Issue Brief

February 2002

The National Quality Forum    

 "The two biggest problems in health care reform today are identifying medical leadership and gaining acceptance of a common vision."   Dr. Kenneth Kizer before the National Institute of Health Policy in November 1999.

Introduction  
Three years ago Dr. Kizer spoke to a conference at NIHP about his experiences trying to reduce medical errors and improve quality of care during his service as Under Secretary for Health in the U.S. Department of Veterans Affairs (VA).  By all accounts he made some amazing progress at the VA and he is now the President and Chief Executive Officer of the National Quality Forum (formally incorporated as the National Forum for Health Care Quality Measurement and Reporting and commonly called NQF).  In his new role he is working on improving quality and reducing medical errors throughout the entire American health care system -- a daunting task.

 Dr. Kizer is coming to Minnesota on February 26 to speak at the Sixth Annual Health Services Research Conference. I thought it would be interesting to find out what he is doing at NQF before that meeting so I asked my staff to meet with him and learn about his latest endeavors. 

We asked Dr. Kizer if he still believed what he had said three years ago -- that a lack of leadership and vision were the two biggest obstacles to health care reform.  He replied, yes, those two problems still exist and they are one of the reasons NQF was created.  In spite of its serious problems, however, he remains amazingly optimistic about the potential for quality improvement and change in our healthcare system. 

What is NQF doing and what else is happening that makes Dr. Kizer so optimistic? 

The Problem
 In November 1999 the Institute of Medicine (IOM) issued a report entitled "To Err is Human:  Building a Safer Health System".  In that report the IOM concluded that errors cause between 44,000 and 98,000 deaths in U.S. hospitals every year.  Since the report was issued there has been considerable controversy and disagreement over the number of unnecessary deaths caused by medical errors, but as Dr. Kizer notes, that discussion misses the point completely.

 Health care in America today presents an amazing contrast of high technology, state of the art wonderful treatment and inconsistent, unnecessarily risky, bad care.  How and why does this happen?   We know that the vast majority of health care providers are highly skilled, well-trained professionals who care about their patients.  Yet the system as a whole produces serious mistakes -- many of them fatal -- that should never happen.  It also produces many minor irritants that are totally unnecessary.    

The problems in the health care system affect all patients regardless of age, gender, race, or financial resources.  They cut across the delivery system and are not the result of any single payment system or financing arrangement, although our current financing systems do not help quality and often may work against quality improvement.  The main types of quality problems are:

            1.      basic mistakes such as medication errors and wrong site surgeries,

2.      unneeded treatments such as excessive testing and medications that result in complications and harmful side effects, and;

3.      inadequate treatment such as not vaccinating children and the elderly to prevent serious illness.

 Even though health care is the nation's largest enterprise and accounts for almost 15% of our gross domestic product, we know very little about quality.  As Dr. Kizer says, "...it (the health care system) touches everybody's lives in one way or another and yet we have no priorities and no goals".  Further, those efforts that have been made to improve quality have been driven by a desire to reduce costs more than a concern for genuine quality improvement. 

The Solution
In 1998, the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry proposed creation of the National Qualify Forum (NQF) as part of an integrated national quality improvement agenda. According to Dr. Kizer, "the concept of the NQF arose in response to the strong American sentiment against government regulation and control of health care quality."  Leaders from consumer, purchaser, provider, health plan, and health service research organizations met throughout 1998 to help define the mission, structure, and financing of the Forum.  It was incorporated as a new organization in 1999.

The Forum is a private, non-profit, open-membership organization whose mission is to increase the provision of high-quality health care.  It is governed by an 18 member Board of Directors representing health care consumers, purchasers, providers, health plans, and experts in health services research.  The Board includes representatives from three federal agencies.  It also has four members that are elected by members of the NQF through their Member Councils.

The NQF has broad participation from all parts of the health care system, including national, state, regional, and local groups.  Its members represent consumers, public and private purchasers, employers, health care professionals, provider organizations, health plans accrediting bodies, labor unions, supporting industries, and research organizations.

Member organizations of the NQF participate through one of four member councils: 

                  1.      Consumer Council,

2.      Purchaser Council,

3.      Provider and Health Plan Council, and

The NQF also has four non-voting liaison seats designated for accrediting organizations such as the American Medical Accreditation Program (AMAP), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Committee for Quality Assurance (NCQA), and the Institute of Medicine.

Obviously, we aren't going to be able to solve the quality problems of the health care system without the government.  It has to be a player and has to be at the table, but it can't be the only force for reform if we are to succeed. 

