Quality of Care – Center for Medicare Advocacy

for more information, follow one of the links below or scroll down the page.

• introduction
• perception versus reality: ‘the quality chasm’
• non-delivery: causes of poor care
• grievance process for quality of care
• what are the standards of care by which quality is judged?
• quality reporting systems: how to choose the best caregivers
• the business case for quality
• pay for performance
• when quality works: a case study
• Maintaining Dignity: Advocacy Tips for Institutions and Patients
• guarantee quality laboratory services
• articles and updates

introduction: what do we understand by quality of care?

quality of care is becoming an increasingly important topic of discussion for researchers and policy advocates. however, its importance as a promotional tool for obtaining and maintaining services is often less obvious. these issues are integral to understanding who receives care, the promptness and appropriateness of care, and to understanding systemically why quality and access problems occur. A focus on quality allows grantees and their advocates to participate in developing appropriate monitoring and enforcement of quality standards. The Center for Medicare Advocacy focuses on quality not only to increase general consumer awareness of this important issue, but also to highlight the use of this growing body of knowledge by advocates to secure and expand services. Racial and ethnic minority populations and the disability community in general should pay special attention to these issues because these groups tend to receive less support from the health care community.

Reading: Quality of care review

the united states institute of medicine (iom) defines “quality” as: the degree to which health services for individuals and populations increase the likelihood of obtaining desired health outcomes and are consistent with current professional knowledge. what this really means is that each individual consumer should receive the best medical care available whenever services are needed. Health care providers must provide care that meets the needs of each individual patient, including the use of appropriate advances in medical technology. Health care must also be non-discriminatory and provide the same quality of service regardless of race, ethnicity, age, sex, or health status.

quality of care: problems and concerns

in november 1999, the institute of medicine published “to err is human,” a groundbreaking study from the us. uu. health care system. Their findings indicated that at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of preventable medical errors. (institute of medicine 1999) Since then, multiple studies have been conducted on various topics, and the results have repeatedly corroborated the iom’s claims.

quality of care continues to be an area for improvement, despite the increased attention it has received in recent years. although researchers and survey organizations have focused on safety and quality through public campaigns and quality measurement and reporting, largely on a voluntary basis, little has been done with this information to make changes to improve quality

everyone, however, has the right to receive timely care that meets the highest quality standards in health care. It is important that consumers and advocates understand the right to high-quality care and take action to ensure that quality care is universal. the task becomes working to translate written standards into practical standards of treatment and care, including establishing an environment or “culture” that promotes patient safety and the highest quality care.

resource tip: make sure you’re getting safe, quality care. check out the agency for health care research and quality guide (http://www.jointcommission.org/topics/default.aspx?k=822&b=) and talk about uptm joint commission on accreditation of health organizations’ (jcaho).

perception versus reality: the “quality chasm”

repeated studies have shown that poor care persists in the united states. In a 2003 article published in the New England Journal of Medicine, the Rand Corporation found that “…on average, Americans receive about half of the recommended healthcare processes…the gap between what we know works and what is actually done is important enough to warrant attention.” (Mcglynn, Elizabeth, et.al. 2003.) These “quality gaps” are persistently found as more and more organizations focus on this problem. recent iom reports produced these indicators:

• Only 55% of patients in a recent randomized sample of adults received recommended care, and little difference was found between care recommended for prevention, to address acute episodes, or to treat chronic conditions

• The time lag between the discovery of more effective forms of treatment and their incorporation into routine patient care averages 17 years.

• 18,000 Americans die each year from heart attacks because they were not given preventive drugs, even though they were eligible to receive them.

• medical errors kill more people each year than breast cancer, AIDS or car accidents.

  (institute of medicine 2003, http://content.nejm.org/cgi/content/full/348/26/2635)

  resource tip: Take steps to ensure you get quality care with 20 tips to help prevent medical errors from the Agency for Health Care Research and Quality.

  failure in childbirth: causes of poor care

  what’s wrong? The causes of poor care can be divided into two equally important parts:

  • structural factors in our health care system that result in poor quality care
  • structural factors in our society that result in poor care.

