From research to policy: enhancing uptake of quality improvement methods in government contracts

Presentation The Centers for Medicare and Medicaid Services (CMS) provide healthcare coverage for 100 million people and, particularly through provisions of the Affordable Care Act, the agency strives to improve care and to ensure coverage for all Americans. Government agencies like CMS need processes that encourage improvements in value and outcomes and reduce variation in quality, and yet have been slow to embrace quality improvement (QI) methods. With QI, the agency could be more effective in partnering with providers to achieve “triple aim” outcomes of improving patient experiences with health care, improving population health, and reducing percapita health care costs [1]. Most CMS work proceeds through contracts that specify actions and on-time deliverables (such as supplies or helpdesk services). Similarly, contracts to “Quality Improvement Organizations” (QIOs) typically require that an “evidence-based” intervention be applied in a certain number of clinical settings – not that the intervention be tested further and adapted to the local context, or even that a particular outcome be achieved. Such contracts are eminently auditable, an important fact in the scrutiny of government contracting by CMS, Congress, the press, and others. Translating efficacious interventions into effective health care processes and outcomes at a local level ordinarily requires iterative, exploratory testing and adaptation, which is the core of QI. CMS’s traditional purpose has been to pay the bills and uphold the “standard of care”; it generally does not issue research grants that allow exploration of novel implementation approaches. Although CMS has not historically been at the forefront of QI methods, the agency’s position is simultaneously changing to adopt QI and encountering challenges along the way. Key points: • Implementation of evidence-based interventions with strict fidelity to the research protocol is often an ineffective strategy; testing and adaptation are usually necessary for optimal implementation and for scaling up. • Quality improvement methods such as statistical process control (SPC), frequent and repeated measurement, rapid-cycle testing of interventions and strategies, and qualitative insights about causal chains and effectiveness are powerful implementation tools that could work better to achieve program goals than implementation of rigidly specified interventions. • Writing an auditable contract for these approaches poses challenges. • Strategic partnerships between QI researchers, QI leaders, and government staffers/officials might be effective in promoting familiarity with QI methods and structuring contracts to allow for integration of QI methods while meeting audit and evaluation needs.