Report
for the President as of September 21, 1999
In March 1998,
the Advisory Commission
on Consumer Protection and Quality in the Health Care Industry
reported that one of the critical steps in advancing the quality
of health care in this country was to unify providers, purchasers,
quality oversight and improvement organizations, and the American
people in their aims to improve health care quality. The President
noted that the Federal agencies with health care responsibilities
exert significant power in the health care industry, and could improve
the quality of health care for Americans if they had common aims
and better coordination. He asked Secretary Donna Shalala to bring
these Agencies together in the Quality Interagency Coordination
(QuIC) Task Force to work to improve health care quality. The QuIC
has provided a significant opportunity for the Agencies to discuss
issues of mutual concern. It has made substantial progress on specific
projects to improve health care since it first met in May 1998.
Briefly, the
Agencies that have been working together in the QuIC are the Departments
of Defense, Veterans Affairs, Labor, Commerce, and Health and Human
Services, and the Office of Personnel Management, the Office of
Management and Budget, the Coast Guard, the Bureau of Prisons, the
Federal Trade Commission and the National Highway Transportation
and Safety Administration. Dr. John Eisenberg, Administrator of
the Agency for Health Care Policy and Research, serves as Operating
Chair of the QuIC.
In its initial
meetings, the QuIC identified five areas of shared interest:
- Providing
patients and consumers with information to assist in their choices.
- Pursuing
key opportunities for clinical quality improvement.
- Enhancing
quality measurement.
- Developing
the workforce to provide higher quality care.
- Improving
information systems.
The QuIC appointed
multi-agency work groups in each of these areas and asked them to
develop specific projects that would move toward these goals. Key
staff were appointed from each of the participating agencies and
are working hard to bring these projects to fruition. The health
care leaders in each agency meet periodically to steer the actions
of the work groups and to ensure appropriate support is available.
Its projects include the following.
QuIC Efforts
to Improve Current Patient Care Practices
The Work Groups
identified several key opportunities to improve the care that is
delivered. Some are areas in which there is scientific evidence
demonstrating what should be done to diagnose and treat patients,
but where common practice does not conform to those scientifically
proven methods. Others are areas where research is needed to inform
the choices that health care providers and managers make when determining
what to do. The QuIC has undertaken efforts in these four specific
areas:
- Diabetes
Care.
In 1997, the President launched the Diabetes Quality Improvement
Project (DQIP) which brought together the Health Care Financing
Administration, The Department of Veterans Affairs (DVA), and
private sector partners to identify ways in which diabetes care
could be improved. Working from research sponsored by the Agency
for Health Care Policy and Research that identified what is most
important and effective in treating patients with diabetes, DQIP
created a small set of measures to use in judging clinical performance
and determining where improvement was needed. The DQIP efforts
led to three specific actions under the QuIC.
- First,
before the QuIC was created, the DVA and the Department of
Defense (DoD) had created a common guideline for care of diabetes
and had planned to use the DQIP measures to assess performance.
Under the auspices of the QuIC, other Federal Agencies were
invited to participate in the creation of the guideline and
to use the guideline to improve the performance of their providers.
- Second,
the DQIP group held a conference aimed at helping providers
and community organization to identify successful strategies
to improve the quality of diabetes care. The QuIC was able
to enrich this conference by bringing to it the Federal Agencies
and care teams with successful strategies to share and by
bringing together teams who were seeking new ideas that could
be tried in their own communities. The conference was highly
successful, and its success will be extended through efforts
to compile and disseminate the "best practices" that were
described at the conference to other providers and community
representatives who were unable to attend.
- Third,
the QuIC is seeking a broad agreement among Federal agencies
to collect and report the performance of providers on the
DQIP measures. The QuIC discussed the importance of Federal
Agencies agreeing to use this common set of measures for patients
with diabetes, and concluded that it would significantly help
to improve patient care. The QuIC has endorsed the idea of
asking the Federal Agencies to agree to use the DQIP measures.
We are in the process of making that request of all of the
participating Federal Agencies and expect to know by mid-October
how they have responded and what it will mean to use the DQIP
measures in their programs.
- Depression
Diagnosis and Care.
As with diabetes, there is substantial research showing that the
diagnosis and treatment of people with mild to moderate depression
could be greatly improved. The DVA and DoD identified this as
an area in which they wished to create a guideline to improve
the care of their populations. Through the QuIC, their efforts
were expanded in two significant ways. First, other Federal agencies
were invited to participate in developing and using the guideline.
