[Federal Register Volume 77, Number 179 (Friday, September 14, 2012)]
[Notices]
[Pages 56920-56984]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2012-22379]
[[Page 56919]]
Vol. 77
Friday,
No. 179
September 14, 2012
Part II
Department of Health and Human Services
-----------------------------------------------------------------------
Secretarial Review and Publication of the Annual Report to Congress
Submitted by the Contracted Consensus-Based Entity Regarding
Performance Measurement; Notice
Federal Register / Vol. 77 , No. 179 / Friday, September 14, 2012 /
Notices
[[Page 56920]]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Secretarial Review and Publication of the Annual Report to
Congress Submitted by the Contracted Consensus-Based Entity Regarding
Performance Measurement
AGENCY: Office of the Secretary of Health and Human Services, HHS.
ACTION: Notice.
-----------------------------------------------------------------------
SUMMARY: This notice acknowledges the Secretary of the Department
of Health and Human Services' (HHS) receipt and review of the annual
report submitted to the Secretary and Congress by the contracted
consensus-based entity as mandated by section 1890(b)(5) of the Social
Security Act, as added by section 183 of the Medicare Improvements for
Patients and Providers Act of 2008 (MIPPA) and section 3014 of the
Affordable Care Act of 2010. The statute requires the Secretary to
publish the report in the Federal Register together with any comments
of the Secretary on the report not later than six months after
receiving the report. This notice fulfills those requirements.
FOR FURTHER INFORMATION CONTACT: Stephanie Mika (202) 260-6366.
I. Background
Rising health care costs coupled with the growing concern over the
level and variation in quality and efficiency in the provision of
health care raise important challenges for the United States. Section
183 of MIPPA also required the Secretary of the Department of Health
and Human Services (HHS) to contract with a consensus-based entity to
perform various duties with respect to health care performance
measurement. These activities support HHS's efforts to achieve value as
a purchaser of high-quality, patient-centered, and financially
sustainable health care. The statute mandates that the contract be
competitively awarded for a period of four years and may be renewed
under a subsequent competitive contracting process.
In January, 2009, a competitive contract was awarded by HHS to the
National Quality Forum (NQF) for a four-year period. The contract
specified that NQF should conduct its business in an open and
transparent manner, provide the opportunity for public comment and
ensure that membership fees do not pose a barrier to participation in
the scope of HHS's contract activities, if applicable.
The HHS four-year contract with NQF includes the following major
tasks:
Formulation of a National Strategy and Priorities for Health Care
Performance--NQF shall synthesize evidence and convene key stakeholders
on the formulation of an integrated national strategy and priorities
for health care performance measurement in all applicable settings. NQF
shall give priority to measures that: Address the health care provided
to patients with prevalent, high-cost chronic diseases; provide the
greatest potential for improving quality, efficiency and patient-
centered health care and may be implemented rapidly due to existing
evidence, standards of care or other reasons. NQF shall consider
measures that assist consumers and patients in making informed health
care decision; address health disparities across groups and areas; and
address the continuum of care across multiple providers, practitioners
and settings.
Implementation of a Consensus Process for Endorsement of Health
Care Quality Measures--NQF shall implement a consensus process for
endorsement of standardized health care performance measures which
shall consider whether measures are evidence-based, reliable, valid,
verifiable, relevant to enhanced health outcomes, actionable at the
caregiver level, feasible to collect and report, and responsive to
variations in patient characteristics such as health status, language
capabilities, race or ethnicity, and income level and is consistent
across types of providers including hospitals and physicians.
Maintenance of Consensus Endorsed Measures--NQF shall establish and
implement a maintenance process to ensure that endorsed measures are
updated (or retired if obsolete) as new evidence is developed.
Promotion of Electronic Health Records--NQF shall promote the
development and use of electronic health records that contain the
functionality for automated collection, aggregation, and transmission
of performance measurement information.
Focused Measure Development, Harmonization and Endorsement Efforts
to Fill Critical Gaps in Performance Measurement--NQF shall complete
targeted tasks to support performance measurement development,
harmonization, endorsement and/or gap analysis.
Development of a Public Web site for Project Documents--NQF shall
develop a public Web site to provide access to project documents and
processes. The HHS contract work is found at: http://www.qualityforum.org/projects/ongoing/hhs/.
Annual Report to Congress and the Secretary--Under section
1890(b)(5)(A) of the Act, by not later than March 1 of each year
(beginning with 2009, NQF shall submit to Congress and the Secretary of
HHS an annual report. The report shall contain a description of the
implementation of quality measurement initiatives under the Act and the
coordination of such initiatives with quality initiatives implemented
by other payers; a summary of activities and recommendations from the
national strategy and priorities for health care performance
measurement task; and a discussion of performance by NQF of the duties
required under the HHS contract. Section 1890(b)(5)(B) of the Social
Security Act requires the Secretarial review of the annual report to
Congress upon receipt and the publication of the report in the Federal
Register together with any Secretarial comments not later than 6 months
after receiving the report.
The first annual report covered the performance period of January
14, 2009 to February 28, 2009 or the first six weeks post contract
award. Given the short timeframe between award and the statutory
requirement for the submission of the first annual report, this first
report provided a brief summary of future plans. In March 2009, NQF
submitted the first annual report to Congress and the Secretary of HHS.
The Secretary published a notice in the Federal Register in compliance
with the statutory mandate for review and publication of the annual
report on September 10, 2009 (74 FR 46594).
In March 2010, NQF submitted to Congress and the Secretary the
second annual report covering the period of performance of March 1,
2009 through February 28, 2010. The second annual report was published
in the Federal Register on October 22, 2010 (75 FR 65340) to comply
with the statutorily required Secretarial review and publication.
In March 2011, NQF submitted the third annual report to Congress
and Secretary of HHS. This notice complies with the statutory
requirement for Secretarial review and publication of the third annual
report covering the period of performance of January 14, 2010 through
January 13, 2011. The third annual report was published in the Federal
Register on September 7, 2011 (76 FR 55474).
Affordable Care Act was signed into law on March 23, 2010. Section
3014 of this Act included a time-sensitive requirement for NQF to
provide input into the national priorities for consideration under for
the National Strategy for Quality for Improvement in
[[Page 56921]]
Healthcare. The NQF convened the National Priorities Partnership and
developed a consensus report on input to HHS on the development of the
National Quality Strategy.
Section 3014 of the Affordable Care Act also required NQF to:
convene multi-stakeholder groups to provide input on the selection of
quality measures, such as for use in reporting performance information
to the public; and transmit multi-stakeholder input to the Secretary.
It also amended the requirements for the Annual Report to include
identifying gaps in quality measures, including measures in the
priority areas identified by the Secretary under the national strategy
and areas in which evidence is insufficient to support evidence of
quality measures in priority areas. Activities required by the
Affordable Care Act will be carried out from 2010 throughout 2014.
In March 2012, NQF submitted its fourth annual report to the
Congress and the Secretary. The report covers the period of performance
of January 14, 2011 through January 13, 2012. This notice complies with
the statutory requirement for Secretarial review and publication of the
fourth NQF annual report.
II. March 2012--NQF Report to Congress and the HHS Secretary
Submitted in March 2012, the fourth annual report to Congress and
the Secretary spans the period of January 14, 2011 through January 13,
2012.
A copy of NQF's submission of the March 2012 annual report to
Congress and the Secretary of HHS can be found at: http://www.qualityforum.org/Publications/2012/03/2012_NQF_Report_to_Congress.aspx.
The 2012 NQF annual report is reproduced in section III of this
notice. This year's annual report has two sections. The first is
entitled 2012 NQF Report to Congress Changing Healthcare by the
Numbers. The second section is entitled NQF Report on Measure Gaps and
Inadequacies. Both sections were reviewed by the Secretary.
III. NQF March 2012 Annual Report
2012 NQF Report to Congress Changing Healthcare by the Numbers
Report to the Congress and the Secretary of the U.S. Department of
Health and Human Services, Covering the Period of January 14, 2011, to
January 13, 2012 Pursuant to Public Law 110-275 and Contract
HHSM-500-2009-00010C
Contents
Letter From William Roper and Janet Corrigan
Executive Summary
Building Consensus About What and How To Improve
Endorsing Measures for Use in Accountability and Performance
Improvement
Aligning Payment and Public Reporting Programs That Reward Value
National Quality Forum: Background
Bridging Consensus About Improvement Priorities and Approaches
National Priorities Partnership
NQF's Focus on Safety
Endorsing Measures and Developing Related Tools
NQF Endorsement in 2011
Culling the NQF Portfolio
Enhancing NQF Endorsement
The Information Technology Accelerant
Aligning Accountability Programs To Enhance Value
Growing Use of NQF-Endorsed Measures
Measure Application and Alignment
Achieving Results
Looking Forward
Endnotes
Appendix A: 2011 Accomplishments: January 14, 2011 to January 13,
2012
Appendix B: NQF Board and Leadership Staff
Appendix C: Overview of Consensus Development Process
Appendix D: Map Measure-Selection Criteria
Appendix E: NQF Membership
Appendix F: 2011 NQF Volunteer Leaders
Letter From William Roper and Janet Corrigan
Over the last decade, Members of Congress from both parties, as
well as federal and private-sector leaders, have increasingly supported
the use of standardized quality measures as part and parcel of a larger
healthcare value agenda. Agreed-upon strategies for improving value--
healthier individuals and communities, as well as better, lower-cost
care--include public reporting of standardized performance measures and
linking measures to payment.
Evidence of support for this agenda includes the fact that
approximately 85 percent of measures currently used in public programs
are endorsed by the National Quality Forum (NQF),\1\ as well as the
significant use of NQF-endorsed measures by private health plans and
employers. In addition, recent statutes--the 2008 Medicare Improvements
for Patients and Providers Act (MIPPA) and the 2010 Affordable Care Act
(ACA)--reinforce preferential use of NQF-endorsed measures on federal
healthcare Compare Web sites, and linkage of endorsed measures to
payment for clinicians, hospitals, nursing homes, health plans, and
other entities.
In 2011, this commitment to a value agenda was significantly
accelerated. Under the auspices of NQF, and in a historic first,
private-sector organizations voluntarily worked in a more coordinated
and collaborative fashion with each other and with the public sector to
forge consensus about how to further this accountability environment.
Specifically, innovations in convening and rulemaking facilitated the
private sector bringing its real-world experience to inform guidance to
the Department of Health and Human Services (HHS) on implementing the
first-ever National Quality Strategy (NQS), and provided advice on
selecting the best measures for use across an array of federal health
programs. Forward-thinking leaders--including those on Capitol Hill and
within HHS--understand that the public and private sectors working
independently will not yield improvements quickly or comprehensively
enough in our unorganized and complex healthcare system.
We are grateful to Congress, HHS, and private-sector leaders for
their vision and tenacity in designing and advancing this ambitious
value agenda, and for the progress we collectively are making against
it each and every day. These advancements are made possible because of
the ever-expanding number of organizations and individuals who are
committing themselves to work in partnership, including our colleagues
at HHS; the more than 450 institutional members of NQF; the hundreds of
experts who volunteer to serve on NQF committees; the NQF staff; and
the many, many organizations that constitute the quality movement. We
are privileged to work at the intersection of so many committed and
diverse organizations that are increasingly rowing in the same
direction to improve both our nation's health and healthcare for the
benefit of the American public.
We are changing healthcare by the numbers.
William L. Roper, MD, MPH
Chair, Board of Directors
National Quality Forum
Janet M. Corrigan, Ph.D., MBA
President and Chief Executive Officer
National Quality Forum
Executive Summary
The U.S. healthcare system is among the most innovative in the
world and patients with very serious and/or unusual conditions are
particularly appreciative of the range of therapies, interventions, and
clinical talent it offers to treat them and restore them to health.
That said, it is also one of the most fragmented, unorganized, and
uncoordinated systems as compared to its counterparts in the
industrialized world--which contributes to less-than-
[[Page 56922]]
optimal quality outcomes, serious patient safety problems, and very
high per-capita costs.2, 3, 4 Consequently, Members of
Congress, business leaders from small and large companies, patients,
physicians, nurses, and many others have come to the conclusion that
Americans are not deriving enough value for the substantial dollars
they spend.
Important strides have been made toward improving this value
proposition over the last decade, starting with the sine qua non of
using standardized performance measures to assess ``how we are doing''
on an array of healthcare quality and cost dimensions, making the
measure results public, and then linking those results to provider
payment. And while establishing this accountability environment is
critical foundational work, it is not sufficient for achieving the kind
of substantial improvements that the National Quality Strategy (NQS)
envisions. Released by the Department of Health and Human Services
(HHS) in March 2011 and supported by public- and private-sector
healthcare leaders, the NQS is built around three compelling aims
focused on healthy people and communities, better care, and more
affordable care. To achieve these ambitious aims also will take
fundamental reform of care delivery and payment, which, while underway,
will still require time, effort, and perseverance to realize.
That said, the accountability environment's basic infrastructure is
moving into place. A key lesson learned in constructing it is that
neither the public nor private sectors, nor any single stakeholder, can
meaningfully shape it on their own. Healthcare is too large and
complex, with too many interrelated parts, for a go-it-alone strategy
to be fully effective. Recent actions of healthcare leaders demonstrate
that they understand that sustainable solutions to our nation's
healthcare challenges are ones that all stakeholders embrace. Over the
last year, significant progress has been made toward forging a shared
sense of priorities for improvement; an agreed-upon way to set,
continuously enhance, and implement strategies to achieve these
priorities; and standardized methods for measuring progress along the
way. Without such agreements, competing strategies and a plethora of
near-identical measures run the risk of whipsawing providers and
overburdening them with redundant and sometimes conflicting reporting
requirements. In addition, such an environment can confuse consumers
who increasingly seek to better inform themselves as they play a more
active role in healthcare decision-making.
Congress, wisely understanding this need for a quality
infrastructure and more public-private collaboration, passed two
statutes that included this notion, and directed HHS to work with a
consensus-based entity to act as a key convener and measurement
standard setter. These statutes include the 2008 Medicare Improvements
for Patients and Providers Act (MIPPA) (Pub. L. 110-275) and the 2010
Patient Protection and Affordable Care Act (ACA) (Pub. L. 111-148). HHS
awarded contracts related to the consensus-based entity to the National
Quality Forum (NQF).
NQF has prepared this third Annual Report to Congress which covers
highlights of work related to these statutes conducted under federal
contract between January 14, 2011 and January 13, 2012. See appendix A
for a complete listing of deliverables worked on and completed during
the contract year.
Building Consensus About What and How To Improve
In the fall of 2010, as HHS was developing the first-ever NQS, the
National Priorities Partnership (NPP), convened by NQF, was asked to
provide initial input on the overarching aims and priority areas and
published a report. Subsequently, in response to a second request from
HHS, NPP identified three goals for each of the NQS six priorities in a
second report, along with appropriate performance measures, and
``strategic opportunities'' to accelerate progress. These opportunities
require leveraging the reach of the many public and private stakeholder
groups participating in NPP, which balances the interests of consumers,
purchasers, health plans, clinicians, providers, federal agency
leaders, community alliances, states, quality organizations, and
suppliers. In 2011, NPP focused further on enhancing patient safety,
one of the six NQS priorities and a very important focus for HHS. More
specifically, NPP worked collaboratively with HHS on its Partnership
for Patients initiative, through hosting quarterly meetings and an
interactive webinar series, which brought tools and ideas for reducing
patient harm to nearly 10,000 front-line clinicians, hospitals, and
other stakeholders across the country. Moving forward in 2012, NPP will
draw on the real-world experience of its partners to develop
implementation strategies, likely targeting patient safety in maternity
care and readmissions.
Endorsing Measures for Use in Accountability and Performance
Improvement
NQF completed 11 endorsement projects during the course of the
contract year--using both the NQS priorities that cross conditions and
leading health conditions with respect to prevalence and cost as a way
to prioritize its efforts. In total, NQF committees evaluated 353
submitted measures and endorsed 170 new measures--or 48 percent of
those submitted. While the number of measures endorsed is considerably
higher than in previous years, the endorsement rate is lower due to the
enhanced rigor of the review criteria. At the same time, NQF placed
emphasis on reducing providers' reporting burden by harmonizing
specifications related to similar measures.
Currently, the portfolio of NQF-endorsed measures includes more
than 700 measures, of which 30 percent assess patient outcomes and
experience with care. Considerable progress also has been made in
specifying measures for use with electronic health records. NQF worked
with 18 measure developers to create eMeasure specifications for 113
existing endorsed measures, and released an initial and updated Measure
Authoring Tool (MAT). The re-tooled measures and MAT are innovations
that enable the field to get substantially closer to having electronic
health records with the capacity to capture and report performance
information during routine care.
Aligning Payment and Public Reporting Programs That Reward Value
A significant proportion--about 85 percent--of the measures used in
federal programs are NQF-endorsed. Further, NQF-endorsed measures are
used extensively by private health plans, state governments, and
others. Such alignment can simultaneously reduce reporting burdens for
providers and accelerate improvement because of the common signals that
payers send. The NQF-convened Measure Applications Partnership (MAP),
launched in the spring of 2011, fostered further alignment with its
series of three performance measurement coordination strategy reports:
Clinician Performance Measurement, Dual-Eligible Beneficiaries, and
Healthcare-Acquired Conditions and Readmissions Across Public and
Private Payers. As a part of these reports, MAP also developed a
framework and criteria to guide the selection of the best measures for
use in numerous payment and public reporting
[[Page 56923]]
programs. Building on these reports, MAP then provided pre-rulemaking
guidance to HHS, including input on measure sets pertaining to 17 HHS
programs, as well as strategies for enhancing consistency and
minimizing reporting burden across federal programs and between public-
and private-sector efforts. Leaders from nine different HHS agencies
are actively participating in MAP.
This advice from MAP--provided many months in advance of relevant
rules--represents a true innovation in rulemaking, with the public and
private sectors now having forums for substantive back-and-forth
dialogue that cuts across program silos, and a unique opportunity to
build a shared perspective and consensus about measure selection.
Measures related to care coordination--essential to making care more
patient centered--are an object lesson for what is possible with pre-
rulemaking convening and endorsement. More specifically, MAP
recommended that an existing care transitions measure focused on
hospitals also be used in other settings, and suggested a broadening of
a readmission measure to include all ages and applicability to
additional kinds of providers. MAP also advised the Center for Medicare
& Medicaid Services (CMS) to require reporting of medication
reconciliation measures at the time of transition between settings. As
it turns out, NQF has already endorsed measures for medication
reconciliation, readmission, and care transitions that apply to
additional settings and populations so these measures can move right
into other federal programs.
Taken together, the reports are important stepping stones for MAP
as the Partnership works on a comprehensive measurement strategy it
will recommend to guide HHS measure selection for federal programs in
the coming years. This strategy will be informed by the Partnership's
in-depth understanding of current measures and their use in relevant
programs, opportunities for potential coordination and integration,
growing collaboration across the public and private sectors, and a
vision for the future.
Numbers are an essential guidepost for gauging healthcare
performance, and measures may be a powerful motivator of change when
paired with public reporting and payment. But alone, they cannot drive
achievement of the value agenda. Rather, implementation of innovative
measures needs to go hand-in-glove with fundamental redesign of
delivery and payment systems to achieve the NQS' three, interconnected
aims. And while local communities are changing the way care is
organized and paid for to break down existing silos, facilitate
integration and coordination of care, and connect healthcare to other
sectors (e.g., employment, education), such innovations have not yet
swept the country. When they do, and are coupled with accountability
strategies embraced by the public and private sectors, we will be able
to achieve our goals of healthier people and communities, and better,
less-costly patient care. We will have then changed healthcare by
design and by the numbers.
1 National Quality Forum: Background
More than a decade after their publication, the Institute of
Medicine's (IOM's) landmark Quality Chasm and To Err is Human reports
still resonate: Our healthcare system continues to fall short on
quality, safety, and affordability. That said, recent years have seen a
re-energized commitment to improving care and constraining healthcare
costs. HHS, NQF, and the increasing number of private-sector
organizations that constitute the quality movement are at the center of
that resurgence.
Established in 1999 as the standard-setting organization for
healthcare performance measures, NQF today has a much-broadened mission
to:
Build consensus on national priorities and goals for
performance improvement, and work in partnership with the public and
private sectors to achieve them.
Endorse and maintain best-in-class standards for measuring
and publicly reporting on healthcare performance quality.
Promote the attainment of national goals and the use of
standardized measures through education and outreach programs.
NQF is governed by a 27-member Board of Directors (see Appendix B)
from a diverse array of public- and private-sector organizations. A
majority of seats on the board is held by consumers, employers, and
other organizations that purchase healthcare services on consumers'
behalf. In 2011, NQF convened hundreds of experts across every
stakeholder group on its priority-setting, measure-review, and measure-
selection committees--individuals who volunteered their time, talents,
experience, and insights (see Appendix F). NQF also directly reached
some 10,000 frontline clinicians, hospitals, and others with
educational programming via webinars. And its endorsed performance
standards touched the care delivered to millions of patients every day.
