Home About the National Quality Strategy Site Map

You Are Here: Working for Quality Health Care > About the National Quality Strategy > Summary of Public Comments

Summary of Public Comments on the Proposed National Quality Strategy and Plan

1.0 Introduction
2.0 Methodology for Public Comment Cataloging and Synthesis
3.0 Overview of Stakeholders that Responded
4.0 Summary of Findings and Key Themes
   4.1 Key Themes for Question 1
   4.2 Key Themes for Question 2
   4.3 Key Themes for Question 3
   4.4 Key Themes for Question 4
   4.5 Key Themes for Question 5
   4.6 Key Themes for Question 6
   4.7 Key Themes for Question 7
   4.8 Key Themes for Question 8
   4.9 Key Themes for Question 9
   4.10 Key Themes for Question 10
   4.11 Key Themes for Question 11
Appendix 1: National Health Care Quality Strategy and Plan - Public Comment Briefing
Appendix 2: Respondent Submissions by Organization Type and Constituency Represented
Appendix 3: Suggested Types of Measures and Existing Measure-Setting Bodies or Programs

1.0 Introduction

The Affordable Care Act (Public Law 111-148) expresses the Nation's commitment to improve the quality and affordability of health care and expand coverage and access to health care for all Americans. The law requires the Secretary of the Department of Health and Human Services to establish a National Strategy for Quality Improvement in Health Care (the National Quality Strategy) that includes national priorities for improvement and a strategic plan for reforming the delivery of health care services, achieving better patient outcomes, and improving the health of the U.S. population. The National Quality Strategy is intended to be a living and changing guide for the Federal government, as well as for States and the private sector. The hope is that the National Quality Strategy will be sustainable over time, and support priorities and associated goals that will be periodically updated and refined to accommodate emerging issues. Ensuring that the National Quality Strategy is effective will require a strong private/public partnership based on a shared commitment to ensuring that Americans receive consistent, high-quality, safe, and affordable care.

HHS developed a briefing, included in Appendix 1, that outlined initial thinking regarding the National Quality Strategy and identified specific areas where feedback would be particularly valuable including various aspects of the National Quality Strategy's proposed structure, principles, and conceptualizations. HHS then posted the briefing to their Website and initiated a public comment period (September 10, 2010 to October 15, 2010) to allow interested parties to provide input. The public had the opportunity to respond to 11 questions posed by HHS (10 specific questions and 1 question that collected any additional comments). The 11 questions are outlined in Section 4.0.

This document outlines the methodology used to catalog and synthesize the comments received, provides an overview of the stakeholders that responded, and includes a summary of the major themes identified for each questions posed.

2.0 Methodology for Public Comment Cataloging and Synthesis

The following methodology was used to effectively organize and synthesize the public comments received, in order to facilitate analysis and identification of key themes.

Taxonomy for classifying respondent organization types and constituency types represented was created.
An analysis plan was created to guide the organization of comments and to ensure the appropriate elements were captured when synthesizing.
Once comments were received, the respondent organization information and comments were logged into an Excel workbook.
1. To the extent the respondent clearly responded to Questions 1-11, the comments were logged under the respective question as appropriate. There were some instances where a respondent submitted a response to a question, but the response related more to another question/topic; in these instances, the comment was reclassified and grouped under the most appropriate question.
2. If the comment did not align with Question 1-10, it was grouped under Question 11
Comments were then synthesized and categorized using two tiers or classifications.
1. The primary classification involved a more high-level grouping or theme that was most often based on the multiple components within a question.
2. The secondary classification involved a more granular or detailed categorization.
3. For example with Question 1, the primary classification was "Suggested Edit to 1st Principle"; the secondary classification was "Define person-centeredness further."
4. Please note the following:
  1. The total number of responders for each question is based on the unique number of commenter IDs that responded to a question and does not take into account multiple themes/response included in a submission.
  2. The percentages displayed for each primary classification are not mutually exclusive (e.g., a respondent could provide comments aligning to each of the primary classification categories). The percentages are based on the total number of unique respondents addressing the first classification category as a fraction of the total number respondents to that question.
  3. The top three to five secondary classification themes were identified based on the highest frequency of unique respondents those themes. All percentages related to the secondary classification categories are calculated as a fraction of the corresponding primary classification category.

