Understanding the Evolution of Our National Healthcare Quality Improvement Process

2011 - 4 August - Nutrition in the ICU
Kristine A. K. Lombardozzi, MD, FACS, FCCM
By outlining the history of the healthcare quality movement and by defining the involved organizations through their missions, leadership, funding, products and relationships, providers can understand better the evolution of healthcare quality.
Healthcare quality as both a functional and political issue has moved into the forefront of providers’ consciousness. However, to most of us, this movement remains a jumble of acronyms and confusing processes. By outlining the history of the healthcare quality movement and by defining the involved organizations through their missions, leadership, funding, products and relationships, providers can understand better the evolution of healthcare quality. Such understanding is vital to learning how quality efforts are characterized and administered today. Processes that define, measure and report healthcare quality have moved from practitioner-controlled entities toward consensus-based, cooperative efforts involving all stakeholders. The following analysis will offer insight into how healthcare quality has evolved from its origins as a professional issue, to the widely publicized – often contentious – multi-stakeholder debate of today.
Although the concept of healthcare quality has been thrust into the public and political consciousness in the last decade, its roots within the healthcare profession began in the early 20th century.
In 1910, Abraham Flexner published The Flexner Report, the first account of poor conditions within U.S. medical education systems and hospitals. Six years later, Ernest Codman, a Boston surgeon and founder of outcome measures in patient care, privately published A Study in Hospital Efficiency to publicize common patient care errors at his hospital.(1) Codman sought to improve the quality of care for surgical patients. His influence contributed to the Hospital Standardization Program initiated by the American College of Surgeons (ACS) in 1917.(2) The program defined five “minimum standards” focused on the quality of in-hospital care through organization and accreditation as well as through supervising medical records, laboratory and radiologic services.(1) Hospitals underwent surveys to be credentialed. In 1952, the ACS, the American College of Physicians (ACP), the American Hospital Association, the American Medical Association (AMA) and the Canadian Medical Association, formed The Joint Commission on Accreditation of Hospitals (today The Joint Commission), which continued to accredit hospitals based on “minimal standards.”(2)
Quality assessment proceeded along these practitionerdefined and -controlled lines until President Lyndon Johnson introduced the 1965 Social Securities Act creating Medicare and Medicaid. “Conditions of participation” included a requirement to be accredited by The Joint Commission.
In response to the more rigorous expectations set by Medicare, The Joint Commission moved toward “optimum achievable standards” in 1966.(1) That same year, the definition of quality care was again re-framed through an article published by Avedis Donabedian, a public health scholar who outlined a new approach to assessing the quality of medical care through examination of three areas of care: structure (facilities and their organization), process and outcomes.(3) The Joint Commission and others eventually gravitated toward this model of quality assessment, which is still used today.
The Joint Commission expanded its audit process into hospital-wide quality assurance programs in the late 1970s. This new approach utilized non-medical reviewers to perform generic screens and monitor clinical indicators, and incorporated physician profiling.(1) Continued focus on structure and outcomes through hospital accreditation led to the 1988 “Agenda for Change,” in which The Joint Commission announced its intent to develop, measure and test its own set of performance measures.(2)
The 1970s began a period of divergence in healthcare quality assessment – the result of non-physician stakeholders entering into the processes of defining, measuring and reporting healthcare quality.
The first significant external quality organization was the Institute of Medicine (IOM). Founded in 1970 as the health arm of the National Academy of Sciences, it serves as an adviser to the nation in the improvement of health.(4) The IOM , a non-profit, non-governmental organization that works to provide balanced information to healthcare stakeholders, is led by physicians and others with expertise in medicine and medical affairs. Evidence gathered by the IOM through studies, consensus committees, forums and roundtables is compiled into reports utilized by all healthcare quality stakeholders in the areas of process and outcomes.
Founded in 1972 by Robert Wood Johnson of Johnson & Johnson Services, Inc., the Robert Wood Johnson Foundation (RWJF) is the largest philanthropic organization in the United States devoted solely to heath and healthcare. It seeks to “confront the most pressing health and healthcare problems threatening our society.”(5) RWJF also supports multiple quality initiatives, such as the Quality Alliance Steering Committee (QASC) and the National Quality Forum (NQF).
The governmental and physician provider roles in defining healthcare quality continued to evolve alongside the non-provider organizations. The Social Security Act amendment of 1972 established the Professional Standards Review Organization (PSRO), a network of physician-run organizations tasked with reviewing services provided to Medicare/Medicaid recipients. PRSOs evaluated efficiency/utilization and collected basic data on patients, providers and hospitals.(1) Found to be ineffective, PRSOs were replaced by Peer Review Organizations (PROs) in the early 1980s.
The Omnibus Budget Reconciliation Act of 1986 enabled Congress – in conjunction with the IOM (established as the premier resource for unbiased and authoritative advice on healthcare quality) – to study quality assurance for Medicare. This was the first notable use of external consensus reporting by the federal government to steer the process for improving healthcare quality.
