The U.S. Department of Health and Human Services (HHS) defines quality improvement efforts as “systematic and continuous actions that lead to measurable improvement in healthcare services and the health status of targeted patient groups.” The Institute of Medicine goes further in stating that quality is the degree to which care increases desired health outcomes.
Since the passage of the Affordable Care Act (ACA) five years ago, much attention has been drawn to healthcare quality improvement by payers, clinicians and consumers alike. The level of buy-in across industry stakeholders highlights the importance of quality improvement efforts in health care. Escalating healthcare costs and a higher-than-ever number of insured Americans have also heightened the need for better quality. Today, a great deal of research around patient outcomes and safety, care coordination, efficiency, and cost cutting is underway. Additionally, care redesign initiatives are being evaluated to guide future healthcare quality improvements.
As mandated by the ACA, the National Strategy for Quality Improvement in Health Care (National Strategy) was created in March 2011 by the Agency for Healthcare Research and Quality (AHRQ) to guide quality improvement efforts at the local, state, and national levels through three key aims (below) and six priorities:
- Improving overall quality by making healthcare more patient-centered, reliable, accessible, and safe;
- Improving the health of the population by supporting proven interventions to address behavioral, social, and environmental determinants of health; and
- Reducing the cost of quality care for individuals, families, employers, and government.
The National Healthcare Quality and Disparities Report (NHQDR) evaluates more than 250 measures of healthcare processes, outcomes, and access yearly in varied settings such as hospitals, community health centers, and private practices. In 2014, the NHQDR reported progress in all six priority areas established by the AHRQ.
Priority 1: Making care safer by reducing harm caused in the delivery of care
In 2013, much attention was paid to the Journal of Patient Safety finding that medical errors in hospitals resulted in more than 210,000 deaths per year. The report further strengthened efforts to promote quality measures and reduce harm in healthcare.
According to the NHQDR, half of all patient safety measures improved, with a median improvement of 3.6 percent per year. Notably, there was a 17 percent reduction in hospital-acquired conditions (including pressure ulcers, falls, and infections), resulting in approximately 50,000 fewer patient deaths and $12 billion in healthcare cost savings. A significant reduction in adverse drug reactions was also found.
Priority 2: Ensuring that each person and family are engaged in care
An essay in Health Affairs describes patient-centered care as a means of enhancing quality and outcomes by involving patients in their own care, building patient-provider relationships, and revolving care around patient needs. Literature shows that person-centered care reduces length of stay, lowers care and operating costs, enhances employee retention, and decreases adverse events.
Nearly all person- and family-centered care measures tracked in the 2014 NHQDR improved. Patient-provider communication improved from 2005 to 2012, with the percentage of adults who reported poor communication with health providers decreasing. Parents also reported a significantly lower degree of poor communication with their children’s health providers.
According to the NHQDR, half of all patient safety measures improved in 2014
Recently, the AHRQ established Consumer Assessment of Healthcare Providers and Systems, a research organization that releases surveys allowing patients to evaluate their care. In future years, these surveys will be a key measure for patient-centered care.
Priority 3: Promoting effective communication and care coordination
According to the National Strategy, effective communication within healthcare delivery settings and care coordination across the healthcare system reduces errors and overutilization of services. It also helps patients move efficiently through a complex system involving different providers across multiple settings.
The NHQDR found that healthcare facilities saw improved discharge processes and care coordination, facilitated by the adoption of health information technologies such as electronic medical records. The report also showed a significant increase in the percentage of patients with serious conditions who received complete, written discharge instructions. Notably, the percentage of heart failure patients who received full discharge instructions increased by 35 percent.
In an effort to improve care coordination, the Centers for Medicare & Medicaid Services (CMS) adopted the Medicare and Medicaid Electronic Health Record Incentive Programs, providing financial incentives for implementing certified electronic health record technology.
Priority 4: Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease
A principal goal of the National Strategy is to target the diseases responsible for the largest number of American disabilities and deaths – such as cardiovascular disease, the nation’s leading cause of death – through intensive prevention and treatment programs.
The NHQDR found that half of effective treatment measures improved for life-threatening conditions. For instance, from 2005 to 2012, the percentage of heart attack sufferers treated within 90 minutes of their arrival to a hospital increased. The overall performance of ten other treatment measures also improved, leading to better outcomes in cancer, pneumonia and HIV care.
