If the third time is a charm, the Institute of Medicine's new report on healthcare quality will move the industry closer to a quality nirvana that until now has been elusive.
The IOM, a private group that advises Congress on medical issues, last week called on the federal government to "take the lead" in improving the quality of healthcare, arguing in its third and latest treatise on the topic that only the nation's largest provider and payer has what it takes to build a safer environment for patients.
"We will make much more progress in our efforts to improve quality if we make comparative quality information available to everyone," Gilbert Omenn, M.D., chair of the IOM Committee on Enhancing Federal Healthcare Quality Programs and professor of internal medicine at the University of Michigan, said last week when he and other researchers presented their report at the National Academies in Washington, the IOM's parent organization.
The IOM report could fuel ongoing quality initiatives such as those led by the Leapfrog Group and the Joint Commission on Accreditation of Healthcare Organizations, although exactly how the various efforts would gel has yet to be determined. Many government and industry sources agreed a national plan to address quality is likely to bode well for efforts already under way.
Characterizing the healthcare industry's current efforts to measure quality as "fragmented," the IOM said the six federal programs that provide care to some 100 million beneficiaries should standardize their performance-measurement efforts and financially reward organizations that improve quality.
If the highly anticipated IOM report ripples through Congress, federal agencies and the provider community, it could build critical momentum to help reduce medical errors and improve clinical outcomes-perhaps even take patient safety to the top of the national healthcare agenda. Alternatively the report could generate more of the uncoordinated pockets of innovation that have followed the two earlier reports (See chart).
In the new environment the IOM envisions, consumers would play a more active role in ensuring the quality of the care they receive, and healthcare organizations with strong patient-safety records would serve as role models for their peers. All the stakeholders-including government programs, hospitals and insurers-would share clinical outcomes information, and congressional proposals to create quality-reporting systems would get a boost.
Meanwhile the federal government would reward hospitals and physicians for quality strides, while Medicare, Medicaid, the Veterans Health Administration and others work with accrediting groups and quality organizations to streamline improvement efforts.
"A real opportunity exists at the federal level. ... If all these programs could be pulled together around a common set of performance expectations and measurement systems, it could be incredibly powerful," said Bruce Bullen, senior vice president and chief operating officer of Wellesley, Mass.-based Harvard Pilgrim Health Care and a member of the IOM committee.
Creating a quality utopia, however, will require significant cooperation-as well as funding-from Congress and the Centers for Medicare and Medicaid Services. Hospitals may be required to invest significant sums of money in information systems at a time when they're pleading for relief to offset routine reimbursement shortfalls. While some industry sources were confident of the prospects for government-driven quality improvement, others think the IOM's vision could still take years to realize, if it's possible at all.
Since the publication of IOM's first quality report in 1999, which said as many as 98,000 people die each year from medical errors, "you've seen some payers rise to the occasion, but we haven't seen anything happen nationally, which has been frustrating. What do we have to do, plaster this on the wall?" said Jack Cox, M.D., senior vice president and chief medical officer of the San Diego-based Premier hospital alliance, which has more than 1,500 hospital members.
"If we had better data, we could do a much better job of measuring and improving what's most important," said Carolyn Clancy, M.D., acting director of the Agency for Healthcare Research and Quality, HHS' health services research arm.
Even IOM committee members acknowledged the challenge, saying current quality activities aren't going anywhere and that a fresh approach requires unprecedented collaboration among government agencies, the creation of new public/private partnerships and funding from Congress. While Congress' appetite for handing out new money may be curbed by other healthcare and national priorities, the lead IOM researcher said the resources are available but need to be used more effectively.
"Two-hundred forty million dollars a year go to (Medicare's) quality-improvement organizations," Omenn said. "In a field where they say there's not much money to do anything about quality, there's a whole lot being spent."
Initially charged with identifying quality problems among Medicare providers and taking corrective action, the QIOs since have moved into a more proactive and evidence-based approach to measuring performance, according to the IOM report.
