NATIONAL CONSENSUS STANDARDS FOR PHYSICIAN PERFORMANCE: ROUND 1 Kenneth W. Kizer, M.D., M.P.H. President and CEO National Quality Forum August 22, 2005

Presentation Overview Provide some context for physician performance standards Provide an overview of the NQF Ambulatory Care PM Project: What has occurred to date? What is forthcoming?

STANDARDS FOR PHYSICIAN THE IDEA OF HAVING STANDARDS FOR PHYSICIAN PERFORMANCE IS NOT NEW

The Quest for Healthcare Quality “If a physician make a large incision with the operating knife and cure it,…, he shall receive ten shekels in money. If a physician make a large incision with the operating knife, and kill him,…, his hands shall be cut off.” Code of Hammurabi, 1870 BC

TODAY’S INCREASED ATTENTION TO HEALTHCARE QUALITY IS BEING DRIVEN BY AN UNPRECEDENTED CONFLUENCE OF FORCES

Healthcare Quality Improvement Driving Forces Knowledge of deficiencies Rising healthcare expenditures Purchaser activism Consumerism Regulation and accreditation

A CROWDED FIELD Who are the “players” in the performance measurement and quality improvement game?

A partial list of the Alphabet Soup of PM/QI-Related Organizations JCAHO NCQA CMS IOM AHRQ FDA NQF CDC QIOs HQA GAO PCPI OPM NBCH ACQA Leapfrog MedPAC ACMQ IHI WBGH PBGH QUIC UHC ABMS

Lots of Signals….. BUT Little Direction

There is need for a single national entity to be the steward for healthcare performance measurement and quality improvement.

NATIONAL QUALITY FORUM The NATIONAL QUALITY FORUM (NQF)

NQF-ENDORSED CONSENSUS STANDARDS

NQF Consensus Development Process Board of Directors, NQF Staff & Management Member Councils, Non-member External Entities Conceptualize and Plan Project Appoint Steering Committee and Technical Advisory Panels NQF ( nominations from membership and public) Steering Committee with NQF Staff (any entity can propose measures, etc., for consideration Identify (open call) and Evaluate measures, etc.; Propose candidate voluntary consensus standard (VCS) Review and Revise Member Councils, Member Organizations, Public Vote by Member Councils Member Organizations Approved by All Member Councils Review and Revision of unapproved VCS Review and Revision of unapproved VCS Member Councils, Member Organizations, Public Repeat Vote Approved by at least 2 Councils Approved by 0 or 1 Council (no further action) Board of Directors Vote Board of Directors Appeals of Board-endorsed VCS Members and Nonmembers directly and materially affected by VCS NQF-Endorsed Voluntary Consensus Standard

NQF National Consensus Standards: Patient Safety Patient Safety Strategic Priorities (2001) Serious Reportable Adverse Events (2002) Safe Practices (2003) Standardized Patient Safety Taxonomy (2005) Improved Medication Use Recommendations (2005) Improved Informed Consent Process (2005)

NQF National Consensus Standards: Institutions/Settings of Care Acute Care Hospital National Performance Measures Initial Set (2003) Nursing Care PMs (2004) Cardiac Surgery PMs (2004) Coordination of Care PMs (2005) Mortality for AMI, CHF and CAP (2005) HCAPHS (2005)

NQF National Consensus Standards: Institutions/Settings of Care Nursing Home Care Performance Measures (2002, 2004) Home Care PMs (2005) Palliative and Hospice Care Framework (2005) Ambulatory Care (2004-2008) Dialysis Centers/ESRD (2006)

NQF National Consensus Standards: Conditions/Populations Diabetes (2002, 2005) Cancer Care Quality Measures (2004-2007) Deep Venous Thrombosis (2005-2007) Child Healthcare PMs (?2006) Behavioral Healthcare PMs (2005-2006)

NQF National Consensus Projects National Priorities for Healthcare Quality Measurement and Reporting 15 Healthcare conditions priorities 5 Process of care priorities 2 Infrastructure priorities

