1. National Quality Strategy Webinar
Using Measurement for Quality Improvement
September 17, 2014

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3. Agenda Welcome Heather Plochman, Facilitator
Introduction to the National Quality Strategy
Nancy Wilson, Executive Lead
National Quality Strategy
Centers for Medicare & Medicaid Services
Kate Goodrich, Director, Quality Measurement and Health Assessment Group
Office of the National Coordinator for Health Information Technology
Kevin Larsen, Medical Director, Meaningful Use
Questions and Answers
Presenters

4. The National Quality Strategy: Using Measurement for Quality Improvement
Nancy Wilson, B.S.N., M.D., M.P.H.

5. Here is a high-level look at how the National Quality Strategy works
Here is a high-level look at how the National Quality Strategy works. I’m going take you through it step by step. Our ultimate goal is the three aims of the National Quality Strategy, which are better care, better health, and lower costs. I’ll take you through this graphic from left to right.

6. Quality Can Be Measured and Improved at Multiple Levels
Community
Population-based denominator
Multiple ways to define denominator (e.g., county, HRR)
Applicable to all providers
Practice setting
Denominator based on practice setting (e.g., hospital, group practice)
Increasing commonality among providers
Increasing individual accountability
Individual physician
We’re here to talk about one of the most important levers for achieving the National Quality Strategy: quality measurement
There are three levels of measurement critical to achieving three aims of National Quality Strategy: the community, the practice setting, and individual physician
Measure concepts should “roll up” to align quality improvement objectives at all levels
Patient-centric, outcomes-oriented measures is preferred at all three levels
The six priorities can be measured and improved at each of the three levels
And yet, despite quality measurement’s many virtues there is also work that needs to be done in harmonizing and aligning the measures we use
Denominator bound by patients cared for
Applies to all physicians
Greatest component of a physician’s total performance 6

7. Rationale for Addressing Measure Proliferation
Proliferation of measures used by HHS Agencies for numerous programs and initiatives
Redundancies and overlaps leading to provider/data collector burden, conflicting results, inefficient use of HHS resources, and lost opportunities to drive improvement through reinforcing program use of key measures
No formal systematic mechanism to align, coordinate, and approve development, maintenance, implementation, and retirement of measures across HHS programs
Precedent work done by Million Hearts™, Partnership for Patients, internal CMS Quality Measures Task Force, and MU2
Quality measurement began in earnest in the 1970s with the HMO movement and standardization of Medicaid and Medicare professional standard review organizations, and increased in importance and number into the 1990s.
At the turn of the millennium, a pair of landmark studies showed us that the right care was only being delivered half the time, and was even doing harm in far too many cases. Meanwhile, health care costs continued to rise at several points above inflation every year.
Providers, purchasers, payers, and policymakers alike demanded improvement, and you can only improve what gets measured. We’ve seen tremendous improvement across the country in the interim, but without a formal system for alignment we’ve also seen the number of quality measures rose to their extraordinary number today: 2,082 documented in the National Quality Measures Clearinghouse as of this morning.
To begin to address this issue within HHS, we came together as a group to form the Measurement Policy Council

8. HHS Measurement Policy Council (MPC)
Assembled in spring 2012 with membership representative across HHS Agencies
Establishes and operationalizes policies for HHS-wide measure development and implementation
Work to date has focused on:
Reviewing publicly available HHS Measures Inventory and tackling topics around nine measure areas
Developing a coordination plan for future measure development
Piloting rules for categorizing measures across the Federal Government and multi-stakeholder groups
The HHS Measurement Policy Council was assembled in spring 2012 with representative membership across HHS agencies
The Council is responsible for coordinating HHS-wide measure development and implementation policies
The work to date includes:
Creation of 9 harmonized core measure sets
A Measure Development Coordination Plan
Rules for Categorizing Measures According to Care Setting and NQS Priorities 8

9. MPC Guiding Principles
Focus on measures and policies that maximize quality improvement, minimize provider burden, and allow for assessment of the health of populations
Deliberately align with National Quality and Prevention Strategies (and others when relevant)
Leverage lessons learned from related HHS and external activities
Develop consensus on standard definitions for data components of measures as well as measures themselves
Maintain a portfolio of easily accessed artifacts from MPC deliberations
Recognize alignment may not always be appropriate, but document justification when this occurs
Use Measure Applications Partnership (MAP) to measure selection criteria
The MPC guiding principles center around:
Aligning measures where appropriate, both inside and outside HHS
Focusing on measures that matter, finding the optimal sets of measures that will be of the most benefit at least cost
Developing standard definitions, data dictionaries, and other guidelines

