Our National Quality Strategy
A Message from Charlie Homer, NICHQ's President and CEO
How exciting! For the first time in American history, the efforts and activities of the Federal Government related to health and health care will be guided by a focused strategy with a well-defined set of aims and priorities, articulated as the National Strategy for Quality Improvement in Health Care. This strategy, the development of which is required by the Affordable Care Act, will be paired with the National Prevention Strategy and other goal setting activities (such as Healthy People 2020) to prioritize federal health activities.
Not surprisingly, the aims reflect the framing Tom Nolan and Don Berwick (Administrator of CMS) developed when Don was the CEO of the Institute for Healthcare Improvement (IHI) as part of IHI’s Triple Aim initiative. Simply stated, the goal is to focus efforts across three dimensions:
- Better Care (defined as patient/family-centered, reliable, accessible, and safe)
- Better Health (healthy people/healthy communities)
- Affordability/Lower Cost—for all (individuals, families, employers and government—not shifting cost burden from one to the other)
Below these high level aims, the National Quality Strategy identifies six key priorities:
- Make care safer/reducing harm
- Ensure each person and family are engaged as partners in care
- Promote effective communication and coordination
- Promote effective prevention and treatment for the leading causes of mortality starting with cardiovascular disease
- Work with communities to promote wide use of best practices to enable healthy living
- Make quality care more affordable by developing and spreading new healthcare delivery models
NICHQ's Alignment with the National Quality Strategy
I am thrilled at how well NICHQ’s priorities and activities align with the National Quality Strategy. Here are some of the ways that our efforts, projects, and principles are already advancing the implementation of the Strategy every day:
The primary focus on NICHQ’s activities has always been and remains the provision of better care, particularly when defined through the lens of patient and family-centeredness. High on our strategies for accomplishing this has been placing the child and family at the center of our efforts. Since our Attention Deficit Hyperactivity Disorder learning collaborative more than a decade ago, we have mandated that NICHQ’s quality improvement teams include parents as team members and we have engaged parents as co-chairs of our collaboratives. What’s more, parents involved in our neonatal and chronic care improvement collaboratives have written of their experiences, creating manuals to inspire and guide other parents eager to proceed on the journey. In fact, just last week at a quality improvement workshop for teams addressing the care of individuals with sickle cell disease from across the nation, each team had two consumers joining them at the table as they set priorities and developed change strategies. And the same week as the Strategy was released last month, two parents of children with autism joined our expert meeting to define the elements of a better system of care for this population.
Similarly, a focus on communication and coordination lies at the core of our work on improving care of children with special health care needs in general and in advancing the medical home in particular. We have emphasized the use of written care plans since our first asthma collaboratives and coordination has been a key emphasis of our efforts since our pioneering work on the medical home, as well as our projects on autism and sickle cell disease. In addition, we routinely include health information technology expertise in all of our expert meetings, since it is now a key enabler of effective coordination. Our sickle cell initiative, for example, will seek to create a patient registry system that may also enable better coordination of care across sites.
At the same time, there are some important ways in which NICHQ can consider shifting its emphasis to improve our alignment with the patient safety priority in the on the “better care” dimension. NICHQ has long been engaged in patient safety, helping to organize the child health “node” of IHI’s 100,000 Lives and 5 Million Lives campaigns. And our Forum served for many years as the key convening of experts in pediatric safety. Yet NICHQ does not now have a major focus or project on patient safety and this will be an area for our future attention.
Nothing speaks more to our emphasis in improving health than our efforts to help reverse the obesity epidemic. We have sought to make primary care practices reliable providers of evidence-informed preventive services and to link closely with community resources so that children and families can remain active and eat well. Our Be Our Voice initiative has moved us into the community, training health professionals to be advocates for policies that make communities healthier places for children and families. And our Collaborate for Healthy Weight project brings these two spheres of activities together in a single program with anticipated broad national reach.
But our efforts to promote better health don’t start and end with our obesity related work, although that is the work most closely tied to cardiovascular health. Our perinatal work has sought to reduce the frequency of prematurity and, in New York State is beginning to show strong results in reducing late preterm births. Other work in New York is promoting the adoption of exclusive breastfeeding, another strongly evidence based health promoting strategy.
NICHQ’s work in improving care and developing new models of care for children and youth with special health care needs looks to the prevention of unplanned high cost utilization – hospitalization and emergency department visits – as one critical outcome. Early assessments of our asthma work showed reduction in emergency department visits in North Carolina counties that were engaged in our programs. Our national medical home learning collaboratives also had promising reductions in emergency department use.
As with the “better care” dimension, NICHQ can look to better align our efforts with the “affordable care” aim. Perhaps because child health care expenditures pale in comparison to expenditures for adults, cost reduction per se has not been at the forefront of NICHQ’s activities. Indeed, we led the preparation of an important Health Affairs article that noted how the benefits of quality improvement in child health often accrued not only to health care organizations outside those investing in the improvement, but to those outside of health care completely (schools, justice systems, etc.). Despite this, it is now time for us to focus on linking our efforts to improve quality with efforts to remove waste and lower costs. Correspondingly, I have asked all of our project leads and improvement experts to include changes focused on affordability and measures of cost in all of our projects and expect to see important results on this front going forward.
Opportunities to Fine-Tune the National Strategy
At the level of aim, the national strategy gets it right: better care, better health, lower cost. But the road map to get there is – in my view – missing several key priorities. Some of these were included in the broader principles underlying the strategy but appear not to have made the final cut, and some were not even in that list.
The most glaring absence from my perspective is the lack of attention paid to earlier influences on later health and development. If the goal is to improve health, e.g., cardiovascular health, then improving care of patients with myocardial infarction, or providing access to cholesterol screening in adults, or even making gyms and healthy foods more available to adults won’t have the impact needed to bend the growth curves, never mind the health or cost curves. We need to start with kids, and even with their mothers during and before pregnancy. Similarly, improving behavioral health outcomes will require greater attention to maternal health and mental health and the environments of childhood. The “life course” lens changes the priorities for intervention in a dramatic way.
The principles underlying the national quality strategy emphasize re-balancing health care to provide a greater focus on primary care; this re-emphasis isn’t apparent in the current priorities, although it is listed as one example of a federal initiative to promote more effective care coordination. Similarly, the principles emphasize the importance of a “whole person” orientation, integrating physical, behavioral and oral health.
Although the principles suggest addressing disparities as a cross-cutting theme across all priorities, the actual strategy provides scarce mention of disparities and strategies to address them. HHS has recently announced a separate Strategic Action Plan to Reduce Racial and Ethnic Health Disparities, but keeping these wholly distinct de-emphasizes the importance of addressing disparities as part of the overall quality strategy.
These three areas will continue to drive NICHQ’s attentions and activities and, as we demonstrate results, we will communicate our lessons and successes to policy makers to inform future priorities and actions.