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41 3 The Healthcare Industry: Structure, History, and Continuous Quality Improvement Associated Press/J. Scott Applewhite Learning Objectives After reading this chapter, you should be able to do the following:

• Analyze the case study at Virginia Mason Medical Center to better understand how continuous quality improvement works.

• Evaluate the structure of the U.S. healthcare system and how multiple players have a role in quality improvement.

• Relate major healthcare reforms in U.S. history to the current state of quality improvement.

• Describe quality management in managed care.

• Examine quality improvement in hospitals and the effect on healthcare.

• Show how physicians and physician practices implement quality improvement projects. fin81226_03_c03_041-072.indd 41 10/30/14 7:43 PM What is Special Education? 1 iStockphoto/Thinkstock Pre-Test 1. You can use the terms disability and handicap interchangeably. T/F 2. The history of special education began in Europe. T/F 3. The first American legislation that protected students with disabilities was passed in the 1950s. T/F 4. All students with disabilities should be educated in special education classrooms. T/F 5. Special education law is constantly reinterpreted. T/F Answers can be found at the end of the chapter. Section 3.1 A Story of Continuous Quality Improvement Introduction In 2004, Virginia Mason Medical Center in Seattle admitted Mary McClinton for a complex but routine procedure to treat a brain aneurysm, which is an abnormal or weak spot on a blood vessel in the brain that causes an outward ballooning of the arterial wall. This can be life- threatening, as a ruptured aneurysm with subsequent bleeding into the brain is lethal. Doc - tors intended to inject a contrast dye through a catheter in her leg as part of the procedure, but instead they injected her with antiseptic, which blocked the blood flow in her leg and caused her organs to fail, one by one. She died 19 days later as a result of this medical mistake because the antiseptic had been placed in an unlabeled container on the same tray as the dye.

Virginia Mason has come a long way since 2004 and was named a top hospital of the decade in 2010 by The Leapfrog Group ( ht tp://w w w.leapfroggroup.org ), a consortium of businesses that purchase health insurance for their employees and focus on improving the quality of healthcare. However, even before Ms. McClinton’s death, the hospital had begun to improve its safety procedures, developed checklists for surgeries and drug dispensations, established patient safety alerts, and encouraged all hospital employees to advocate for patient safety (AARP, 2013). Virginia Mason became one of the best hospitals in safety and quality standards within a few years of that tragic event. This was accomplished by the coordinated efforts of all hospital employees.

3.1 A St ory of Continuous Quality Improvement The story of Virginia Mason Medical Center demonstrates how one healthcare system suc - cessfully used continuous quality improvement to improve the care of its patients.

In 2001, Virginia Mason began to examine ways it could change its healthcare delivery to improve both quality and safety. During the search for a management method to achieve those goals, medical center leaders became aware of how the Boeing air - plane manufacturer had used a system created by a Japanese car manufac - turer to improve its processes. Called the Toyota Production System (TPS, sometimes also called lean production or lean theory ), Boeing used the sys - tem to eliminate waste and improve quality in manufacturing its airplanes.

You will find more on lean theory and how Virginia Mason put it into practice in Chapter 7.

But what similarities do car and air - plane manufacturing have with health - care? Virginia Mason leaders found that the Toyota Production System principles—the customer comes first, Shizuo Kambayashi/Associated Press The Virginia Mason Medical Center used the principles of the Toyota Production System to improve the quality and safety of its healthcare delivery. fin81226_03_c03_041-072.indd 42 10/31/14 9:41 AM Section 3.1 A Story of Continuous Quality Improvement dedication to the highest quality, obsession with safety, the aim for high staff satisfaction, and a successful economic enterprise—translated very well to healthcare.

While patients are certainly not cars, manufacturing and healthcare are both filled with com - plex production processes. In healthcare, those processes include admitting a patient, con - ducting a clinic visit, or performing surgery. As with manufacturing, these processes should embrace the concepts of quality, safety, customer satisfaction, staff satisfaction, and cost effectiveness—each of which Virginia Mason’s quality improvement system tries to optimize on behalf of its patients.

Virginia Mason adopted the Toyota system and began to apply the tenets that worked suc - cessfully in car manufacturing through a number of quality improvement initiatives, naming its program the Virginia Mason Production System (VMPS). Its goal was to eliminate waste and improve quality and safety through tools and techniques adapted from the manufactur - ing world.

Early on in the quality improvement process, Virginia Mason used VMPS to develop a new Patient Safety Alert (PSA) system, which requires all staff members who encounter a situ - ation likely to harm a patient to make an immediate report and stop any activity that could cause further harm. This is called “stopping the line,” or stopping the activity and correct - ing the problem, in the same way a worker at the Toyota plant could pull a cord to signal a problem and stop the production line rather than allowing a potential product defect. Senior leaders would respond to the most serious of these PSAs. If the safety of a patient is indeed at risk, an investigation is immediately launched to correct the problem. From the program’s inception in 2002 through 2009, more than 14,500 PSAs were reported and most were pro - cessed within 24 hours (Virginia Mason Medical Center, 2014, “VMPS Success Stories”). That contrasts sharply with the years prior to 2002, when reports took 3 to 18 months to resolve.

Mary McClinton’s death occurred early in the VMPS implementation. The hospital had recently switched antiseptics (the solution used to clean skin before and after procedures) from a brown iodine-based solution to a colorless liquid (Perry & Ostrom, 2004). She was accidentally injected with an antiseptic, which was one of three clear liquids in bowls on the surgical tray; the other liquids were contrast solution, to make blood vessels visible on x-rays, and saline. This mistake caused Mary to suffer kidney failure, a sudden drop in blood pressure, and a stroke. The hospital publicly explained what had happened and apologized for the error.

The case sparked sweeping changes in patient safety protocols at Virginia Mason. The hospi - tal mistake-proofed the process by purchasing swabs with solution already on them to pre - vent future errors. As part of a legal settlement with Mary’s family, Virginia Mason used her case to teach medical staffers the importance of proper labeling of medications. She became the namesake of the hospital’s patient safety award, which is given annually to the team that develops and implements the most significant measures that enhance patient safety. Mary’s death was a watershed moment, further demonstrating the need to integrate the calling out of errors and defects in the organization’s culture.

The problem also went beyond the walls of Virginia Mason and resulted in other hospitals changing their processes. Following Mary’s death, as well as several other high-profile cases, The Joint Commission (TJC) included the requirement that hospitals label all medication con - tainers and solutions in procedure areas in its 2006 National Patient Safety Goals. fin81226_03_c03_041-072.indd 43 10/30/14 7:43 PM Section 3.2 The United States Healthcare System The purpose of continuous quality improvement programs is to improve healthcare by iden - tifying problems, implementing and monitoring corrective actions, and studying its effective - ness. In this case, the problem at Virginia Mason was clearly identified by the preventable death of a patient and the hospital immediately began looking for ways to keep this situation from recurring.

It is important to remember that CQI focuses on system issues. Beyond the mix-up that occurred during this specific procedure at Virginia Mason, it was important that the hospital look at the overall issue of properly labeling all medications and solutions to prevent errors throughout the system. By sharing its error, Virginia Mason also highlighted the problem so other healthcare organizations could make changes to their own systems.

3.2 The United States Healthcare System The U.S. healthcare system is a fiscally driven entity that spends more on healthcare than any other developed country in the world (Organization for Economic Co-operation and Development, 2013). Despite the limited access to basic healthcare by the millions of unin - sured, healthcare costs continue to rise rapidly. In 2010, annual national health expendi - tures totaled $2.6 trillion, in comparison to $27.3 billion in 1960 (U.S. Census Bureau, 2012).

By 2018, it is estimated that the United States will spend more than $4.3 trillion per year, or 20.3% of the gross domestic product (GDP), which is the monetary value of all finished goods and services produced within the United States in a year (Centers for Medicare and Medicaid Services, 2011a).

In 2011, the United States spent 17% of its GDP on healthcare. This spending level far exceeds that of other Organization for Economic Co-operation and Development (OECD) nations: the next highest spender is France, which spent 11.2% of GDP in 2011 (OECD, 2013). In equal dollar terms, in 2011 the United States spent $8,175 per person, as compared to $3,970 per person in France. Despite spending more than double the amount of money on healthcare, health outcomes (such as life expectancy) are no better, and often worse, in the United States.

Of course, there are many reasons for the high cost of healthcare in the United States, which must be balanced with the medical care the system provides. Take for instance, the fact that other countries place major restrictions on the amount of damages that can be awarded in malpractice lawsuits. That is the not the case in the United States, where a jury can decide Questions to Consider 1. Discuss how, despite such major differences between manufacturing cars and caring for patients, the same quality improvement method can be used in healthcare and manu - facturing. 2. When a patient death or major injury occurs, do you think a hospital should publicly explain what happened and offer an apology for the error? How can this benefit a hospi - tal? How can such a public admission hurt the organization? 3. Can you think of an error that might occur at one hospital that could result in changes to other hospital systems? fin81226_03_c03_041-072.indd 44 10/30/14 7:43 PM Section 3.2 The United States Healthcare System to award millions of dollars to settle malpractice lawsuits brought against physicians and healthcare organizations. Malpractice reform, which has long been discussed, would help bring down healthcare costs in the United States.

It’s also necessary to look at the care various countries are able to provide. Consider that technology is advanced in the United States and is far better than in many other countries.

Access to medical services is also good in America compared to the wait times to see a doctor or schedule a surgery in many other countries. Costs would also go down if the healthcare system could address major health problems and create a healthier population of patients.

For instance, obesity rates in America are among the highest in the world, leading to many health complications.

