Quality Medical Care
by Marjorie Lazoff, MD
Medical Computing Today
accepted for publication in Medical Computing Today September 1997
Originally published in edited form September 1997 in Medical Software Reviews.
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The two major agencies accrediting medical organizations, Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and National Committee for Quality Assurance (NCQA), now or will very soon require periodic outcome and performance measures as part of each facility's ongoing quality assessment program. Certainly it is unethical to keep these statistics private, even if a prerequisite for quality improvement programs, if these measures can help patients select the best health plans, hospitals, and physicians. But do we really know whether any measures relate to quality care? Do we know whether there is a meaningful relationship between measures and medical decision making? What is their relationship to biostatistics, or to the elegant statistical proofs upon which total quality management (TQM) principles are based? Sadly, does it even matter -- if, as physicians, we must nevertheless participate to maintain employment and hospital privileges, or to be acceptable to insurance plans and satisfy our patients, and if our hospitals and clinics must do the same to maintain their accreditation?
Several excellent online articles further explore many of the quality care (QA) issues raised in the introduction above. Donald Berwick, MD's Sounding Board from January 5, 1989's New England Journal of Medicine on Continuous Improvement As An Ideal In Health Care is a classic article explaining the philosophy and logistics behind QA. Well-respected quality care researchers wrote a six-part series,
Quality of Health Care published last fall in NEJM; scroll down to access all sections of Part I, then navigate through the rest of the series by returning to that issue's Table of Contents and advancing one by one through the next five issues. Correspondence in response to the series exposes the controversy and skepticism typically accompanying these discussions. Although the original JAMA article is not on line, there is an interesting letter and reply on Assessing Quality of Care: Process Measures vs. Outcome Measures. Arnold Epstein, MD, an early senior health advisor to President Clinton, wrote a 1995 NEJM Sounding Board explaining the prototypes, problems, and prospects of
Performance Reports on Quality. Finally, to learn more about applying TQM, a popular article from the early 1990s by A. Blanton Godfrey and Donald Berwick, MD, explains How Quality Management Really Works in Health Care.
Another excellent online resource is the October 15, 1997, Annals of Internal Medicine supplement on Measuring Quality, Outcomes, and Cost of Care Using Large Databases: The Sixth Regenstrief Conference. Although some history and theory is introduced, this series of articles is more practical and futuristic, and considers quality from the perspective of databases and electronic medical records, research, evidence based medicine, and medical administration.
HealthEconomics.com maintains a list of medical industry Questionnaires & Performance Assessments. Many are commercial products, but included here are government and educational sites as well. Also scan their list of government, educational, and commercial Consultants.
In May 1998 the three key accreditation organizations -- the American Medical Accreditation
Program (AMAP), the National Committee for Quality Assurance (NCQA), and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) -- established the Performance Measurement Coordinating Council (PMCC), a 15-member group whose goal, as stated in its Principles for Performance Measurement in Health Care, will facilitate cooperation among these agencies.
The AMA's American Medical Accreditation Program (AMAP) verifies the credentials, continuing medical education, and other quality activities to health care employers and managed care organizations, for its enrolled physicians. The online site, which includes an FAQ sheet and application information, has a marketing rather than clinical or academic feel.
NCQA is an independent, not-for-profit organization whose stated mission is to evaluate, report on, and accredit all U.S. managed care organizations. At present, almost 90 percent of all health insurance plans and eight states use its performance measurement tool, the Health Plan Employer Data and Information Set or HEDIS 3.0 to satisfy quality care requirements. For additional background, read Inglehart's 1996 report in NEJM on the National Committee for Quality Assurance.
