Chapter Ten

Karen A. WagerIFrances Wickham LeeIJohn P. Glaser

• To explain the significant role of health information in national private andpublic quality improvement initiatives
• To compare and contrast licensure, certification, and accreditation processes
• To discuss the role of the Joint Commission and the National Committee forQuality Assurance in ensuring the quality of care in the US
• To understand performance measurement development in the US
• To identify the roles of specific public and private organizations in thedevelopment and endorsement of national performance measures
• To understand the origins and uses of major health care comparative data sets

Learning Objectives

• Licensure, certification, and accreditation
• The Joint Commission
• National Committee for Quality Assurance (NCQA)
• Data sources for quality measures
• Comparative health care data sets
• Quality improvement
  • –Federal initiatives
  • –CMS initiatives

Outline

• Licensure
  • –The process that gives a facility legal approval to operate
  • –State governments oversee the licensure of health care facilities
• Certification
  • –Gives a health care organization the authority to participate in the federalMedicare and Medicaid programs
  • –CMS developed minimum standards, conditions of participation (CoPs)
• Accreditation
  • –Voluntary, external review process
  • –Financial and legal incentives for accredited organizations

Definitions

• An independent, not-for-profit organization
• Best-known health care accrediting agency in the US
• Site-surveys every 3 years(2 years for laboratories)
• Standards manuals are publishedannually
• Categories of accreditation
  1. Preliminary accreditation
  2. Accreditation
  3. Accreditation with follow-up survey

The Joint Commission

4. Contingent accreditation
5. Preliminary denial of accreditation
6. Denial of accreditation

• Record of Care (RC), Treatment, and Services Standards
  • –Content needed for a complete health record, regardless of its format
• Information Management (IM) Standards
  • –Apply to bothnoncomputerizedsystems and systems with the latesttechnologies

StandardsThe Joint Commission

• National Committee for Quality Assurance (NCQA)
• Leading accrediting body for health plans
  • –Quality management and improvement
  • –Utilization management
  • –Credentialing andrecredentialing
  • –Member’s rights and responsibilities
  • –Member connections
  • –Medicaid benefits and services
  • –Health effectiveness data and information set (HEDIS)

NCQA

• Crossing the Quality Chasm
  • –Published in 2001 by Institute of Medicine (IOM)
  • –Outlined 6 aims for establishing quality health care
    • Safe
    • Effective
    • Patient-centered
    • Timely
    • Efficient
    • Equitable

Quality of Care

• Administrative Data
  • –Claims databases
• Disease registries
  • –Data on patients with specific conditions
• Health records
  • –Detailed patient information
• Qualitative data
  • –Patient surveys or interviews

Quality CareData Sources for Measures

• HEDIS
  • –Set of health care performance measures
  • –90% of health plans in the US collect and report HEDIS data
• Clinicalquality measures (CQMs)
  • –Identified and updated by CMS each year
  • –Developed by private organizations, health care societies,collaboratives,alliances, and government agencies
  • –Required for accreditation by the Joint Commission

Quality CareMeasurement Development

• Comparative health data sets
  • –Benchmarking: comparing one or more performance measures against astandard
• Patient satisfaction data sets
  • –Survey data
  • –Agency for Healthcare Research and Quality (AHRQ)
    • Consumer Assessment of Healthcare Providers and Systems (CAHPS) program
• Practice patterns data set
  • –Dartmouth Atlas: interactive, online tool funded by the Dartmouth Institutefor Health Policy and Clinical Practice

Data Sets

• Clinical data sets
  • –Quality Check: established by the Joint Commission
  • –Hospital Compare: sponsored by CMS
• Comparative data for health plans
  • –NCQA health care report cards
  • –Accessible athttp://reportcard.ncqa.org

Data Sets

• Patient Safety Act
  • –Patient safety organizations (PSOs): responsible for the collection andanalysis of health information that is referred to in the Final Rule as patientsafety work product (PSWP)
  • –PSWP: contains identifiable patient information covered by specificprivilege and confidentiality protections
    • Incidents
    • Near misses (or close calls)
    • Unsafe conditions
  • –Common formats: established by AHRQ to help providers uniformly reportpatient safety events

Quality ImprovementFederal Initiatives

• National Quality Strategy (NQS)
  • –Established by the Affordable CareAct
  • –3 broad aims
    • Better care
    • Healthy people/healthycommunities
    • Affordable care
  • –“Levers” to ensure alignment withthe NQS
    • Measurement and feedback
    • Public reporting
    • Learning and technical assistance
    • Certification, accreditation, regulation
    • Consumer incentives & benefit designs
    • Payment
    • Health information technology
    • Innovation and diffusion
    • Workforce development

Quality ImprovementFederal Initiatives

• Original value-based programs were an attempt to link performance onendorsed quality measures to reimbursement
  • –Hospital value-based purchasing (HVBP)
  • –Hospital readmissions reduction (HRR)
  • –Hospital-acquired conditions (HAC)
  • –Value modifier (VM) (or Physician value-based modifier [PVBM])
• The Medicare Access and CHIP Reauthorization Act (MACRA)
  • –Enacted in 2015
  • –Streamlines quality programs under the Merit-based Incentive PaymentSystem (MIPS)

Quality ImprovementCMS Programs

• Licensure, certification, andaccreditation
• The Joint Commission
• National Committee for QualityAssurance (NCQA)
• Datasources for qualitymeasures
  • –Administrative data
  • –Disease registries
  • –Health records
  • –Qualitative data
• Measurement development
  • –HEDIS
  • –CQMs
• Comparativehealth care datasets
  • –Benchmarking
  • –Patient satisfaction
  • –Practice patterns
  • –Clinical data
  • –Comparative data for health plans

Summary

• Qualityimprovement
  • –Federalinitiatives
    • Patient Safety Act
    • Patient safety workproduct (PSWP)
    • National Quality Strategy (NQS)
  • –CMSinitiatives
    • Value-based programs
    • MACRA
      • –MIPS

Summary