The healthcare system has multiple players including employers, insurance companies, and managed care companies; health service professionals, which include physicians, nurses, and therapists; health service organizations such as hospitals, integrated delivery systems, and nursing homes; and the government. The players with substantial political and financial power try to influence decisions and maximize their interest in the largest industry in the nation. Each player has a different economic interest, but none can dominate the industry except the government. Quality improvement efforts to reduce medical errors, such as inju - ries and deaths, are made by all parties involved in the healthcare delivery system. These efforts are ongoing and steady progress has been made to improve patient safety records and medical errors.

While different players have their own interests in the healthcare system—an insurance com - pany may look to keep costs under control while a physician may want to order many tests to diagnose a patient’s problem—all of the players benefit from quality improvement proj - ects that reduce patient injuries. For example, a hospital may launch a quality improvement project to reduce patient falls. It is beneficial to the insurance companies who would have to cover a longer hospital stay if a patient fell and broke his or her hip, needing more days in the hospital as well as possible rehabilitation. Or hospitals that follow best practices, such as prescribing beta blockers to heart attack patients, can keep them healthier, allowing them to return to work and cutting future healthcare costs.

Insurers, providers, employers, and healthcare professionals can all cooperate in creating a system that can reduce total healthcare costs and premiums while achieving better outcomes for patients. The Institute for Healthcare Improvement (IHI) calls this the “Triple Aim”: better care for individuals, better health for populations, and a lower per capita cost. The IHI sup - ports initiatives to move the country to a system that achieves these goals. Web Field Trip For an overview of the healthcare system, visit the Kahn Academy website ( http://www .khanacademy.org ) and search for the video Healthcare System Overview. In the video, Pro - fessor Laurence C. Baker, Stanford University, considers some of the basic who, what, and how elements of the healthcare system. fin81226_03_c03_041-072.indd 45 10/30/14 7:43 PM Section 3.2 The United States Healthcare System Employers and Insurance The United States has a fragmented healthcare delivery system in comparison to other devel - oped countries such as England, Germany, and France. The system is described as fragmented because of the large number of insurers, health systems, and physicians that lack effective mechanisms to coordinate care. The system is unique because many working citizens receive their health insurance from their employer with a shared financial responsibility. Employ - ers screen health insurance plans before offering a small number of these plans to employ - ees. Screening is based on price, quality, and coverage, which is a layer of competition health insurance companies are required to successfully pass. This system allows approximately 195 million Americans to obtain insur - ance through their employer, while another 105 million are covered by two major government programs:

Medicare and Medicaid (Shi & Singh, 2013). This combination of employer- and government-based insurance left approximately 47 million Americans without any health insurance in 2012 (Kaiser Family Foundation, 2013).

The healthcare system includes about 1,000 insurance companies, 70 Blue Cross and Blue Shield plans, 452 health maintenance organizations (HMOs), and 925 preferred provider organiza - tions (PPOs) (Shi & Singh, 2013). Health Service Providers Individuals who provide healthcare are at the center of the delivery system, making crucial decisions to treat patients. The types of providers who drive care decisions include physi - cians, physician assistants, nurse practitioners, therapists, and others. These providers are also in a position to make decisions to improve financing, delivery, and quality of healthcare.

Generally, the central point of healthcare delivery is the provider’s diagnosis and treatment plan. Quite often, quality improvement projects focus here because the patient’s journey typi - cally begins with a visit to a primary care provider or specialist.

Nurses are the largest group of healthcare professionals in the healthcare system, with approximately 2.8 million registered nurses (RNs), including advanced practice registered nurses, and about 690,000 licensed practical nurses (LPNs) (Health Resources and Services Administration, 2013). They are employed as caregivers in various settings to provide health - care to patients alongside physicians and other providers. Nurses with advanced training and certification (such as nurse practitioners) are assuming an increasingly important role in care delivery.

Therapists are health professionals whose role is to improve a patient’s functional move - ment (physical therapist) or to teach the patient how to carry out activities of daily liv - ing and to cope with working environments (occupational therapist) in the context of any F1 ONLINE/SuperStock The U.S. healthcare system includes about 1,000 insurance companies. fin81226_03_c03_041-072.indd 46 10/30/14 7:43 PM Section 3.2 The United States Healthcare System limitations imposed by their health. Respiratory therapists and speech therapists are fre - quently employed in the healthcare system to help patients with breathing problems and speech impediments.

While these healthcare professionals provide direct care to patients, they cannot do their jobs well without support from many other professionals who work in healthcare organizations.

For instance, clinical safety and facility safety go hand in hand. Facility managers can make vital contributions to patient safety efforts. Patient safety, employee safety, and facility safety programs can work in conjunction to create a safe environment for everyone. Look at it this way: If a nurse gives out one wrong medication dose, it jeopardizes the safety of one patient.

If a nursing home does not have a fire safety program, with a plan to evacuate all of its elderly residents in an emergency—some of whom are confined to bed and can’t get themselves out in case of a fire—everyone in that building can be put at risk.

While physicians and nurses provide care to newborn babies in a hospital nursery, the facil - ity’s security manager helps put in place the security system to protect those babies from abductions—a rare but frightening occurrence in hospitals. The hospital security guards will be the first to respond if someone tries to take a baby from that nursery without authorization.

Patients count on having a secure and accurate medical record. That happens because of the work of health information management managers and staff who oversee a hospital’s medi - cal records. HIPAA compliance officers put measures in place to ensure a patient’s protected health information—whether on paper or on a computer—is kept safe and isn’t accessed by unauthorized individuals.

From housekeeping managers and staff to food services, it takes many people in different roles to keep healthcare organizations running.

Health Service Organizations There are numerous organizations that provide health services, including hospitals, inte - grated delivery systems, and nursing homes.

Hospitals are a central point to healthcare delivery, as they offer patient services (diagnos - tic and therapeutic) for medical conditions, overnight stay, food and nutritional necessities, along with continuing nursing care for patients who are admitted (American Hospital Associ - ation, 1994). In 1980, the number of non-federal hospitals in the United States reached about 5,830 because of the financial support provided by the 1946 Hill-Burton Act and the passage of Medicare and Medicaid in 1965 (Shi & Singh, 2013). Hospital spending skyrocketed in the 1960s and 1970s because of elderly and vulnerable populations newly insured by Medicare and Medicaid.

Today, many hospitals are actually part of a healthcare system that includes numerous com - ponents, ranging from surgery centers and physician practices to birthing centers, nursing homes, and assisted living facilities. An integrated delivery system (IDS) combines various health and social services providers under one entity to offer comprehensive and coordinated care to patients who would otherwise receive care at separate healthcare facilities. The IDS model is considered efficient and less prone to medical errors (Laplante, 2005). An IDS some - times includes an HMO, which allows the IDS to handle the insurance functions of delivering medical care (e.g., Kaiser Permanente). fin81226_03_c03_041-072.indd 47 10/30/14 7:43 PM Section 3.2 The United States Healthcare System Long-term care is used to describe many types of facilities that focus primarily on the elderly and provide different levels of care: assisted living, skilled nursing, sub-acute care and inter - mediate care facilities, and Alzheimer care facilities.

Nursing homes provide residential care to patients with significant deficiencies in activities of daily living. Nursing home care includes room and board along with some level of care for the residents. Independent or retirement living centers provide housing for elderly residents, but typically provide little to no nursing care.

Healthcare Spending U.S. healthcare spending in 2010 was $2.6 trillion (about 17.9% of the GDP) (Aetna, n.d.).

Hospitals received the largest share from the national healthcare spending at approximately 31%, followed by physicians at about 20% (Centers for Medicare & Medicaid Services, 2013i).

The rest of the spending went to pharmaceuticals and medical products (13%), nursing and home healthcare (13%), administration (7%), research and equipment (6%), and public health (3%). Figure 3.1 shows the distribution of U.S. healthcare expenditures in 2010.

The reason hospital expenditures are high is that most expensive life-saving procedures are provided at hospitals. They have the most expensive equipment and provide a high level of specialization in many illnesses and a wide scope of services. In addition, hospitals or medical centers engage in the education of healthcare personnel and comply with many government regulations. A majority of quality improvement efforts are directed at hospital operations in order to reap relatively higher potential savings. In addition, the operation of hospitals requires a relatively large amount of capital, which allows them to allocate more money for quality improvements. Questions to Consider 1. In comparison to other developed nations how do experts describe the U.S. healthcare system? Why? 2. The U.S. healthcare system has many players. Is the power structure amongst these players about the same or different? Why do some healthcare providers receive a larger share of the healthcare spending than the others? 3. Discuss the role of education, experience, licensure requirements, and strength in a pro- fessional organization. Figure 3.1: Distribution of U.S. national health expenditures in 2010 Hospitals received the largest portion of spending, an amount that is reflective of their life-saving procedures, expensive equipment, scope of services and specializations, and education efforts for personnel.

Source: Shi, L., & Singh, D. A. (2013) Essentials of the U.S. health care system . Burlington, MA: Jones & Bartlett. Hospital care Physician and other professional services Nursing home careand home health Prescription drugsand medical products Administration Public health Research structuresand equipment 31% 20% 13% 13% 7% 3% 6% fin81226_03_c03_041-072.indd 48 10/30/14 7:43 PM Section 3.3 History of Healthcare Delivery and Reforms 3.3 History of Healthcare Delivery and Reforms Understanding the development of the healthcare industry will provide some insight into the goals and challenges in the maintenance of health, in addition to an understanding of its pur - pose. Looking into the past, present, and future of this continually evolving world will allow for improved decision making capabilities.

