NCQA Primer
NCQA Primer
Table of Contents
NCQA
INTRODUCTION
CHAPTER
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
APPENDIX
Quality Initiatives/Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
APPENDIX
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
A Letter from
Margaret E. OKane
A decade ago, The Essential Guide to Health Care Quality could not have been written. Then, as now, the issues
of rising medical costs and swelling numbers of uninsured Americans were a focus of our national debate. But
systematic measurement of health care quality didnt exist back then; in fact, some questioned whether doing so was
even possible. However, a few visionaries realized that measuring health outcomes and public reporting of the results
were not just possible, but necessary next steps if America was going to address these issues.
We now know that measurement and reporting of health care quality are more than just possible. Quality
measurement identifies where things are going well, shows where things need improvement and helps define how to
make those improvements. Over the past 10 years, progress in health care quality has saved more than 53,000 lives
through improvements in controlling high blood pressure, blood sugar levels in diabetic patients and administering
beta blockers to those who have suffered heart attacks.
At the same time, there has also been a sharp increase in the number and type of quality measurement activities in
the U.S. as a rising number of individuals and organizations endeavor to learn as much as they can about this
important topic.
The Essential Guide to Health Care Quality is designed to provide policy makers and health care stakeholders a clear
understanding of the issues, initiatives and organizations that are working to improve health care quality. It answers
questions from who does what to the philosophical questions of what a quality health care system would look like
and how it would work. It also contains a glossary of terms and a list of useful resources.
Since 1990, the National Committee for Quality Assurance (NCQA) has been improving the quality of health care
through measurement, transparency and accountability. We are proud to bring you this primer on health care quality.
In addition, we hope you will take the opportunity to visit our Web site, www.ncqa.org, for the latest news and
information about health care quality.
Sincerely,
Margaret E. OKane
President, National Committee for Quality Assurance
Thank you for your interest in the quality of Americas health care. We hope this primer is a useful reference to
which you will refer frequently in the future.
CHAPTER
Every American has his or her own definition of highquality health care. For some people, that definition
revolves around whether they can go to the doctor or
hospital of their choice. For others, it means access to
specific types of treatment. In recent years, there has
been a great deal of attention paid to defining health
care quality so that we, as a nation, can work together
to improve care.
In 2001, the highly regarded Institute of Medicine
(IOM) of the National Academy of Sciences issued a
landmark reportCrossing the Quality Chasm: A New
Health System for the 21st Centurythat called on the
nation to aggressively address the dramatic deficiencies
in the quality of health care delivered in the U.S. The
IOM defined quality health care as safe, effective,
patient-centered, timely, efficient and equitable.[1]
The Agency for Healthcare Research and Quality
(AHRQ), the federal governments leading agency
charged with improving the quality, safety, efficiency
and effectiveness of health care for all Americans,
defines quality health care as doing the right thing for
the right patient, at the right time, in the right way to
achieve the best possible results.[2]
Both definitions provide us with a clear picture of good
quality health care. It is based on scientific and medical
evidence, it takes the specific details of a patients life
What We Found
Potentially Preventable
Complications or Deaths*
68,000 deaths
Heart Attacks
37,000 deaths
Pneumonia
10,000 deaths
Colorectal Cancer
9,600 deaths
Hypertension
Whats next?
The evidence that Americans health care needs
improvement seems to have convinced many leaders
that it is time to act. The number of efforts to
improve care is growing quickly. As a result, we are
learning new ways to do so. The following chapters
provide more details on these exciting initiatives that
hold great promise.
A 2003 study that found that one in three patients who received
antibiotics for sore throats was later found to have had a viral
infection (for which the medicine did absolutely no good[14]) and the
overuse of antibiotics helps build up resistance to those drugs, in
individual patients and in entire communities. In addition, overuse of
antibiotics costs our country more than $250 million a year.
CHAPTER
What Affects
Health Care Quality?
