AHQA Comments on the Strategic Framework Board Report to the National Quality Forum 20 May 2001 Effective delivery of health care is a very complex undertaking. It requires timely diffusion of and investment in, ever-changing technology, integrated information management, judicious deployment of financial resources, meaningful patient education and participation in care, well-organized and supportive administrators, and patient, flexible, and well-educated health care professionals. Recent studies have demonstrated inadequacies in reaching this ideal and have highlighted serious gaps in the delivery of even well documented, basic care practices. The report developed by the Strategic Framework Board (SFB) offers an ambitious vision for a more effective health care system and provides an agenda for change over the next two decades. The recommendations, if implemented, will require enormous investment and change in behavior by payers, government, health professionals, and patients. Whether this level of change is possible given the multitude of pressures felt by administrators, physicians, nurses and payers is of great concern to the community of local quality improvement organizations that we represent. The QIOs/PROs work with providers every day who struggle to keep up with changing care practices, personnel shortages, and increasing regulatory expectations. These recommendations must be considered in that context and would have been strengthened by a more thorough discussion of those pressures. In addition to providing a more thorough discussion of the barriers to implementing these recommendations, the document does not include much discussion of the measurement and quality improvement efforts already underway upon which these actions would build. Providers and practitioners, their national and state associations, private and public sector quality data analysts and consultants, accreditation organizations and purchasers are already at work on measuring the performance of the health care system. In fact, some of the models discussed are well illustrated by current efforts. The PRO program for example, is built on the premise that measuring whether patients received treatment well documented to be associated with more positive outcomes is an effective way of measuring quality. The report outlines this concept, but does not use the PRO program as an example. A more thorough discussion of this and other experiences with this model could have highlighted issues related to collection of data, measure specifications, and motivation for change that would have connected the vision in this paper with the manner in which the vision would be put into practice. We do not point this out to suggest that there is no need for more effort. Clearly, more focus and resources are critical. The SFB recommendations would have been more easily implemented if the reader could connect the vision laid out with current efforts. Specific Comments Motivational Factors. "A primary assumption of this paper is that "extrinsic" motivation is necessary to speed adoption by providers of "improvement adoption." The report then suggests that health professionals and administrators must be subject to public reports, threats of de-selection or given tools - the primary tool discussed is a sophisticated information system -- to consider improving the quality of the care they deliver or arrange to be delivered. AHQA agrees that these forces are sometimes very useful in encouraging provider behavior change. However, the implications of relying on these forces must also be examined. For example, in considering the use of public reporting of data for accountability as a primary driver for quality improvement, it is critical to appreciate the negative consequences of this strategy: such reliance increases the technical difficulty of measure construction and increases the defensiveness of health professionals under such scrutiny. In addition, while a sophisticated information management system would be a great facilitator of quality improvement processes it is also very expensive and complex to put in place. Heavy reliance on purchaser selection to drive health quality improvement has never really been tested. It is a tool that is very difficult for public programs to use because of the need to provide access to all beneficiaries and the importance of the government as a payer. It is also difficult for private purchasers to limit their networks. The public appears to care more about access to large networks than the quality of each individual provider or practitioner. One consequence of a model that relies heavily on the breadth of accountability measures discussed in this report could be system fatigue which could reduce the likelihood that the system will achieve the long term goals as expressed in this manuscript. One way to use external pressure to encourage quality improvement without creating the negative consequences described above is to use a sequential strategy for quality improvement. This would be done by introducing measures for improvement purposes and determine at a later point in time if and when the measures should be used for accountability purposes, e.g. whether improvement is occurring without published accountability data. This approach gives health professionals the opportunity to understand the dynamics of such data and integrate the clinical message into operations in a timely fashion. Accountability should be an expected event rather than an unwelcome surprise. AHQA does agree with the SFB comments regarding financial incentives. We believe a concerted effort is needed to consider ways to align the financial incentives within the system so that improving the quality of care is rewarded. Measure Development and Use. AHQA supports the concept outlined in this report of using the needs of information users to drive the development of software. Currently, most information systems in institutions are designed for payment purposes, not for quality improvement. In the future, the needs of patients and clinicians for quality improvement purposes must also be considered in the development of information systems. These systems must not only be useful for internal management, but as stated in the recommendations for external reporting and data gathering. Expecting providers to collect the information once for patient care purposes and again for performance measurement and improvement is unsustainable. The report advocates the development and adoption of clinically relevant, minimally burdensome, risk adjusted performance measures, but the technical difficulties in designing and implementing such measures are understated. Measures designed for internal quality improvement purposes will not require the level of rigor that measures used for comparison or public accountability will need. Engaging Health Care Providers to Improve the Quality of Care. The report includes a very thorough analysis in the Chapter entitled "Engaging Health Care Consumers to Improve the Quality of Care" of the limitations of current efforts to engage consumers in driving the market for clinical quality and outlines several ways in which they could become more engaged. It is notable that the report did not include such a chapter on provider engagement. Careful examination of the forces that inhibit broader quality improvement efforts and the inclusion of examples in which providers have worked successfully on their own or with external organizations to improve quality would have made it more likely that these recommendations would be used. AHQA believes that information for consumers to choose plans, providers and treatment options is an important goal all on its own. However, the role for consumers in quality improvement is an indirect one. They press for changes and the providers implement them. The distinction between information for consumer choice and for quality improvement must be clear, and mechanisms for engaging health care providers should be addressed directly. Role of the NQF. The report includes very useful suggestions for how the NQF could go about developing measures. AHQA believes it is critical for the NQF members, board of directors and staff to determine its role in measure development. As the NQF process of developing various measure sets through the process of its Steering Committee, questions will arise about the level of detail and whether the measures have been adequately tested for the purposes for which they were designed. For example, if the NQF is going to develop numerators and denominators or reporting formats it is critical that, in addition to the consensus process outlined in the report, it create a process for Alpha and Beta testing to determine if the measures provide the information envisioned. In summary, the Strategic Framework Board report represents a vision which will require years of investment and creative work to become reality. While performance measurement for accountability will become an inevitable aspect of the system, over reliance on it to drive quality improvement may undermine some of the goals articulated in this report. In addition, the technical barriers to the creation of effective performance measures that meet the specifications outlined in this report should not be underestimated. We believe that the National Quality Forum, for whom this Report was prepared, is a logical place for the next level of discussion to occur -- how to move our national resources for quality improvement and measurement towards this framework.