NCQA's image map has a physician and administrator shaking hands amid the many disparate groups served by its Web site: government, health care organizations, employers and unions, consumers, health care providers, NCQA teams, and researchers. All these groups enter fundamentally the same NCQA database of status reports, articles about NCQA, and information on its conferences and products. Missing are any introductory articles explaining quality medical care for patients, physicians, or even health care administrators, aside from one quick article for consumers shopping for health plans. The Accreditation Status will return a list of local health plans by city and/or state, but avoid the search engine if checking the status of a specific plan and scan the list of available reports instead. This is limited information at best; the real database of comparative information, Quality Compass reports for 226 health plans, is available at a rather steep price. Articles regarding NCQA's background and goals are written from a consumer's perspective but are important reading for physicians and other health care professionals, as is the 1996 Annual Report, which discusses future plans and addresses several performance and outcome issues mentioned in the introduction. Other recommended resources: Overview of Accreditation '99 describes the draft of the new managed care accreditation standards. Visit News for articles and press releases on NCQA and its interactions with other organizations. NCQA is on the move.
NCQA's major rival is no slouch either. JCAHO is an independent, not-for-profit organization that evaluates and accredits more than 18,000 U.S. hospitals, networks, home care organizations, long term and behavioral health care facilities, laboratories, and ambulatory care services. ORYX is JCAHO's new quality initiative that will integrate the use of outcomes and other performance measures, such as JCAHO's Indicator Measurement System (IMSystem), into the accreditation process. To provide a continual source of approved indicators for performance measure systems, JCAHO is creating the National Library of Healthcare Indicators (NLHI), a catalog of indicators applicable to ongoing quality improvement efforts related to the accreditation of health care organizations. The first NLHI publication will include measures from AHCPR (presumably Conquest, below), NCQA, Northwestern University, Primary Care Outcomes Research Institute, and Kaiser Permanente, among others.
JCAHO's straightforward Web site is unchanged since the original review. It is a graphic menus-within-menus format with occasional frames. The main menu displays sections for news, information about the organization and its publications, educational conventions, and multimedia products for sale. The other sections contain interesting background but most physicians will want to click on Performance Measurement, the section housing information on Oryx, IMSystem, RFI (instructions for those who wish to place a Request For Indicators), and NLHI. Government Relations discusses JCAHO's relationship to HCFA and other government agencies, and concludes with a 1996 subcommittee testimony before the House of Representatives on accreditation standards for managed care organizations. (For a different perspective on the same topic, compare it with American College of Physicians president William Reynolds, MD's testimony to a Senate committee on Federal Initiatives on Quality of Care).
Elsewhere on the site, for a $295 entry fee accredited organizations may apply for the first Ernest A. Codman award honoring excellence in use of performance measures. As with NCQA, there is virtually nothing on the management philosophy, statistics, historical perspective, practical guidance, or documentation explaining or supporting quality assurance, quality indicators, or performance measures. However, JCAHO is offering free access to Resources, a biweekly annotated bibliography of recent articles from the top health management journals, divided into topics.
Several agencies within the Department of Health and Human Services (HHS) contain important and useful information regarding quality care. The Agency for Health Care Policy and Research (AHCPR) is best known for its Clinical Practice Guidelines, obviously relevant here. But look under Quality Assessment for the agency's clinical performance measures software Conquest (available as freeware on line), instructions for ordering free case studies and discussion papers on quality indictors, an overview of the multi-centered five-year Consumer Assessments of Health Plans Study (CAHPS) currently underway, the Foundation for Accountability Discussion Paper Abstracts, and sobering articles on consumer satisfaction and score (report) cards. Elsewhere on the site is a nice if somewhat off-topic introductory article by J. Michael Fitzmaurice, PhD, on Using Computers To Advance Health Care, which may be of interest to readers and their computer-resisting colleagues. Regardless of one's specialty or philosophic bent, AHCPR's Web site is filled with valuable clinical and administrative information.
HHS Health Care Financing Administration (HFCA) has an overview page HFCA Quality of Care Information describing their certifying and quality improvement initiatives.
The Rand Corporation has the largest private program on health policy research in the United States, and it generously shares its progress and results on line. Some of the best information on Quality of Care research is cited under the very extensive listing of publications from 1995 to present. These include online links to abstracts (rarely, to full-text articles), but most articles can be ordered free of charge.
