Module 2: A Framework for State-Led Quality Improvement
States can play a central role in improving the quality of health care for their residents. This module presents a framework to help States play this role.
Key Ideas in Module 2:
- States can play a strategic role in designing, implementing, and assessing health care quality improvement.
- Existing models for quality improvement can be adapted to enable States to play a leadership role.
- The State-led framework is adapted from quality improvement models in other industries and incorporates a Plan-Do-Assess approach.
- The State-led quality improvement framework contains three stages:
- Provide leadership to create a vision.
- Work in partnership with key stakeholders.
- Implement improvement by creating interventions and assessing their impact.
Quality Health Care and the Quality Improvement Movement
Health care quality has been defined as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge" (Institute of Medicine [IOM], 1990). Increased attention to quality of care in recent years has highlighted the gap between optimal health care and the care that Americans typically receive. While producing unrivaled innovation and new medical treatments, the U.S. health care system struggles to deliver high quality care consistently. Researchers estimate, for example, that nearly 100,000 people die annually in the United States because of medical errors (IOM, 2001). And even when fatal errors are not involved, people receive appropriate treatment only about half of the time (McGlynn, et al., 2003).
Compared with other industries in the United States, health care has been slow to embrace quality improvement (Chassin, 1998). By contrast, some manufacturing- and service-based industries have implemented sophisticated and rigorous quality improvement processes, such as the Six Sigma movement adopted by large firms including Motorola and General Electric. This movement is named for its goal, "six sigma," which refers to a measure of extremely low tolerance for mistakes. Specifically, six sigma represents 3.4 defects per million events (Spanyi and Wurtzel, 2003). The Six Sigma approach thus sets a very ambitious goal for reducing error. Health care processes typically operate at a considerably higher tolerance for error—500,000 defects per million opportunities (based on the conclusion of McGlynn, et al., 2003)—or less than two sigma rather than six.
One of the obstacles to quality improvement in health care has been a lack of rigorous measures and data to drive improvement. To help address this gap, the Agency for Healthcare Research and Quality (AHRQ) released the first National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR) designed to establish a baseline of quality measures for tracking health care quality in the United States in 2003. The second NHQR and NHDR were released in 2004 and began to track health care quality. The 2004 NHQR concluded that quality is improving in many areas, but change takes time, the gap between the best possible care and actual care remains large, and further improvement in health care is possible (AHRQ, 2004b).
In addition, AHRQ has begun to develop resource guides and workbooks aimed toward helping States take action to improve quality of care for specific chronic conditions (e.g., diabetes and asthma). These and other resources from AHRQ and other Federal agencies designed to stimulated quality improvement are listed at the end of this module.
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A Strategic Role for States
Improving quality of care requires active involvement from many participants—providers, patients, payers, policymakers, and the public. Among all of these stakeholders, however, State governments have a unique leadership role to play. Small networks of providers have developed around quality improvement, but strong leadership at the State level is needed to help these develop, coalesce, and survive. States also have a span of control over a network of providers that they license and can help integrate the efforts of the various networks. Furthermore, they have the ability to lead providers in developing a quality improvement process and can muster a statewide impetus behind small efforts that might otherwise die for lack of energy. Some parts of State government stand to benefit from quality improvement in terms of improved services and lower costs. These include Medicaid agencies and mental health and substance abuse agencies that also control payments to providers.
To lead a quality improvement effort, States need a model of how to improve quality and a way to target areas for improvement. These are discussed in more detail below.
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Developing a Framework for State-Led Quality Improvement
None of the current models for quality improvement used on the front lines of medical care addresses a strategic role for State governments. Therefore, this Resource Guide proposes a State-led quality improvement approach that combines general models from product manufacturing with specific models developed for health care services. Advocates of quality improvement have argued that a quality improvement model adapted from manufacturing can work just as well in service industries (Harry 1998, as cited in Chassin 1998). Various quality improvement models used in different circumstances are discussed below then a State-led framework, built by borrowing from other models, is presented.
