Neurosurgery quality: pay-for-performance, guidelines, and outcome measures.

The healthcare quality movement can trace its origins back to the man considered to be the architect of healthcare quality, Avedis Donabedian (1919–2000), who did his major work on defining quality in healthcare from the 1960s through 1985, and who published three seminal volumes, entitled Explorations in Healthcare Quality and Monitoring between 1980 and 1985 (21–23). Donabedian first classified and characterized healthcare quality characteristics into Structural, Process, and Outcomes measures. The work of Donabedian launched initial forays into the healthcare “quality assurance” (QA) movement. Eventually, the healthcare QA movement became strongly influenced by the “continuous quality improvement” (CQI) aspects of “total quality management” (TQM),18,20,41 and the result was a shift to more of a systems-based “quality improvement” (QI) approach.6,8,25,44–47 “Pay-for-performance” (P4P) is the latest quality initiative to come along in the continuing evolution of healthcare QI. Although the general origins of healthcare quality have already been outlined above, P4P arose from two very specific root sources. The Institute of Medicine (IOM) Quality Initiative that began in 1996 collided with the Center for Medicare and Medicaid Services (CMS) strategic planning initiative stemming from the Medicare prescription drug improvement and Modernization Act of 2003 (MMA 2003), to produce the CMS QI Roadmap of 2005, which included P4P as one of its five system strategies. P4P affects both hospitals and physicians, but this chapter deals only with physicians. The interplay of elected versus government officials and agencies as well as private institutes and organizations in the P4P development, implementation, and oversight processes can be dizzyingly complex and very confusing, as can the new array of organization abbreviations involved. The schematic outlined in Figure 27.1 as well as the abbreviation list in Table 27.1 are provided to assist the reader in navigating this interactive maze. Elected government officials are indicated in royal blue, appointed government officials and agencies in light blue, and private agencies and organizations in green. Formal lines of influence are indicated with solid arrows, whereas less formalized relationships are indicated with dashed arrows. Areas with lobbying potential and important impact on neurosurgical practice are indicated with asterisks. Figure 27.1 is not intended to represent an organizational chart. Rather, it represents one person’s perception at one snapshot in time of perceived lines and directions of influence between the various agencies, organizations, and officials involved. These relationships have shown themselves to be very liquid and dynamic during the last 12 months, and a similar chart created 6 to 12 months from now might differ in certain details, particularly as they relate to private organizations and agencies. It is hoped that Figure 27.1 will assist the reader in maintaining overall orientation and perspective as we proceed through a reductionist analysis of the individual agencies involved.