LDI Health Policy Seminar Series


Keeping Health Care Quality on the Policy Agenda

Thursday, April 18, 2002
Inn at PENN (3600 Sansom St.)
Mark/Regent Rm


In a spirited panel discussion and debate, national experts presented their views on how to focus and keep public attention on issues of health care quality. The April 18, 2002 panel, Keeping Health Care Quality on the Policy Agenda, was sponsored by the Leonard Davis Institute of Health Economics, the Annenberg Public Policy Center, the Center for Health Outcomes and Policy Research, and the School of Nursing at the University of Pennsylvania.

Moderator Kathleen Hall Jamison, PhD, Dean of Penn's Annenberg School of Communication, introduced the topic by recounting recent difficulties in obtaining care for her son in the middle of the night. "It is in those kinds of moments that the public comes to an awareness that the level of education it has is inadequate, that the system that serves those of us that are entitled and well-to-do isn't as good as it ought to be. In those moments you wish that we had a national debate about how to make the system work for all Americans, and to ensure not only quality care but also quality information about quality care."

Trudy Lieberman, Senior Health Policy Editor of Consumer Reports, said that most people in this country don't believe that we have a problem with health care quality. Although people might see an occasional story about wrong-site surgery or a drug mistake at the local hospital, "most of them don't have a clue about the pervasive overuse, misuse, and underuse of medical care in this country," she stated. Deep cultural biases favorable to health care, such as "the doctor is always right," "more in medicine is always better," and "we have the best health care system in the world," obscure the public's view of gaps in health care quality, Ms. Lieberman explained.

She criticized consumer-oriented efforts to deal with quality issues, such as report cards, "as fragmented and sporadic at best, and often very self-serving." She observed that many Internet efforts involve "companies trying to make money by selling all kinds of data that somehow is going to make you a better 'consumer' of health care." Compiling data and translating them into useful information for consumers is a difficult and expensive task, she said, pointing to recent work with the California Healthcare Foundation to rank Medicare HMOs on various quality measures. But before these kinds of activities can work, she said, a national strategic plan is needed to chip away some of the cultural biases, and convince people that there is a problem. Applying the lessons of Marketing 101, she stated that this plan must start "where people are at." The challenge to the press and to quality advocates, she said, is to make sure that health care quality is not "a one-day story."

One case study in gaining and maintaining attention to quality was the Institute of Medicine's 1999 report, To Err is Human, according to Gregg Meyer, MD, Director of the Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality (AHRQ). It garnered the attention of the public, Dr. Meyer said, because people understood the story of patient safety and could relate to it. Within 90 days of the IOM report's release, he added, a major federal initiative, "Doing What Counts" was launched, which pulled together major federal agencies to address patient safety. The federal policy response was vigorous, resulting in 90 action items now being initiated. This includes the development of annual national health care quality reports, which AHRQ will begin to release in fiscal year 2003.

In terms of gaining attention and motivating action, Dr. Meyer asked, "Was the patient safety story the model, or was it the aberration?" The second IOM report, Crossing the Quality Chasm (2001), generated far less attention, although commentators have referred to it as "the rest of the iceberg," extending the findings of the first report to the broader quality problems. "The public policy reaction to this report was relatively muted," Dr. Meyer explained, partly because the recommendations were less prescriptive that in the first report. He noted that the third IOM quality report, Envisioning the National Health Care Quality Report (2001), garnered almost no publicity, but it provides the framework for the upcoming AHRQ report. He hoped that the release of the report in September of this year would be "above-the-fold" news in every newspaper in America.

Dr. Meyer reviewed some of the take-home messages from the three IOM reports. First, rather than focusing on medication error rates, he said, we need to move to a systems approach, where people have access to and understanding of the systems that are associated with the provision of high quality and safe care. Second, we need to recognize that health care quality and patient safety is not the responsibility of any one part of the health care sector, but rather, everyone's job. "This is really a shared commitment that we need to make," he said, to translate national reports and data into action items that can help us reach the goals set forth in the IOM reports.

Dennis O'Leary, MD, President of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), also commented on the attention garnered by the first IOM report on patient safety. He pointed to two reasons for its success: one, that negative messages seem to get more media and consumer attention, and two, that most people have personal experiences of, or know someone who has experienced, medical errors. He encouraged this emphasis on patient safety in hospitals for a number of reasons, including "doing first things first." Hospitals are a reasonable place to start, he said, because they are the most complex places for health care delivery, and therefore the most error-prone and dangerous. "They also have the most resources available to address the error issue," he said. However, attracting new resources and convincing health care leaders to deploy organizational resources will be difficult, if not impossible, without the sustained attention of the public and legislators.

Hospital leaders are not enthusiastic about quality improvement initiatives in the absence of public pressure and support. Dr. O'Leary noted that a typical reaction is, "So you want me to spend a lot of money to produce data that is going to embarrass me?" He mentioned other barriers to quality improvement-such as a lack of standardized measures, inadequate information systems to collect data, inadequate resources to pay for data collection and translation, and technological issues such as small sample sizes and measures of questionable validity. Given these barriers, he noted that quality improvement can become a "quagmire." Part of the solution, Dr. O'Leary said, is to help people translate data into knowledge and systemic strategies. "If we are going to make any progress in quality improvement, people have to understand what to do with the data. Collection of data is not an end point, it is a beginning point." Improving health care quality, he concluded, "is not an impossible job, but a long and difficult journey."

