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The Quality Imperative: Creating a New Health Care System

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Title: The Quality Imperative: Creating a New Health Care System


1
The Quality ImperativeCreating a New Health
Care System
  • Janet M. Corrigan, PhD
  • President and CEO
  • National Quality Forum

2
Creating a New Health Care System
  • Background on NQF
  • Quality - A Growing Sense of Urgency
  • National Strategy for Fundamental Change
  • Strengthening the National Quality Measurement
    and Reporting Capacity

3
National Quality Forum
  • Presidents Advisory Commission 1998
  • NQF became operational 2000
  • Merger with National Committee for Quality Health
    Care - 2006

4
NQF -- Purpose
  • To improve the quality of health care
  • Transparency
  • Endorse national standards for performance
    measurement and public reporting
  • Education and Information Dissemination
  • Policy-to-practice bridgehe mission of the NQF is
    to improve American healthcare through
    endorsement of consensus-based national standards
    for measurement and reporting of healthcare
    performance data that provide meaningful
    information to the public and healthcare
    providers about whether care is safe, timely,
    patient-centered, beneficial, equitable and
    efficient.
  • The mission of the NQF is to improve American
    healthcare through endorsement of consensus-based
    national standards for measurement and reporting
    of healthcare performance data that provide
    meaningful information to the public and
    healthcare providers about whether care is safe,
    timely, patient-centered, beneficial, equitable
    and effici

5
National Quality Forum Key Characteristics
  • Open membership organization (330)
  • Multi-stakeholder
  • Public and private sector partnership
  • Voluntary consensus standard setting body

6
National Technology and Transfer Advancement Act
of 1995
  • Defines 5 attributes of voluntary consensus
    standards body (i.e., openness, balance of
    interest, due process, consensus, and appeals
    process)
  • Obligates federal government to adopt voluntary
    consensus standards (when adopting standards)
  • Encourages federal government to participate in
    setting voluntary consensus standards

7
NQF-Endorsed Measures
  • Over 200 measures, events, practices
  • Standardized specifications to facilitate
    comparisons
  • Science-based, field-tested
  • Best in class
  • Publicly availableopen source
  • Maintenance structure
  • Measures of choice by federal government and
    others

8
Growing Sense of UrgencyJust the Facts
  • 55 overall adherence to recommended care
  • Health care costs rising 1.5 to 2 times the rate
    of inflation
  • Uninsured now total 45.5 M
  • Up to 2-fold variation in per capita spending
    across communities
  • U.S. spends more than all other industrialized
    countries by sizable margins

9
Current National Strategy forClosing the Quality
Gap
  • Create a marketplace rich in information on
    quality and cost (public reporting)
  • Reward providers for providing safe and effective
    care and doing it efficiently (P4P)
  • Encourage patients to seek high value providers
    by having skin in the game (high deductible
    plans, HSAs)

10
Pay-for-Performance
  • About 200 P4P projects
  • Half target physicians and one-third hospitals
  • Rely on process measures
  • Incentive payments- 2 to 6

11
CMS DEMOS AND VOLUNTARY REPORTING
  • Demos, Demos, Demos
  • Premier Hospital Quality
  • Physician Group Practice
  • Medicare Care Management
  • Medicare Health Care Quality
  • Medicare Health Support
  • Dx Mgmt for Severely, Chronically Ill
  • Dx Mgmt for Dual Eligible
  • ESRD Dx Mgmt
  • Care Mgmt for High Cost Beneficiaries
  • Nursing Home P4P
  • Voluntary Reporting
  • Hospitals (P4R)
  • Physicians

12
Providers Engaged in Selecting Developing
Measures
  • Broad-based Collaborative Efforts
  • Hospital Quality Alliance
  • Ambulatory Care Quality Alliance
  • Pharmacy Quality Alliance
  • Cancer Quality Alliance
  • Specialty Specific Efforts
  • 30 specialty/subspecialty societies
  • 100 measures?

13
Starter Sets
14
Impact of P4P and Public Reporting?
  • Financial incentives motivate change.
  • Public reporting is strong incentive too.
  • Engaging/educating physicians is critical.
  • Information integrity is important.
  • P4P is not THE solution part of a broader
    effort.

