Quality Improvement: Tools to Benchmark and Measure Quality. Transcript of Web Conference (continued)

Cindy DiBiasi: Jean?

Jean Slutsky: Yes, I would just add to that to not forget childhood asthma, which I think for States is really a huge, costly disease if it is not managed well because you have a lot of emergency department visits and admission rates for kids that could potentially be handled very well on an outpatient basis. I think it will take the State to look at what their huge cost centers are with certain conditions and try to target those areas for improvement.

Dale Shaller: I would just add that this is a very important question and the reason you heard a big sort of gap, a silence is because there really is kind of a big gap of evidence on the business case for quality. But I do think that while we are waiting for that, States can play a major role in helping to create a business case for quality by the way they buy because once they begin to change the incentives in their own purchasing programs, that creates the business case for providers and plans to do the kinds of quality improvement that we are talking about so that is a huge role that States can play, short of investing in their own programs to improve quality. Just change the way they buy and reward quality.

Dr. Ed Kelley: Can I just add a real quick thing? That is not to spend too much time on it, but it is real important. There are a couple of organizations that have, AHRQ's bread and butter is evidence and so we sort of have the, I wouldn't say "higher standard" of evidence, but we may be a little bit more anal than others in terms of this. There are groups out there that have put together really compelling case studies on the business case for quality like Dale was talking about. Midwest Business Group on Health has a great book that came out a year ago on making the case for quality. NCQA has its state of health care quality that frequently talks about the gains that are going to be associated with this. Then I would agree with Jean on asthma and just because I have been working so much on diabetes, I will just jump back to it. CDC has its national diabetes education program, which works with States and they have a number of case studies that look at where States have made advances, and what has it meant for them.

Cindy DiBiasi: A question from the New Hampshire Department of Health and Human Services from Joan Asheim. "Is the CAHPS® being used or appropriate for use in community centers or other public health facilities?"

Dale Shaller: Yes. In fact, a number of the users of the CAHPS® survey are affiliated with the, in fact there is a trade group; I am going to blank on the name but I think it is the, it is the Community Center Affiliated Health Plans, that I got the acronym, I don't even have the acronym. It is underway, it is in use. There are a number of organizations. There is one in particular that has just jumped on the CAHPS® Quality Improvement Guide. It is the Primary Care Development Corporation in New York City which works with that population through community health centers and attended one of our learning labs through the Institute for Healthcare Improvement and has decided to make a major commitment to using CAHPS® to measure quality at the inventory level and do the kinds of improvements that we talk about. So absolutely.

Cindy DiBiasi: A question from Roger Cochran. He wants to know, "To what extent can any of these tools and measures be used now to help a hospital understand how well the community thinks it is doing in meeting patient needs?"

Dr. Ed Kelley: That is a great point and actually it gives me an excuse to talk about the difference between these national reports and some of the reporting efforts that are out there right now that are through Federal partners and private sector partners. These reports track measures that are being used in a lot of different arenas to track quality but track them at the national level and where appropriate, at the State level. The nice thing is that they line up with, for instance, quality improvement measurement that is going on through CMS and through the Voluntary Hospital Measurement Initiative, which put together a list, a relatively targeted list with ten-plus measures that also correspond with the Joint Commission's Measurement as well as the National Quality Forms, recommended Hospital Measures and the QIO Program at CMS so there is a lot of confluence on this measurement. It is things like beta-blockers for heart attack, aspirin for heart attack, timing for antibiotics for admissions on pneumonia and that kind of thing. Those, the CMS Website does have information on comparing, it will have information on comparing different hospitals according to those measures. In terms of the reports themselves, it stays at the national and State level. I think that is a good key point for States, for hospitals to consider.

Cindy DiBiasi: Question. "Do you think that health plans are going to follow guidance provided by the government? Most health plans are already doing their own improvement initiatives." Interesting question. Jean?

Jean Slutsky: I'd like to answer that. I think that, at least AHRQ, we have had a very good relationship with health plans and have found that they have been quite interested in not only the work that we sponsor but also partnering with us. For example, the American Association of Health Plans partnered with us in developing the National Guideline Clearinghouse. We also find that Consortium of Health Plans have been doing some interesting work in this area and as Dale said, The ICSI Group out of Minnesota, The Institute for Clinical Systems Improvement has worked very closely with AHRQ and many of our grantees on implementing quality improvement techniques.

Dale Shaller: Just to be clear, all of the improvement strategies that are outlined in The CAHPS® Improvement Guide are not from the Federal government; they are from the health care industry itself, the plans, and the medical groups, who are the audience for this guide. We have talked to them and are incorporating their ideas and their case examples in this guide so it is not an invention of the Federal government. It is a compilation that was funded by the Federal government, but it is clearly trying to represent some of the best practices that are out there today that others can learn from.

