Marcia Guida James, MS, MBA; Margaret E. O’Kane, MPH; Peter Salgo, MD; and Jed Weissberg, MD
This module reviews “the quality enterprise”—what that term means, the key players, and the implications for healthcare reform.
The quality enterprise and healthcare reform are closely linked. Although there has long been interest in healthcare quality, the topic has now come to the forefront, as ever-increasing healthcare costs have outstripped inflation and wage growth. Although Americans pay more for healthcare, they do not receive better healthcare in return.
The current system is flawed. Greater specialization and complexity have led to inefficiencies—including lack of communication and information sharing across healthcare silos and settings, and avoidable medical errors—that potentially increase costs and may harm patients. The traditional fee-for-service (FFS) model incentivizes and rewards quantity of services rather than quality. Moreover, this flawed system must accommodate the impending surge of demand from the aging baby boomer population.
Clearly, fundamental reform is necessary. The FFS model must be supplanted by a value-based model that incentivizes and rewards quality. To that end, various reform efforts have been undertaken in the public and private sectors.
Once voluntary, quality improvement is now mandated under the Patient Protection and Affordable Care Act (PPACA). The PPACA imposes requirements and offers incentives for value-based approaches, interoperable electronic medical records (EMRs), health information technology (HIT), comparative effectiveness research (CER), and public reporting of quality measures. Quality improvement efforts will therefore accelerate under the PPACA.
The quality enterprise, which centers on defining, measuring, and rewarding quality care, plays an integral role in achieving the transition to value- and quality-based models.What Is Quality in Healthcare?
The panel considered how to define “quality” in healthcare.
IOM Definition of Quality
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
To define quality, Ms O’Kane distills a simple question from the Institute of Medicine (IOM) definition: “Does an action, intervention, or treatment improve health?” Answering this question requires analysis and measurement, because under the PPACA the question will become: “If something improves health, are you doing it? If it does not, why are you doing it?”
Consumers typically perceive quality differently. They focus on getting better, rather than the process of getting better. “Sick patients want to go to the doctor or the hospital and get better,” said Dr Salgo.What Is the Quality Enterprise?
Consumers may focus on getting better, but getting better (an outcome) is intertwined with the process of getting better. “Outcomes depend on process,” said Ms James. Exploring the “process” can help to further define the quality enterprise.
The process of delivering good outcomes involves all stakeholders, and they must coordinate and collaborate. However, aligning multiple constituents with divergent definitions of quality and divergent goals presents a major obstacle to reform.Current Professional Knowledge: Demands and Challenges
The IOM’s principle of “current professional knowledge” fits squarely into the quality enterprise. It implies that the best medical science should be applied in practicing medicine and delivering healthcare.
This principle is also relevant to consumers. According to research, patients want to be guided toward quality by medical experts. Those experts therefore need access to the latest information about what works best, and must stay current.
Staying current is a daunting task. Medical information proliferates; journals publish thousands of reports each month. Consumers expect their doctors to absorb all of this information and explain it to them, and these demands have been folded into the definition of quality.
There are other “professional knowledge” impediments to quality. First, the reservoir of current knowledge, although substantial, is incomplete: for many conditions, consensus treatment standards do not exist. Second, the quality enterprise calls for collaboration, but each specialty tends to hoard its own knowledge.
The Quality Enterprise
“Quality enterprise” means the totality of the various inputs and constituents throughout the healthcare spectrum that are involved in delivering and improving evidence-based care. The quality enterprise embraces transparency and accountability to provide safe, effective, patient-centered care efficiently, equitably, and in a timely manner.
Players and Stakeholders
Patients/consumers and their families
Office and hospital executives and staff
Payers (public/private insurers)
Pharmacy benefit managers
Government policy makers, agencies, and regulators
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