Historically there have been similar alliances that included nursing as partners in efforts to improve quality. These alliances have either dissolved in lieu of other broad‐based partnerships to impact the quality and safety of patients, or have been absorbed into other existing entities. These groups included Hospital Quality Alliance, Ambulatory Care Quality Alliance, Alliance for Pediatric Quality, Long‐Term Quality Alliance, Kidney Care Quality Alliance, Quality Alliance Steering Committee, and Institute of Pediatric Nursing.
Federal Agencies Engage with Alliances
It becomes clear from studying the configuration of most of these alliances that allegiance to and partnerships with federal agencies such as AHRQ and CMS are critical to any strategy driving health care system change that is focused on higher quality. CMS, at the behest of Congress, controls decisions determining reimbursement for services, how to reward for higher‐quality care, and how to make deductions in reimbursement due to preventable negative outcomes of care. NQF has been made the arbiter of measure endorsement and of which measures’ data, gathered by institutions and providers, point to the outcomes that either get rewarded or penalized. And AHRQ has played a major role from a federal perspective in the creation and validation of standards, offering guidelines for best practice, and being a clearinghouse of national quality measures and research related to quality, safety, and best practice. Any professional alliance looking to develop measures or to suggest that given measures are or are not appropriate for considerations of payment would do well to bring these entities along to the discussion, keep them informed of challenges and lessons learned, and either heed or shape the future they want to see. Some of the alliances that have developed and achieved endorsement of their measures from NQF ensured their measures continued through AHRQ representation.
Centers for Medicare and Medicaid Services
CMS is a federal agency that administers Medicare, Medicaid, and CHIP. CMS utilizes other entities to survey health care institutions and programs for maintenance of minimum standards of quality, yet retains ultimate authority. CMS reports to HHS. Even though Medicaid services are provided by each state, CMS provides guidance for administering services and can audit the services provided to Medicaid recipients. CMS has several newly created offices as a result of the ACA, including the Center for Medicare and Medicaid Innovation and the Center for Dual Eligibles. CMS manages the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for the MIPS. One of its newer initiatives, Patients over Paperwork, has looked to reduce the paperwork burden for providers while continuing to monitor for quality. CMS itself takes on great importance in the quality arena more broadly. The 2020 CMS quality conference drew over 3,500 attendees from across the country, and showcased the increasing involvement of CMS staff and contractors in quality measurement data analysis and reporting, and in engaging with the Meaningful Measures Initiative, the QIO 12th Scope of Work, and other efforts to embrace quality.
In approximately 2010, CMS, at the request of ANA leadership, created a Nursing Steering Committee that includes several CMS officials who are nurses, willing to address concerns that arise from external nursing organizations about Medicare and Medicaid reimbursement, service issues for Medicare or Medicaid recipients, and quality and safety issues. This Steering Committee includes a number of nursing organizations and continues to meet quarterly by conference call, addressing problems, new CMS initiatives, proposed rules, and most recently efforts to address the concerns of nurses in the field with regard to the COVID‐19 pandemic.
One of the key supportive features of CMS during the pandemic was its commitment to providing multiple weekly stakeholder calls to support the various health care workforce‐related issues that surfaced. Weekly nursing stakeholder calls were reported to be well attended, and CMS staff reached out to nurse leaders to provide advice to the front lines and hear their concerns during these calls, focused on addressing safety and quality of care.
CMS staff and leadership, in response to COVID‐19 and related emergency declarations, took steps to prepare and implement emergency rules. Several of these impacted nurses and APRNs. Scope of practice restrictions were lifted, depending upon the statutes in each state. Nurses who were willing to travel out of state to assist others in dealing with COVID‐19 workforce shortages had barriers such as licensure in another state lifted. Providers including APRNs, depending on scope of practice, were allowed to provide and bill for telehealth visits.
As policy efforts have shifted from passage of the ACA to defining the rules and regulations that impact implementation of its many provisions, the CMS Nursing Steering Committee continues to be extremely valuable in identifying opportunities for the profession to weigh in with public comment on proposed rules, and in calling to attention and advocating for changes to language that would disadvantage nursing practice or reduce nursing’s ability to keep patients safe. It continues to serve as a welcome venue for getting timely information about CMS initiatives that potentially affect the profession and consumers.
Agency for Healthcare Research and Quality
AHRQ (www.ahrq.gov) is the lead federal agency charged with improving the quality, safety, efficiency, and effectiveness of health care for all Americans. It is one of 12 agencies within the HHS. AHRQ supports research that helps people make more informed decisions and improves the quality of health care services. It is committed to improving care safety and quality, and does this through successful partnerships and the development of knowledge and tools needed for long‐term improvement. AHRQ’s research goals include measurable improvements in health care, with a focus on improved quality of life, improved patient safety and outcomes, and high‐value care for each dollar spent. AHRQ’s Patient Safety Network (PSNet) highlights journal publications, books, and tools related to patient safety. It had developed tool kits and, until funding from Congress was cut, hosted national clearinghouse services related to care guidelines and quality measures.
Standard Setting by Nonfederal Agencies
Accreditation bodies such as the Joint Commission, the National Commission on Quality Assurance, the Utilization Review Accreditation Commission, and other CMS‐deemed entities impact how quality is recognized and monitored in practice settings. They drive quality through formal policy mechanisms of setting, monitoring, and evaluating accreditation standards and recognition criteria. Although accreditation is voluntary and paid for by the institution seeking it, accreditation processes wield a great deal of power in shaping expectations of quality and safety. To ensure the reasonableness of standards and evaluation criteria, professional organizations and alliances participate in the development and revision of accreditation and recognition criteria and measures. ANA and others seek to ensure that nurses provide board representation, public comments, or advocacy efforts as checks and balances on the rigor of the accreditation standards and recognition criteria these entities use as the yardstick by which performance is evaluated.
Joint Commission