Cindy DiBiasi: Certainly there is no one answer to this very complex problem.

Dale Shaller: Exactly, exactly.

Cindy DiBiasi: A question from Gail Medero. "Are you collecting any data regarding how volume of services relates to quality? For instance, a provider performs a certain number of procedures annually and how does that connect to the quality of their performance of the procedure?"

Dr. Ed Kelley: That is a good question. I am going to do like they have done in the recent presidential debates and say I would like to answer another question. (Laughs.) To go back to the previous point, I just wanted to mention to you because I had neglected it. There is some work underway right now on a tool that hospitals can, which may have been the original questions, can compare themselves to others on patient experience of care and we are working on The Hospital CAHPS® Tool, HCAHP Tool. That is sort of in development and we hope sometime this year I gather we will be getting more information on that.

But on this point there has been a long debate on the role of tracking volume in terms of considering health care quality. Without getting into that, I think that there is general agreement that there is some value to tracking those measures. The current report, we had gotten guidance from The Institute of Medicine regarding the types of measures we should have in here. We feel like it is real commensurate with that guidance, the measures we ended up with. We are in the process right now of revising the measure set and we will be putting out a Federal Register notice on the revisions to the measure set. One of the potential revisions would be to include the inpatient quality indicators from AHRQ's Healthcare Cost and Utilization Project, which include mortality measures and volume measures. AHRQ has kind of positioned on this whenever it has come up at the National Quality Forum or other settings is that those measurements of mortality and volume should really be done together so you get the full picture. There is a lot that could go into C-section rate, for instance, so we don't really know what the ideal rate is and what does that mean if you don't really know the ideal rate. So tracking rates for certain like PRCA volume as well as mortality is a consideration for future reports.

Cindy DiBiasi: We have a steady stream of questions here so I am going to try and move you along so we can get to all of them before we run out of time. From the Minnesota Department of Health, Charmin Allen wants to know, "We want to evaluate clinics for cultural competency. As we work with more refugees and immigrants, do you have any tools to do that?"

Jean Slutsky: There are some tools on the Quality Tools Website that may be of use to you. I really encourage you to look through the Website to see if there is something there that may be helpful.

Dale Shaller: Once again, the CAHPS® survey has a couple of questions currently that relate to cultural competency. It is an area that in our CAHPS® II work we are trying to expand and develop a little bit further, but there is a resource there that can be helpful.

Cindy DiBiasi: Dale, a question for you from John Henry. "Where did the information to populate the chart entitled "Using CAHPS® to Identify Improvement Opportunities" come from? The rationale for the question is to determine if there is a tool available to individual hospitals to use to gather the information and to develop their own grid."

Dale Shaller: Well, there were two charts that have that label and I am assuming the grid refers to the quadrant chart. That particular set of data was based on the actual experience from the CMS Medicare/Managed Care Survey so that represents the national experience and how that relates.

I would be happy, there is contact information in the guide to follow up with that question and lead that person to specific additional resources to develop their own charts.

Cindy DiBiasi: OK, we will follow up with that. For Ed from Curtis Condon, "Does the NQHR provide information below the level of individual States? For example, does it have breakouts by county?"

Dr. Ed Kelley: No, it doesn't. That's it. (Laughs.)

Dale Shaller: We would love to move in more analysis along those lines. We tried as hard as we could to get State level information.

Dr. Ed Kelley: It was a lot of work to get State level. We would like to get more State level.

Cindy DiBiasi: Right. A question from Betsy McCannick-Dake, "I am interested in finding client education pieces that are geared towards our Social Security income population, the aged, blind and disabled. Is there anything out there that has been developed that specifically targets both Medicare and Medicaid dual eligible with one or more of the above conditions?"

Jean Slutsky: That is a broad question. It is an important question because this particular population really is at risk. There are a lot of consumers publications that deal with how to manage your medications, which would be particularly important for this population. They are available through the Quality Tools Website. There are also some prevention messages that have been developed for Medicare on how to encourage individuals to get preventive services so they are covered under Medicare. All those are available.

Cindy DiBiasi: A question from The Vanderbilt Center for Evidence-based Medicine. Paul Keckly wants to know, "For a group interested in a pay-for-performance application, for what conditions, diagnoses does CAHPS® provide evidence-based indications for measurement?"

Dale Shaller: Well, the entire CAHPS® survey is based on quite an extensive amount of evidence in terms of the relationship between what patients say is important to them. There are a number of studies that talk about the relationship between the patient experience of care and clinical outcomes. I don't have the citations with me, but I would be happy to follow up on that question with the caller if we have that information.

Cindy DiBiasi: Another question, a follow-up question. Dale, is the CAHPS® Survey available to a group practice and if so, how can it be obtained?

