Meeting Minutes, November 9, 2012
Call to Order and Approval of April 13, 2012, Summary Report
The 2012 NAC Subcommittee on Children's Health Care Quality Measures
Linking Research to Change/Improvement Levers
Chairman's Wrap-Up and NAC Input
NAC Members Present
Bruce Siegel, M.D., M.P.H., National Association of Public Hospitals and Health Systems (Chair)
Mitra Behroozi, J.D., 1199SEIU Benefit and Pension Funds (by telephone)
Paul N. Casale, M.D., FACC, Lancaster General Hospital
Jane Durney Crowley, Catholic Health Partners
Helen Darling, M.A., National Business Group on Health
Louise-Marie Dembry, M.D., M.S., M.B.A., Yale-New Haven Hospital
Helen W. Haskell, Mothers Against Medical Error
Michael P. Johnson, P.T., Ph.D., O.C.S., Bayada Home Health Care
Newell E. McElwee III, Pharm.D., M.S.P.H., Merck Global Medical Affairs
Andrea H. McGuire, M.D., M.B.A., Meridian Health Plan
Henry H. Ng, M.D., M.P.H., FAAP, FACP, MetroHealth Medical Center
Welton O'Neal, Jr., Pharm.D., Foundation for Managed Care Pharmacy, Academy of Managed Care Pharmacy
David F. Penson, M.D., M.P.H., Vanderbilt University Medical Center
Katherine A. Schneider, M.D., M.Phil., Medecision, Inc.
Harry P. Selker, M.D., M.S.P.H., Tufts University
Alan R. Spitzer, M.D., MEDNAX Services/Pediatrix Medical Group/American Anesthesiology
David Atkins, M.D., M.P.H., Veterans Health Administration
Sandra L. Decker, Ph.D., National Center for Health Statistics, Centers for Disease Control and Prevention
Shari M. Ling, Ph.D., Centers for Medicare & Medicaid Services (for Patrick Conway, M.D.)
AHRQ Staff Members Present
Carolyn M. Clancy, M.D., Director
Boyce Ginieczki, Ph.D., Acting Deputy Director
Jaime Zimmerman, M.P.H., NAC Coordinator
Karen Brooks, CMP, NAC Coordinator
Bruce Siegel, M.D., M.P.H., Chair of the National Advisory Council (NAC), Agency for Healthcare Research and Quality (AHRQ), called the group to order at 9:00 a.m. and welcomed the NAC members, other participants, and visitors. He noted that the following NAC members would be rotating off the council following this meeting: Helen Darling, M.A., Louise-Marie Dembrey, M.D., M.S., M.B.A., Silvia M. Ferretti, D.O., Helen W. Haskell, Ardis Dee Hoven, M.D., Welton O’Neal, Jr., Pharm.D., and Katherine A. Schneider, M.D., M.Phil.
Dr. Siegel referred to the draft minutes of the previous NAC meeting (July 13, 2012) and asked for changes and approval. The NAC members approved the July 13, 2012, meeting minutes with no changes.
Denise Dougherty, Ph.D., Child Health and Quality Improvement, AHRQ, and Francis D. Chesley, Jr., M.D., Office of Extramural Research, Education, and Priority Populations, AHRQ
Dr. Dougherty reviewed progress of the NAC Subcommittee on Children's Health Care Quality Measures (SNAC), which has been developing voluntary quality measures in light of the reauthorization of the Children's Health Insurance Program (CHIP). She provided an ongoing timeline for the project, which has featured initial priority setting and a continuing effort to identify a parsimonious list of core measures. The project is an AHRQ-CMS partnership, with CMS offering capacity for supporting eventual implementation of the measures. The effort to develop pediatric core measures follows an earlier effort to develop adult health care measures.
Dr. Dougherty described processes that have occurred, including the use of centers of excellence and public calls for proposed measures. Initial rounds of assessment of proposed measures, with input from experts and stakeholders, led to a set of draft core measures. A second phase is seeking to improve the initial core set, using public input and with the broad goal of increasing the portfolio of evidence-based consensus pediatric quality measures available to public and private purchasers of children's health care services, providers, and consumers.
A 2012 process of nomination and review of 63 proposed measures led to 5 measures being added to the draft core set. The committee overseeing the process includes a wide variety of clinicians and other experts, led by co-chairs Charles E. Irwin, Jr., M.D. and Charles Gallia, Ph.D., and including NAC members Alan R. Spitzer, M.D. and Jeffery Thompson, M.D., M.P.H.
