Quality Oversight Organizations should make a commitment to participate in the work of the Advisory Council on Health Care Quality and the Forum for Health Care Quality Measurement and Reporting. The Forum is a voluntary, private sector approach intended to produce an efficient and comprehensive approach to quality measurement and reporting by promoting collaboration across existing QOOs. The Council, in its annual reports, should evaluate the success of this approach in obtaining the cooperation of QOOs.
Quality Oversight Organizations should take steps to increase public confidence in their oversight processes. QOOs can accomplish this by expanding the representation of consumers on governing boards and committees that establish oversight standards and make determinations; providing for public review of and deliberation on existing and proposed standards; making standards and survey protocols used to reach licensing, certification, and accreditation decisions (as well as results of oversight processes) available to the public at little or no cost; and fully disclosing all funding sources. Alternative funding mechanisms for accreditation processes should be explored to further minimize conflicts of interest and equitably spread the costs of oversight across all health care organizations. QOOs also should ensure adequate input from health care workers into their oversight processes and enhance mechanisms to assess the care of vulnerable populations.
Quality Oversight Organizations should take steps to move to a common set of quality standards for each sector of the health care industry (i.e., health plans, facilities, and other health care entities). These standards should be strongly oriented to quality improvement and should be required of all entities within each sector of the industry.
Quality Oversight Organizations should coordinate their quality oversight processes within the health care industry. Once common standards are agreed upon, use of one oversight organization's findings to satisfy another oversight organization's need for assurance on the same standard(s) (i.e., "deeming") should be pursued so long as standards to ensure public confidence in, and the integrity of, oversight processes and accountability to the public are in place.
The Bill of Rights and Responsibilities specifies the following rights to be ensured: information disclosure, choice of providers and plans, access to emergency services, participation in treatment decisions, respect and nondiscrimination, confidentiality of health information, and complaints and appeals. Table 1 identifies potential roles of each of the above four entities in ensuring the implementation of these rights, as well as in promoting consumer responsibilities. The Commission encourages all health plans, providers, and facilities to move rapidly to implement the provisions of the Consumer Bill of Rights and Responsibilities through existing policies and practices. Group purchasers and quality oversight organizations can provide strong mechanisms for holding health plans, providers, and facilities accountable for doing so. Their efforts will be aided by the creation of the Advisory Council on Health Care Quality and the Forum for Health Care Quality Measurement and Reporting.
The Advisory Council has the responsibility for tracking implementation of the Bill of Rights and Responsibilities, identifying barriers and obstacles to its implementation, and reporting on the progress made in its annual report. The Commission recommends that the Advisory Council annually assess the extent to which quality oversight organizations and group purchasers have incorporated the provisions of the Consumer Bill of Rights and Responsibilities into contractual and oversight requirements. Three years after the promulgation of the Bill of Rights and Responsibilities, the Council should issue a comprehensive report assessing the extent to which the Bill of Rights provisions have been adopted through legislative, regulatory, or voluntary measures, and if necessary, make recommendations for enhancing compliance.
The Advisory Council will need to perform its analysis of progress in implementing the Bill of Rights and Responsibilities by examining data and information from two sources. From quality oversight organizations, it will need to obtain copies of the standards and reviewer guidelines utilized by the public and private sector licensing, accreditation and certification entities. These can inform the Advisory Council of the extent to which quality oversight organizations have adopted the Bill of Rights and Responsibilities. The QOOs would then be asked to provide to the Council summary (i.e., aggregate) information on the extent to which the entities that have been reviewed against these standards are in compliance with them. To determine the extent to which group purchasers have adopted and adhered to the provisions of the Consumers Bill of Rights and Responsibilities, the Advisory Council may wish to conduct a survey of a sample of group purchasers.
