Quality, Safety, and Standards

Organizations COVID-19 Impact

Assessment: Lessons Learned
and Compelling Needs

This discussion paper is part of the National Academy of

Medicine’s Emerging Stronger After COVID-19: Priorities
for Health System Transformation initiative
By C. Clancey et. al. July 26 2021
• The quality and safety focus of the American health care system has a
long history, dating back to the 19th and early 20th century.

• Quality of care is generally understood as providing the right care for the
right person at the right time—every time.
Main drivers of Quality
measurements, Improvements and
Safety standards
1. Survey, certification, and accreditation of facilities, laboratories, health
plans, and providers

2. Quality measurement, incentives, and payment reforms

3. Public ratings of providers and facilities

4. Quality improvement learning and action networks.

• In 1990, the National Committee for Quality Assurance (NCQA) was
established as a nonprofit organization that accredits quality programs for
health plans, physicians, and other providers. NCQA developed the first set of
standards for health plan quality using a set of evidence-based requirements
and measurements.
• Despite the establishment of standards to ensure high quality care
throughout the 1980s and 1990s, numerous academic research
studies demonstrated the substantial burden and threat that poor-
quality care (often described as overuse, underuse, and misuse)
continued to have on public health.

• The National Academy of Medicine, report “To Err is Human” in 1999,

demonstrated that most Americans receive less than 60% of
recommended care.
 Social Determinants of Health
• An integral part of delivering high-quality health care includes gaining an
understanding of the social determinants of health (SDOH) of patients
and communities in their respective contexts.

• SDOH are defined by the World Health Organization (WHO) as the

“conditions in which people are born, grow, live, work, and age”
• An important dimension of quality measurement involves recognizing
the challenges that communities of color, as well as people with low
incomes, low levels of education, and other social drivers of health,
experience in achieving optimal health and health care.
Communities of Colour
• Communities of color and communities that have been made to be
vulnerable experienced higher incidence of infection with COVID-19 than
their White peers. The most proximal cause was the exposures of these
communities to sources of COVID-19 infections because of their
concentration in person-facing essential jobs in the service sector,
including workers in public transit, transportation, logistics, food,
beverage, janitorial services, and childcare and social services.

• These communities often experience higher barriers to accessing quality

care.
• The pandemic demonstrated the stark divide between our public health and
clinical care systems. For decades, public health has been underfunded at all
levels of the government, which hampered U.S. pandemic preparedness and
response.

• In addition, the quality and safety focus areas for public health and clinical
care have been poorly aligned, with health systems focused more on specific
clinical areas such as treatment for acute cardiac conditions and avoidance
of localized nosocomial infections.
• Public health systems are traditionally more focused on communicable disease
control and prevention of chronic disease and injuries.

• There was no existing data infrastructure across these systems that included
key variables and metrics around readiness to inform preparedness and the
response capacity of the health care system.
 System weaknesses
• Among the weaknesses highlighted by the pandemic was the inability of the
U.S. to develop clinical guidelines, related decision supports, and quality
measures, quickly.

• These same weaknesses have contributed to the inability to develop and

deploy digital quality measures across care settings pre-pandemic.
• To increase the ability to care for patients with COV-ID-19, hospitals canceled
elective surgeries and, where possible, expanded the physical capacity to care
for the expected influx of patients and to separate physically those infected
with COVID-19 from other patients.
• To safeguard the health and safety of health care workers, patients, and their
family members, many hospitals limitation of visitors and other personnel in
direct patient care areas and implemented universal symptom screening of all
entering a facility.
Health sector response
• 1. Survey, certification, and accreditation of facilities, laboratories,
health plans, and providers.
•
2. Quality measurement, incentives, and payment
reforms.
•
3. Quality improvement learning and action networks.
 Survey, certification, and accreditation:
Hospitals
• Hospital accrediting bodies had to shift their focus and operations rapidly in
response to COVID-19. One of the largest AOs, the Joint Commission,
suspended routine in-person surveys for health care organizations to enable
health systems to prepare and implement rapid COVID-19 response efforts.

• Limited accreditation surveys resumed in June 2020, with virtual surveys being
tested in several sites. The resultant impacts of virtual surveys on the public’s
health and safety remain unknown and should be studied.
 Future attention
• Attention should also be paid to the effectiveness of accreditation
requirements to determine which requirements should be retired in favor of
standards that reflect health care system readiness for future pandemics and
are more likely to support quality and safety.
Survey, certification, and
accreditation:
Nursing homes
• Prior to COVID-19, fewer than 4,000 of the nation’s 15,400 Medicare-certified
nursing homes voluntarily reported health care-associated infections (HAIs) to
the CDC’s National Health Safety Network (NHSN), which provides health care
facilities with a system to track infections and prevention measures.
Outcome
• The CDC developed a new COVID-19 module for reporting data that
subsequently became required for reporting on May 8, 2020.

