1. THE HEALTHCARE QUALITY IMPROVEMENT IMPERATIVE Kenneth W. Kizer, M.D., M.P.H. President and CEO National Quality Forum April 28, 2005 ©

2. Presentation 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?

3. THE QUEST FOR HEALTHCARE QUALITY IMPROVEMENT IS NOT NEW

4. “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 Quality

5. “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 Quality

6. “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)

7. TODAY’S UNPRECEDENTED ATTENTION TO HEALTHCARE QUALITY IS BEING DRIVEN BY 5 INTERRELATED FORCES

8. Healthcare Quality Improvement Driving Forces 1. Knowledge of deficiencies 2. Rising healthcare expenditures 3. Purchaser activism 4. Consumerism 5. Regulation and accreditation

9. 1998 – A Watershed Year for 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

10. IOM National Roundtable on 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

11. What is the Quality Gap? What is the Quality Gap? The quality gap, or the need for quality improvement, is the difference between what is scientifically sound and possible and the actual practice and delivery of health services. The quality gap, or the need for quality improvement, is the difference between what is scientifically sound and possible and the actual practice and delivery of health services.

12. The Four Parts of the Quality Gap  Overuse  Underuse  Misuse/errors  Waste

13. IOM Committee on Quality of Health Care in 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

14. Healthcare Quality Improvement Driving Forces 1. Knowledge of deficiencies 2. Rising healthcare expenditures 3. Purchaser activism 4. Consumerism 5. Regulation and accreditation

15. U.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

16. Health Insurance Premiums General Inflation Costs 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

17. Why are Healthcare Costs 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 services 5. Legislated healthcare service mandates 6. Consolidation of healthcare providers 7. Rising liability insurance costs 8. Excessive or inappropriate demand 9. Restriction of managed care practices 10. Widely variable medical practice *not priority ranked

18. Healthcare Quality Improvement Driving Forces 1. Knowledge of deficiencies 2. Rising healthcare expenditures 3. Purchaser activism 4. Consumerism 5. Regulation and accreditation

19. Purchaser Activism Has Resulted From Purchaser Activism Has Resulted From  Rising health care 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

20. Some Manifestations of Purchaser Activism Some Manifestations of 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

21. THE COST OF POOR QUALITY* THE COST OF POOR 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

22. Healthcare Costs and Quality Improved processes of care generally produce:  Better health outcomes  More satisfied patients  More satisfied caregivers  Reduced cost But the payment system neither rewards nor provides incentives for improvement

23. Healthcare Payment Reform Goals 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)

24. Healthcare Quality Improvement Driving Forces 1. Knowledge of deficiencies 2. Rising healthcare expenditures 3. Purchaser activism 4. Consumerism 5. Regulation and accreditation

25. What is “healthcare consumerism”? …the collective demand for more responsive care and service by a growing mass of educated and empowered consumers

26. The 5 C’s of Consumerism  Choice  Convenience  Comfort  Control  Collaboration

27. Reasons for Healthcare Consumerism  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

28. Healthcare Quality Improvement Driving Forces 1. Knowledge of deficiencies 2. Rising healthcare expenditures 3. Purchaser activism 4. Consumerism 5. Regulation and accreditation

29. Regulation and Accreditation 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

30. WHO ARE THE “MAJOR PLAYERS” IN QUALITY IMPROVEMENT?

31. The Alphabet Soup of QI-Related Organizations JCAHO NCQA IOM CMS AHRQ FDA IHI CDC QIOs QUIC GAO OIG OPM NBCH PCPI Leapfrog MedPAC FACCT NQF PBGH NBCH WBGHCPDG MBGH

32. Lots of Signals….. BUT Little Direction Lots of Signals….. BUT Little Direction

33. We Are Concerned About the Confusion and Waste that Results From Multiple Initiatives Institute of Medicine UHC Clinical Profiles

34. There is great need for a single national entity to be the lead steward for healthcare quality improvement.

35. The NATIONAL QUALITY FORUM (NQF)

36. WHAT IS THE NQF? The National Quality Forum is a private, non-profit voluntary consensus standards setting organization.

37. Voluntary Consensus Standards  Widely used in non-healthcare industries  Developed collaboratively by industry stakeholders  Have legal status  Must abide by requirements specified in federal law

38. NQF 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)

39. 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.

40. 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 NQF?

41. 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.

42. SO, WHAT ARE THE IMPLICATIONS FOR LABORATORY MEDICINE?

43. Healthcare – 2013 1. Annual healthcare expenditures exceed $3.4 trillion per year (18.4% GNP) 2. Performance measurement and public reporting of performance are the norm 3. “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

44. Implications for Laboratory 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

45. Implications for Laboratory 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

46. Implications for Laboratory Medicine  Quality improvement should be laboratory medicine’s essential business strategy. Need standardized performance metrics for quality, service and efficiency