NATIONAL CONSENSUS STANDARDS FOR AMBULATORY CARE

NQF National Consensus Standards: Ambulatory Care Project Phase I (2004) – Identify priority areas Phase II (2005) – Expedited consensus of existing ambulatory care PMs Phase III (2005-2008) – Flesh out all 12 priority areas; four cycles

National Consensus Standards for Ambulatory Care: Phase I - Priority Areas Patient experience with care Coordination of care Asthma Prevention, including immunization Medication management Ischemic heart disease Diabetes Hypertension Depression Obesity

National Consensus Standards for Ambulatory Care: Additional Priority Areas Prenatal care Bone conditions

National Consensus Standards for Ambulatory Care: Phase II 36 physician-focused PMs endorsed in seven priority areas (8/3/05) 6 measures will undergo a second round of voting 2 measures not endorsed will be re- considered in Phase 3

NQF-EndorsedTM Ambulatory Care Consensus Standards Asthma/Respiratory Illness (4) Behavioral Health/Depression (3) Bone Conditions (2) Heart Disease—CAD(10), CHF (7) Hypertension (2) Prenatal Care (2) Prevention, Immunization, and Screening (6)

NQF-EndorsedTM Ambulatory Care Consensus Standards Asthma/Respiratory Illness Asthma assessment Asthma: pharmacologic therapy Appropriate treatment for children with upper respiratory infection Appropriate testing for children with pharyngitis

NQF-EndorsedTM Ambulatory Care Consensus Standards Behavioral Health/Depression Optimal practitioner contacts for medication management Effective acute phase treatment Effective continuation phase treatment Bone Conditions Osteoarthritis: assessment for use of anti-inflammatory or analgesic over-the-counter medications Osteoarthritis: functional and pain assessment

NQF-EndorsedTM Ambulatory Care Consensus Standards Heart Disease—Coronary artery disease Symptoms and activity Cholesterol screen Lipid profile Drug therapy for lowering low-density lipoprotein (LDL) cholesterol Cholesterol control LDL cholesterol level Anti-platelet therapy Beta blocker therapy–prior myocardial infarction ACEI/ARB therapy Smoking cessation and smoking cessation intervention      

NQF-EndorsedTM Ambulatory Care Consensus Standards Heart Disease—Congestive heart failure Left ventricular function (LVF) assessment Weight measurement Assessment of clinical symptoms of volume overload Assessment of activity level Beta blocker therapy ACEI/ARB therapy Warfarin therapy for patients with atrial fibrillation

NQF-EndorsedTM Ambulatory Care Consensus Standards Hypertension Plan of care Controlling high blood pressure Prenatal Care Anti D immune globulin Screening for human immunodeficiency virus (HIV)

NQF-EndorsedTM Ambulatory Care Consensus Standards Prevention, Immunization, and Screening Tobacco use and tobacco cessation Advising smokers to quit, discussing smoking cessation medication, and discussing smoking cessation strategies Discussing urinary incontinence and receiving urinary incontinence treatment Flu shot for older adults and flu shot for adults ages 50-64 years Influenza vaccination Pneumonia vaccination    

Phase II Measures in 2nd Round of Voting Use of appropriate medications for people with asthma Coronary artery disease: Beta-blocker treatment after a heart attack Childhood immunization Breast cancer screening Colorectal cancer screening Cervical cancer screening

National Consensus Standards for Ambulatory Care: Phase III Cycle 1 (Fall 2005): care coordination, medication management, obesity, asthma, hypertension, prevention Cycle 2 (Spring 2006): patient experience with care, heart disease, bone conditions, prenatal care, behavioral health, diabetes

National Consensus Standards for Ambulatory Care: Phase III Cycle 3 (2006-2007): special ambulatory settings of care (i.e., ambulatory surgical centers) Cycle 4 (2007-2008): development of index/composite measures

National Consensus Standards for Ambulatory Care: Project Deliverables Sets of endorsed consensus standards Recommendations for implementation and research issues for each set. Commissioned background paper on barriers to small group (< 5), provider-level implementation Index(es)/composite(s) for ambulatory care measurement and reporting. Workshop to guide ambulatory care measurement research, development, and testing