  The first category can affect all Americans at random. the second disproportionately affects minority populations such as women, racial and ethnic minorities, the elderly, or people with disabilities. Because these two causal categories have such a strong impact on quality of care, it is imperative that advocates are aware of the unique issues each category poses and how to address them to create the best solutions.

  The US health care system, while among the best in the world, faces multiple systemic barriers to providing the best possible care for every patient. In its 2003 State of Health Care Quality report, the National Committee for Quality Assurance cites six major factors that prevent many Americans from receiving the highest standards of care. include:

  • the slowness with which the health care industry adopts new technologies, information and guidelines.
  • current and historical lack of government incentives, standards, or direction.
  • inconsistent care from physicians and other health professionals.
  • lack of widespread collaboration and information sharing among health care organizations.
  • the failure of existing funding and reimbursement mechanisms to provide incentives for excellence.
  • the failure of the health system to measure and report on performance.

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  (national quality assurance committee 2003)

  These issues are widespread and endemic in the health care system, and need to be addressed nationally as well as at each individual facility.

  There are many people who do not receive quality care because of their race, ethnicity, gender, socioeconomic status, age, or health status. As evidenced by the current national debates on universal health care, not everyone has insurance or access to health care. Beyond that, there are many specific groups that often cannot access the same quality of care as the general population. Some of these groups include: women, children, the elderly, racial and ethnic minority groups, residents of rural areas, people with mental disabilities or disabilities, people in need of long-term care, and other people with special needs. In the 2003 National Health Care Disparities Report, the Agency for Health Care Research and Quality cites four factors as key barriers to the delivery of quality care. these include:

  • admission to the health system; accessibility of care.
  • structural barriers; the ease of navigating the system to receive the best care.
  • patient perceptions; cultural and socioeconomic relationship problems between patients and providers.
  • utilization of attention; access the right care at the right time.

  (Agency for Health Care Research and Quality 2003)

  These factors sometimes result in severe disparities in the quality of care provided to the general population and the care received by minority populations. it is important that both consumers and advocates are aware of the multiple factors that cause such disparities in care and learn to combat them.

  resource tip: Learn what providers can do to prevent health care disparities in quality guidance and provider culture.

  what are the standards of care by which quality is judged?

  There are several organizations that oversee the quality of care provided by health care providers and set standards of acceptable care. Some of the major ones include: The Joint Commission on Accreditation of Health Care Organizations (JCHAO), The Leap, The American Association for Healthcare Quality, The Institute for Safe Medication Practices, The National Center for Leadership in health care, the national coalition for quality health care, the national committee for quality assurance, the national forum on health quality, and the center for medicare and medicaid services (cms).

  The standards affect the accreditation status of hospitals and other health care facilities and include many standard point-by-point-of-care processes that all accredited hospitals must adhere to. Health care facilities are regularly inspected by the standards-setting organization to determine their level of compliance with the organization’s standards of care. The facility’s accreditation status is then assessed and the report is made available to consumers. the idea is that if a facility is found to meet the standards, it is accredited and consumers will be able to know that they will receive care from that facility in accordance with published standards.

  There has been some criticism regarding the effectiveness and adequacy of these standards. A consortium of employers called LeapFrog that has come together to advocate for quality improvement has been specifically criticized. however, independent studies on the impact of standards on quality of care are few and far between. Most of the information on how well standards work to promote change effectively comes from the standard-setting organizations themselves. because of this, it is important that consumers and advocates be especially careful when trusting data collected from these sources. it is useful to compare more than one study to ensure a complete picture of the situation.

  resource tip: check the accreditation status of health care facilities online at the jchao quality assurance site.

  quality reporting systems: how to choose the best caregivers?