Next steps are the posting of technical specifications of the full set of core measures by CMS, voluntary use of the measures by States, and State reporting of results to the U.S. Department of Health and Human Services (HHS). Dr. Dougherty stated challenges of the program, including the large number of measures (when added to the adult measures), a limited ability to use the measures within Medicaid and CHIP, and a limited ability of CMS to provide technical assistance and reporting. It is hoped that particularly important measures eventually will be shared and used broadly.
Ms. Darling asked that the SNAC and AHRQ forward copies of the full set of measures to NAC members. She wondered how many measures could be described as high leverage. Such measures have the ability to drive quality and affect most patients. She encouraged the SNAC to identify the high-leverage measures. This may be important in light of potential pushback by providers to the use of a large number of measures. Marsha Lillie-Blanton, Ph.D., a SNAC member joining the group by telephone, noted that the SNAC considered the issue of high-leverage measures and it stressed the fact that the States would be free to choose which measures to report. Dr. Dougherty added that the SNAC cited high-leverage measures that target, for example, asthma and prenatal care to avoid cesarean sections.
Andrea H. McGuire, M.D., M.B.A., cautioned that the high number of measures might ensure that some are not used. She suggested that CMS encourage providers to prioritize and focus the use of measures within a schedule of multiple years. Ms. Darling raised the issue of the effects of timing for children who move in and out of the Medicaid-CHIP programs. In addition, health care coverage will shift as children move about the new health care insurance exchanges.
Dr. Irwin, also joining the group by telephone, stated that the list of core measures is a beginning. A process for reducing the number will follow. Many organizations are creating measures and monitoring systems. Perhaps the efforts can be brought together.
Dr. Spitzer cautioned that the final list features process measures rather than outcome measures. He argued that process measures are not as helpful, and he encouraged AHRQ to stress toolkits that will address outcomes. He suggested selecting measures that physicians can easily use and that can be tracked over time. Dr. Dougherty cited the issue of how much (how little) one is in control of a particular outcome.
David Atkins, M.D., M.P.H., raised the issues of accountability and measurability. Has the idea of measurement burden been addressed? Dr. Dougherty noted that Congress is interested in holding the Medicaid and CHIP programs accountable. Feasibility for each of the measures was considered. Michael P. Johnson, P.T., Ph.D., O.C.S., stressed the importance of implementation and the need for toolkits that will help clinicians use the measures.
Dr. Siegel wondered about the role of the National Quality Forum, and Dr. Dougherty responded that the forum has been welcome to submit measures. The congressional legislation does not require endorsement of the measures by outside groups. AHRQ supports a broad effort to achieve alignment. The posting of specifications by CMS will encourage alignment.
Carolyn M. Clancy, M.D., AHRQ Director, welcomed the NAC members, speakers, and other guests. She expressed her gratitude to the seven members who were rotating off the council, and she noted that NAC member Jeffery Thompson, M.D., has accepted a new role as Principal at Mercer in Washington.
The Big Picture
Dr. Clancy stated that the FY 2013 budget request for AHRQ features $10 million for patient-centered outcomes research (an additional $62.4 million will come from the Patient-Centered Outcomes Research Institute [PCORI]), $15.9 million for prevention and care management, $88.9 million for cross-cutting grants ($2.7 million of which is for new grants), $62.6 million for patient safety, $25.6 million for health IT, and $3.6 million for value research. The total request is $408.8 million. AHRQ is being funded under a 6-month continuing resolution. A new budget is due on March 27, 2013.
Dr. Clancy reviewed the following recent accomplishments:
- The AHRQ-supported Comprehensive Unit-Based Safety Program (CUSP) has been implemented in more than 1,000 hospital intensive care units nationwide. Central line-associated bloodstream infections (CLABSIs) were reduced from 1,915 infections per 1,000 hospital days to 1,133 infections per 1,000 days. More than 2,100 infections were prevented and many lives were saved. The toolkit is available online at http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/index.html.
- The Tel Aviv Sourasky Medical Center, in Israel, implemented a version of CUSP, leading to a near elimination of CLABSIs during an 18-month period. The program involved 2,700 physicians and nurses.
- The North Carolina Department of Health and Human Services consulted AHRQ's "Particle Beam Radiation Therapies for Cancer" technical brief in revising its Medicaid coverage of selected cases of child patients. It used AHRQ's "Efficacy and Comparative Effectiveness of Off-Label Use of Atypical Antipsychotics" to explain medication safety and quality programs.
