The Quality Improvement Puzzle
David Julian Martin, CAE
Chief Executive Officer/Executive Vice President
Society of Critical Care Medicine
Most Society of Critical Care Medicine (SCCM) members are involved in one or more quality improvement and performance measure activities. Recently, more members have been asking exactly how measures are developed and who is setting the agenda for U.S. critical care providers in this regard, noting that not every activity results in improved patient outcomes. In a work schedule that already is very busy, critical care professionals want to ensure that their activities are sound, not duplicative and in harmony with other hospital policies, procedures, guidelines and recognized best practices.
So, how did we get into this situation? Briefly, quality improvement activities were undertaken simply as a way to improve the care patients receive. Of course, to know if quality was being achieved, healthcare professionals had to measure it. This turned into an accreditation activity used by The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) and morphed further into the pay-for-reporting initiatives of the Centers for Medicare and Medicaid Services (CMS). From there, we have moved on to pay-for-performance initiatives.
These are sponsored primarily by payors and have been trialed across the United States. Finally, these quality improvement and measurement activities are being included in maintenance of certification requirements by the various certifying boards. In this issue’s column, I have attempted to sort and explain how the various quality initiatives fit together within organized medicine in the United States. If you think you are confused about how these initiatives are generated and developed, do not feel bad. It turns out that the process is not as orderly as one would hope, but several groups have launched efforts to improve consistency and lessen duplication.
National Quality Forum
Janet Corrigan, PhD, MBA, and the CEO of the National Quality Forum (NQF), has presented several talks related to this matter. The mission of the NQF has expanded; it has begun setting national priorities and goals in addition to providing information about the measures used to support those goals. The NQF comprises 330 member organizations, including professional groups like SCCM, purchaser and consumer groups, and related U.S. federal government agencies. The group endorses more than 200 measures, events and practices, and a simple majority is needed to pass a specific measure. The government agencies that participate have identified measures or areas of choice. NQF now requires that all measures have a maintenance plan and be harmonized with The Joint Commission and other established groups. For example, the Pennsylvania Cancer Pain Initiative (PCPI) already has end-of-life care consensus standards for cancer patients, and anything adopted by NQF must be harmonized with these widely followed standards. The current effort to define national priorities will focus on episodes of care and value. The NQF believes this broader focus will have the greatest potential to improve care and reduce costs, as these factors vary greatly by community. An episode of care refers to a patient’s care from the initial caregiver visit, through hospitalization, and back to ambulatory community-based care. The first two episodes of care likely will address acute myocardial infarction and diabetes; however, a gap assessment must be performed to determine exactly where the greatest gains in these areas are possible.
Two other major NQF initiatives also underway involve stimulating the development, evaluation and endorsement of measures related to healthcare-acquired infections and improving medication management.The latter measure, being undertaken in conjunction with the Pharmacy Quality Alliance, will look across all settings, providers and patient types. Both projects will take two years to complete. The NQF is establishing a system for requesting the consideration of measures, which will include formatting standards. The NQF will select a common grading system along with other standard submission criteria to help standardize design and to make electronic health record implementation less costly and easier. To accomplish this, NQF is attempting to define the roles of the various groups involved in quality improvement initiatives. A final report on this subject from the NQF board should be available soon.
The NQF is trying to move away from quality and measurement alone and shift toward combining quality and value, which together they call efficiency. We can expect more efficiency measures in the future. It likely will take five years to make serious progress in all of the above areas. For more information, visit the NQF Web site at www.qualityforum.org
Measure Development and Implementation
Many different organizations are in the process of developing measures, including individual professional organizations, patient/caregiver consortia, and large entities such as The Joint Commission, VHA, Inc., and the American Medical Association (AMA). The AMA Physician Consortium for Performance Improvement (The Consortium) was established to identify, develop and define performance measurement sets and quality improvement tools. SCCM is a member of this group, advocating for the role of the integrated team of dedicated experts in all proposals that affect the delivery of quality critical care. The Society also sends representatives to other organizations to represent the critical care team, and it plays a significant role in The Joint Commission’s development of intensive care unit measure sets with numerous SCCM leaders serving on the steering committee for this project. Once measures are developed, they are sent to the NQF for review and approval before becoming available for local implementation. While there has been some attempt to harmonize previously developed measures, it is not at all certain if this will be possible 100% of the time. Of course, not all measures are created equal, and there is some concern about the quality level of the development and testing of measures.