General models of quality improvement are based on the "Plan-Do-Check-Act" or the "Plan-Do-Study-Act" (PDSA) model (Langley, et al., 1996). Within a production process, these models convey the importance of the following:
- Planning—Identifying the problem and potential solution.
- Doing—Actually testing out the proposed solution.
- Studying—Measuring to see if the solution worked.
- Acting—Implementing the successful solution.
Two key features of this model are measurement and the continuousness of the process. Organizations measure the effect of a change to know whether the solution is working. A familiar mantra in quality circles is: "Without measurement, there can be no improvement." If the test solution did not work, the group starts again to plan a better approach, do another test, and assess its effect. Businesses apply this continuous process of planning, doing, and assessing until they know they have solved a problem. Then they implement the solution company wide.
Although this model has stood the test of time in manufacturing circles, it requires special application in health care. Unlike centrally controlled manufacturing processes, health care delivery is decentralized and resistant to top-down directives from government, corporate decisionmakers, or professional organizations. Health care quality improvement happens in clinical settings, often one patient at a time. The decentralized nature of health care delivery thus creates a substantial obstacle to implementing large-scale quality improvement programs. In light of this fact, the components of the process must be carefully adapted to the health care setting.
Three components in particular that need special attention are the composition of the team, the plan for measurement and assessment, and the implementation process. First, the quality improvement team is as crucial to success as the process. This is true in companies that compose their teams of knowledgeable and empowered employees, but more so within complex systems of disconnected entrepreneurs, such as in medicine. Highly effective teams are committed to the process, champion the cause, apply their energy to implement solutions, and continue the quality improvement cycle by moving on to the next problem. Achieving this in health care can be particularly challenging. A State's leadership can influence the composition of the team.
Second, the plan for measuring and assessing which proposed solutions are likely to work requires data collection, careful analysis, and skillful interpretation. While the quality improvement objective should be paramount and data and analysis should not paralyze the quality improvement team, the complexity of the health care system will present challenges to measurement and assessment. Fragmentation of the health care system, financial incentives that can discourage change, busy practitioners who may believe they have little time for quality improvement, and solo practice or employment arrangements that promote practitioner independence are special challenges to instituting change. A State's experience around data collection can be an important asset to the team
Finally, while implementation within the walls of a manufacturing plant may be straightforward, implementation in a complex health care environment may not be. Thus, the plan-do-study part of the cycle may be needed to help implement change—plan the change, measure its spread, and assess its impact on the goal. A State's involvement may be essential to advertising and assessing the effect of specific interventions statewide.
Existing Clinical Models
The general PDSA model has been applied successfully to the delivery of health care services. These applications have focused primarily on clinical processes—i.e., how health care teams of physicians, nurses, technicians, managers, and others change specific processes to improve the outcome of their service and the health of their consumers, the patients. These applications have generally focused on one clinical condition (e.g., diabetes) or one set of procedures (e.g., anesthesia services) at a time. The clinical condition or procedure focus is an aspect of clinical models that will likely be reflected in State-led quality improvement circles. Furthermore, the clinical quality improvement process may be used within the State-led quality improvement initiative.
Institute for Healthcare Improvement
One approach to quality improvement with relevance for State-led efforts was developed by the Institute for Healthcare Improvement (IHI). The IHI has been working with teams of clinicians from around the country for several years on improving systems of care to enhance care processes and outcomes. IHI has developed a two-part model to spur improvement in clinical settings:
The IHI Methodology
- Forming the team: This step involves identifying the key players and addressing three specific questions as shown below:
- Setting the aims: What are the goals?
- Establishing measures: How can teams measure whether a change is an improvement?
- Selecting changes: What changes can teams make that will result in improvement?
- Testing changes: This step draws from the Plan-Do-Study-Act cycle. PDSA is a way of testing a change in a real work setting—by planning it, trying it, observing the results, and acting on them.
- Implementing changes: After testing changes on a small scale, learning from the tests, and refining the change through several PDSA cycles, the team can implement the change on a broader scale—for example, for an entire pilot population.
- Spreading changes: After implementation of a change for a pilot population, the team can spread change to other parts of the organization or to other organizations.