  Although some consumers are aware that quality issues exist, it is difficult to know how to choose a health care provider based on quality of care. Currently, there is no consistent or organized national quality reporting system in the US health care industry. Although public and private plans are making quality information available to their members (particularly CMS’ Hospital and Nursing Home Comparison), most consumers rely on word-of-mouth recommendations to choose their health care providers. medical attention. this is problematic, as reputations are often based on anecdotal evidence.

  To improve quality of care, reporting systems must become more comprehensive, standardized, and widely available. plans, hospitals, and other providers must use the information they report to make meaningful reviews and changes to improve quality. Steps should also be taken to encourage beneficiaries to use available information when choosing their health care providers. however, beneficiaries should be careful as the data is presented in different ways depending on the information source, sometimes leading to confusion or misinterpretation. most measures focus on a particular detail of care and should not be used as a substitute for measuring overall quality. many people see the internet as becoming a valuable tool in the future of quality reporting, increasing the ease of both collecting and disseminating quality of care information. however, since there is no national quality reporting system, patients should verify the reliability of their sources. (Bates, David and Gawande, Atul. 2000)

  tip: the agency for health care research and quality now has a website to help consumers choose the best health care provider for them. can be found at www.ahrq.gov/consumer/qnt/.

  what is the business case for quality?

  Although the incentives to provide quality care seem obvious, for many looking at profit margins, there is a need to make a “business case” for quality improvement. Many health care providers, focused on the “bottom line” profit margin, do not take steps to improve quality because improvements will cost money. in fact, many quality improvements, while they may have a positive impact on patients, only provide marginal savings or gains to the healthcare facilities themselves. Without evidence that there are indeed economic incentives to improve quality, it is unlikely that the private sector will move with any speed towards the adoption of proven quality improvements. (Leatherman, Shelia, et. al., “the business case for quality: case studies and an analysis” health affairs, vol 22, no. 2, March/April 2003, p. 18.) This lack of economic impetus provides a strong case for a functioning federal regulatory system that would ensure compliance with quality standards regardless of the financial consequences to the facility.

  The structure of payment systems is one of the most important factors affecting the business case for quality. In many cases, due to the way our insurance system is structured, payment is not related to quality of care, and consumers have little or no choice of health care providers. Because many Americans depend on the health benefits they receive from their employers, your choices of plans and providers are limited to those covered by the employer’s plan. similarly, the cost of procedures or medical care is determined independently between the employer plan and the health care provider before the care is received. payment is completely independent of the quality of care provided. therefore, care providers have no incentive to provide quality care; the consumer cannot stop choosing another caregiver, and cannot refuse to pay for poor care.

  According to a study by the Agency for Health Care Research, “Nearly half (45%) of respondents with employer-based coverage say they are only offered a health plan through their work, leaving them without a choice of plans to compare and, understandably, less interested in comparative information.” (“Americans as Consumers of Health Care: The Role of Quality Information,” 1/26/2003 www.ahrq.gov/qual/kffhigh.htm) there is a great need for system change to educate consumers to be sensitive to changes in quality of service and to align payment with the quality of care provided.

  resource tip: Unfortunately, a firm business case for quality has not yet been established. For a deeper look at this issue, take a look at NCQA’s site on the business case for quality.

  pay for performance

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  Insurance companies, large corporations that provide health benefits to their employees, Medicare, and other purchasers of health care are seeking to improve the quality of health care and control costs by changing the way they pay for health care: pay doctors, hospitals, and other providers more for high-quality care and less for poor-quality care. This approach is often called pay-for-performance or value-based purchasing and is gaining popularity among public and private payers[1], despite the fact that there are no systematic studies of the effectiveness of such programs[2]. quality-based variable payment is an attempt to address the persistent and well-documented “quality gap” in our health care system[3], but details of the effectiveness of such programs require further study.

