January 17, 2002 Kenneth W. Kizer, MD, MPH President and CEO National Quality Forum 601 Thirteenth St, NW Suite 500 North Washington, DC 20005 Dear Dr. Kizer: On behalf of The American Health Quality Association (AHQA), an NQF member representing the national network of Quality Improvement Organizations (QIOs, formerly known as Peer Review Organizations), we thank you for this opportunity to comment on the NQF’s Strategic Framework Board (SFB) recommendations. We wish to communicate our sincere appreciation to the members of the SFB for their dedication and service to the NQF. AHQA supports NQF adoption of the SFB recommendations with the amendments that we provide in the body of our comments. We note that the underlying SFB report, which provides the substantive underpinnings for these recommendations, is couched in theoretical terms. We view it as a shortcoming of the report that it takes no notice of the national Medicare health care quality improvement program (HCQIP) continuously operated by the Centers for Medicare and Medicaid Services (CMS, formerly HCFA) and the QIOs since 1994. This state of the art program is already implementing most of the SFB recommendations, including those pertaining to reliance on national goals, careful development of quality measures, and communication and education of providers, practitioners, and consumers. The national Medicare QIO program is now preparing to expand several state projects into a national program to simultaneously report quality measures to the public while facilitating quality improvement by providers, practitioners, and health plans. When appropriate we offer modifications we believe will strengthen the recommendations. We have also provided specific examples of the work of the QIOs as it exemplifies the principles presented by the SFB. We believe the experience of CMS and the QIOs, along with other pioneering efforts such as the Veterans Affairs improvement program you guided, illustrates both the feasibility of the SFB recommendations and the challenges that must be resolved in implementing them. As NQF works to incorporate the elements of the SFB recommendations into its strategic and staff work plans, AHQA invites the NQF leadership and staff to consider AHQA and the national QIO network as a valued resource for your quality measurement and improvement efforts. Sections A & B: Setting National Goals and Using Quality Measures. SFB Recommendations #1 – 3. The Strategic Framework Board recommended: The NQF should establish a set of specific goals for health care quality improvement that: are consistent with the six aims for the health care system proposed by the Institute of Medicine, will drive the selection and implementation of common measures, relate to clinical conditions that are prevalent or have a high risk of disability, suffering or death, represent the needs of diverse populations, are based on evidence that effective clinical care strategies exist, and are supported by expert groups and compelling to relevant constituents. The NQF should develop a parsimonious common set of quality measures that is continually improved based on feedback from providers and other key users of the information. To be selected, common measures must: be linked directly to a national goal, have a clear and compelling use, not impose undue burden on those who provide data, help providers improve the delivery of care; and help consumers select plans, providers, or treatments. All agencies and organizations that request data on health care processes and outcomes from providers and plans should commit to reducing the burden of reporting by eliminating redundancy and rework. AHQA agrees with the SFB principles relating to the setting of national goals and adopting measures. These principles have already largely been implemented on a national scale by hospitals, physicians, and QIOs under a model program, the Health Care Quality Improvement Program (HCQIP). This national quality improvement initiative is built on carefully selected set of goals that have already led to improved care for Medicare beneficiaries in six critical disease areas— breast cancer, diabetes, heart attack, heart failure, pneumonia, and stroke. CMS engaged a broad community of interest in targeting clinical goals. Working in collaboration with national organizations representing physicians and researchers, as well as QIOs, CMS developed HCQIP using the principles similar to those contained in the SFB recommendations. For example: The targeted clinical goals for HCQIP were selected because of their salience to efforts to reduce morbidity and mortality in the population of older Americans. The clinical indicators selected for the HCQIP program have "strong scientific evidence and practitioner consensus that there are processes of care that can substantially improve outcomes" and documented need to improve performance. (JAMA, October 2000, Vol. 284(13). CMS dedicated resources to coordinate projects to improve care provided to diverse and underserved populations. The HCQIP project includes financial resources and a system for medical record abstraction so that providers would not be burdened with this responsibility. QIO activities were structured to improve systems of care, rather than seek out an individual practitioner or provider. Federal mandated confidentiality protections are integral to the HCQIP, to encourage the free exchange of information and documentation without the fear of punishment. QIOs have a special responsibility to recognize the burden associated with their work under HCQIP. Over the years, QIOs have engaged in a number of activities designed to alleviate duplication of effort and centralization of data collection. The 24 current measures employed by the HCQIP include most of the HEDIS clinical measures, and a number of QIOs are licensed Oryx vendors. A number of Information Systems (IS) products have been developed by CMS and the QIOs and made available for use by providers in data collection and analysis. We have attached documents reflecting CMS’ draft deliberations during 2000, as it evaluated potential goals and measures for the upcoming QIO contract cycle. It is worth noting that in managing the Medicare QIO program, CMS officials have been taking into account additional factors not evident in the SFB’s recommendations, such as evidence of interest by potential partners, costs that may be incurred by a variety of stakeholders, and the existence of