Friends. Proposal to Designate The National Quality Forum as the National Coordinating & Standard-Setting Center for Performance Measures

Transcription

1 Friends NQF of March 5, 2007 Proposal to Designate The National Quality Forum as the National Coordinating & Standard-Setting Center for Performance Measures Summary Statement A comprehensive measure development strategy that addresses the performance of health care provider organizations and practitioners is urgently needed. The federal government should designate the National Quality Forum as its National Coordinating and Standard- Setting Center for Performance Measures, and provide stable and adequate funding. The National Quality Forum is an established public/private sector partnership that has an excellent track record in evaluating, endorsing, and promulgating performance measures. This recommendation is based on the fundamental beliefs that assurance of an effective national performance measurement strategy is a federal responsibility and that information resulting from performance measurement is a public good. The Congress articulated the former responsibility in the Deficit Reduction Act of 2005, but has yet to provide funding to permit full execution of that strategy. A national performance measurement strategy is needed to guide the development of a coherent compendium of standardized performance measures that address national health care quality priorities and goals and can be progressively expanded as these priorities and goals evolve over time. The stakes are high. Standardized performance measures are needed to support quality improvement activities wherever health care is delivered; to create a source of reliable comparative performance information upon which consumers may rely in making informed decisions about their care; to assure that provider organizations and practitioners are held accountable for the quality and efficiency of their performance; and to provide a basis for establishing performance incentive programs for providers and practitioners. The United States is an acknowledged leader in developing health care performance measures, but it has not established a credible, integrated national performance measurement system that meets the needs of key users. Critical gaps and weaknesses in current processes include the absence of a national priority and goal-setting process; lack of coordination of and insufficient investment in measure development and maintenance efforts; inadequate and uneven funding support for measure evaluation and endorsement activities; and lack of a strategy for transitioning performance measures into electronic health records. These problem areas require attention on an urgent basis, and the National Quality Forum is the best-qualified entity to provide appropriate leadership, direction and coordination of the necessary effort. This effort is a fundamental building block for

2 creating a national health care system that provides high quality service and is affordable and accessible to all Americans. Problem Definition The U.S. health care sector is undergoing fundamental change. Serious concerns have been raised about health care quality, safety, costs, access and disparities in care. Numerous efforts are underway to address these concerns. These include the pay-forperformance initiatives being undertaken by public and private sector purchasers; public reporting of performance information by the Centers for Medicare and Medicaid Services (CMS), state governments and others; quality oversight by accreditation, regulatory, and professional certification entities; and quality improvement activities being conducted by the Quality Improvement Organizations (QIOs), health care providers, practitioners and others. And progress is indeed being made. Clinical leaders are actively engaged in measure development through the American Medical Association s Physician Consortium for Performance Improvement, The Joint Commission, the National Committee for Quality Assurance and others. The National Quality Forum is evaluating measures on a continuing basis, and identifying the best in class measures to serve as national standards. The Hospital Quality Alliance (HQA) and the AQA, as multi-stakeholder coalitions, are setting priorities for hospital and physician performance measurement efforts, respectively. Medicare Compare continues to expand to include additional comparative performance data on various types of providers, and, most recently, DHHS and private foundations are encouraging community-based efforts aimed at quality measurement, reporting, and improvement. But these pieces, while laudable, do not add up to a strategically focused, efficient, and financially stable enterprise. Indeed, various expert panels have called for a more coordinated approach for nearly a decade. 1 The fact is that critical gaps and weaknesses in the current configuration of performance measurement activities leave it far short of being a coherent national performance measurement system, and are actively threatening the many promising efforts that are presently geared towards restructuring and improving the health care delivery system. These gaps and weaknesses include the following: 1. Absence of a National Priority and Goal-Setting Process. There is currently no existing, let alone ongoing, national priority-setting process to guide the development and/or selection of performance measures for public reporting. But there is no lack of priorities. A number of important stakeholder groups have legitimate vested interests in setting their own priorities. The AQA and HQA are important decision-making bodies that prioritize and recommend measures to CMS and other purchasers for use in public reporting. Professional societies and organizations involved in accreditation 1 See for example: Institute of Medicine, Performance Measurement: Accelerating Improvement, 2006; National Quality Forum s Strategic Framework Board, 2003; President s Advisory Commission on Consumer Protection and Quality, Page 2 of 7

