FEENEYNAPHFellowProg ramNovember17 2006 FeeneyNQF

NQF’s Role in Enhancing Safety and QualityNational Association of Public Hospitals and Health Systems Fellows ProgramNovember 17, 2006: 

NQF’s Role in Enhancing Safety and Quality National Association of Public Hospitals and Health Systems Fellows Program November 17, 2006 Dianne Feeney, BSN, MS Vice President National Quality Forum

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“ It would be a good thing for the world at large, however unprofessional it might be, if medical men were required by law to write out in full the ingredients named in their prescriptions. Let them adhere to the Latin, or Fejee if they choose, but discard abbreviations, and form their letters as if they had been to school one day in their lives, so as to avoid the possibility of mistakes on that account.” Mark Twain San Francisco Morning Call October 1, 1864 The Quest for Healthcare Quality is Not New

Phases of Healthcare Reform: 

Phases of Healthcare Reform Phase I - Awareness of Quality Gap 1998 – present Phase II – Alignment of Environmental Forces 2002 – present Phase III – Activation of Communities 2003 – present

Phase I: Awareness of Quality Gap: 

Phase I: Awareness of Quality Gap 1995 2000 2005 President’s Quality Commission IOM Quality Roundtable RAND Synthesis of Quality Evidence To Err is Human Crossing the Quality Chasm AHRQ Annual Quality & Disparities Reports CMWF International Comparisons Dartmouth Quality Studies PBS Remaking American Medicine

Growing Sense of Urgency:Just the Facts: 

Growing Sense of Urgency: Just the Facts 55% overall adherence to recommended care On average, 1 medication error per day per hospital patient Uninsured now total 45.5 M

Growing Sense of Urgency:Just the Facts: 

Growing Sense of Urgency: Just the Facts Health care costs rising 1.5 to 2 times the rate of inflation Up to 2-fold variation in per capita spending across communities U.S. spends more than all other industrialized countries by sizable margins

NQF: Result of Awareness and an Effort to Align Environmental Forces: 

NQF: Result of Awareness and an Effort to Align Environmental Forces Open membership- 350+ members Public and private sector representation on governing board Equitable status of stakeholder sectors (member councils) Attention to overall strategy for measuring and reporting healthcare quality, including establishing national goals Focus is on the entire continuum of healthcare Unbiased convener of quality stakeholders Formal consensus process (“voluntary consensus standards”)

Consensus Development Process: 

Consensus Development Process Based on the National Technology and Transfer and Advancement Act of 1995 and OMB Circular A-18 Defines the 5 key attributes of a “voluntary consensus standards body” (i.e., openness, balance of interest, due process, consensus, and an appeals process) Obligates federal government to adopt voluntary consensus standards (when the government is adopting standards) Encourages federal government to participate in setting voluntary consensus standards

Fundamentals of NQF Consensus: 

NQF/Steering Committee/Technical Advisory Panels (TAPs) Pre-work- Measures/standards/frameworks evaluations Draft consensus report Member/public comment period Final consensus report (voting version) Report and ballot to NQF Members Member voting period NQF Board consideration and endorsement Appeal Fundamentals of NQF Consensus

NQF Work To Date : 

NQF Work To Date Endorsed 250+ performance measurement standards 30 Safe Practices 27 Serious and Reportable Events Frameworks and Preferred Practices for Quality in Behavioral Health, Child Health, Substance Abuse and End of Life Care

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NQF Evaluation Measure Development NQF Endorsement Implementation What information does NQF need from the Alliances and other implementers and do the implementers need from the NQF? What information does NQF need from measure developers and do developers need from NQF? What role can NQF take to improve the CDP & provide the information that is needed on both ends of the supply chain? National Priority Setting What role can NQF take in developing a “National Priority Agenda”? NQF is Currently Revising the CDP Process

Phase II:Alignment of Environmental Forces: 

Phase II: Alignment of Environmental Forces Pay-for-Performance - Reward providers for providing safe, effective, efficient care Public Reporting - Create a marketplace rich in performance information Health Information Technology – Encourage Investment in EHRs and development of RHINs

Pay-for-Performance: 

Pay-for-Performance About 200 P4P projects Half target physicians and one-third hospitals Predominant Reliance on process measures Incentive payments- 2 to 6%

“Bottom Up” Medicare Reform Strategy – P4P and P4R: 

“Bottom Up” Medicare Reform Strategy – P4P and P4R Demos, Demos, Demos “Community-based” P4P “Gain-sharing” Hospital Quality Physician Group Practice Medicare Care Management Medicare Health Care Quality Medicare Health Support Dx Mgmt for Severely, Chronically Ill Dx Mgmt for Dual Eligible ESRD Dx Mgmt Care Mgmt for High Cost Beneficiaries Nursing Home P4P Voluntary Reporting Hospitals (P4R) Physicians

Public Reporting: Provider-Level: 

Public Reporting: Provider-Level Medicare Compare Series Most significant effort Becoming all payor State Reporting Programs Community-Based Efforts Private Employers/Insurers