QOOs will need to participate in and support the work of the Council in several ways:
Participation of QOOs in the Forum for Quality Measurement and Reporting is even more critical. Because QOOs have been the national leaders in the measurement and reporting of quality for public accountability, and because the mission of the Forum is to translate the national aims into specific quality measures and ensure the implementation of standardized core measurement sets, the active participation and support of QOOs are important ingredients to achieving widespread compliance with the measurement and reporting strategy advanced by the Forum.
|Council||Forum||Group Purchasers||Quality Oversight Organizations|
|Information on health plans, facilities, and professionals||Specify aims for improvement and goals for measuring and reporting performance information on health plans, facilities, and individual providers||Implement a quality measurement and reporting strategy to make information on quality available on all sectors of the industry to the public at large||Require reporting of information as part of their contracting requirements; participate in and support the work of the Forum||Work collaboratively with the Forum and each other to implement quality reporting requirements; assess compliance of health care organizations with reporting requirements|
|Choice of health care providers||Track implementation and report progress in its annual report||Offer health plans that provide adequate choice of providers||Encourage and assess compliance through standards and review processes|
|Access to emergency services||Track implementation and report progress in its annual report||Require adherence to this standard in their health plan contracts||Encourage and assess compliance through standards and review processes|
|Participation in treatment decisions||Track implementation and report progress in its annual report||Require adherence to this standard in their health plan and provider contracts||Encourage and assess compliance through standards and review processes|
|Respect and nondiscrimina- tion||Track implementation and report progress in its annual report||Require adherence to this standard in their health plan and provider contracts||Encourage and assess compliance through standards and review processes|
|Confidentiality of health information||Track implementation and report progress in its annual report||Require adherence to this standard in their health plan and provider contracts||Encourage and assess compliance through standards and review processes|
|Complaints and appeals||Track implementation and report progress in its annual report||Require adherence to this standard in their health plan and provider contracts||Encourage and assess compliance through standards and review processes|
|Patient responsibilities||Sponsor or encourage public education to enhance consumer awareness of rights and responsibilities||Sponsor or encourage public education to enhance consumer awareness of rights and responsibilities||Assist in educating employees regarding their rights and responsibilities||Encourage and assess compliance through standards and review processes|
While a number of QOOs already have exercised leadership nationally in the development of core quality measurement sets, by bringing together the strongest possible group of stakeholders committed to quality measurement, the Forum can bring to bear greater expertise, resources, and support for the activities of existing QOOs. QOOs that may not have had the resources or the authority to advance the practice of quality measurement as fast as they may have liked would now have the commitment and influence of the Forum to assist them in their efforts to develop the strongest possible quality measurement data sets. Because of this, the Forum and QOOs will need to create a strong partnership that builds on the quality measurement and oversight expertise that the QOOs already have and aids them in taking the next steps to implement even stronger measures of quality for all sectors of the health care industry.
An accrediting organization can be faced with the contradictory pressures of setting standards high enough to be credible but not so high that a large number of entities will not meet the standards. This is particularly true when accreditation is voluntary and paid for by the entity seeking review. These customers understandably are upset when the entity that is supposed to serve their needs and that they chose to be reviewed by, for which they will incur large costs not incurred by entities not willing to be reviewed, treats them in a punitive fashion, such as when accreditation is denied or other sanctions are taken (Brennan and Berwick, 1996) or when they believe the standards are inappropriately high.
Quality oversight organizations also have a second set of customers -- health care consumers -- who depend on the work of these organizations to make comparative judgments about the quality of certain types of health care organizations. This is particularly true when public regulators use accreditation as a means of meeting public standards (e.g., when JCAHO-accredited hospitals are deemed to have met Medicare Conditions of Participation). Consumer advocacy organizations become concerned when the accrediting organization seems overly solicitous of the views of the industry or when very few organizations have their accreditation denied (Scholsberg and Jackson, 1996; Dame and Wolfe, 1996).
Strengthening the methods used by quality oversight organizations and operating in a stronger climate of public participation and disclosure can reduce real or apparent conflicts of interest. This can be accomplished by (1) expanding the representation of health care consumers, public purchasers, and regulators on governing boards and the committees that establish standards and make accreditation decisions; (2) expanding public input into the standard-setting process through public review and deliberation on existing and proposed standards; (3) making standards and survey protocols used to reach accreditation decisions, as well as detailed information from the accreditation surveys, available to the public at low or no cost; (4) using unannounced inspections for some elements of the survey process; (5) making full disclosure of funding sources; and (6) creating alternative funding mechanisms that reduce potential conflicts of interest.
