National Strategy for Quality Improvement in Healthcare On Wednesday, March 23, 2011, U.S. Health and Human Services Secretary Kathleen Sebelius appeared before Congress to present the "National Quality Strategy" for improvement in healthcare. This strategy flows from a provision in the Patient Affordability of Care Act of 2011 (the "ACA") signed into law by President Obama just one year before. The "National Strategy" recognizes that "all health care is local," but expresses the intent that local efforts to improve quality in healthcare be coordinated with the National Strategy to ensure that the local efforts are in sync with "the national shared aims and priorities."

The Strategy report delivered to Congress makes clear that the quality of care in the U.S. is remarkably poor.

Health care-related errors harm millions of American patients each year and needlessly add billions of dollars to health care costs. The Centers for Disease Control and Prevention (CDC) estimate that at least 1.7 million healthcare-associated infections occur each year and lead to 99,000 deaths. Adverse medication events cause more than 770,000 injuries and deaths each year—and the cost of treating patients who are harmed by these events is estimated to be as high as $5 billion annually.

The Strategy recognizes that to solve these quality problems, it will require an extraordinarily coordinated effort:

[A]... high-quality health care... system requires, for example, the design of standard operating procedures, a workforce with diverse yet complementary skills, workloads that allow enoughtime for errors to be corrected or mitigated and leadership that promotes continuous improvement.

And it will require changes in the way that healthcare is paid for:

All too often, however, the way health care is paid for does not foster coordination but instead pays more to providers for doing more instead of working together...

 

Payment arrangements should offer incentives that foster better health; promote quality improvement and greater value while creating an environment that fosters innovation.
Health care systems should be rewarded for working collaboratively to improve efficiency and adopt evidence-based practices across the spectrum of inpatient and outpatient services.

The ACA called on the HHS to develop agency-specific plans, goals, benchmarks, and standardized quality metrics (where available). Although the Strategy is projected to be updated annually, this first-year Strategy does not include the elements listed purportedly to "allow them to be developed with additional collaboration and engagement of the participating agencies along with private sector consultation." The Strategy does, however, list three broad aims that will be used to guide and assess local, state, and national efforts to improve health and the health care delivery system:

1. Better Care: Improve the overall quality, by making health care more patient-centered, accessible, and safe.
   
2. Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social and, environmental determinants of health in addition to delivering higher-quality care.
   
3. Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.

The Strategy intends to achieve these aims through the implementation of the following six priorities:

• Making care safer by reducing harm caused in the delivery of care.
• Ensuring that each person and family are engaged as partners in their care.
  
• Promoting effective communication and coordination of care.
  
• Promoting the most effective prevention and treatment practices for the leading causes of
  mortality, starting with cardiovascular disease.
  
• Working with communities to promote wide use of best practices to enable healthy living.
  
• Making quality care more affordable for individuals, families, employers, and governments by
  developing and spreading new health care delivery models.

Importantly, the National Strategy acknowledges that organizations like CHCC will continue to play an important role in helping move the quality improvement in healthcare agenda forward. The Strategy states in pertinent part:

Many stakeholders have important roles in promoting high quality care. It starts with clinicians and health professionals, but employers, government, advocates, and many others also have an interest in improving the quality of care. Employers and other private purchasers, for example, have been leaders in demanding better quality by pushing provider organizations to achieve new levels of excellence.

Notably, CHCC's efforts to advance performance, pricing and value transparency are supported by the National Strategy:

Public reporting initiatives offer consumers and payers vehicles to compare costs, review treatment outcomes, assess patient satisfaction, and hold providers accountable. This is done while ensuring the protection of personal health information and adjusting for factors beyond providers' control... The new consumer focused web site, healthcare.gov will also improve transparency. The site allows all consumers to view the insurance plans in their area, compare them by price and benefits and pick the one that is best for them and their families. There will also be hospital pricing information, in addition to performance data, available online to help inform consumer decisions about where to obtain care.

The National Strategy is a "broad roadmap that will require the ongoing development of specific goals, measures, benchmarks, and initiatives, through a continued transparent collaborative process with all stakeholders." To participate, interested stakeholders will have to work with the Agency for Healthcare Research and Quality, which is tasked with supporting and coordinating the implementation planning and further development and updating of the Strategy.

All of the National Strategy's efforts are based on 10 principles that were developed after consulting hundreds of stakeholders. It is hoped that stakeholder organizations will also align their efforts with these principles in order to effectively coordinate efforts nationally and so that these organizations can better hold themselves accountable to the Strategy's aims and priorities:

1. Person-centeredness and family engagement, including understanding andvaluing patient preferences, will guide all strategies, goals, and health care improvement efforts.
   
   
2. Specific health considerations will be addressed for patients of all ages, backgrounds, health needs, care locations, and sources of coverage.
   
   
3. Eliminating disparities in care—including but not limited to those based on race, color, national origin, gender, age, disability, language, health literacy, sexual orientation and gender identity, source of payment, socioeconomic status, and geography—will be an integral part of all strategies, goals, and health care improvement efforts.
   
   
4. Attention will be paid to aligning the efforts of the public and private sectors.
   
   
5. Quality improvement will be driven by supporting innovation, evaluating efforts around the country, rapid-cycle learning, and disseminating evidence about what works.
   
   
6. Consistent national standards will be promoted, while maintaining support for local, community, and State-level activities that are responsive to local circumstances.
   
   
7. Primary care will become a bigger focus, with special attention towards the challenges faced by vulnerable populations, including children, older adults, and those with multiple health conditions.
   
   
8. Coordination among primary care, behavioral health, other specialty clinicians and health systems will be enhanced to ensure that these systems treat the " whole person."
   
   
9. Integration of care delivery with community and public health planning will be promoted.
   
   
10. Providing patients, providers, and payers with the clear information they need to make choices that are right for them, will be encouraged.

Importantly, the National Strategy begins the important process of developing quality metrics to be applied to health care generally. The Strategy states:

Valid, reliable measures are the cornerstone of monitoring quality improvement efforts. In order to achieve the quality improvements envisioned by the National Quality Strategy, data on care delivery
and outcomes should be measured using consistent, nationally-endorsed measures in order to provide information that is timely, actionable, and meaningful to both providers and patients.

An appendix to the report lists examples of measures that may be useful for monitoring the progress in achieving the Strategy's priorities. Actual targets and measures will be identified later in 2011. It is hoped that the first update on the National Strategy provided to Congress in 2012 will include additional detail on how federal agencies are addressing the priorities and goals in agency-specific strategic plans.

Although the National Strategy currently employs no enforcement "teeth," it is intended to serve "as a guide for HHS agencies as they develop programs, regulations, and new initiatives, as well as a vital tool in evaluating the full range of Federal health care efforts." (Emphasis added.)

The ACA also called on the Secretary to establish a National Prevention and Health Promotion Strategy. The National Prevention and Health Promotion Strategy will align with the National Quality Strategy and will provide a more specific plan for improving population health.