proven intervention strategies that may be employed to bring about improvement. These should be incorporated in the final list of principles adopted by the NQF. SFB Recommendations #4 – 6. The Strategic Framework Board recommended: Measures in the common set must include: an explicit clinical model, an appropriate registry structure and content for patient identification and measurement by front-line providers, specific report formats that have successfully passed testing with intended user groups, conditions under which risk adjustment is required, and audit standards for assessing implementation. Measures included in the common set will: collect data once; use clear, standard, functional definitions; collect data as close to their source as possible by being integrated into the process of care delivery; and collect data so that they can be combined, analyzed, and reported to serve a wide variety of purposes. Electronic medical record developers should: use the NQF common measures as a template for system designs; and, use the NQF framework for assessing and improving quality as the basis for developing standard data definitions needed for effective use of electronic medical records. With regard to the elements of the common data set, AHQA strongly supports the conditions included under each set. The conditions are consistent with the conditions QIOs consider when developing goals and quality measures. With regard to the electronic medical record (EMR), AHQA supports the development of EMR systems that follow the SFB principles. By incorporating quality measures and the tools to abstract quality measures into the template for the EMR, funds currently dedicated to data collection could be redirected to systems improvement. Section C: Communication and Education AHQA supports these recommendations, with some modifications. Communication and education are critical components of the QIO quality improvement work plan. Without consumer, provider, and practitioner buy-in, quality improvement is unachievable. SFB Recommendation #7 – 9. The Strategic Framework Board recommended: The NQF should work with private and public groups to develop a communications strategy to: increase public awareness about the nature and magnitude of quality problems, and identify the actions that the public, health professionals, and institutional providers can take to improve health care. The NQF should lead the effort to ensure that public performance reports are compelling and useful to consumers and are designed to support decision-making. The NQF should define and develop the processes necessary for the timely delivery of widely disseminated performance reports that are targeted to the needs of different audiences and their uses (e.g., choice, improvement). AHQA concurs with these recommendations. We would like to suggest some ways NQF may build on the experience of others who have already begun the work the SFB has called for. In addition, we propose some modifications to the SFB’s recommended approach that take cognizance of the nature of the NQF’s leadership role. Medicare is investing significant resources in a national communication strategy, that will constitute the nation’s largest quality improvement communications program. The strategy includes Medicare beneficiary outreach and education, as well as public reporting of provider specific quality measurements. CMS, working with the QIOs, is engaged in an effort to ensure that public performance reports are compelling and useful to consumers. CMS and QIOs are also working together on public reporting delivery mechanisms that are responsive to the needs of consumers, providers, practitioners, payers, and other stakeholders. SFB recommendation number 9 is a good description of the kind of leadership that NQF can bring to coordinating the various public and private programs involving public reporting of quality data. Recommendations 7 and 8 should be revised to reflect this appropriate role for the Forum. Modification #1: In order to preserve NQF’s limited financial and human resources, AHQA recommends it play the role of facilitator of a national communications strategy, rather than developer. In SFB recommendation number 7, strike the word "develop" and replace with, "facilitate." Modification #2: With regard to public reporting and the development of population specific resources, NQF should focus on the coordination of public performance reports and serve as the clearinghouse for various products and tools already in existence. In SFB recommendation number 8, strike the word "lead" and replace with, "coordinate." Section D: Making It Happen SFB Recommendation #10. The Strategic Framework Board recommended: Private and public purchasers (e.g., large employers, CMS) should require providers (hospitals, nursing homes, physicians) and health systems to routinely and publicly report performance on a common set of measures. We recommend that NQF include language recognizing the significant technical and statistical challenges, usually specific to particular care settings, disease states, procedures and data sources, that must be resolved before mandatory reporting can contribute to advancing the quality improvement agenda. These challenges are being overcome in several states, often with the assistance of QIOs, and the lessons learned thereby should be incorporated in any national reporting strategy. SFB Recommendations #11 – 12. The Strategic Framework Board recommended: The NQF should develop, test, and implement processes that will: evaluate quality measurement, remove barriers to quality improvement, and establish awards for quality performance. Health professionals’ education must include the knowledge and skills basic to quality improvement. AHQA is supportive of the intent of these recommendations. However, the action plan recommended for #12 is not educational and does not describe a learning process. NQF should carefully examine the role of academic institutions and academic accrediting agencies in developing knowledge and skill sets in health care professionals. SFB Recommendation #13: The Strategic Framework Board recommended: Provider organizations should ensure that individual providers are able to effectively interpret and utilize performance information for decision-making and quality improvement. AHQA and its member QIOs consider that providing providers and practitioners with the information and assistance necessary to interpret and utilize