For more information, go to: http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/.
Chronic Care Model
Another model of quality improvement in the clinical setting is the Chronic Care Model. Dr. Edward Wagner and his team at Group Health Cooperative in Seattle, with support from the Robert Wood Johnson Foundation, developed the Chronic Care Model. The U.S. health care system is oriented more toward care for acute episodes of disease rather than prevention and management of chronic conditions. Thus, the Chronic Care Model emphasizes a collaborative approach among health care teams, involved patients, and supportive communities to develop new and better clinical procedures and systems that support treatment and management of chronic illness over time. More information is provided below on involvement of State health departments in Diabetes Collaboratives that use the Chronic Care Model to achieve rapid advancement in diabetes care at community health centers. More information on the Chronic Care Model is available on the Improving Chronic Illness Care (ICIC) Web site at: http://improvingchroniccare.org.
Chronic Care Model—The Six Core Components
- Community —Mobilizing all the available community resources to meet the needs of people with chronic illnesses.
- Health system—Creating organizational cultures, systems and mechanisms that promote safe, high quality care throughout the health care system.
- Self-management support—Empowering and preparing active patients to manage their health and navigate the health care system.
- Delivery system design—Assuring the delivery of effective, efficient clinical care and self-management support through appropriate design of the delivery system.
- Decision support—Promoting appropriate clinical care consistent with scientific evidence and patient preferences.
- Clinical information systems—Organizing patient and population data to facilitate efficient and effective care for people with chronic illnesses.
Source: Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. Journal of the American Medical Association 2002;288(15):1909-14.
Federal models. None of these models speaks directly to the Federal role in promoting quality improvement. To fill the need for such a model, the Centers for Medicare & Medicaid Services (CMS) published its own quality roadmap—a strategy for how CMS plans to lead quality improvement at the clinical level for its beneficiaries (CMS, 2005).
The CMS Quality Improvement Roadmap vision is: The right care for every person every time." Its goals are to: "Make care safe, effective, efficient, patient-centered, timely, and equitable." The strategy, in brief, is to:
- Work with partnerships to achieve quality goals.
- Support quality measurement and information.
- Create the right incentives by paying for quality, not ineffective, health care.
- Assist practitioners to improve quality.
- Drive better use of effective health care technologies.
The Center for Medicaid and State Operations (CMSO) announced a quality initiative for Medicaid and the State Children's Health Insurance Program (SCHIP) in August 2005 that is committed to the vision of the CMS Quality Improvement Roadmap for Medicaid and SCHIP beneficiaries. The initiative stresses the importance of working in partnership with States and external organizations, such as AHRQ, to promote innovation as a strategy for obtaining the best value for health care resources invested. The Medicaid SCHIP quality initiative includes a series of projects in five key areas, namely:
- Evidence-based care and quality measurement.
- Pay for performance.
- Health information technology.
- Information dissemination.
CMSO plans to work with States to encourage Medicaid and SCHIP providers to adopt well accepted clinical guidelines with demonstrated effectiveness in improving quality and reducing costs for specific conditions in priority areas.
This initiative has direct implications for States to align quality improvement and incentives to provide effective care for beneficiaries. In order to meet the objectives of the Quality Improvement Roadmap, it will be necessary for States to implement quality improvement strategies for effective care for chronic conditions such as asthma.
A New Framework for State-Led Quality Improvement
This Resource Guide proposes a new tool for State leadership in quality improvement. The State-led framework draws elements from the models described above. It overlays the PDSA model, which here is shortened to Plan-Do-Assess for States because they are not in a position of actually changing clinical practice but rather of leading others to improve. States can play a central role at three different stages of quality improvement: leading, partnering, and implementing improvement. Each stage follows the Plan-Do-Assess cycle with an emphasis on measurement and information which States may be in a unique position to support. Each stage is described in more detail below.