The history of the healthcare industry can best be divided into three eras: pre-industrial, post-industrial, and corporate (Shi & Singh, 2013). The pre-industrial era took place between the 1700s and 1800s when medical training was based on apprenticeship and care was experienced-based. During this time, medical care lagged behind other developed nations, such as England. The post-industrial era lasted until about the 1970s and showed significant improvements in medical education; drug and treatment discoveries; and establishment of new modern facilities, such as hospitals, clinics, and medical centers. The corporate era, in which healthcare became more like a business and organizations began to act like corpora - tions, followed and continues to the present.

During this history, healthcare reforms were taking place. Healthcare reform refers to a major health policy creation or changes that affect and develop healthcare delivery. Its goal is typically to improve the affordability, access, and quality of medical care and services for Americans (Hoo, Lansky, Roski, & Simpson, 2012). Despite popular belief, health reform has been ongoing long before President Barack Obama’s Patient Protection and Affordable Care Act passed in 2010. Web Field Trip The Patient Protection and Affordable Care Act of 2010 marked the beginning of a major healthcare system overhaul in the United States. Though the 2010 act is milestone in the his - tory of care, it is not the country’s first attempt to create more inclusive coverage. In a video story for CNN, Sanjay Gupta presents a brief overview of healthcare reform. See the video “60-year road to Obamacare” at CNN’s website: http://w w w.cnn.com/video/data/2.0 /video/us/2012/06/25/gupta-60-year-road-to-obamacare.cnn.html Long-term care is used to describe many types of facilities that focus primarily on the elderly and provide different levels of care: assisted living, skilled nursing, sub-acute care and inter - mediate care facilities, and Alzheimer care facilities.

Healthcare Spending U.S. healthcare spending in 2010 was $2.6 trillion (about 17.9% of the GDP) (Aetna, n.d.).

Hospitals received the largest share from the national healthcare spending at approximately 31%, followed by physicians at about 20% (Centers for Medicare & Medicaid Services, 2013i).

The reason hospital expenditures are high is that most expensive life-saving procedures are provided at hospitals. They have the most expensive equipment and provide a high level of specialization in many illnesses and a wide scope of services. In addition, hospitals or medical centers engage in the education of healthcare personnel and comply with many government regulations. A majority of quality improvement efforts are directed at hospital operations in order to reap relatively higher potential savings. In addition, the operation of hospitals requires a relatively large amount of capital, which allows them to allocate more money for quality improvements. Questions to Consider 1. In comparison to other developed nations how do experts describe the U.S. healthcare system? Why? 2. The U.S. healthcare system has many players. Is the power structure amongst these players about the same or different? Why do some healthcare providers receive a larger share of the healthcare spending than the others? 3. Discuss the role of education, experience, licensure requirements, and strength in a pro- fessional organization. fin81226_03_c03_041-072.indd 49 10/30/14 7:43 PM Section 3.3 History of Healthcare Delivery and Reforms Pre-Industrial Era The pre-industrial healthcare era in America lasted until the beginning of the 20th century, and was characterized by physicians who lacked formal training and who did not base deci - sions on medical science. Practitioners lacked knowledge of germs and the difference between bacteria and viruses. As a result, they often did not practice in sanitary conditions and did not promote behavior such as proper hand washing. Procedures were performed without adequate sterilization, and standards for quality service were nowhere to be seen. During this time, the concept of health insurance for procedures and services was yet to be imagined.

In the late 1700s, a few hospitals began to take shape. The first medical school to be estab - lished was the Pennsylvania Hospital in 1768, followed by Kings College in New York two years later. Shortly after, medical schools in Boston, New Orleans, and St. Louis emerged.

These schools only accepted small cohorts of students each year, resulting in minimal oppor - tunities for the remaining applicants, who relied on apprenticeships for training in lieu of professional education. The time frame for medical school was about six to eight months, while apprenticeships lasted approximately three years. Because there was no standardiza - tion for medical education, anyone could become a practitioner. Barbershops became prime locations for treating patients, and barbers often became town doctors (Shi & Singh, 2013).

The infamous poles outside the barbershops were painted red and white to represent the blood and bandages from treating patients (Shi & Singh, 2013).

Before the 1800s, official medical clinics were yet to be established. Town doctors often made house calls to treat the sick. With the lack of health insurance and managed care plans, pay - ment for care was done through bartering. Establishments such as penthouses and alms - houses were built to treat the “undesirables.” Penthouses were used to quarantine conta - gious individuals, such as patients with smallpox. The almshouses were used as a place for the impoverished community to receive basic nursing care. Almshouses became known as places where the destitute were sent to be removed from society. Dispensaries were created to administer outpatient charity care in more urban communities.

Post-Industrial Era The post-industrial era occurred between the late 1800s and the 1970s, when urbanization was beginning to take place. The populations within the various cities grew and created a need for more physicians and nurses. The increased need for providers led to higher quality medical programs. Colleges such as Harvard and Johns Hopkins established three-year medi - cal programs. The Flexner Report was generated to monitor whether medical schools were meeting basic standards of education and found that most schools were operating under sub - par standards (Duffy, 2011).

The poor standards of education led to the formulation of the Council on Medical Educa - tion. This became the accrediting body of the American Medical Association (AMA), which set strict standards for a quality medical degree. Universities that did not meet the standards were not accredited and were forced to close. The concept of the medical clinic began to take shape, replacing the previous methodology of home visits.

As more medical students graduated with higher quality degrees, they began focusing on various areas of care, and because of this, medical specialties such as pediatrics and orthope - dic medicine emerged. This marked the beginning of the disparity between generalists and specialists. fin81226_03_c03_041-072.indd 50 10/30/14 7:43 PM Section 3.3 History of Healthcare Delivery and Reforms Awareness for proper sanitation grew after the germ theory was established in the 19th cen - tury (British Medical Journal, 1888). This discovery proved that bacteria and microorganisms could cause diseases. Therefore, a connection was made between the high rates of illness or mortality and the lack of sanitation and hospital hygiene. Germ theory resulted in the prac - tices of sterilizing medical equipment before each new patient and creating patient rooms instead of open spaces with many beds.

As education and scientific research progressed, and as more researchers understood how bacteria and viruses enter the body, companies began creating medications such as antibi - otics and vaccines. The term antibiotic was first used in 1942 by Selman Waksman and his collaborators to describe any substance that inhibits bacterial growth or kills bacteria (Waks - man, 1947). For more complicated procedures, scientists developed anesthesia to allow for pain-free surgical procedures and provide quality care for patients. Small clinics multiplied, and the modern hospital began to develop. Hospitals began contracting with doctors and cre - ating physician networks.

During this era, the first healthcare reforms were also taking place. Beginning in the early 1900s, medical technology was improving rapidly and hos - pitals were performing more specialized surgeries and research. This resulted in cost increases, which have continued to rise from that time forward. In 1912, the government began considering ways to make healthcare more affordable. One of the first efforts to conduct healthcare reform is credited to Theodore Roosevelt. However, he was defeated in the run for president in 1912, despite support from progressive healthcare reformers. Progres - sives campaigned for federal sickness insurance but failed because of opposition from the AMA and urban workers who already had sickness insurance through employer-based sickness funds.

By the end of the 1920s, most of the middle class was unable to afford medical care. The AMA rec - ognized this disparity and formed the Committee on the Costs of Medical Care to review options for Americans who could not afford needed services.

This was the first time that communities accepted private health insurance as a viable option to sub - sidize costs. As a result, Baylor University Hospital began to offer pre-paid medical insurance to schoolteachers at a discounted rate of 50 cents per month. This medical insurance was identified by an iconic symbol still used today, the Blue Cross. In the 1930s, with the Great Depression, the number of people who could not afford medical services increased. Health insurance plans began to form as a method of pay - ment for medical procedures and services.

Hospitals and physician groups began offering group health insurance policies to employers.

By the end of the 1930s, nearly 3 million Americans were enrolled in Blue Cross plans. Everett Collection/SuperStock Companies began creating vaccines and antibiotics as education and scientific research progressed during the mid-20th century. fin81226_03_c03_041-072.indd 51 10/30/14 7:43 PM Section 3.3 History of Healthcare Delivery and Reforms During Franklin D. Roosevelt’s presidency, he declared accessibility to healthcare to be a basic human right. However, because of AMA opposition, he was unsuccessful in including national health insurance in the Social Security Act in 1935. President Harry Truman served from 1945 to 1953 and attempted to establish a national insurance program for anyone who wanted to pay into it voluntarily, but the AMA declared this to be socialized medicine and President Tru - man was also unsuccessful.

In the 1950s, employer-based health insurance began to gain popularity, which provided effective healthcare coverage for a vast majority of the population. However, the elderly and the underserved continued to lack subsidized care. In 1960, President John F. Kennedy was unsuccessful at establishing an insurance program for the elderly, but in 1965, President Lyn - don B. Johnson convinced Congress to pass the largest government healthcare plans still used today, Medicare and Medicaid. Financed by the federal and state governments, respectively, these programs cover millions of older and vulnerable Americans. The government became a major player in the financing of healthcare delivery and its budget was greatly impacted by the cost of these programs. Subsequently, the government passed numerous regulations to control healthcare spending and reduce provider payments. By 1970, the share of healthcare spending in GDP increased to 7.2%, showing early signs of what was yet to come.

Corporate Era The corporate era ranges from the 1970s to the present. During this time, healthcare organi - zations began to act like well-motivated corporations following the footsteps of other indus - tries that completed the same transition long before the healthcare industry did. The main goal for all healthcare companies was to grow in order to obtain efficiencies of a larger organi - zation, and gain negotiation power with payers, such as managed care companies. This strat - egy led to many mergers and acquisitions of healthcare facilities while managed care became the prominent healthcare delivery and financing model for this era.

