National Committee for Quality Assurance
Founded in 1990, the National Committee for Quality Assurance (NCQA; http://ncqa.org) is a private, nonprofit organization dedicated to improving health care quality and elevating health care quality to the top of the national agenda. NCQA is governed by an independent board composed of multiple stakeholder groups and has deemed status from CMS. NCQA develops quality standards and performance measures for a broad range of health care entities. These standards and measure are the tools that organizations and individuals can use to identify opportunities for improvement. Annual reporting of performance against such measures provides direction for improvement. NCQA collects Healthcare Effectiveness Data and Information Set data, known as HEDIS (Health Plan Employer Data and Information Set Measures), from more than 700 health plans; conducts accreditation, certification, and state plan surveys; and develops and conducts formal recognition programs, including the Primary Care Medical Home Recognition Program. No nursing organizations are included in the governance of NCQA, although nurses have been in key positions at one time or another. However, nursing organizations have actively engaged with NCQA to urge acceptance of APRNs as leaders of medical homes, so that several nurse‐led medical homes are now recognized by NCQA’s programs. Nurse faculty and others have worked with NCQA to mine relevant data regarding APRN practice and the outcomes of patients receiving care by APRNs in practice settings.
Utilization Review Accreditation Commission
The Utilization Review Accreditation Commission (URAC; www.urac.org),
initiated in 1990, is a nonprofit organization promoting health care quality by accrediting health care organizations, developing measurement, and providing education. URAC’s mission is to protect and empower the consumer. Its first mission was to improve the quality and accountability of utilization review programs. Its spectrum of services has grown to include a larger range of service functions, including the accreditation under its deemed status of integrated health plans. URAC is governed by a board with representatives from multiple constituencies, including consumers, providers, employers, regulators, and industry experts. Nursing has a long well‐established presence on its board.
Common Strategies Run through Formalized Initiatives
There are common strategies that each collective effort employs to gain political will for quality improvement. The various alliances and other collaborative initiatives have several strategies in common, which in and of themselves contribute to a set of tactics around quality that may be applied to other policy discussions. Strategic themes among these initiatives include the following, which are critical when considering quality and safety:
Most formal entities include consumers on their governing bodies or among the stakeholder groups they convene to ensure that the needs of the recipients of the care are heard and addressed.
Many health systems, and those entities seeking to improve quality, are actively seeking patients and families as advocates and representatives, as health systems seek to close the gap between providers and patient satisfaction, in part driven by measures of the patient’s experience of care.
Increasing emphasis, often less than successful, is focused on seeking broader diversity of patient, family, and consumer representation in order to reduce health care disparities.
The inclusion of a broad base of stakeholders is almost universally applied, acknowledging the complexity of the challenges facing health care.
The inclusion of multiple disciplines in most formal collaboratives reinforces that developing policy solutions is a team sport, with no discipline having the political clout to dictate or finalize solutions independently.
Most collective efforts include one or more federal agencies among their board members in some capacity to ensure federal efforts and other entities are moving in concert.
Professional organizations and other stakeholder groups participate in multiple efforts, maximizing their opportunities to influence policy.
Participants on the various alliances, agencies, and accrediting bodies often participate with multiple groups. Questions remain over whether this is more expeditious or not.
Consensus building is the preferred approach to derive proposed solutions.
Convergence on proposed solutions occurs among stakeholders and alliances, with the result that while the details might look a little different, the same conceptual underpinnings run similarly across many collaborative efforts.
The cost of health care is a worry that overrides all other efforts to improve quality, increase access to care, and ensure patient safety.
Social determinants of health are increasingly shown to challenge all efforts to improve health and reduce negative outcomes of care.
Challenges All Collective Efforts Face in Improving the Quality of Care
With approximately 200 national entities, including professional organizations and consumer groups, along with thousands of hospitals and other institutions and agencies engaged in the effort to improve quality, there have been substantial investments of financial and other resources, including human resources, over the last 30 years. The timing of many of these efforts in the early 1990s suggests that long before the publication of To Err Is Human and Crossing the Quality Chasm, leaders in the health care industry understood that lack of quality was a significant problem. Nurses were early adopters in hospital efforts to identify opportunities for continuous quality improvement. Many engaged in dialogue with individual physicians who were being challenged by state performance review boards and utilization review committees. Then the focus was primarily on local quality improvement and policy initiatives rather than state or national efforts. Global quality leaders (Deming, 1986; Juran, 1998) stated that 85% of errors in complex organizations were due to system design rather than to inadequate individual job performance. But even their discussions were addressed in departmental, corporate, or institutional policy terms.
Yet, in 2022, the magnitude of the current efforts to transform the health care system into a high‐quality system dwarfs all previous efforts. Health systems were focused on being high‐reliability organizations while at the same time striving to be recognized as safety cultures and just cultures. Why has this exploded to such mammoth proportions?
Prior to the implementation of the ACA, looking at any acute care facility, large or small, the number of outpatient procedures and the revenue generated from them had kept pace or overtaken the revenue from acute care services. Now the numbers of providers in even the smallest facility have increased, including increases in specialists, whether providing virtual or face‐to‐face medicine. The enormity and complexity of the systems now needing improvement do not differ all that