11
13
CHAPTER
What Was
Measured
Controlling High
Blood Pressure
69.4%
62%
Child
Immunization
Status
78.9%
63.5%
0%
10%
20%
30%
40%
50%
60%
70%
80%
HEALTH PLANS THAT PUBLICLY REPORT THE QUALITY OF CARE AND SERVICE THAT MEMBERS
RECEIVE PERFORM BETTER THAN PLANS THAT DO NOT
15
17
CHAPTER
Bridges to Excellence, the largest employersponsored P4P program in the U.S., has paid
nearly $3 million in bonuses to doctors who
achieve specific quality improvements in
treating diabetes and heart conditions and who
use information technology to better
communicate with patients. Participating
employers include General Electric, UPS,
Procter & Gamble, Marriott, Raytheon and Bell
South. Doctors are rewarded for following
policies and standards that are linked to better
quality and patient safety, such as participating
in disease management programs and using
automated prescribing systems.
Another employer-led health care quality
initiative, The Leapfrog Group, is experimenting
with linking payment to improvements in patient
safety. The Leapfrog Group includes 170
companies and organizations that purchase
health care, including General Motors, General
Electric, Marriott International and Lockheed
Martin, and focuses on proven safety measures.
Doctors and hospitals are rewarded for using
computers to reduce medication prescribing
errors, referring patients for high-risk surgeries
to use high-volume hospitals with better
outcomes and staffing intensive care units with
physicians who are certified in critical care
medicine. Leapfrog says that these safety
measures could save 65,000 lives and $41.5
billion in health expenditures each year.
Public programs like Medicare and Medicaid
are also experimenting with new payment
systems to encourage better quality care. See
Chapter 8 for details.
19
CHAPTER
Poor hygiene.
Equipment failures.
Mistaken diagnoses.
Misuse or overuse of drugs, lab tests or other services.
21
23
CHAPTER
Using Health
Information Technology
Consumers want:
25
27
CHAPTER
29
CHAPTER
31
33
CHAPTER
All Americans would have affordable access to highquality care when they need it.
Health Care
Spending
Healthy/
Low Risk
High
Risk
At Risk
Early
Symptoms
Active
Disease
A value-based health care system moves people to the left and keeps them there
0%
20%
40%
60%
80%
100%
Number of Patients
Source: HealthPartners
20% of people
generate
80% of costs
35
APPENDIX
Glossary
37
APPENDIX
Government Agencies
Agency for Healthcare Research and Quality
www.hhs.gov/healthit
Non-Profit Organizations
American Board of Internal Medicine Foundation
(ABIM): An organization focused on medical
professionalism, physician leadership, science-based
medicine and quality health care.
www.abimfoundation.org
American Health Information Community: A
federally chartered commission that provides input and
recommendations to the U.S. Department of Health
and Human Services (HHS) on how to make health
records digital and interoperable and ensure the privacy
and security of those records.
www.hhs.gov/healthit/ahic.html
American Health Quality Association (AHQA):
Represents quality improvement organizations (QIO)
and professionals working to improve the quality of
health care in the U.S. QIOs are independent, largely
non-profit health care organizations under contract
with Medicare to work in communities in every state
to promote health care quality. www.ahqa.org
American Hospital Association (AHA): The national
organization that represents and serves all types of
hospitals, health care networks and their patients and
communities. Close to 4,800 institutional and 33,000
personal members belong to AHA. www.aha.org
American Medical Association (AMA): The nations
largest physician group, it advocates on issues
concerning national health, including patient safety
and health care quality. www.ama-assn.org
39
Commercial: 18
Medicaid: 6
Both: 14
Total: 38
DC
NC Recognizes
MBHO Accreditation
41
APPENDIX
www.ahrq.gov
www.cmwf.org/topics/topics.htm?attrib_id=11997
www.allhealth.org/issues.asp?wi=13
approach (Briefing).
www.iom.edu/CMS/8089.aspx
www.allhealth.org/briefing_detail.asp?bi=78.
RAND-McGlynn
www.randeconomics.org/health/surveys_tools/qatoo
ls/index.html
McGlynn E.A., S.M. Asch, J. Adams, J. Keesey, J.
Hicks, A. DeCristofaro, and E.A. Kerr. June 2, 2003.
