Program Goals:

The goal of the Fund's Program on Health Care Quality Improvement and Efficiency is to improve the quality and efficiency of health care in the United States. The program is rooted in the belief that improvements are most likely to occur when the need for change is understood, measured, and publicly recognized; when providers have the capacity to initiate and sustain change; and when appropriate incentives are in place. To that end, the program supports projects that:

• promote the development and widespread adoption of health care quality and efficiency measures
• assess and enhance the capacity of health care organizations to provide better care more efficiently
• promote the development and adoption of payment and incentive models that encourage providers to improve quality and efficiency.

The Program on Quality Improvement and Efficiency is led by Vice President Anne-Marie J. Audet, M.D.

The Issues:

The quality and efficiency of American health care is not what it should be. Despite a dedicated and hardworking provider community, there are ample opportunities for improvement in multiple domains of quality, including getting the "right care" (i.e., effective and appropriate care for a given condition), and care that is safe, timely, well-coordinated, and patient-centered. According to the most recent National Scorecard published by the Commission on a High Performance Health System, up to 101,000 deaths could be prevented each year if the U.S. raised standards of care to benchmark performance levels achieved abroad. This relative poor performance by the U.S. on quality, coupled with the highest spending on health care in the world, also suggests an inefficient system—one that doesn't achieve the expected value from the investment in resources. This is supported by evidence of overuse, inappropriate care, and waste in the health system.

Recent Projects

New Payment Models. Over the past five years, efforts to align payments with quality and efficiency, especially through pay-for-performance programs, have been rapidly growing in number. The Fund supported one of the first formal evaluations of a pay-for-performance program, conducted by Meredith Rosenthal, Ph.D., of the Harvard School of Public Health. With Fund support, Dr. Rosenthal is currently evaluating other pay-for-performance programs. However, even with pay-for-performance incentives in place, fee-for-service provider payment systems have limited potential to promote coordinated and efficient care is limited. New payment systems based on care delivered to a patient over an episode of illness, rather than individual services, may be better suited for this. One such payment system is Prometheus, which provides evidence-informed case rates for episodes of care. The Fund provided support to develop the developmental work Prometheus model, which is being pilot-tested under a demonstration program led by the Robert Wood Johnson Foundation.

Chronic Care Management. Steve Shortell, Ph.D., and his colleagues at the University of California at Berkeley recently conducted a Fund–supported study to follow up on the 2000 National Survey of Physician Organizations. The results will shed light on many aspects of chronic care management in physician practices. For example, one study to be published in Health Affairs will show how well physician practices are performing as patient-centered medical homes.

Variation in Hospital Quality Improvement. Alan B. Cohen, Sc.D., of Boston University and colleagues surveyed top quality officers at 470 U.S. hospitals to examine the extent to which hospitals are embracing the principles and methods of quality improvement. The researchers, whose work was published in Medical Care Research and Review, found that quality improvement is an evolutionary process that can take decades, and that top hospital executives, managers, and nurses are far more involved in improvement activities than are physicians.

Measuring Physician Cost Efficiency. In Beyond the Efficiency Index: Finding a Better Way to Reduce Overuse and Increase Efficiency in Physician Care, (Health Affairs Web Exclusive, May 20, 2008), leaders of the 3,400-physician Rochester Individual Practice Association (RIPA) found that use of global measures of physician cost efficiency, such as the efficiency index, "tends to interfere with quality improvement." RIPA leaders have sought instead to decrease overuse by identifying variations in the key drivers of cost.

Improving Quality and Safety. In the article, Does the Leapfrog Program Help Identify High-Quality Hospitals?, Ahish K. Jha, M.D., of the Harvard School of Public Health and colleagues found that hospitals that implemented patient safety practices endorsed by the Leapfrog Group—a coalition of 65 employers and agencies that purchase health care for approximately 34 million Americans—reported better quality of care and lower mortality rates. These results, published in The Joint Commission Journal on Quality and Patient Safety in June 2008, demonstrate that "hospitals can clearly improve quality and safety together without need for a trade-off," the authors say.

Future Directions

The Commonwealth Fund is supporting a series of projects to better understand the key drivers of high performance in hospitals, group practices, physician offices, and health plans. For instance, researchers at the University of Iowa, led by Barry R. Greene, Ph.D., are examining what elements of leadership are related to hospital quality, and how ti improve quality through leadership interventions. Arnold M. Epstein, M.D., and Ashish K. Jha, M.D., of the Harvard School of Public Health, are assessing the relationships between clinical quality, costs, and patient experience in hospitals.

Greg Pawlson, M.D., of the National Committee for Quality Assurance and Bob Berenson, M.D., of the Urban Institute are conducting a survey of health plan organizational characteristics and activities, to see which factors are associated with better quality and lower resource utilization.

Steve Shortell, Ph.D., and his colleagues at the University of California at Berkeley are performing case studies to determine why some physician organizations excel at implementing evidence-based chronic disease management processes.

Hospital readmissions are a major quality and cost problem in the United States. Among Medicare beneficiaries, the chances of being readmitted to a hospital within 30 days of discharge are about 18 percent. The wide variation in hospital readmission rates among states, and the successful efforts of some institutions to reduce readmissions suggest that it is possible to significantly reduce readmission rates nationally. The Commonwealth Fund is launching a multi-state, five-year demonstration project aimed at reducing avoidable hospital readmissions. During the first year, the Institute for Healthcare Improvement identify and develop processes, protocols, and other tools to assist states in reducing readmissions; select three to five states to participate in the demonstration; and map out a strategy for implementation.

To apply for a grant from the program, visit the Applicant and Grantee Resources page.