Transcript The National Quality Forum - American Academy of Nursing

National Agenda for
Performance Measurement:
Strategic Imperatives
Helen Burstin, MD, MPH
Senior Vice President, Performance Measures
AAN Pre-Course
October 13, 2011
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Outline
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The quality enterprise
The evolution of performance measurement
Evaluation of performance measures
Strategic implications for nursing
Discussion
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Strategies for Reforming Health Care
 Public Reporting: engaging consumers and
others stakeholders
 Health Information Technology: enabling
improvement
 Value-Based Payment: rewarding achievement
 Clinically-Integrated Delivery Systems:
achieving patient-centered, coordinated care
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NQF’s Mission
To improve the quality of American healthcare by:
 Building consensus on national priorities and
goals for performance improvement and working
in partnership to achieve them;
 Endorsing national consensus standards for
measuring and publicly reporting on
performance; and
 Promoting the attainment of national goals
through education and outreach programs.
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NQF’s Roles
 Standard setting organization
 Performance measures, serious reportable
events, and preferred practices
 Neutral convener
 National Priorities Partnership (NPP)
 Measure Applications Partnership (MAP)
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NQF: Public-Private Partnerships Encourages Alignment
Accreditation
& Certification
Health IT
Incentives
Value-based
Payment
Prioritize
se
Endorse
Set Priorities and
Goals
Standardize Measures
National Quality
Strategy
High-Impact
Conditions
Portfolio of NQFEndorsed Measures
Public
Reporting
Implement
Build Consensus
About Select
Measures for
Reporting, Payment,
QI, and Evaluation
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HHS’s National Quality Strategy
BETTER
CARE
HEALTHY
PEOPLE/
COMMUNITIES
AFFORDABLE
CARE
Principles reflect:
 Patient-centeredness
and family
engagement
 Quality care for
patients of all ages,
populations, service
locations, and
sources of coverage
 Elimination of
disparities
 Alignment of public
and private sectors
© National Priorities Partnership
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HHS’s National Quality Strategy
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Measure Applications Partnership
Health reform legislation, the Affordable Care
Act (ACA), requires HHS to contract with the
consensus-based entity (currently NQF) to
“convene multi-stakeholder groups to
provide input on the selection of quality
measures” for public reporting, payment,
and other programs.
HR 3590 §3014, amending the Social Security Act (PHSA) by
adding §1890(b)(7)
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Outline
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The quality enterprise
The evolution of performance measurement
Evaluating performance measures
Strategic implications for nursing
Discussion
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Measurement
Improvement
Measurement is not an end in itself – the purpose is to
improve healthcare quality
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Quality Measurement in Evolution
• Drive toward higher performance
• Measure disparities in all we do
• Shift toward composite measures (all/none and
weighted composite)
• Harmonize measures across sites and providers
• Measurement across longitudinal patient-focused
episodes
– Outcome measures
– Appropriateness measures
– Cost/resource use measures coupled with quality
measures, including overuse
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Composite Measures
• A composite measure is a combination of two or more
individual measures in a single measure that results in a
single score.
• Examples:
• CAD: Optimally Managed Modifiable Risk (HealthPartners)
• Description: Percentage of members who have optimally managed
modifiable risk factors (LDL, tobacco non-use, blood pressure
control, aspirin usage).
• Pediatric Patient Safety for Selected Indicators (AHRQ)
• Description: A composite measure of potentially preventable
adverse events for selected pediatric indicators including:
accidental puncture or laceration, decubitus, ulcer, iatrogenic
pneumothorax, postoperative wound dehiscence, postoperative
sepsis and selected infection due to medical care
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Harmonization and Competing Measures
• Avoid duplicative measures that don’t add value
(and increase burden)
• Measure only where and when measurement is
appropriate
• Harmonized measures should be used to assess
care across providers and settings
– Immunizations
– Central line blood stream infections
– Pressure ulcers
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Integrated Framework for
Performance Measurement
© National Priorities Partnership
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Episodes Model Measurement Domains
• Patient-level outcomes (better health)
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Patient experience of care
Morbidity and mortality
Avoidance of complications (e.g., HAIs)
Functional status and health-related quality of life
• Processes of care (better care)
– Composites
– Care coordination and transitions
– Alignment with patients’ preferences
• Cost and resource use (overuse, waste, misuse)
– Total cost of care across the episode
– Indirect costs
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Use of Patient Reported Outcomes
• Validated patient-level outcome measures and
instruments (e.g., PROMIS)
• Challenges to use for accountability and
performance improvement:
– Not in widespread use in clinical practice; and
– Little is known about aggregating these patient-level
outcomes for measuring performance of the healthcare
entity delivering care
• Recent examples:
– Depression remission at 6 and 12 months using PHQ9
– Functional capacity and HRQOL for COPD patients
before and after pulmonary rehabilitation
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New NQF PRO Project
• Facilitate the development, testing, endorsement,
and implementation of PRO-based performance
measures
• Methodological issues that need to be addressed
to use PROs for performance measurement.
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Units of Analysis
Risk Adjustment/Stratification
Organization-Level Measures
Global versus Condition-specific Measures
Data collection/survey methods
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Resource Use Measures: A Building Block
Value
Efficiency
Stakeholder
Preference
Quality
Resource use
Costs/resources used to
provide care
Time
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Payment Reform Models
Payment for service
Fee-forservice
Augmented
fee-forservice
(e.g., P4P)
Payment for event or
condition
Bundled
payment
(single
provider)
Bundled
payment
(multiple
providers)
Payment for care of a
population
Partial
capitation
Full
capitation
Increasing aggregation of services into a unit of payment
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Outline
•
•
•
•
•
The quality enterprise
The evolution of performance measurement
Evaluation of performance measures
Strategic implications for nursing
Discussion
22
www.qualityforum.org
NQF Evaluation Criteria
• Importance to measure and report
• What is the level of evidence for the measures?