Additionally, the Centers for Disease Control and Prevention will continue pursuing prevention efforts to reduce heart disease risk factors such as smoking, sodium intake, and high blood pressure. In 2015, the agency invested nearly $300 million in state and community prevention initiatives targeting heart disease, obesity, diabetes, stroke, and health disparities through campaigns such as Million Hearts, Tips From Former Smokers, and Sodium Reduction in Communities.
Priority 5: Working with communities to promote wide use of best practices to enable healthy living
The National Strategy is committed to working in communities to promote healthy living, increase preventive services, and enhance evidence-based interventions to improve population health and wellness.
The NHQDR found that half of measures of healthy living improved. Adolescent vaccines were among notable improvements from 2008 to 2012 – including increases in the percentage of adolescents receiving the meningococcal and tetanus-diphteria-acellular-pertussis vaccines. The recent anti-vaccination movement seems to be reversing this trend, however.
HHS is also leading programs to enhance healthy living, such as Let’s Move, an initiative to improve the health of children by providing guidance for parents, healthy meals in schools, and physical activity programs. Health Leads, another program, is integrating patients’ social needs into their medical care, with clinicians “prescribing” basic resources like food and heat. Health Leads advocates also connect patients to helpful social programs. In 2014, advocates connected more than 13,000 patients and their families to the resources they needed.
Priority 6: Making quality care more affordable for individuals, families, employers, and governments by developing new healthcare delivery models
Prior to the ACA, the NHQD report shows that care was becoming more expensive; however, it reports that after 2010, care affordability “leveled off” or stopped worsening. The report also shows that the percentage of people who indicated that a financial impediment caused their lack of a primary care provider has not increased in the past two years. Access and cost barriers to health insurance are being targeted through tax credits, more coverage options within the Health Insurance Marketplace and cost-sharing reductions. According to the Kaiser Family Foundation, the average U.S. insurance premium increased by three percent in 2014, which is the smallest increase since 1999.
Buy-in across industry stakeholders highlights the need for quality improvement in health care.
CMS has established innovative initiatives such as the Medicare Shared Savings Program and the Accountable Care Organization (ACO) Model, whereby ACOs are responsible for the cost and quality of the care they provide to Medicare beneficiaries. By forcing providers to share in costs and savings, the ACO model incentivizes quality care and reduces costs. Since 2010, more than 420 Medicare ACOs have been established, serving more than 7.8 million Americans. In 2014, pioneer ACOs (including Harvard-affiliated Partners HealthCare) and Medicare Shared Shavings Program ACOs generated more than $411 million in total savings. By the end of 2016, HHS is aiming to move 30 percent of Medicare provider payments to value- and quality-based alternative payment models such as ACOs.
Areas in Need of Improvement
Despite the aforementioned progress, a great deal of work lies ahead. The NHQD report’s executive summary identified several areas where disparities and gaps in quality still exist. The development of special efforts is underway to address them. For instance, only 70 percent of people with high blood pressure are receiving the recommended level of care. Further, disparities in two areas – hospice care and chronic disease management – increased. Healthcare affordability is another top priority with once-increasing costs leveling off, but not yet decreasing. Across all six priorities, disparities still exist according to income, race, and ethnicity.
Resources to Learn More
- The Institute for Healthcare Improvement’s “Science of Improvement” offers a clear, organized process for improving outcomes in healthcare by asking three questions and employing a change cycle.
- The CMS’s fact sheet entitled “Better Care, Smarter Spending, Healthier People: Improving Our Health Care Delivery System” offers a detailed summary on healthcare quality improvement efforts focusing on spending, coverage, and safety.
- The Institute for Healthcare Improvement’s illustrated video offers a unique, visually impactful description on the history and process of healthcare improvement.
- The Kaiser Family Foundation’s essay on “Measuring the Quality of Healthcare in the U.S.” offers unique insight on the process of measuring and tracking quality progress.
- Read “A Primer on Project Management in Health Care” from Harvard Chan School
Harvard T.H. Chan School of Public Health offers Health Care Project Management: The Intersection of Strategy, People, and Process, an intensive training course in health care project management. To learn more about this opportunity, click here.