- General Electric (GE) employed data from the Medical Expenditure Panel Survey (MEPS) in developing a visualization tool that combines data from MEPS and a GE electronic medical records database. The tool shows the costs of managing 10 chronic conditions. The visualization features computer graphics displays with cost data.
- AHRQ's Spanish-language consumer guide, "Premixed Insulin for Type 2 Diabetes: A Guide for Adults," was distributed by the Puerto Rican Diabetes Association at a recent two-city expo featuring glucose screening.
- The American Academy of Physician Assistants included AHRQ's "Health Literacy Universal Toolkit" in its development of health literacy policy, recommending the toolkit to the academy's 44,000 members and promoting it on its Web site.
- Capital Health, of Nova Scotia, used AHRQ's Project RED (Re-Engineered Hospital Discharge) to help patients organize information about health status prior to discharge.
- South Dakota State University continued to use the TeamSTEPPS® program to teach senior nursing students about leadership and team skills in clinical practice, patient safety, and care quality. About 950 students and 10 faculty members have used TeamSTEPPS® since 2008.
- The Rhode Island Department of Health created a link from its Web site to the AHRQ State Snapshots as part of a mandated public reporting program to inform consumer decisionmaking.
AHRQ Program Updates
Dr. Clancy reviewed the following AHRQ program activities:
- The 2012 AHRQ Annual Conference took place September 9–11, 2012, at the Bethesda North Marriott Hotel & Conference Center, in Maryland. About 1,400 people attended. There were 61sessions, 34 of which featured continuing education.
- AHRQ developed the Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for medication reconciliation. The toolkit guides hospitals through the reviewing of current medication reconciliation processes and indicates how to create new processes.
- AHRQ developed an "ERASE C. difficile" toolkit to help reduce the occurrence of the microbe. The toolkit assists staff and leadership in creating an effective antibiotic stewardship program and features checklists, surveys, and templates for developing a business case (http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/cdifftoolkit/).
- AHRQ released factsheets based on its health care quality and disparities reports, addressing racial and ethnic groups, women, minority women (new), and lesbian, gay, bisexual, and transgender populations (new).
- AHRQ's U.S. Health Information Knowledgebase now contains details for all Stage I and Stage II quality measures (http://ushik.ahrq.gov). Meaningful use Stage II regulation and specifications were issued recently.
- In July 2012, AHRQ released an environmental snapshot print report, describing current health information technology (IT) and quality measurement activities. The report suggests possibilities for the next generation of quality measurement. AHRQ published a request for information on health IT-enabled quality measurement and reporting. The comment period produced 65 responses, including descriptions of infrastructure challenges, successful strategies, and proposed priorities.
- AHRQ produced a paper for Medical Care Supplement, titled "Advances from the Consumer Assessment of Healthcare Providers and Systems (CAHPS®)," featuring discussions of new CAHPS surveys, variations in care experiences, and reporting and improving CAHPS performance.
- AHRQ developed and tested the CAHPS Cultural Competence and Health Literacy Item Sets, which are used to measure the extent to which care is culturally and linguistically appropriate from the patient's perspective. The sets are designed to be used with the CAHPS core questions. The project is described in the Medical Care Supplement piece.
- New TeamSTEPPS® tools include a TeamSTEPPS® Long-Term Care Version and a TeamSTEPPS® Limited English Proficiency Module.
- The AHRQ patient safety project released a new tool, Survey of Patient Safety Culture for Community Pharmacies. The project funded an effort to adapt CUSP for the improvement of patient safety in ambulatory surgery. It joined a new HHS initiative for the prevention of adverse drug events and provided ongoing support for the Partnership for Patients Initiative.
- New AHRQ grants are supporting research in (1) improving reports of health care quality for consumers, (2) designing reports for diverse priority populations, (3) disseminating reports using social media, mobile devices, and patient navigators, and (4) improving methods of measuring quality of care, care coordination, and classification of providers.
- AHRQ developed and placed online recommendations for how to design, disseminate, and evaluate private reports by physicians—that is, providing private "Performance Feedback." AHRQ has supported webinars for disseminating the recommendations. Information can be found at http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/value/localnetworks.html.
- Early findings of ARRA grants on delivery systems research have revealed that practices within a single organization can differ because of different cultures and organizations of care management. These phenomena can be targeted by aligning implementation strategies and content with practice organization and culture.