The quality of health care delivered to adults in the
United States. New England Journal of Medicine 348
(26): 2635-45. www.rand.org/pubs/research_
briefs/RB9053-2/index1.html
RAND Health. The first national report card on quality
of health care in America (Research Briefing).
www.rand.org/pubs/research_briefs/
RB9053-2/index1.html.
www.usnews.com
www.ncqa.org
_series/diabetes/index.asp
43
APPENDIX
Quality Initiatives/Resources
www.ihi.org/IHI/Programs/Campaign/
www.markle.org
www.aqaalliance.org
www.bridgestoexcellence.org
A multi-state, multi-employer coalition that recognizes and
financially rewards high-quality health care providers.The
largest employer-sponsored pay-for-performance program
in the U.S., BTE has paid close to $3 million in bonuses to
doctors who have achieved specific quality improvements.
www.hsrd.research.va.gov/queri
www.qualitynet.org/dcs/ContentServer?cid=1143577
170595&pagename=QnetPublic%2FPage%2FQnet
Tier2&c=Page
The Centers for Medicare & Medicaid Services (CMS)
established the Doctors Office Quality Information
Technology (DOQ-IT) project as a three-year,
national quality improvement initiative to help doctors
purchase and adopt electronic health record systems in
their practices, thereby improving the quality and
safety of care provided under Medicare.
www.hospitalcompare.hhs.gov
A Web-based consumer information initiative launched by
the Centers for Medicare & Medicaid Services (CMS) and
the Hospital Quality Alliance (HQA). The Hospital
Compare Web site allows consumers to search for
information on how often hospitals provide good care for
heart attacks, heart failure, pneumonia and surgery. In this
way, consumers can make informed decisions about where
to go for the best care.
Hospital Compare
www.leapfroggroup.org
45
ClearinghouseTM (NQMC)
www.ncqa.org
www.qualitymeasures.ahrq.gov
Quality Tools
www.qualitytools.ahrq.gov
Sponsored by AHRQ, Quality Tools is an on-line
clearinghouse for practical, ready-to-use tools for
measuring and improving the quality of health care.
Talking Quality
www.talkingquality.gov
This Web site is designed for people and organizations
trying to educate consumers about health care quality and
for those who provide consumers with information on the
performance of health plans and providers. It is sponsored
by the AHRQ, CMS and the Office of Personnel
Management.
Acknowledgements
47
APPENDIX
References
49
Program www.phc4.org/reports/FYI/fyi11.htm
(July 26, 2006).
[32] Maureen Glabman. 12 DM Trends You Should
Know About. August 2005,
www.managedcaremag.com/archives/0508/0508/twelve
dmtrends.html (July 26, 2006), Managed Care.
[33] Villagra, V.G., and t. Ahmed. 2004. Effectiveness
of a disease management program for patients with
diabetes. Health Affairs 23 (4): 255-66.
[34] Bodenheimer, Thomas, and Alicia Fernandez. July
5, 2005. High and rising health care costs. Part 4: Can
costs be controlled while preserving quality? Annals of
Internal Medicine 143 (1): 26-31.
[35] Glabman, op cit.
[36] Asch, S.M. et al. Dec. 21, 2004. Comparison of
quality of care for patients in the Veterans Health
Administration and patients in a national sample.
Annals of Internal Medicine 141(12): 938-45.
[37] www.aqaalliance.org/
[38] www.cms.hhs.gov/HospitalQualityInits/15_
HospitalQualityAlliance.asp
[39] www.pqaalliance.org/
[40] Berwick, Donald M. 2002. Escape fire: Lessons
for the future of health care. New York: The
Commonwealth Fund.
[41] National Program Office of the Robert Wood
Johnson Foundation (RWJF) Investigator Awards in
Health Policy Research, August 2004. Learning from
mistakes: Toward error-free medicine; Lucian L. Leape,
MD. Research in Profile. New Brunswick, NJ:
National Program Office of the RWJF Investigator
Awards in Health Policy Research.
National Committee For Quality Assurance The essential guide to health care quality