• Under this rule, noncompliance on reporting standards could result in the

imposition of civil money penalties. Within weeks, at least 95% of nursing
homes began to report data in the four pathways within NHSN’s Long-term
Care Facility Component, providing valuable information on:

1. resident impact,
2. facility capacity,
3. staff and personnel supplies and PPE,
4. ventilator capacity and supplies.
 Nursing home surveys during
pandemic
• Survey findings of nursing homes often pointed to a breakdown
in basic infection control processes such as proper hand hygiene, doffing and
donning PPE, social distancing, staff screening, and precautions.

• The findings point out that it is not sufficient to just have regulations in place.
Training, technical assistance, oversight, and enforcement must also be in
place to ensure adherence to quality and safety standards
 Quality measurement, incentives, and payment
reforms.

• Quick pandemic action halted quality efforts that were not specifically
necessary during the pandemic so that providers could focus on caring for
patients. Health care quality data reporting was mostly suspended.

• While there were no direct measures associated with pandemic performance,

quality measurements can indicate poor systemic performance during a
pandemic.
Typical and common TV news report during the pandemic
• While some measures were suspended, other quality measures and incentives
were developed to encourage clinician participation in deploying novel
treatments and therapeutics.

• Examples:
• Incorporation of patient and personnel vaccination as part of quality measures
in nursing homes and dialysis facilities.
• Merit based Incentive Payment System Program offered credit for clinicians
participating in COVID-19 clinical trials and registries. In March 2021, Medicare
began paying approximately $40 per required dose of COVID-19 vaccines.
Quality improvement learning and action
networks.
Quality improvement networks were activated immediately to provide
training and support to the health care system, with particular attention to
nursing homes.

Quality Innovation Network-QIO and the CMS Quality Improvement

Contractors, focused their technical assistance on providing nursing homes
with onsite or virtual training in areas of identified concern, particularly in
COVID-19 outbreak hotspots.
Opportunities for Improvements in
Quality,
Safety, and Standards Sector
• Urgent actions:
1. ensuring strategy and infrastructure preparedness;
2. digitizing and sharing critical information across sectors;
3. improving population health measures;
4. streamlining metrics;
5. addressing inequities that can be taken to transform readiness, bolster the
public health infrastructure, and improve health outcomes.
 1. Ensuring strategy and
infrastructure preparedness

• Revisit the consensus definition of preparedness at the national, state, and

local levels, with attention to planning and execution and robust health
surveillance and vulnerability detection.
Challenges to address
• Simultaneous threats to public health in the form of:
• climate change,
• regional and ecological reservoirs of known and novel disease,
• national and regional outbreaks and epidemics,
• global pandemics,
• mass refugee migration, and cyberthreats.
 Metrics to consider
• Develop short-term metrics to assess interventions with rapid results over the
days and weeks immediately following an emergency.

• Develop long-term metric measures such as six-month hospitalization and

mortality following disasters or changes in health indicators for those
developing chronic diseases after an emergency.

• Develop a preparedness measurement strategy to potentially capture the

emerging capacities of virtual care and telemedicine.
2. Digitizing and sharing critical
information across sectors
• Develop timely access to accurate digital information and efforts to increase
access to this information.

• Develop a system of data integration to deliver the right information to the

right place at the right time and from every setting where health care is
provided.

• Transmit data across local, state, and regional public health departments,
schools, outpatient health delivery entities, and short-term and long-term
institutional living facilities.
 3. Improving population health
measures
• Create and implement local, state, and regional metrics for population health
status and assessment of vulnerabilities using sensible geographic
demarcations.
• Investments in the public health entities serving highly vulnerable areas
followed by direct financial incentives and additional investments for
improved performance and decreased population vulnerability over time.

• Develop a new system of metrics that increases the use of digital measures.
 4. Streamlining metrics
• The process for data capture, implementation of novel measures, and removal
of measures that are no longer useful must be addressed.

• Learning from COVID-19 by evaluating current measures post-pandemic to

determine if there was any relationship or predictive value to the measures
and the success of nursing homes, hospitals, or other care settings to manage
patients with COVID-19.
 5. Addressing inequities
• Segregation in care, derived from structural racism in housing and lack of access
to adequate care, is a substantial driver of racial and ethnic health care
disparities.
• Develop and use patient reported outcome measures focused on the
experiences of discrimination in health care delivery,
• Provide antiracism training in staff training, and accreditation, board
certification, and continuing education for individual and institutional health
care providers
Final thoughts
• Post-pandemic activities must include collective and earnest efforts to address
inequities and health disparities (racism) that existed prior to COVID-19.

• Investing in the expansion of digital data capture in public health and

congregate settings.

• Strengthen and modernize the quality measurement strategy and

infrastructure.

• Investments in and design of new models and standards for collaboration

between health care and public health systems should be significantly
increased.
• Develop cross disciplinary and multidisciplinary leadership training
programs and experiences to foster shared learning by health care
business leaders, public health leaders, and clinical leaders.