- The U.S. Preventive Services Task Force (USPSTF) released five final recommendations in recent months. They were for menopausal hormone therapy for the primary prevention of chronic disease, screening for ovarian cancer, screening for chronic kidney disease, screening for hearing loss in older adults, and screening for coronary heart disease with electrocardiography. The USPSTF has continued its new strategy of engaging stakeholders up-front in its deliberations.
- The USPSTF is developing its second Report to Congress on High-Priority Evidence Gaps in Clinical Preventive Services. The report will highlight recent activities and focus on increasing transparency and public engagement. It will identify evidence gaps related to recent USPSTF recommendations.
- AHRQ has supported, with ARRA funds, the development of an electronic data infrastructure linking 11 HMO research network sites to produce the largest civilian diabetes registry (about 1.1 million patients).
- AHRQ is supporting the Surgical Care and Outcomes Assessment Program (SCOAP) in Washington, which features a statewide surgical quality improvement program, ARRA-funded comparative effectiveness research, and a quality-improvement registry.
- AHRQ is supporting research on the use of metformin and sulfonylureas in patients treating type 2 diabetes. The research has found sulfonylureas to be associated with increased risk of cardiovascular events, including death, when compared with the use of metformin.
- In August, 11 institutions were awarded 5-year contracts to serve as Evidence-Based Practice Centers (EPCs). The EPCs are eligible to compete for individual task orders to conduct systematic reviews. They will be supported by the Scientific Review Resource Center, provided by the Portland VA Research Foundation.
- AHRQ provided assistance to Congress on coverage trends and health care costs, offering research findings that can inform health policy. The Agency has provided fast-track responses to various requests from Congress.
- AHRQ is coordinating with HHS to develop content in MEPS to evaluate components of the Affordable Care Act. This includes attention to enhanced linkages to administrative data and greater capacity for longitudinal analyses.
- AHRQ continues to work within the National Quality Strategy (NQS). The NQS was created by the Affordable Care Act to align public- and private-sector stakeholders to achieve better health and health care for Americans. The NQS has six main priorities (for example, making care safer by reducing harm caused in the delivery of care) and features levers (for example, payment systems) to support the priorities.
Harry P. Selker, M.D., M.S.P.H., encouraged AHRQ to work with the Assistant Secretary for Planning and Evaluation (ASPE) to track changes that will occur with implementation of the Affordable Care Act.
Newell E. McElwee III, Pharm.D., M.S.P.H., noted the CERTS grant program (Centers for Education and Research on Therapeutics) and challenges in making the centers collaborate. A collaboration on medication adherence is currently under way. He suggested that the CERTS program be discussed in the next NAC meeting.
David F. Penson, M.D., M.P.H., cited a collaborative program to advance quality of surgery in the State of Michigan. He suggested that the program could serve as a helpful model. The approach is value-based.
Sandra L. Decker, Ph.D., raised the issue of expanding Medicare eligibility and the effect on the MEPS program (will there be matching funds?).
Ms. Darling noted the work of the ABIM Foundation, which comprises 36 organizations and features the "Choosing Wisely" campaign to promote discussions between patients and clinicians about health care costs. Perhaps AHRQ could leverage with ABIM. Dr. Clancy added that cultural assumptions can be even more influential than costs in health care decisions.
Shari M. Ling, Ph.D., wondered about the breadth of uptake in the use of AHRQ toolkits. Dr. Clancy responded that AHRQ has some data, although more would be helpful.
Dr. Clancy asked the NAC members to begin a discussion about ways in which research can transform health care. Transformation will include shifts:
- From variable quality, with expense and waste, to consistently better quality, with lower cost and greater efficiency.
- From payment for volume of health care to payment for quality.
- From payment for transactions to episodes based on care.
- From quality assessment based on provider and setting to quality assessment based on patient experience (outcomes).
The NQS, within the Affordable Care Act, establishes three broad goals in the following areas: better care, healthy people/communities, and affordable care. It calls for efforts to focus on the following six priorities:
- Making care safer by reducing harm caused in the delivery of care.
- Ensuring that each person and family are engaged as partners in their care.
- Promoting effective communication and coordination of care.
- Promoting effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.
- Working with communities to promote wide use of best practices to enable healthy living.
- Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.
