National Agenda for Performance Measurement: Strategic Imperatives Helen Burstin, MD, MPH Senior Vice President, Performance Measures AAN Pre-Course October 13, 2011

Outline The quality enterprise The evolution of performance measurement Evaluation of performance measures Strategic implications for nursing Discussion 2

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 3

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. 4

NQF’s Roles  Standard setting organization  Performance measures, serious reportable events, and preferred practices  Neutral convener  National Priorities Partnership (NPP)  Measure Applications Partnership (MAP) 5

Set Priorities and Goals National Quality Strategy High-Impact Conditions Standardize Measures Portfolio of NQF- Endorsed Measures se Prioritize Endorse Implement Build Consensus About Select Measures for Reporting, Payment, QI, and Evaluation 6 Accreditation & Certification Health IT Incentives Public Reporting Value-based Payment 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 BETTER CARE AFFORDABLE CARE HEALTHY PEOPLE/ COMMUNITIES 7

HHS’s National Quality Strategy 8

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) 9

Outline The quality enterprise The evolution of performance measurement Evaluating performance measures Strategic implications for nursing Discussion 10

Measurement Improvement 11 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

13 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 14

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16 © 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 21

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 18

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 19

Resource Use Measures: A Building Block 20 Value Stakeholder Preference Efficiency QualityTime Resource use Costs/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 21

Outline The quality enterprise The evolution of performance measurement Evaluation of performance measures Strategic implications for nursing Discussion 22

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 23

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

Endorsed Measures by Measure Type Color legend: Process (white); Outcome (blue), Structure (orange) Outcomes = One third of endorsed measures

Quality Data Model Logic Standards Measure Authoring Tool Capture Data Calculate Performance Measures Real-Time Info to Clinician Publicly 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 33

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 STATUS Cross-Cutting Aims: Prevention, Safety, Quality, Efficiency Population Health System Individual Measurement Perspective Employers Payers HEALTH INFORMATION FRAMEWORK Healthy People / Healthy Communities 34

Outline The quality enterprise The evolution of performance measurement Evaluation of performance measures Strategic implications for nursing Discussion 28

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. 29 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.” 30 Lamb & Jennings, American Nurse Today, January 2011

HHS’s National Quality Strategy 31

Example: Person- and Family-Centered Care Goals: 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 Partnership 32 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 Partnership 33 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 34

35 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, MPH Senior Vice President, Performance Measures