The New Consensus Favoring IOM's Definition of Quality

Cover Story

MANAGED CARE June 2004. ©MediMedia USA

We often use such words as "quality," "transparency," "accountability," "evidence-based," and "effectiveness," but not always in the same ways.

Martin Sipkoff

Contributing Editor

Quality, like beauty, is in the eye of the beholder. The word is ubiquitous in health care, but what does it mean to health plan leaders, providers, patients, and payers? Is quality a process, a tactic, or just an aspiration?

Most important: Can a universally understood definition of quality be a guiding light, helping us keep our eye directed along a bumpy road?

Surprisingly, in an industry hardly known for harmony, the answer appears to be yes. In the last three years, the Institute of Medicine's definition of quality has become widely accepted as a common and defining plan of action. In its seminal 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century, the IOM defined quality as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."

That prescript contains just two concepts: measurement and knowledge. But its implications are powerful, say health care leaders. So powerful, in fact, that the definition is redirecting health care, according to purchasers, consumer groups, physicians, and health plan executives. "This is what we all need to look at," says Peter Lee of the Pacific Business Group on Health in San Francisco. "And people are willing to start their discussions at this point. That's a new thing and it's increasingly obvious."

Working together

Today — more frequently than talking about a divisive issue like cost control or an evasive issue like patient satisfaction — health care leaders are discussing how they can work together to create concrete improvement in outcomes, and they express faith that improved outcomes will result in lower costs and greater patient satisfaction.

The IOM definition is a way back out of the "looking glass," say some experts, away from the now largely disfavored idea that decreased access is the best way to lower costs. The IOM's work marks a good beginning, a path back from what the public too often sees as an autocratic, paternalistic system of care, says Tom Granatir, Humana's senior adviser for clinical health plan policy.

"It's got everyone thinking about the same thing, all shaped by the IOM's report. It's got people thinking about systems of care, not just does this work or does that work," he says. "It's the first step in making care as responsive as possible to what consumers need."

"Quality has taken center stage away from cost and access in the debate about health care," says Mark R. Chassin, MD, chairman of the Department of Health Policy at Mount Sinai School of Medicine in New York and an author of Crossing the Quality Chasm.

Opportunity knocks

Donald Berwick, MD, president and founder of the Institute for Healthcare Improvement and an author of the Chasm report, says the IOM's work creates an opportunity for change. "Its major contribution is that it allows us to agree there is a problem," he says. "It's so clear in what it says, and it's so clear that what it says is far from where we should be, that a conversation can begin. Whether we have the political will to get there is a separate issue."

Physicians, who historically aren't enamored of metrics, are receptive to the IOM definition, says Yank Coble, MD, a trustee and past president of the American Medical Association who frequently addresses AMA perspectives on the quality of health care. "It gives us all something we can agree to," he says. "No one can argue with a need for clarity, and the work provides a way to come together, something to talk about besides how much things cost."

"It is understandable that so many physicians have reacted to the debate over the quality of care with anger, skepticism, or simply disinterest, but such reactions are a luxury that physicians can no longer afford," wrote David Blumenthal, MD, of the Institute for Health Policy at Massachusetts General Hospital, in Health Affairs in 1996, one of the first articles examining the essential characteristics of quality. That is truer today than ever, says Blumenthal, a member of the IOM. He and others say that the IOM's work creates a vernacular for discourse on quality. "It offers a common language at this point," agrees W. Allen Schaffer, MD, Cigna's senior vice president and chief medical officer. "We look at our work and match what we do across the IOM definition."

"We've had a Tower of Babel of talk and standards," says PBGH's Lee. "We need to change that, using a common understanding of where we want to go as a way to begin."

The National Quality Forum, led by Kenneth Kizer, MD, former Undersecretary for Health in the Department of Veterans Affairs, is trying to create a set of national standards around concepts of evidence-based medicine. "It's simple, actually," says Kizer. "The IOM definition asks us to look hard at how well the services we provide fill the needs of the people we serve. And standards should reflect that by measuring the practice of medicine as it is consistent with evidence-based knowledge."