3.0 Overview of Stakeholders that Responded

A total of 335 unique respondent submissions were received from stakeholders. Exhibit 1 summarizes the number of respondents by organization type and highlights the types of constituencies represented by these organization types. The predominant organization types that responded were member associations, providers, and advocacy groups. More detail on the number of respondents by each constituency type is displayed in Appendix 1: National Health Care Quality Strategy and Plan – Public Comment Briefing.

Exhibit 1: Number of Respondents by Organization Type

Organization Type	Types of Constituencies Represented	Total
Advocacy Group	Clinical Condition Advocacy, Consumer Advocacy, Employer/Business Coalition, Labor Union, Other Advocacy	51
Federal Government	Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), Indian Health Services (IHS), Veterans Administration (VA)	5
Health Plan	Health Plan	7
Individual/Consumer	Individual – Independent of any organization	47
Member Association	Academic, Clinical Professionals, Employers, Health IT Vendors, Health Plan, Hospitals, Medical Product Vendors, Other, Pharmaceutical Industry	94
Other	Consulting Firm, Law Firm, Other	6
Pharmaceutical	Pharmaceutical Company	2
Provider	Ambulatory Care, Health System, Hospice/Palliative Care, Hospital, Long Term Care, Other Clinical Professional, Physician	67
Quality Organization	Measure Development, Other Quality Organization, Quality Improvement Organization (QIO), Quality Collaborative	19
Research/Academic	Academic Institution, Research, Think Tank	24
State/Local Government	State Agency	8
Vendor	Product Vendor, Service Vendor	5
Total Respondent Submissions		335

4.0 Summary of Findings and Key Themes

The following sub-sections highlight summary findings and key themes based on each of the eleven public comment questions posed by HHS. These key themes were identified using the primary and secondary classification scheme described in Section 2.0, and they are based on comments from all respondents for the respective question. For each question's primary classification, the top three to five key themes, as identified by the unique number of respondents and using the secondary classification, are highlighted and further detail or examples based on comments are provided accordingly.

For all questions, the total number of respondents to the particular question is included. A more granular breakdown of respondents by organization type is not included for each question; given the predominant organization types that submitted public comments were member associations, providers, and advocacy groups (go to Exhibit 1), these organization types were naturally the predominant respondents for each question. The same logic exists for constituency types represented in that there is not a more granular breakdown of respondents. In general, clinical professional member associations, health systems and hospice/palliative care providers, and consumer advocacy and clinical condition advocacy groups were the predominant constituency types that submitted comments. As a result, these constituency types were naturally the predominant respondents for each question. An exception holds true in the case of Question 1 and Question 2. With these two questions, the hospital constituency type (associated with the provider organization type) was more predominant with responses, and is therefore highlighted.

For each question's primary classification, the percent of respondents that addressed that classification is included. As previously indicated, the top three to five themes using the secondary classification are included. It is explicitly noted if a theme is clearly dominant for the secondary classification (i.e., 51% or more of respondents).

4.1 Key Themes for Question 1

Public Comment Question 1: Are the proposed Principles for the National Strategy appropriate? What is missing or how could the principles be better guides for the Framework, Priorities, and Goals?

A total of 237 respondents submitted comments in response to Question 1, which addressed the four proposed National Quality Strategy Principles as displayed in Exhibit 2. Member Associations (specifically clinical professionals), Providers (specifically, health systems, hospitals, and hospice/palliative care providers) and Advocacy groups (specifically, consumer and clinical condition advocacy) combined represent the majority of the organizations that responded to Question 1. Respondents addressed whether the Principles are appropriate, they suggested edits to the Principles, and they proposed including additional Principles. Details related to respondent comments follow.