  Although quality of care unfortunately varies by location, population, and procedure[4], the United States spends unprecedented amounts on health care, regardless of quality or consistency. Most current payment systems reimburse hospitals, physicians, and other providers based on the number of services, with little review of appropriateness or whether the procedure produced the desired results. many believe this system is one of the main contributors to skyrocketing health care costs. in 2003, $1.7 trillion was spent on health care, representing 15.3% of gross domestic product and a nearly 150% increase in spending since 1990.[5] This disconnect between the cost of care and the quality of that care has led private and public health care purchasers to take advantage of their position as payers to force providers to make quality improvements. today, programs tend to offer annual rewards or bonus payments on top of the provider’s regular income, which is up to a 5% increase, to those who simply report quality data. in the future, these programs will condition payment on quality improvement and achievement.

  Pay for performance is designed to address criticism of the current pay structure, which rewards providers based on the quantity of services delivered, regardless of quality. In the current system, a provider who makes investments in quality, resulting in fewer patient visits, for example, will save the health system money. however, the provider will actually lose revenue because they are providing fewer actual services. Pay-for-performance, advocates argue, would correct this disincentive by passing a portion of the savings made from higher-quality care to providers who help implement quality improvements. less services, is not an isolated measure of quality. Other factors, such as appropriateness of care and patient preferences, must be considered for such a system to be feasible and reliable.

  As large employers and buyers across the country move to incorporate performance pay into their pay structures, Medicare and Medicaid are pushing ahead with demonstration projects. Whether it is a pilot program or a full reimbursement structure, the evaluation of performance pay as a quality assurance tool should consider:

  1. Available and agreed standardized quality data: Most pay-for-performance programs seek to measure quality through standardized clinical measures. The measures could qualify, for example, if a heart attack patient received beta-blockers upon leaving the hospital. Payers, like Medicare, decide what quality measures facilities and physicians must follow to receive bonus payments. providers who wish to receive bonus payments must collect and report data showing how well they performed on those measures.

  Although pay for performance may seem straightforward, complexities arise in deciding precisely how to measure quality.[6] there are measures of quality on which there is agreement in the medical community, but there are an equal number, if not more, on which there is a great deal of uncertainty. uncertainty can arise when there is insufficient research, when research results require interpretation, or when multiple equally effective treatment options are available.[7] Furthermore, there is no single clearing house for the development of quality measures on which the bonuses are based. therefore, buyers can select the quality measures of their choice. in fact, there is much variation in the sets of quality measures buyers use for performance incentive programs, and in the way they are presented and explained.[8] one buyer might, for example, require hospitals to report whether they followed recommended guidelines for treating a heart attack patient, while another might give bonuses to hospitals that implement computerized patient records.

  It’s also important to remember that medicine evolves. the scientific community is constantly discovering new treatments and refining old guidelines. what is considered “good medicine” today can be improved or, conversely, considered inappropriate or harmful tomorrow. A study published in the New England Journal of Medicine highlights this issue in relation to guidelines for cardiac care. The study revealed that while guidelines recommend giving beta-blockers to patients at high risk for cardiac complications undergoing non-cardiac surgery, hospitals often give them to low-risk heart patients as well. a review of patient records revealed that this practice actually increased the risk of mortality in low-risk patients by 43%.[9] While most pay-for-performance programs rely only on the most widely accepted evidence-based measures, it’s important to note that even credible standards may need adjustment. any viable pay-for-performance program must account for such contingencies while maintaining consistent program principles and guidelines.

  2. Assessment and weighting of self-reported quality data: There is currently no national quality reporting system in place for many categories of healthcare providers. therefore, pay for performance is dependent on providers recording and submitting their own data. by making payment contingent on “good” data, providers may be inclined to inflate their numbers to get paid. In addition, to ensure quality improvement, Medicare’s Quality Improvement Organizations (QIOs) are charged with helping hospitals implement pay-for-performance. in fact, the payment to the qios is contingent on getting the hospitals to achieve a higher quality in certain indicators. This duplicate system is not only expensive (Qios has a budget of over a billion dollars over three years, while Medicare reserves $21 million over three years for bonds on its Premier Demonstration Project, Inc.), it also provides incentives. perverse for both the provider and the agencies responsible for oversight to game the system in order to receive bonuses.

