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

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?

THE QUEST FOR

HEALTHCARE QUALITY IMPROVEMENT

IS NOT NEW

“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)

TODAY’S UNPRECEDENTED

ATTENTION TO HEALTHCARE

QUALITY IS BEING DRIVEN BY 5

INTERRELATED FORCES

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

The 5 C’s of ConsumerismThe 5 C’s of Consumerism

Choice Convenience Comfort Control Collaboration

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

Lots of Signals…..

BUT

Little Direction

Lots of Signals…..

BUT

Little Direction

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.

The The

NATIONAL QUALITY FORUMNATIONAL QUALITY FORUM

(NQF)(NQF)

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

Implications for Implications for Laboratory MedicineLaboratory Medicine

Quality improvement should be laboratory medicine’s essential business strategy. Need standardized

performance metrics for quality, service and efficiency