In recent years, the number and variety of NQF-endorsed measures
has greatly expanded. More than 700 NQF-endorsed measures now address
most settings of care, conditions, and types of providers. The measures
portfolio includes clinical process measures, patient experience of
care, the actual outcomes of care, the costs and resources that go into
providing care, as well as select structural measures. The portfolio is
being enhanced with advanced measures, such as functional outcome and
crosscutting care-coordination measures. At the same time, the NQF
portfolio is being carefully culled to retire measures that no longer
meet the more rigorous criteria. In the last year alone, 353 measures
were submitted to NQF and 170, or nearly half, were endorsed. This
endorsement rate--or ratio of submitted-to-endorsed measures--reflects
NQF's efforts to systematically raise the bar on performance
measurement, even as it seeks to reduce the burden on providers by
eliminating duplicative measures.
To be NQF endorsed, a measure must be a process or outcome that is
important to measure and report, be scientifically acceptable, be
feasible to collect, and provide useful results. NQF conducts an eight-
step, consensus-based process that has been continually improved over a
decade (see Appendix C). Review committees are comprised of multiple
stakeholders; consumer organizations are equal partners with clinicians
and other stakeholders throughout the process. There is a strong
commitment to transparency and NQF invites public participation at
every step, ranging from nominations for committees, to decisions on
specific measures. Endorsed measures are re-evaluated every three years
to ensure their actual use and usefulness in the field and their
continuing relevance with current science, and to determine whether
they continue to represent the best in class.
Measures included in the NQF portfolio are developed and maintained
by about 65 different organizations. The following gives a sense of the
range of organizations NQF works with: CMS, the National Committee on
Quality Assurance (NCQA), the American Medical Association-Physician
Consortium for Performance Improvement (AMA PCPI), Ingenix, the Joint
Commission, American College of Surgeons (ACS), Bridges to Excellence,
Cleveland Clinic, Minnesota Community Measurement, and Pharmacy Quality
Alliance.
In recognition of its skill in building consensus across multiple
stakeholders in the measure-endorsement realm, NQF
[[Page 56924]]
has been asked to convene diverse committees to advise the public and
private sectors on priorities for improvement, related implementation
strategies, and selection of measures to both drive these strategies
and gauge results. The NQF-convened NPP and MAP and their published
reports are tangible outcomes of this work. An equally important
outcome of these partnerships is the ongoing alignment across
stakeholder groups and across public- and private-sector leaders about
what levers to use to both improve healthcare performance and move the
delivery system to be more patient centered.
NQF has been fortunate to have received support from the federal
government for over 10 years, with more substantial support starting in
2008 when federal leaders strongly committed themselves to designing
and implementing a value agenda. More specifically:
MIPPA has provided NQF with $10 million annually over a
four-year period starting in 2009. These funds--awarded to NQF through
a competitive process--are supporting the organization's efforts to
identify priority areas for improvement, endorse and update related
performance measures, foster the transition to an electronic
environment, and report annually to Congress on the status and progress
to date of this effort.
ACA has provided NQF with support of about $10 million,
starting in 2011. Under section 3014, Congress directed HHS to contract
with ``the consensus-based entity under contract'' to provide multi-
stakeholder input into the NQS, as well as advice to the Secretary of
HHS on the selection of measures for use in various quality programs
that utilize the federal rulemaking process for measure selection. With
federal leadership and support, as well as the support of foundations
and over 450 NQF member organizations, much has been collectively
accomplished since NQF's founding in 1999. With more substantial and
predictable support from the federal government over the last three
years, and an enhanced commitment on the part of the public and private
sectors to work together, the basic infrastructure for performance
measurement is moving into place and our ability to shape and further
an environment of accountability has grown. NQF's accomplishments
during 2011 will be described against that backdrop.
Sidebar 1--Working With NQF Helped Spur Rapid Evolution of
Ophthalmology Measures
There are many intangible benefits from the endorsement activities
supported under the HHS contract. One of these is that it provides
valuable input to measure developers which helps focus measure
development resources on important gap areas. The efforts of the
American Academy of Ophthalmology (AAO) are a case in point.
As early as the 1980s, and before many other specialty societies,
AAO developed ``preferred practice patterns'' to provide practice
guidance for ophthalmologists. These guidelines proved to be a solid
foundation to draw from when, in 2006, AAO began developing related
quality measures for quality improvement feedback and public reporting
purposes. Over the last five years, AAO has developed ever more
sophisticated performance measures--evolving from process, to outcome,
to functional status--and credits involvement with the NQF review
process as an important catalyst in this evolution.
More specifically:
AAO--in collaboration with the AMA-PCPI--first worked to
develop process measures focused on eye-care issues such as diabetic
retinopathy (damage to the eye's retina as a result of long-term
diabetes), and performance of optic nerve exams in primary open-angle
glaucoma (chronic, progressive optic-nerve damage) patients.
Recognizing that measures that evaluate actual results of
care are more critical to improving quality, NQF encouraged AAO to
shift its focus to developing clinical outcome measures. As a result,
NQF later endorsed a measure focused on reducing glaucoma patients' eye
pressure (which can lead to optic-nerve damage or blindness) by 15
percent.
More outcome measures were later developed and endorsed
under the HHS-funded outcomes project, focusing on issues such as
complications within 30 days following cataract surgery, as well as 20/
40 or better visual acuity within 90 days of cataract surgery.
Recently, the NQF board has approved measures related to
patient functional status, attempting to measure improvement in
patients' visual functional status and their overall satisfaction
within 90 days following cataract surgery. These measures are currently
under NQF review, and have been included in the 2012 Physician Quality
Reporting System (PQRS) measure set.
Dr. Flora Lum, executive director of AAO's H. Dunbar Hoskins Jr., MD
Center for Quality Eye Care, noted that NQF's ability to bring patient
and consumer perspectives to the Steering Committee responsible for
evaluating measures has been invaluable over the years. AAO's efforts
to advance healthcare quality continue, with the organization now
striving to develop appropriateness-of-care measures.
The evolution of AAO's measures over a short time period is
noteworthy and the information that results from the measures provides
physicians with multi-faceted feedback about the care they deliver.
Ideally, such information is available in rapid-response reports, with
educational interventions to help facilitate improvements at the
practice level, and over time, so that ophthalmologists and patients
can gauge progress. As AAO has gone on this journey to develop ever-
increasingly sophisticated and meaningful measures, NQF has been
pleased to be a part of it. [End of Sidebar 1]
Sidebar 2--Resource-Use Measures: Critical to the Value Agenda
U.S. healthcare per-capita spending is greater than that in any
other country, yet it has not resulted in better health for Americans.
With costs increasing beyond annual inflation, spending is largely
focused on treating acute and chronic illnesses rather than prevention
and health promotion.
Deriving more value from health spending is predicated on having
both quality and cost (or resource use) information. To date, limited
information about resource use exists. CMS and many measure developers
are working to change that, and in 2009, NQF was tasked with further
defining resource-use measures and identifying important attributes to
consider when evaluating them. NQF also endorsed its first-ever
resource-use measures during the 2011 contract year.
As defined by NQF, resource-use measures are comparable measures of
actual dollars or standardized units of resources applied to the care
given to a specific population or event--such as a specific diagnosis,
procedure, or type of medical encounter. The endorsed measures:
Relative Resource Use for People with Diabetes
Relative Resource Use for People with Cardiovascular
Conditions
Total Resource Use Population-Based Per-Member Per-Month
(PMPM) Index
Total Cost of Care Population-Based PMPM Index
[[Page 56925]]
``The endorsement of standardized measures of healthcare resource use
and cost fills a huge void that has kept the nation from measuring the
value of healthcare in a consistent way,'' said Steering Committee
member Dolores Yanagihara, director, pay for performance, at the
Integrated Healthcare Association. ``That said, it is a complex
process, both technically and from an accountability standpoint. The
measures recommended for endorsement give us a broader picture of
healthcare--overall and related to specific conditions.'' [End of
Sidebar 2]
2 Bridging Consensus About Improvement Priorities and Approaches
Released by HHS in March 2011, the country's NQS focuses the public
and private sectors on an inspiring set of three, interconnected aims--
better care, more affordable care, and healthier people and
communities--as well as six related priority areas (see Figure 1).
While the field has long targeted improving clinical care, the NQS
gives significant, equal heft to the notion of health/wellbeing and
affordability.
[GRAPHIC] [TIFF OMITTED] TN14SE12.000
The NQS provides a critical framework for the efforts of the
multiple-stakeholder committees convened by NQF. These efforts range
from discussions at the highest, most conceptual levels about a three-
to-five-year measurement strategy to undergird the evolving value
agenda; to committees working in a new measurement area and developing
consensus about what and how to measure; to those simultaneously
enhancing and culling a set of measures in an established area, while
considering their larger context within the NQF-endorsed measurement
portfolio.
National Priorities Partnership
Development of the landmark NQS was informed by the collective
input of the NQF-convened National Priorities Partnership (NPP), a
collaboration of 51 public- and private-sector organizations uniquely
qualified to represent the array of stakeholders needed to improve the
nation's healthcare system. As the NQS was being formulated, HHS sought
multi-stakeholder input from NPP on its aims and priorities. After
publication of the NQS in March 2011, HHS again reached out to NQF to
convene NPP to provide input on further specifying goals, measures, and
implementation pathways to move the national strategy and related
priorities forward, drawing upon the real-world experience of its
stakeholder participants.
The NPP recommendations are captured in a follow-up report to the
HHS Secretary, Priorities for the National Quality Strategy, published
in September 2011. This second report identifies goals and measure
concepts that address the three NQS aims and six priorities
simultaneously. For example, there are suggestions for goals and
measurement areas related to care coordination that cut across clinical
conditions. This would encourage better, more integrated care delivery,
enhanced health outcomes, and fewer wasted resources. The NPP report
also acknowledges that successful implementation of NQS-related goals
and measures are predicated on strategic and technical measure
alignment--or agreement--across various levels of accountability in our
healthcare system. This starts at the most granular level--the patient
and physician--and moves in a linked chain across a family of measures
and levels of increasing aggregation. Without agreement about strategic
direction and concordance on measure selection, a predictable cacophony
results, frustrating clinicians and confusing consumers. The
cholesterol-control example (Figure 2) provides an illustration of a
family of measures with linkages across levels and illustrates this
crucial strategy of alignment. Further, these NQF-endorsed measures are
included in HHS's newly launched and broad-based Million
[[Page 56926]]
Hearts Campaign--a public-private initiative that aims to prevent one
million heart attacks and strokes in five years.
In addition to NPP's consultative role as it relates to the NQS,
NPP has served as a catalyst in developing implementation strategies--
working across diverse stakeholder groups to spur collective action--
focused on improving patient safety and reducing patient harm. Such a
focus also can reduce costs, with the IOM estimating that decreasing
healthcare-associated infections (HAIs), complications, and unnecessary
readmissions by 10 to 20 percent could result in $2.4 billion to $4.9
billion annual savings for the U.S. healthcare system.\5\
[GRAPHIC] [TIFF OMITTED] TN14SE12.001
NQF's Focus on Safety
In 2011, NQF's work in the safety realm spanned updating of
measures and serious reportable events (SREs), a recommended approach
for further aligning public- and private-sector patient-safety
measurement strategies, and development of implementation strategies in
support of HHS's Partnership for Patients Initiative.
Partnership for Patients is engaging stakeholders from the private
and public sectors to reduce all-cause harm (i.e., all forms of harm
that can affect patients) and hospital readmissions. More specifically,
NPP partnered with the Partnership for Patients to host 11 webinars
that attracted about 10,000 frontline clinicians, hospitals, and others
across the country and provided education, tools, resources, and
insight on key safety issues. These webinars ranged from big-picture
interventions (e.g., how to get your Board on board when it comes to
improving patient safety), to those with a more laser focus on clinical
teams (e.g., reducing surgical-site infections [SSIs]). Nearly 90
percent of webinar participants, who came from every region of the
country, reported that they would be able to implement something new in
their institutions as a result of this novel public-private
programming. Moving forward in 2012, NPP is developing two action
pathways, which its multiple partners can implement and spread. These
pathways are focused on the health of mothers and babies by reducing
elective deliveries before 39 weeks, and reducing avoidable admissions
and re-admissions across all settings of care. These represent 2 of the
10 areas Partnership for Patients is pursuing to achieve its global
safety and harm-reduction goals. Reaching these goals also will
substantially reduce costs.
In addition, MAP released a report, Coordination Strategy for
Healthcare-Acquired Conditions and Readmissions Across Public and
Private Payers, in October 2011, detailing the ways in which public and
private healthcare providers can align performance measurement to
enhance patient safety. Specifically, the report makes three
recommendations: (1) There needs to be a national set of core safety
measures applicable to all patients; (2) Data need to be collected on
all patients to inform these national core safety measures; and (3)
Public and private entities need to coordinate their efforts to make
care safer. MAP's recent pre-rulemaking report further emphasizes the
importance of safety measures by supporting their inclusion in federal
public reporting and performance-based payment programs, and MAP will
focus on alignment of core safety measures across programs in 2012.
With respect to measure review, NQF endorsed numerous patient-safety
measures, including healthcare-associated infections (HAIs), which now
address long-term, acute-care and rehabilitation hospitals, and
radiation-safety measures, to name a few.
NQF also updated its list of SREs, a compilation of serious,
harmful, and largely--if not entirely--preventable patient-safety
events, designed to help the healthcare field assess, measure, and
report performance in providing safe care. In the 2011 update, the
events were broadened in focus to explicitly include hospitals, office-
based practices, ambulatory surgery centers, and skilled nursing
facilities to reflect the various settings in which patients receive
care and could experience harm. Based on input from users, the
implementation guidance for each event was expanded, and a glossary was
added to facilitate
[[Page 56927]]
uniformity in reporting of the events. The list includes wrong-site
surgery; death or serious injury associated with medication errors or
unsafe blood products; and failure to follow up on lab, pathology, or
radiology test results. Public and private purchasers have drawn
heavily from the SRE list in identifying healthcare-associated
conditions for use in payment and reporting programs. (See Sidebar 3.)
Sidebar 3--NQF and Patient Safety
Patient-Safety Measures
NQF's inventory of endorsed measures includes more than 100
patient-safety measures, with several focused specifically on
healthcare-associated infections or HAIs. Preventing HAIs has become a
national priority for public health and patient safety. To date, 27
states are requiring public reporting of certain HAIs. Further, the NQS
has identified safer care as one of its primary aims and, in 2013,
hospitals' annual Medicare payment updates will be tied to submission
of infection data, including central line-associated bloodstream
infections and surgical-site infections (SSIs).
In this past year, NQF endorsed four additional patient-safety
measures focused on HAIs, including a successfully harmonized measure
from the American College of Surgeons and the Centers for Disease
Control and Prevention focused on SSIs, and updates of existing HAIs
addressing urinary tract infections and bloodstream infections. These
efforts were completed under federal contract.
Serious Reportable Events
Preventing adverse events in healthcare is also central to NQF's
patient-safety efforts. To ensure that all patients are protected from
injury while receiving care, NQF has developed and endorsed a set of
serious reportable events (SREs). This set is a compilation of serious,
harmful, and largely--if not entirely preventable--patient safety
events, designed to help the healthcare field assess, measure, and
report performance in providing safe care. The SREs focus on the
following areas:
Surgical or invasive-procedure events
Product or device events
Patient-protection events
Care-management events
Environmental events
Radiologic events
Potential criminal events
Originally envisioned as a set of events that would form the basis
for a national state-based reporting system, the SREs continue to serve
that purpose. To date, 26 states and the District of Columbia have
enacted reporting systems to help stakeholders identify and learn from
SREs. The majority of those states incorporate at least some portion of
NQF's list to help align reporting efforts and encourage learning
across healthcare systems. [End of Sidebar 3]
Finally, NQF launched a project in 2011 that will leverage health
IT data to address patient safety and quality concerns associated with
medical devices, such as pumps used to deliver intravenous medications
at home. This project, which continues in 2012, will determine what
data needs to be collected and shared to improve quality and safety
related to devices. It also will focus on ways to identify and report
adverse events associated with the use of such devices.
3 Endorsing Measures and Developing Related Tools
With its extensive evaluation (see Sidebar 4) and multi-stakeholder
input, NQF is recognized as a voluntary consensus standards-setting
organization under the National Technology Transfer and Advancement Act
of 1995. In addition, NQF adheres to the Office of Management and
Budget's formal definition of consensus.\6\ Consequently, NQF-endorsed
measures have special legal standing allowing federal agencies to
readily adopt them into their programs, which they have done at a
striking rate. About 85 percent of measures in federal health programs
are currently NQF-endorsed, including those that apply to hospitals,
clinicians, nursing homes, patient-centered medical homes, and many
other settings.
In 2011, NQF completed 11 endorsement projects--reviewing 353
submitted measures and endorsing 170, or 48 percent. Enhancements to
the endorsement process over the last year included strengthening its
rigor by requiring testing of measures prior to measure review,
initiation of a project to reduce endorsement cycle time, integration
of review of existing measures with new measures to ensure
harmonization and best-in-class assessment, and creation of an
expedited review process to respond to important regulatory or
legislative requests. In addition, NQF worked with 18 measure
developers to update 113 electronic measures, or eMeasures, so they
could be more readily collected through EHRs, and introduced and
updated tools to respectively facilitate development and collection of
eMeasures.
Sidebar 4--What does it take for a measure to get endorsed?
With the enhanced rigor of NQF's endorsement criteria, only about
50 percent of submitted measures were endorsed this past year.
The leading reason that measures do not pass the grade is failure
to meet the ``must pass'' importance-to-measure-and-report criterion.
This includes being able to demonstrate that the proposed measure or
related data is focused on a high-impact health goal or priority; there
is less-than-optimal performance; and there is strong scientific
evidence for the measure, with respect to quality, quantity, and
consistency. NQF expert committees rate the evidence based on specific
guidance.
The second ``must pass'' criterion is scientific acceptability of
measure properties. In other words, do the data from testing the
measure show that it is reliable and valid and precisely specified?
Expert committees look for moderate-to-high ratings so they are
confident the measure results are reliably consistent and can be
compared across providers and analyzed longitudinally. Other important
criteria include usability and feasibility--assessing whether intended
audiences can understand the results and find them helpful for
decision-making and quality improvement. The criteria also consider
whether providers can collect data without undue burden. See Appendix C
for more detail. [End of Sidebar 4]
NQF Endorsement in 2011
The overall framework used to guide the NQF measures portfolio is
multi-dimensional. It includes the NQS crosscutting priorities, as well
as leading health conditions with respect to prevalence and cost that
affect an array of populations. Figure 3 provides a snapshot of how the
current NQF-endorsed measures portfolio stacks up against the NQS, with
the percentages reflecting the proportion of NQF-endorsed measures
against the six priorities. Some measures are counted in multiple
priority areas. The chart shows gaps in emerging measurement areas,
including patient-family centered care, measures related to community
health and wellbeing, and affordability. These gaps require significant
foundational work to understand what to focus on for measurement and
how to best overcome technical barriers. NQF has undertaken this
foundational work over the last year, and has started to bring in
measures in all of these areas for endorsement review.
[[Page 56928]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.002
The 170 measures newly endorsed by NQF in 2011 include many outcome
measures; measures that focus on populations previously under-
represented, including pregnant women and children; a number of
patient-safety measures--given the importance of reducing patient harm;
measures in new areas that fill important gaps, such as cost (resource
use); as well as the updating of measures related to highly prevalent
conditions, (e.g., cardiac and surgical care). More specifically:
Outcome Measures
NQF has made great strides over the past year to endorse measures
that evaluate results of care, particularly in the patient-safety,
nursing-home, and surgical-care areas. Outcome measures are considered
most relevant to patients and providers looking for improved quality
and patient experience, as opposed to measures that assess process or
structure. Examples of outcome measures endorsed in 2011 include
potentially avoidable complications for select conditions (i.e.,
stroke, pneumonia), remission of symptoms in patients with depression,
and patient experience in nursing homes and dialysis facilities.
Patient-Safety Measures
Long a focus of NQF, these new patient-safety measures span
settings and types of conditions. They include measures focused on HAIs
(urinary tract, central-line-associated bloodstream, and SSIs), and
measures focused on issues such as standardized data collection and
reporting of radiation doses.
Maternal and Child-Health Measures
These populations have been underrepresented in performance
measurement. NQF has worked to fill these gaps through two endorsement
projects over the past year--child health, and perinatal and
reproductive health. Child-health measures focus on important
screenings and access to care, including immunizations, hearing
assessments, and well-child visits. Other measures address population
health outcomes, including the number of school days missed due to
illness and birth outcomes. Proposed perinatal measures (this project
is still underway) address procedures such as cesarean sections and
elective delivery prior to 39 weeks.