Kenneth Shine, MD, provided his viewpoints as the President of the IOM and as a practicing physician. He pointed to the need for a new communications strategy about quality, one that would invent a new vocabulary for discussing the issues. "The word quality not only turns off the press, it also turns off doctors who equate quality with cost containment or cost reduction," he said. The new vocabulary should include patient safety, which Dr. Shine believes the public and health care professionals will embrace. "The public believes that their own doctor is fantastic, but the system stinks," he said. The challenge is to communicate gaps in the quality of the system without scaring or disenfranchising people, he added.

Dr. Shine echoed the need to translate data into actions, but emphasized that the audience for outcomes data are institutions rather than individual physicians or consumers. "Most people will choose that which is convenient, and that which their doctor refers them to," Dr. Shine said. The key is to provide data on outcomes in the public domain that cause institutions to change their behavior. Dr. Shine also stressed the need for financial incentives for physicians and other providers to improve quality. "The American health care non-system delivers exactly what you pay for. As long as we continue to pay for what we've got, we're going to continue to get it." But he voiced optimism about advancing the quality agenda, citing the rise of consumerism, and the development of public and private sector initiatives such as the AHRQ national quality report, Leapfrog, and the National Quality Forum.

Reacting to the panelists, Linda Aiken, PhD, RN, Director of Penn's Center for Health Outcomes and Policy Research suggested that making a "business case" for quality was critical to advancing quality initiatives. If consumers are given the flexibility to pay for higher quality, or if higher quality can be shown to reduce costs, then health care decisionmakers will implement quality improvement strategies. To promote public awareness of gaps in quality, Dr. Aiken suggested linking quality to issues that the public does understand, such as the acute nursing shortage and dissatisfaction with HMOs.

David Asch, MD, MBA, Executive Director of Penn's Leonard Davis Institute and general internist at the VA, encouraged the group to consider how quality improvement strategies "trickle down" to affect clinical care. He cautioned against seeing data and information technology as a panacea for improving clinical care, especially in outpatient settings. The VA has implemented many information systems to improve care, such as online medical records, electronic order entry, and automated reminders for preventive care. While this has changed clinical care and probably improved it, according to Dr. Asch, it leaves less time to talk about the clinical issues the patient might bring up. He commented that when the computers go down, and the built-in quality improvement measures turn off, "We have a great time and I get to be a doctor with my patients."

Although keeping quality on a national agenda is important, ultimately quality is a product of local and individual decisions, according to Mary Foley, RN, MS, President of the American Nurses Association. She commented that the goal was to give everyone access to satisfactory, safe care at the local level. Under the umbrella of patient safety, legislators and the public have begun to ask important questions about the level of nurse staffing and to seek reassurance that they will be cared for by well-trained, competent staff when hospitalized.

Mark Pauly, PhD, health economist at Penn's Wharton School, questioned the current emphasis on quality. "I'm much more concerned about the uninsured, who don't get to be patients," he stated. He disagreed about the extent of the gap in quality, saying, "For middle class people, quality's not that bad, and getting better." Bringing the uninsured into the system we have now, Dr. Pauly maintained, would have a much bigger impact on overall quality than the current focus. But he agreed that to the extent that care could be improved, more financial incentives for consumers would be required. "The system won't really change unless consumers can be induced…to care about quality."

The panel was the inaugural event of an invitational, state-of-the science conference on measuring and improving health care quality, organized by Norma Lang, RN, PhD, Professor of Nursing at Penn. The conference was supported by the Agency for Healthcare Quality and Research, Annenberg Public Policy Center, American Academy of Nursing, the National Institute of Nursing Research, and the American Nurses Association. The panel was dedicated to John Eisenberg, the late director of AHRQ and former chief of the Division of Internal Medicine at Penn.

3:30 - 4:30pm            Reception

4:30 - 4:40pm            Welcome & Opening Remarks

David A. Asch, MD, MBA
Robert Eilers Professor and Executive Director
Leonard Davis Institute of Health Economics, University of Pennsylvania

Norma Lang RN, PhD, FAAN, F.R.C.N.
Professor, Lillian S. Brunner Chair in Medical Surgical Nursing
Senior Research Fellow, Annenberg Public Policy Center, School of Nursing
University of Pennsylvania

4:40 - 6:30pm            Panel Discussion

Kathleen Hall Jamieson, PhD

Professor and Dean, The Annenberg School for Communication
University of Pennsylvania

Trudy Lieberman
Senior Health Policy Editor, Consumer Reports
Gregg Meyer, MD
Director, Center for Quality Improvement and Patient Safety
Agency for Healthcare Research and Quality
Dennis O'Leary, MD
President, Joint Commission on Accreditation of Healthcare Organizations
Kenneth Shine, MD
President, Institute of Medicine

Linda Aiken, PhD
Claire M. Fagin Leadership Professor in Nursing
Director, Center For Health Outcomes and Policy Research
University of Pennsylvania School of Nursing
David Asch, MD, MBA
Robert Eilers Professor and Executive Director
Leonard Davis Institute of Health Economics, University of Pennsylvania
Mary Foley, RN, MS
President, American Nurses' Association
Mark Pauly, PhD
Bendheim Professor and Chair, Health Care Systems
The Wharton School, University of Pennsylvania

The panel is sponsored by the University of Pennsylvania Leonard Davis Institute for Health Economics, Center for Health Outcomes and Research, School of Nursing and the Annenberg Public Policy Center as part of a larger state-of-the science conference supported by the Agency for Healthcare Quality and Research, Annenberg Public Policy Center, American Academy of Nursing, the National Institute of Nursing Research, and the American Nurses.

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