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Editorial: On Designing Integrated Quality Oversight Policy

Integrated health systems seem to be all the rage now. We are rapidly developing coordinated delivery of primary, acute, and long-term care with federal and state government and provider encouragement. What appears to be lacking is some attention to integrating the quality oversight policies of providers of these various levels of care and coordinated quality policy by the funding and accrediting agencies. In short, can we design a model of quality oversight that will include appropriate values, methods, and roles of federal and state regulators, accrediting bodies, and providers? Five questions summarize our interests in this topic: 1. Do we value integrated quality oversight? Both administrative and clinical leaders tend to grumble about the duplication in quality oversight, but they do so in the context of wanting to maintain autonomy. How would providers feel about a policy design that apportioned quality oversight roles to federal and state agencies and the providers themselves, based on a division of needs, methods, and capabilities? This is a complicated task, involving sharing data and granting even greater public access. Proposals would bring about resistance from those who actually like the currently divided and weakened perspective of quality policy actors with limited scope and resources. Without strong support, integrated quality oversight will clearly not happen. 2. Do we have the total approaches and methods to deliver on promises about quality oversight? We have already invested a considerable amount of time addressing the strengths and limitations of our quality assessment and improvement methodologies. But we rarely pay attention to how to create packages of approaches and methods that would form a coherent model for oversight. And, as we move to more integrated systems of primary, acute, and long-term care, some actors, e.g., hospitals,would need to expand their quality responsibilities. Quality management models focused on acute care would be necessary but not sufficient. For example, inpatient satisfaction scores and surgical outcomes from operating rooms would be a smaller part of the quality indicator set. 3. How would we structure this division of roles and responsibilities among the major actors? Differential roles for federal and state organizations requires that we eliminate redundancies and fill gaps in quality policy across organizational boundaries. We could easily suggest that federal and state agencies focus on structural components (e.g., staffing levels, board certification) and outcomes (e.g. mortality, patient satisfaction), leaving process review and critical path improvement to the operating providers of services. But even this simple division would require that each actor agree to use some of the information provided by others. Reliability and validity battles would abound at the start, and we would confront the issues of trust and potential misuse of the data. 4. Do we believe in the contribution of integrated quality oversight? Here we come faceto-face with our beliefs about quality improvement and quality related data. Are we prepared to have comparative information available? Do we truly want to move our quality oversight capabilities forward in an environment of intense competition? Proposing to integrate policy will bring about either a psychology of support or one of blocking, based on core beliefs about the contributions of accessible information and on previous experience. Data can be used for continuous improvement and learning or for policing and summative judgments. When policy actors, such as regulatory agencies, speak the language of improvement, but