Stage 1: Provide leadership
Figure 2.1, (4 KB) depicts the first stage of quality improvement—leadership. State government is the principal player at this stage. The State's leadership role can be built with the aid of the Plan-Do-Assess tool. For example:
Specific leadership tasks can be addressed with this framework. For example, an early question will be how a State official would initiate a quality improvement project. With the PDA tool, the State official would:
- Plan—A State official leads the process by assigning high-level staff who identify partners from among stakeholders and prepare for a kickoff targets for improvement, readily available data across clinical conditions or settings of care.
- Do—Staff convene partners, a high-profile State official kicks off the meeting, and staff support the partners in a planning process.
- Assess—Staff assess the partnership (for example, who is attending and contributing at meetings) and adjust the partner membership, if necessary.
A key component of State government leadership at this stage is championing the need for quality improvement. It also is critical to State efforts to identify one or more high placed champions from the health care community who can muster support and provide a vision for change.
Stage 2: Work in partnership
Figure 2.2 (28 KB) adds the second stage of State-led quality improvement, as a ring surrounding the first circle (Figure 2.1, 4 KB). The second ring focuses on the partnership activities, encompasses the core of the improvement process, and relies heavily on the partnership to define activities, plan solutions, and assess them before any implementation campaigns are undertaken. Many issues will be decided during this stage, usually during a series of group meetings. Again, the Plan-Do-Assess tool can be used for each major decision, which at this stage might include, for example:
- Plan—The new partnership will develop a strategy about how the group will function (perhaps through consensus) and what clinical condition(s) and/or settings of care will be the focus of quality improvement, commit to both the group process and the focus, and design a plan for quality improvement and specific solutions for the condition(s) and/or settings selected.
- Do—Team members will test proposed intervention(s) through study of the literature and/or a pilot study at a health plan or facility and during the study or test, they will measure and quantify the effect of the intervention(s).
- Assess—Team members will analyze and interpret the results of the intervention(s) and present the results to the partnership.
Depending on the results, the cycle may begin again with modification of the idea or generation of new ones and with the test, measure, analyze, and interpret steps again. Or, the group may be ready to move to implementation of the initial idea(s).
These activities rely on a vibrant, committed partnership of stakeholders in the industry (the State being one stakeholder/partner) to identify health care problems, propose and test solutions, measure and analyze results of the test, and assess the promise of statewide implementation for improving quality. The solutions will undoubtedly include private-sector and public-sector solutions.
Stage 3: Implement improvement
Figure 2.3 (37 KB) completes the quality improvement process by adding the third and final ring—implementing improvement. This stage is essential for spreading success. Because this is where complex partnerships might falter, this ring also uses the Plan-Do-Assess process for implementation. The activities might include:
- Plan—A written plan to spread ideas for change in public and private programs might encompass an advertisement campaign and/or new financial incentives or award mechanisms for quality improvement. The plan should specify how each partner will contribute to the process of bringing about change. A written plan is important to test and coalesce the group's commitment, which will be essential for successful implementation.
- Do—The implementation begins as the group sets about to spread the change and measure the impact of the effort to spread change. The group could falter here by assuming the work of the group is finished. However, the measurement step at this point is key to determining whether the groups' ideas are effective, continue to be implemented, and have the desired effect.
- Assess—The group should reconvene periodically to evaluate and discuss the spread of change and its outcome—successes and failures. It may be necessary to modify the plan and try new approaches, continuing to measure and evaluate the modifications. Or, the group may be ready to tackle the next area for improvement.
Here, the continuous cycle of quality improvement is apparent. The team identifies areas in need of improvement, designs a solution, tests it, and plans how to move the solution beyond a specific demonstration setting and into the broader practice of health care. The team also measures the spread and uptake of the solution in practice, assesses whether the spread has been successful and tackles the next problem area. An effective team is committed to ongoing quality improvement.
The Complete Framework
The process of quality improvement may take more than a single turn around the circles before results are seen. Furthermore, it will require continuous application of the framework to specific quality problems to improve health care quality statewide. This means that commitment, leadership, continuity, and the right incentives are essential. States, as health care purchasers and leaders in health policy, are well positioned to provide these characteristics.