With the help of the Health Maintenance Organization Act of 1973, health maintenance organizations (HMOs) penetrated many markets nationwide in the 1990s to place pressure on healthcare providers to cut costs and slow down the national healthcare spending. HMOs became a common form of insurance in the 1980s and 1990s because of their low cost, which was appealing to younger individuals and families with children. An HMO is a state-licensed health plan that requires each member to have a primary doctor who acts as a “gatekeeper” for the care delivered to the HMO members. HMOs not only charged lower premiums but also required significantly lower copays.

The 1973 legislation created incentives for establishing HMOs to offset the fee-for-service plans that were causing “moral hazard” and excess spending. Moral hazard is created when the incentive to guard against risk is removed. In a fee-for-service payment system, those providing care (e.g., doctors, hospitals) are paid more when they provide more services; thus, if a patient experiences a complication and requires more healthcare services, the provider is paid more for the extra services necessary to treat the complication. In a system that is not volume-based, such as a global payment system, which pays a single fee for all care associated with an intervention (like a hip replacement), the cost of any complication is borne by the healthcare provider—and therefore an incentive to reduce complications and improve qual - ity is created. The late 1980s and 1990s also saw the major growth of managed care organiza - tions (History News Network, 2013). fin81226_03_c03_041-072.indd 52 10/30/14 7:43 PM Section 3.3 History of Healthcare Delivery and Reforms As a result of many of these changes, healthcare facilities started to explore vertical integra - tion strategies and horizontal integration strategies to form integrated delivery systems and local and national hospital systems. Vertically integrated strategies are those in which an organization owns and operates all of the services necessary for the care of a patient’s condi - tion. For example, a health system may own primary care clinics, specialist clinics, surgical centers, and an inpatient care facility. In contrast, horizontal integration strategies are those in which an entity owns and operates a larger expanse of a single component of the care spec - trum. For example, an entity may own and operate a network of hospitals, focusing only on delivery of inpatient care, but across a wider geographic area.

The corporate era also marked the beginning of the information age. Prior to the early 1990s, most physician offices and hospitals documented patient records on paper and placed them in file cabinets. As a result, legibility of physicians’ orders became a problem, leading to incor - rect medications or doses for patients. The paper-based patient records caused long waits for lab reports and feedback from various diagnostic tests. The appointment calendar was on a large chart, and patients were given an appointment card to remind them of their next visit.

The only information technology (IT) at this time was used for billing in doctor’s offices.

Since the 1990s, there has been rapid growth in the use of computers, which has expanded to tasks such as scheduling appointments, recording lab reports, and ordering prescriptions.

The additional uses of IT have allowed for improvements in efficiency and accuracy of care provided for patients.

Due to the high cost of healthcare, many Americans have looked outside of the country for treatment and other medical procedures. Globalization has expanded tremendously, as other countries have developed quality care initiatives to mirror the care provided in the United States. One of the major attractions for procedures abroad is cosmetic surgery. Many physi - cians caution consumers looking abroad that there may be risks associated with the lesser price tag. In addition, physicians in the United States are reluctant to repair damages as a result of seeking surgery abroad due to liability concerns (Konrad, 2009). Nevertheless, global medical care is growing in popularity, and is sought out by consumers as a cheaper alternative.

Throughout this era, there have been many political efforts to reduce the cost of healthcare and ensure all Americans have access to that care. In 1993, President Bill Clinton and First Lady Hillary Clinton tried to create a universal healthcare system in the United States, which was officially known as the Health Security Act. However, this plan was defeated in the follow - ing year. Although this proposal promised benefits for average Americans, it placed pressures on employers, healthcare providers, and insurance companies by requiring tight government regulations to control costs.

The U.S. government took a step toward more efficient healthcare by enacting the Health Insurance Portability and Accountability Act (HIPAA) , signed by President Bill Clinton in 1996. The HIPAA Privacy Rule established national standards to protect patients’ protected health information (PHI) and secure medical staff in dealing with patients and other indi - viduals. There are two parts in HIPAA. Title I covers insurance reform, limiting the use of pre-existing medical conditions to prevent an employee from receiving health insurance cov - erage. Title II simplifies administrative costs. The HIPAA Privacy Rule was followed by the HIPAA Security Rule, which took effect in 2005, and outlines the basics of what a healthcare provider must do to protect electronic PHI that exists on desktop and laptop computers, tab - lets, smartphones, and other digital devices, such as fax machines and copiers. fin81226_03_c03_041-072.indd 53 10/30/14 7:43 PM Section 3.3 History of Healthcare Delivery and Reforms In 2003, President George W. Bush signed the Medicare Prescription Drug, Improvement, and Modernization Act (the Medicare Modernization Act or MMA). In an attempt to help patients afford their medications, the Act provided prescription drug coverage under Medicare. This also helped to relieve physicians’ difficulties when considering the gap between the best med - icine for patients and what was affordable for them.

The Patient Safety and Quality Improvement Act was enacted in 2005, demonstrating efforts to improve patient safety and the quality of care. The Act created patient safety organizations (PSOs) to collect and analyze information from voluntary and confidential reporting of events that adversely affect patients. After analyzing, PSOs determine measures to eliminate patient safety risks and hazards.

The year 2010 saw some major healthcare reform measures. On March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (the Senate healthcare bill). On March 30, 2010, Obama signed into law the reconciliation bill, the Health Care and Education Reconciliation Act. The Act has initiated many significant changes to reform the U.S. healthcare system. Some of these changes are: • Health insurance exchanges will be operated through a government website called the “Marketplace.” Through the website, people can compare and choose health plans, find answers to their questions, and check their eligibility for health cover - age. The Marketplace started operation in October 2013, and insurance health plans became available on the website after January 1, 2014. Clear, simple language is required in the summary benefits and coverage so that patients can thoroughly understand and make their own best choice. • People who cannot afford health insurance can be subsidized by the government’s financial assistance programs, depending on the person’s income level and family size. • Except for some people with certain religious beliefs, Native American tribes, illegal immigrants, people in jails, and people having income below a certain level, most Americans are required to have a basic level of health insurance, effective from Janu - ary 1, 2014. People without coverage for more than three months will be charged a tax penalty by the government. • No-cost preventive care, including immunizations, diabetes, cancer screenings, and counseling for smoking and alcohol abuse, is expanded. • Insurance companies can no longer deny anyone with a pre-existing medical condi - tion. No annual or lifetime limits on essential health benefits are allowed. • Health insurance is required to spend 80–85% of premiums on healthcare and qual - ity improvement. The new law also sets out to improve quality of care in preventive care and health home services.

This act also promises higher quality in healthcare delivery through incentive programs and changes in payment methods. Care providers are encouraged to increase quality and innova - tion by receiving rewards for excellent performance and efficiency. Questions to Consider 1. Select two major events in the history of the U.S. healthcare system and explain how these two events are related to healthcare quality. 2. Health maintenance organizations (HMOs) became a common form of insurance in the 1980s and 1990s. Do you feel they improved or harmed healthcare quality? Explain your reasoning. 3. Describe how health reforms since 1993 have attempted to improve the following fea- tures of care delivery in the United States:

a. Cost of care b. Access to care (that is, insurance coverage) c. Quality of care fin81226_03_c03_041-072.indd 54 10/30/14 7:43 PM Section 3.4 Quality Management by Managed Care 3.4 Quality Management by Managed Care Managed care is an umbrella term that describes all health plans that use mechanisms to reduce costs and improve quality of care. These plans coordinate with the defined network of primary care physicians (PCPs), hospitals, and other providers to deliver comprehensive care to their enrollees for a fixed periodic premium.

Forms of Managed Care Organizations Two common forms of managed care organiza - tions (MCOs) are HMOs and preferred provider organizations (PPOs) . As previously noted, HMOs are state-licensed health plans that require each member to have a PCP acting as a “gatekeeper” for the care delivered. HMOs often require referrals to specialists, precertification, and pre-authorization for non-emergency hospital admissions, outpatient procedures, and treatments. However, the laws have changed over the years so that referrals are not needed to see a gynecologist/obstetrician or for many behavioral health services.

HMOs consist of a variety of models, including inde - pendent practice association (IPA), staff, group, or exclusive provider organizations. In some HMO models, providers are paid a fixed amount per mem - ber per month (PMPM), sometimes known as capi - tation, for taking care of the primary care needs of the patient for a month. Other HMO models still pay providers on a fee-for-service basis, depending on the contractual arrangements negotiated between the physicians and the HMO. In 2003, President George W. Bush signed the Medicare Prescription Drug, Improvement, and Modernization Act (the Medicare Modernization Act or MMA). In an attempt to help patients afford their medications, the Act provided prescription drug coverage under Medicare. This also helped to relieve physicians’ difficulties when considering the gap between the best med - icine for patients and what was affordable for them.

a. Cost of care b. Access to care (that is, insurance coverage) c. Quality of care Blend Images/SuperStock Primary care physicians act as “gatekeepers” for the care delivered to HMO members. fin81226_03_c03_041-072.indd 55 10/30/14 7:43 PM Section 3.4 Quality Management by Managed Care PPOs offer patients a list of member providers who agree on a predetermined list of charges.

The patient pays deductibles and co-insurance payments of 20–25% of the predetermined charge and the insurer pays the balance. The main difference between HMOs and PPOs is that the member does not have to register a PCP and does not have to stay in the network of phy - sicians and providers in PPO plans. If the member chooses to seek care out of the preferred network, copay and co-insurance increase along with charges. PPOs pay physicians and other providers fee-for-service rates under a payment model in which services are unbundled and paid for separately, so that a provider gets paid for each service, such as an office visit, test, or procedure. Member physicians of PPOs prefer these fee-for-service arrangements over capi - tation rates, where they are paid a set amount for each patient assigned to them.