Exhibit 2: HHS' Proposed Principles Guiding the National Quality Strategy

#	Principle
1	Person-centeredness and family engagement will guide all strategies, goals, and improvement efforts
2	The strategy and goals will address all ages, populations, service locations, and sources of coverage
3	Eliminating disparities in care – including but not limited to those based on race, ethnicity, gender, age, disability, socioeconomic status and geography – will be integral to all strategies and goals
4	The design and implementation of the strategy will consistently seek to align the efforts of public and private sectors

Appropriateness of Proposed Principles: Person-centeredness and family engagement will guide all strategies, goals, and improvement efforts:

Forty-seven (47%) percent of respondents indicated that the proposed Principles, shown in Exhibit 2, are appropriate. Ninety-two (92%) percent of these respondents, answered 'yes' to this question, and represented all organization types, except pharmaceutical. Exhibit 3 highlights some of the recurring comments received in reference to the Principles' appropriateness.

Exhibit 3: Example Comments in Response to Appropriateness of Proposed Principles

Appropriate (n=111)	Not Appropriate (n=11)
Overall focus on quality is good All Principles are important	Principles are too broad and not actionable Clarification of intent and purpose of National Quality Strategy is needed

Suggested Edits to the 1st Principle: Person-centeredness and family engagement will guide all strategies, goals, and improvement efforts

Twenty-one (21%) percent of respondents provided feedback on how to edit the first Principle. Respondents' recommendations for suggested edits to the first Principle were centered on a few themes. For example, several comments emphasized the importance of expanding and clarifying the meaning of "person-centeredness" to incorporate specified parameters which encompass patient and family engagement or care that is patient- and family-centered. Examples of increased engagement could include accessing one's personal health information; participating in shared decision-making; and enabling awareness of all aspects of one's health. Relating to specific priorities and goals of the first Principle, a number of organizations suggested addressing quality of end-of-life care.

Suggested Edits to the 2nd Principle: The strategy and goals will address all ages, populations, service locations, and sources of coverage

Nine (9%) percent of respondents recommended changes to the second Principle. No dominant theme emerged from their suggestions. Some respondents suggested that this Principle include reference to a strategy which is evidence-based, and one that involves all stages of care (i.e., pre- and post-diagnosis) and phases of life. Respondents also suggested highlighting specific populations, including those with chronic and life-threatening illnesses.

Suggested Edits to the 3nd Principle:Eliminating disparities in care – including but not limited to those based on race, ethnicity, gender, age, disability, socioeconomic status and geography – will be integral to all strategies and goals

Fourteen (14%) percent of respondents provided suggestions for the third Principle; however there was no dominant suggestion. Several respondents stressed the need to include language that references disparities in health – not just disparities in care. Another terminology suggestion involved the use of the term "health inequities", instead of "disparities in care". There were also suggestions to expand the demographic examples to include chronically ill, sexual orientation, and health literacy status. Respondents also emphasized the need to highlight cultural competency as a way to reduce disparities.

Suggested Edits to the 4th Principle: The design and implementation of the strategy will consistently seek to align the efforts of public and private sectors

Ten (10%) percent of respondents provided a variety of feedback on the fourth Principle. Respondents commented that the fourth Principle should address alignment with the efforts of providers and other healthcare professionals. Additional alignment efforts suggested by respondents involved harmonization of performance measurement activities, data sharing, reimbursement/payment methods, and healthcare regulations. A few respondents expressed concern that the fourth principle is framed in a way that implies the strategy will work through parallel efforts between the public and private sector; respondents preferred that the principle reflect the reduction of competing or conflicting strategies, and promote joint efforts of all intended parties to design and implement the strategy. Respondents also recommended that the principle be expanded to indicate the need for diverse stakeholder engagement and input.

Additional Concepts to be Addressed by Principles

Respondents commonly recommended the following aspects be included in new or existing principles:

Evidence-based care
Cost containment
Population health and prevention
Transparency of information and data sharing

4.2 Key Themes for Question 2

Public Comment Question 2: Is the proposed Framework for the National Strategy sound and easily understood? Does the Framework set the right initial direction for the National Health Care Quality Strategy and Plan? How can it be improved?

A total of 210 respondents submitted comments in response to Question 2, which targeted the proposed National Quality Strategy Framework as displayed in Exhibit 4. Member Associations (specifically clinical professionals) and Providers (specifically, health systems, hospice/palliative care providers, and hospitals) combined represent the majority of the organizations that responded to Question 2. Respondents addressed whether the Framework is sound/easily understood and whether it sets the right initial direction for National Quality Strategy; respondents also provided suggestions for how the Framework and its components could be improved. Details related to each of these aspects follow.

