AHRQ NAC Subcommittee on Children’s Healthcare Quality Measures for Medicaid and CHIP Programs Carolyn Clancy, MD Director, AHRQ Introductory Remarks and Charge to the Subcommittee July 22, 2009

Children’s Healthcare Quality Measures AHRQ’s Role in Children’s Health Insurance Program Reauthorization Act (CHIPRA) Quality AHRQ’s Role in Children’s Health Insurance Program Reauthorization Act (CHIPRA) Quality Subcommittee Focus and Role Subcommittee Focus and Role Questions Questions

Overview of AHRQ’s work in CHIPRA Quality – Identification of initial core measure set Identification of initial core measure set Pediatric quality measure development program Pediatric quality measure development program Identification of an improved core measure set Identification of an improved core measure set Evaluation of the Centers for Medicare & Medicaid Services (CMS) demonstration grants program Evaluation of the Centers for Medicare & Medicaid Services (CMS) demonstration grants program Development of a model pediatric electronic health record (EHR) template Development of a model pediatric electronic health record (EHR) template Lead on Institute of Medicine (IOM) study Lead on Institute of Medicine (IOM) study Technical consultation Technical consultation

Why AHRQ Wanted to be Engaged in CHIPRA Quality Quality is in our name and mission Quality is in our name and mission Children are a priority population for AHRQ Children are a priority population for AHRQ Quality Measurement Expertise Quality Measurement Expertise – Consumer Assessment of Health Providers and Systems (CAHPS) – Healthcare Cost and Utilization Project (HCUP) Quality Indicators – Medical Expenditure Panel Survey (MEPS) Quality Measures – Annual reports – Child Health Insurance Research Initiative (CHIRI) Quality Improvement Expertise Quality Improvement Expertise – Health information technology (HIT) portfolio – Patient safety portfolio – Prevention/care management portfolio – Value portfolio – Innovations in research and evaluation methods Link from Comparative Effectiveness Research to Quality Link from Comparative Effectiveness Research to Quality

AHRQ’s Engagement in CHIPRA (Continued) Beyond repeated identification of problems Measures that will get used – Accountability – Improvement

Other Federal Partners Office of the Secretary Office of the Secretary – Assistant Secretary for Planning and Evaluation (ASPE) – Office of the National Coordinator for Health Information Technology (ONC) Centers for Disease Control and Prevention (CDC) Centers for Disease Control and Prevention (CDC) Health Resources and Services Administration (HRSA) Health Resources and Services Administration (HRSA) Indian Health Service (IHS) Indian Health Service (IHS) Substance Abuse and Mental Health Services Administration (SAMHSA) Substance Abuse and Mental Health Services Administration (SAMHSA)

AHRQ, CMS, and Federal Partners

Charge to this Subcommittee Charge VERY Focused Identify initial core health care quality measurement set for Medicaid and CHIP programs Identify initial core health care quality measurement set for Medicaid and CHIP programs Core set must be posted for public comment by January 1, 2010 Core set must be posted for public comment by January 1, 2010 Subcommittee charter expires December 31, 2009

AHRQ, NAC, and Subcommittee Roles Director, AHRQ Secretary, HHS AHRQ National Advisory Council on Healthcare Research and Quality on Healthcare Research and Quality Subcommittee on Children’s Healthcare Quality Measures for Healthcare Quality Measures for Medicaid and CHIP Programs Medicaid and CHIP Programs

Timeline to January 1 Posting for Public Comment 2009 Law passed, CMS-AHRQ partnership established JanuaryAprilJuly Subcommittee Meeting #2 (September) Subcommittee Meeting #1 October Revised draft to Secretary (November) First full draft of initial core set for Federal review 2010 Final for posting (Dec. 24) Revisions if needed (December)

Three Charges to the Subcommittee 1) Provide guidance on criteria for identification of initial core set 2) Provide guidance on a strategy for identifying additional measures in use for consideration 3) Review and apply criteria to compilation of measures currently in use by Medicaid/CHIP

AHRQ’s Guidance – Consider Measures in Use by Medicaid/CHIP Rationale: Rationale: – Time available – “In use” an indicator of feasibility THIS WILL BE CHALLENGING THIS WILL BE CHALLENGING Be patient: Be patient: – Pediatric Measures Development and Enhancement Program $15 million/year for 4 years – extramural awards $15 million/year for 4 years – extramural awards Federal Register notice to come – recommendations for priorities for the program Federal Register notice to come – recommendations for priorities for the program

AHRQ’s Guidance – Transparency and Public Engagement Public meetings Public meetings – Today, tomorrow, July 24 NAC – September your comments any time: your comments any time:

Questions for AHRQ to Date Validity and feasibility as core criteria for including as a priority? YES Validity and feasibility as core criteria for including as a priority? YES – Evidence base – Be explicit Include “stretch” measures? Include “stretch” measures? – Depends on definition of “stretch” – We want to move all measures along the continua of validity, reliability, feasibility Number of measures in the ideal core set? Number of measures in the ideal core set? – Up to the group How do we think about health care quality? How do we think about health care quality?

What is health care quality? Leading complementary definitions/frameworks “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” “Doing the right thing for the right person at the right time in the right way” “Doing the right thing for the right person at the right time in the right way” A high quality health care system is one in which care is reliably Safe, Timely, Effective, Efficient, Equitable and Patient-centered (STEEP) A high quality health care system is one in which care is reliably Safe, Timely, Effective, Efficient, Equitable and Patient-centered (STEEP) 3 Notes: Notes: – Bullets one and two are clinician-focused; by 2001 – explicitly system-focused – All are aspirational IOM, Medicare: A Strategy for Quality Assurance, 1990, p IOM, Medicare: A Strategy for Quality Assurance, 1990, p Eisenberg, Testimony to Congress, IOM, Crossing the Quality Chasm, 2001.

Getting more specific: A measurement framework Structure, process and outcome Structure, process and outcome – Structure: characteristics of the resources in the health care system; presumed capacity Professional – licensure, board certification Professional – licensure, board certification Facilities – government certification, accreditation, policies, procedures, HIT capabilities Facilities – government certification, accreditation, policies, procedures, HIT capabilities System – policies, procedures, incentives, regulation System – policies, procedures, incentives, regulation – Process (of care) – clinical activities undertaken during prevention, diagnosis, treatment, management – Outcomes – survival, symptom relief Source: Donabedian, 1966

Getting more specific: A consumer framework Staying healthy Staying healthy – Health promotion – Disease prevention Getting better Getting better – Acute care Living with illness Living with illness – Chronic care Coping with the end of life Coping with the end of life Source: Bethell/FACCT, adopted by the Institute of Medicine (IOM), Guidance on National Healthcare Quality Reports (NHQR) and National Healthcare Disparities Reports (NHDR), 2001, 2002.

Comprehensive Framework, NHQR and NHDR SafeTimelyEffectiveEfficient Patient- Centered Staying healthy Getting better Living with illness and disability Coping with end of life Within each cell: structure, process, outcome measures (aspirational) ACROSS ALL DOMAINS, WITHIN ALL CELLS: EQUITY

Thanks to… Rita Mangione-Smith and Jeff Schiff Rita Mangione-Smith and Jeff Schiff – GREAT co-chairs Responsible for everything good about this meeting Responsible for everything good about this meeting Other subcommittee members Other subcommittee members – in advance Paper authors Paper authors Presenters Presenters Public Public

Thank you Questions?