In the 1980s and 1990s, managed care plans were successful in controlling healthcare costs using techniques such as providing patients with a limited list of medical providers, requiring patients to see a PCP before visiting specialists, requiring permission for certain nonemer - gency procedures, reviewing and controlling inpatient stays and expensive treatments, and implementing programs managing the more costly healthcare services. These tight utilization control methods also caused a backlash against managed care. Some people believe that HMO plans prioritized profits over care (Sekhri, 2000). For instance, some managed care organi - zations, such as HMOs, pursued cost-cutting strategies, such as the insistence that mothers leave the hospital 24 hours after a normal birth. Some people also believed that managed care has decreased the time doctors spend with patients, made it difficult for patients to see specialists, and limited medically necessary services to patients.

Doctors and hospitals also felt dominated by managed care, which triggered a wave of merg - ers and affiliations to gain market share and therefore leverage to negotiate with managed care plans. While managed care plans took a step back in the cost controls, they increased health insurance premiums. According to the Annual Employer Health Benefits Survey com - pleted in 2012, private health insurance premiums rose by 14% in 2003 and throughout the 2000s (Kaiser Family Foundation, 2012). To make up for these rising premiums, employers increased workers’ copays for care or took more money out of their paychecks, and as a result, employees received lower wages (Mechanic, 2004).

Managed care plans continue to evolve, offering other options such as point of service plans (POS) , with more creative features in health plan design and comprehensive care networks. Point of service plans typically do not have specific networks of approved providers and will provide coverage regardless of who provides healthcare. In addition, high deductible health plans, paired with healthcare savings accounts, are increasingly offered by employers as a way to control costs and shift risk for health expenditures to employees. Managed care remains a strong method to control costs in the United States.

Quality Initiatives Managed care organizations can create quality initiatives at various levels of implementation.

These initiatives involve quality assurance, quality improvement, and quality management, three terms that are often used interchangeably. Though they all focus on quality care, they are distinctly different and involve various levels of accountability.

Quality assurance is the reactive method of ensuring quality and is primarily focused on identifying outliers in the process and removing them to create a uniform standard. Gener - ally it involves finding the failure or faulty party, and eliminating it. For instance, let’s assume fin81226_03_c03_041-072.indd 56 10/30/14 7:43 PM Section 3.4 Quality Management by Managed Care an average patient wait time in a primary care clinic of an HMO is 20 minutes, but 10% of patients wait over an hour. To improve this, the HMO could set up a quality assurance pro - gram to reduce this rate to 5%. The program is set up as a result of studying past information, which places it in the category of quality assurance.

Quality improvement is defined as evaluating current performance in an organized way, and developing and implementing systematic efforts to improve performance. It is used through - out an organization, and measures performance improvement throughout the continuum of care. Generally, quality improvement programs include many parts, and represent more advanced thinking and planning compared to quality assurance. These programs typically use healthcare industry norms and standards in addition to the organization’s own internal data to set realistic targets for performance improvement.

For instance, a typical HMO would have a quality improvement program to control the choles - terol, blood pressure, and diabetes of its members. The goal is to improve the health of HMO members in these three specific areas, which ultimately should lead to better overall health.

The challenge is to convince members to regularly take their medication and to exercise.

Because of a lack of education, or differing lifestyles or cultural beliefs, some patients may not comply with the doctor’s orders. To improve the situation, a specific quality improvement program must be set up to monitor patient behaviors. In some instances, HMOs impose qual - ity improvement programs on physicians, their offices, and hospitals. Physicians are finan - cially rewarded for trying to improve predetermined specific measures.

Finally, quality management is the establishment of policies and standards in the healthcare facility to improve outcomes of medical services provided and to continuously aim to achieve better performance. Quality management is engrained in the framework of the organization and plays a significant role in the development of policies, protocols, and standards. HMOs, physicians and physician groups, and hospitals have their own quality management programs that include various quality improvement projects with specific targets.

Harvard Pilgrim Health Care (HPHC), a full-service health plan serving mainly in Massachu - setts, New Hampshire, and Maine, provides a good example of quality management. HPHC has implemented many quality improvement interventions, which make up part of the qual - ity management program. For example, HPHC established an asthma management program that effectively reduced the rate of emergency room (ER) visits and hospital stays, oper - ated the “Quality Advance Program” to encourage physicians to improve their practices, and offered new online tools to improve web access and navigation for members with disabilities.

HPHC has succeeded in strongly committing to high quality care by consistently maintaining top positions in the annual NCQA’s Health Insurance Plans Rankings, scoring high in qual - ity measures of customer services, preventive services, and chronic disease treatment (such as asthma, diabetes, and heart disease). It was recognized as number one in NCQA’s Health Insurance Plans Rankings for 2012–2013 (National Committee for Quality Assurance, 2012).

External quality review organizations (EQROs) also play a role in managed care. Federal regu - lations issued by the Centers for Medicare & Medicaid Services (CMS) require that states that contract with managed care organizations conduct an external quality review of each entity.

States can do external quality review directly, but most state Medicaid agencies typically con - tract with independent EQROs to conduct quality-of-care studies (Medicaid.gov, 2014). The level of federal financial participation in these activities varies depending upon the entity conducting them. fin81226_03_c03_041-072.indd 57 10/30/14 7:43 PM Section 3.5 Quality Management by Hospitals EQROs analyze and evaluate information on quality, timeliness, and access to the healthcare services that a managed care organization furnishes to Medicaid recipients. In addition to any optional external quality review activities, states must contract to include the following three mandatory activities as part of the quality review: • Validation of performance improvement projects • Validation of performance measures • Review, within the previous three-year period, to determine if the managed care organization complies with state standards for access to care, structure and opera - tions, and quality measurement and improvement In the state of Texas, the Institute for Child Health Policy at the University of Florida serves as the ERQO for the Texas Medicaid Managed Care and Children’s Health Insurance Program (CHIP). The ERQO evaluates these state health programs based on many quality measures.

For instance, it evaluated the preventive care for pediatric patients, looking at whether chil - dren and adolescents have access to primary care practitioners, whether they receive well- child visits in the first 15 months of life and whether those continue each year into adoles - cence, whether they receive childhood immunizations, and whether they receive an annual dentist visit.

How did the health programs in Texas measure up when it came to access to dental care, which is consider integral to a child’s overall physical well-being? The ERQO evaluated access to dental care and services for children enrolled in CHIP based on a measure developed by HEDIS. The measure calculates the percentage of members aged 2 to 21 who had at least one dental visit during the year. In Texas, the rate of annual dental visits rose from 59% in 2009 to 66% in 2011—greatly exceeding the 2011 national average determined by HEDIS data of 48%. Texas’ health programs didn’t do as well in making sure children receive their childhood immunizations against preventable diseases. Less than one half of 2-year-olds in one health program received the appropriate vaccinations by their second birthday (45%), although this rate did exceed the 2011 HEDIS national mean of 32%.

So, as you can see, managed care organizations are being held accountable for the quality of care they provide.

3.5 Quality Management by Hospitals Providing quality of care with limited resources is a challenging task. One of the most com - mon ways a hospital will improve quality of care is to regularly monitor, or collect and ana - lyze, a core set of health indicators to set up a system for improvement. This is called quality Questions to Consider 1. How have managed care organizations had a positive effect on the healthcare system? What about negative effects? 2. What other measures might ERQOs use to access the care provided to pediatric patients? What about measures to assess the quality of preventive care in adults? fin81226_03_c03_041-072.indd 58 10/30/14 7:43 PM Section 3.5 Quality Management by Hospitals monitoring, which is generally part of a more comprehensive system of quality management.

Hospital quality management could include training healthcare workers and providing feed - back to them; developing new policies and making organizational changes to improve report - ing and communication channels of the hospital employees; introducing new concepts and methods, such as root cause analysis , a method used to determine the underlying, systemic causes of a medical error after the fact, or continuous quality improvement and training the staff for these new concepts; and, most importantly, empowering all employees to be part of the quality improvement efforts.

It’s important for a hospital to build a culture that supports quality improvement. Culture, the shared values and beliefs of individuals within an organization, is important because it drives behavior and outcomes. For example, a hospital can encourage people to pay attention to details and have a questioning attitude. Having a questioning attitude means that rather than reacting passively to a potential problem and thinking that someone else will report it, staff members will realize something isn’t right and report the issue themselves to the appropriate department, manager, or supervisor. For instance, imagine there is a contact precaution sign on a patient’s door indicating that those entering the room should use precautions to prevent the spread of an infectious disease, such as wearing gloves, a mask, and a gown. However, a nurse notices that visitors are going in and out of the room without putting on personal protective equipment. Does she ignore the situation or does she alert the floor supervisor?

Failure to take action means that visitors can carry the infection to other people in the hospi - tal. In another instance, a person comes into the emergency department and a staff member is concerned he or she may become violent. The staff member calls the security department and describes the situation, letting security know the person is starting to get out control and asking that officers respond right away.

A hospital’s quality management program generally identifies many improvement opportuni - ties, but the question is how will these improvement opportunities be materialized and who will lead the change? Quality improvement teams must be assembled with various individu - als each taking a specific role, such as sponsor, team leader, or recorder. Once an improvement model and tools are chosen, the improvement team works together to achieve the assigned task (Spath, 2009).

Today, hospitals are required to meet strict standards on quality of patient care and keep up with the continually improving industry quality standards. Hospitals deliver a number of reports on quality of care to accrediting bodies and independent agencies for quality recogni - tions and ratings so managed care companies, CMS, and the public have reliable information to judge the quality of care.