Medical ignorance

Seems obvious, but that is not what's been happening. A headline in the Wall Street Journal last November read "Medical Ignorance Contributes to Toll from Aortic Illness," quoting "studies that suggest there has been little or no improvement in a longstanding misdiagnosis rate of about 35 percent of aortic dissections." A May 2004 study by the Information Technology Association of America concluded that lack of adequate treatment of Medicare patients with severe chronic conditions causes 1.7 million unnecessary hospitalizations and costs more than $30 billion a year. (See "Still Far To Go")

Still far to go

In defining what health care quality is, the Institute of Medicine found many — far too many — examples of how far we have to go. Here are just a few:

Between 44,000 and 98,000 Americans die from medical errors annually.
Only 55 percent of patients in a recent random sample of adults received recommended care, with little difference found between care recommended for prevention, to address acute episodes, or to treat chronic conditions.
Medication-related errors for hospitalized patients cost roughly $2 billion annually.
Forty-three million uninsured Americans exhibit consistently worse clinical outcomes than the insured, and are at increased risk for dying prematurely.
The lag between the discovery of more effective forms of treatment that what is being used and their incorporation into routine patient care averages 17 years.
About 18,000 Americans die each year from heart attacks because they did not receive preventive medications, although they were eligible for them.
Medical errors kill more people per year than breast cancer, AIDS, or motor vehicle accidents.
More than 50 percent of patients with diabetes, hypertension, tobacco addiction, hyperlipidemia, congestive heart failure, asthma, depression and chronic atrial fibrillation are currently managed inadequately.

A Rand study described in an article titled "Profiling the Quality of Care in Twelve Communities" in the May/June 2004 issue of Health Affairs found that Americans get only half the recommended medical care and screenings from their doctors that they should receive. "The best role for managed care is that of an information system," says Robert Brook, MD, chairman of Rand Health, "providing the data necessary so consumers, who really just want to be treated with respect, can make informed choices."

New awareness

Many health plan executives say they are keenly aware of a lack of evidence-based care, and some say the IOM's work is the start of a new awareness of the need to change business as usual. Cigna and other health plans have long used the National Committee for Quality Assurance's HEDIS standards as a basis of determining how well they are performing. HEDIS remains a critical external audit, of course, says Schaffer, but "the IOM work is an order of magnitude advance beyond measuring what percentage of people are being screened for what procedure." That's because IOM's definition, and the standards that evolve from that definition, provide a "user-based focus of care," he says.

Cigna is not alone in considering IOM standards key elements of achievements, according to experts attending the January 2004 World Health Care Congress in Washington, D.C. Speakers there repeatedly referred to the IOM definition as way out of our current mess, the way to truly transform our current system. Politicians like senators Hillary Clinton and Bill Frist, health care leaders like Robert Brook, MD, and government leaders like Leslie Norwalk, acting deputy administrator of the Centers for Medicare & Medicaid Services, agreed on at least one thing: IOM has created a common language for quality, although we have some way to go to create commonly acceptable measurement standards.

Just what does it mean?

"The word has meant so many things," says Humphrey Taylor, chairman of the Harris Poll, whose company has conducted many polls about consumer and professional perceptions of quality care. "It can mean anything from a good bedside manner to a lowered death rate from a specific procedure. They're all related, all reasonable, and all different. People are working hard to find a way to all mean the same thing."

The Harris Poll conducted a survey of the World Health Congress speakers and attendees and found that 79 percent believed that standards based on IOM definitions are an "effective and desirable" way to control costs. Only lowering administrative costs scored higher, at 81 percent. And standards based on those definitions scored highest (49 percent) in the number of respondents who believe they are among the top two ways to lower costs. Second was increased provider efficiency, at 29 percent.

IOM officials themselves describe their work as a beginning, not an end (See "What Is The IOM?"). "A basic definition understood to mean the same thing to virtually everyone is a start, just a start, to reforming a very broken system," says Janet Corrigan, PhD, director of the board on health care services at IOM, who attended the Congress to talk about transparency. "It's the beginning of changing systems of care."

What is the IOM?

The Institute of Medicine in Washington, D.C., is part of the National Academy of Sciences, which was created by the federal government to be an adviser on scientific and technological matters. However, the academy and its associated organizations, including the IOM, are described as private, nongovernmental organizations. Studies are funded out of appropriations made available to federal agencies.

IOM officials say it is an independent body. Each report goes through the IOM/NRC (National Resource Council) institutional process, including a peer review. Committees form the deliberating and authoring bodies for all the Institute's reports. The IOM reports on quality in health care are written by the Committee on Quality of Health Care in America, composed of representatives from every segment of the nation's health care industry.

So far, the IOM quality initiative has produced the following reports, all of which are available for viewing at the IOM website, www.iom.edu: [1]

Leadership by Example: Coordinating Government Roles in Improving Health Care Quality
Crossing the Quality Chasm: A New Health System for the 21st Century
Ensuring Quality Cancer Care
Envisioning the National Health Care Quality Report
To Err is Human: Building A Safer Health System
Fostering Rapid Advances in Health Care: Learning from System Demonstrations
Health Professions Education: A Bridge to Quality
Priority Areas for National Action: Transforming Health Care Quality
Key Capabilities of an Electronic Health Record System
Patient Safety: Achieving a New Standard for Care
Keeping Patients Safe: Transforming the Work Environment of Nurses

The IOM has also published other health care-related reports that address the development of quality measures, such as Insuring America's Health: Principles and Recommendations and In the Nation's Compelling Interest: Ensuring Diversity in the Health Care Workplace.