Dale Shaller: It is available. In fact, we have talked about the ICSI Project in Minnesota that is a variation of that is being used in that project. Again, through the SUN Website, there should be contact information. If they need a phone number, there is a 1-800 number and we will provide that information to the caller.

Cindy DiBiasi: Great. Jean, could you please repeat the Website for the two reports you mentioned that discusses mental health measures?

Jean Slutsky: Yes. Actually I would suggest going to the National Quality Measures Clearinghouse™, which is www.qualitymeasures.ahrq.gov.

Cindy DiBiasi: A question from Dolores Mays. She would like information regarding quality initiatives concerning young populations. She says we have multiple resources for initiatives for end-of-life care. Please provide other resources other than NCQA for young populations. Dale?

Dale Shaller: Actually, there is an initiative that hasn't been brought up. It is called the Child and Adolescent Health Measurement Initiative. You can get to that initiative through the FACCT Website. That is www.facct.org. What CAHMI has developed through a group of researchers over the years are three specific measures related to kids. One is the CAHPS® survey for children with special health care needs. The second has to do with promoting healthy development among children and the third is the youth and adolescent health survey, which deals with high-risk behaviors in that age group. So there are specific tools designed for that population and they can be accessed through that Website.

Cindy DiBiasi: Well, as you can see, there has been a tremendous amount of interest in this issue. Before we sign off, I would like to just go around and get last thoughts from our experts. Ed?

Dr. Ed Kelley: I guess I would just sum up to say that I think that today's session really highlighted the connectivity in terms of the programs that AHRQ has going, both from the status of giving us a snapshot of where things stand with the reports to providing tools as well as both through the Quality Tools Website and stuff we have directly had a strong hand in developing through our partners here that Dale was talking about with the Consumer Assessment of Health Plans Guide. That is the reports themselves summing that up I think provide a nice framework that we will be continuing to improve on.

Cindy DiBiasi: Jean?

Jean Slutsky: I would just like to end by encouraging the listeners to sign up for the weekly updates for the Quality Tools and the National Quality Measures Clearinghouse™ Websites so that you get the new material that is added to these sites every week. These are dynamic sites, new tools and measures will be added to both sites weekly and I would hate for anyone to miss out on something that they are interested in this week, but won't be there until next week.

Cindy DiBiasi: Dale?

Dale Shaller: I think there are certainly a lot more questions than I think we have answers for. What I am encouraged by is the overwhelming response that we have had among organizations that really have a desire to improve and go beyond the measures themselves but to actually take action to improve their performance. We have made a first start here with the improvement guide for ambulatory care. We would like to continue to develop and expand it and with the help of organizations working on these issues out there, I think we will be able to create the next version and expand it to other domains and we look forward to doing that.

Cindy DiBiasi: Thank you for joining us this afternoon. Very interesting information you are giving to us and obviously from the audience reaction you can tell there is a lot of interest out there.

If you have any unanswered questions, you can send an E-mail to info@ahrq.gov and depending on the number of questions, we will try to answer you directly. We also encourage you to send us any researchable questions that you are facing for AHRQ's consideration as the agency plans its future research priorities. In a minute, we are going to ask you to provide some input on today's event by filling out a short evaluation.

But as we wind down, let me mention that a number of products from this audio conference will be available at a later date. An audio-streamed archive of today's call, written transcripts and all of the presenter's slides, including those used in the question and answer session will be posted to the following Web site at www.hsrnet.net/ulp/ahrqtools. The presentation slides as well as text versions of the slides will also be available for downloading at the same Web address. An audiotape of this event will be available for purchase in several weeks' time. The cost for the tape of this audio conference will be $10. To order a copy, call the AHRQ Publications Clearinghouse at 1-800-358-9295 and ask for AHRQ04-0014-AU. It is entitled Making Quality Count: Tools, Strategies and Resources.

Before we sign off today, please mark you calendars for the final event in our Quality Tools series that will be Wednesday, February 18th, 2004 from 2:00-3:30 PM Eastern time. We will be addressing using measurement data to improve quality. You may sign up for this event at www.hsrnet.net/ulp/ahrqtools.

Finally, before you log off, don't forget to take a few minutes to fill out the brief evaluation form that will appear on your screen at the end of the broadcast. Easy to follow instructions are included. For those of you who have been listening by phone only and not using your computer, please stay on the line. The operator will ask you to respond to the same evaluation questions by using the keypad on your telephone. You may also E-mail your comments to us at https://info.ahrq.gov. Thank you. We look forward to your joining us on February 18th for the final call in this series. Have a nice day.

Return to Web Conference

Current as of June 2004

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Internet Citation:

Quality Improvement: Tools to Benchmark and Measure Quality. Transcript of Web Conference, broadcast February 10, 2004. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ulp/qcount/evnt1trans.htm

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