1. The Quality Initiative
A Public Resource on
Hospital Performance
August 2003
I am delighted to be able to join you for this important colloquium on patient safety.
We share a common goal of improving care for all Americans.
On behalf of the American Hospital Association and the many other organizations involved in the Quality Initiative, I consider it a privilege to have this opportunity to tell you about our public-private partnership efforts to make hospital quality more transparent.
I expect to offer two perspectives-
One as at an AHA Board member
One as a Hospital CEO
Our Hospital is committed to quality- quality monitoring- disclosure
This is the way that we can improve quality and hold ourselves accountable.
With this said I also think that there must be standards and definitions in order to make sure that the information and data is relevant, accurate, and comparable.

2. Honoring Our Commitments
To give the best care we know how to give
Foster a relationship of caring and trust with each patient
Foster a relationship of caring and trust with the communities we serve
The dilemma:
The public gets little information on quality
Hospitals are inundated with requests for data
Let me start by reminding you that all American hospitals are committed to:
Providing the best possible care
Fostering a relationship of trust and caring with the patients we serve and with the communities we serve
In recent years, the Institute of Medicine’s reports, “To Err is Human and Crossing the Quality Chasm”, as well as many reports in the lay press have generated much attention to the issue of quality, including safety, in our health care delivery system.
These reports have correctly pointed out that despite our efforts, too often there is a gap between the care we should give and the care we do give.
As part of fostering that relationship of trust with the communities we serve, hospitals and other health care facilities need to be accountable for the quality of their care, but currently the public gets little information about health care quality.
Simultaneously, hospitals are being inundated with requests for data on quality by purchasers, payers, oversight organizations, and others who are acting on behalf of consumers and purchasers of care.

3. The Quality Initiative
Objective
Create a shared national strategy for quality measurement and public accountability
This dichotomy --- lots of data being collected, but little information being produced to fill the very real need to give the public as well as hospitals and health care providers a picture of health care quality ---- is what led the AHA, the Association of American Medical Colleges, and the Federation of American Hospitals to begin talking to other national organizations.
We wondered if we could work together to meet the public’s need for information and to reduce the redundant, wasteful and confusing data collection activities.
We wanted to work together to create a shared national strategy for quality measurement and public accountability.

4. The Quality Initiative
Goals
Share useful information with the public
Prioritize measurement areas
Standardize measurement specifications
Facilitate predictable measurement reporting
Reduce duplication
These were our common goals:
To share useful information with the public
Find ways to prioritize measurement so that hospitals were working to deliver information that was the most useful to the public
Ensure we used standardized measurement specifications that were scientifically valid and reliable assessments of quality
That we would bring some predictability to measurement reporting by mapping out a long term strategy for what should be measured and how it would be measured,
And through all of these steps, reduce duplication

5. The Quality Initiative
Agreement
Voluntary reporting - Start with 10 measures of 3 conditions
Acute myocardial infarction
Congestive heart failure
Pneumonia
Add patient perception of care measures
Add more clinical measures - IOM priority conditions
Support performance improvement
What will we do in this Quality Initiative?
First, we are starting by asking hospitals to make information available from 10 well-known and proven clinical measures of care for 3 specific conditions Heart attack, heart failure and pneumonia.
These are process measures that look at whether the right drug or test is being given to the patient at the right time
Some have noted that using well known measures of these 3 conditions is not a bold step forward in quality measurement. They are right of course.
The challenges we thought needed to be addressed in this first phase were not those of bold innovation in measurement, but rather issues of:
whether we could keep all of these diverse organizations working together to achieve a common goal;
whether we could marshal the resources to collect, validate, and analyze these data in a manner acceptable to all involved;
and most importantly, whether we could figure out how to turn these data points into real information that is understandable and useful to the public.
It has not been easy.
We are looking forward to the next phases of our work, in which we will add patient perceptions of care and additional measures of different clinical conditions, drawn at least initially from the Institute of Medicine’s list of 20 priority conditions.

