About the Confusion and Waste that Results From Multiple Initiatives
Institute of Medicine
UHC Clinical Profiles
There is great need for a There is great need for a single national entity to be the single national entity to be the
lead steward for healthcare lead steward for healthcare quality improvement.quality improvement.
WHAT IS THE NQF?
The National Quality Forum is a private, non-profit voluntary consensus
standards setting organization.
Voluntary Consensus Voluntary Consensus StandardsStandards
Widely used in non-healthcare industries
Developed collaboratively by industry stakeholders
Have legal status Must abide by requirements
specified in federal law
NQF HISTORYNQF HISTORY
Presidential Advisory Commission on Consumer Protection and Quality in the Health Care Industry established (1996)
Commission recommended the creation of a private sector entity (“Quality Forum”) that would bring healthcare stakeholder sectors together to standardize health care performance measures and standards (1998)
Quality Forum Planning Committee convened by White House (1998)
NQF incorporated in District of Columbia (1999)
NQF operational (2000)
WHAT DOES THE NQF DO?
The NQF was established to improve the quality of U.S. health care by: standardizing health care performance
measurement and reporting; designing an overall strategy and
framework for a National Healthcare Quality Measurement and Reporting System;
serving as an “honest-broker” convener for quality-related matters; and
otherwise promoting, guiding and leading health care quality improvement.
NQF’s activities are a manifestation of the changing
societal views and expectations of healthcare – i.e., of the shift from
blind trust and acceptance to demanding transparency and
accountability, quality and safety, and partnership. The healthcare
provider who ignores this cultural upheaval will lose.
Why Should I Care About Why Should I Care About NQF?NQF?
Why Should I Care About Why Should I Care About NQF?NQF?
NQF-endorsed measures will be the basis of incentive and
reward payments and accountability
measurements that will affect provider selection by
consumers, health plans and hospitals.
SO, SO,
WHAT ARE THE WHAT ARE THE
IMPLICATIONS FOR IMPLICATIONS FOR
LABORATORY MEDICINE? LABORATORY MEDICINE?
Healthcare – 2013Healthcare – 20131. Annual healthcare expenditures exceed
$3.4 trillion per year (18.4% GNP)2. Performance measurement and public
reporting of performance are the norm3. “Value-based payment” is the norm 4. State-of-the-art information management
technology is a routine part of care delivery
5. Consumers and purchasers are intensely aware of and engaged on quality and cost
6. Large, organized systems of care (e.g., Integrated delivery systems) becoming the norm
Implications for Implications for Laboratory MedicineLaboratory Medicine
Laboratory medicine needs to be a fully integrated partner in healthcare today Laboratory and Pharmacy (and
Radiology) should be linked Should have automated systems for
follow up of abnormal results Must better understand the
epidemiology and effects of errors
Implications for Implications for Laboratory MedicineLaboratory Medicine
Greater attention has to be paid to quality improvement in the pre- and post-analytic phases of testing Must better understand the
frequency and effects of errors Need better feedback systems for
all personnel involved with lab testing
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