And that is where the NQF comes into play.  The Forum is unique in health care in that the Administrator of CMMS sits at the table next to the head of General Motors.  "We have the largest public and the largest private purchasers sitting next to each other with the idea that they will be pursuing the same agenda and they will be able to leverage both their arenas towards the same end," notes Kizer.

National Quality Forum Efforts
Many of the conflicts and differences that exist within the world of health care manifested themselves as NQF was trying to get started.  The Forum is an organization of organizations and as such has faced its share of challenges.  As noted earlier, all members belong to one of four councils.  For instance, the provider and health plan council includes physicians, hospitals, health plans, nurses, and non-physician caregivers all of whom historically have competed against each other.  Together they get one vote -- the same as the one vote that consumers get on the consumer council. 

Not surprisingly one of the first challenges before the Forum came from a group representing physicians who wanted their own council.  The Board heard the issue and voted and said "no, we want you to serve on the same council with the other providers".  Others have asked how can you count providers on the same basis as consumers?  These are natural questions given the history of the way our health care system has operated.

A primary objective of the NQF is to develop consensus among the many different actors in the healthcare system about standardized indicators that can be used to measure and report on healthcare quality.  To that end, the Forum is currently working on several projects.  Among these are projects on safe practices, standardizing measures of hospital quality, a "never events" list, minority healthcare quality, and an information technology summit to be held in the spring of 2002.

1. The "Never Events" List  
 The NQF's first product will come out of the "never events" project.  The document entitled "Serious Reportable Events" is currently out for review among the purchaser, provider, research, and consumer groups that comprise NQF membership.  It contains a list of 27 adverse events that should never occur.  The first phase of the project is for NQF members to agree on the list of these events and their definition.  "We need to define them with sufficient clarity so that the list can be used across the country to get consistent and reliable data about these adverse events so that we can start to make apple-to-apple comparisons about their occurrence", says Kizer.  So far there appears to be good agreement on the items on the list with an understanding that the list will probably change over time.  There also appears to be agreement on many aspects of a potential reporting system.  There are still, however, major hurdles to overcome such as whether reporting these events should be mandatory or not.

2. The Safe Practices Project  
A second effort of great importance to NQF is the "Safe Practices" project.  We know quite a bit about how to prevent errors and promote safety, but there's a problem in applying that knowledge.  That's why the NQF began this project to identify what core practices should be in place at all healthcare facilities in order to minimize errors.  After extensive research the forum plans to produce a guidebook of safe practices that all health care provider could use to reduce errors.  Dr. Kizer predicts that the guidebook will be published by next spring. 

3. Information Technology  
A third project, is a National Summit on Information Technology and Healthcare Quality which will be cosponsored by the IOM, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the Veteran's Health Administration, U.S. Army Medical Research and Materiel Command, the Kaiser Foundation Health Plan and others. 

The purpose of the summit is to reach agreement among critical stakeholders about an action plan for defining the governance, operating standards and funding of a national healthcare information infrastructure.  Since we are so dependent on a standardized data base, Dr. Kizer has placed extremely high priority on this endeavor.  He hopes they will be able to develop an action plan to have an electronic medical record and automated information system by 2005.  While, that may be an ambitious goal, the fact that they are willing to put a date on it makes it much more likely to happen.

Conclusion
As NQF works on these and its many other projects it tries to develop consensus among healthcare's many stakeholders about standards.  The forum has just gone through its fifth iteration of a consensus process.  How do you develop a voluntary consensus standard that meets the law and can work in the "real world"?  This is a new effort in the health care sector.  

The government agrees to honor any standards that are set through a voluntary consensus process.  So, for instance, if the board endorses performance measures, they become the standards of the land and Medicare must honor them.  A lot of people are just now beginning to understand the power of this consensus process and how it could drive things in ways they haven't been driven before.

There will be many activities that will not require a formal consensus among NQF members but any  " ...any activities aimed at endorsing sets of measures, indicators or practices that should become standards for the healthcare industry will be carried out through the consensus development process...."   For more information regarding NQF's consensus process you may want to visit their web site at www.qualityforum.org.

There are other promising developments in the world of healthcare quality.  One of the more recent events was the release of hospital information by the Leapfrog Group.  Leapfrog is a group of Fortune 500 companies comprising more than 90 private and public organizations that buy healthcare benefits for 28 million people.  This organization recently released information showing where 241 hospitals stand in meeting three patient safety standards.  While the number of hospitals involved is not large, the endeavor symbolizes a whole new approach to health care quality and that makes Dr. Kizer very optimistic.  As he noted in our conversation, "the forces of change are clearly evident even though we don't know what form they will take.  Quality improvement should be an essential business strategy for health care providers of the future.  Not just because it is the right thing morally, philosophically, and ethically but because if makes sense as a business strategy."