3 and certification also have measurement agendas that fit their own evaluation objectives. And consumers and private-sector purchasers, and those organizations that represent these constituencies (e.g., the Consumer/Purchaser Disclosure Group, the AARP, the Leapfrog Group, the National Business Coalition on Health), each have efforts underway aimed at setting national performance improvement agendas. A coordinated national priority and goal-setting process is needed to: Focus Provider and Practitioner Attention. The greatest improvements will be achieved if attention is focused on a limited number of high-leverage areas having the greatest potential to enhance quality and slow the rate of growth in health care expenditures. Systematically Raise the Bar of Performance Expectations. Fundamental change in the delivery system will only be achieved if performance expectations are set through a legitimate consensus process and progressively raised over time. Assure the Efficient and Effective Deployment of Scarce Measure Development Resources. Measure development and testing is an expensive process, and each dollar committed to this effort needs to be well spent. The absence of national priorities and goals is a basic impediment to the development of a coherent national system of performance measurement. 2. Discordant Measure Development and Maintenance Activities. Sizable amounts of resources and energy are currently being invested in the development of performance measures by many organizations, including accrediting bodies, more than 30 specialty and subspecialty societies and boards, government organizations, proprietary organizations, and others. Having many organizations involved in measure development brings a wealth of knowledge and expertise to the table, and engages clinical and other leaders in shaping the quality agenda, but this also presents challenges: Incomplete Portfolio of Measures. In the absence of a national prioritysetting process, each measure developer naturally sets and follows its own measure development agenda. Most measure developers focus on a specific clinical area (e.g., cardiac measures) or provider setting (hospitallevel measures). The majority of quality measures tend to focus on narrow aspects of care, such as management of HbA1c levels in diabetics, as opposed to outcome measures or overall measures of diabetes management. Critical areas for which no single group is solely accountable such as care coordination, end-of-life care, longitudinal care, or even care efficiency and patient-safety tend to get short shrift and may be overlooked. Further, too little attention is paid to measures of Page 3 of 7

4 patient engagement in decision-making and patient knowledge and preparedness to implement their treatment plans. Inadequate attention is also being paid to high-volume, high-cost procedures (e.g., imaging) and to measures of underuse. Lack of Measure Harmonization. Efforts to develop measures for physician performance and for hospital performance have tended to move on separate tracks. While not unreasonable on its face, this approach creates the risk that different measures of precisely the same dimension of care will be created, and that is indeed now happening on a rapidly growing scale. This coordination failure, a result of diffusion of leadership, is more than a problem of duplicative efforts. This expanding problem will lead to misalignment of performance expectations for hospitals and physicians respecting care for specific conditions; will inevitably create conflict if such measures become the basis for incentive payment programs; and will create confusion among consumer users of the resulting performance data. Coordination of measure development for physicians and hospitals in the multiple overlapping areas of interest is needed to assure that, whenever possible, measures roll up (e.g., postsurgical infection rates should be calculated the same way for surgeons and hospitals); measures are setting-neutral (e.g., measures of pain management are the same for nursing home and home health patients); measures related to specific groups apply common conventions (e.g., paired process and outcome measures for patients with depression employ the same denominator population for each measure); and measures can be aggregated into composites or summary metrics that are meaningful to potential users of this information. Variability in Measure Specification, Testing and Maintenance. The quality of measures earlier endorsed by NQF and/or currently in use for public reporting (or in the pipeline) is highly variable. This is true with respect to the evidence bases for these measures, the level and precision of measure data element specification (necessary for reliable data collection), and the conduct of measure field-testing (if any). In addition, measure developers have exerted variable levels of effort to assure that their measures remain consistent with current evidence and practice (i.e., are maintained ). Some measure developers are highly skilled and experienced in measure development and testing, while others have had only modest levels of experience. Virtually all developers that produce measures intended for use in the public domain struggle with inadequate funding to support measure development and ongoing maintenance. 3. Insufficient Support for Measure Evaluation and Endorsement. In a relatively brief time period, the National Quality Forum has emerged as the Page 4 of 7