  3. “score well” incentive limits patient access to care: Pay-for-performance programs can provide perverse incentives for providers to limit patient access to the care they need. when performance measures are inadequate or do not exist for particular conditions, providers may hesitate to accept patients with those conditions for fear of unfairly lowering their quality score.[10] This problem was highlighted in a study published in the Journal of the American Medical Association, which reported the inadequacy of certain clinical practice guidelines, especially when used for performance measurement purposes, for patients with multiple chronic conditions. the study concluded that adverse drug interactions and disease complications were likely to occur in people with multiple chronic conditions if guidelines for each specific condition were followed.[11] In a pay-for-performance system, a physician who recognizes the need to adequately manage multiple conditions to avoid adverse reactions will not necessarily earn high scores based on clinical or performance guidelines. therefore, such a system could limit a provider’s willingness to accept certain patients. a separate study on skilled nursing facilities by the inspector general shows that reimbursement rates affect the willingness of providers to treat certain patients in a timely manner. in that report, the inspector general concluded that patients whose conditions required expensive medication or treatment or who were not adequately reimbursed experienced delays in accessing appropriate care.[12] These studies highlight the danger of oversimplifying performance measurement, as well as the complexities that arise in developing a performance measurement or variable payment system that does not discriminate against patients based on payment problems or health status.

  4. Developing an appropriate balance between cost control or cost containment and quality: Although initially promoted as a quality improvement tool, performance pay is increasingly being discussed as a tool for cost containment.[ 13] many health care plans believe that rising health care costs are the result of overutilization. in his view, pay-for-performance offers an effective method of limiting unnecessary services. however, caution should be exercised, as past experience has shown that barriers to access, such as copayments, also reduce the use of necessary services.[14] using pay-for-performance to reduce utilization by limiting access is an inappropriate and potentially more costly use of a quality improvement tool.

  resource tip: many quality information brokers are publishing pay-for-performance principles. These principles represent a set of first steps in the development of widely accepted software standards in this emerging field. see american medical association (www.ama-assn.org/ama/pub/category/14416.html#ama), johns hopkins performance appraisal program along with “performance-based compensation: pay-for-performance design “American Healthways Principles” at http://www.healthleadersmedia.com/content/145150.pdf.

  when quality works: a case study

  Is consistent, quality healthcare possible? in pittsburgh, the answer is a resounding yes. Formed in 1997, the Pittsburgh Regional Health Care Initiative (PRHI) is creating an innovative model for achieving measurable and sustainable improvements in health care throughout the region. Its goal is to achieve seamless patient care across the region using specific patient-focused goals. the prhi consists of hundreds of physicians, 42 hospitals, four major insurers, dozens of healthcare buyers from companies large and small, corporate and civic leaders, and elected officials throughout the pittsburgh region. Although still in the development stages, the PRHI has achieved notable successes. Using a focus on leadership as the key to progress, the prhi set four specific goals for 2003:

  • eliminate central line-associated bloodstream infections
  • eliminate medication errors
  • eliminate hospital mortality after coronary artery bypass graft surgery
  • share each major event or learning regionally as soon as possible

  The prhi relies on a system of work groups, real-time reporting, and aggressive problem-solving systems to work toward these goals. Her accomplishments for 2003 will be announced in February 2004. For more information on this remarkable role model, click the link above or visit http://www.prhi.org.

  resource tip: find out what others are doing that is working! Some state or regional organizations include: California Health Outreach; Texas Healthcare Business Group and Massachusetts Healthcare Quality Partners.