Quality Measurement Advisory Service (QMAS)'s Web site contains several articles under Quality Measuring Tools, on organizing initiatives and measuring health care quality for value-based purchasing. QMAS, a group within The Foundation for Health Care Quality, is a not-for-profit organization established in 1996 to assist state and local health care coalitions, purchasing groups, and health information organizations in their efforts to measure health care quality for value-based purchasing and other purposes.
The National Institute of Standards and Technology's National Quality Program sponsors the Baldridge National Quality Award to inspire quality improvement efforts among U.S. businesses and organizations. For the first time, not-for-profit health organizations will be eligible to apply in 1999. Select the PDF version of the 1998 Baldridge criteria for important industry standards to consider when designing medical QA or CQI programs.
Online Resources, Education/Research, and Journals
The Association for Health Services Research (AHSR) is a national membership organization promoting health services research and networking among private, public, and educational institutions. Its database of more than 4,000 health services research grants, HSRProj, includes projects on quality care and can be accessed on line or through the National Library of Medicine.
Several universities are involved in medical quality care and research, but only Harvard School of Public Health's Center for Quality of Care Research and Education has a Web page describing its projects.
The International Society for Quality in Health Care is a networking resource covering more than 50 countries for its several hundred members; check out its Quality News for information and links from around the world. The site links to the tables of contents (no abstracts) for the past two years of its International Journal for Quality in Health Care. The electronic version of Clinical Performance and Quality Health Care has over a year's worth of abstracts, accessible by issue or via a technologically clever but functionally weak Java-script search engine covering all Slack publications on line.
Health professionals debate freely over the best way to collect, measure, and distribute process and/or outcomes data, but true skeptics question whether any of these data truly address quality issues. Some advocate a moratorium on data collection until validity and reliability can be demonstrated. Many of their cogent arguments are presented in the article references above, and as Criticisms of related topics as outlined by Carl Slater, MD.
Lists of Lists
Look under Web Resources/Quality Assurance and Improvement at University Research Corporation-Center for Human Services Web Site or Curious Cat Management Improvement Resource List for two excellent lists of general quality sites, particularly for those looking to learn the basics about TQM and its leaders Deming and Juran. Barber, Associates' The Healthcare Quality Assessment Page is an annotated listing of articles maintained as a public service.
Though not specific to quality assurance, Jay Brandes' Health Care Administration on the WWW is an excellent labor-of-love reference site.
QP-HEALTH E-mail Discussion List is open moderated for discussion of quality-related issues for professionals in health care.
The convenience, breadth, and timeliness of quality care information on the Web makes this a reasonably good resource for physicians. Areas of strength include the many online articles from major medical journals and respected quality care experts, and several government and private sector Web sites describing past and present research in quality care. Not mentioned in this review are the numerous sites describing outcomes research and evidence-based medicine, much of which is relevant to quality care. I wish there were better online dialog between the proponents and detractors of the various methods of quality assessment.
In updating this article, aside from a brief explanation of the QA framework structure-process-outcome, I was still unable to locate articles or information teaching the basic concepts behind quality care for medical students and physicians, most of whom are unfamiliar with this important topic; even a simple Java-script program with minimal multimedia would be a wonderful resource. Also, I could not find instructions or interactivity for physician-administrators looking to design their own meaningful QA/CQI or outcomes research, either conceptually or with the use of computers, other than the consultant-laden mailing list mentioned above. Basic and practical resources, and multiuser interactivity are areas in which the Web typically excels, so their absence in connection with quality care is especially compelling.
Paradoxically, Web users must venture beyond NCQA and JCAHO to locate substantive information about quality care. Both organizations are positioned as this nation's premier quality care watchdogs, yet both sites contain an alphabet soup of confusing organizations and measures, seemingly duplicate each other's efforts, and offer mostly superficial reflection and self promotion. Providing a reference library of core quality care information to educate practicing physicians, and better resources to help others understand the limits of measures, should not take away from their consulting or publication profits. The status of JCAHO and NCQA as "voluntary" accreditation and independent not-for-profit organizations belies their interrelationship with major industry and government organizations and their tremendous impact on U.S. health care. Free access to quality resources would be a relatively inexpensive way to pay back the medical community.
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