15
National Quality Measurement Reporting
Infrastructure Areas for Improvement
  • Lack a Coherent Strategy for Focusing and
    Evolving Measure Sets
  • Variability in Measures
  • Lack a Single Pipeline for Pooling Reporting
    Data
  • Lack of a Model of Accountability

16
NQF Strategic Framework BoardNational Quality
Measurement and Reporting System
Goals
Measure Development
NQF Endorsement
Measure Selection For Public Reporting
Data Collection, Aggregation, Verification
Public Reporting
Accountability
QI
Were the 6 Aims and Goals Achieved?
17
National Goal-Setting Capacity is Needed
  • NQF Will Engage Leaders in Setting Community-wide
    Transformational Goals
  • Population health behaviors environmental
    safety threats
  • Leading chronic conditionscomposite measures and
    longitudinal efficiency
  • Cross cutting process issuescare coordination
    team communication medication management
  • Patients and family caregivers health literacy,
    engagement in decision-making self-management
  • End of life care

18
Performance Measurement and Reporting Current
Status
  • Starter Sets
  • Provider is unit of analysis (e.g., hospital)
  • Low hanging fruit available from claims data
  • Primarily narrow process measures
  • Some patient perceptions

19
Evolution of Measure Sets
  • Current measure sets have
  • Limited scope of measurement
  • Narrow time window
  • Provider-centric focus
  • Narrow definition of accountability
  • Future measure sets will be
  • Comprehensive
  • Longitudinal
  • Patient and population focused
  • Shared accountability
  • Adapted from IOM, 2005

20
Longitudinal Measures
  • Patient episode of illness- unit of analysis
  • Process and outcomes
  • Underuse and overuse
  • Composite measures --Did the patient receive all
    the services from which they would likely have
    benefited?
  • Longitudinal efficiency Did the patient receive
    only the services from which they would likely
    have benefited?

21
Diabetes Composite Measure
  • Numerator -- diabetic patients that received all
    5
  • evidence-based services


  • Denominator Type 1 and Type 2 diabetics age
    18-75
  • HbA1clt 8 percent mg/dl LDL cholesterol lt 130
    mg/dl blood pressure lt 130/85 mmHg aspirin for
    gt 40 years documentation of non-use of tobacco.


22
Variability in Performance Measures
  • Sizable number of measure developers with varying
    levels of capability and experience
  • Need standardized format for measure
    specifications
  • More coordination with EHR standard setting and
    vendor community will be critical

23
Lack of Single Pipeline for Pooling Reporting
Data
  • Unnecessary Burden Providers comply with
    numerous payer-specific reporting requirements.
  • Less Reliable Conclusions Complete view of
    providers practice is lacking.
  • Public Confusion Many public reporting
    programs-different measures, different subset of
    patients, different formats.

24
Data Collection, Aggregation and Verification
  • AQA
  • 6 regional pilots for pooling data
  • HQA
  • Booz, Allen and Hamilton assessment of hospital
    measurement and reporting issues includes
    alternative options for creating a single pipeline

25
Public Reporting
  • Medicare Compare
  • Most significant effort
  • Public and private sector data for some providers
  • To date, institutional providers only

26
AQA National Health Data Steward
  • Data Analysis
  • Data Validation
  • Use of Data
  • Data Access
  • Data Aggregation
  • Data Collection
  • Data Attribution
  • Methodologies

27
Lack of an Accountability Model
  • Rationalize Payment
  • Greater focus on populations (capitation) and
    patients (per episode) to achieve greater
    emphasis on
  • Access
  • Prevention and early detection
  • Align payments with appropriate level of
    accountability
  • Capital investment in systems and organizational
    supports
  • Flexibility

28
Lack of an Accountability Model
  • Develop Systems of Care and Hold Accountable
    for Longitudinal Performance
  • Quality health care is a team sport
  • Patients needs cross settings and professionals
  • Organizational supports are critical
  • Greater system integration needed
  • Standardization of care processes
  • Shared accountability shared rewards

29
  • National Quality Forum
  • www.qualityforum.org
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