Quality and Accreditation As mentioned at the end of Chapter 2, each accreditor maintains a minimum set of standards and methods of gathering data on performance, analysis, and reporting, and there is signifi - cant overlap in the minimum standards that must be met for accreditation. Many hospitals voluntarily go through an accreditation process and are evaluated against that organization’s standards. CMS currently recognizes and approves four accreditation programs for hospitals seeking to participate in the Medicare program via deemed status. Deemed status means that the hospitals can undergo an accreditation survey rather than their state health department’s fin81226_03_c03_041-072.indd 59 10/30/14 7:43 PM Section 3.5 Quality Management by Hospitals inspection to ensure compliance with hospital regulations, which are also called conditions of participation . The four accreditors are listed below. • The Joint Commission, the oldest of the organizations, has been working with health - care organizations for more than half a century (The Joint Commission, 2013c).

It accredits more hospitals than its competitors and is best known. It has also expanded to accredit many other types of healthcare organizations, such as ambula - tory care and laboratories. It has also expanded outside the United States to include an international branch that accredits organizations overseas. The Joint Commission accreditation program consists of hospital standards that address performance in specific areas, such as the environment of care, infection control, emergency manage - ment, and credentialing and privileging. Its standards also address quality measures and patient safety goals to access how well the hospital is performing. • Det Norske Veritas Healthcare, Inc. (DNV), which received deeming authority for acute care hospitals from CMS in 2008 and has since been granted authority for critical access hospitals, has a corporate purpose to safeguard life, property, and the environment. The approval of DVN gave hospitals another option when it comes to accreditation. DNV’s program integrates the International Organization for Stan - dardization’s ISO 9001 quality management system requirements with the Medi - care conditions of participation for hospitals. Both are integrated into one survey process. Although developed for manufacturing, ISO 9001 is made up of broad principles of quality management that are now applied across a range of industries, including healthcare. • The Healthcare Facilities Accreditation Program (HFAP) is a nationally recognized accreditation organization whose mission is to advance high quality patient care and safety through its standards. It is a program established by the American Osteo - pathic Association and began as a survey program to monitor the quality of care in hospitals providing postdoctoral training for osteopathic physicians. It has grown beyond those beginnings to now accredit hospitals across America. It includes standards that are linked to the conditions of participation, as well as standards of quality improvement. • The Center for Improvement in Healthcare Quality (CIHQ) is the newest accredi - tor; it was approved by CMS in August 2013 to accredit acute care hospitals. Its approved program does not apply to psychiatric hospitals or critical access hospi - tals, which are different provider types for which there are separate accreditation programs. The hospital accreditation program is designed to ensure that hospitals comply with the conditions of participation and improve the quality of care, treat - ment, and service. CIHQ says its philosophy and approach to accreditation is to engage with hospitals in a collegial, respectful, and educational manner, with ser - vices provided at a reasonable cost. In addition to the organizations that accredit hospitals, there are others that accredit other types of healthcare organizations, such as ambulatory care facilities, rehabilitation hospitals, and health plans. These include the Accreditation Association for Ambulatory Health Care (AAHC), CARF International, the Accreditation Commission for Health Care (ACHC), the Cen - ter for Improvement in Healthcare Quality (CIHQ), and others. fin81226_03_c03_041-072.indd 60 10/30/14 7:43 PM Section 3.5 Quality Management by Hospitals Special Recognitions In addition to accreditation, some hospitals choose to seek special recognition(s) through programs such as the American College of Surgeons National Surgical Quality Improvement Program or American Heart and American Stroke Association Program. Table 3.1 shows qual - ity indicators for Centennial Medical Center located in Frisco, Texas. The table indicates areas in which the Centennial Medical Center performs above and below other accredited organiza - tions in Texas. These quality indicators are part of the Surgical Care Improvement Project at the medical center and are compared to accredited hospitals in the state of Texas. All of Cen - tennial’s quality measures received “above average” ratings except the colon/large intestine surgery category, making it one of the “top” performing hospitals in Texas.

Table 3.1: Centennial Medical Center, National Quality Improvement Goals (reporting period: January 2012–December 2012) Quality indicator Above most accredited organizations (✓) Below most accredited organizations (✓) Not displayed (ND) National Quality Improvement Goals Heart attack care ✓ Heart failure care ND Pneumonia care ✓ Surgical Care Improvement Project (SCIP) Infection prevention ✓ Blood vessel surgery ND Colon/large intestine surgery ✓ Coronary artery bypass graft ✓ Hip joint replacement ✓ Hysterectomy ✓ Knee replacement ✓ Open heart surgery ND Source: The Joint Commission. (2013e). Quality check [Database]. Retrieved from http://www.qualitycheck.org/consumer /SearchQCR.aspx Hospitals voluntarily pursue the Leapfrog Group recognition and its letter grade approval for the quality of care provided. The Leapfrog Group uses an online survey to collect data on 26 categories and assigns star ratings and letter grades from A to F to demonstrate the level of quality at each surveyed hospital. Table 3.2 shows Centennial’s star ratings, which lead to a letter grade of hospital safety score. The data is frequently updated from interim reports provided by the hospital. fin81226_03_c03_041-072.indd 61 10/30/14 7:43 PM Section 3.5 Quality Management by Hospitals Table 3.2: Centennial Medical Center Leapfrog ratings (results submitted June 2013) Ratings Willing to report data on quality standard ( ) Some progress towards quality standard ( ) Substantial progress towards quality standard ( ) Fully meets quality standard ( ) Overall patient safety ratings Prevent medication errors Appropriate ICU staffing Steps to avoid harm Managing serious errors Safety-focused scheduling Maternity care standard precautions Rate of early elective deliveries High risk treatment safety ratings Reduce hospital- acquired pressure ulcers Reduce hospital- acquired injuries Reduce central-line infections in ICUs Reduce urinary catheter infections in ICUs High-risk birth delivery Abdominal aortic aneurysm repair Length of stay for common acute conditions Readmission for common acute conditions Hospital safety score A Source: The Leapfrog Group. (2013). Leapfrog hospital ratings . Retrieved from http://www.leapfroggroup.org/cp . Copyright © Leapfrog Group. Reprinted by permission. fin81226_03_c03_041-072.indd 62 10/30/14 7:43 PM Section 3.5 Quality Management by Hospitals Hospitals submit service quality data to CMS using the Consumer Assessment of Healthcare Providers and Systems Hospital Survey (CAHPS). The CAHPS is the first national publicly reported standardized survey and data collection methodology that measures all patients’ perspectives on their hospital care. Individual hospitals’ scores are compared to benchmark scores calculated by CMS for participating hospitals located in a particular state and are updated quarterly on the Medicare website. Collection and reporting of data are voluntary.

According to Medicare.gov (2013), Centennial has service quality indicators that are consis - tently lower than or equal to those of an average Texas hospital, but are better than overall industry benchmarks as reported by CMS (see Figure 3.2). For instance, nurse and MD com - munication are 3 percentage points each behind the Texas statistics. Although staff respon - siveness and pain management are a few points lower than those of an average Texas hos - pital, they exceed the overall industry standards by 2% and 1%, respectively. Centennial’s quality of care deserves an “A” rating because most of its service quality measures exceed or equal the industry standards.

Quality Improvement Initiatives Reporting quality measures and complying with accreditations and government regulations is one important function of hospitals, but another important function of hospitals’ quality departments is to undertake quality improvement initiatives to eliminate deficiencies and improve hospital ratings. In some situations, raising quality ratings by a few percentage points can be challenging and costly. A brief review of hospitals’ quality efforts nationwide shows that hospitals are involved in many quality improvement projects, including managing the supply chain, improving process, ordering standardized supplies, and reducing practice variation across clinicians (McCarthy & Blumenthal, 2006).

Figure 3.2: Centennial Medical Center CAHPS CAHPS measures patients’ perspectives of their hospital care, which are then compared to the benchmark scores of other participating hospitals in the state.

Source: Medicare.gov. (2013). Hospital Compare [Database]. Retrieved from http://www.medicare.gov/hospitalcompare /search .ht ml 0% 20% 40% 60% 80% 100% Nurse communication MD communication Staff responsiveness Pain management Medicines explained Cleanliness Quietness Discharge information 76% 76%79% 81%83% 83% 67% 65% 71% 71% 60% 68%70% 84% 84%88% 63%65%61% 73%74 % 73%70% 69% Centennial Medical Center Texas Average National Average fin81226_03_c03_041-072.indd 63 10/30/14 7:43 PM Section 3.5 Quality Management by Hospitals For instance, Johns Hopkins Hospital, located in Baltimore, Maryland, has been implementing Six Sigma and lean techniques (see Chapter 7) to improve hospital operations (see Table 3.3).

Johns Hopkins uses the term lean Sigma to describe the combination of lean theory and Six Sigma principles.