New and Existing Measurement Areas
NQF reviewed measures related to resource use, both those related
to conditions (e.g., diabetes and cardiovascular disease), and those
related more to global resource use. Endorsement projects in 2011 also
focused on reviewing existing measurement areas for high-prevalence
conditions or areas (palliative care and end-of-life care,
cardiovascular disease and kidney disease), adding new measures, and
retiring others as the expert committees saw fit. More specifically,
NQF endorsed or maintained measures focused on optimal vascular care,
complications or death for specific surgical procedures, and assessment
of post-dialysis weight by nephrologists for kidney disease patients.
Although NQF has made considerable progress in endorsing outcome
measures--which constitute about 30 percent of the portfolio--
differences exist with respect to outcome and process measures across
conditions, which is illustrated in Figure 4. For example, there are
more outcome measures for surgery and perinatal care than for mental
health and cancer care. Also, HAIs are reflected under surgery, not
infectious disease.
[[Page 56929]]
When NQF begins to address a new measurement area, the relevant
expert committee will often start by developing a framework report to
guide its future measurement review. These reports may include a scan
of existing measures, a discussion about where there are key
opportunities for improvement, and consideration of potential technical
barriers. For example, NQF is developing a population health-
measurement framework aimed at aligning delivery system, public health,
and community stakeholder efforts to improve health outcomes and the
social determinants of health. Historically, there has been little
coordination across these sectors. NQF is also developing a patient-
centric measurement framework for assessing the efficiency of care
provided to individuals with multiple chronic conditions. This report
will inform NQF's future efforts to endorse measures that apply
respectively to population health and care for people who have more
than one chronic condition.
[GRAPHIC] [TIFF OMITTED] TN14SE12.003
Culling the NQF Portfolio
A key part of NQF's review process is focusing on endorsing best-
in-class measures and eliminating similar or even identical measures
that create confusion and burden across clinical settings and
providers. This alignment of very similar measures--or measure
harmonization--can reduce reporting burden for providers and enhance
comparability of results for patients and payers, thereby reducing
confusion and enabling decision-making. The harmonization of the
surgical site infection measures from the Centers for Disease Control
and Prevention and the ACS is a case in point (see Sidebar 5). Further,
NQF's maintenance process retires existing measures that no longer meet
the higher endorsement bar, thereby further culling the portfolio.
Sidebar 5--Harmonizing Surgical-Site Infection Measures
As part of NQF's federally funded Patient-Safety Measures project,
similar and competing surgical-site infection (SSI) measures from the
Centers for Disease Control and Prevention (CDC) and the American
College of Surgeons (ACS) were reviewed. The CDC SSI measure has been
in use since 2005; the ACS measure since 2004.
As a result of NQF member and public comments, and requests by the
Steering Committee, the developers worked with NQF support to harmonize
these two competing approaches to measurement. The result is a newly
harmonized SSI measure, which is currently focused on abdominal
hysterectomies and colon surgeries. CDC and ACS will jointly maintain
the measure. The two organizations have also committed to developing
harmonized measures for other procedures and will incorporate them into
the combined SSI measure.
Notably, CMS has selected this harmonized measure for inclusion in
the 2012 final rule of the Inpatient Prospective Payment System (IPPS).
Dr. Clifford Ko, director of ACS's National Surgical Quality
Improvement Program, was directly involved in this effort. Dr. Ko noted
that the resulting measure--Harmonized Procedure-Specific Surgical-Site
Infection Outcome Measure--will now be available to literally thousands
of hospitals that want to measure and improve their surgical-site
infection rates.
Dr. Daniel Pollock, surveillance branch chief in CDC's Division of
Healthcare Quality Promotion, says CMS' decision to include this
measure will significantly increase SSI reporting rates in hospitals
throughout the country. With increased reporting, providers will have
more opportunities to identify areas for improvement. In addition,
patients and payers will have SSI rate information when they are
choosing between hospitals in a community.
While both Drs. Ko and Clifford noted that some characteristics of
the original measures may be diminished or lost,
[[Page 56930]]
they agreed that harmonized measures help eliminate the confusion non-
comparable measures create and that, ultimately, providers, payers, and
the public benefit. [End of Sidebar 5]
The recent Cardiovascular Project illustrates how NQF expert
committees now consider new measures against existing endorsed
measures. Using the measure evaluation criteria and guidance on
evaluating related and competing measures, the Cardiovascular Committee
reviewed proposed new measures and those undergoing maintenance,
focusing on measures that address the broadest patient population or
settings, while avoiding duplication whenever possible. Based on this
rigorous vetting, 39 out of 65 measures (7 new and 32 undergoing
maintenance) were endorsed (see Figure 5). When all is said and done,
between 2010 and 2011 this represents approximately 13 percent fewer
NQF-endorsed cardiovascular measures in this project.
[GRAPHIC] [TIFF OMITTED] TN14SE12.004
Enhancing NQF Endorsement
As NQF's measures portfolio evolves, so too does its endorsement
process. In 2011, NQF enhanced the rigor of its process by requiring
that measures be tested before they are reviewed. This requirement now
ensures that expert committees have crucial information about measure
reliability and validity as they consider endorsement. In addition, NQF
also established an approach that added greater consistency to review
of the underlying evidence for measures, and created an expedited
endorsement pathway to be responsive to key regulatory or legislative
requests. Finally, NQF embarked upon a number of efforts to enhance
effectiveness of the review process, including a lean effort to further
reduce endorsement cycle time. This effort, which got underway in late
2011, maps each of the steps of the endorsement process to drive out
redundancy, waste, and ultimately costs for measure developers, NQF,
and HHS.
The Information Technology Accelerant
A future healthcare system that fully embraces health information
technology (HIT) will allow for performance data to be collected in
real time across settings, integrated, and regularly fed back to
providers to inform practice and decision-making. It also will allow
performance information to be made accessible in aggregated, de-
identified, and timely public reports for payers and patients. Recent
federal efforts--to simultaneously wire ambulatory practices and
hospitals and assess providers' ``meaningful use'' of electronic health
records (EHRs)--have been important steps on the path to a future HIT-
enabled system.
Such milestones have been augmented by a number of NQF efforts that
are helping the field move to a common electronic data platform that
allows for the collection of more clinically relevant and actionable
performance-measurement data. These HIT-enabled environments hold out
the promise of reducing reporting burden for clinicians and other
providers, and enhancing the precision and comparability of results.
In the past year, NQF has worked with measure developers to re-
specify paper-based measures for EHRs, and developed tools that allow
measure developers to marshal the building blocks necessary for their
successful implementation. In both cases, these efforts broke new
ground. To the best of NQF's knowledge, they have never been
attempted--or accomplished--before. More specifically:
E-Measures
In 2010, at the request of HHS, NQF worked with 18 measure
developers to re-tool 113 existing, endorsed measures for the
electronic environment--that is,
[[Page 56931]]
to develop electronic specifications that allow an EHR to calculate the
measure--so they could be included in the Meaningful Use program. These
eMeasures were further updated and enhanced in 2011. The measure
stewards and NQF found that re-tooling measures for a new (electronic)
platform was not a simple, straightforward matter; rather it involved
the stewards re-conceptualizing each of the measures, with the support
of NQF.
Quality Data Model (QDM)
This information model provides measure developers with a first-
ever ``grammar,'' which defines data elements. These data elements can
then be efficiently assembled and re-assembled into performance
measures to be read by EHRs. Work on the QDM began in 2007, with
funding from the Agency for Healthcare Research and Quality (AHRQ). In
2011, the third version of the QDM was released, which includes data
elements to enable development of measures in gap areas, including
patient/consumer engagement and disparities, as well as new methods of
data capture and use. In summary, this effort makes a substantial
contribution toward being able to more readily leverage existing
electronic health-record data to produce clinically relevant, advanced
measures.
Measure Authoring Tool (MAT)
This non-proprietary, web-based tool makes it easier and more
efficient for measure developers to specify, submit, and maintain
electronic measures, or eMeasures. Introduced in 2011, there are now
more than 35 organizations using this tool for eMeasure development.
Work that began in 2011 and carries over into 2012 includes a
project focused on sharing data across settings, convening a forum for
stakeholders to share best practices related to implementation of
eMeasures, and a project that will leverage health IT data to address
patient safety and quality concerns associated with medical devices,
which was described previously. More specifically, with respect to the
first two projects:
HIT Systems To Support Care Coordination Measurement: Data Sources and
Readiness
This project is analyzing the current process for identifying and
sharing data on significant patient factors, planned interventions, and
expected outcomes (care goals) to support quality measurement related
to transitions of care. It will recommend a critical path forward with
specific action steps that the government can take to enable electronic
measurement around care plans.
E-Measure Collaborative
The eMeasure Collaborative, a public forum convened by NQF, is
bringing together stakeholders from across the quality enterprise. The
eMeasure Collaborative's goal is to promote shared learning and advance
knowledge and best practices related to the development and
implementation of eMeasures.
4 Aligning Accountability Programs To Enhance Value
At the request of HHS, NQF commissioned RAND Health to conduct an
initial evaluation to better understand who is using NQF-endorsed
measures and for what purposes. The RAND studies--coupled with NQF's
own internal tracking efforts to understand measure use--have helped to
provide some important context for HHS, NQF, and the NQF-convened MAP
discussions.
Growing Use of NQF-Endorsed Measures
RAND interviews of key stakeholders using NQF-endorsed measures and
online research across approximately 75 varied organizations found that
nearly all used NQF-endorsed measures, although the extent varied as
did the particular measures selected for use. Further, the study showed
that most organizations used endorsed measures in quality-improvement
efforts, followed closely by public reporting, then payment programs.
The 2011 study also found that there is a strong preference to use NQF-
endorsed measures where they exist because they are vetted, evidence-
based, and seen as more credible within the provider community
NQF's additional research outside of the HHS contract indicates
that about 90 percent of the portfolio of NQF-endorsed measures is
being used in varied programs across the public and private sectors.
Figure 6 is an estimation of the use of NQF-endorsed measures by:
federal programs; private payers such as health plans and employers;
states; and an amalgamation of other key stakeholders such as national
registries, accrediting and specialty board certifying organizations,
and community alliances. The gold-colored, hatched, and dotted areas on
the chart represent alignment in use of the same measures by key
sectors--specifically the overlap between private payers (health plans
and employers) and federal programs, and the overlap between state and
federal efforts. Alignment holds out the promise of reducing data-
collection burden for providers and associated costs, while
simultaneously accelerating improvement by sending the same message
about where providers should be focusing improvement resources.
[[Page 56932]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.005
Overall use of NQF-endorsed measures by the federal government is
high--about 85 percent of measures used in federal programs are NQF-
endorsed. Yet the proportion of NQF-endorsed measures in use by various
federal programs does differ. Sometimes it is a matter of timing. For
example, the federal government has recently moved some non-endorsed
measures into the Physician Quality Reporting System (PQRS) to better
address the range of physician specialties. NQF is poised to quickly
review such measures.
States also are heavy users of NQF-endorsed measures, in part due
to federal programs that encourage or require standardized reporting at
the state level, such as AHRQ's Health Care Utilization Project (HCUP),
CDC measures and surveys, CHIPRA, and Medicaid. For example, 81 percent
of CHIPRA measures and 88 percent of core adult Medicaid measures are
NQF-endorsed. In the safety realm, more than half of states and the
District of Columbia have implemented reporting systems for SREs, as
well as reporting of key patient-safety indicators such as bloodstream
and SSI measures.
Sidebar 7--AF4Q: Alignment at the Community Level
At the community level it is more challenging to get a
comprehensive picture of use of NQF-endorsed measures. That said,
leading multi-stakeholder alliances in communities across the country
use NQF-endorsed measures, including the Robert Wood Johnson
Foundation's Aligning Forces for Quality (AF4Q) alliances. To support
community interest in aligning the measures they are using, a recent
analysis conducted by NQF outside of the HHS contract has shown that at
least 170 NQF-endorsed measures are being used in one or more of the 16
AF4Q alliances. In addition, NQF endorsed measures are being used by
many of the Chartered Value Exchange (CVE) collaboratives, the
federally-funded Beacon communities, other communities and a number of
states. Given that there is no national requirement to use standardized
measures at this level, communities/states have shown leadership in
adopting such measures into their local programs.
[[Page 56933]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.006
The Robert Wood Johnson Foundation's Aligning Forces for Quality
initiative seeks to increase the quality of healthcare and reduce
racial and ethnic disparities in 16 diverse communities--with the
involvement and collaborative efforts of physicians, patients, consumer
groups, hospitals, health plans, and others.
The U.S. Agency for Healthcare Research and Quality (AHRQ) supports
24 Learning Network Chartered Value Exchanges. The CVEs are
experimenting with new ways to bring healthcare stakeholders together
to collect data and improve the quality of care.
The federal Beacon Community Cooperative Agreement program provides
17 communities with funding to improve quality, cost-efficiency, and
population health using electronic health records and other health
information technology tools to collect and analyze clinical data. The
program's goal is to demonstrate the ability of health IT to transform
local healthcare systems.
i Geographic reach of these efforts varies, e.g., state-wide, county-
specific [End of Sidebar 7]
Measure Application and Alignment
Convened by NQF in the spring of 2011, the Measure Applications
Partnership (MAP) is a public-private partnership made up of 60
organizations representing major stakeholder groups, 9 federal
agencies, and 40 subject-matter experts. It was established to provide
HHS with thoughtful, pre-rulemaking input about which performance
measures to use in public reporting and payment within and across 17
federal programs. Simultaneously, MAP is informing the thinking and
decisions of private-sector leaders with respect to their measure-
selection strategies.
Federal Agencies Participating in Map
Agency for Healthcare Research and Quality
Centers for Disease Control and Prevention
Centers for Medicare & Medicaid Services
Health and Human Services' Office on Disability
Health Resources and Services Administration
Office of the National Coordinator for Health Information
Technology
Office of Personnel Management
Substance Abuse and Mental Health Services Administration
Veterans Health Administration
MAP represents an important innovation in the regulatory process
made possible by ACA statute. In contrast to traditional federal
rulemaking--where there are limited, unidirectional forums for input
before draft rules are issued and no forums that cross programmatic
areas--MAP enables public- and private-sector leaders to work together
on creating a measurement strategy and implementation plan that is
crosscutting and coordinated across settings of care; federal, state,
and private programs; levels of measurement analysis; payer type; and
points in time. This is not an overnight prospect, but important,
unprecedented steps in the direction of strategic alignment were taken.
In 2011, MAP consisted of four programmatic-oriented workgroups--
clinician, hospital, LTC/PAC, and dual-eligible beneficiaries--and an
ad-hoc safety workgroup, each of which makes recommendations to the MAP
Coordinating Committee. This independent committee then integrates and
aligns these recommendations across the four programmatic areas--which
represent 17 different federal programs--and advises HHS directly. (See
Sidebar 8)
Sidebar 8--Measure Applications Partnership Workgroup Leadership
MAP Coordinating Committee Co-Chairs
George Isham, MD, MS, Chief Health Officer, Health Partners
Elizabeth McGlynn, Ph.D., MPP, Director Center of Effectiveness and
[[Page 56934]]
Safety Research (CESR), Kaiser Permanente
MAP Advisory Workgroups
Ad-Hoc Safety Workgroup:
Frank G. Opelka, MD FACS, Chair, Vice Chancellor for Clinical Affairs
and Professor of Surgery, Louisiana State University
Clinician Workgroup:
Mark McClellan, MD, Ph.D., Chair, Director, Engelberg Center for Health
Care Reform, Senior Fellow, Economic Studies, Brookings Institution,
Leonard D. Schaeffer Chair in Health Policy Studies
Dual-Eligible Beneficiaries Workgroup:
Alice R. Lind, MPH, BSN, Chair, Senior Clinical Officer, Center for
Health Care Strategies
Hospital Workgroup:
Frank G. Opelka, MD FACS, Chair, Vice Chancellor for Clinical Affairs
and Professor of Surgery, Louisiana State University
Post-Acute/Long-Term Care (PAC/LTC) Workgroup:
Carol Raphael, MPA, Chair, President and Chief Executive Officer,
Visiting Nurse Service of New York [End of Sidebar 8]
In the fall of 2011, and in advance of future measure-selection
recommendations, MAP issued reports offering advice to HHS about how
the agency might better coordinate its measure strategies as it relates
to efforts focused on improving safety and clinician performance. Its
reports include MAP Coordination Strategy for Clinician Performance
Measurement and MAP Coordination Strategy for Healthcare-Acquired
Conditions and Readmissions Across Public and Private Payers. In 2011,
MAP also released the first of two reports focusing on dual-eligible
beneficiaries who are enrolled in both Medicare and Medicaid programs:
MAP Strategic Approach to Performance Measurement for Dual-Eligible
Beneficiaries. Despite many of these individuals being the sickest and
poorest patients enrolled in any federal program, not to mention among
the most expensive, there has been little effort to date to use
measurement as a tool to improve their care. For more detail about
NQF's efforts to address vulnerable populations, see sidebar 6.
Sidebar 6--NQF Focuses on Vulnerable Populations
Vulnerable populations--from the disabled, to veterans, to special
needs kids, to low-income individuals and racial/ethnic minorities,
among others--often require a different and frequently higher level of
care. Over the past year, NQF has taken on two major projects with a
prime focus on such vulnerable individuals--The Measure Applications
Partnership (MAP) Strategic Report: Performance Measurement for Dual
Eligible Beneficiaries Interim Report to HHS, and measurement work
focused on disparities in healthcare.
The interim MAP report provides multi-stakeholder input on
performance measures to assess and improve the quality of care
delivered to individuals who are eligible for both Medicare and
Medicaid (dual-eligible). An estimated 8.9 million individuals are
classified as dual-eligible, a population that includes many of the
poorest and sickest individuals in our communities. This particular
population frequently experiences fragmented care and accounts for a
disproportionate share of total healthcare costs.
In its initial phase of work, MAP has developed a strategic
approach to performance measurement and identified opportunities to
promote significant improvement in the quality of care provided to
these vulnerable populations. The core of the strategic approach is
composed of:
A vision for high-quality care. Centered on the needs and
preferences of an individual and his or her loved ones, this relies on
holistic supports to maximize function and quality of life.
Guiding principles. These include desired effects, measurement
design, and data.
A discussion of high-need subgroups. MAP deliberations suggested
that there is not yet an established taxonomy for classifying subgroups
of the dual-eligible population. MAP members observed that combinations
of particular risk factors lead to high levels of need in an additive
or synergistic manner.
High-leverage opportunities for improvement through measurement.
MAP reached consensus on five areas where measurement could drive
significant positive change, including quality of life, care
coordination, screening and assessment, mental health and substance
use, and structural measures of coordination between Medicare and
Medicaid benefits.
In addition to the four primary elements, MAP also considered
issues related to data sources and program alignment as inputs to the
strategic approach. MAP will next consider gaps in currently available
measures and may propose new measure concepts for development. A final
report with MAP's input on improving the quality of care delivered to
dual-eligible beneficiaries, including recommendations related to
measures, is due to HHS on June 1, 2012.
NQF's healthcare disparities measurement efforts are multi-faceted.
For example, measure developers are required to submit measure results
stratified by race and ethnicity at the time of measure evaluation. NQF
has also worked to endorse measures that address vulnerable
populations, including measures used for the Children's Health
Insurance and Reauthorization Act (CHIPRA) and Medicaid, as well as
measures that fulfill important needs for vulnerable populations,
including frail elders, pregnant women, children, and those who suffer
from mental illness. With respect to already endorsed measures, NQF is
working to identify measures across all settings that should be
routinely stratified by race and ethnicity in order to identify
conditions and populations that require targeted improvement efforts to
improve quality and eliminate disparities. [End of Sidebar 6]
MAP's initial pre-rulemaking report published on February 1, 2012,
and based on the consensus of 60 organizations:
Recommends that 40 percent of the measures CMS was
considering move into federal programs targeting clinicians, hospitals,
dual-eligible beneficiaries, and PAC/LTC settings via rules issued in
2012, with another 15 percent targeted for future consideration after
further development, testing, and feasibility issues are worked out.
MAP did not support inclusion of about 45 percent of other measures
proposed by CMS. CMS submitted a large number of measures and measure
concepts to get early, detailed feedback about them from key
stakeholders. Consequently, many of the measures submitted did not have
enough information to guide MAP measure evaluation and selection. See
Appendix D for the criteria MAP used to guide measure selection.
Expresses clear preference for use of NQF-endorsed
measures and feedback loops Nearly 87 percent of measures MAP supported
for inclusion are currently endorsed by NQF, and many more are likely
eligible for expedited review. That said, assessing the qualitative and
quantitative impact of NQF-endorsed measures in the field would provide
new and important information for future MAP analyses and decision-
making.