IOM published recommendations in 1990 and covered four areas: definitions of quality care and quality assurance, methods for measuring quality, the need for research and professional experts, and a strategy for implementation of a quality assurance program for Medicare and Medicaid.6 Among the findings were the recognition that PROs were not effective and a recommendation to enact a Medicare Program for Quality Assurance (MPQA) that would be proactive and foster internal quality improvement. Also, the report asked the Department of Health and Human Services (HHS) to “support, expand and improve research in and the knowledge base of the efficacy, effectiveness and outcomes of care and to support a systematic effort to develop clinical practice guidelines and standard of care.”(6) HHS acted on these recommendations the following year, creating the Health Care Quality Improvement Initiative. This initiative worked toward continuous quality improvement and contained the first major effort toward utilization of practice guidelines. It also resulted in the creation of the Agency for Healthcare Policy and Research (later called the Agency for Healthcare Research and Quality [AHRQ]).(1)
The AHRQ mission is to “improve the quality, safety, efficiency and effectiveness of healthcare.”(7) It “supports research that helps people make more informed decisions.”(7) AHRQ is one of 12 agencies inside the HHS. It is directed by a physician and has eight office/center directors who are both physicians and non-physicians. A 21-member panel of private sector experts advises the director on priorities for the department’s efforts. This panel is composed of representatives from seven federal agencies (including the Centers for Medicare and Medicaid Services [CMS[), healthcare plans, providers, purchasers, consumers and researchers. AHRQ sponsors research in the areas of quality improvement, patient safety, and healthcare value, resulting in the development of quality-related products.
The following decade was marked by a significant escalation in the number of quality entities – both collaborative and independent – influencing the processes that defined healthcare quality. These efforts were at times, duplicative and uncoordinated.
In 1991, the Institute for Healthcare Improvement (IHI) was formed to “improve the lives of patients … by focusing on .. six improvement aims for the healthcare system: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.”(8) Led by a management team that includes physician and non-physician members, the IHI’s efforts center on healthcare models, adaptation of best practices and promotion of innovation. A board of directors that includes The Joint Commission and RWJF representatives oversees work and utilizes influential physicians and scientists as senior fellows for strategic planning. The IHI is funded through its own fee-based services and donations from private entities such as RWJF.
The NQF was created in 1999 at the recommendatioof yet another government-requested investigation. The 1998 President’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry recommended that a private sector entity be created to bring stakeholders together, standardize performance measures and promote public reporting.(9) The NQF operates under a three-part mission: to improve healthcare quality by building consensus on national priorities and goals for performance improvement, to endorse national consensus standards for measures and publicly reporting on those measures, and to promote these goals through education and outreach programs.(10) The organization’s 27-member board of directors (representing key stakeholders in the private and public sector as well as CMS, AHRQ and the National Institutes of Health) has three standing committees to guide the Forum’s actions: the Consensus Standards Approval Committee (CSAC), National Priorities Partnership (NPP) and the Leadership Network. More than 500 participating organizations are grouped under eight councils, which include the Health Professionals Council and the Quality Measurement, Research and Improvement Council. NQF draws funding from public and private sources, including grants from foundations, corporations, and the federal government; RWJF, CMS, AHRQ , as well as industry, also provide financial support. Thirty-four percent of the organization’s total funding comes directly from membership dues. The NQF also has been awarded government contracts by HHS. Its products include best practice standards and measure endorsements (257 of these are hospital-related measures).(10)
In 2000, corporate America entered the playing field of healthcare quality with the launch of The Leapfrog Group, a collection of large companies seeking to use their purchasing power to influenced healthcare quality.(11) The group now represents both corporations and agencies responsible for buying healthcare benefits. The Leapfrog Group began to collect hospital data in 2001 (now published as the Leapfrog Hospital Survey) and assesses efforts to improve the safety, quality and efficiency of care through implementation of practices endorsed by the NQF.
The IOM continued to champion for refinement and expansion of healthcare quality improvement through landmark publications, such as “To Error is Human” in 2000 and “Crossing the Quality Chasm: A New System for the 21st Century” in 2001. These reports highlighted the impact of preventable medical errors and the failure of healthcare systems to provide consistent, high-quality medical care to all people.(12,13) They outlined strategies for improvement in patient safety, along with reinvention of our system to improve delivery of care and to comprehensively raise standards and expectations for healthcare quality.(12,13) Within the 2001 report, the IOM promoted a definition of high-quality care that remains the standard today: “care that is safe, effective, patient-centered, timely, efficient and equitable.”(13) These reports marked a transition in the efforts of stakeholders away from individualized efforts to define, measure and promote healthcare quality and toward collaboration to accomplish common goals.