Second, the research agencies, such as the National Institutes
of Health, the Agency for Health Care Policy and Research, and
the Substance Abuse and Mental Health Administration, were involved
and able to bring the latest and most compelling evidence from
their research to the effort. A guideline that will enhance the
care of depressed individuals will be completed by the end of
October and disseminated to Federal providers and made available
to the public. One of the final steps needed is to marry performance
measures to the guideline to ensure that the care for people with
depression is getting better. Unfortunately, there is no clearly
generally accepted superior set of depression care measures like
the DQIP measures were for diabetes. Therefore, the QuIC organized
a conference of experts in depression and measurement at the end
of September and will produce not only the best measures available
currently for monitoring performance, but also a research agenda
for creating a more enduring set of critical measures.
- Reducing
Errors. As
indicated in the Advisory
Commission's report, there is currently an unacceptable level
of errors in health care. The QuIC is working with the Institute
for Healthcare Improvement (IHI) to create an initiative that
will test several strategies for rapidly reducing the number of
errors committed. Our effort will be targeted specifically at
health care delivery settings where patients are in need of urgent
assistance and decisions have to be made rapidly, which we are
calling "high hazard environments." These would include emergency
rooms, operating rooms, intensive care units, and on-site rescue
operations. This is the first such initiative targeted at error
reduction in these high hazard environments. Based on the results
of previous IHI initiatives, we hope that some sites will be able
to achieve reductions of 25 percent to 30 percent in the number
of errors within 12 to 15 months. The QuIC endorsed this effort
at its meeting on September 21, and we are in the process of asking
the agencies to decide if they wish to participate and how many
teams they would like to have participate in the effort. Whatever
is learned through this Federal effort will be shared broadly
to help others reduce errors in their own health care delivery
settings.
- Effect
of Working Conditions on Quality of Care. From
studies in other industries, we know that the conditions under
which people work can dramatically affect their productivity and
the quality of work that they do, but little research has been
done on this issue in health care. Recent changes occurring nationwide
in the levels of staffing in hospitals and nursing homes, as well
as questions about how the organizational structure and physical
environment affect the quality of care delivered, have made this
an important topic in health care quality. These questions prompted
the QuIC to look for research that could inform provider organizations
about working conditions within their control that could influence
the quality of care they deliver, but little research was available.
Therefore, the QuIC elected to organize an expert meeting that
will identify what is known about how working conditions affect
the quality of care in health care and, more importantly, to identify
the critical questions to be explored about the effect of working
conditions on quality of care. We are collaborating in this effort
with health care provider organizations, unions and other representatives
of health care workers, and experts in facility design, art, organizational
design, and quality improvement. This conference will provide
a framework for Federal and private research efforts.
Future efforts
to improve patient care will be developed based on the priorities
of the Agencies involved and are likely to continue to expand on
efforts to improve mental health care and move into cardiac disease,
cancer, and other major diseases. For example, the QuIC can take
advantage of the National Cancer Institute’s Quality of Cancer Care
Initiative to affect the quality of cancer care delivered in ways
that the NCI can not do solely through research efforts.
QuIC Efforts
to Create Quality Improvement Tools
One of the major
benefits of the collaboration occurring under the QuIC is the ability
to develop and share tools that enable the Federal agencies and
others to improve the quality of care. The QuIC Work Groups identified
several tools that were needed. By ensuring collective use of these
tools, the QuIC will help to minimize the confusion that health
care providers encounter in dealing with the various Federal agencies
and improve the efficiency of the agencies’ work. These include:
- A Common
Credentialing Effort.
Currently, each Federal agency separately credentials the health
care professionals who work for them. When professionals seek
joint appointments from more than one agency, move from one agency
to the other, or are called upon in times of national need, such
as the Gulf War, to fill in for their colleagues who are serving
abroad, the credentialing effort must begin again at the new agency.
To prevent such duplication of effort and to improve the rigor
of the initial credentialing process, the Federal agencies are
working on a joint credentialing program that would allow electronic
sharing of information across the agencies. This process began
with an effort between the DVA and the Health Resources and Services
Administration to test the feasibility of creating such a credentialing
process for physicians and dentists. It has been judged successful,
and the QuIC is working to expand both the number of Federal agencies
that will use the process and the types of professionals who can
be credentialed through the program. We expect this effort will
take many more months of effort, but it is progressing.
- Information
on Measures.
A goal of the QuIC is to ensure that the Federal agencies are
using common measures and risk adjustment methods when possible.
These steps will help to reduce reporting burden for health care
providers and increase our ability to compare performance across
providers. Initial steps have been taken to enable us to move
toward this goal.