From a basic idea

Two sets of precise definitions of quality have grown from the IOM's basic definition of quality. The Crossing the Quality Chasm authors used the definition to create STEEEP, i.e., all health care should be safe, timely, effective, efficient, equitable, and patient-centered:

patients should not be harmed by the care that is intended to help them (safe);
care should be based on sound scientific knowledge (effective);
care should be responsive to individual preferences, needs, and values (patient-centered);
unnecessary waits and harmful delays should be reduced (timely);
care shouldn't be wasteful (efficient); and,
it shouldn't vary in quality because of patient characteristics (equitable).

"For most people, STEEEP is where defining quality begins," says Humana's Granatir.

10 basic rules

From those six elements the Chasm authors created 10 basic rules of health care, calling them "guides to the redesign of our current system." Each rule reflects a STEEEP standard:

Care based on continuous healing relationships.
Customization based on patient needs and values.
The patient as the source of control.
Shared knowledge and the free flow of information.
Evidence-based decision-making.
Safety as a system property.
The need for transparency.
Anticipation of needs.
Continuous decrease in waste.
Cooperation among clinicians.

Two years later, in a report titled Priority Areas for National Action: Transforming Health Care Quality, the IOM went much further. The authors of that report — including several of the people who had written the Chasm report — created a set of 20 priority areas that they said should be the focus of all health plan activity (see "Priority Areas of Care"). "Collective action in these areas could transform the entire health care system," says the IOM's Corrigan.

Priority areas of care

In a 2003 report titled Priority Areas for National Action: Transforming Health Care Quality, the Institute of Medicine set 20 areas of priority concern for the nation's health care system. Those areas are what the IOM calls the most urgent, and many health plan leaders agree.

"They mark the areas where we know we can play a critical leadership role," says W. Allen Schaffer, Cigna's medical director. "We place them at the front of what we consider to be the provision of quality care." Cigna and other plans use a series of measures, including the National Committee for Quality Health Care's HEDIS standards, to determine how well they are meeting the IOM's priorities.

The 20 priorities are in the following areas:

Asthma — Encourage the use of anti-inflammatory medications and disease management. "This is an area of making certain we are providing appropriate care," says Schaffer.

Care coordination — The IOM calls this priority "the key in the effective treatment of chronic conditions," saying that clinicians and plans should actively collaborate and communicate to ensure an appropriate exchange of information.

Children with special health care needs — Children who have a chronic physical, developmental, behavioral, or emotional condition, or who are at increased risk of developing one, require more than the typical level of pediatric care, according to the IOM report.

Diabetes — Diabetes is the fifth-leading cause of death in America, predisposing people to long-term medical complications such as heart disease, hypertension, and blindness. But it is significantly undertreated, says Carolyn Clancy, director of the Agency for Healthcare Research and Quality. "The lack of adequate diabetes-related testing, using basic data we know is correct, is as clear an example of the flaws of our current system as it's possible to have," says Clancy.

End of life with advanced organ system failure — Heart, lung, and liver failures account for about one-fifth of all fatalities in America. Care should minimize symptoms and reduce the rate of exacerbations of organ malfunction, says the IOM report.

Evidence-based cancer screening — Cancer is the second-leading cause of death in the United States. Scientific research indicates that screening can significantly reduce death rates for several forms of cancer, especially colorectal and cervical cancer, says the report.

Frailty associated with old age — With more Americans living longer, more people will experience the multiple mental and physical health challenges associated with advanced age.

Hypertension — This affects 1 in 4 adults in the United States, leading to life-threatening complications, including stroke, heart attack, and kidney failure. But nearly a third of people with high blood pressure do not know that they have it, says the report. Interventions should emphasize early detection and management.

Immunization — Every year diseases that can be prevented by vaccination kill about 300 children and between 50,000 and 70,000 adults. Influenza and pneumonia account for most of the adult deaths. Efforts should target nursing-home residents, who are susceptible to contagious illnesses because of advanced age and close living quarters, as well as black and Hispanic adults, and low-income, inner-city children, populations that tend to have lower-than-average immunization rates.

Ischemic heart disease — This condition is the leading cause of death among adults in the United States. Efforts should focus on preventing heart disease and reducing recurrence of heart attacks through promotion of healthy lifestyle changes and use of cholesterol-lowering drugs, surgery, and timely administration of medications after a heart attack.

Major depression — Treatment rates for depression are significantly lower than those for many other chronic conditions; fewer than half of individuals with depression are correctly diagnosed. National rates of screening and treatment should be improved.

Medication management — Efforts should focus on preventing medication errors, particularly through greater use of computer technology.