• Is there an opportunity for improvement?
• Relation to a priority area or high impact area of care?
• Scientific acceptability of the measurement properties
• What is the reliability and validity of the measure?
• Usability
• Are the measure results meaningful and understandable to
intended audiences and useful for both public reporting and
informing quality improvement?
• Feasibility
• Can the measure be implemented without undue burden,
capture with electronic data/EHRs?
• Assess related and competing measures
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Evidence for Measure Focus
• Hierarchical preference for
– Outcomes linked to evidence-based processes/structures
– Outcomes of substantial importance with plausible
process/structure relationships
– Intermediate outcomes
Most closely linked to outcomes
– Processes/structures
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Endorsed Measures by Measure Type
Color legend: Process (white); Outcome (blue), Structure (orange)
Outcomes = One third of endorsed measures
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NQF’s Health IT Portfolio Supporting Development of the
Necessary Electronic Infrastructure
Capture Data
Calculate Performance
Measures
Real-Time Info to
Clinician
Publicly Report
Quality
Data
Model
What is available in an EHR that I can use to
create my measure?
Logic
How can I say what I want so that all
readers will interpret it the same way?
Standards
How can I create my measure so that an
EHR and the average clinician can each
understand it?
Measure
Authoring Tool
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Performance Measures and Information
Requirements Will Change Overtime
Measurement
Perspective
Population
HEALTH INFORMATION FRAMEWORK
Healthy People / Healthy Communities
Individual Characteristics
Community / Environmental
Behaviors, Social/Cultural Factors,
Resources, Preferences
Payers
Employers
HEALTH STATUS
Cross-Cutting Aims: Prevention, Safety, Quality, Efficiency
Health System
Individual
Characteristics
Health Related Experience
Clinical Characteristics
Patient, Consumer, Care Giver
Data Sources
EHR PHR
HIE
Public
Health
Survey
Registry
Etc.
(Structured / unstructured, clinical, claims)
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Outline
•
•
•
•
•
The quality enterprise
The evolution of performance measurement
Evaluation of performance measures
Strategic implications for nursing
Discussion
28
www.qualityforum.org
NQF and Nursing
• 2004 Nursing Care Framework:
– Patient-centered outcomes
– Nursing-centered intervention measures
– System-centered measures
• Future research focus on care functions central to
nurses -- demonstrate positive effects of nursing
on patient education, transitions, symptom
management, outcomes, improved functional
status.
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MD Naylor, Med Care Res Rev 2007; 64; 144
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Examples of Nursing Contributions to NPP
• Patient and family engagement
– “Informed decision making, honoring patient choices, and
providing tools for patients and families to manage their care
are time honored in the nursing profession.”
• Care coordination
– “The area with the greatest opportunity for nursing to advance
and accelerate the achievement of NPP goals”
• Population health
– “Performance measures that reflect health rather than disease,
including measures that capture nursing’s contributions to
population outcomes.”
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Lamb & Jennings, American Nurse Today, January 2011
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HHS’s National Quality Strategy
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Example: Person- and Family-Centered Care
Goals:
• Improve patient, family, and caregiver experience
of care related to quality, safety, and access
• Using a shared decisionmaking process, develop
culturally sensitive and understandable care plans
• Enable patients and their families and caregivers
to effectively navigate and coordinate their care
Measure Concepts:
 Patient and family experience
of quality, safety and access
 Patient and family involvement
in decisions about their care
 Joint development of
treatment goals and plans of
care
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Confidence in managing
chronic conditions
Easy-to-understand
instructions to manage
conditions
© National Priorities Partnership
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Identifying Measure Gaps
Patient Safety:
Health & Well-Being:
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Healthy lifestyle behaviors
Community environmental assessment
Productivity measures
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Prevention & Treatment of
Cardiovascular Disease:
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Effective Communication & Care
Coordination:
ABCS
Healthy foods
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Person- & Family-Centered Care:
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Healthcare-associated condition measures
Harmonized readmission measures
Inappropriate medication use &
polypharmacy
Unnecessary imaging
Person & family experience of care
composites
National indicator of the use of
experience surveys in various settings
Care planning
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Affordable Care:
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Care transitions
End-of-life care
Exchange of patient information/records
Vulnerable populations requiring
healthcare and social supports
Affordability indices
Measures of unwarranted variation and
overuse © National Priorities Partnership
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Take Home Messages
• Strategic directions for performance measurement:
– Greater focus on outcomes for patients and populations,
including disparities
– Safety, quality and cost matter
– Take advantage of emerging longitudinal electronic data
platform to capture patient-reported outcomes
– Nothing about patients without the voice of patients and
their families
– Harmonize measures whenever and wherever possible
• Strategic implications for nursing: Measurement in
these emerging areas will naturally bring greater focus
to the role of nurses
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The Measurement Imperative
Not everything that counts can be
counted, and not everything that can be
counted counts
~Albert Einstein
But…
You can’t improve what you don’t measure
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Thank You
Helen Burstin, MD, MPH
Senior Vice President, Performance Measures
[email protected]
www.qualityforum.org