Considers how to further align measures across programs
and with the private sector with the goal of more targeted,
interrelated sets of measures that are reported by different kinds of
providers, in different settings and
[[Page 56935]]
sectors, and across time. A good example is care-coordination measures
contained within existing programs--care transitions, readmissions, and
medication reconciliation--which MAP recommends be applied to
additional kinds of providers, types of settings, and, consequently, to
span and be integrated across federal programs. See Figure 7 to get a
more detailed sense for MAP's crosscutting recommendations for care
coordination.
Lays out guiding principles for a future three-to-five-
year measurement strategy that supports movement towards a healthcare
system that enhances value for patients, communities, and those that
pay the bills on their behalf. In this future 21st century system,
priority is placed on measures that drive the system toward meeting the
NQS; measurement is person- rather than clinician- or setting-focused;
and measures span settings, time, and types of clinicians. Person-
centered measurement provides information about what matters to
patients (e.g., ``Will I be able to run after I recover from knee
surgery?'') and measures that are specific to patient populations or
care over time, (e.g., ``Did I get the care and support needed to
manage my diabetes so that I did not lose my vision or my mobility?'').
This kind of measurement is predicated on a redesigned delivery and
payment system, and an HIT-enabled environment that facilitates both
coordination and integration of care for a range of patients across the
continuum.
Figure 7--Aligning Care Coordination Measures Across Programs
----------------------------------------------------------------------------------------------------------------
Post-acute care/long-
Clinician Hospital term care
----------------------------------------------------------------------------------------------------------------
Care Transitions..................... Support CTM-3 (NQF Support immediate Support CTM-3 if
0228) if inclusion of CTM-3 successfully
successfully measure and urge for developed, tested, and
developed, tested, and it to be included in endorsed in PAC-LTC
endorsed at the the existing HCAHPS settings.
clinician level. survey.
Support several Identify specific
discharge planning measure for further
measures (i.e., NQF exploration for its
0338, 0557, use in PAC-LTC
0558). settings (i.e., NQF
0326, 0647).
Readmissions......................... Readmission measures Support the inclusion Identify avoidable
are a priority measure of both a readmission admissions/
gap and serve as a measure that crosses readmissions (both
proxy for care conditions and hospital and ER) as
coordination. readmission measures priority measure gaps.
that are condition-
specific.
Medication Reconciliation............ Support inclusion of Recognize the Identify potential
measures that can be importance of measures for further
utilized in a health medication exploration for its
IT environment reconciliation upon use across all PAC-LTC
including medication both admission and settings (i.e., NQF
reconciliation measure discharge, 0097).
(NQF 0097). particularly with the
dual eligible
beneficiaries and
psychiatric
populations.
----------------------------------------------------------------------------------------------------------------
The MAP proposed guiding principles support the direction of many
public- and private-sector leaders who are innovating to move the
nation's care delivery system towards more organization and shared
accountability for patient welfare, community health, and stewardship
of scarce resources. Where appropriate, they are encouraging
transitioning from solo-physician practices to actual and virtual
patient-centered medical homes, from stand-alone hospitals to those
working collaboratively with an array of providers in an integrated
delivery system or Accountable Care Organization (ACOs), and from
single-specialty to multi-specialty physician groups working more
closely with public health oriented organizations. Figure 8 details
some key principles to guide measure selection, measurement tactics,
the providers the measures are focused on, and the related federal
programs.
Implementation of more advanced measures will be possible once care
is more organized and integrated, payment crosses settings and
providers, and HIT infrastructure is widely in place. Advanced measures
could include how well patient care is coordinated between primary and
specialty care and across specialists; whether patients are free of
pain and can return to work, school, and other daily obligations; the
degree to which patient preferences are incorporated into care
decisions; and whether recommended care was appropriate in the first
place and delivered cost effectively. Progress is being made as it
relates to the development and implementation of such advanced
measures, but is predicated on more integrated payment and delivery
systems, as well as robust, common electronic data platforms.
[[Page 56936]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.007
Achieving Results
Those working to improve performance of the healthcare system are
impatient for results, which take time to demonstrate and are
influenced by many factors beyond measurement. Nevertheless, there are
promising examples, particularly for hospitals and health plans that
have been collecting, reporting, and acting on performance measures for
a number of years. The case studies included in this section of the
report were selected to provide illustrative examples of different
kinds of programs and providers using NQF-endorsed measures (although
they are efforts conducted outside of the federal contracts.) Taken
together, and reflecting upon NQF's accomplishments over the last year,
the case studies provide a clear sense that there is forward momentum,
as well as a growing commitment on the part of healthcare leaders to
enhance healthcare value for patients, communities, and payers.
Eight Years of Hospital Reporting Show Results
In 2002, three hospital industry associations demonstrated
leadership by joining with HHS, The Joint Commission, consumer
organizations, and other stakeholders to create a more unified approach
to reporting hospital performance information to the public. They
launched the Hospital Quality Initiative--later re-named the Hospital
Quality Alliance (HQA)--and defined its role as:
Identifying measures for reporting that are meaningful,
relevant and understood by consumers;
Rallying hospitals to participate in the initiative and
act on the performance results; and
Aligning stakeholders to reduce redundant and wasteful
data collection and reporting.
From the beginning, HQA recommended NQF-endorsed measures because
of the organization's transparent, rigorous multi-stakeholder consensus
process and strong evidence-based approach to endorsement.
In 2003, performance results for over 400 hospitals were reported
on the CMS Web site for the first time. A year later, CMS began
penalizing hospitals financially if they did not report to CMS the same
performance information they were required to send to The Joint
Commission to maintain hospital accreditation. Between 2003 and 2004,
the number of hospitals reporting their results to CMS tripled--from
over 400 to more than 1,400 hospitals. In 2005, CMS launched Hospital
Compare. Today, over 4,000 hospitals simultaneously report performance
data to CMS and The Joint Commission, and the number of measures
collected has steadily increased. In 2012, The Joint Commission will
incorporate hospital performance into its accreditation determinations
for the first time.
Performance results improved steadily over the last eight years. A
recent analysis of hospitals shows marked improvement based on NQF-
endorsed measures between 2002 and 2009.\7\ More specifically, in 2002,
about 20 percent of hospitals exceeded 90 percent performance on 22 key
measures; by 2009 that percentage had climbed significantly to 86
percent. Key NQF-endorsed measures include measures related to heart
attack and heart failure care, surgical care, children's asthma care,
and pneumonia care, among others.
This tight alignment between HQA, CMS and The Joint Commission
regarding use and reporting of NQF-endorsed measures is a likely
contributor to hospitals improving their performance over time. At the
end of 2011, HQA decided to close its doors--noting that it had
accomplished what it had set out to do: establishing a unified approach
to collection and public reporting of hospital performance information.
HQA also acknowledged that recommendations for measure selection going
forward would be best left to the NQF-convened MAP, which is
constituted to look across all federal
[[Page 56937]]
programs to foster alignment and a clear strategic direction for
measurement use.
Linking Quality Measurement to Payment Reform
Blue Cross Blue Shield Massachusetts' Alternative Quality Contract
In January 2009, Blue Cross Blue Shield of Massachusetts (BCBS)
piloted the Alternative Quality Contract, a pay-for-performance model
directly linking payment to meeting quality and cost benchmarks. The
private-payer program provides financial bonuses to participating
provider organizations such as multispecialty groups, independent
practice associations, and physician-hospital organizations that stay
within a specified annual budget and meet clinical quality targets. The
budget takes into account the entire spectrum of care, ranging from
inpatient and outpatient services to long-term care and prescription
drug costs.
Performance was evaluated on the quality of care delivered in
several clinical settings based on NQF-endorsed measures. More
specifically:
Seven participating clinical groups were eligible for bonus
payments as high as five percent based on 32 NQF-endorsed ambulatory
and office-based quality measures. Measures included and focused on
conditions and procedures such as diabetes testing and controlled LDL-C
levels; breast, cervical, and colorectal cancer screenings; and patient
experience with accessing and understanding care options.
Providers were eligible for another five percent bonus payment
based on 32 NQF-endorsed hospital-based measures. These measures
focused on surgical site and wound infections, in-hospital mortality
rates, and patient satisfaction communicating with doctors and nurses.
Initial performance evaluations showed that across the board,
provider groups delivered care within the scope of their budgets and
performed well on clinical quality measures, allowing them to receive
financial rewards of up to 10 percent of the total per-member per-month
payments.\8\
The results illustrate that programs like the Alternative Quality
Contract can offer providers strong incentives to control healthcare
spending across the continuum while continuing to provide high-quality
care. This idea is in line with recent policy proposals to design
payment systems that reward high-quality, efficient, and integrated
care.
National Priorities Focus North Carolina Hospitals
The North Carolina Center for Hospital Quality and Patient Safety
(NCQC) was established by the North Carolina Hospital Association
(NCHA) in 2004. The two organizations worked in partnership to conduct
quality improvement collaborative projects across the state for about
four years, but progress had grown stagnant. With North Carolina
ranking as only the 35th healthiest state, NCQC's director embraced the
NPP's 2008 National Priorities and Goals report recommendations as a
way to focus, spur action, and benchmark North Carolina hospitals
against national goals. Subsequent NPP reports have built on this first
report.
The NCQC targeted much of its initial efforts on patient safety,
made sure that frontline staff understood how their actions related to
the hospital-wide improvement goals, and focused on both culture change
and building up quality improvement skills. The Central Line-Associated
Bloodstream Infection (CLABSI) Collaborative, which involved 40 ICUs,
was particularly successful. Using a separate intervention program that
sought to learn from mistakes and improve safety, the CLABSI
Collaborative achieved a 46 percent reduction in central-line
infections over the 18-month time period. These results translated into
saving approximately 18 lives (using a 15 percent fatality rate) and
saving $4.5 million (using $40,000 as the extra cost to a hospital for
a CLABSI) across 40 hospitals.\9\
It is important to note that although many individual hospitals had
success, not all hospitals in North Carolina participated, and the
state rate of CLABSIs did not decrease as much as NCQC had hoped. To
address this, NCQC launched a Phase 2 of the initiative to continue its
focus on reducing central-line infections, using the NQF-endorsed
CLABSIs measure as a way to guide progress and benchmark themselves
nationally. The NCQC has stated that it is too early to tell if
alignment with the NPP priorities will enable it to meet its own
performance goals, but does acknowledge measureable and exciting
progress against benchmarks it set.
Performance of Thoracic Surgeons Published in Consumer Reports
More than two decades ago, The Society of Thoracic Surgeons (STS)
launched the Adult Cardiac Surgery Database to track and improve
surgical quality. It is the largest cardiothoracic surgery outcomes and
quality improvement program in the world, containing more than 4.5
million surgical records and representing approximately 94 percent of
all adult cardiac surgery centers throughout the U.S.
Twenty plus years after the launch of its database, STS made the
bold decision to offer participating surgical groups the option of
voluntarily reporting their performance data in Consumer Reports. More
specifically, Consumer Reports began publicly reporting heart surgery
ratings at the surgical group level starting in 2010--including
survival rates, complication rates, and other key NQF-endorsed
measures. These ratings are now available on a bi-yearly basis.
A variety of factors influenced STS's decision to begin publicly
reporting surgical performance, including the organization's vast
experience with collecting and analyzing performance measures; a desire
to leverage public reporting to further accelerate improvements in
thoracic surgeon performance; and wanting to exhibit leadership in an
environment of enhanced accountability.
Doris Peter, manager, Consumer Reports' Health Ratings Center,
notes that reaction to the reports has been very positive from cardiac
surgery groups and consumers alike. Peter noted that the first time
STS's data was published in Consumer Reports, there were 20 million web
impressions on the ratings. Consumer Reports' readership is 8 million.
Due to this success, the subsequent September 2011 release made the
cover of Consumer Reports print edition. To date, 36 percent of STS
surgery groups are participating in the Consumer Reports ratings, a 65
percent increase from the first release.
Looking Forward
A dozen years in existence, NQF has been able to make particularly
strong strides in the last three years with the support of federal
funding stemming from MIPPA and ACA, building very much upon the strong
collaborative relationship that has been established between NQF, its
hundreds of private sector partners, and HHS. At a high level, results
over these three years include:
The ability of NQF to now set and implement a multi-year
plan for measure endorsement that is cognizant of addressing gaps and
focused on implementing a vision for where advanced measurement is
heading in a 21st century healthcare system. Over the three years, NQF
endorsed 184 measures under the federal contracts, and completed
maintenance of 136
[[Page 56938]]
previously endorsed measures. Currently, there are 233 measures under
maintenance review, another 157 measures undergoing updates to
specifications, and 43 measures having testing results reviewed. These
efforts involved approximately 65 measure developers and hundreds of
experts who volunteered their time on review committees. In addition,
NQF has developed tools that allow measure developers to more readily
create and implement eMeasures so that providers can collect more
meaningful and actionable clinical data that is both comparable for
public reporting and valid for payment purposes.
Broad recognition that NQF is an effective and trusted
convener of public- and private-sector leaders--reflected in the
organization's multi-stakeholder membership, established processes for
achieving consensus, and its commitment to scientific evidence and
transparency. This recognition has translated into requests that NQF-
convened committees advise HHS on the first-ever NQS and related
measurement strategy, as well as detailed measure-selection
recommendations. NQF deliverables to HHS have been in the form of
reports. Less perceptible perhaps is the growing consensus between
scores of public- and private-sector leaders about how to collaborate
to improve performance, which is translating into alignment around
quality-improvement priorities and measure use.
Looking ahead, NQF and the broader quality movement are at an
exciting juncture. A robust measurement infrastructure is moving into
place, and increasingly there is a shared commitment about what to
improve and what measures to use in the process of doing so. Over the
next couple of years, NQF will be:
Putting the patient first by facilitating efforts that
move the field toward a focus on patient-oriented as opposed to
clinician-oriented measurement. Implementation of patient reported
measures--including those that address experience of care, functional
status, patient reported outcomes and care coordination--can help put
the patient at the center of care.
Helping drive waste out of the system by focusing on
bringing more cost/resource use measures through NQF endorsement and
understanding in more detail how existing NQF endorsed quality/safety
measures--including readmission, medication reconciliation and care
coordination measures--can contribute to a more cost-efficient system.
Facilitating a future measurement vision by supporting
efforts of the NPP and MAP Partnerships to develop a 3-5 year
comprehensive measurement strategy--with broad and strong backing from
multiple stakeholders--to recommend to HHS. The intent is that this
strategy will cross settings and levels of care, as well as types of
clinicians, and will in essence drive a strategic plan for payers that
moves the needle with respect to the NQS's six priorities.
Bringing the public and private sectors closer together by
further strengthening collaboration and deepening their commitment to
the value agenda, further aligning their respective measurement
strategies to reduce redundant data collection, and dramatically
accelerate improvements in performance of the U.S. healthcare system.
In the coming years, the country should be in the position of
realizing many benefits from these efforts to change healthcare by the
numbers.
Endnotes
1 Federal use of NQF-endorsed measures is based on an initial
analysis by NQF during the Fall of 2011.
2 The Commonwealth Fund, Why Not the Best: Results from the National
Scorecard on U.S. Health System Performance, 2008, New York,
NY:Commonwealth Fund, 2008. Available at www.commonwealthfund.org/
Publications/Fund-Reports/2008/Jul/Why-Not_the_Best_Results-from-
the-National-Scorecard-on-U-S_Health-System-Performance_2008.aspx.
Last accessed February 2012.
3 Bodenheimer T, High and rising health care costs. Part 1: seeking
an explanation, Ann Intern Med,2005;142(10):847-854.
4 Bodenheimer T, Fernandez A, High and rising health care costs.
Part 4: can costs be controlled while preserving quality? Ann Intern
Med,2005;143(1): 26-31.
5 Institute of Medicine (IOM), Roundtable on Value & Science-Driven
Health Care--The Healthcare Imperative: Lowering Costs and Improving
Outcomes: Workshop Series Summary, Washington, DC: National
Academies Press; 2010. Available at www.iom.edu/Activities/Quality/VSRT.aspx. Last accessed January 2012.
6 The White House, U.S. Office of Management and Budget (OMB).
Circular No. A-119, February 10, 1998, Washington, DC:OMB; 1998.
Available at www.whitehouse.gov/omb/circulars_a119/. Last accessed
January 2012.
7 Chassin MR, Loeb JM, Schmaltz SP et al., Accountability measures--
using measurement to promote quality improvement, New Engl J Med,
2010;363(7):683-688. Available at www.nejm.org/doi/full/10.1056/NEJMsb1002320. Last accessed February 2012.
8 Song Z. Safran DG, Landon BE et al., Health care spending and
quality in year 1 of the Alternative Quality Contract, New Engl J
Med, 2011;365(10):909-918. Available at www.nejm.org/doi/full/10.1056/NEJMsa1101416. Last accessed February 2012.
9 National Quality Forum (NQF), Evaluation of the National
Priorities Partnership, Washington, DC:NQF, 2011. Available at
www.qualityforum.org/SettingPriorities/EvaluationoftheNational_Priorities_Partnership.aspx. Last accessed February 2012.
Appendix A: 2011 Accomplishments: January 14, 2011 to January 13, 2012
----------------------------------------------------------------------------------------------------------------
Status (as of 1/13/ Notes/scheduled or
Description Output 12) actual completion date
----------------------------------------------------------------------------------------------------------------
I. Priorities, Principles, and Coordination Strategies
----------------------------------------------------------------------------------------------------------------
Provision of input on priorities Input to the Secretary of Completed............. September 1, 2011.
for the NQS. Health and Human Services
on Priorities for the
National Quality Strategy;
final written report of
Partnership and
Subcommittee meeting
deliberations and
recommendations.
MAP report recommending measures Measure Applications Completed............. October 1, 2011.
for use in the improvement of Partnership Coordination
physician performance. Strategy for Clinician
Performance Measurement;
final report including MAP
Coordinating Committee
recommendations.
[[Page 56939]]
MAP report recommending measures Measure Applications Completed............. October 1, 2011.
that address the quality issues Partnership Strategic
identified for dual-eligible Approach to Performance
beneficiaries. Measurement for Dual-
Eligible Beneficiaries;
interim report including
MAP Coordinating Committee
recommendations.
MAP report recommending measures to Measure Applications Completed............. October 1, 2011.
be used by private and public Partnership Coordination
payers to reduce readmissions and Strategy for Healthcare-
healthcare-acquired conditions Acquired Conditions and
(HACs). Readmissions Across Public
and Private Payers; final
report including
recommendations regarding
the optimal approach for
coordinating readmission
and HAC measures.
Measures for use in quality Measure Applications In progress........... Completed February
reporting programs under Medicare. Partnership Pre-Rulemaking 2012 after close of
Report: Input on Measures reporting year.
Under Consideration by HHS
for 2012 Rulemaking.
MAP report recommending measures Final report including In progress........... June 1, 2012.
that address the quality issues potential new performance
identified for dual-eligible measures to fill gaps in
beneficiaries. measurement for dual-
eligible beneficiaries.
----------------------------------------------------------------------------------------------------------------
II. Measure Endorsement
----------------------------------------------------------------------------------------------------------------
Cardiovascular measures and Two-phase project to Completed............. 39 measures endorsed
maintenance review. endorse new cardiovascular in January 2012.
measures and conduct
maintenance on existing
NQF-endorsed measures.
Emergency regionalization medical Environmental scan and Completed............. Framework endorsed in
care measurement framework. white paper comparing how January 2012.
regions coordinate and
perform on delivering
emergency services.
Patient safety: SREs............... Reviewed existing list of Completed............. Updated list of 29
NQF SREs for hospitals to SREs endorsed in May
identify ones appropriate 2011.
for other settings;
considered potential new
SREs for all settings.
Patient outcomes measures.......... Three-phase project Completed............. 38 measures endorsed:
endorsing measures --30 measures endorsed
specific to outcomes on in January and March
Medicare high-impact 2011.
conditions, child health, --8 measures endorsed
and mental health. during previous
contract year
(September 2010).
Patient-safety measures............ Two-phase project endorsed Completed............. Phase 1: 4 measures
new measures of patient endorsed in January
safety (e.g., healthcare- 2012.
associated infections, Phase 2: 2 measures
medication safety) and endorsed in August
maintaining currently and September 2011.
endorsed measures.
Nursing-home measures.............. Endorsed measures of Completed............. 5 measures endorsed in
nursing-home care quality. February 2011.
Child-health measures.............. Endorsed measures specific Completed............. 44 measures endorsed
to the care of children. in September 2011.
Surgery measures and maintenance Two-phase project to Phase 1 complete; Phase 1: 18 measures
review. endorse new surgery Phase 2 in progress. endorsed in December
measures and conduct 2011.
maintenance on existing NQF Board endorsed
NQF-endorsed measures. Phase 2 measures
after the close of
the contract year.
