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by Dr. William L. Roper


A growing revolution is working its way through U.S. health care systems. It's a revolution in the quality of care that consumers receive, and it's driven by people just like you. To be sure, many people in academia, as well as organizational managers and leaders in health care practice, are working hard in this area. They're doing the research, creating measures and implementing policies to help improve the quality of care in our health care system. This shift offers a chance for consumers and patients to really take control of their care and make the choices that will get them the best quality available. A number of tools are now available to help consumers identify what constitutes good--or not-so-good--care, and make it easier to voice their opinions. Increasingly, consumers will be able to voice their desire for the best possible care by choosing to frequent only those providers who meet their quality standards.

Are we there yet? Does the average consumer understand the meaning of infection rates or surgery success rates? Is the information about these complicated issues easily accessible and usable? No. We still have a lot of work to do, but the movement has begun. This article offers a summary of the kind of information that's available and necessary to make informed choices about health care quality. It's not a comprehensive list, but if we know what we need, we can push for it to be produced.

The roots of the health care quality movement
The movement toward measuring and improving the quality of health care has been building for more than two decades. I've been involved in the process almost from its inception, and I'm happy to report that we're making steady progress. Although consumers aren't the ones making diagnoses and holding scalpels, they'll ultimately determine the quality of their health care. Individuals really carry the movement forward.

I started my career as a public health director in Jefferson County, Alabama. One of my major concerns involved the sanitation standards of the restaurants we inspected. In driving quality improvements, we were one of the first health departments to publish restaurant sanitation ratings in the local newspaper. Once consumers became educated on the process and aware of the quality grades of these restaurants, owners began calling the health department for assistance in improving their grades. Although some will contend that health care is different, the same consumer pressure applies and, most important, drives improvement.

Later I was the administrator for the Health Care Financing Administration, the agency that administered Medicare and Medicaid. Today it's known as the Centers for Medicare and Medicaid Serv-ices (CMS). During my tenure there, we decided to publish mortality rates of Medicare beneficiaries at hospitals. We used a complicated statistical approach to adjust the rates and make sure that hospitals weren't unfairly penalized for taking care of sicker patients, and therefore having higher mortality rates. The rates were first published in 1986. At that time, the idea of quality and measuring how well doctors and hospitals were caring for people just wasn't in the common parlance, and publishing those rates made some hospitals administrators quite angry. Some of them had valid points about problems with our methods and approach; in the end, we all learned a great deal and began a dialogue and a movement about measuring quality that continues today.

At the beginning of the health care quality movement, we weren't even really sure what quality meant. A few scientists started noticing that rates of good outcomes really differed for given treatments across the country, and that there wasn't always a large amount of strong scientific evidence on the benefit of some common treatments. In 1988, we launched the HCFA Effectiveness Initiative, the premise of which was that quality of care should be a unifying condition in all health care. The first Bush administration embraced that initiative, and it became an important program in the government's Health and Human Services department. Then legislation was passed that created the Agency for Health Care Policy and Research, now called the Agency for Healthcare Research and Quality.

Defining quality for consumers
Throughout the following 10 years, a number of important studies were conducted, roundtables convened and reports produced. Many of them involved both the AHCPR and the Institute of Medicine in an attempt to put the brightest and most innovative thinkers on the task of ensuring quality care.

An early step was to define quality for consumers. One early definition was that quality care is the "degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are current with professional knowledge." During the next few years, this definition was refined and operationalized; the Institute of Medicine described quality care as patient-centered, timely, efficient, effective, safe and equitable, as well as coordinated, compassionate and innovative. The last term is important because medicine must continue to innovate if we intend to improve the quality of medical care in the United States. Ultimately, it means not underutilizing care that could help people, not using the wrong kind of care and not overusing care that isn't necessary. It's with regard to these basic points that consumers can demand effective action and change where necessary.

Consumers should call on health care systems to provide the information they need to make confident decisions in choosing a physician, hospital or course of treatment. They must insist that health care providers measure and report how well they do their jobs. Information about how well health care meets accepted standards must be presented to consumers in an understandable and actionable way. This is actually a bit more complicated than it sounds. After all, what does it really mean to provide quality care? What sort of questions should consumers ask to determine if they're getting good care? It can be difficult to ask physicians to provide evidence of the quality of the care they provide before they perform surgery or supervise the care for a patient with a chronic illness. The good news is that information exists that can help you.

The AHRQ has produced a booklet called "Guide to Health Care Quality: How to Know It When You See It," which is available online at www.ahrq.gov/consumer/guidetoq/guidetoq.pdf. It emphasizes that the most important element for consumers is to take charge of their own health care. Whether you're well and receiving preventive care, or addressing an illness or health challenge, you're part of the team that's caring for your health. That means making sure you understand your health situation by asking questions and communicating fully with your health care provider. Making certain that your health care provider knows what's going on with you will also help ensure that you get the right services at the right time ¾thus avoiding the underuse, misuse and overuse described above. Of course, these measures assume that you have chosen a high-quality provider.

What kind of information can help you make that choice? Increasingly, quality report cards are becoming part of the normal business of health care. Recently, HHS began publishing information on hospital care that consumers can use in selecting which hospital to go to for certain kinds of care. You'll find this tool online at www.hospitalcompare.hhs.gov. If your concern is nursing home care, CMS publishes detailed quality information at www.medicare.gov/nhcompare/home.asp. Your job as a consumer is to gather and use this information. In turn, many of us believe that market forces represented by the choices we make will encourage all health care providers to improve their quality, thus ensuring that they meet accepted standards and receive good ratings.

The rise of health savings accounts
Many individual consumers are making more health care decisions on their own--a change fueled by the rapid growth of health savings accounts (HSA). About 17 million people now have an HSA or a traditional flexible spending account (FSA), and this number is expected to exceed 29 million within five years. The new HSAs are paired with high- deductible plans where consumers are responsible for paying a portion of their health care up front until they reach a certain deductible, which is a minimum of about $1,000. One of the ideas behind HSAs is that when consumers have to spend their own money, they'll do so carefully. They'll make sure they're not overusing unnecessary care, and they'll do the research to make sure that the care they're getting is of the highest quality. That should put some pressure on practitioners in the health care system to provide the best care. With millions of individual payers focusing on health care quality, we eventually will revolutionize our understanding and acceptance of the standard of care we receive.

Nonetheless, consumer knowledge about how to ensure high-quality care is low. One reason is that employers, insurers and government payers have been the de facto guardians of quality on behalf of the consumers they serve. It's time to apply the same commitment to driving quality improvements to educating consumers, who have the most at stake. The more consumers know about how health care quality is measured and what constitutes high-quality care, the more emphasis health care institutions will place on quality. Information and knowledge will ultimately fuel the consumer health care quality revolution.

In fact, some insurance companies that offer HSAs are also working to ensure that insured consumers have the quality information they need to make good choices. For example, Aetna now provides information on the cost, quality and efficiency of physicians in a number of its markets and encourages the insured to make use of the highest quality care through network programs. For more infor- mation, visit www.aetna.comnews/2006/pr_20060613.htm .

It's no easy task to define and measure quality, and it will take a consumer revolution to make continuous quality improvement one of the top priorities of all health care providers. However, the same consumer power that ensures that your next restaurant meal doesn't harm you can certainly become the driving force that motivates every health care provider to meet or exceed the high standards of care we all expect them to deliver.

About the author
Dr. William L. Roper, MD, MPH, is CEO of the University of North Carolina Health Care System, a former director of the Centers for Disease Control and Prevention, and administrator of the Health Care Finance Administration, now the Centers for Medicare and Medicaid Services. He's chairman of the National Quality Forum.