performance information is one of our most critical duties and significant strengths. The recommendation seems to allocate full responsibility for this function to provider organizations, implicitly suggesting that only providers have a stake in quality improvement. AHQA believes purchasers have a stake in this principle, and should assume some measure of responsibility for the quality of the products and services they purchase on behalf of health plan enrollees. CMS provides an excellent example in this regard, by making sure that performance information for decision-making and quality improvement is readily available and understandable. The Leapfrog Group has also assumed a leading role in developing such information and making it available to providers, practitioners, and the public. Other purchasers have a similar responsibility toward their covered populations. Modification #3: To broaden the scope of recommendation number 13, AHQA recommends that NQF strike "provider organizations" and replace with, "Purchasers, provider organizations, quality improvement organizations and other relevant stakeholders." SFB Recommendation #14: The Strategic Framework Board recommended: AHRQ should be funded to develop a program of technical assistance for health care delivery systems moving aggressively to implement quality improvement as a strategy. AQHA generally supports this recommendation, but we also feel that it is important to recognize the contributions and partnerships of other key federal agencies (e.g., PHS, CMS, VA, DoD, SAMHSA, HRSA) to assist in quality improvement in health care delivery systems. For example, SAMHSA has worked closely with CMS and the QIOs in the development of a model system for bringing about improved quality in the diagnosis and treatment of depression in managed care settings. Modification #4: Broaden the scope of recommendation number 14 to recognize the role of other federal agency collaborators, by adding "and other federal agencies" after "AHRQ". Section E: Research and Development SFB Recommendations #15 –17. The Strategic Framework Board recommended: HHS should convene a national research agenda conference to identify needs, funding strategies and implementation of a 5-year agenda. Federal research agencies and private foundations should focus funding on the following areas where gaps exist and needs are clear. Funding for and investment in quality measurement, reporting, and improvement research and development should have the following goals: (a) triple AHRQ’s budget over the next five years, (b) the NQF should establish a target for national quality investment, (c) AHRQ should fund research to determine the investments in information systems and other infrastructure development necessary to support quality improvement efforts. AHQA is generally supportive of these suggestions. We offer a concern that these recommendations may be too focused on AHRQ as the sole federal agency receiving all of the NQF’s support. Modification #5: To broaden the scope of SFB recommendation number 17 and to recognize the important contributions that could be provided through other federal agencies, delete subsection (a) of recommendation 17 and emphasize the importance of subsection (b). This can be accomplished by removing the parentheses in subsection (b), and offering a strong recommendation about a specific percentage increase in the nation’s investment in quality improvement. Thank you for affording this opportunity to comment on the Strategic Framework Board’s recommendations. Please contact me or Dr. Mark Boesen at (202) 261-7571 with any questions regarding this letter. Sincerely, David G. Schulke Executive Vice President Attachments Attachment 1: Topic Significance Criteria Importance to Medicare population. How many people have the condition or receive the service; how many associated disabilities, deaths, etc.? Science. II. A. Treatment. Good science supports that there are treatments that make a difference. II. B. Measurement. There are valid, tested, feasible measures of performance that can be used to measure success in improvement. Performance Gap. There is a substantial difference between actual performance and what is achievable that, on the basis of science, results in substantial harm to the health of Medicare beneficiaries. Interventions. There are interventions that PROs (and partners) can take to reduce the performance gap. These interventions may have been proven by the PROs or by other quality improvement organizations. Partnerships. V. A. Outside Partners. There are partners interested in this priority area that will make a significant contribution to improvement, either through their independent contributions or through support for PROs' work or through PROs using the work of partners to leverage the effect of the PROs' work V. B. Departmental Priorities. Departmental priorities such as disparities, mammography, and antibiotic resistance may make a topic more appealing. Cost. VI. A. To PROs. The cost to PROs is reduced if there are particularly simple or efficacious strategies, if work in the priority area synergizes with work in other areas in which PROs are already engaged, or if collaboration with partners can reduce costs. VI. B. To Providers, Practitioners, and Plans. Cost to providers, practitioners, and plans will strongly influence their willingness to participate. Cost can be reduced either by making participation efficient or by arguing a business case for investment in quality. VI. C. To Medicare Trust Funds. Will the project either increase or reduce trust fund outlays. Applicability to non-Hospital settings. Both because the PROs are currently focused fairly heavily on hopsital settings and because health plans/QISMC have a special interest in projects in nonhospital settings, projects in those settings have a high priority. Even within a setting such as hospitals, projects that broaden the scope of PRO activities are preferred to intensify an existing focus. Attachment 2: Readiness Criteria Three products must be available for a topic to be considered ready for implementation as a PRO national priority topic: A set of validated, including clinically validated, and reliable quality measures appropriate for use in PRO performance-based contracting. State-specific baseline rates for the quality measures. Successful interventions demonstrating that PROs can improve care as reflected in the quality measures are available to all PROs.