Phase 2 addendum
report issued for
public comment just
after contract year
closed.
Efficiency and resource-use Endorsed measures of Completed............. Imaging Efficiency
measures. imaging efficiency; white In progress; completed (Complete)
paper drafted; endorsed just after contract --6 imaging efficiency
measures of healthcare year. measures endorsed in
efficiency. February 2011.
--1 imaging efficiency
measure was
recommended to be
combined with an
existing NQF measure
and was endorsed in
April 2011.
Efficiency--Resource
Use (In Progress).
Cycle 1: 4 measures
ratified by Board
January 2012.
[[Page 56940]]
Cycle 2: 4 measures
posted for public
comment in December
2011; voting closed
in February 2012.
Cancer measures and maintenance Project to endorse new In progress........... Call for nominations
review. cancer measures and completed in November
conduct maintenance on 2011; call-for-
existing NQF-endorsed measures deadline was
measures. January 2012.
Perinatal measures and maintenance Project to endorse new In progress........... Steering Committee
review. perinatal measures and reviewed 23 measures
conduct maintenance on in December 2011.
existing NQF-endorsed
measures.
Renal measures and maintenance Project to endorse new In progress........... Steering Committee
review. renal measures and conduct reviewed 33 measures
maintenance on existing by December 2011;
NQF-endorsed measures. member and public
commenting to
conclude after close
of reporting year.
Pulmonary/critical-care measures Project to endorse new In progress........... Call for nominations
and maintenance review. pulmonary/critical-care closed in December
measures, and conduct 2011.
maintenance on existing Call-for-measures
NQF-endorsed measures. deadline was January
2012.
Palliative and end-of-life care.... Project to endorse new In progress........... NQF Board endorsed
palliative and end-of-life measures after close
care measures and conduct of reporting year.
maintenance on existing
NQF-endorsed measures.
Care-coordination measures and Set of endorsed care- In progress........... Call for measures
maintenance review. coordination measures. closed January 9,
2012.
Population Health Phase 1: Set of endorsed measures In progress........... Member and public
Prevention measures and for preventative services. commenting period
maintenance measures review. concluded February
2012.
Population health Phase 2: Commissioned paper In progress........... Draft paper completed
Population health measures. addressing population January 2012 after
health measurement issues close of reporting
and set of endorsed year.
population health measures.
Behavioral health measures and Set of endorsed measures In progress........... Call for nominations
maintenance review. for behavioral health. closed December 13,
2011.
Call for measures
closed February 14,
2012.
All-cause readmissions (expedited Set of endorsed all-cause In progress........... Member and public
Consensus Development Process readmission measures. commenting concluded
[CDP] review). January 2012.
Multiple Chronic Conditions Work plan completed; In progress........... May 30, 2012.
Measurement Framework report interim report available
analyzing measures being used to for public comment.
gauge quality of care for people
with multiple chronic conditions.
Patient-reported outcomes (PROs) Two workshops discussing In progress........... June 30, 2012.
workshops addressing prerequisites commissioned papers
for endorsed PRO measures. addressing methodological
prerequisites for NQF
consideration of PRO
measures for endorsement
(The Veterans
Administration may fund
the papers; proposal is
pending their approval).
Oral health........................ Report that catalogs oral In progress........... July 6, 2012.
health measures, measure
concepts, priorities and
gaps in measurement.
Rapid-cycle CDP improvement Summary of process In progress........... Four rapid-cycle
(measure-endorsement process). improvement approach, improvement events
events, and metrics used completed in November
to enhance the quality and and December 2012;
efficiency of CDP process. additional events
planned during first
quarter of 2012.
----------------------------------------------------------------------------------------------------------------
III. Health Information Technology
----------------------------------------------------------------------------------------------------------------
Retooled eMeasures, eMeasures Published 113 measures for Completed............. All updates and
Format Review Panel, and eMeasure an electronic environment related activities
Updates. eMeasure Format Review completed by December
Panel reviewed retooled 22, 2011.
measures to ensure the Completed first cycle
electronic specifications of review in Fall
or requirements of these 2010, following
measures are consistent public comment
with the original focus period.
and intent of the measure.
Held 10 webinars/conference
calls to solicit comments
and proposed resolutions..
[[Page 56941]]
MAT................................ Non-proprietary, web-based Completed............. Total number of unique
tool that allows Contractor training; organizations using
performance-measure release of the MAT MAT: 32.
developers to specify, Basic Version on 9/
submit, and maintain 2911; enhanced
electronic measures in a version on target for
more streamlined, release.
efficient, and highly
structured way.
QDM maintenance.................... Updated the QDM (Version 3, Review and updates to Each new version of
released in April 2011) to QDM are ongoing based the QDM will be
reflect additional types on annual cycle. published annually;
of data needed to support NQF will post a draft
emerging measures (e.g., of modifications for
measures that include the next version;
social determinants of annual QDM updates
health, patient/consumer and versions will be
engagement). integrated into MAT
and, moreover, enable
incorporation of
required data
elements in
electronic measures
as new types and
sources of data are
recognized over time.
eMeasures process and technical Provided education, Ongoing............... Developed and posted
assistance. training, and ad-hoc MAT User Guide to
support to HHS, HHS provide manual for
contractors, MAT users, MAT and eMeasure
QDM users, eMeasure development.
developers, EHR vendors, Completed 5 technical-
providers implementing assistance trainings
measures, and other to CMS' eMeasure
relevant quality and contractors, focusing
health IT stakeholders. on topics such as QDM
and in-depth MAT
training.
Completed 7 public
webinars (with as
many as 740 attendees
per webinar),
focusing on topics
such as eMeasures
training for measure
developers and IT
vendors.
Patient-safety-complications Set of endorsed measures on In progress........... Steering Committee
measures and maintenance review complications-related reviewed 27 measures
(Phase 1). areas. in December 2011.
Commissioned paper on data sources Final report and In progress........... Draft paper available
and readiness of HIT systems to commissioned paper. for public comment in
support care coordination. February 2012.
Critical path...................... Examine new measurement Ongoing............... End of September 2012.
areas (e.g. care plans) to
understand the feasibility
of measuring such areas in
an electronic environment.
eMeasure Learning Collaborative.... Examining issues related to Ongoing............... End of September 2012.
implementation of
eMeasures with a multi-
stakeholder group in order
to define best practices
and recommendations to the
Office of the National
Coordinator's Federal
Advisory Committees.
----------------------------------------------------------------------------------------------------------------
IV. Measure Use and Application
----------------------------------------------------------------------------------------------------------------
Patient safety: state-based Convened 27 state-based Completed............. Majority of work
reporting agencies initiative. patient-safety reporting completed during
agencies to discuss safety previous contract
reporting efforts and year; final HHS-
share ``best practices''. funded call completed
January 24, 2011.
RAND report analyzing uses of NQF- An Evaluation of the Use of Completed............. ......................
endorsed measures. Performance Measures in
Health Care; work plan and
list of research questions
completed; report by
independent researcher
completed.
Recommendations for measures to be Measure Applications In progress........... Completed in February
implemented through the federal Partnership Pre-Rulemaking 2012 after close of
rulemaking process for public Report: Input on Measures reporting year.
reporting and payment. Under Consideration by HHS
for 2012 Rulemaking.
[[Page 56942]]
MAP report recommending measures Final report including MAP In progress........... June 1, 2012.
for use in quality reporting for Coordinating Committee
Prospective Payment System-exempt recommendations.
cancer hospitals.
MAP report recommending measures Final report including MAP In progress........... June 1, 2012.
for use in quality reporting for Coordinating Committee
hospice care. recommendations.
NPP support for Partnership for First round of work In progress........... ......................
Patients' HHS initiative focused included 2 quarterly
on patient safety. convenings and 8 webinars.
Content of meetings and
webinars were captured in
individual summaries.
Next round of work includes
creating affinity groups
to implement specific
patient-safety strategies
and webinars.
----------------------------------------------------------------------------------------------------------------
Appendix B: NQF Board and Leadership Staff
Board of Directors
William L. Roper, MD, MPH (Chair), Dean, School of Medicine, Vice
Chancellor for Medical Affairs and Chief Executive Officer, UNC
Health Care System, University of North Carolina at Chapel Hill
Andrew Webber (Vice Chair), President and CEO, National Business
Coalition on Health
Gerald M. Shea (Treasurer), Assistant to the President for External
Affairs, AFL-CIO
Lawrence M. Becker, Director, HR Strategic Partnerships, Xerox
Corporation
Judy Ann Bigby, MD, Secretary, Executive Office of Health & Human
Services, Commonwealth of Massachusetts
Janet M. Corrigan, Ph.D., MBA, President and CEO, National Quality
Forum
Maureen Corry, Executive Director, Childbirth Connection
Leonardo Cuello, Staff Attorney, National Health Law Program
Helen Darling, MA, President, National Business Group on Health
Robert Galvin, MD, MBA, Chief Executive Officer, Equity Healthcare,
The Blackstone Group
Ardis Dee Hoven, MD, Chair, American Medical Association Board of
Trustees, Medical Director, Bluegrass Care Clinic, Affiliated with
the University of Kentucky School of Medicine
Karen Ignagni, MBA, President and CEO, America's Health Insurance
Plans
Chris Jennings, President, Jennings Policy Strategies, Inc.
Charles N. Kahn III, MPH, President, Federation of American
Hospitals
Donald Kemper, Chairman and CEO, Healthwise, Inc.
Mark B. McClellan, MD, Ph.D., Senior Fellow and Director, Engelberg
Center for Health Care Reform and Leonard D. Schaeffer Chair in
Health Policy Studies, The Brookings Institution
Sheri S. McCoy, Worldwide Chairman of the Pharmaceuticals Group,
Johnson & Johnson
Harold D. Miller, President and CEO, Network for Regional Healthcare
Improvement
Dolores L. Mitchell, Executive Director, Commonwealth of
Massachusetts Group Insurance Commission
Mary Naylor, Ph.D., RN, FAAN, Director, New Courtland Center for
Transitions & Health and Marian S. Ware Professor in Gerontology,
University of Pennsylvania School of Nursing
Debra L. Ness, President, National Partnership for Women & Families
Samuel R. Nussbaum, MD, Executive Vice President and Chief Medical
Officer, WellPoint, Inc.
J. Marc Overhage, MD, Ph.D., Chief Medical Informatics Officer,
Siemens Medical Solutions, Inc.
Bernard M. Rosof, MD, Chair, Board of Directors, Huntington
Hospital, Chair, Physician Consortium for Performance Improvement
John C. Rother, JD, President and CEO, National Coalition on Health
Care
Joseph R. Swedish, FACHE, President and CEO, Trinity Health
John Tooker, MD, MBA, MACP, Associate Executive Vice President,
American College of Physicians
Richard J. Umbdenstock, President and CEO, American Hospital
Association
CMS
Don Berwick, MD, Administrator (until 12/2/11)
Marilyn Tavenner, BSN, MPA, Acting Administrator and Chief Operating
Officer (12/5/11-present), Centers for Medicare & Medicaid Services
Designee: Patrick Conway, MD, Chief Medical Officer
AHRQ
Carolyn M. Clancy, MD, Director, Agency for Healthcare Research and
Quality
Designee: Nancy Wilson, MD, MPH, Senior Advisor to the Director
HRSA
Mary Wakefield, Ph.D., RN, Administrator, Health Resources and
Services Administration
Designee: Terry Adirim, MD, Director, Office of Special Health
Affairs
CDC
Thomas R. Frieden, MD, MPH, Director, Centers for Disease Control
and Prevention
Designee: Peter A. Briss, MD, MPH, Captain, U.S. Public Health
Service Medical Director
Ex Officio (Non-Voting):
Timothy Ferris, MD, (Chair, Consensus Standards Approval Committee),
Associate Professor of Medicine, Massachusetts General Hospital
Paul C. Tang, MD, MS, (Chair, Health Information Technology Advisory
Committee), Vice President and Chief Medical Information Officer,
Palo Alto Medical Foundation
NQF Leadership Staff
Janet M. Corrigan, President and Chief Executive Officer
Karen Adams, Vice President, National Priorities
Heidi Bossley, Vice President, Performance Measures
Helen Burstin, Senior Vice President, Performance Measures
Floyd Eisenberg, Senior Vice President, Health Information
Technology
Larry Gorban, Vice President, Operations
Ann Greiner, Vice President, External Affairs
Ann Hammersmith, General Counsel
Lisa Hines, Vice President, Member Relations
Connie Hwang, Vice President, Measure Applications Partnership
Rosemary Kennedy, Vice President, Health Information Technology
Laura Miller, Senior Vice President and Chief Operating Officer
Nicole Silverman, Vice President, Federal Program Management
Lindsey Spindle, Senior Vice President, Communications and External
Affairs
Diane Stollenwerk, Vice President, Community Alliances
Jeffrey Tomitz, Chief Financial Officer, Accounting & Finance
Thomas Valuck, Senior Vice President, Strategic Partnerships
Kyle Vickers, Chief Information Officer
Appendix C: Overview of Consensus Development Process
For each Consensus Development Project (CDP), NQF follows a
careful eight-step process that ensures transparency, public input,
and discussion among representatives across the healthcare
enterprise.
1. Call for Nominations allows anyone to suggest a candidate for
the committee that will oversee the project. Committees are diverse,
often encompassing experts in a
[[Page 56943]]
particular field, providers, scientists, and consumers. After
selection, NQF posts committee rosters on its Web site to solicit
public comments on the composition of the panel and makes
adjustments as needed to ensure balanced representation.
2. Call for Measures starts a 30-day period for developers to
submit a measure or practice through NQF's online submission forms.
3. Steering Committee Review puts submitted measures to a four-
part test to ensure they reflect sound science, will be useful to
providers and patients, and will make a difference in improving
quality. The expert steering committee conducts this detailed review
in open sessions, each of which starts a limited period for public
comment.
4. Public Comment solicits input from anyone who wishes to
respond to a draft report that outlines the steering committee's
assessment of measures for possible endorsement. The steering
committee may request a revision to the proposed measures.
5. Member Vote asks NQF members to review the draft report and
cast their votes on the endorsement of measures.
6. CSAC Review marks the point at which the NQF Consensus
Standards Approval Committee (CSAC) deliberates on the merits of the
measure and the issues raised during the review process, and makes a
recommendation on endorsement to the Board of Directors. The CSAC
includes consumers, purchasers, healthcare professionals, and
others. It provides the big picture to ensure that standards are
being consistently assessed from project to project.
7. Board Ratification asks for review and ratification by the
NQF Board of Directors of measures recommended for endorsement.
8. Appeal opens a period when anyone can appeal the Board's
decision.
Appendix D: MAP Measure-Selection Criteria
The Measure Applications Partnership (MAP) has developed
measure-selection criteria to guide its evaluations of program
measure sets. The term ``measure set'' can refer to a collection of
measures--for a program, condition, procedure, topic, or population.
For the purposes of MAP's pre-rulemaking analysis, we qualify the
term measure set as a ``program measure set'' to indicate the
collection of measures used in a given federal public reporting or
performance-based payment program.
The measure-selection criteria are intended to facilitate
structured discussion and decision- making processes. The iterative
approach employed in developing the criteria allowed MAP in its
entirety, as well as the public, to provide input on the criteria.
Each MAP workgroup deliberated on draft criteria and advised the
Coordinating Committee. Comments were received on the draft criteria
through the public comment period for the Coordination Strategy for
Clinician Performance Measurement report. A Measure-Selection
Criteria Interpretive Guide also was developed to provide additional
descriptions and direction on the meaning and use of the measure-
selection criteria.
1. MAP measure-selection criteria and the interpretive guide
were finalized at the November 1, 2011, Coordinating Committee in-
person meeting The following criteria were then used as a tool
during the pre-rulemaking task:
2. Measures within the program measure set are NQF-endorsed or
meet the requirements for expedited review.
3. The program measure set adequately addresses each of the NQS
priorities.
4. The program measure set adequately addresses high-impact
conditions relevant to the program's intended populations (e.g.,
children, adult non-Medicare, older adults, or dual-eligible
beneficiaries).
5. The program measure set promotes alignment with specific
program attributes, as well as alignment across programs.
6. The program measure set includes an appropriate mix of
measure types (e.g., process, outcome, structure, patient
experience, and cost).
7. The program measure set enables measurement across the
person-centered episode of care.
8. The program measure set includes considerations for
healthcare disparities.
9. The program measure set promotes parsimony.
Public commenters supported the MAP measure-selection criteria
and noted that the tool served MAP well in its pre-rulemaking
activities.
Appendix E: NQF Membership
NQF members represent more than 450 organizations from across
the country committed to advancing healthcare quality. Members of
NQF participate in one of eight Member Councils organized by
stakeholder group--consumers; health plans; health professionals;
provider organizations; public-community health agencies;
purchasers; quality measurement, research, and improvement; and
supplier-industry--and are afforded a strong voice in crafting
national solutions to quality concerns. Member organizations are
from every region of the country as the map below indicates.
[[Page 56944]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.008
NQF Member Organizations
3M Health Care
AARP
Abbott Laboratories
ABIM Foundation
Academy of Managed Care Pharmacy
Academy of Medical-Surgical Nurses
Accreditation Association for Ambulatory Health Care Institute for
Quality Improvement
ACS-MIDAS+
Ada County Paramedics
Adventist Health System
Advocate Physician Partners
Aetna
Affinity Health System
AFL-CIO
Agency for Healthcare Research and Quality
Albuquerque Coalition for Healthcare Quality
Aligning Forces for Quality-South Central Pennsylvania
Alliance for Health
Alliance of Community Health Plans
Ambulatory Surgery Foundation
Amedisys
American Academy of Allergy, Asthma and Immunology
American Academy of Dermatology
American Academy of Family Physicians
American Academy of Hospice and Palliative Medicine
American Academy of Neurology
American Academy of Nurse Practitioners
American Academy of Nursing
American Academy of Ophthalmology
American Academy of Orthopaedic Surgeons
American Academy of Otolaryngology-Head and Neck Surgery
American Academy of Pediatrics
American Academy of Physical Medicine and Rehabilitation
American Association of Birth Centers
American Association of Cardiovascular and Pulmonary Rehabilitation
American Association of Clinical Endocrinologists
American Association of Colleges of Nursing
American Association of Diabetes Educators
American Association of Neurological Surgeons
American Association of Nurse Anesthetists
American Association of Nurse Assessment Coordination
American Board of Medical Specialties
American Board of Optometry
American Case Management Association
American Chiropractic Association
American College of Cardiology
American College of Cardiology/American Heart Association Task Force
on Performance Measures
American College of Emergency Physicians
American College of Gastroenterology
American College of Medical Quality
American College of Nurse-Midwives
American College of Obstetricians and Gynecologists
American College of Physician Executives
American College of Physicians
American College of Radiology
American College of Rheumatology
American College of Surgeons
American Data Network
American Dietetic Association
American Federation of Teachers Healthcare
American Gastroenterological Association Institute
American Geriatrics Society
American Health Care Association
American Health Information Management Association
American Health Quality Association
American Heart Association
American Hospice Foundation
American Hospital Association
American Medical Association
American Medical Association-Physician Consortium for Performance
Improvement
American Medical Directors Association
American Medical Informatics Association
American Nurses Association
American Occupational Therapy Association
American Optometric Association
American Organization of Nurse Executives
American Osteopathic Association
American Pharmacists Association Foundation
American Physical Therapy Association
American Psychiatric Association for Research and Education
American Psychiatric Nurses Association
American Sleep Apnea Association
American Society for Gastrointestinal Endoscopy
American Society for Radiation Oncology
American Society of Anesthesiologists
American Society of Breast Surgeons
American Society of Clinical Oncology
American Society of Colon and Rectal Surgeons
American Society of Health-System Pharmacists
American Society of Hematology
American Society of Nuclear Cardiology
American Society of Pediatric Nephrology
American Society of Plastic Surgeons
American Urological Association
America's Health Insurance Plans
AmeriHealth Mercy Family of Companies
AMGEN Inc.
AmSurg Corp.
Anesthesia Quality Institute
Arkansas Medicaid
Ascension Health
Association for Professionals in Infection Control and Epidemiology
[[Page 56945]]
Association for the Advancement of Wound Care
Association of American Medical Colleges
Association of periOperative Registered Nurses
Association of Rehabilitation Nurses
Association of Women's Health, Obstetric and Neonatal Nurses
AstraZeneca
Atlantic Health
Aultman Health Foundation
Aurora Health Care
Avalere Health LLC
Baptist Health South Florida
Baptist Memorial Health Care Corporation
Baxter Healthcare
BayCare Health System
Baylor Health Care System
Betsy Lehman Center for Patient Safety and Medical Error Reduction
Better Health Greater Cleveland
BJC HealthCare
BlueCross BlueShield Association
Boehringer Ingelheim
Bon Secours St. Francis Health System
Booz Allen Hamilton
Bristol-Myers Squibb Company
Bronson Healthcare Group, Inc.