Table 3.3: Improving healthcare quality by applying best practices and enhancing patient safety at hospitals Johns Hopkins Medicine Apply lean Sigma Comprehensive Unit-Based Safety Program (CUSP) Project to reduce cathe - ter-related bloodstream infections in the ICU • Headquartered in Baltimore, Maryland, Johns Hopkins is one of the leading healthcare systems in the United States. • Johns Hopkins Hospital continuously ranked #1 in the nation for 21 years and again in the year 2013 by U.S. News & World Report . • Johns Hopkins Home Care Group provides services to 10,000 patients statewide. • Using process mapping to identify and eliminate wastage. • Establishing an interdisciplinary team to identify the cause of discarded packed red blood, which was mainly due to improper administration, then making changes to reduce the blood wastage by more than 50%. • Changing front-desk staffing patterns to be more aligned with the patient flow. • Reducing traveling time of nurses to gather materials by using bedside supply carts to securely store all necessary items in the triage exam rooms. • Reorganizing the workspace in the Johns Hopkins Outpatient Chemotherapy pharmacy to reduce the distance the technicians have to walk to obtain materials. • Simplifying kidney transplant procedures to be more efficient and take less time. Engaging and empow - ering staff to identify and eliminate patient safety hazards through a five-step framework:

1. Train staff in the science of safety. 2. Engage staff to identify defects and safety concerns. 3. Meet monthly with a senior executive to discuss safety issues to push accountability to the frontline and bridge the gap between senior leaders and staff. 4. Continue to learn from defects, share success sto - ries, and dissemi - nate results. 5. Implement simple tools with detailed instruc - tions to help physicians and nurses coordinate better and miti - gate safety risks. • The vascular access device policy requires all providers to receive education on evidence-based infection control practices and complete a post-test as a precondition to catheter insertion. • Creating central-line insertion “bundles” with all standardized supplies and sterile material ready for the procedure. • Creating a checklist of five simple steps to prevent bloodstream infections:

1. Insert a line only when needed. 2. Wash hands before inserting. 3. Avoid the groin area. 4. Clean the inser - tion area with chlorohexadine. 5. Use full barrier precautions. • Empowering nurses to speak up or even to intervene in the procedure if providers violate the guidelines. • Physicians are required to fill in the daily goals form during daily patient rounds to state whether catheters can be removed. Source: McCarthy, D., & Blumenthal, D. (2006). Committed to safety: Ten case studies on reducing harm to patients. The Commonwealth Fund . Retrieved from http://www.commonwealthfund.org/Publications/Fund-Reports/2006/Apr/Committed-to-Safet y—Ten -Case-Studies-on-Reducing-Harm-to-Patients.aspx fin81226_03_c03_041-072.indd 64 10/30/14 7:43 PM Section 3.6 Quality Management by Provider Groups Projects at Johns Hopkins implement process mapping , a method to graphically represent the steps of a process to help understand them and optimize the efficiency and outcomes of the process, in order to identify and eliminate waste. They also establish interdisciplinary teams , which are composed of members from different professional backgrounds, such as doctors of varying medical specialties, nurses, laboratory technicians, and administrators.

U.S. hospitals employ dedicated programs in an effort to improve quality of care. Reported quality metrics are higher at some hospitals than others, suggesting that some organizations are further along the journey to becoming a high-performing healthcare organization. It is important to understand that quality improvement is not a process with a defined end; many researchers and quality managers rightfully call the efforts of hospital and healthcare compa - nies continuous quality management , meaning that organizations focus on continually assessing the causes of quality defects and making interventions to improve quality.

3.6 Quality Management by Provider Groups Physicians and other providers are an important part of the healthcare system and their efforts are crucial to achieving quality improvement goals. A physician’s role is to evaluate a patient’s condition, assign a diagnosis, and prescribe a treatment. Many physicians are office-based practitioners working in various settings such as group practices, ambu - latory clinics, diagnostic and imaging centers, and managed care organizations. Increasingly, physi - cians and other providers are directly employed by care organizations. Health plan quality management programs heavily involve physicians and physician groups because the patient-physician relationship begins in the outpatient care setting. In addition, phy - sician groups and clinics desire efficient operations and reputable quality in order to attract patients.

Physicians and medical groups collect consumer satisfaction measures (interpersonal quality measures) to ascertain how much benefit patients received from the services delivered and how good the physician’s bedside manner was. Consumer satisfaction includes a number of measures that physicians and physicians’ offices are evaluated on, such as: Questions to Consider 1. How can a healthcare organization build a culture that supports quality improvement? What role does accreditation play in this process? 2. Explain how the program at Johns Hopkins improves the quality of care delivered at the hospital. Alexander Raths/iStock/Thinkstock Patient-physician relationships begin in the doctor’s office, so physicians and physician groups are heavily involved with health plan quality management programs. fin81226_03_c03_041-072.indd 65 10/30/14 7:43 PM Section 3.6 Quality Management by Provider Groups 1. satisfaction with services , which measures how easily and quickly patients receive care; 2. satisfaction with physicians , which measures how well doctors communicate, rating of primary-care doctors, rating of specialists, and rating of care provided; 3. prevention , which measures how well physicians, in conjunction with patients’ health plans, provide screenings, immunizations, and other preventive services; and 4. treatment (clinical quality measures) , which measures how well a doctor or doctor’s office provides treatment for certain common conditions. Different areas of care are evaluated, such as asthma medication use, high blood pressure control, glaucoma screening, and osteoporosis management (AltaMed, 2013). It is important to note that patient satisfaction is influenced by many confounding variables that a healthcare organization has no control over. These can include the time of year (for instance, holidays), general economic conditions/unemployment rates, billing accuracy and timing, and life changes and circumstances. Those factors, which are outside the control of healthcare, can affect patient satisfaction ratings.

Depending on the physician organization, reports may be prepared monthly, quarterly, or annu - ally to monitor the progress in each category. These reports are distributed to individual pro - viders and managing partners for informational purposes, and for suggestions and ideas for improvements. There are incentives for individual providers to improve their services, such as receiving annual quality improvement recognition and financial awards.

Incentive Programs To ensure the quality of care delivered to patients by healthcare professionals, CMS has imple - mented three incentive programs that offer payment incentives to eligible Medicare profes - sionals and group practices that report their quality information based on specific quality measures. The Physician Quality Reporting System (PQRS) , which is set up by CMS, is a pay-for-reporting program that gives eligible professionals incentives and payment adjust - ments if they report quality measures data of the services delivered to Medicare and Medicaid patients. Those who do not satisfactorily report quality data will receive a reduction in their payment amount beginning in 2015.

Although PQRS is a stand-alone program, it touches on other CMS programs that require quality reporting, such as the Electronic Prescribing (eRx) Incentive Program and the Electronic Health Record (EHR) Incentive Program . The eRx Incentive Program is a pro - gram mandated by federal legislation that offers incentive payments to successful electronic prescribers. Payment reductions are also planned for those who fail to apply electronic prescription in their Medicare Part B services. The EHR Incentive Program is voluntary and provides Medicare and Medicaid incentive payments to eligible professionals, hospitals, and group practices for implementing certified EHR technology in delivering their services and improving the quality of care (Centers for Medicare and Medicaid Services, 2013i).

Example of a Quality Management Program at a Clinic In California, the Integrated Healthcare Association (IHA) measures the performance of phy - sician groups in treating their Medicare Advantage patients on a subset of the Medicare Stars Clinical Care Measures. For each physician group, this report card shows an overall clinical star rating, as well as individual scores with corresponding star ratings for seven measures:

breast cancer screening, colorectal cancer screening, cholesterol management (LDL screening fin81226_03_c03_041-072.indd 66 10/30/14 7:43 PM Section 3.6 Quality Management by Provider Groups for patients with heart conditions), diabetes care (LDL cholesterol screening), diabetes care (LDL cholesterol control), diabetes care (nephropathy monitoring), and diabetes care (Hemo - globin A 1c control). There is more information about these measures at IHI’s website ( h t t p : // iha.ncqa.org/reportcard/ ). Data for the Medicare Stars measures are collected from partici - pating health plans and from physician groups that self-report this data.

Only electronic sources of data can be used, and all data must be audited. Restricting data to electronic sources encourages adoption of health information technology in support of patient management, but creates challenges in collecting clinical data and measuring out - comes of care. Because of this restriction, the rates displayed in this report card are not com - parable to measures that allow data to be extracted manually from patient charts.

A sample of physician groups located in Orange County, California, is included in Table 3.4.

Star ratings of the physician groups ranged from five stars (Edinger Group) to two stars (Asso - ciated Hispanic Physicians of Southern California). Because this is a relatively new program, not many physician groups report data yet; however, more groups may begin to participate in the program because of the financial incentives offered.

Table 3.4: Comparison of overall physician group ratings, 2012 Physician group Rating Prospect Medical Group ★ ★ ★ ★ Southern California Permanente Medical Group – Antelope Valley ★ ★ ★ ★ ★ AMVI Medical Group Too Few Patients to Report Regal Medical Group ★ ★ ★ ARTA Health Network ★ ★ ★ Associated Hispanic Physicians of Southern CA ★ ★ Brookshire IPA Too Few Patients to Report Edinger Medical Group ★ ★ ★ ★ ★ Family Choice Medical Group Too Few Patients to Report Genesis Healthcare ★ ★ ★ ★ Stewart Medical Group ★ ★ ★ ★ Allied Physicians of California ★ ★ ★ Advanced Primary Care Network ★ ★ Source: Integrated Healthcare Association, NCQA. (2014). 2012 Medicare stars physician group clinical care report card . Retrieved from http://iha.ncqa.org/reportcard/ Questions to Consider 1. What are the most common quality programs in physician groups? Why? 2. Do the star ratings clearly measure the quality of care delivered in physician groups/ clinics? Critique the system used to assign stars to physician groups. fin81226_03_c03_041-072.indd 67 10/30/14 7:43 PM Summary & Resources Summary & Resources Chapter Summary Through the evolution of the healthcare industry there has been a constant need to improve quality. Healthcare in the United States is an intricate system comprised of various institu - tions, individual practitioners, resource networks, and other health-related organizations.

Through this intricate system, providers, organizations, and institutions must work together to achieve an increased quality of life for the consumer. The U.S. healthcare system involves four key players: 1) employers, 2) patients, 3) payers, and 4) providers. Although these major players function in the same healthcare system, each group has specific interests.