In this framework, the State is the supporting structure that brings the partnership together and nourishes it. State leadership provides energy, facilitates group processes, supplies data when available and may collect new data, disseminates evidence-based information (or asks another partner to assume that role), and stimulates the group to improve health care quality. The State provides an environment for competitors to come together and improve their professional services.
As noted earlier in the discussion of general models, many local and regional quality improvement efforts already exist among disconnected groups, and thus a critical aspect of the State role will be outreach and education to coordinate and harmonize these diverse efforts.
Selecting Targets for Improvement
Improving any process requires targeting specific areas or problems. In health care, specific conditions or treatments are usually the place to start. Deciding which health conditions or procedures to select for improvement is the first challenge facing State leaders and their partners. Finding candidates for improvement will be relatively easy narrowing the list will be difficult.
Various criteria can be used to identify targets. Answers to a series of questions can help determine a priority list of targets for quality improvement. The quality improvement team may want to add to or subtract from these:
- Is there clinical or quality improvement evidence that specific changes will improve health care outcomes?
- What measures of quality health care exist for this targeted area?
- Are there benchmarks for high quality care?
- Is there variation across geographic areas, vulnerable subpopulations, or individual providers in the quality of care delivered? Is the variation excessive compared to that in underlying clinical conditions that clinicians must treat in different ways?
- Is there a way to assess how a State or smaller geographic area performs in a targeted area?
- How many lives are affected by the condition or treatment (i.e., prevalence, morbidity, and mortality related to the condition)?
- What is the cost of care and the potential for a return on (or saving from) investment in quality improvement?
Most of these questions take considerable effort to answer. For this reason, AHRQ has begun to assemble a set of resources targeted to helping States implement quality improvement initiatives.
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Information Resources for Quality Improvement
AHRQ-Sponsored Resources for States
AHRQ provides a number of resources for information and measures on health care quality. AHRQ supports research programs and publications intended to provide scientific evidence for quality improvement. Other important Federal resources on asthma are noted below also.
NHQR and NHDR
Two valuable resources are the National Healthcare Quality Report and the National Healthcare Disparities Report mentioned above. The former offers benchmarks for tracking U.S. health care quality nationally and by State the latter looks at quality of care and access to care for vulnerable subpopulations, such as racial/ethnic minority groups and low income groups. The reports, mandated by Congress, were first published in 2003 and are produced annually to date, reports for 2003 through 2008 are available. All releases of the NHQR and NHDR can be accessed at: http://www.ahrq.gov/qual/measurix.htm.
State Resources for Selected Measures from the NHQR
Measures at the State level from the 2007 NHQR are available as a user-friendly, interactive Web resource for examining the performance of each State and the District of Columbia across various dimensions of quality. These dimensions include types of care (preventive, acute, and chronic), settings of care (hospital, ambulatory, nursing home, and home health), and total quality (a summary of all State-level measures in the NHQR). Also included are breakdowns of the measures that go into creating each summary measure. Users can also find quality measures available for specific clinical conditions in downloadable tables. These State resources are available at: http://statesnapshots.ahrq.gov/snaps08/index.jsp.
HCUP and Statewide Discharge Data Systems
Another source for State-level data is the statewide discharge data developed within States by State governments, hospital associations, and other private data organizations. The Healthcare Cost and Utilization Project is a public-private partnership sponsored by AHRQ with 37 participating statewide data organizations that accounted for about 90 percent of U.S. discharges in the United States in 2004. As noted in Module 1, HCUP provides asthma hospitalization rates for participating States. More information on HCUP is available at: http://www.hcup-us.ahrq.gov.
AHRQ-sponsored Evidence-based Practice Centers (EPCs) review all relevant scientific literature on clinical, behavioral, and organization and financing topics to produce evidence reports and technology assessments. These products are used for informing and developing coverage decisions, quality measures, educational materials and tools, guidelines, and research agendas. EPCs also conduct research on methods of quality improvement. Topics are chosen for their relevance to clinical, social science/behavioral, economic, and other health care organization and delivery issues—specifically those that are common, expensive, and/or significant for the Medicare and Medicaid populations. There are over 170 evidence reports assessing various clinical issues (including asthma) and other topics, such as approaches for closing the gap in health care quality. A list of these reports is available at: http://www.ahrq.gov/clinic/epc/epcseries.htm.
