The recent release of the third in a series of Institute of Medicine reports on the quality of healthcare in the U.S. prompts the question: Will the sustained focus of the IOM produce measurable quality improvement in the healthcare system?
My answer is yes, that these reports have not only stimulated public debate on medical errors and healthcare quality but also spawned an array of national and regional efforts to measure and address the patient-safety problem. Governments, foundations, health plans, purchasing coalitions and provider systems have initiated programs and joint ventures designed to better protect patients.
The first two highly publicized IOM studies (1999's To Err is Human: Building a Safer Health System and 2001's Crossing the Quality Chasm: A New Health System for the 21st Century) sought to create a context for change; the first by identifying patient safety as a national problem and the second by providing both a diagnosis and the conceptual framework for a cure. Now a third report calls on the federal government to take the lead in promoting focused, measurable quality improvement in its own programs and throughout the broader marketplace-where the rubber meets the road, so to speak.
Already, the Quality Interagency Coordination Task Force, created to foster collaboration across federal HHS agencies, has recommended numerous patient-safety improvements, many of which have been implemented. Congress gave the Agency for Healthcare Research and Quality $50 million to fund safety-related programs.
The private sector is also responding to the IOM's call to action. The Robert Wood Johnson Foundation initiated two major grant programs: the Pursuing Perfection initiative with the Institute for Healthcare Improvement, which focused on model process redesign to improve quality, and the Rewarding Results program to promote quality-based performance contracting between health plans and provider systems.
The Leapfrog Group effort is a well-publicized example of a large-scale marketplace initiative on patient safety, but many regional activities also have begun to appear that haven't drawn the same kind of attention. These include e-prescribing collaborations between health plans and provider systems, health plan products in which providers are tiered according to relative quality of care provided and the transformation of traditional risk-sharing arrangements between health plans and physician/hospital groups into performance contracts that tie reimbursement directly to quality improvement.
The second IOM study identified six attributes of quality care (safe, effective, patient-centered, timely, efficient and equitable) and described the gap that exists between current practice and achievement of each category. It called on the federal government to pull together a fragmented healthcare delivery system and highlighted the critical role of technology in bringing about a paperless system through which quality might be measured and promoted more effectively.
Organizations such as the National Committee for Quality Assurance, the Joint Commission on Accreditation of Healthcare Organizations and the Foundation for Accountability are all employing standardized quality measures in their spheres of influence. And the efforts of HHS' Quality Interagency Coordination Task Force to coordinate the activities of public quality programs are being mirrored in the private sector by the National Quality Forum. Increased use of Web-based tools by plans and providers has begun to create an electronic infrastructure for data exchange that, fueled by looming electronic transaction requirements of the Health Insurance Portability and Accountability Act of 1996, previews a paperless system of the future.
The newly issued third IOM report, Leadership by Example: Coordinating Government Roles in Improving Health Care Quality, makes specific recommendations for federal action. The institute found that the federal government occupies the unique position of healthcare provider, purchaser, regulator and researcher, yet despite isolated examples of innovation within its agencies its quality programs do not speak with one voice or provide clear and consistent leadership. By adopting standardized performance measures across its programs, committing to electronically aided transparency of information and directly rewarding plans and providers for quality improvement, the federal government can shift its focus away from adversarial, often futile enforcement efforts and toward dynamic, quality-improvement leadership.
With input from private quality-improvement groups, the federal government, according to the third IOM report, should require its quality programs to adopt the same set of standardized performance measures for the treatment of 15 common health conditions, such as diabetes, asthma and heart disease. With help from Congress in the form of authority to reward high-quality Medicare and Medicaid providers with higher rates of payment and in the form of financing to support the development of needed information and technology infrastructure, the federal government would implement fully these measures across its directly provided and purchased healthcare programs by 2008.
In a marketplace increasingly dominated by consumer choice, alive with Web-based business-to-business activity and rife with quality-improvement experiments, it is hard to imagine the healthcare system failing to respond to this kind of concerted federal leadership.
Bruce Bullen, chief operating officer of Harvard Pilgrim Health Care, Wellesley, Mass., was on the IOM panel that produced the recent quality report.