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National Agenda for Performance Measurement:

Strategic Imperatives

Helen Burstin, MD, MPHSenior Vice President, Performance Measures

AAN Pre-CourseOctober 13, 2011


Outline

• The quality enterprise• The evolution of performance

measurement • Evaluation of performance measures• Strategic implications for nursing• Discussion

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Strategies for Reforming Health Care

Public Reporting: engaging consumers and others stakeholders

Health Information Technology: enabling improvement

Value-Based Payment: rewarding achievement

Clinically-Integrated Delivery Systems: achieving patient-centered, coordinated care

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NQF’s Mission

To improve the quality of American healthcare by:

Building consensus on national priorities and goals for performance improvement and working in partnership to achieve them;

Endorsing national consensus standards for measuring and publicly reporting on performance; and

Promoting the attainment of national goals through education and outreach programs.

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NQF’s Roles

Standard setting organization

Performance measures, serious reportable events, and preferred practices

Neutral convener

National Priorities Partnership (NPP) Measure Applications Partnership (MAP)

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Set Priorities and Goals

National Quality Strategy

High-Impact Conditions

Standardize Measures

Portfolio of NQF- Endorsed Measures

sePrioritize Endorse Implement

Build ConsensusAbout Select Measures for

Reporting, Payment, QI, and Evaluation

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Accreditation& Certification

Health IT

Incentives

Public Reporting

Value-basedPayment

NQF: Public-Private Partnerships Encourages Alignment


HHS’s National Quality Strategy

Principles reflect: Patient-

centeredness and family engagement

Quality care for patients of all ages, populations, service locations, and sources of coverage

Elimination of disparities

Alignment of public and private sectors

© National Priorities Partnership

BETTERCARE

AFFORDABLECARE

HEALTHY PEOPLE/

COMMUNITIES

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Measure Applications Partnership

Health reform legislation, the Affordable Care Act (ACA), requires HHS to contract with the consensus-based entity (currently NQF) to “convene multi-stakeholder groups to provide input on the selection of quality measures” for public reporting, payment, and other programs.

HR 3590 §3014, amending the Social Security Act (PHSA) by adding §1890(b)(7)

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Outline


measurement • Evaluating performance measures• Strategic implications for nursing• Discussion

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Measurement Improvement

1111

Measurement is not an end in itself – the purpose is to improve healthcare quality


• Drive toward higher performance • Measure disparities in all we do• Shift toward composite measures (all/none

and weighted composite)• Harmonize measures across sites and

providers• Measurement across longitudinal patient-

focused episodes– Outcome measures– Appropriateness measures – Cost/resource use measures coupled with quality

measures, including overuse

Quality Measurement in Evolution


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Composite Measures

• A composite measure is a combination of two or more individual measures in a single measure that results in a single score.

• Examples:• CAD: Optimally Managed Modifiable Risk

(HealthPartners)• Description: Percentage of members who have optimally

managed modifiable risk factors (LDL, tobacco non-use, blood pressure control, aspirin usage).

• Pediatric Patient Safety for Selected Indicators (AHRQ)• Description: A composite measure of potentially

preventable adverse events for selected pediatric indicators including: accidental puncture or laceration, decubitus, ulcer, iatrogenic pneumothorax, postoperative wound dehiscence, postoperative sepsis and selected infection due to medical care


Harmonization and Competing Measures• Avoid duplicative measures that don’t add

value (and increase burden) • Measure only where and when

measurement is appropriate• Harmonized measures should be used to

assess care across providers and settings– Immunizations– Central line blood stream infections– Pressure ulcers

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© National Priorities Partnership

Integrated Framework for Performance Measurement


Episodes Model Measurement Domains

• Patient-level outcomes (better health)– Patient experience of care– Morbidity and mortality– Avoidance of complications (e.g., HAIs)– Functional status and health-related quality of life

• Processes of care (better care)– Composites– Care coordination and transitions – Alignment with patients’ preferences

• Cost and resource use (overuse, waste, misuse)– Total cost of care across the episode– Indirect costs

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Use of Patient Reported Outcomes

• Validated patient-level outcome measures and instruments (e.g., PROMIS)

• Challenges to use for accountability and performance improvement:– Not in widespread use in clinical practice; and – Little is known about aggregating these patient-level

outcomes for measuring performance of the healthcare entity delivering care

• Recent examples:– Depression remission at 6 and 12 months using PHQ9– Functional capacity and HRQOL for COPD patients

before and after pulmonary rehabilitation

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New NQF PRO Project

• Facilitate the development, testing, endorsement, and implementation of PRO-based performance measures

• Methodological issues that need to be addressed to use PROs for performance measurement.– Units of Analysis– Risk Adjustment/Stratification– Organization-Level Measures– Global versus Condition-specific Measures– Data collection/survey methods

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Resource Use Measures: A Building Block

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Value

StakeholderPrefere

nce

Efficiency

Quality

Time

Resource useCosts/resources used to

provide care


Payment Reform Models

Increasing aggregation of services into a unit of payment

Payment for service Payment for event or condition

Payment for care of a population

Fee-for-service

Augmented fee-for-service

(e.g., P4P)

Bundled payment (single

provider)

Bundled payment (multiple

providers)

Partial capitation

Full capitation

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Outline



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NQF Evaluation Criteria

• Importance to measure and report • What is the level of evidence for the measures? • Is there an opportunity for improvement?• Relation to a priority area or high impact area of care?