Exhibit 4: HHS' Proposed Framework for the National Quality Strategy

Framework Component	Definition
Better Care	Person-centered care that works for patients and providers. Better care should expressly address the quality, safety, access, and reliability of how care is delivered, as well as the experience of individuals in receiving that care; active engagement of patients and families; and the best possible care at all stages of health and disease
Affordable Care	Care that reins in unsustainable costs for families, government, and the private sector to make it more affordable
Healthy People/Healthy Communities	The improving health and wellness at all levels through strong partnerships between health care providers, individuals, and community resources

Framework Soundness/Understandability and Appropriateness in Setting the Right Initial Direction

Exhibit 5 includes the percentage of respondents that explicitly commented on whether the Framework was sound/easily understandable and whether the Framework sets the right initial direction. Forty-eight (48%) percent felt the Framework was sound/easily understandable and that it sets the right initial direction. Some respondents also provided supporting context with their response. Key themes based on additional context provided are highlighted in Exhibit 5.

Exhibit 5: Key Themes in Response to Framework Soundness/Understandability and Appropriateness in Setting the Right Initial Direction

Sound/ Easily Understandable (29% of respondents)	Sets the Right Initial Direction (19% of respondents)	Not Sound/Easily Understandable (5% of respondents)	Does Not Set the Right Initial Direction (3% of respondents)
Suggest aligning with CMS' Triple Aim, which addresses very similar components as the proposed Framework Suggest highlighting value-based care (high quality-low cost care) Acknowledge that data sharing and evidence-based medicine will drive optimal care		Components are vague and subjective Unclear as to how the components relate to the proposed Principles and whether they will be used independently or in concert with the Principles to develop priorities

Suggested Improvements for Better Care Component

Thirty-three (33%) percent of respondents suggested improvements for the Better Care component. No dominant suggestion emerged from the comments. Slightly more than one-third of respondents that specifically addressed Better Care suggested that the following attributes of care be highlighted: timely, coordinated, appropriate, evidence-based, provide optimal outcomes. The majority of respondents were split among advocacy groups and member associations. Respondents also suggested further defining better care attributes such as access and person-centeredness, and addressing who is responsible for defining whether better care is provided/received. Comments also suggested including a reference to specific populations (e.g., disabled, chronically ill or end-of-life patients), and the need to be culturally sensitive to a patient's needs.

Suggested Improvements for Affordable Care Component

Twenty-three (23%) percent of respondents suggested improvements for Affordable Care, although no dominant suggestion emerged. Nearly one-third of respondents that addressed the Affordable Care component suggested emphasizing that costs will be reigned in and care will be clinically appropriate and evidence-based, and quality will not be compromised. Some respondents indicated that this component's definition is too vague and challenging to interpret as affordability is a relative concept. Alternatively, some respondents suggested highlighting ways to achieve affordability including increased patient education, aligned public/private sector efforts, increased system efficiencies, and reduced unnecessary regulation.

Suggested Improvements for Healthy People/Healthy Communities Component

Sixteen (16%) percent of respondents provided suggestions on ways to improve the Healthy People/Healthy Communities component. No dominant theme emerged from the responses, however, slightly more than one-third of respondents suggested highlighting ways to achieve healthy people and healthy communities (e.g., increased access to health and wellness resources; patient engagement and self-management), and the need to highlight "prevention" in the definition as it one of the primary ways to achieve greater public health. This component of the Framework received the least amount of responses when compared to Better Care and Affordable Care.

4.3 Key Themes for Question 3

Public Comment Question 3: Using the legislative criteria for establishing national priorities, what national priorities do you think should be addressed in the initial National Health Care Quality Strategy and Plan in each of the following areas:

Better Care: Person-centered care that works for patients and providers. Better care should expressly address the quality, safety, access, and reliability of how care is delivered and how patients rate their experience in receiving such care;
Affordable Care: Care that reins in unsustainable costs for families, government, and the private sector to make it more affordable; and
Healthy People/Healthy Communities: The promotion of health and wellness at all levels.