5 prime national evaluation and endorsement entity for performance measures. Most NQF measure evaluation and endorsement activities are currently supported by project-specific contracts and grants from a variety of public and private sector sources. While this type of funding is a great asset, it is also potentially problematic in that it may divert attention from measure development and evaluation efforts that are of greater importance to the public. The fact is that the lack of core, public sector support for NQF s measure evaluation and endorsement activities inhibits NQF s ability to establish an objective and relevant platform of standardized national measures. 4. The Challenging Transition to Electronic Health Records. Much of the future hope and promise for gathering and reporting performance measure results on a substantially broader scale than today is premised on the eventual wide adoption of EHRs by health care provider organizations and practitioners. The current rate of adoption is problematic in that regard, but an equally daunting problem is that few, if any, existing EHRs have demonstrated the ability to embed performance measures in a fashion that will consistently permit the accurate and reliable collection of performance data. This in fact is a high priority issue that is currently under consideration by the new Quality Committee of the American Health Information Community (AHIC). For EHRs to adequately support performance measurement and reporting, greater dialogue is needed between the performance measurement community and EHR suppliers. To permit ready incorporation of measures into EHRs, performance measure developers must follow common conventions (e.g., use standardized lists for denominator exclusions) and carefully specify measure data elements. Here again, the need for a performance measure coordinating center that could link with AHIC and the HIT community is evident. This would allow for closer alignment between performance measures and clinical decision-support. Potential Coordinating and Standard-Setting Roles for the National Quality Forum A Congressional mandate and a stable funding stream are needed to address the current gaps and weaknesses described above that stand between today s realities and the creation of a coherent national system for establishing performance measures. High quality standardized performance measures are a public need as well as a public good that benefits all stakeholders. The processes for developing, evaluating and promulgating standardized measures should be transparent, based on science and expert judgment, and free of vested interests. The National Quality Forum is, by orders of magnitude, the most logical and qualified entity to take on the challenges that have been framed herein. Congress should therefore designate the National Quality Forum as the National Coordinating and Standard-Setting Center for Performance Measures and provide adequate funding to close the four critical gaps identified in the current system. Page 5 of 7

6 1. National Priority and Goal-Setting Process. The National Quality Forum should assume a lead role in synthesizing evidence and periodically convening key stakeholders and other parties at interest for the purpose of establishing national priorities and goals as the basis for framing the going-forward performance measure development agenda. 2. Measure Development and Maintenance. The National Quality Forum should take the lead in defining measure development needs, identifying lead measure developers, channeling resources to these developers to permit them to fill those needs, and holding measure developers accountable for producing high quality measures that meet specified criteria and for maintaining these measures over time. 3. Measure Evaluation and Endorsement. The National Quality Forum should be provided sufficient unrestricted federal funding to permit it to carry out its proposed national priority-setting, measure development and maintenance, and measure evaluation and endorsement roles. 4. Transition to Electronic Health Records. The National Quality Forum should assume a coordinating role in linking measure developers, EHR vendors and the AHIC toward the goal of making the EHR the primary vehicle for performance measure data gathering and reporting. In sum, there is an urgent need for a credible, competent entity to take the lead in fulfilling the goal of establishing a coherent national system of performance measure development. Effective performance measurement is the linchpin for achieving some of this nation s highest health care priorities, whether these be sustained quality improvement, enhanced consumer decision-making capability, meaningful provider organization and practitioner accountability, or a more incentive-based payment system. The broad availability of high quality, standardized performance measures is today the Achilles heel of these efforts; tomorrow it must become their foundation. This will not happen without the federal designation and funding of a credible and competent leadership entity that can get this job done. That entity should be the National Quality Forum. About the National Quality Forum The mission of the National Quality Forum is to improve the quality of American health care by setting national priorities and goals for performance improvement, endorsing national consensus standards for measuring and publicly reporting on performance, and promoting the attainment of national goals through education and outreach programs. Founded in 1999 pursuant to the recommendations of the President s Advisory Commission on Consumer Protection and Quality, the National Quality Forum is uniquely positioned to serve as the proposed National Coordinating and Standard-Setting Center for Performance Measures. Page 6 of 7

7 Mission Alignment. The NQF s mission aligns directly with the responsibilities of the proposed Coordinating Center. Accountability to Consumers. One of NQF s founding principles is that consumers and those who purchase services on their behalf are to maintain a simple majority of at-large seats on the Governing Board. Standard-Setting Accountability. The National Quality Forum is a recognized standardsetting organization under the National Technology Transfer and Advancement Act. Public and Private Sector Partnership. The National Quality Forum is structured to assure public and private sector participation. The Governing Board includes permanent seats for the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Services, and the National Institutes of Health. Multi-Stakeholder Organization. The National Quality Forum is a multi-stakeholder organization in which 350 organizations representing consumers, purchasers, health care professionals, provider organizations, health systems, health insurers, suppliers, state governments, and federal agencies participate. Collaborator. The National Quality Forum works collaboratively with the multiple quality alliances and the many organizations involved in performance measure development. Experience. NQF has, to date, evaluated and endorsed over 200 performance measures, and many are in widespread use. The measures address physician performance and provider organization performance across a variety of health care settings and entities that provide acute care, nursing home care, ambulatory care, and home care, among other services. Page 7 of 7