  Maintaining Dignity: Advocacy Tips for Institutions and Patients

  Patient dignity is a central, sometimes overlooked, facet of quality medical care in hospitals and other institutions. dignified care involves several aspects, the underlying theme of which is respectful and open communication between patients and providers. patients must feel respected and involved in the decisions made about their health at all times. Lack of communication between providers and patients can leave patients feeling intimidated, confused about their plan of care, and completely cut off from the decision-making process. What follows are some suggestions that advocates, institutions, and patients can use to facilitate communication and promote patient dignity.

  defenders and institutions

  • Advocates may wish to work with local hospitals to implement a system-wide protocol for staff interaction with patients. the protocol may include some simple but significant steps providers can take to promote dignity:
  • knock on the door before entering a patient’s room and ask for permission to enter;
  • give your name verbally and conspicuously display it on your jacket in legible handwriting;
  • Before any procedure, ask for the patient’s consent. Explain what the procedure is, why you are doing it, and how it will feel.
  • inform patients whenever their plan of care is changed and explain the reasons behind the changes.
  • Hospitals should have an appropriate redress mechanism to document patient complaints regarding inappropriate behavior by staff. This may involve a broader effort to document patient satisfaction, something Medicare should incorporate into its reimbursement terms or certification requirements. such grievance procedures should include:
  • providing information to patients about their right to make a complaint, including how to start the process;
  • the ability to initiate a complaint without feeling intimidated or belittled by center staff;
  • the possibility for someone other than the staff member concerned to record the complaint in the patient’s file;
  • the serious review of the complaints by the administrators of the institution, with the objective of modifying or implementing protocols to improve the satisfaction and dignity of the patient.

  patients

  • ask questions. it is okay to ask the doctor to repeat or explain information that is not clear. Ask your doctor to write down the instructions if he thinks they are complicated or you will forget them. instructions should be readable and make sense to you.
  • When possible, have a trusted family member or friend with you at all times who is willing to talk and ask questions on your behalf.
  • Ask to see the doctor’s orders for procedures performed by other staff. this duplicated process can make you feel more in control and force staff to review orders, which can reduce medical errors.
  • Ask the staff to explain the procedures they are performing, why they are doing them, what they will feel like, and how long it will take.

  These few steps can make a significant difference in a patient’s healthcare experience. Communication between patient and provider is crucial at every step of the process, from admission to a facility to discharge and throughout recovery. Some of the steps outlined will not only enhance the dignity of the patient, but will also help ensure patient safety.

  resource tips

  For more information on what patients can do to make it easier to communicate with their providers and improve their safety while in hospital and during their recovery, see the Joint Commission on Accreditation of Care Organizations speak uptm campaign of health (jcaho). medicare is also working to improve the dignity and safety of patients through its medicare health support pilot project, which provides chronically ill patients with health coaches who help them manage their condition and maintain communication and coordination with its suppliers. more information is available at http://www.cms.gov/reports/downloads/mhs_second_report_to_congress_october_2008.pdf. The project is described in the August 8, 2005 Associated Press article titled “Health Coaches Helping Medicare Patients.”

  articles and updates

  • Gaps in Hospice Abuse and Neglect Reporting January 12, 2023
  • Study Finds Link Between Religiously Affiliated Nursing Homes and Complaints, Standard of Care Violations, April 21, 2022
  • Second State Report Recommends Ban on Medicaid Payments to Chronically Underperforming Nursing Facilities February 10, 2022
  • elderly justice newsletter, vol. 3 number 8 already available on July 8, 2021
  • Senior Justice Newsletter: Vol. 3, issue 6 now available on April 29, 2021
  • Oscar-nominated documentary infiltrates Chilean nursing home on April 22, 2021
  • Special Report: Nursing Homes Cited With Infection Control Deficiencies During Pandemic: Poor Health Inspections, Low Staffing Levels June 17, 2020
  • cdc report on coronavirus at a seattle nursing facility: what it tells us about staffing issues across the country; what we need to do to address the lessons learned April 9, 2020
  • changes to consumer cms websites on February 13, 2020
  • Study Finds Nursing Home Comparison Data on Falls of Seriously Injured Patients Unreported and “Highly Inaccurate” Jan 30, 2020

  for older articles, see our archive.

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