A recent arrival on the scene is the Care Focused Purchasing (CFP) initiative, a group of large U.S. employers that want to develop and adopt “marketplace tools” to transform the employer healthcare market. CFP members believe that current employer health plans and cost-sharing strategies focus on the short term and fail to solve the underlying causes of annual cost increases, inconsistent quality and varied outcomes. The employer group wants to change the current approach to buying healthcare benefits, turning the focus on the quality and efficiency of healthcare providers – what they call care-focused purchasing.
Last fall, CFP began the aggregation of medical claims data from employers and major insurance carriers (Aetna, CIGNA, Fiserv Health, Humana, Preferred Care, Regence BlueShield and WellPoint/Anthem Blue Cross Blue Shield). This ultimately will allow consumers to access performance information on physicians and hospitals across the United States, producing a consumer report card across these insurance plans.
Everyone appears hopeful that, in the end, CFP will work within the NQF framework, but this is yet to be determined. CFP has convened its own expert panel of researchers and health plan medical directors to decide on a set of measures, drawing on work done by the NQF, The Leapfrog Group and the National Committee for Quality Assurance. CFP Measures Version 1.0 was approved by the panel in August 2006 and will now be applied to the data in the CFP data warehouse. The Society was well represented in The Leapfrog Group’s original project. While some of these issues may not yet have had a large impact on critical care, it is possible that, as prior work is picked up and included in future initiatives, SCCM’s mem- bers and the patients they serve will benefit.
Once measures are developed and approved, they go to the Hospital Quality Alliance (HQA), the AQA (formally the Ambulatory Care Quality Alliance), CMS and other groups that work to implement them.
To better coordinate these activities, the AQA and HQA formed the Quality Alliance Steering Committee (QASC), which is chaired by Michael Leavitt, secretary of the U.S. Department of Health and Human Services (DHHS). This collaboration, with an initial investment of $20 million from DHHS, has developed three levels of quality-measurement organization, which are now in trial modes. Six better quality information (BQI) organizations have been selected within the United
States to use NQF metrics at the center of their activity. Additionally, these BQIs received nearly contemporaneous Medicare data, allowing them to compare and contrast results from their quality improvement activities with those of other regions throughout the United States.
Value Exchanges, a process for designating a further class of organizations in the network, also have been created. There are BQIs in development, and by the end of 2008, there is hope that more than 190 of these activities will be underway. The DHHS secretary can appoint community leaders to lead these activities at the local level. Mr. Leavitt has stressed that the government does not have the capacity to collect high-quality national data, stating that data must be collected locally. He emphasized that trust and collaboration will be important aspects of the solution, and trust is engendered best at the local level. He suggested that the NQF be the endorser of the measurement program, the AMA be the developer of the program, and the AQA and HQA prioritize implementation.
SCCM Is Your Voice
As you can see, all these activities have developed spontaneously over the past several years. They have not been fully coordinated and integrated, but an effort is underway to organize better the many groups participating in this arena. The figure on page 6 attempts to provide you with a quick guide to understanding this complex and developing area and represents how these organizations hope to interact
going forward.
The Society is an active participant in all of the above key quality improvement activities, which includes the Society’s Pay for Performance Task Force. The SCCM leadership feels it is vital to have a voice where goal-setting discussions are occurring and where measures are developed and approved that impact critical care delivery. The Society will continue these important activities to ensure SCCM members and the patients they serve are represented appropriately as this area evolves.
