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Pioneering new ways to ensure quality health care.

Efforts to improve quality in health care services aren't new. In fact, over 120 years ago, Florence Nightingale implemented a system to methodically collect and review data on hospital mortality rates. Her efforts illuminated significant variance among the hospitals she studied. What is new is a surge in interest to pioneer new ways to ensure quality.

Until recently, quality was primarily the purview of health care delivery systems, regulators, and accreditors. However, the composition of stakeholders in quality-related activities and the strategies for operationalizing their interests has changed markedly. Today, concern regarding quality of health care is voiced by a wide range of stakeholders including consumers, employers negotiating with health plans, the federal government looking for value for the money paid to obtain care for beneficiaries of programs such as Medicare, elected representatives responding to dissatisfied constituents, labor unions concerned about their members' jobs as well as ability to voice concerns, and health care practitioners as well as health services researchers. Exemplifying the emphasis on providing quality in the health care community, the entire May/June 1997 issue of the journal Health Affairs was devoted to measuring quality. At the policy level, 1997 has emerged as the year of local, state, and national discussions regarding quality of health care with related issues playing out in state legislatures across the country as well as at the federal level. While everything from defining quality to strategies for protecting and enhancing quality care are debatable, given the sweeping changes in health care finance and organization, ensuring quality care is emerging as everybody's business.

An often cited definition of quality hails from the Institute of Medicine (1990): "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." Absent a precise definition, quality may include issues ranging from the amount of time spent in a health care practitioner's waiting room to the application of a "prudent layperson standard" in determining payment for emergency room care. In spite of the breadth and fuzziness of many quality-related issues, policymakers are boldly moving forward in search of ways to protect and enhance this perceived hallmark of America's health care system. For example, at the state level as of April 1, 1997 comprehensive consumer protection bills had been introduced in 26 states (Health Policy Tracking Service, 1997). Similarly, the issue of preserving and protecting quality is very much on the screen of both members of the U.S. Congress as well as the Clinton Administration.

Quality Health Care and the Clinton Administration

Illustrating the importance of the issue of quality of health care within the Department of Health and Human Services (DHHS), in March Secretary Donna Shalala named John Eisenberg, MD, the new administrator for the Agency for Health Care Policy and Research, to the newly created post of Senior Advisor to the Secretary on Quality. Additionally, the Secretary has identified quality as one of six major focal points within DHHS this year.

On another front, at the end of March, President Clinton announced his newly formed Presidential Advisory Commission on Consumer Protection and Quality in the Health Care Industry. This 32-member commission has representatives from business, labor, insurance, local and state government, as well as health providers. Three nurses, Beverly Malone, Marta Prado, and I were named to this commission as well. The purpose of the commission is to advise the President on the impact of health care delivery system changes on quality, consumer protection, and the availability of needed services. Highlighting the vast interest in health care quality, approximately 1,000 nominations to the commission were submitted for consideration, making it perhaps the most sought after appointed body during President Clinton's tenure in office. With a preliminary report due in January 1998 and a final report due to the President in March 1998, the commission's work is led by its co-chairs, the Secretary of Health and Human Services and the Secretary of Labor. With 2-day meetings scheduled every month, except August, the commission has structured much of its work to be conducted through four subcommittees. The first subcommittee is charged with pursuing President Clinton's first priority, to develop a Consumer Bill of Rights, Protections, and Responsibilities. Areas to be considered by this subcommittee include coverage issues, choice of practitioners, privacy and confidentiality, disclosure of qualifications of practitioners, external appeals processes, among others. The subcommittee on performance measurement and quality oversight will address issues related to processes for development, promulgation and use of performance measures by purchasers and consumers, and strategies to improve the validity and reliability of performance measurement data. The third subcommittee, which I was asked to chair, focuses on creating a quality improvement environment. This subcommittee focuses on the extent to which the external environment encourages or impedes quality improvement efforts of providers and health plans as well as looking at the internal characteristics of health care organizations that promote or impede quality improvement. The fourth subcommittee, on roles and responsibilities of public/private purchasers and quality oversight organizations, will focus on issues including roles of public and private oversight entities, strategies to achieve balance between market-driven quality incentives and regulatory requirements, and responsibilities of group purchasers to protect quality.