Buyers Health Care Action Group
California HealthCare Foundation
California Hospital Association
California Hospital Patient Safety Organization
California Maternal Quality Care Collaborative
California Office of Statewide Health Planning and Development
CareFirst BlueCross BlueShield
CareFusion
CaroMont Health
Case Management Society of America
Caterpillar Inc.
Catholic Health Association of the United States
Catholic Health Initiatives
Catholic Healthcare Partners
Cedars-Sinai Medical Center
Center for Health Care Quality, Department of Health Policy, George
Washington University
Center to Advance Palliative Care
Centers for Disease Control and Prevention
Centers for Medicare & Medicaid Services
Childbirth Connection
Children's Hospital Boston
Children's Hospitals and Clinics of Minnesota
CHRISTUS Health
CIGNA HealthCare
Citizens for Patient Safety
City of Hope
Cleveland Clinic
Colorado Business Group on Health
Commission for Case Manager Certification
Community Health Accreditation Program
Community Health Alliance- Humboldt County Del-Norte
Community Health Foundation of Western and Central New York
Connecticut Center for Patient Safety
Connecticut Hospital Association
Consumer Coalition for Quality Health Care
Consumers Advancing Patient Safety
Consumers' Checkbook
Consumers Union
Coral Initiative, LLC
Core Consulting, Inc.
Council of Medical Specialty Societies
Crozer-Keystone Health System
Dallas-Fort Worth Hospital Council Education and Research Foundation
Dana-Farber Cancer Institute
Deloitte Consulting LLP, Health Sciences and Government
Dental Quality Alliance
Detroit Medical Center
Dialog Medical
Edwards Lifesciences
eHealth Initiative
Eisai, Inc.
Eli Lilly and Company
Elsevier Clinical Decision Support
Emergency Nurses Association
Employers' Coalition on Health
Englewood Hospital and Medical Center
Epstein Becker & Green, P.C.
Exeter Health Resources
Federation of American Hospitals
FirstWatch Solutions, Inc.
Florida Health Care Coalition
Florida Hospital
Florida State University, Center for Medicine and Public Health
Forest Laboratories, Inc.
Foundation for Informed Medical Decision Making
Fox Chase Cancer Center
Franciscan Alliance
GE Healthcare
Genentech
Genesis HealthCare System
Gentiva Health Services
GlaxoSmithKline
Good Samaritan Hospital
Greater Detroit Area Health Council
Greenway Medical Technologies
Group Health Cooperative
H. Lee Moffitt Cancer Center and Research Institute Hospital, Inc.
Hackensack University Medical Center
Harborview Medical Center
Health Action Council Ohio
Health Level Seven, Inc.
Health Management Associates, Inc.
Health Resources and Services Administration
Health Services Advisory Group
Health Services Coalition
Health Watch USA
HealthCare 21 Business Coalition
Healthcare Information and Management Systems Society
Healthcare Leadership Council
HealthGrades
HealthPartners
HealthSouth Corporation
Healthy Memphis Common Table
Heart Rhythm Society
Henry Ford Health System
Highmark, Inc.
Hoag Hospital
Horizon Blue Cross Blue Shield of New Jersey
Hospice and Palliative Nurses Association
Hospira
Hospital Corporation of America
Hospital for Special Surgery
Hudson Health Plan
Humana Inc.
Huntington Memorial Hospital
Illinois Hospital Association
Infectious Diseases Society of America
Infusion Nurses Society
Inland Northwest Health Services
Institute for Clinical Systems Improvement
Institute for Safe Medication Practices
Integrated Healthcare Association
Intelligent Healthcare
Interim HealthCare, Inc.
Intermountain Healthcare
Iowa Healthcare Collaborative
IPRO
Jefferson School of Population Health
Johns Hopkins Health System
Kaiser Permanente
Kansas City Quality Improvement Consortium
Kidney Care Partners
Lamaze International
Lehigh Valley Business Coalition on Health Care
LHC Group, Inc.
Long-Term Quality Alliance
Louisiana Health Care Quality Forum
Maine Health Management Coalition
Maine Quality Counts
Maine Quality Forum
Maryland Health Care Commission
Maryland Patient Safety Center
Massachusetts Health Quality Partners
Mayo Clinic
McKesson Corporation
MedAssets
MedeAnalytics, Inc.
Medisolv, Inc.
MedStar Health
Memorial Hermann Healthcare System
Memorial Sloan-Kettering Cancer Center
Merck & Co., Inc.
Mercy Medical Center
Meridian Health System
MHA Keystone Center for Patient Safety & Quality
Middlesex Hospital
Midwest Care Alliance
Milliman Care Guidelines
Minnesota Community Measurement
Mothers Against Medical Error
Mount Auburn Hospital
National Academy for State Health Policy
National Academy of Clinical Biochemistry
National Alliance of Wound Care
National Association for Behavioral Health
National Association for Healthcare Quality
National Association of Certified Professional Midwives
National Association of Children's Hospitals and Related
Institutions
National Association of Dental Plans
National Association of EMS Physicians
National Association of Health Data Organizations
National Association of Pediatric Nurse Practitioners
National Association of Psychiatric Health Systems
National Association of Public Hospitals and Health Systems
National Association of State Medicaid Directors
National Breast Cancer Coalition
National Business Coalition on Health
National Business Group on Health
National Center for Healthcare Leadership
National Coalition for Cancer Survivorship
National Committee for Quality Assurance
National Consensus Project for Quality Palliative Care
[[Page 56946]]
National Consortium of Breast Centers
National Consumers League
National Council of State Boards of Nursing
National Council on Aging
National Forum for Heart Disease and Stroke Prevention
National Health Law Program
National Hospice and Palliative Care Organization
National Institute for Quality Improvement and Education
National Nursing Staff Development Organization
National Partnership for Women & Families
National Patient Safety Foundation
National Pressure Ulcer Advisory Panel
National Rural Health Association
National Sleep Foundation
NCH Healthcare System
Nemours Foundation
Neocure Group
New Jersey Health Care Quality Institute
New Jersey Hospital Association
New York Presbyterian Healthcare System
New York University College of Nursing
Next Wave
Niagara Health Quality Coalition
North Carolina Center for Hospital Quality and Patient Safety
North Mississippi Medical Center
North Shore-Long Island Jewish Health System
North Texas Specialty Physicians
Northeast Health Care Quality Foundation
Northwestern Memorial HealthCare
Norton Healthcare, Inc.
Novartis
Nursing Alliance for Quality Care
Oakstone Medical Publishing
Oncology Nursing Society
Oregon Health Care Quality Corporation
Ortho-McNeill-Janssen Pharmaceutical, Inc.
OSUCCC-James Cancer Hospital
P2 Collaborative of Western New York
Pacific Business Group on Health
Park Nicollet Health Services
Partners HealthCare System, Inc.
Partnership for Prevention
Patient Centered Primary Care Collaborative
Pennsylvania Health Care Association
Pfizer
Pharmacy Quality Alliance
PhRMA
Phytel, Inc.
Planetree
Premier, Inc.
Press Ganey Associates
Professional Research Consultants, Inc.
Providence Health & Services
Puget Sound Health Alliance
PULSE of New York
Quality Outcomes, LLC
Quantros, Inc.
Renal Physicians Association
Resolution Health, Inc.
Rhode Island Department of Health
Robert Wood Johnson University Hospital-Hamilton
Rockford Health System
Roswell Park Cancer Institute
Saint Barnabas Health Care System
Saint Francis Hospital and Medical Center
Sanofi Pasteur
Sanofi-Aventis
Scott & White Healthcare
Seattle Cancer Care Alliance
Sharp HealthCare
Siemens Healthcare, USA
Sisters of Charity of Leavenworth Health System
SNP Alliance
Society for Academic Emergency Medicine
Society for Cardiovascular Angiography and Interventions
Society for Healthcare Epidemiology of America
Society for Maternal-Fetal Medicine
Society for the Advancement of Blood Management
Society for Vascular Surgery
Society of Behavioral Medicine
Society of Critical Care Medicine
Society of Gynecologic Oncology
Society of Hospital Medicine
Society of Thoracic Surgeons
Southeast Texas Medical Associates, LLP
St. Joseph Health System
St. Louis Area Business Health Coalition
Stamford Health System
State Associations of Addiction Services
Substance Abuse and Mental Health Services Administration
Summa Health System
Surgical Care Affiliates
Sylvester Comprehensive Cancer Center, University of Miami Hospitals
and Clinics
Taconic IPA, Inc.
Takeda Pharmaceuticals North America, Inc.
Tampa General Hospital
Telligen
Tenet Healthcare Corporation
Texas Health Resources
Texas Medical Institute of Technology
The Advanced Medical Technology Association
The Alliance
The Alliance for Home Health Quality and Innovation
The Commonwealth Fund
The Coordinating Center
The Empowered Patient Coalition
The Federation of State Medical Boards of the U.S., Inc.
The Health Alliance of Mid-America, LLC
The Health Collaborative
The Joint Commission
The Leapfrog Group
The National Consumer Voice for Quality Long-Term Care
The National Forum of ESRD Networks
The Partnership for Healthcare Excellence
Thomas Jefferson University Hospital
Thomson Reuters
Trauma Support Network
Trinity Health
Trust for America's Health
UCB, Inc.
UMass Memorial Medical Group, Inc.
United Surgical Partners International
UnitedHealth Group
Universal American Corp.
University HealthSystem Consortium
University of California-Davis Medical Group
University of Kansas School of Nursing
University of Michigan Hospitals & Health Centers
University of North Carolina-Program on Health Outcomes
University of Pennsylvania Health System
University of Texas Southwestern Medical Center
University of Texas-MD Anderson Cancer Center
University of Virginia Health System
URAC
Urgent Care Association of America
US Department of Defense-Health Affairs
UW Health
Vanderbilt University Medical Center
Vanguard Health Management
Verilogue, Inc
Veterans Health Administration
VHA, Inc.
Virginia Business Coalition on Health
Virginia Cardiac Surgery Quality Initiative
Virginia Mason Medical Center
Virtua Health
WellPoint
WellSpan Health
WellStar Health System
West Virginia Medical Institute
Wisconsin Collaborative for Healthcare Quality
Wisconsin Medical Society
Wound, Ostomy and Continence Nurses Society
Yale New Haven Health System
Zynx Health
Appendix F: 2011 NQF Volunteer Leaders
Stancel M. Riley, Chair, Ambulatory and Office-Based Surgery
Technical Advisory Panel Serious Reportable Events in Healthcare
Project
Chair, Patient Safety Serious Reportable Events Technical Advisory
Panel, Massachusetts Board of Registration in Medicine
Mary George, Co-chair, Cardiovascular Endorsement Maintenance
Steering Committee, Centers for Disease Control and Prevention
Raymond Gibbons, Co-chair, Cardiovascular Endorsement Maintenance
Steering Committee, Mayo Clinic
Donald Casey, Co-chair, Care Coordination Endorsement Maintenance
Steering Committee, Atlantic Health
Gerri Lamb, Co-chair, Care Coordination Endorsement Maintenance
Steering Committee, Arizona State University
Thomas McInerny, Co-chair, Child Health Quality Measures Steering
Committee, University of Rochester
Marina L. Weiss, Co-chair, Child Health Quality Measures Steering
Committee
Co-chair, National Voluntary Standards for Patient Outcomes Child
Health Steering Committee, March of Dimes
David Classen, Co-chair, Common Formats Expert Panel, University of
Utah
Henry Johnson, Co-chair, Common Formats Expert Panel, ACS-MIDAS+
Timothy Ferris, Chair, Consensus Standards Approval Committee,
Massachusetts General Hospital/Institute for Health Policy
Ann Monroe, Vice-chair, Consensus Standards Approval Committee,
Community Health Foundation of Western and Central New York
Doris Lotz, Co-chair, Efficiency Resource Use Steering Committee,
New Hampshire Department of Health and Human Services
Sally Tyler, Co-chair, Patient Safety SRE Steering Committee, AFSCME
Gregg S. Meyer, Co-chair, Patient Safety SRE Steering Committee,
Massachusetts General Hospital
[[Page 56947]]
Paul C. Tang, Chair, Health Information Technology Advisory
Committee, Palo Alto Medical Foundation and Stanford University
Dennis Andrulis, Co-chair, Healthcare Disparities and Cultural
Competency Consensus Standards Committee, Texas Health Institute
Denice Cora-Bramble, Co-chair, Healthcare Disparities and Cultural
Competency Consensus Standards Committee, Children's National
Medical Center
Michael Doering, Co-chair, Improving Patient Safety through State-
Based Reporting in Healthcare Workgroup, Pennsylvania Patient Safety
Authority
Diane Rydrych, Co-chair, Improving Patient Safety through State-
Based Reporting in Healthcare Workgroup, Minnesota Department of
Health
Iona Thraen, Co-chair, Improving Patient Safety through State-Based
Reporting in Healthcare Workgroup, Utah Department of Health
William Corley, Chair, Leadership Network, Community Health Network
George J. Isham, Co-chair, Measure Applications Partnership
Coordinating Committee, HealthPartners, Inc.
Elizabeth A. McGlynn, Co-chair, Measure Applications Partnership
Coordinating Committee, Kaiser Permanente Center for Effectiveness
and Safety Research
Frank G. Opelka, Chair, Measure Applications Partnership Ad Hoc
Safety Workgroup
Chair, Measure Application Partnership Hospital Workgroup, Louisiana
State University Health Sciences Center
Mark McClellan, Chair, Measure Applications Partnership Clinician
Workgroup, The Brookings Institution, Engelberg Center for Health
Care Reform
Alice Lind, Chair, Measure Applications Partnership Dual Eligible
Beneficiaries Workgroup, Center for Health Care Strategies
Carol Raphael, Chair, Measure Applications Partnership Post-Acute
Care/Long-Term Care Workgroup, Visiting Nurse Service of New York
Michael Lieberman, Chair, Measure Authoring Tool Oversight and
Testing Workgroup, Oregon Health and Science University
Caroline S. Blaum, Co-chair, Multiple Chronic Conditions Measurement
Framework Steering Committee, University of Michigan Health System--
Institute of Gerontology
Barbara McCann, Co-chair, Multiple Chronic Conditions Measurement
Framework Steering Committee, Interim HealthCare
Helen Darling, Co-chair, National Priorities Partnership, National
Business Group on Health
Margaret O'Kane, Co-chair, National Priorities Partnership, National
Committee for Quality Assurance
Bernard Rosof, Co-chair, National Priorities Partnership, Physician
Consortium for Performance Improvement convened by the American
Medical Association
Peter Crooks, Co-chair, National Voluntary Consensus Standards for
End Stage Renal Disease
Co-chair, Renal Endorsement Maintenance Steering Committee, Southern
California Permanente Medical Group
Kristine Schonder, Co-chair, National Voluntary Consensus Standards
for End Stage Renal Disease
Co-chair, Renal Endorsement Maintenance Steering Committee,
University of Pittsburgh School of Pharmacy
Tom Rosenthal, Co-chair, National Voluntary Consensus Standards for
Endorsing Performance Measures for Resource Use: Phase II, UCLA
School of Medicine
Bruce Steinwald, Co-chair, National Voluntary Consensus Standards
for Endorsing Performance Measures for Resource Use: Phase II
Co-chair, Efficiency Resource Use Steering Committee, Independent
Consultant
G. Scott Gazelle, Co-chair, National Voluntary Consensus Standards
for Imaging Efficiency, Massachusetts General Hosital
Eric D. Peterson, Co-chair, National Voluntary Consensus Standards
for Imaging Efficiency, Duke University Medical Center
David A. Johnson, Chair, National Voluntary Consensus Standards for
Patient Outcomes Biliary and Gastrointestinal Technical Advisory
Panel, American College of Gastroenterology
Dianne Jewell, Chair, National Voluntary Consensus Standards for
Patient Outcomes Bone/Joint Technical Advisory Panel, Virginia
Commonwealth University
Lee Newcomer, Chair, National Voluntary Consensus Standards for
Patient Outcomes Cancer Technical Advisory Committee, United
HealthCare
Edward Gibbons, Chair, National Voluntary Consensus Standards for
Patient Outcomes Cardiovascular Technical Advisory Panel, University
of Washington School of Medicine
David Herman, Chair, National Voluntary Consensus Standards for
Patient Outcomes Eye Care Technical Advisory Panel, Mayo Clinic
E. Patchen Dellinger, Chair, National Voluntary Consensus Standards
for Patient Outcomes Infectious Disease Technical Advisory Panel,
University of Washington School of Medicine
Sheldon Greenfield, Chair, National Voluntary Consensus Standards
for Patient Outcomes Metabolic Technical Advisory Panel, University
of California, Irvine
Barbara Yawn, Chair, National Voluntary Consensus Standards for
Patient Outcomes Pulmonary Technical Advisory Panel, Olmstead
Medical Center
Tricia Leddy, Co-chair, National Voluntary Consensus Standards for
Patient Outcomes Mental Health Steering Committee, Rhode Island
Department of Health
Jeffrey Sussman, Co-chair, National Voluntary Consensus Standards
for Patient Outcomes Mental Health Steering Committee, University of
Cincinnati
Charles Homer, Co-chair, National Voluntary Standards for Patient
Outcomes Child Health Steering Committee, NICHQ
David Gifford, Co-chair, National Voluntary Standards for Nursing
Homes, American Health Care Association and National Center for
Assisted Living
Christine Mueller, Co-chair, National Voluntary Standards for
Nursing Homes, University of Minnesota School of Nursing
June Lunney, Co-chair, Palliative Care and End-of-Life Care
Endorsement Maintenance Steering Committee, Hospice and Palliative
Nurses Association
Sean Morrison, Co-chair, Palliative Care and End-of-Life Care
Endorsement Maintenance Steering Committee, Mount Sinai School of
Medicine
Sherrie Kaplan, Co-chair, Patient Outcomes: All-Cause Readmissions
Expedited Review Steering Committee, UC Irvine School of Medicine
Eliot Lazar, Co-chair, Patient Outcomes: All-Cause Readmissions
Expedited Review Steering Committee, New York Presbyterian
Healthcare System
Lisa J. Thiemann, Co-chair, Patient Safety Measures Steering
Committee, Surgical Care Affiliates
William A. Conway, Co-chair, Patient Safety Measures Steering
Committee
Co-chair, Patient Safety Measures: Complications Endorsement
Maintenance Steering Committee, Henry Ford Health System
Darrell A. Campbell, Jr., Chair, Patient Safety Measures HAI
Technical Advisory Panel, University of Michigan Hospitals & Health
Centers
David Nau, Chair, Patient Safety Measures Medical Management
Technical Advisory Panel, Pharmacy Quality Alliance
Steven Clark, Chair, Patient Safety Measures Perinatal Technical
Advisory Panel, Hospital Corporation of America
Pamela Cipriano, Co-chair, Patient Safety Measures: Complications
Endorsement Maintenance Steering Committee, University of Virginia
Health System
Tejal Gandhi, Chair, Patient Safety Serious Reportable Events
Technical Advisory Panel
Chair, Physician Office Technical Advisory Panel Serious Reportable
Events in Heatlhcare, Partners Healthcare
Eric Tangalos, Chair, Patient Safety Serious Reportable Events
Technical Advisory Panel
Chair, Skilled Nursing Facility Technical Advisory Panel Serious
Reportable Events In Healthcare Project, Mayo Clinic
Laura Riley, Co-chair, Perinatal and Reproductive Health Endorsement
Maintenance Steering Committee, Massachusetts General Hospital
Carol Sakala, Co-chair, Perinatal and Reproductive Health
Endorsement Maintenance Steering Committee, Childbirth Connection
Paul Jarris, Co-chair, Population Health: Prevention Endorsement
Maintenance Steering Committee, Association of State and Territorial
Health Officers
Kurt Stange, Co-chair, Population Health: Prevention Endorsement
Maintenance Steering Committee, Case Western Reserve University
David Bates, Co-chair, Quality Data Model Sub-committee, Partners
Healthcare
Caterina Lasome, Co-chair, Quality Data Model Sub-committee, Ion
Informatics
Arthur Kellermann, Co-chair, Regionalized Emergency Medical Care
Services Steering Committee, The RAND Corporation
[[Page 56948]]
Andrew Roszak, Co-chair, Regionalized Emergency Medical Care
Services Steering Committee, Department of Health and Human Services
James Weinstein, Chair, Resource Use Project: Phase II Bone/Joint
Technical Advisory Panel, The Dartmouth Institute for Health Policy;
Dartmouth-Hitchcock Clinic
David Penson, Chair, Resource Use Project: Phase II Cancer Technical
Advisory Panel, Vanderbilt University Medical Center
Jeptha Curtis, Co-chair, Resource Use Project: Phase II
Cardiovascular/Diabetes Technical Advisory Panel, Yale University
School of Medicine
James Rosenzweig, Co-chair, Resource Use Project: Phase II
Cardiovascular/Diabetes Technical Advisory Panel, Boston Medical
Center and Boston University School of Medicine
Kurtis Elward, Co-chair, Resource Use Project: Phase II Pulmonary
Technical Advisory Panel, Family Medicine of Albermarle
Janet Maurer, Co-chair, Resource Use Project: Phase II Pulmonary
Technical Advisory Panel, American College of Chest Physicians
Arden Morris, Co-chair, Surgery Endorsement Maintenance Steering
Committee, Ann Arbor Veterans Affairs Medical Center
David Torchiana, Co-chair, Surgery Endorsement Maintenance Steering
Committee, Massachusetts General Physicians Organization
NATIONAL QUALITY FORUM
1030 15th Street NW., Suite 800
Washington, DC 20005
www.qualityforum.org
NQF Report on Measure Gaps and Inadequacies
Overview
The Affordable Care Act (ACA) (Pub. L. 111-148, sec. 3011),
requires the Secretary of Health and Human Services to establish a
National Strategy for Quality Improvement in Health Care, which serves
as a strategic plan for improving the delivery of health care services,
achieving better patient outcomes, and improving the health of the U.S.
population. The strategy will be continually updated as the Affordable
Care Act is implemented.