• Scientific acceptability of the measurement properties • What is the reliability and validity of the measure?

• Usability • Are the measure results meaningful and understandable

to intended audiences and useful for both public reporting and informing quality improvement?

• Feasibility • Can the measure be implemented without undue burden,

capture with electronic data/EHRs?• Assess related and competing measures

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Evidence for Measure Focus

• Hierarchical preference for– Outcomes linked to evidence-based

processes/structures– Outcomes of substantial importance with plausible

process/structure relationships– Intermediate outcomes– Processes/structures

Most closely linked to outcomes

OutcomeIntermediateOutcome

ProcessStructure


Endorsed Measures by Measure Type

Color legend: Process (white); Outcome (blue), Structure (orange)

Outcomes = One third of endorsed measures


QualityDataModel

Logic

Standards

Measure Authoring Tool

Capture DataCalculate Performance

MeasuresReal-Time Info to

ClinicianPublicly Report

How can I say what I want so that all readers will interpret it the same way?

How can I create my measure so that an EHR and the average clinician can each understand it?

What is available in an EHR that I can use to create my measure?

NQF’s Health IT Portfolio Supporting Development of the Necessary Electronic Infrastructure

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http://www.clker.com/clipart-26534.html

http://www.clker.com/clipart-26534.html


Performance Measures and Information Requirements Will Change Overtime

Individual Characteristics

Behaviors, Social/Cultural Factors, Resources, Preferences

Community / Environmental Characteristics

Clinical Characteristics

Health Related Experience

Patient, Consumer, Care Giver

HEALTH STATUSCross-Cutting Aims: Prevention,

Safety, Quality, Efficiency

Data Sources

(Structured / unstructured, clinical, claims)

EHR PHR HIE

Public Health Surve

y

Registry Etc.

Population

Health SystemIndividual

MeasurementPerspective

Employers

Payers

HEALTH INFORMATION FRAMEWORKHealthy People / Healthy

Communities

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Outline



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NQF and Nursing

• 2004 Nursing Care Framework: – Patient-centered outcomes– Nursing-centered intervention measures– System-centered measures

• Future research focus on care functions central to nurses -- demonstrate positive effects of nursing on patient education, transitions, symptom management, outcomes, improved functional status.

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MD Naylor, Med Care Res Rev 2007; 64; 144


Examples of Nursing Contributions to NPP

• Patient and family engagement– “Informed decision making, honoring patient choices, and

providing tools for patients and families to manage their care are time honored in the nursing profession.”

• Care coordination– “The area with the greatest opportunity for nursing to

advance and accelerate the achievement of NPP goals”• Population health

– “Performance measures that reflect health rather than disease, including measures that capture nursing’s contributions to population outcomes.”

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Lamb & Jennings, American Nurse Today, January 2011



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Example: Person- and Family-Centered CareGoals: • Improve patient, family, and caregiver

experience of care related to quality, safety, and access

• Using a shared decisionmaking process, develop culturally sensitive and understandable care plans

• Enable patients and their families and caregivers to effectively navigate and coordinate their care

© National Priorities Partnership32

Measure Concepts: Patient and family

experience of quality, safety and access

Patient and family involvement in decisions about their care

Joint development of treatment goals and plans of care

Confidence in managing chronic conditions

Easy-to-understand instructions to manage conditions


Identifying Measure Gaps

Health & Well-Being: Healthy lifestyle behaviors Community environmental

assessment Productivity measures

Prevention & Treatment of Cardiovascular Disease: ABCS Healthy foods

Person- & Family-Centered Care: Person & family experience of care

composites National indicator of the use of

experience surveys in various settings

Care planning

© National Priorities Partnership33

Patient Safety: Healthcare-associated condition

measures Harmonized readmission measures Inappropriate medication use &

polypharmacy Unnecessary imaging

Effective Communication & Care Coordination:

Care transitions End-of-life care Exchange of patient

information/records Vulnerable populations requiring

healthcare and social supports

Affordable Care: Affordability indices Measures of unwarranted variation

and overuse


Take Home Messages

• Strategic directions for performance measurement:– Greater focus on outcomes for patients and

populations, including disparities– Safety, quality and cost matter– Take advantage of emerging longitudinal electronic

data platform to capture patient-reported outcomes– Nothing about patients without the voice of patients

and their families– Harmonize measures whenever and wherever

possible• Strategic implications for nursing:

Measurement in these emerging areas will naturally bring greater focus to the role of nurses

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Not everything that counts can be counted, and not everything that can be

counted counts

~Albert Einstein

But…

You can’t improve what you don’t measure

The Measurement Imperative


Thank You

Helen Burstin, MD, MPHSenior Vice President, Performance

[email protected]

mailto:[email protected]

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Documents

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performance improvement

quality enterprise

measures portfolio of

composite measures allnone

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