6. Starter Set of Clinical Measure
AMI (heart attack)
Aspirin at arrival
Aspirin at discharge
Beta-Blocker at arrival
Beta-Blocker at discharge
ACE Inhibitor for LVSD
Heart Failure
Left ventricular function assessment
Pneumonia
Initial antibiotic timing
Pneumococcal vaccination
Oxygenation assessment
Here are the 10 specific clinical measures we are using.

7. IOM Priority Areas of Focus
Care Coordination
Self-Management/
Health Literacy
Asthma
Cancer Screening
Children w/ Special Health Care Needs
Diabetes
End of Life Care for those with major organ failure
Frailty with Old Age
Hypertension
Immunizations
Ischemic Heart Disease
Major Depression
Medication Management
Nosocomial Infections
Pain Control in Advanced Cancer
Pregnancy and Childbirth
Severe and Persistent Mental Illness
Stroke
Tobacco Dependence
Obesity
These are the 20 areas that the IOM identified in the report released January 20 (National Priorities for Health Care Improvement)
As you look at this list, you see some that are clearly related to inpatient care
You also see some more relevant for the ambulatory setting (e.g., asthma, tobacco dependence, cancer screening)
One of our tasks over the next few months will be to determine what about hospital care should be measured for these priorities.
A process for soliciting this input is being crafted; but there will be opportunities for you to contribute ideas in the near future.
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Note to JS: If asked, you can tell them that the options for soliciting ideas include both calls for written comments, discussions held at meetings such as the Colloquium, and asking state and local hospital associations to work with local community groups to host some discussion sessions that would provide input.

8. Partners AHA, AAMC, FAH CMS AHRQ JCAHO National Quality Forum AFL-CIO
AARP
Nat’l Assoc of Children's Hospitals
The Disclosure Group
AMA
These are the organizations involved in this public-private partnership are:
The American Hospital Association
The Association of American Medical Colleges
The Federation of American Hospitals
The Department of Health and Human Services, particularly the Centers for Medicare and Medicaid Service and the Agency for Healthcare Research and Quality
The Joint Commission
The National Quality Forum
The AARP
The AFL- CIO
the National Association of Children’s Hospitals and Related Institutions
and more recently, the American Medical Association, and a group called The Disclosure Group, which is comprised of some of the business organizations and consumer organizations that have been most adamant about making information on quality available to the public.

9. New Developments Participation - Hospitals Pledged Eligible
Participants Hospitals %
Total Hospitals , %
Number of Beds , , %
Admissions 14,157,731 34,233, %
One of the major features of this Initiative is that it is voluntary.
We feel strongly that this will allow hospitals to prove that they are willing to share valid and reliable information with the public they serve and to be more interested in using the data to make improvements.
While some were skeptical that hospitals would volunteer for this Initiative, we believe that the strong initial response has shown that hospitals will step forward.
As of mid-August, a total of 1,503 hospitals have volunteered to participate, and they have 35% of the general acute care beds in the country and provide care to 41 % of the admissions.
We continue to work hard to get additional hospitals to volunteer, and are dedicated to getting much closer to involvement from all of the eligible hospitals.
Please know that it takes an investment to participate- there is a cost to abstract the charts and it can divert quality staff from areas identified as priorities at individual hospitals.

10. Public Release of Data
September 2003 as information for health professionals ----
Summer 2004 as information for the public
We will begin making information available that is designed for use by health professionals next month.
We will continue to work hard to figure out how to turn that clinical data into information that is suitable for the public --- that makes it clear both what the data mean and, importantly, what they do not mean.
All the while, we will continue to work to expand the information we make available.