The subcommittees will provide progress reports and findings to the full commission which then will be responsible for making decisions and developing recommendations through a process of consensus.

The commission's second meeting was held June 25-26 in Washington, DC with an agenda that included testimony on consumer choice, performance measures, access to emergency services, and protecting vulnerable populations. In addition, a number of members of Congress testified before the committee speaking to general issues surrounding quality and/or to bills that they had introduced designed to enhance quality and protect consumers. In creating the commission, part of the intent was to have this body serve in a consultative role as relevant legislation moved through Congress between now and when the commission completes its work. Consequently, the commission will be attentive to legislative initiatives under consideration by the Congress.

As the commission continues its work, there are a number of opportunities for individuals to track activities and to inform the commission's work. All commission meetings are open to the public and at the conclusion of subcommittee and full commission meetings, time is allocated for public comment. Consequently, individuals who wish to directly address the co-chairs and commissioners in this public forum may do so. Also, the commission has a website to which comments can be sent and all published commission materials may be accessed. The website address is: Accessing the website is an excellent strategy for staying current regarding the activities and products of the commission. Finally, while most of the commission meetings will be held in Washington, DC, three meetings are planned in other cities. The meeting schedule is as follows:

* July 21-22, Burlington, VT

* September 9-10, Chicago, IL

* October 21-22, Washington, DC

* November 18-19, Washington, DC

* December 16-17, Washington, DC

* January 27-28, 1998 Seattle, WA

* February 25-26, Washington, DC

The Clinton Administration has been actively involved in quality and consumer protection initiatives including providing support for increasing choice and consumer information, limiting physician incentive arrangements, and requiring health plans to provide for 48-hour stays after mastectomy or delivery of a baby. The advisory commission is one more Administration initiative designed to address quality by helping to build consensus on ways to improve quality of care.

Quality Health Care and the Congress

Policy concerns related to quality have been raised in Congressional hearings as well as in legislative initiatives this year. For example, at the end of May, the Senate Committee on Labor and Human Resources held a hearing on health care quality, with testimony focusing on access to health care, need for effective grievance and appeals processes; concerns regarding barriers to physician-patient relationships, including gag rules; and the need for ongoing assessment and improvement in health care quality. Demonstrating the depth of interest among policymakers, five members of Congress joined invited witnesses to testify before the Senate Committee chaired by Senator Jeffords (R-VT).

During this session of Congress, numerous bills have been offered by both Republicans and Democrats to protect consumer access to quality health care. The number and scope of bills introduced demonstrate a serious interest in dealing with quality at a national level. Many of the legislative initiatives address similar issues such as: (a) emergency services including the application of a prudent layperson standard in determining payment coverage for emergency services rendered and bans on pre-authorization; (b) provisions that affect coverage of experimental therapies; (c) anti-gag rules; and (d) information disclosure on the part of health plans to current and potential enrollees including information on financial incentives for providers, prior authorization requirements, and quality indicators.

The catalyst for many of these initiatives are media accounts and constituent complaints of problems in accessing quality health services. While no policymaker can speak with certainty about where legislative initiatives related to quality will finally end, there is widespread opinion that to the extent consumer health care is jeopardized or perceived as jeopardized, the public will expect policymakers to act on their behalf Speaking specifically to managed care, Congresswoman Roukema (R-CT) recently stated that if some of the problems with health maintenance organizations aren't addressed, the country will likely see discussion of a single-payer plan revisited.

Health care providers, including nurses, directly affect quality of care and are affected by public policy efforts related to improving health care quality. Now is the time for engaging in the public dialogue about this multifaceted and critically important issue and sharing your important views with the individuals whose role it is to craft quality related policy.


Health Policy Tracking Service. (1997, April). Issue brief. Comprehensive consumer rights bills. Washington, DC. Institute of Medicine. (1990). Medicare: A strategy for quality assurance, Volume 1. Washington, DC: National Academy Press.
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Author:Wakefield, Mary K.
Publication:Nursing Economics
Date:Jul 1, 1997
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