Health Information Technology: 

Health Information Technology Markle Foundation Connecting for Health (2001) Consolidated Health Informatics (2003) ONCHIT (2004) America’s Health Information Community (2005)

President’s Executive Order: 

President’s Executive Order August 2006 Gov’t programs directed to encourage: Acquisition of interoperable HIT Transparency of Quality & Pricing Info Promote Quality and Efficiency Through P4P

Phase II: Alignment of Environmental Forces: 

Phase II: Alignment of Environmental Forces

Phase III:Activation of Communities (2004 -): 

Phase III: Activation of Communities (2004 -) “Bottom Up” Approach to Health Reform—Early Efforts CMS Demos and Pilots - P4P AHRQ State/Regional Demos – HIT

Phase III:Activation of Communities (2004 -): 

Phase III: Activation of Communities (2004 -) AQA Better Quality Information for Medicare Beneficiaries (BQI) Secretary Levitt’s Challenge: From 6 to 60 physician-hospital pilots in 2 years Value Exchanges RWJF Aligning Forces

Phase III: Activating Communities: 

Phase III: Activating Communities

Library of NQF Endorsed Standards: 

Library of NQF Endorsed Standards HCAHPS® (2005) Serious Reportable Adverse Events (2002, updated 2006) Ambulatory/Physician Care (2004-2008) Safe Practices (2003, updated 2006) Adult Diabetes Care Consensus Standards (2003, updated 2006) Hospital Care- National Framework (2002) Hospital Consensus Standards (2003, updated 2006) Cardiac Surgery Consensus Standards (2004) Nursing Care Consensus Standards (2004)

Library of NQF Endorsed Standards: 

Library of NQF Endorsed Standards Nursing Home Care Consensus Standards (2004) Home Health Care Consensus Standards (2005) Child Healthcare Quality Measurement and Reporting Workshop (2004) National Framework for Palliative and Hospice Care Quality Measurement (2006) Healthcare-associated infections (2006-2007) Substance Use Disorders Practices (2006-2007) Therapeutic Drug Management Quality Project (2006-2007)

Limitations of Current Metrics: 

Limitations of Current Metrics Probably not focusing on the majority of highest priority areas Measure selection influenced by Need for provider buy-in (i.e., siloed sets) Feasibility of short-term implementation (i.e., measure availability; based on administrative data) Serious harmonization and implementation challenges

Critical Vulnerabilities: 

Critical Vulnerabilities Metrics Data Aggregation, Auditing & Reporting Accountability Model Funding and Technical Assistance

Metrics: NQF National Priorities Program: 

Metrics: NQF National Priorities Program Initial Focus: Longitudinal Efficiency Priorities, Goals and Metrics for Episodes of Care Collaborative Effort Oct 2006 – Dec 2008 3 issue papers Definitions, Measurement Framework Operational examples – AMI and diabetes Future Vision and R&D Agenda

Metrics: Longitudinal Measure Sets for Chronic Conditions: 

Metrics: Longitudinal Measure Sets for Chronic Conditions Patient episode of illness- unit of analysis Process and outcomes Measures of patient engagement Underuse and overuse Composite measures --Did the patient receive all the services from which they would likely have benefited? Longitudinal efficiency– Did the patient receive only the services from which they would likely have benefited?

Metrics: Moving Towards Comprehensive Measurement Framework : 

Metrics: Moving Towards Comprehensive Measurement Framework Cover key domains and aspects of care 6 IOM Aims FACCT –staying healthy, getting better, living with illness, care transitions High Volume/Cost Conditions Cross Cutting Issues Interlocking measure sets that are harmonized

Metrics: Measure Harmonization and Implementation Challenges: 

Metrics: Measure Harmonization and Implementation Challenges

Data Aggregation, Auditing & Reporting : 

Data Aggregation, Auditing & Reporting Unnecessary Burden: Providers comply with numerous payer-specific reporting requirements. Less Reliable Conclusions: Complete view of provider’s practice is lacking. Public Confusion: Many public reporting programs-different measures, different subset of patients, different formats.

Data Aggregation & Reporting: Local/Regional Value Exchanges (VE): 

Data Aggregation & Reporting: Local/Regional Value Exchanges (VE) 6 to 60 Initiative Aggregate data across public & private insurers Data stewardship board

Need a New Accountability Model: 

Need a New Accountability Model Current P4P and public reporting programs are an add-on to Medicare Part A and B Payment Programs Enormous challenges to implementing P4P at the level of individual clinicians Quality health care is a team sport Need models of “shared accountability” Organizational supports are critical

Accountability Models of the Future : 

Accountability Models of the Future Align measurement, reporting and rewards with appropriate level of accountability—clinician, hospital, system, community Target some payments and rewards at system level to encourage: Accumulation of capital to invest in organizational supports Capture return on investment in safety, quality, and chronic care management Encourage system integration and standardization of care processes

Building a 21st Century Health System: Progress Report: 

Building a 21st Century Health System: Progress Report PHASE I

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National Quality Forum www.qualityforum.org