The Hospital Quality Alliance (HQA) was formed in 2002 as hospitals joined with consumers, physician and nursing professional organizations, employers and purchasers, oversight groups and the government to develop, promote and report performance measures of hospital care.(14) Principal members include AHRQ , CMS, The Joint Commission, NQF and the Society of Critical Care Medicine. The HQA’s 21 principals work together in groups and collaborate with other quality improvement organizations. The measurement workgroup evaluates outpatient and inpatient measures in a timeframe that is concurrent with the NQF measure-endorsement process. The vision workgroup creates strategy for enhanced public reporting. One HQA product is Hospital Compare (http://www.hospitalcompare.hhs.gov), a website within the HHS domain that contains hospital performance information based on NQF quality measures.
In 2003, CMS and The Joint Commission joined forces to create the National Hospital Inpatient Quality Measures. These common “core measure sets” include acute myocardial infarction, children’s asthma care, heart failure, hospital-based inpatient psychiatric services, hospital outpatient department measures, perinatal care, pneumonia, stroke, surgical care improvement project and venous thromboembolism.(2)
The AQA (formerly the Ambulatory Care Quality Alliance) was formed in 2004 by the American Academy of Family Physicians (AAFP), the ACP, America’s Health Insurance Plans (AHIP), and AHRQ. The intent was to improve performance measurement, data collection and data reporting in the ambulatory setting.(15) Since that time, the AQA has become as a coalition of more than 135 organizations that develop and promote a common strategy for performance measures on a physician level in multiple settings. The organization’s work is accomplished through three workgroups: Data Sharing and Aggregation, Performance Measurement, and Reporting.
In 2006, HQA and the AQA joined with other stakeholders to develop an overall framework for the use of standardized quality measures.(16) They formed the Quality Alliance Steering Committee (QASC) whose membership is now inclusive of AHRQ , The Joint Commission, NQF, RWJF, and CMS, as well as healthcare professional organizations, purchasers, insurers, and hospitals. Funding sources for the QASC are not made readily available. Its mission is to better coordinate the promotion of quality measures identified by both the HQA and AQA and to allow for their consistent and effective implementation. The work of the QASC is carried out through workgroups chaired by members and populated with appointed subject matter experts. There are three standing workgroups: Episodes of Care, Measure Implementation and National-Regional Implementation.(16) The membership utilizes the products of the work groups to further the work of their representative organizations.
In 2008, marking the most important act of convergence, the NQF convened the National Priorities Partnership (NPP) to counsel HHS on setting national priorities and goals for the HHS National Quality Strategy.(17) The partners in this collaboration included AQA, HQA, IHI, IOM, The Joint Commission, the Leapfrog Group, NQF, QASC, AHRQ and CMS. The NPP set six priorities: Patient and Family Engagement, Population Health, Safety, Care Coordination, Palliative Care and End-of-Life Care and Overuse. Work in these six areas has already resulted in the IHI’s Triple Aim initiative targeted toward effective and appropriate care without unnecessary resource utilization and CMS’s program aimed at reducing readmissions and optimizing patient transitions across care settings.(17)
The Affordable Care Act (ACA) of 2010 required HHS to develop a National Strategy for Quality Improvement in Health Care and charged the NQF with giving input into the development of HHS’s National Quality Strategy.(9) In addition to the NPP and as a part of the obligation established under the ACA, the NQF created the Measures Application Partnership (MAP),(10) whose purpose is to identify the best available healthcare performance and provide input measures for use in public reporting, value-based payment, and other programs.(10) This partnership is overseen by a multi-stakeholder coordinating committee, and work is accomplished through advisory workgroups: Ad Hoc Safety, Clinician, Dual Eligible Beneficiaries, Hospital, and Post-Acute/ Long-Term Care. The Hospital Workgroup today is focused on readmission and healthcare-acquired condition measures. Processes for participation in workgroups are transparent and public, allowing the broadest level of stakeholder participation.
The landscape of healthcare quality now looks very different from that of Codman’s era. Healthcare providers still hold prominent seats at multiple tables where quality is defined, measured and analyzed. As we move to a more collaborative approach, healthcare providers share overlapping roles with the government, private and public sectors when it comes to quality improvement. Providers must be well informed of the motives of the other stakeholders and embrace the strengths that their perspectives bring to the discussion. High-reliability and lean approaches, process improvement tools, and suggestions for increased patient/consumer engagement are just a few concepts being introduced by non-provider stakeholders.(9) Healthcare providers can engage in this process through professional societies, by providing individual responses during public comment periods, or by serving as representatives and leaders for improvement programs at all levels. The Society of Critical Care Medicine represents the interests of intensive care professions with the HQA (Ivor Douglas, MD) and the MAP (Mitchell Levy, MD, FCCM). Engagement is key, or providers risk further weakening their ability to guide and influence those processes that greatly affect practices.
The process of defining, measuring and reporting healthcare quality has evolved from a provider-based process to a collaborative, consensus-based one that involves all stakeholders. Our definition of quality has moved from one solely concerned with structure and outcomes, to one that incorporates consensus-based process, outcomes and standardized care measures, public reporting and continuous re-evaluation and improvement of measures. Armed with a better understanding of how the issue of healthcare quality emerged, as well as the players involved, providers can be poised to meet their professional obligations and participate in the evolution of the healthcare system.

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 The author has no disclosures to report.