Nosocomial infections — Hospital-acquired infections kill nearly 90,000 patients in the United States each year and cost an additional $5 billion to treat. Wider implementation of the nosocomial infection guidelines from the Centers for Disease Control and Prevention would save more than 40,000 lives annually, reduce infection rates by up to 50 percent, and save nearly $2.75 billion, says the IOM report.

Obesity — Each year more than 300,000 deaths can be attributed to obesity. The condition eventually could become the nation's single most preventable cause of premature death and disability.

Pain control in advanced cancer — Twenty percent of Americans die from cancer, often after months of painful, progressive illness. Effective programs have shown that this pain typically can be controlled enough to give patients a satisfactory level of comfort.

Pregnancy and childbirth — The quality of prenatal care and care related to labor and delivery should be enhanced to boost the long-term health of women and their children. Some key goals should be to increase the number of women who start prenatal care in the first trimester and to screen more pregnant women for sexually transmitted diseases.

Self-management/health literacy — Public and private entities should systematically provide educational programs and interventions that aim to boost patients' skills and confidence in managing and assessing their health problems.

Severe and persistent mental illness — The goal should be to improve the quality of mental health care in the public sector, which includes state hospitals, community mental-health centers, and various federal and state programs.

Stroke — This is the third-leading cause of death in the United States. Efforts should focus on seamlessly integrating care across health care settings and clinical disciplines.

Tobacco-dependence treatment in adults — Tobacco use and dependence are the nation's most preventable causes of disease and death.

"No improvement"

Corrigan's right, of course. In December 2003, the Agency for Healthcare Research and Quality issued the National Healthcare Quality Report that said we have a long way to go. Of 57 measures, 37 "have either shown no improvement or have deteriorated" over several years.

AHRQ found that of the six STEEEP standards, five were currently measurable by dozens of readily accessible tools. The only standard that lacks measurement tools is efficiency.

"Measurement is not the problem," says Carolyn Clancy, AHRQ's director. "We know how to do that. And it's not because we don't want to achieve quality. We know what it is and how to get there. What we don't have are the systems in place to make it happen. The next frontier is how to get the job done."

"The 20 domains serve as a starting point to dramatically increase the level of quality across the board," says the IOM's Priority Areas report. "Low-quality care typically does not stem from a lack of effective treatments, but from inadequate systems to carry them out."

How do we build those systems? How do we create processes, strategies, and infrastructures that, to use Chassin's phrase, "make the right thing to do the easy thing to do?"

A clue can be found in how the authors of Priority Areas developed their priorities. The committee that wrote the report selected areas that range from broad interventions to preventive services to palliative care for the dying. They used three criteria:

the breadth of impact on patients, on families, and on communities;
improvability, or the likelihood of closing large quality gaps; and,
inclusiveness, which deals with both the diversity of people affected and the likelihood of improvements having positive effects throughout the health care industry.

Two of the areas — care coordination and self-management/health literacy — are referred to in the report as "cross-cutting" because they cut across specific conditions and benefit many patients.

Patients benefit

It's in direct benefit to patients that IOM definitions have the greatest value, say leaders of research and consumer groups. In January 2004, for example, the Commonwealth Fund published the results of an extensive survey comparing U.S. health care to health care in four other English-speaking countries — Australia, New Zealand, Canada, and the United Kingdom. The survey used the STEEEP standards as its basis for comparative analysis. The U.S. did well in timeliness, not so well in the others. The survey is at «www.cmwf.org».

"Quality is a multifaceted concept," says the Commonwealth Fund's president, Karen Davis. "The IOM definition brings together in a single construction those elements of most importance to patients, and no understanding of quality is complete, or even meaningful, without the patient's perspective."

Myrl Weinberg, president of the National Health Council, the consumer group, goes one step further: She says patient-centered care is the foundation of quality.

"STEEEP really comes down to that," says Weinberg. "Just imagine a system where patients and their families are able to shape critical decisions."

"Sense of urgency"

"We need a paradigm shift," agrees Debra Ness, executive vice president of the National Partnership of Women and Families and co-chairwoman of the Consumer-Purchaser Disclosure Project, a coalition of consumer groups and purchasers that is working with Kizer's NQF and several major health plans to develop a national set of standards.

"Right now, in part because of the IOM work and but mainly because of rapidly rising costs, there's a sense of urgency. We need to get there, even if it's in steps. We can't let the perfect be the enemy of the good."

It is consumer groups such as the National Heath Council and efforts like NQF and the Disclosure Project that will probably make the most effective use of the mandate for change inherent in the IOM work, say some experts.

"Our system is too big, too fragmented, too complicated," says IOM's Corrigan. "The IOM work on quality is a marker for beginning change at the community level."