10. MPC Scope of Work: Short-Term
To date, the Measurement Policy Council has reviewed and prioritized measures in nine major areas:
Hypertension
Depression
Smoking Cessation
Hospital-Acquired Conditions
Care Coordination (closing the referral loop)
Patient Experience of Care
HIV/AIDS
Perinatal
Obesity/BMI
We’ve been busy on the Council, creating core measure sets for nine topics to date (with several more on the way). You can access the core measure sets at the Working for Quality Web site.
These topics span the six NQS priorities, and represent some of the highest-importance topic areas.
Up next will be diabetes, cardiovascular disease, patient-reported outcomes, among others. 10

11. MPC Scope of Work: Long-Term
Measure alignment
Develop criteria on when it is appropriate/not appropriate to align measures within HHS
Develop consensus on the measure aspects on which to align (concepts, specifications, data sources, etc.)
New measure development and implementation
Implement strategic direction for future measurement priorities
Coordinate measure submissions to the MAP
Coordinate measure development contracts
Measurement policy/management
Manage measure domains
Identify measure selection, removal, and retirement criteria
Create core sets of measures
The long term scope of work for the MPC is laid out here.
In the interest of person-centeredness, we’d love to hear from you on areas where the MPC could help you – topics that need alignment, measure gaps, areas requiring standardization, or areas requiring innovation. You can your comments to
I’d now like to turn the floor over to my colleague, Dr. Kate Goodrich, Director of the Quality Measurement and Health Assessment Group at the Centers for Medicare & Medicaid Services and co-chair of the HHS Measurement Policy Council.

12. Centers for Medicare & Medicaid Services
Kate Goodrich, M.D., M.H.S. Director, Quality Measurement and Health Assessment Group
Centers for Medicare & Medicaid Services

13. Objectives & Desired Outcomes Performance Measures and Targets
Strategy Logic
Strategic
Altitude
Mission
Vision
Goals
Objectives & Desired Outcomes
Performance Measures and Targets
Initiatives
Activities
What do we exist to do?
30,000 ft.
What is our picture of the future?
What are our main focus areas for improvement? What results are needed to satisfy stakeholders?
What continuous improvements are needed to get results?
How will we know if we are achieving desired results?
15,000 ft.
What actions could contribute to the desired results?
What will support the initiatives?
Ground Level

14. The Strategy is to Concurrently Pursue Three Aims
Better Care
Improve overall quality by making health care more patient-centered, reliable, accessible, and safe
Improve population health by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care
Healthy People /
Healthy Communities
Affordable Care
Reduce the cost of quality health care for individuals, families, employers, and government 14

15. CMS Framework for Measurement Maps to the Six National Quality Strategy Priorities
Care Coordination
Patient and family activation
Infrastructure and processes for care coordination
Impact of care coordination
Population / Community Health
Clinical Quality of Care
Measures should be patient- centered and outcome-oriented whenever possible
Measure concepts in each of the six domains that are common across providers and settings can form a core set of measures
Care type (preventive, acute, post-acute, chronic)
Conditions
Subpopulations
Health Behaviors
Access
Physical and Social environment
Health Status
Efficiency and Cost Reduction
Person- and Caregiver- Centered Experience and Outcomes
Cost
Efficiency
Appropriateness
Patient experience
Caregiver experience
Preference- and goal-oriented care
Safety
All-cause harm
HACs
HAIs
Unnecessary care
Medication safety 15 15

16. Reduce inappropriate and unnecessary care
Make Care Safer
Objectives
Reduce inappropriate and unnecessary care
Prevent or minimize harm in all settings
Improve support for a culture of safety
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6

17. Promote Effective Prevention and Treatment
Objectives
Increase appropriate use of screening and prevention services
Strengthen interventions to prevent heart attacks and strokes
Improve quality of care for patients with multiple chronic conditions
Improve behavioral health access and quality care
Improve perinatal outcomes
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6

18. CMS’ Vision for Quality Measurement
Align measures with the National Quality Strategy and six measure domains/priorities
Implement measures that fill critical gaps within the six domains, particularly patient experience and patient-reported outcomes
Align measures across CMS programs whenever possible
Promote parsimonious and core sets of measures
Remove measures that are no longer appropriate (e.g., topped out)
Align measures with external stakeholders, including private payers, boards, and specialty societies
Improve measures over time (a major aim) 18