A total of 232 respondents submitted comments in response to Question 3. These comments addressed national priorities for each of the Framework components: Better Care, Affordable Care, and Healthy People/Healthy Communities, and included other general suggestions related to priorities that should be set. A summary of the comments received for each of these points is included below.

Suggested Priorities Relating to Better Care

Eighty-two (82%) percent of respondents suggested priorities for the Better Care component, although there was no central theme to the responses. Respondents most commonly suggested priorities that involved increased access to appropriate, coordinated, patient-centered care with a focus on primary care and prevention/wellness services. Specifically related to increased access, respondents suggested focusing on alternative, non-traditional methods of providing care (e.g., telemedicine, email, web-based communication, remote consultations). Respondents also commented on the need for appropriate and qualified providers of care, and the need for access to health services regardless of health insurance or ability to pay. Comments indicated that coordination across the continuum of care and integrating various provider specialties and care settings (such as through the medical home model), is critical to improving patient outcomes and lowering the cost of care. This is especially the case with caring for chronically ill, frequent users of the healthcare system. Comments also suggested that patient-centered care should involve shared decision-making, be responsive to patient and family needs, recognize the whole patient (i.e., not just treat the illness), and that care should be designed to address needs across all stages of life.

A specific focus on palliative/hospice/end-of-life care, including availability of resources and measurement of care provided, was another strong recommendation in terms of national priorities related to better care. Respondents noted that given the nature of this type of care in addressing physical, emotional, and spiritual needs, it naturally aligns with patient-centered strategies. Additional suggestions included payment equities and provider/care setting accountability through performance measurement be addressed.

Priorities Relating to Affordable Care

Seventy-four (74%) percent of respondents suggested a variety of priorities relating to Affordable Care, without any overriding theme. Establishing national priorities relating to reducing the cost of care was the most frequently provided suggestion (although did not constitute an overall majority) among comments relating to Affordable Care. Respondents commonly highlighted that the current health care system is not sustainable given the rates of cost escalation. Comments also highlighted the extreme costs associated with managing chronic illnesses, including associated medications. Controlling unnecessary care, including misuse and overuse of diagnostic testing was another specific priority described by respondents relating to reducing care costs.

The need for payment reform was also a common theme among respondents. Comments suggested that the quality of care and the value of care should drive payment. Other comments suggested the need for changes in how commercial insurers structure payment contracts. Respondents recommended testing innovative payment models (e.g., pay for performance, bundled payments, increased reimbursement for Accountable Care Organization models) that promote more affordable care and that moves the system away from rewarding more, and often unnecessary, services.

The need for addressing tort and malpractice reform was mentioned by respondents as a way mechanism for addressing affordable care. Comments suggested addressing malpractice laws, which currently encourage providers to practice "defensive medicine". They indicated that this type of defensive care practice is often unnecessary and contributes to the escalating cost issue.

Suggested Priorities Relating to Healthy People/Healthy Communities

Sixty-nine (69%) percent of respondents suggested priorities related to the Healthy People/Healthy Communities component. No dominant theme emerged from the submitted suggestions. Of the comments specific to Healthy People/Healthy Communities, respondents most frequently highlighted increased access to health and wellness resources as a national priority to be addressed. Respondents identified schools as an optimal means to educate children about health and wellness, not only through curricula, but also by improving school menus, and increasing physical education or recess time. Comments suggested the need to support and prioritize prevention programs or programs to support healthy behaviors. They indicated such programs might involve physical activity or exercise sessions, and education or support groups for maintaining a healthy weight/diet, tobacco cessation, and drug/alcohol use.

Respondents also suggested prioritizing primary care and prevention, as it is critical to improving public health and containing costs. Palliative/hospice/end-of-life care was another common recommendation for prioritization; comments noted the need to engage patients and their families in healthcare decision-making around palliative and end-of-life care, and its role in providing alternative, often more comfortable care.

Other General Suggestions

Respondents provided additional suggestions not specific to any given Framework component. A few comments related to alignment of the Principles to the Framework components. Other comments suggested incorporating priorities set forth by the National Priority Partnership and National Quality Forum.

Return to Contents
Proceed to Next Section (4.4)