In order to achieve high quality of care delivered by the joint efforts of these parties in the healthcare system, the use of technology is the key to connect these groups, allowing col - laboration and communication for higher quality of care.

Quality improvement fosters a sense of confidence and reliability. Organizations that do not consider the importance of quality tend to be challenged with various issues. These orga - nizations typically lose customers, or consumers, and often give way to competitors. Fur - thermore, employee morale is often a reflection of organizational quality. Therefore, quality improvement is necessary for organizational success.

The evolution of the healthcare industry has resulted in a highly complex world of varying services and needs. As customer needs have changed—as a result of technological break - throughs, regulations, and methods of care—so too has the measure of quality. Learning the development of and relationships within the healthcare industry provides a better understanding for the importance of quality improvement. The various aspects of quality, including its impact on factors such as health, government, and economics, forever change.

Because these changes within the healthcare industry never end, the pursuit of continued quality improvement must be a constant. Losing sight of this can be detrimental to any healthcare organization.

Mini Case Study Able Healthcare entered into a “performance guarantee” arrangement with one of its clients, Bank of Florida. Able Healthcare agreed that no less than 80% of the calls received from the client during the one-year contract period would be answered within 30 seconds of call initiation. This agreement was offered by Able Healthcare to promote customer sat - isfaction, remain attractive to the marketplace, and to hold itself accountable in delivering services. However, if the organization failed to meet the service level agreement of 80%, the organization would refund Bank of Florida 20% of the service fees, which equated to about $3 million.

In order to establish this performance, it was important for both parties to agree upon metrics to be used. Therefore, the following formula was agreed upon in the service level calculation: Service Level % = Number of calls answered within 30 seconds / Total number of call opportunities fin81226_03_c03_041-072.indd 68 10/30/14 7:43 PM Summary & Resources The total number of call opportunities included “reroute” calls, “dropped” calls, and all calls answered. Reroute calls were call opportunities that were sent to an employee who did not answer within 120 seconds, which would then be routed to another available employee.

This could occur when employees would step away from the workstation without set - ting the telephone into an “unavailable” mode and a call would be transferred. A call to an employee that was answered, but during which the caller disconnected from the call, was marked as a dropped call. In addition, any call in which the caller disconnected from the call prior to it being answered was considered a dropped call. Dropped calls would reduce the service level (because of a loss in caller opportunity).

The contract between Able Healthcare and Bank of Florida became effective on July 18 and got off to a great start. However, after a couple of months, it became evident that there were periods of low performance. While there had been changes in the telephone customer service processes over a period of time, Able Healthcare recognized that performance could fluctuate daily. Therefore, it became important to continually measure performance in order to sustain the level agreed upon.

Figure 3.3 illustrates Able Healthcare’s customer service performance data collected from July 18 through November 7. The information exhibits a decline in performance beginning on August 29, hitting a low of about 56% on September 25. During the decline in performance, it was determined that target levels were not reached primarily because of staff not answer - ing calls within 30 seconds. In addition, a significant increase of rerouted and dropped calls occurred on September 25 and 26. It was determined that several staffing challenges had resulted in the decline in performance, requiring modifications to the staffing model.

Figure 3.3: Able Healthcare telephone service ratio, July through November In this example, Able Healthcare recognized that performance can fluctuate from one day to the next so it was important to continually measure performance to help maintain higher levels of quality. Service Ratio 18-Jul 25-Jul 1-Aug 8-Aug 15-Aug 22-Aug 29-Aug 5-Sep 12-Sep 19-Sep 26-Sep 3-Oct 10-Oct 17-Oct 24-Oct 31-Oct 7-Nov 50% 60% 70% 80% 90% 100% fin81226_03_c03_041-072.indd 69 10/30/14 7:43 PM Summary & Resources This case illustrates the importance that quality measure has in the performance of Able Healthcare’s ability to meet their client’s expectations. Performance is an ongoing challenge, which can change over a period of time based on various factors.

Discussion Questions 1. Why is quality important for this managed care company? 2. How is quality measured in this case? Consider other measures of quality for this particular case. Do you think any of the measures you created are better than the quality measure used? Explain your reasoning. 3. In the competitive healthcare market today, why is it important to continuously improve quality? How do cost, consumer interests, and historical changes impact the look of quality? 4. Within healthcare organizations, what do you believe are the factors that influence the way consumers perceive quality? Key Terms consumer satisfaction The degree to which care services meet consumers’ expectations.

continuous quality management An approach to improving and maintain - ing the quality of care that focuses on constantly assessing causes of quality defects and implementing interventions in improvement.

Electronic Health Record (EHR) Incen - tive Program A voluntary program that provides Medicare and Medicaid incentive payments to eligible healthcare providers for implementing certified EHR technology in delivering their services and improving their quality of care.

Electronic Prescribing (eRx) Incentive Program An incentive program to encour - age electronic prescription.

Health Insurance Portability and Accountability Act (HIPAA) 1996 Act of Congress that protects people covered by healthcare plans and sets standards for the use and storage of private medical data. health maintenance organizations (HMOs) State-licensed health plans that require each member to have a PCP who acts as a “gate - keeper” for the care delivered to the HMO members.

healthcare reform Health policy creation or changes made by the government that affect the healthcare delivery system.

horizontal integration strategies Ways an organization finds to own and operate a larger amount of a single component of the care spectrum. For example, an entity may own and operate a network of hospitals, focusing only on delivery of inpatient care.

interdisciplinary team A group of health - care providers of different backgrounds working together toward a common goal for a patient or a process.

Physician Quality Reporting System (PQRS) A pay-for-reporting program that gives eligible professionals incentives and payment adjustments if they report quality measures data of the services delivered to Medicare and Medicaid patients. fin81226_03_c03_041-072.indd 70 10/30/14 7:43 PM Summary & Resources Critical Thinking Questions 1. You are the chief executive officer of a large hospital. Doctors at your hospital com - mit an error that results in the death of a patient. What would you do? Would you tell the public exactly what happened? Would you take responsibility for the error?

What consequences might your organization face? 2. You are the chief human resources officer for a large business in Pennsylvania with 500 employees, and it is time to renegotiate health plan coverage on behalf of your employees. You are considering an HMO, a high-deductible health plan, and a pre - ferred provider organization. What factors might influence the company’s costs, the employees’ costs, and your preferences for the plan you want to offer your employees? 3. Despite many advances in health information technology, evidence that costs are decreasing because of more health information technology (HIT) is rare. What are some factors that might prevent cost savings even though electronic health records are rapidly being deployed? point of service plan (POS) A health insurance plan that typically does not have a specific network of providers, but will pro - vide coverage for any provider that a patient chooses to see for healthcare.

preferred provider organizations (PPOs) PPOs offer patients a list of member provid - ers who agree on a predetermined list of charges.

prevention Measures how well physicians, in conjunction with patients’ health plans, provide screenings, immunizations, and other preventive services.

process mapping Activities of structural analysis, including drawing out the steps or the flow of a process.

quality assurance The reactive method of ensuring quality, which is primarily focused on identifying outliers in the process and removing them to create a uniform standard.

quality management The establishment of policies and standards in the healthcare facility to improve health outcomes of medi - cal services provided and continuously aim to achieve better performance. root cause analysis A problem-solving method that identifies the root causes of errors or problems.

satisfaction with physicians Measures how well doctors communicate, rating primary-care doctors, rating specialists, and rating care provided.

satisfaction with services Measures how easily and quickly patients receive care.

treatment (clinical quality measures) Measures how well a doctor or doctor’s office does in providing treatment for cer - tain common conditions.

vertical integration strategies Ways an organization finds to own and operate all of the services necessary for the care of a patient’s condition. For example, a health system may own primary care clinics, specialist clinics, surgical centers, and an inpatient care facility. fin81226_03_c03_041-072.indd 71 10/30/14 7:43 PM Summary & Resources 4. Physicians practice medicine in a wide variety of settings, from small individual practices to large group practices to health-system-based networks of hundreds of physicians and other providers. Describe some factors in each of these settings that either promote or discourage quality improvement efforts. 5. Based on what you have learned from this chapter, describe what you think would be the best healthcare system for the United States (that is, how hospitals, doctors and other providers, payers, and patients should be organized) and explain why. Suggested Websites • Centers for Medicare and Medicaid Services:

ht tp://w w w.cms.gov/ A federal government website to help manage Medicare, Medicaid, the Children’s Hospital Insurance Program, and the Health Insurance Marketplace. • Florida Agency for Health Care Administration, FloridaHealthFinder.gov:

ht tp://w w w.f loridahealthfinder.gov/index.html Florida state government website providing quality indicators for Florida healthcare providers. • Integrated Healthcare Association (IHA), Physician Group Clinical Care Report Card:

ht tp://iha.ncqa.org/reportcard/ A statewide organization that administers programs to promote quality improve - ment, accountability, and affordability of health services. • Medicare.gov, Hospital Compare:

ht tp://w w w.medicare.gov/hospitalcompare/search.html Hospital Compare is a federal government website that provides a tool to compare hospitals based on several different quality measures. • The Joint Commission, Quality Check:

ht tp://w w w.qualit ycheck.org/consumer/SearchQCR.aspx Quality Check is a website that provides information about the quality indicators for healthcare services that have been accredited or certified by The Joint Commission. • The Leapfrog Group, Leapfrog Hospital Ratings:

ht tp://w w w.leapfroggroup.org/cp?form=cp_start The Leapfrog Group Hospital ratings provide comparative information about several quality indicators for hospitals. fin81226_03_c03_041-072.indd 72 10/30/14 7:43 PM