Section 3014 of ACA requires a report from the National Quality
Forum (NQF) regarding the identification of gaps in endorsed quality
measures--to include measures within the National Quality Strategy
priority areas--to be provided to the Secretary by February 1, 2012 and
annually thereafter. The report was also intended to identify areas
where evidence was insufficient to support endorsement of quality
measures in priority areas.
Methods
In order to prepare this report on measure gaps, NQF staff
consulted numerous data sources to identify endorsed measure and
evidence gaps. Staff reviewed approximately 750 endorsed measures
within the NQF portfolio and identified the measures that address one
or more of the National Quality Strategy (NQS) priority areas and areas
where gaps remain. Staff also reviewed NQF-related efforts that address
many of the priority areas, including NQF project consensus development
project reports. NQF endorsement committees routinely identify gaps as
part of the work of the consensus development process. The NQF report
``Prioritization of High-Impact Medicare Conditions and Measure Gaps''
developed by the Measure Prioritization Advisory Committee and
published in May, 2010 was also used as a data source for gaps.
NQF has captured this information in a high-level matrix organized
by priority area and the high impact clinical conditions which
highlights where endorsed measures exist and gaps remain. Given the
volume of clinical conditions and cross-cutting areas addressed within
the NQF portfolio, a targeted list of clinical conditions is included.
It is anticipated that this analysis will continue to evolve over
the coming years through the NQF National Priorities Partnership, the
Measures Applications Partnership, endorsement maintenance projects,
and other activities.
National Quality Strategy Overview
The NQF-convened National Priorities Partnership (NPP) proposed
goals and measure concepts in its September 1, 2011 report ``Input to
the Secretary of Health and Human Services on Priorities for the
National Quality Strategy'' regarding the six national priorities:
1. Making Care Safer
2. Ensuring Person- and Family-Centered Care
3. Promoting Effective Communication and Coordination of Care
4. Promoting the Most Effective Prevention and Treatment of the Leading
Causes of Mortality, Starting with Cardiovascular Disease
5. Working with Communities to Promote Wide Use of Best Practices to
Enable Healthy Living
6. Making Quality Care More Affordable
The proposed goals and measure concepts are intended to ``provide a
set of clear aims with which the NQS can guide the nation to achieve
safe, timely, effective, efficient, and equitable care,'' and are
discussed in more detail below. Some of the measure concepts identify
important measurement gaps, while measure development may be limited by
evidence gaps.
The Secretary's National Quality Strategy requires a wide array of
quality and efficiency measures for implementation. While some of the
strategy's priority areas may be well-supported by NQF-endorsed
measures, others may have fewer, or in some cases, no endorsed measures
aligned with them.
For the purposes of this report, we have expanded the applicability
of the fourth priority area, related to prevention and treatment,
beyond cardiovascular disease to the other conditions listed below.
While there are numerous condition-specific clinical process measures,
there are major gaps for some conditions (e.g., Alzheimer's). There are
also important gaps in condition-specific measures that address
critical national priorities (e.g., cost measures for high-cost
conditions).
Alzheimer's Disease
Cancer
Cardiovascular
Cataract
Child Health
Depression
Diabetes
Glaucoma
Hip/Pelvic Fracture
Maternal Health
Osteoporosis
Pulmonary
Renal Disease
Rheumatoid Arthritis/Osteoarthritis
Serious Mental Illness
Stroke
Since there is a strong desire to move toward patient-focused
outcomes of care, the report also identifies potential outcome gaps for
clinical and cross-cutting areas. For example, while there are numerous
cancer-related process measures, there are no endorsed cancer outcome
measures. Recent work by NQF's Evidence Task Force identified a
hierarchical preference for outcomes linked to evidence-based processes
and structures (Figure 1). While there is still a need for process and
structural measures, especially for quality improvement, they should be
closely linked to outcomes. In the tables that follow, gaps for outcome
measures in some high impact clinical areas are identified.
[[Page 56949]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.009
The NQF Evidence Task Force also emphasized the importance of
assessing the quality, quantity and consistency of evidence underlying
the measure focus. While endorsement of some clinical measures has been
limited by empirical evidence, NQF provides an exception in cases for
which expert opinion can be systematically assessed with agreement that
the benefits to patients greatly outweigh potential harms. In some
cross-cutting priority areas, such as pain management and patient
engagement, Committee expert opinion has been used to satisfy the
evidence requirement.
There has also been a strong interest from numerous stakeholders,
including consumers and purchasers, in moving to composite measures.
Composite measures are defined as one or more measures that are
combined into a single score. Because composite measures provide a more
comprehensive view of care and may be more understandable to end users,
there has been a shift toward composite measures in many clinical
areas. For example, an endorsed cardiovascular care composite
encompasses the key secondary prevention elements critical for
prevention of cardiac events (e.g., use of aspirin, non-smoking status,
lipid control, and blood pressure control). Given the interest in these
measures, gaps for composite measures are also noted in the tables that
follow.
Gaps Across Cross-Cutting Areas
While many measures within the NQF portfolio relate to specific
conditions or clinical areas, others address or are applicable to
cross-cutting areas such as safety and care coordination. Currently
NQF-endorsed measures are categorized by these cross-cutting areas when
applicable, overlapping with many of the cross-cutting national
priorities outlined within the NQS.
Figure 2 provides a graphic representation of the more than 750
measures across these areas. This figure provides information on NQF-
endorsed measures by cross-cutting area, as well as the type of measure
(structure, process, outcome, and composite).
As demonstrated in the figure below, population health/prevention
and safety represent the cross-cutting areas with the largest number of
measures, while there are clear measure gaps in cross-cutting areas
such as care coordination and patient experience and engagement. In
addition, for areas with a range of measures, many focus on processes
of care. However, there has been an increased focus on outcome measures
with outcome measures now representing approximately 30 percent of the
NQF portfolio. Measure development is also evolving to new areas such
as resource use/cost (an area for which NQF is now endorsing measures)
and patient-reported outcomes. Planned NQF endorsement projects in the
coming year in these high priority areas, such as patient engagement
and population health, should help to fill some of these important
gaps.
[[Page 56950]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.010
The following sections address measures and gaps related to each of
the cross-cutting areas.
Making Care Safer
NQF has endorsed a robust set of patient safety measures. However,
gaps remain. For example, there is a need for measures that assess
broader, more cross-cutting issues of medication safety, rather than
measures that apply to separate medications. There is also interest in
``templates'' for medication management and safety that could be
applied to different medications or conditions. In addition, more
research on standard medication monitoring and its effect on outcomes
or complications are needed. There is also a recognized need to expand
available patient safety measures beyond the hospital setting and
harmonize safety measures across sites and settings of care. There have
also been recognized patient safety gaps in potentially high leverage
areas, such as healthcare associated infections (e.g., MRSA) and
measures that assess the culture of safety.
The NPP provided guidance on proposed goals and measure concepts
related to the National Quality Strategy. The following table provides
the NPP-recommended goals and measure concepts on Priority Area
1, Making Care Safer. Under the identified measure concepts,
there are gaps related to inappropriate medication use and
polypharmacy. There are also continued efforts to expand all-cause
safety measures.
[GRAPHIC] [TIFF OMITTED] TN14SE12.011
[[Page 56951]]
Ensuring Person- and Family-Centered Care
There have been a growing number of standardized measures that
assess patient experience in multiple care settings. However, as noted
in the NPP measure concepts related to this priority area, there is a
significant gap in measures that assess patient and family involvement
in decisions about healthcare. There is a growing evidence base on
decision quality and there is an expectation that these measures will
be submitted to NQF in the coming year. The measurement of care
planning and joint development of treatment goals has not been limited
by available evidence. It has been difficult to construct meaningful
measures that move beyond ``checkbox'' measures that assess whether a
plan exists.
[GRAPHIC] [TIFF OMITTED] TN14SE12.012
Promoting Effective Communication and Coordination of Care
In the area of care coordination, measures that focus on
communication and transitions across setting (e.g., medication
reconciliation and transitions from inpatient facilities to other
settings) and healthcare home have been endorsed, leaving many areas
outlined in the NQF care coordination framework (i.e., proactive plan
of care and follow-up, information systems) without current endorsed
measures. NQF is aware of some work to begin to leverage information
systems to facilitate care coordination, but in a recent call for
measures related to Care Coordination, NQF did not receive any new
measures to address this area. Some limited development is underway,
but much work remains.
The table below from the National Priorities Partnership's
September report shows the NPP-recommended goals and measure concepts
for Promoting Effective Communication and Coordination of Care, the
third priority area in HHS' National Quality Strategy. Several of the
measure concepts have associated endorsed measures, such as transition
records and advanced care planning. These endorsed measures tend to be
limited to certain populations and settings and there is a need for a
measure development and testing that would move these measures to
broader populations.
The NPP goals also specifically note the need for measures that
assess symptom management and functional status. While there have been
measures that assess patient function and well-being in certain
settings, such as home health and nursing homes, measures that assess a
change (or ``delta'') in function have been limited. In addition, while
there are many patient-level instruments/measures of health status and
function, there are few performance measures that utilize these tools
to assess the care provided by healthcare entities. In 2012, NQF will
work with experts to address some of methodological challenges that
have limited use of patient-reported outcomes across data platforms as
performance measures.
[GRAPHIC] [TIFF OMITTED] TN14SE12.013
[[Page 56952]]
Promoting the Most Effective Prevention and Treatment of the Leading
Causes of Mortality, Starting With Cardiovascular Disease
The following table provides the NPP-recommended goals and measure
concepts on Priority Area 4, Promoting the Most Effective
Prevention and Treatment of the Leading Causes of Mortality, Starting
with Cardiovascular Disease. While most of the identified
cardiovascular prevention concepts relate to currently endorsed
measures, there are some measurement gaps related to access to healthy
foods and nutrition. Evidence will likely be strong for these
cardiovascular prevention measures. The current NQF Population Health
project may bring some of these measures forward for evaluation for
endorsement.
Condition-specific measures and the gaps related to effective
prevention and treatment of high impact conditions, including
cardiovascular care, are discussed in the condition-specific section of
this report.
[GRAPHIC] [TIFF OMITTED] TN14SE12.014
Working With Communities To Promote Wide Use of Best Practices To
Enable Healthy Living
Measures that can assess the health of populations are a growing
area of interest in the measurement enterprise. Population health
focuses not only on disease across multiple sectors, but also on
prevention and health promotion. Identifying valid and reliable
measures of performance across these multiple sectors can be
challenging. The NPP-recommended goals and measure concepts for this
priority area are noted below. The NPP recommended a three-tiered
approach to population health to address the national priority of
working with communities to promote the wide use of best practices to
enable healthy living and well-being. While there have been endorsed
measures that relate to the receipt of clinical preventive services and
immunization measures across the lifespan, most, but not all, of these
measures focused on clinical rather than community settings. There are
measurement gaps in many of the population-level concepts below,
including social support, unhealthy drinking, obesity, and dental
health. In the current Population Health Project, NQF will evaluate
submitted population-level measures that include a focus on healthy
lifestyle behaviors and community interventions that improve health and
well-being. A new oral health project will also help to prioritize
dental concepts and identify gaps in both dental measures and evidence.
[GRAPHIC] [TIFF OMITTED] TN14SE12.015
Making Quality Care More Affordable
A new area for NQF endorsement is related to cost and resource use.
Currently, a small number of measures are under NQF review, examining
some specific clinical conditions as well as the total cost of care for
patients who interact with the healthcare system in a given year. While
private payers have captured and reported the associated costs and
resources used for patients within their systems, these measures had
not yet been publicly vetted; the current NQF work can pave the way for
[[Page 56953]]
increased transparency as well as the possibility of tracking costs in
a consistent manner by multiple payers and other interested parties.
Many challenges remain within this area, specifically enabling
measurement and reporting of costs/resources at the individual provider
level, and in the future, pairing these measures with those of quality
to begin to capture efficiency.
The NPP's guidance on proposed goals and measure concepts related
to this priority area appears in the table below. There are important
measure gaps related to access, per capita expenditures and
affordability. In addition, development of measures around potential
overuse of specific procedures may be limited by the available evidence
in clinical guidelines. However, the overuse measures that have failed
endorsement to date primarily relate to the lack of availability of the
detailed clinical information in claims data. Similarly, the ability to
construct a measure of preventable emergency department use has been
limited by the availability of data to assess the concept of
preventability.
[GRAPHIC] [TIFF OMITTED] TN14SE12.016
Identification of Gap Areas Based on Federal Programs' Measure Usage
The Measure Applications Partnership (MAP) is a public-private
partnership convened by the National Quality Forum (NQF) for the
primary purpose of providing input to the Department of Health and
Human Services (HHS) on selecting performance measures for public
reporting, performance-based payment programs, and other purposes. In
its first year, the MAP focused on the availability of measures for
federal programs and provided input on important measurement gaps. The
MAP Pre-Rulemaking Report provides input on over 350 measures under
consideration by HHS for nearly twenty clinician, hospital, and post-
acute care/long-term care performance measurement programs, using the
six NQS priorities to guide its recommendations. The findings of the
MAP related to gaps in the federal programs reinforce the gap analysis
presented in this report. For example, MAP found that most federal
reporting programs lacked measures in the areas of person and family-
centered care, and cost and appropriateness. Looking specifically at
clinical areas, MAP also noted a lack of measures in the area of mental
health. All these findings echo the lack of NQF-endorsed measures in
these areas as described.
In part due to MAP's required focus on the federal programs, which
to date have often been defined by setting of care, the MAP work
identified gaps by setting or provider type for the clinician, hospital
and Post-Acute Care/Long Term Care (PAC/LTC) federal reporting
programs. The high-level measure development and implementation gaps in
federal programs are included in the table below:
------------------------------------------------------------------------
---------------------------------------------------------------------------
Clinician Programs
------------------------------------------------------------------------
Patient-reported outcomes, health-related quality of life.
Shared decision-making, patient activation, care planning.
Care coordination.
Multiple chronic conditions.
Palliative and end-of-life care.
Cost including total cost, cost transparency, efficiency, and
resource use.
Appropriateness.
------------------------------------------------------------------------
Hospital Programs
------------------------------------------------------------------------
Cost--total cost of care, episode, transparency, efficiency.
Appropriateness--admissions, treatment.
Care coordination--transitions of care, readmissions, hand-off
communication, follow-up.
[[Page 56954]]
Patient-reported outcomes--patient and family experience of
care and engagement, patient and family preferences, shared decision-
making.
Disparities in care.
Special populations--behavioral health, child health, maternal
health.
Quality of life/well-being.
Pain.
Malnutrition.
Palliative Care--comfort, integration of patient values in care
planning.
------------------------------------------------------------------------
PAC/LTC Programs
------------------------------------------------------------------------
Functional status is a high-priority gap across all programs
because assessing function and change in function over time is a
baseline for tailoring care for individuals and population subsets.
A second prominent gap is measures that incorporate the
patient, family, and caregiver experience and their involvement in
shared decision-making.
Measures that assess if care goals are established using a
shared decision making process and if those goals are attained.
Measures understanding how providers use assessment information
to tailor goals.
Establishing and attaining care goals.
Care coordination, including transitions.
Cost.
Mental health.
Nutritional status.
------------------------------------------------------------------------
Gaps Across National Priority Areas by Condition-Specific Areas
To better highlight gaps areas, NQF further grouped its endorsed
measures by the following high impact conditions, and reported gaps by
each condition, mapped to the NQS priority areas. The condition-
specific areas map to the Prioritization of High-Impact Medicare
Conditions and Measure Gaps report prepared for HHS in 2011, with
additional high impact areas added to address younger populations
(e.g., child health, maternal health, and serious mental illness). For
example, NQF broadened the high-impact condition COPD to include other
pulmonary conditions (such as asthma.) Finally, related conditions,
such as acute myocardial infarction and congestive heart failure, have
been grouped together under the broader term of cardiovascular.
Alzheimer's Disease
Cancer
Cardiovascular
Cataract
Child Health
Depression
Diabetes
Glaucoma
Hip/Pelvic Fracture
Maternal Health
Osteoporosis
Pulmonary
Renal Disease
Rheumatoid Arthritis/Osteoarthritis
Serious Mental Illness
Stroke
In addition to categorizing the measures by NQS priority area, the
measure type (i.e., structure, process, outcome, and composite) have
been included in these tables. Figure 3 offers a high level analysis of
measures by clinical system. As evident in the table, there are many
clinical areas that need further outcome measure development.
[[Page 56955]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.017
As a result, high-level information is presented below regarding
gaps in endorsed quality measures within the priority areas identified
in the NQS. While there are many reasons for the persistent gaps in
performance measurement described below, many developers who submit
measures to NQF report that the lack of adequate financial support for
measure development is a major driver. In addition, measure gaps
persist due to insufficient evidence (e.g., management and treatment of
Alzheimer's disease) and methodological challenges related to emerging
measurement areas (e.g., aggregation of patient-reported outcomes into
measures appropriate for accountability and quality improvement).
Gaps Across National Priority Areas by Condition-Specific Areas
For each condition, the shaded spaces in the tables below represent
areas where there are NQF-endorsed measures addressing NQS priority
areas, by measure type. The blank spaces represent areas where there
are gaps in NQF-endorsed measures.
Alzheimer's Disease
While Alzheimer's is recognized as a critical area for measurement,
there is a gap in endorsed measures for this condition. There has been
limited measure development in this area, which was evidenced through a
request for measures by NQF that resulted in no submissions in 2010.
Through recent discussions with several developers, NQF has learned
that some development has begun. Future NQF measure endorsement
projects will include an opportunity for submission of newly developed
measures related to Alzheimer's disease.
[[Page 56956]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.018
Cancer
The set of endorsed cancer measures is primarily oriented to cancer
screening and effectiveness of treatment for specific cancers. For the
priority area of prevention, there are process measures addressing
breast, cervical, and colorectal cancer screening. For this topic,
there are gaps across all measure types in the healthy living priority
area. In the person and family centered care priority area, there are
several process measures and there are measures that specifically
address the quality of care received at the end of life through
caregiver surveys. For safer care, there are several process measures
and a small number of outcome measures. There is a gap in outcomes
related to cancer survival. There are a small number of overuse
measures related to affordable care. Gaps related to the quality of
life and other critical outcomes of care related to patients diagnosed
with cancer remain. No measures were brought forward to address these
gap areas in the recent call for measures for the current NQF Cancer
Endorsement Project.
[GRAPHIC] [TIFF OMITTED] TN14SE12.019
Cardiovascular Care
NQF has a very large set of endorsed cardiovascular measures
addressing conditions such as acute myocardial infarction, coronary
artery disease, and congestive heart failure. There are also endorsed
process, outcome, and composite measures related to healthy living and
prevention, including measures that align with the CDC goals in its
national initiative ``Million Hearts'' to prevent one million heart
attacks and strokes. While each of the clinical conditions within the
larger topic area of cardiovascular care has a robust set of measures
of process and outcome measures, gaps remain in the area of person- and
family-centered care. As a result of the NQF Patient Outcomes project
completed in 2011, several composite measures that examine care
transitions for cardiovascular care are now included in the NQF
portfolio. In addition, measures that assess coordination of care, such
as the recently endorsed measure that assesses referral to cardiac
rehabilitation after a heart attack, are in development. Measures that
begin to address affordable care are slowly increasing in numbers. For
example, NQF recently endorsed measures of appropriate use of cardiac
stress testing as well as measures that capture resources or costs
associated with specific cardiovascular conditions, but many gap areas
remain.