The QuIC
has created a compendium of all of the measures currently in
use by Federal agencies. It is available to all who are seeking
information on the measures currently available for use in assessing
quality. The information also will be available through a National
Measures Clearinghouse Web site that is under development by
the Agency for Health Care Policy and Research. The QuIC members
are sharing and testing the most advanced risk adjustment methods
available. Comparisons will be made on the results, the relative
costs of each method, and their effectiveness. A workshop is
planned to discuss which measures and risk adjustment methods
work best for particular purposes, and to agree on which are
best.
- Formulary
Guidance. Several Federal organizations maintain formularies
for their beneficiaries. Others, such as the Health Care Financing
Administration, must oversee organizations that provide care to
their beneficiaries and need a method by which they can ensure
that the formularies of provider organizations are adequate to
meet the expected needs of the populations they serve. A team
of individuals is working to determine how to provide guidance
based on scientific evidence that will help provider organizations
determine what a formulary must contain to be adequate to meeting
these expected needs.
- A Taxonomy
of Quality Improvement Methods. A tool that is essential if
the nation is to learn which quality improvement strategies work
best in various situations is a common method and language for
identifying and describing quality improvement interventions.
The QuIC Agencies conducted an expert meeting and are in the process
of finalizing a taxonomy that will allow us to describe and compare
the quality improvement strategies used in Federally sponsored
research, and in projects of the DVA, DoD and HCFA's peer review
organizations. This taxonomy will be published in a professional
journal for broad use, and will be put to work immediately upon
completion by the Federal agencies in their solicitations for
research proposals, descriptions of on-going projects, and instructions
to their provider organizations.
- Improved
Information Exchange across Agencies. Common information is
used by the Federal agencies, but much of it is not exchanged
electronically in a format that can be used by all agencies. The
information systems experts have been studying methods to improve
the efficiency and completeness of the data that are used in many
agencies. They have started with the "exclusions list,"
which is the list of individuals and organizations to which the
Federal agencies can not make health care payments. Individuals
and organizations appear on this list after they have committed
fraud or other similar actions in the delivery of health care
goods and services. Agencies have noted that they are not sure
they have accurate and up to date information on this list, or
that they are missing information, such as the individual’s or
organization’s unique identifier code, and must make inquiries
to verify identities before paying for services. Work is underway
to determine if a single, searchable list that has the complete
information needed by the agencies can be maintained and shared
electronically. Further projects to explore the impact that information
systems improvement can have on quality are being discussed.
- Strategies
for Ensuring Patients’ Rights. In November 1997, the President
directed the Federal agencies to bring their programs into compliance
with the Patients’ Bill of Rights that was developed by the Advisory
Commission. As part of the efforts to bring our programs into
compliance, key agency staff have been discussing their approaches
and the challenges. They have been able to share ideas and strategies
for bringing about compliance with the Bill of Rights to the extent
that current legislation permits. These discussions have proven
useful for all of the agencies.
QuIC
Efforts to Help Inform Americans About Health Care
The QuIC agencies
share responsibility for communicating with the American people
about their health care choices and are developing three products
that will greatly enhance our ability to do so. These are:
- A Gateway
to Consumer Information Available from Federal Agencies.
The QuIC has aided the Federal Trade Commission in augmenting
its Consumer.gov Web site
to include information on health care quality. Through this gateway,
the QuIC now links to all of the Federal sites that provide information
to assist people in making choices about their health care plans
and providers, including information on the quality of health
plans for Medicare beneficiaries, Federal employees, and participants
in the DoD Tricare plans. There are also links to the Department
of Labor's health benefits education campaign to help people understand
what they are getting and what their rights are.
- A Glossary
of Commonly Used Terms. The QuIC agencies realized that there
could be great benefit to the American people if we could agree
to reduce the chance of confusion by using the same terms to mean
the same things in our public communications. A set of terms has
been developed and is being circulated to the Federal Agencies
to solicit their agreement to use the terms. We expect to have
that agreement in October.
- Guidance
for Producing Report Cards.
Many organizations, including several Federal agencies, large
purchasers, and employers, are attempting to help patients make
better choices about their health care by providing "report cards"
on provider and plan performance to the American people. There
are scientific studies that show what is effective in providing
these report cards to various types of people, and there are many
organizations with experiences that can help others who are attempting
to provide high quality report cards. To inform report card producers,
the QuIC agencies have brought together researchers and report
card producers to develop guidance based on the science and reported
experiences. This information will be made available through a
Web site that is currently under development. It is expected to
be available this spring.
Current as
of September 21, 1999
Internet
Citation:
Progress
of the Quality Interagency Coordinating Task Force as of September
21, 1999. Quality Interagency Coordination Task Force. http://www.quic.gov/abut/progress.htm
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