11. Endorsements State Hospital Associations Endorsing the Initiative
The state hospital associations have been very supportive to our efforts.
Many have formally endorsed the Quality Initiative, as shown in blue on this map.
The three states shown in red are the 3 states involved in a pilot project sponsored by CMS, which was designed to experiment with ways in which we can turn clinical data into information that is useful to the public and to test the patient survey that I will talk about in a minute.
In these 3 pilot states, the hospital associations have been intimately involved in recruiting hospitals and helping to turn data to information.
State Hospital Associations Endorsing the Initiative
State Hospital Associations Engaged in CMS Pilot Project

12. Next Steps Patient Perspectives of Care
Needed to round out quality picture
Hospital CAHPS tool created by CMS and AHRQ
Being pilot tested in AZ, MD, NY
AHA View --- should address 8 aspects of care, including patient perspectives on safety
We believe that some of the best information for members of the public will come from the patient perception of care survey that is under development by AHRQ and CMS.
Surveys of the public have told us consistently for the past 25 years that when faced with hospitalization, people rely consistently on the advice of their doctors and their friends and family about the quality of care provided in their community hospitals
This survey will provide them with information on not only how their own friends and family members felt about the care they received, but also how lots of other people friends and family members felt.
As some of you may know, the survey was sent to 44,000 people in Arizona, New York and Maryland as part of a pilot test. The results are currently undergoing scrutiny so that the survey instrument can be perfected and shortened from its current length of 66 questions.
We have advocated to CMS and AHRQ that as they work to improve the survey, they focus on eight critical aspects of care that have been important to the work that hospitals have done in working with their patient survey vendors, such as the quality of the nursing care, the quality of the physician care, and their assessment of patient safety.

13. AHA View Patient Perspectives of Care
Allow hospitals to incorporate into existing patient surveys
Flexibility in administration, but comparability first
Continuous data collection
Conduct survey within 45 days of discharge
Adjust for patient differences
We have also suggested to CMS and AHRQ that the most effective way to administer the survey will be to allow it to become part of the normal work that hospitals do with their current patient satisfaction survey vendors.
For most hospitals, there is a long-standing relationship of trust with one of the major survey vendors, and those vendors not only have expertise in the administration of surveys to patients, they also can provide assistance to hospitals seeking to improve their performance in their patient’s eyes.
Still, we know that different methods of surveying can produce different results, and so we have suggested that in allowing different vendors to administer the survey, AHRQ and CMS need to identify what methods of surveying are acceptable and how we can adjust for any differences in ratings that might result solely from the method of administration.
Further, to ensure the accuracy of the data, we have suggested that
The surveys be conducted continuously to avoid seasonal affects in the data,
The surveys should be conducted within 45 days of a patient’s discharge, and that
The survey results be adjusted for differences in the demographics and state of health of the patients that might influence the results.

14. Strategic Issues
Broaden agreement on single data collection and reporting
Necessary so hospitals can accommodate more measures
Add measures
Start with IOM priorities, but get broad input
Move ahead rapidly, but only after attain consensus on measures
Increase hospital participation
As we move forward with this Initiative, we know that we face some significant challenges.
First, to accomplish our goals of reducing the redundant data collections and freeing hospital resources to focus on priority areas for measurement and improvement, we need to engage a broader array of organizations in working with us on this single effort.
These might include insurers, business coalitions, quality improvement organizations, state agencies, and others seeking to measure and share information on hospital quality
Simultaneously, we need to expand the clinical aspects of care that we are measuring so that we are providing the opportunity for the public to take a look at critical aspects of hospital care, without being buried in data.
To ensure we are moving ahead to deliver information that people really want to know and can use, we will be soliciting input from a broad array of interested parties over the next few months. Using the list of the Institute of Medicine’s 20 priority conditions as a starting point for these conversations, we will seek to get input so that we can prioritize our additions to the measures we are using and the conditions we are measuring.
We are working through the National Quality Forum to ensure that each of the measures we choose has been vetted through their consensus process and found to be valid, reliable, and useful.
Additionally, while we are pleased with the response we have received thus far from hospitals to the invitation to participate in the Initiative, we know that the project will only be successful if we achieve greater levels of participation. We will be working hard to learn why hospitals have not signed up, and to eliminate those barriers.

15. The Quality Initiative
A Public Resource on
Hospital Performance
August 2003
Thank you for this opportunity. I welcome your suggestions about how we can make the Quality Initiative more successful.