Overview: North Carolina has great doctors who are dedicated to delivering high quality care to their patients. Given the numerous burdens on the health care system, however, patients don’t always receive the recommended care for certain conditions. In fact, national studies have shown patients receive just over half of all recommended health care services. In North Carolina as in most places across our country, physician practices do not have a systematic way to measure the care they provide and identify the outcomes of their care.

Contributing to this quandary are the more than 1,800 evidence-based clinical guidelines to treat patients with different health conditions. These guidelines change over time and new ones are developed, as health professionals gather new evidence about what treatments work best for different conditions. The vast array and changing nature of the practice guidelines make it difficult for physicians to keep up with all the newest recommended care guidelines.

New models of practice are needed to effectively implement appropriate guidelines, measure and improve quality of care, and positively affect health outcomes. Physicians and other health care providers are trained to treat individual patients. The one-on-one relationships between physicians and their patients, as well as the effectiveness of care, can be enhanced, or impaired, by the availability or lack of community supports addressing the patients’ needs. A community-based approach is needed to address the growing numbers of older adults and people with chronic illnesses. With broad community support, we can improve the quality of health care of all North Carolinians by ensuring that evidence-based best practices are applied uniformly across the entire state.

Similarly, the work of other organizations in promoting population health will be enhanced through the work of the medical community. A community-wide effort, involving teams of providers and other health-related organizations, along with patients and their families, is needed to effectively manage the health of our state in the future. Helping physicians, patients and their families, and other health care providers adapt to the changing environment will improve the health of all North Carolinians.

Governor Easley has called the health care community into action to form an alliance of stakeholders to ensure that North Carolinians receive the best available care. This initiative will identify common sets of guidelines to use throughout the state to improve the quality of care and reduce the variation of care received from different providers. The initiative will be governed by the Governor’s Quality Improvement Committee (GQIC), a group of health care stakeholders, including representatives of Governor Easley’s office, providers (North Carolina Medical Society and North Carolina Hospital Association), Area Health Education Centers program (AHEC), Community Care of North Carolina, insurers and payers, North Carolina Institute of Medicine, and others. Preliminary members have been meeting since 2006 to develop a plan to meet the Governor’s goals. The NC Foundation for Advanced Health Programs (NCFAHP) and the NC Institute of Medicine will help the initiative.

Quality Measures: At the outset, the initiative will focus on improving care for diabetes, asthma, congestive heart failure, hypertension, and myocardial infarctions. These conditions were selected because they affect many North Carolinians and there are evidence-based guidelines to improve quality. As the initiative evolves, other conditions and delivery settings will be included. A clinical advisory committee, consisting of 15-25 clinical experts including primary care physicians, specialists in the specified initiative disease conditions, and other health care professionals (e.g. nurses, physician assistants, pharmacists), will advise the GQIC on quality measures and diseases or conditions as they relate to the measure set. The current list of measures is available here.

Practices that are members of Community Care of North Carolina (CCNC) will participate initially. Other practices that wish to take part in the initiative may join CCNC. Claims-based quality measures will be computed for all practices with eligible patient populations, regardless of whether they participate in the initiative. Chart auditors will visit each participating practice during which a random sample of medical records will be reviewed to compute the chart audit measures for each condition. By standardizing the clinical quality measures across insurers and other payers, physicians will no longer need to meet different criteria depending on the patient’s insurance status. In addition, every effort will be made over time to reduce the cost and administrative burden on practitioners of additional data collection activities.

A central data warehouse (CDW) will securely receive, store, process, update, and manage the data used to compute the quality measures, compile for the practice, the names of individuals identified as having one of the five conditions, and develop a system to securely deliver quality reports to practices via the internet. Practices will receive periodic reports on the quality of the health care they deliver to their patients. Community and statewide averages for the quality measures will be publicly available. Payer-specific averages for the quality measures will be available to the specific payer while practice-specific averages for the quality measures will be available to the specific practice, payers, and quality improvement consultants (described below). Payers will not use the quality measure values to solely or primarily change the practice’s underlying reimbursement, but may use the aggregate quality measures for non-punitive quality improvement purposes.

Practice support: One of the unique features of the initiative is the support that will be available to participating practices to help them improve quality. Services available to participating practices include regular reports on quality of care, disease registries and electronic health record consultation, quality collaboratives, free CME up to 20 hours/year, support to reach NCQA standards, staff development and continuing education, free access to the AHEC digital library, streamlined and coordinated practice support, and public recognition for participation. Quality improvement consultants will be available to help practices improve their quality by providing expertise on practice redesign, EHR consultation, assistance with rapid cycle quality improvement, and other services useful to practices interested in improving quality. Eventually, practice support may include a web-based tool that practices can use to implement rapid-cycle improvement by remotely submitting and tracking quality over time. To help offset initial costs to the practices, the initiative has built-in funding for one-time support to participating practices to help offset some of the additional costs incurred by in participating in this initiative.

This initiative is only possible due to the unique partnership of physicians, hospitals, insurers, state government, business, and other organizations committed to improving healthcare quality in North Carolina. Using uniform evidence-based measures and employing community supports will help improve health outcomes, lower costs, and result in a healthier North Carolina.