19. Landscape of Quality Measurement
Historically a silo approach to quality measurement
Different measures within each quality program
Different reporting criteria for each quality program
No clear measure development strategy
Typically disease-specific measures
Confusing and burdensome to stakeholders
Burdensome to CMS, with stovepipe solutions to quality measurement 19

20. The Future of Quality Measurement for Improvement and Accountability
Transition meaningful quality measures away from setting-specific, narrow snapshots
Reorient and align measures around patient-centered outcomes that span across settings
Base measures on patient-centered episodes of care
Capture measurement at three main levels (individual clinician, group/facility, population/community)
Why do we measure?
Improvement
Source: Conway PH, Mostashari F, Clancy C. The Future of Quality Measurement for Improvement and Accountability. JAMA 2013 June 5; Vol 309, No –2216.

21. CMS Activities on Patient-Reported Outcome Measures (PROMs)
In 2012, CMS funded the NQF to develop guidance on development of PROMs
CMS currently uses a number of PROMs in our clinician reporting programs (e.g., depression, functional status)
CMS and HHS are working to identify existing PROMs that can be rapidly incorporated into our quality reporting programs, including the ACO program and CMMI models
CMS and ONC are currently developing PROMs for the hospital and outpatient setting
Disease-specific functional status
General functional status
CMS now includes patients in all measure development work in order to understand the outcomes that are most important to patients and families
NQF workshop: Two white papers developed and a 2 day multi-stakeholder meeting held to identify methodologic issues with development of PROMs and guidance on overcoming barriers, and identified topics for PROM development in the near term. 21

22. Kevin Larsen, M.D., FACP Medical Director, Meaningful Use
Office of the National Coordinator for Health Information Technology

23. Health Information
Exchange

24. “I am the expert about me.”
Patient-Reported Outcomes
SF homeless outreach
Geisinger patients doing med rec from home
Open notes
Nurses in hospitals able to fill care gaps
Sandy
Blue button 24

25. INTEROPERABILITY

26. Common Data Elements: The Future
A terminology based metadata solution frees data consumers from data interpretation

27. HIV Cascade
Source: CDC, July 2012 27

28. HHS Measurement Alignment
MU, PQRS, IQR, ACO, VBP, HRSA, CDC
Current
Unified
Outcome Measures
EHR as primary reporting platform, with secondary reporting from registry, claims
CMS’ commitment to alignment includes finalizing the same CQMs used in multiple quality reporting programs for reporting beginning in 2014
Other programs include Hospital IQR Program, PQRS, CHIPRA, and Medicare SSP and Pioneer ACOs
Full alignment by 2020?

29. Only those who provide care can improve care

30. Car With No Dashboard

31. Clinical Decision Support: CDS 5 Rights
To improve targeted health care decisions/outcomes, information interventions (CDS) must provide:
The right information
To the right people
Via the right channels
In the right formats
At the right times
Optimize information flow: what, who, where, when, how

32. popHealth
Test Patient Data

33. “Small Data is our short term focus”
—Dr. Joe Kimura
“Small Data is our short term focus”
Provider/Care Team Level Analytics – The action is happening at the microsystem level so business intelligence and analytic systems need to support work at the care team/individual physician level. BI systems need to easily and seamlessly telescope metrics up and down all levels of the organization and align metrics across cost to quality to patient experience domains. Robust physician-level analytics will require new analytic methods since methods developed for large populations can be glaringly problematic. For example, episode groupers offer significant conceptual appeal when aiming to understand clinician practice pattern variation driving expense differences for similar quality outcomes. However, at the individual PCP or specialist level, the methodological problems are magnified ,and limits validity and provider acceptance. 33

34. The Learning Health System

35. Future State: HIT-Enabled QI Toolkit
Stakeholders
Unambiguous human readable
Value Set Authority Center
Public Domain
Unambiguous machine readable
EHR Certification Tools
Population Health Tool
Electronic Health Records
Clinical Registries
Clinical Decision Support
CMS Quality Reporting
Other HIT Tools

36. How to Find More Tools and Resources
Working for Quality Web Site
CMS Quality Strategy
Meaningful Use

37. Questions and Answers
Presenters

38. Questions and Answers
For users of the audio broadcast, submit questions via chat
For those who dialed into the meeting, dial 14 to enter the question queue

39. Thanks for attending today’s event
The presentation archive will be available at within 2 weeks