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."
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.
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."
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")
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."
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."
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.
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.
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."