Industry sources said consistent performance measures would help hospitals know what clinical information to collect, where to collect it and how to use it to improve quality.
Hospitals' ability to do that depends in large part on how effectively one provider can compare itself to another, said Jeff Prescott, a spokesman for HCA, the Nashville-based for-profit, echoing the sentiment of many other providers.
In its report the IOM proposed that the Quality Interagency Coordination Task Force promulgate standard performance measures for 15 leading health conditions in 2003 and 2004. The 4-year-old task force is charged with coordinating the activities of federal agencies that regulate, provide and study healthcare services.
If the IOM's recommendations are implemented, providers that participate in federal programs would be required to submit audited patient-level performance data on those conditions by 2007. Quality-improvement organizations might be tapped to handle the auditing responsibilities, according to IOM committee members.
In fiscal 2008, each of the six government health programs then would publicly release comparative quality reports for the 15 conditions. Although the IOM has yet to identify the conditions for measurement, they might include asthma, depression, diabetes or stroke.
"The committee realizes this is an ambitious agenda," the IOM report said. "It does not, however, represent a radical departure from the status quo."
Not everyone agreed. "It would take some major revamping to tweak to a new standard," said Everett Jones, M.D., a director in the Veterans Health Administration's Office of Quality Performance. For instance, Jones said, hospitals and other providers have many ways of describing a given treatment or procedure, and establishing common naming conventions alone can be a daunting challenge.
Others were concerned with the time and resource commitment. "If they want us to improve in 17 different disease areas at one time, I don't see the resources being there," said Michele Kearney, senior director of health information services at 210-bed Columbus Hospital in Newark, N.J., which last week won an award from the Peer Review Organization of New Jersey for the success of recent quality- improvement projects.
As it did in its second quality report, the IOM said robust information systems that can exchange data with other players in the industry are a critical piece of the puzzle.
Perhaps some money will help. In its report the IOM argued for tying reimbursement to quality, saying such a step must be taken for hospitals and other providers to move en masse toward standard performance measurement.
Although the report suggested possibilities such as bonuses and increased payments, "we don't know how best to do this," Janet Corrigan, director of the IOM's Board on Health Care Services, said last week at the National Academies.
However quality bonuses might be structured, many sources said implementing the IOM's pay-for-quality proposal would bolster other efforts already under way. CMS Administrator Thomas Scully, for instance, told Modern Healthcare in September that the CMS is working toward a system that would ultimately link hospital payments to quality of care.
Several observers agreed the IOM's report could boost government and private efforts to improve quality with financial incentives.
Medical-error reporting bills now circulating through Congress also stand to benefit from the IOM's recommendations. "I think (the IOM report) will give momentum to error reporting bills," said Omenn, who met last week with congressional aides and Bush administration officials after his presentation of the IOM report.
If Congress is productive during its upcoming lame-duck session, it could pass measures including one sponsored by Rep. Nancy Johnson (R-Conn.) that would implement a national, voluntary medical-error reporting system.
The JCAHO said it supports the framework laid out by the IOM, and that carrying out the report's action plan would have no major effect on the accrediting process.
The JCAHO is most concerned about ensuring that the necessary information technology is in place. That could take more time, especially for the 1,000 or so hospitals not currently accredited by an organization that requires performance measurement, said Margaret VanAmringe, the JCAHO's vice president of external relations.
Lawmakers' growing focus on bioterrorism preparedness could help hospitals get the funds they need to acquire information technology that can simultaneously help prepare for disasters and improve overall quality, said Elizabeth McGlynn, associate director of Rand Health in Santa Monica, Calif., and an IOM committee member.
"Providers should be encouraged by this report; it emphasizes standardization, flexibility and consistency across programs," said Sam Ho, M.D., senior vice president and chief medical officer of PacifiCare Health Systems in Cypress, Calif., and an IOM committee member. "Any radical change is going to require patience. ... Change takes time."