1. Getting from Good to Great: Quality Measurement in Hospice & Palliative Care
Arif Kamal MD, MBA, MHS
Physician Quality Outcomes Officer
Duke Cancer Institute
Co-Chair, Global Palliative Care Quality Alliance
Chair, ASCO Quality of Care Committee

2. Outline Framework for Healthcare Quality and Palliative Care Quality
How quality measures are developed
Areas of caution in developing measures

3. “For the great enemy of truth is very often not the lie--deliberate, contrived and dishonest--but the myth--persistent, persuasive, and unrealistic.”
John F. Kennedy 1962 Yale Commencement address

4. Defining Quality
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 at the right time in the right way for the right person and having the best results possible.
The Institute of Medicine (IOM) is an American non-profit, non-governmental organization founded in 1970, under the congressional charter of the National Academy of Sciences.
The United States Department of Health and Human Services (HHS), sometimes referred to as the Health Department, is a Cabinet department of the United States government with the goal of protecting the health of all Americans and providing essential human services.
The National Health Service (NHS) may refer to one or more of the four publicly funded healthcare systems within the United Kingdom.
In healthcare everyone has two jobs: to do your work and to improve it.
No needless deaths. No needless pain. No helplessness. No unwanted waiting. No waste.

5. Healthcare Quality Quality Error-prone Underused Unresponsive Overused
Safe
Patient-Centered
Timely
Efficient
Equitable
Effective
Underused
Unresponsive
Overused
Disparate
Delayed
Wasteful
Institute of Medicine Crossing the Quality Chasm: The new health system for the 21st century

6. Palliative Care Quality
8 Domains A. Structure and Processes of Care B. Physical Aspects of Care C. Psychological and Psychiatric D. Social Aspects of Care E. Spiritual, Religious, and Existential F. Cultural Aspects of Care G. Care Near the End of Life H. Ethical and Legal Aspects of Care = 27 Clinical Guidelines =284+ quality measures

7. “Palliative care, and the medical sub-specialty of palliative medicine, is specialized medical care for people living with serious illness. It focuses on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family.
Palliative care is provided by a team of palliative care doctors, nurses, social workers and others who work together with a patient’s other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.”

8. New Domains? Caregivers Informational and Prognostic Understanding
Rapport and Relationships
Communication
Care coordination
Financial distress

10. Do Palliative and Hospice Care Improve Quality?
Patient-centered? Yes
Beneficial? Yes
Timely? No
Safe? Maybe
Equitable? No
Efficient? Yes

11. Healthcare quality measures
Numerator
how do you know the measures were met
Denominator
to whom the measures applies
Exclusions
In which situations, does the measure not apply

12. Types of Measures Structure Process Access Population Health Outcomes
Intermediate
Health State “classical”
Utilization
Patient-reported

13. Opportunities to Improve the Future
Outcomes = higher stakes
Attribution
Risk Adjustment
Balance Measures
Proscription of instruments
Ceiling effects

14. Some summative thoughts
There are many important domain and measure gaps in specialty palliative care AND primary palliative care
Healthcare at large wants outcome measures, palliative care is ready for structure and process measures
There are many types of outcomes, other than utilization, important to serious illness care