Is There a Place at the Table for Quality?
"Polls have established that when nurses speak out, the public listens. Why should the CEO of an insurance company, or a business office — someone who has never seen the inside of an operating room — define quality health care? As a nurse, you have the expertise, the knowledge and the know-how, and you have a vehicle for action: UNA/AFSCME. Through your union, you have the opportunity to show people that, when it comes to quality health care, no one is more qualified or better able to offer definitions than the frontline nurse. You are the voice of so many of the voiceless in America."
Gerald W. McEntee,
International President
Think back to health care 10, 15, 20 years ago: Was there ever talk about quality — quality measures, quality standards, etc? Not really. The system was: Doctors treat, nurses care and insurance companies pay. Quality was assumed — a given.
As recently as the early 1990s, the focus was on expanding benefits and coverage to more Americans and combatting the effects of cost-shifting. Quality was still assumed. Measures such as mandatory second opinions, pre-admission testing and certification were sold because they would not only save money but improve quality by avoiding unnecessary overtreatment.
The first generation of cost-cutting measures has taken hold and actual cost increases have begun to slow. For some large groups, costs have actually fallen. Managed care, redesign, de-skilling, practice parameters, shifts in delivery settings are among the new generation of cost-cutting measures. All have internal cost-cutting and quality implications that are now being recognized by consumers (i.e., unions, seniors, children's advocates, the disabled population) and payors (primarily large private and public sector groups). Coalitions are beginning to ask about the types of standards that can be set, legislated and negotiated in agreements to insure that managed care cost-cutting does not threaten the quality of health care services.
The science of measuring quality is still in its infancy. The most complete but least effective measures are retrospective and indirect. They include items like infection rates, readmission rates, falls, medicine errors, mortality and morbidity figures.
Process and screening measures comprise the current second level of quality assessments. Process measures include peer review, consumer protections and practice protocols. Screening measures include the plan or institution's effectiveness with preventative screening tools such as immunizations, PAP smears, mammography, cholesterol, etc. This is at least a concurrent measurement.
The most sophisticated and least applicable tools are outcome measurements. These measurements actually rate the experience of a plan or facility or system with diseases and conditions such as diabetes, CHF, pneumonia, stroke, or heart disease. The goal should be that purchasers and consumers can choose health plans, practitioners and facilities on the basis of actual experience with a particular disease process. That is the type of prospective review that consumers deserve.
Unfortunately, a telling survey of employers conducted by the American Management Association revealed that while employers were using managed care to control their costs, issues of employee choice and quality of care were low on their list of priorities when choosing plans.
