Much of the Affordable Care Act (ACA) is a plan and strategy, rather than a blueprint. Reform will largely occur in how we implement it.  And although many did not have a role in its formulation, many more will have more of a role in how it is implemented and the form that it takes. 

As reform emerges, those involved will adapt to the environment, conditions and situation. ACA represents an infection, or tipping point, from which real reform will progress. Much of the implementation will depend on the capacity and commitment of those implementing the changes. While some of the dissonance and opposition occurs from vetted and vested interests who see the change as challenging their role, authority, income and status, a good deal is occurring from the change in how we conceive and think about healthcare (Mental Models) and our comfort and investment in them.


In this multi-part series, I’ll explore one aspect of the ACA — outcome assessment, specifically its importance and the elements needed. We are ready to see outcome assessment as a tool for change management.

Affordable Care Act

The Affordable Care Act (ACA) enunciates four stated and one latent principle. The four stated are: person-centered care, evidence-based practice, outcome assessment and transparency. The one latent is sustainability. The intention here is to examine one aspect of outcome assessment. While outcome assessment is one part of the process, it requires significant change in the way we think. It is a different mental model than the usual approach that we have to “quality.” For facilities in Accountable Care Organizations (ACOs), there will be a need to provide outcome measures that assess performance.

Outcome assessment will likely supersede what was represented as quality assurance, quality improvement and total quality management. 

In many ways ACA has linked outcomes to cost and cost to access. While the focus of the act was admittedly to improve access, it was funded through an increase in outcome. The supposition is quality services reduce inefficiency, waste and untold results, which results in a reduction.

Outcome and Outcome Assessment

When we talk about quality, we are talking about outcomes. This means discussions about quality become more concrete, measureable, capable of being gauged, determinate and accountable. With proper outcome assessment, a facility will develop a more robust performance improvement and change management system.

Outcome assessment, performance improvement and change management has a long history in defense, agriculture, education, behavioral services, ecology and rehabilitation. Fields, such as education, deliberately differentiate between basic research and evaluation research. Operations research and techniques in organizational development delineate the commercial sector’s involvement in this process. Fortunately, there is a good deal of literature guiding this effort, especially in bundling of services and in assessing the value of components as they contribute to value of the whole (program).
Outcomes assessment requires being proactive. Much of what we do in skilled nursing is reactive – done to correct an issue or fix a problem, rather than anticipating issues through information management and assessment.

Tune in next week for a discussion on Quality Assurance and Performance Improvement.

James Lomastro, Ph.D., has worked in acute, community based and long-term care for 33 years. He has held an administrator license since 1991. Prior to involvement in administration, he held academic and research appointments at Boston University School of Medicine and Northeastern University.