Quality Improvement Tools
AHRQ also publishes resources for quality improvement for specific chronic illnesses. This updated Resource Guide is the second published by AHRQ to focus on a specific chronic illness for States. Diabetes Care Quality Improvement: A Resource Guide for State Action and Diabetes Care Quality Improvement: A Workbook for State Action were published in 2004. These resources provide measures and benchmarks for States to develop their own quality improvement goals and strategies in addition to the ones provided in the National Healthcare Quality and Disparities Reports. Copies of the diabetes Resource Guide and companion Workbook can be downloaded at http://www.ahrq.gov/qual/diabqualoc.htm.
National Quality Measures Clearinghouse™ (NQMC)
AHRQ sponsors the National Quality Measures Clearinghouse™. This online clearinghouse is a database and Web site for information on specific evidence-based health care quality measures and measure sets. It provides practitioners, health care providers, health plans, integrated delivery systems, purchasers, and others a way to get detailed information on quality measures for quality improvement. The NQMC is available at: http://www.qualitymeasures.ahrq.gov.
Other Federal Data Resources for States
Data sources that can be found within States may include disease registries, hospital discharge data programs, etc. After seeking asthma data within the State, States will need to look for national asthma data to use for benchmarking their progress.
Behavioral Risk Factor Surveillance System (BRFSS)
BRFSS is a national data source that provides data at the State level. Currently, it provides the richest source of asthma data nationwide and by State. BRFSS data are based on telephone surveys developed by the Centers for Disease Control and Prevention (CDC) but administered by each State independently. The survey consists of a core set of questions developed by CDC, additional questions developed by the States, and separate, optional modules for States to use. The asthma module, which contains the quality-of-care questions, is optional for State use. More information about the BRFSS data and methods as well as interactive databases with some State and local level asthma data are available at: http://www.cdc.gov/brfss/.
National Asthma Control Program (NACP)
The Centers for Disease Control and Prevention also supports a number of Federal programs for States including the National Asthma Control Program. (Select Appendix C for a list of State interventions for asthma.) This program funds States to provide surveillance on asthma and other interventions. Information about the NACP can be found at http://www.cdc.gov/asthma/NACP.htm.
National Asthma Survey (NAS)
States should also note that the National Asthma Survey has been developed by CDC and other partners as a model for States to use to collect information on asthma prevalence and care. The NAS data set includes the BRFSS asthma measures in addition to nearly 70 other measures for asthma. (NAS measures are discussed more fully in Module 4 and in Appendix D.) A pilot data release of NAS data for four States is available at: http://www.cdc.gov/nchs/about/major/slaits/nas.htm.
National Asthma Education and Prevention Program (NAEPP)
Another Federal program for States, the NAEPP works with intermediaries including major medical associations, voluntary health organizations, and community programs to educate patients, health professionals, and the public. NAEPP is coordinated by the National Heart, Lung, and Blood Institute. Part of the National Institutes of Health (NIH), NHLBI develops clinical guidelines for diagnosis and treatment of asthma. Information about NAEPP can be found at http://www.nhlbi.nih.gov/about/naepp/.
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Summary and Synthesis
States have typically viewed their role in quality improvement from the perspective of the guardian of public health, a manager of health care for the poor or disabled, or a buyer of health insurance for State employees. However, States can play a more comprehensive leadership role, and indeed some States are already doing this, at least in part, with respect to asthma.
The framework described in Module 2 envisions three roles for States in quality improvement:
- Provide leadership, which entails providing a defining vision for change, identifying partners to set goals, and providing an environment that fosters improvement.
- Work in partnership, which involves creating a committed partnership of stakeholders dedicated to identifying and proposing and testing solutions and developing plans for improvement.
- Implement improvement, which means creating interventions within a strong partnership, measuring and analyzing the results of changes, and applying successful improvements on a broader scale. The solutions will undoubtedly include those from both the private and public sectors.
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