[[Page 56957]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.020
Cataract
While only a handful of measures have been endorsed in the area of
cataracts, these measures address the outcomes of cataract surgery.
Complications following surgery and improvement in patients' visual
function have been targeted. Currently, the measures focus on those
patients who have had surgery. Future measures should address the
appropriate selection of treatment of patients with cataracts, ensuring
that only those patients whose visual function and quality of life is
compromised receive surgery. There is also a need for measures that
address cataract outcomes for patients with multiple co-morbid
comorbidities, including diabetes. These may be examples where the
evidence base may limit applicability of these measures to more complex
patients.
[GRAPHIC] [TIFF OMITTED] TN14SE12.021
Child Health
The number of endorsed measures focused on child health has grown
in the last year--in part due to a targeted NQF Child Health project
that was completed in 2011. The portfolio has also expanded to
accommodate core measures for the CHIPRA program. Similar to Maternal
Health discussed below, Child Health has many measures focused on
screening, immunizations, well-child visits, and treatment for specific
clinical conditions. While there are endorsed outcome measures for
children, such as those that examine infection, mortality, and
readmission in the intensive care units, they are primarily hospital
focused rather than ambulatory. In terms of affordable care, there is a
measure focused on length of stay in pediatric intensive care units and
a measure of emergency department visits for children with asthma, both
of which address use of resources.
An opportunity exists to increase the number of measures that apply
to children by adapting adult-focused measures to apply to younger
ages. This gap is very dependent on measure developers' willingness to
apply measures to younger populations, but age-based population limits
and this limitation should only occur when the evidence does not
support the expansion to those under 18 years of age. In January 2011,
NQF released a report from the Measure Prioritization Advisory
Committee focused on measure development and endorsement agenda that
identified child health gaps in the areas of care coordination
(transitions, referrals, medical homes); acute and chronic management
(health promotion, community resources, timely and appropriate follow-
up of screening tests); and population health outcomes.
[[Page 56958]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.022
Depression and Serious Mental Illness
There is a growing set of endorsed outcome and process measures
that address depression. There are some endorsed measures that address
Healthy Living and Prevention (e.g., maternal depression screening,
suicide risk assessment). In NQF's Patient Outcomes project, measures
looking at whether remission of symptoms was achieved at 6 and 12
months were recently endorsed--a step toward assessing patient outcomes
related to depression. Many gaps remain specific to person- and family-
centered care. There are also a small number of endorsed process
measures related to safer care in the areas of medication management
and evaluation and assessment for major depressive disorder. There are
a limited number of measures that assess coordination of care, such as
persistent use of needed antidepressants, as well as follow-up care
after hospitalization.
There are many measurement gaps for patients with serious mental
illness. Currently, only measures specific to schizophrenia and bipolar
disease are endorsed, leaving many other mental health conditions
unaddressed. There are endorsed process measures that address
prevention and safer care (e.g., screening for potential comorbidities
for patients with bipolar disorder, use of multiple antipsychotic
medications). However, gaps remain specific to other priorities. There
is an endorsed patient experience of care measure for inpatient
psychiatric care and a set of measures that assess transition from
inpatient to outpatient care. Measure gaps relate to affordability,
such as potential measures that assess overuse of multiple
antipsychotic medications. There are also important population health
gaps for serious mental illness, including measures that would address
issue of social support and homelessness. NQF anticipates that
additional measures related to serious mental illness will be submitted
in the upcoming Behavioral Health project.
[GRAPHIC] [TIFF OMITTED] TN14SE12.023
Diabetes
While NQF has endorsed multiple diabetes measures, they are
primarily oriented to prevention and healthy living, including two
composite measures that address both processes and intermediate
outcomes for patients with diabetes. In healthy living, there are also
population-level measures that assess potentially preventable
admissions for diabetic complications. While there are measures that
address the treatment of patients with the disease, measures have not
yet been developed or endorsed that adequately
[[Page 56959]]
address the pediatric population or primary screening and prevention of
diabetes for high-risk individuals. Many of these gaps are due to the
lack of consistent, strong evidence on appropriate screening and
treatment. In the current NQF Resource Use project, a recently endorsed
measure captures the relative resource use for patients with diabetes.
This measure should allow implementers including payers to identify the
costs and resources associated with this chronic illness.
[GRAPHIC] [TIFF OMITTED] TN14SE12.024
Glaucoma
Two measures have been endorsed in the area of glaucoma that
address appropriate evaluations and the reduction of intraocular
pressures. Many gaps remain, including addressing patients' quality of
life, experience with care, care coordination, and education related to
treatments.
[GRAPHIC] [TIFF OMITTED] TN14SE12.025
Hip/Pelvic Fracture
There is a limited set of endorsed measures that address hip and
pelvic fracture. Two outcome measures were recently endorsed that
target the rate of complications and readmissions after hip surgery.
There is also an endorsed measure that examines the mortality rate
related to these fractures. Beyond these three outcomes measures, the
NQF portfolio includes measures that address osteoporosis screening and
treatment with several specifically targeting those patients who have
had a hip or pelvic fracture. Those measures are captured within the
discussion and analysis of osteoporosis and are not reflected in the
table below. Many gaps remain related to the coordination of care and
person/family centered care. For affordable care, resource use measures
related to hip fracture are under consideration in the current NQF
Resource Use Project.
[[Page 56960]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.026
Maternal Health
NQF has a growing set of endorsed measures that relate to maternal
health. There are several important process measures, such as ensuring
adequate screening, prenatal and postpartum visits, and appropriate
treatment during delivery. Several measures related to appropriate
processes or intermediate outcomes during labor and delivery (e.g., use
of prophylactic antibiotics and health-care acquired infections in the
newborn) are linked to the priority area of Safer Care. There are
measures that relate to affordable care, such as the rate of Cesarean
sections for first-time mothers and elective deliveries prior to 39
weeks. One significant area for which measures may be in development
but have not yet been submitted to NQF is related to reproductive
health.
[GRAPHIC] [TIFF OMITTED] TN14SE12.027
Osteoporosis
Few measures have been endorsed in the area of osteoporosis. To
date, those measures have focused on appropriate screening and
treatment, such as endorsed measures that target appropriate screening
or treatment following a fracture, or general screening of women at
risk. Significant gaps remain in areas that assess patients' quality of
life and functional status and care coordination, in addition to the
dearth of outcomes measures and the lack of applicability of the
current measures to men.
[[Page 56961]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.028
Pulmonary
For the purpose of this report, pulmonary conditions include
asthma, chronic obstructive pulmonary disease (COPD), and pneumonia.
There are many process measures that examine care for adults and
children with asthma, measures of appropriate use of medications to
prevent and treat exacerbations of COPD, and outcome measures related
to mortality and readmission for pneumonia. Several outcome measures
for pulmonary conditions were recently endorsed through the NQF Patient
Outcomes project, including care transitions for patients with
pneumonia and quality of life for patients with COPD in pulmonary
rehabilitation programs. While some measures looking at safer care and
person/family centered care have now been endorsed, measures related to
other pulmonary conditions or applicable to broader settings are
needed.
[GRAPHIC] [TIFF OMITTED] TN14SE12.029
Renal Disease
There is a broad set of measures related to End Stage Renal Disease
(ESRD) and a small but emerging set of measures related to chronic
renal disease. NQF has endorsed several process and outcome measures on
this topic, in the priority area of Healthy Living and Prevention. As
part of a recent End Stage Renal Disease (ESRD) endorsement project, a
CAHPS measure was endorsed that assesses patient experience with in-
center hemodialysis. There are also multiple outcome measures related
to adequacy of dialysis and infection rates. Evidence continues to
evolve regarding the appropriate target hemoglobin for patients with
ESRD. Due to the black box warning issued by the FDA and continued
changes to what hemoglobin levels are considered safe targets, NQF and
its committees have been reluctant to endorse measures for which the
evidence is not yet consistent to support a performance measure.
Additional gaps remain related to care coordination and affordable
care.
[[Page 56962]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.030
Rheumatoid Arthritis/Osteoarthritis
Few measures have been endorsed in the areas of rheumatoid
arthritis and osteoarthritis. To date, those measures have focused on
appropriate screening and treatment. For example, NQF has endorsed
measures related to medication safety for patients with rheumatoid
arthritis as well as measures that focus on ensuring appropriate
follow-up and testing to prevent toxicity. Significant gaps remain in
areas that assess patients' quality of life and functional status and
care coordination. There is also an absence of outcomes measures such
as functional status.
[GRAPHIC] [TIFF OMITTED] TN14SE12.031
Stroke
Within stroke, there are endorsed process and outcome measures
related to prevention, safer care and care coordination. Within safer
care, there are outcome measures related to potentially avoidable
complications and mortality after stroke. NQF has also endorsed primary
prevention related measures, such as anticoagulation for patients with
atrial fibrillation and secondary prevention related measures, such as
use of statins. There are multiple measures that assess the appropriate
care and screening for patients after stroke, including issues related
to anticoagulation and ongoing need for speech therapy. There is a
single endorsed measure related to stroke education, but no endorsed
measures that assess person and family centered care. There are also
gaps in measures in the healthy living and affordable care priority
areas. While NQF has not previously endorsed measures related to
affordable care, there are stroke-related resource use measures
currently in the NQF endorsement process.
[[Page 56963]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.032
Conclusion
While the NQF portfolio of endorsed measures can address many
important priority area and high priority clinical conditions, there
are many gaps that remain. While many measure gaps could be filled with
measure development, there would be a small sub-set where development
would be limited by available evidence. Another important impediment to
measure development in many high priority areas relates to the lack
high quality data for measurement. The move toward an electronic data
platform should help increase capacity to measure some of these
important concepts. Collectively, the NPP, MAP and endorsement-related
work provide a roadmap to where measures are needed to fill many
important gaps. This report can be used to target measure development
resources to areas where there are critical development gaps.
Appendix of Measures Included Within the Condition-Specific Areas
Alzheimer's Disease
* There are no measures in the portfolio for this condition.
BILLING CODE P
[[Page 56964]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.033
[[Page 56965]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.034
[[Page 56966]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.035
[[Page 56967]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.036
[[Page 56968]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.037
[[Page 56969]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.038
[[Page 56970]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.039
[[Page 56971]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.040
[[Page 56972]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.041
[[Page 56973]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.042
[[Page 56974]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.043
[[Page 56975]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.044
[[Page 56976]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.045
[[Page 56977]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.046
[[Page 56978]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.047
[[Page 56979]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.048
[[Page 56980]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.049
[[Page 56981]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.050
[[Page 56982]]
[GRAPHIC] [TIFF OMITTED] TN14SE12.051
BILLING CODE C
IV. Secretarial Comments on the Annual Report to Congress
The Secretary is pleased with the scope and vision of NQF's March
2012 annual report to Congress (the ``annual report''). An internal
multidisciplinary cross-component HHS team is working collaboratively
with NQF to provide for a clear multi-year vision to ensure the most
efficient and effective utilization of the HHS contract. The contract
with NQF provides an important opportunity to further enhance HHS'
efforts to foster a collaborative, multi-stakeholder approach to
increase the availability of national voluntary consensus standards for
quality and efficiency measures.
Over the past year NQF continued work on tasks outlined in the
Statement of Work, including: Providing additional input on the
development of a national strategy for performance measurement and
prioritization of measures for development and endorsement; conducting
measure endorsement projects focused on measure gap areas such as
outcomes measures and patient safety measures; maintaining current NQF-
endorsed measures; promoting Electronic Health Records through
activities that include developing a measure authoring software tool;
and retooling of a subset of existing NQF-endorsed measures into
electronic measure format. NQF provided input on the implementation of
the national priorities of the National Strategy for Quality
Improvement in Healthcare (NQS). The NQF convened the National
Priorities Partnership (NPP) and delivered a report that focused
further on enhancing patient safety, one of the six NQS priorities. The
NPP worked with HHS on the Partnership for Patients initiative. The
[[Page 56983]]
NQF continued its endorsement of quality measures for use in
accountability and performance improvement with a focus on crosscutting
measures and measures addressing costly and prevalent health
conditions. NQF convened the Measure Applications Partnership (MAP) to
foster alignment of measures in order to reduce reporting burden and
accelerate improvement in reporting. The MAP provided pre-rulemaking
guidance to HHS, including input on the selection of quality and
efficiency measures.
The Secretary has reviewed the annual report and has the following
comments. First, the Secretary notes an inadvertent statement in the
annual report. The statement appears in the third sentence of the first
paragraph on page 16 of the Report to Congress under the section
entitled ``3. Endorsing Measures and Developing Related Tools''. It
refers to NQF-endorsed measures and states they have ``special legal
standing''. The suggestion that NQF-endorsed measures enjoy ``special
legal standing'' is ambiguous and could be misinterpreted. Numerous
statutory provisions in the Social Security Act (the ``Act'') require
the Secretary to specify measures for quality programs that have been
endorsed by the consensus-based entity with a contract under section
1890(a) of the Act. NQF currently holds this contract and the Secretary
often selects NQF-endorsed measures for quality programs. Nonetheless,
the suggestion that these measures ``have special legal standing'' does
not describe the significance of NQF endorsement for measures the
Secretary selects. In addition, this statement oversimplifies the
complex intellectual property concerns that frequently attend federal
agency use, adoption, and dissemination of NQF-endorsed measures.
Second, the Secretary wishes to clarify a statement that has the
potential to be misleading. This statement appears in the final
sentence of the first full paragraph on page 7 of the Report to
Congress and states: ``As it turns out, NQF has already endorsed
measures for medication reconciliation, readmission, and care
transitions that apply to additional settings and populations so these
measures can move right into other federal programs.'' This sentence is
vague and the reference to measures moving `right into other federal
programs' does not accurately describe the process by which measures
are selected for use in quality programs.
Third, the Secretary also wishes to clarify a statement in the
sentence in the middle of the second column in ``Sidebar 5: Harmonizing
Surgical-Site Infection Measures'' on page 20 of the Report to
Congress. The sentence states: ``Notably, CMS has selected this
harmonized measure for inclusion in the 2012 final rule of the
Inpatient Prospective Payment System (IPPS).'' This sentence suggests
that the referenced measure--Surgical Site Infection--was included in
Fiscal Year 2012 Inpatient Prospective Payment System (IPPS)/Long term
Care Hospital Prospective Payment System final rule as part of the
payment for the IPPS program, when in fact this measure was finalized
in that rule for use in the Hospital Inpatient Quality Reporting
(``Hospital IQR'') program.
Fourth, the section entitled ``Eight Years of Hospital Reporting
Show Results'' on page 31 of the Report to Congress discusses
simultaneous reporting on measures by hospitals to the Centers for
Medicare & Medicaid Services (``CMS''), presumably for the Hospital IQR
program, and to the Joint Commission for hospital accreditation.
Although there may be some overlap in the measures on which hospitals
report to CMS and the Joint Commission, this section suggests that CMS
and the Joint Commission run the Hospital IQR program together, which
is not the case.
Fifth, the Secretary notes some ambiguity with respect to the
description of funding that NQF receives from the MIPPA and the
Affordable Care Act. Specifically the language in the Report to
Congress implies that the two laws directly appropriated funds to the
NQF, which is not accurate. The NQF receives MIPPA and Affordable Care
Act funding through a contract from HHS. In addition, regarding the
first bullet point before the text box entitled `Working with NQF
Helped Spur Rapid Evolution of Ophthalmology Measures,' the Secretary
clarifies that section 3014 of the Affordable Care Act amended section
1890(b) of the Social Security Act by adding paragraphs (7) and (8),
which require NQF to convene multi-stakeholder groups to provide input
on the selection of quality and efficiency measures and national
priorities for improvement in population health and the delivery of
healthcare services for consideration under the national strategy, and
to transmit the multi-stakeholder group input to the Secretary.
Sixth, the Secretary also wishes to note that section 3014 of the
Affordable Care Act added additional items that must be included in the
report that the consensus-based entity submits to Congress and the
Secretary that are not included in the last bullet in the narrative
prior to the next section, `2 Bridging Consensus About Improvement
Priorities and Approaches,' of the Report to Congress. Section 3014 of
the Affordable Care Act amended section 1890(b)(5)(A) of the Social
Security Act to require that the report submitted to Congress and the
Secretary identify gaps in endorsed quality and efficiency measures,
including gaps in priority areas identified in the national strategy,
instances where quality and efficiency measures are unavailable or
inadequate to address such gaps, areas in which evidence is
insufficient to support endorsement of quality and efficiency measures,
including priority areas, as well as the input provided by multi-
stakeholder groups on the selection of quality and efficiency measures
and the national priorities.
Finally, the Secretary wishes to clarify the first sentence in the
second paragraph on page 1 of the Overview section of the NQF Report on
Measure Gaps and Inadequacies. Section 3014 of the Affordable Care Act
amended section 1890(b)(5)(A) of the Act to add additional topics to
the items that must be described in the Report to Congress, but these
amendments did not change the date by which the entity with a contract
is required to submit the Report to Congress and the Secretary. That
date is March 1 of each year (beginning in 2009), not February 1, 2012
and annually thereafter, as the addendum states.
The Secretary is pleased with the progress and timeliness of the
work outlined in the Annual Report.
V. Future Steps
HHS provided a four-year contract to NQF. During this performance
year of the contract, NQF completed deliverables for each task required
by section 183 in MIPPA and by section 3014 in Affordable Care Act. In
the final year of the contract, HHS will continue to task NQF with
projects than can be completed wholly or partially by the expiration of
the current contract. In addition, HHS will develop a contract
mechanism to support the Affordable Care Act-required work needed
through FY2014.
Maintenance of Consensus-Based Endorsed Measures
During January 14, 2012 to January 13, 2013, NQF will maintain
endorsed measures relevant to HHS-wide programs and will continue to
maintain consensus-based endorsed measures as developed under the
priority process. Maintenance of NQF-endorsed measures encompasses five
areas: (1) Review of time-limited measure results, (2) annual updates,
(3) endorsement maintenance
[[Page 56984]]
projects, (4) ad hoc reviews, and (5) education to measure developers
on endorsement maintenance activities. In 2012, 42 time-limited
endorsed measures are expected to undergo NQF review while 276 measures
will require annual updates. Measures in these topical areas are
undergoing endorsement maintenance: Cardiovascular, surgery,
palliative/end-of-life-care, renal, perinatal, cancer, and pulmonary/
critical care measures. In addition, NQF will begin endorsement
maintenance projects for the following four topics: Gastrointestinal/
genitourinary; infectious diseases; neurology; head, ears, eyes, nose
and throat (HEENT). Finally, NQF is prepared to undertake ad hoc
endorsement reviews as needed and will be hosting web-based educational
events on its endorsement maintenance activities.
Promotion of Electronic Health Records
In 2012, NQF will continue to support the promotion of electronic
health records as part of HHS-wide efforts. NQF's contributions will
include enhancements of the Quality Data Model, which specify the
necessary data for electronic and personal health records. NQF will
continue hosting and enhancing the Measure Authoring Tool, and will
provide technical assistance and support to tool users. NQF will also
maintain an online Knowledge Base of information gleaned during the
eMeasure retooling process of 2011, the subsequent comment and updating
process, and the ongoing consulting activities that began in 2011. The
Knowledge Base will be available on the NQF Web site for public use and
updated at a minimum on a monthly basis to highlight new critical
issues that are identified. The content of the Knowledge Base will
support educational requirements for measure developers, measure
implementers, EHR vendors, clinician, health care organizations, health
information exchanges, and others as new stakeholders are identified.
In addition, NQF will help HHS transition the Measure Authoring Tool to
HHS for continued hosting and enhancements.
Focused Measure Development, Harmonization, and Endorsement Efforts To
Fill Critical Gaps in Performance Measurement
In 2012, NQF will finish endorsement efforts focused on efficiency/
resource use measures and regionalized emergency care services. In
addition, NQF will perform an assessment of need among key stakeholders
for a measure registry, a system capturing the lifecycle of a measure
with capability to track versions of measures as they proceed through
their lifecycle. Such a registry could assist measure developers and
users to better identify measures in development, especially those
identified as filling critical gaps, and how measures are similar and
different version to version. General issues/concerns regarding
establishing, using, and maintaining a registry (e.g., intellectual
property, data quality, incentives for use) will be explored specific
to health care performance and cost measures.
Convening Multi-Stakeholder Groups
NQF will continue work to provide further input into the National
Quality Strategy and annual selection of quality measures for use in
public and private reporting programs and value-based purchasing
programs.
V. Collection of Information Requirements
This document does not impose information collection and
recordkeeping requirements. Consequently, it need not be reviewed by
the Office of Management and Budget under the authority of the
paperwork Reduction Act of 1995 (44 U.S.C. 35)
Dated: August 27, 2012.
Kathleen Sebelius,
Secretary, Department of Health and Human Services.
[FR Doc. 2012-22379 Filed 9-13-12; 8:45 am]
BILLING CODE P