One of the key challenges in this area is the development of accreditation standards that can assess whether health plans, facilities, integrated delivery systems, and other providers have the structures in place to care for different vulnerable populations. Although accreditation and licensure standards often address areas such as the availability of interpreter services for patients who speak languages other than English and physical accessibility, greater attention should be focused on assessing the adequacy of care management processes and specialized delivery programs (e.g., whether a health plan has appropriate services for members with a particular disabling or chronic condition).
For example, the standards used by States for licensing HMOs are not always the same as those used by private accrediting organizations or those used by Medicare or Medicaid. Across private accrediting organizations, managed care plans can be accredited against very different sets of standards. While it may be healthy to have different entities developing standards (in the same way that it may be desirable to have different entities develop stronger performance measures), more collaboration and coordination of quality standards used by quality oversight organizations could result in greater efficiency in the health care system. A process for jointly testing and implementing new standards could allow the development of stronger standards while reducing unnecessary inconsistency.
Discussions of deeming often are contentious. Many consumer advocates, for example, are concerned about the use of private accreditation as a replacement for government regulation (Scholsberg and Jackson, 1996; Scholsberg, 1997; Dame and Wolfe, 1996). Some of their concerns include (1) the lack of independence of private accrediting bodies; (2) decreased accountability to the public when the raw data from the accreditation process are not as available to the public as the findings of licensing or Medicare and Medicaid reviews; (3) reduced public participation in the development of private standards, as compared to the public's role in establishing government standards; and (4) diminished access to standards and the results of accreditation surveys. Accrediting bodies generally charge the public for their standards, while government agencies provide them free of charge.
Addressing these concerns while pursuing ways to increase the coordination of quality oversight activities is a worthy goal. Federal and State governments may want to use demonstration projects to test new approaches to deeming that can address these questions. The Health Care Financing Administration currently is pursuing a modified approach to the deeming of Medicare managed care plans through an initiative known as "Enhanced Review." Under this approach, HCFA plans to use select results from private accreditation surveys to supplement its own work. If HCFA determines that the methodology used in a private accreditation survey is equal or superior to its own, HCFA has the option of using that information instead of doing its own review. Health plans will participate on a voluntary basis. Plans that choose not to participate or have not received an accreditation from an organization participating in this project will continue to have complete reviews of their operations by HCFA.
In addition to such coordination between public and private oversight entities, private accrediting bodies could also make use of deeming to simplify their own work. An organization that accredits health plans, for example, could make use of accreditation decisions or survey results from the organizations that accredited the hospitals, clinics, and medical groups affiliated with that health plan.
Accreditation of health plans or facilities (e.g., long-term care facilities) often is voluntary, although less so to the extent that a given marketplace requires accreditation as a condition for receiving contracts. In addition, as newer types of health care delivery organizations are created (e.g., provider-sponsored organizations), and as different types of entities are held accountable for care delivery (e.g., medical groups), it is difficult for licensing, accrediting, and certification entities to keep up with the evolution of new health care delivery models and entities in the marketplace. In order for greater uniformity of assurance to be offered to the marketplace, all types of health care plans and care delivery organizations should comply with common standards for quality.
Compliance with such standards can be achieved in a variety of ways. Many health care entities choose to meet quality standards to live up to their own internal commitment to pursue excellence, as well as to distinguish themselves in the marketplace, as entities offering high-quality health care. In instances in which a health care entity may not perceive the need to adhere to external quality standards, group purchasers can require compliance with quality standards as a condition of doing business with any given health care entity. Licensure and other regulatory approaches can also be utilized. While the Commission hopes that quality standards will be embraced voluntarily, there is a need to monitor the achievement of compliance through voluntary and marketplace incentives. For this reason, it is recommended that the Advisory Council on Health Care Quality be established and charged with monitoring the Nation's progress in improving care and recommending when approaches are needed to stimulate additional mechanisms for quality improvement (see Chapter 5).
Dame, Lauren and Sidney Wolfe, The Failure of Private Hopsital Regulation (Washington, DC: Public Citizen, 1996).
Schlosberg, Claudia, Privatizing Government Regulation of Publicly Funded Health Plans: The Limits of Private Accreditation (Washington, DC: National Health Law Program, Inc., July 7, 1997).
Schlosberg, Claudia, and Shelly Jackson, "Assuring Quality: The Debate Over Private Accreditation and Public Certification of Health Care Facilities," Clearinghouse Review 30(7):699-719, November 1996.