AHRQ's 2011 National Healthcare Quality and Disparities Reports revealed that, overall, improvements in the quality of care have remained suboptimal and access to care has not been improving. Few disparities in quality are getting smaller and almost no disparities in access are getting smaller. Quality of care varies across the Nation. Dr. Clancy presented building blocks that can be used to support the transfer from our rich base of scientific knowledge and expertise to interventions in the world of patients, payers, communities, and families. These include the following:
- Practical approaches (toolkits, culture surveys, TeamSTEPPS®, simulations).
- Systematic reviews of policies.
- Innovations exchanges.
- SCHIP implementation.
- Patient-centered outcomes research focused on care delivery strategies.
- Collaborative work on patient-centered medical homes.
Challenges and opportunities include the following:
- Many components are in place, and mostly are topic-specific.
- Initiatives supporting competencies and skills are topic-specific.
- Partnerships are essential (success factors must be identified).
- We need an operating model for AHRQ investments that is broad and flexible yet responsive to patients and caregivers.
In 2013, AHRQ will publish a Guide to Patient and Family Engagement: Final Environmental Scan Report. The document will feature an assessment of current literature, tools, and resources. We need to change the way and with whom we perform the work and report results. We need to incorporate quality improvement and innovation. We need training programs and academic incentives. Dr. Clancy asked the NAC members to consider the following questions:
- Is anything missing or in need of greater emphasis?
- What are the most important needs of front-line clinicians? What are gaps in skills and competencies?
- What are the most important needs of hospitals, especially those addressing the underserved?
- Which systems and networks offer the greatest potential for collaboration to accelerate improvements?
- How might we go about a rapid environmental scan?
- How do we keep it practical?
Dr. Atkins referred to work at the VA and its emphasis on reducing variation in the system to increase reliability. Other goals are to improve the mean and to find ways to de-implement procedures and actions that are no longer desired. A certain tension between patient-centered care and customization exists. The use of checklists is not sufficient.
Dr. Johnson cited the intersections among implementation, leadership, and improvement. One source of good ideas about such processes is the Harvard Business Review. Behavioral change is the key to implementation of new systems. Data and the use of data are important.
Paul N. Casale, M.D., FACC, cautioned that efforts to reduce variation must accept the idea that health care is a complex process. Decisions must be made in light of training, experience, and guidelines. It is important to determine current thought processes before proceeding with implementation of new ideas. Local expertise, local solutions, and flexibility should be considered. Patients and communities can offer ideas. Information at the point of care is important.
Dr. Spitzer stressed the importance of data on quality. Data are key in getting clinicians to accept new ideas and to engage a cultural shift. Jane Durney Crowley agreed and noted that clinicians ordinarily have unreasonably high estimations of their current quality results.
Dr. Selker encouraged AHRQ to refer to communication science. Dr. Schneider encouraged AHRQ to consider product management and solution marketing, ideas used by software developers. Health care workers are not trained for continuous change. Dr. Spitzer added that medical students must assimilate a large volume of information. Tools for change must be simple and work at the bedside.
Dr. Ling stressed the need for systems and strategies for learning. She appreciated the benefits of standardization of data collection and noted that doctors are not good data collectors.
Dr. Atkins proposed that AHRQ's research agenda consider (1) turning evidence into practice, (2) examining change as a local phenomenon, and (3) examining change as a cultural phenomenon requiring leadership and training.
Ms. Haskell cautioned that data are only as good as the inputs. Good data can come from patients.
Dr. Siegel noted the isolation of many hospitals, making systemic change difficult in some ways. Governing boards and leadership might help address this situation.
There were no public comments.
Chairman's Wrap-Up and NAC Input
Dr. Siegel asked the NAC members for final comments and suggestions for the next meeting agenda.
- Dr. O'Neal expressed his appreciation for a strong final meeting in his tenure on the NAC. He encouraged AHRQ to stress the use of data to personalize care.
- Dr. Casale stressed the importance of implementation, and Dr. Siegel suggested asking people about the results of using the AHRQ toolkits.
- Dr. Ng listed important themes of the meeting, including the use of data to lead change, understanding a readiness for change, the use of tools and data collection, and issues about timing, point of care, training, different venues (hospitals), and information sharing. He stated that maintaining the patient perspective is very important.
- Dr. Schneider also expressed appreciation for her final meeting and noted the breadth and depth of expertise on the NAC.
- Dr. Selker stated that he has observed great progress in AHRQ issues in recent years.
- Ms. Haskell encouraged AHRQ to work to maintain the patient at the center of the health care processes, a charge that AHRQ has always accepted.
Dr. Siegel thanked the NAC members, invited speakers, and guests and adjourned the meeting at 3:15 p.m.