Future Directions for the National Healthcare Quality and Disparities Reports
Chapter 2: Re-Envisioning the NHQR and NHDR (continued)
The Committee's Recommended Priority Areas
As required by its statement of task (go to Chapter 1), the Future Directions committee identifies a set of eight national priority areas for focusing national health care quality improvement efforts and for use in selecting measures for the NHQR and NHDR. Before presenting the committee's recommendations, however, it is important to define and distinguish among the terms aim, priority area, goal, benchmark, and target as they are used by this committee (go to Box 2-2).
Over time, setting an ideal level of performance in a priority area (aspirational goal) would be informed by progress on the highest quantifiable level of performance achieved so far (benchmark) so that realistic levels of actual performance can be utilized in setting national targets for achievement. (The use of benchmarking in health care is discussed further in Chapter 6.)
Previously Identified National Priorities
The committee considered efforts by various entities that have identified priority areas specifically for health care quality improvement, developed scorecards on key quality performance areas, or focused resources on health care quality improvement and disparities elimination. As discussed below, these efforts include work by previous IOM committees, the National Priorities Partnership (NPP) convened by NQF, HHS, and others.
Box 2-2. Definitions Used in This Report
In the interest of clarity, the IOM Future Directions committee defines the terms aim, priority area, goal, benchmark, and target as they are used in this report.
a This definition was adopted by the Future Directions committee to be consistent with how the term is used by the National Priorities Partnership (NPP).
Previous IOM Committees' Recommended Priorities
The 2001 Crossing the Quality Chasm report (IOM, 2001a) delineated six aims for quality health care (safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity) and recommended that goals be set for each of the aims. That report also identified 16 priority conditions on the basis of their high cost to the system, although the report set no specific goals with regard to these conditions and none were set subsequently. AHRQ has used four of the six aims specified in the Crossing the Quality Chasm report as a way to frame the organization of the NHQR and NHDR (go to Chapter 3).
In the 2003 report Priority Areas for National Action: Transforming Health Care Quality, the IOM proffered 20 priority areas for national action (IOM, 2003). That report stressed a mix of early interventions, self-management, and care coordination for conditions or populations that had a high impact from the burden of the condition (disability, mortality, and economic costs) on "patients, families, communities, and societies" (p. 4) and that had a probability that the gap between current practice and desired levels of recommended care could be improved. AHRQ has included many of these priority areas in its portfolio of measures (IOM, 2003). More recently, conversations about transforming the U.S. health care system and its quality have stressed the significance of looking at the whole patient experience over time and across sites of care (e.g., episodes of care, care coordination) instead of just looking at single condition-specific process measures (HHS, 2009a; McKethan et al., 2009; NPP, 2008).
The National Priorities Partnership's Six Recommended Priority Areas
In 2008, the NPP was convened by NQF as a cross-section of 28 public and private stakeholders, including AHRQ, the IOM, CMS, and the Centers for Disease Control and Prevention.6 That same year, the NPP reached consensus on a set of six national priority areas considered to be "the work of many to achieve the transformational change that is needed for the United States to have a high-performing, high value healthcare system" (NPP, 2008, p. 7). The NPP focused on national priorities�as well as on what the NPP considered to be aspirational but ultimately achievable goals for each priority�that would,7 if implemented broadly, reduce harm, improve patient-centered care, eliminate health care disparities, and remove waste from the U.S. health care system. The six NPP priorities for the U.S. health care system are: (1) patient and family engagement, (2) population health, (3) safety, (4) care coordination, (5) palliative care, and (6) overuse (NPP, 2008).
The NPP's identification of these six national priorities has several attractive features:
- The NPP priority areas involve measuring health care quality in new ways that represent the whole patient rather than a single disease, look across settings of care, and trace care and outcomes longitudinally (i.e., patient-focused episodes of care).
- The NPP priority areas and goals were established through a robust, consensus-based process involving a broad variety of public and private stakeholders.
- The NPP's national priority areas and goals represent areas in which the NPP thought it possible to achieve substantial progress by beginning with measures that are available now and adding to them as new measures become available.
- The NPP was convened by the NQF, which is recognized as "a neutral convener of consumers, purchasers, providers, practitioners, government and oversight agencies, supporting industries and other interested parties to identify and standardize �best-in-class' measures of clinical quality and health system performance" (RWJF, 2009b).
- Each of the NPP priority areas is supported by an extensive evidence base reviewed by the partners.8 (Note: This evidence base is not repeated in this report; for more information see the 2008 NPP report National Priorities & Goals. Aligning Our Efforts to Transform America's Healthcare [NPP, 2008].9)
- The NPP priorities are ones to which the public and policy makers can easily relate.
- Within the first year of the release of the NPP priority areas, numerous groups outside the original circle of developers found that the NPP priorities reflect their own priorities and are moving to align activities. Such activities include (1) strategic planning (e.g., nursing and pediatric groups), (2) operations (e.g., Aligning Forces for Quality's regional health care collaborative in Maine), (3) research (e.g., Regenstrief Center for Healthcare Engineering), and (4) public outreach (e.g., the development by the National Business Group on Health of consumer-friendly fact sheets around NPP-identified areas of unnecessary overuse of health care).10
Since its inception, the NPP has grown in membership to broaden the engagement of more than the initial core of partners. It also has established a workgroup for each priority area (NPP, 2009c). These workgroups are continuing to identify strategies such as promoting the adoption of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) and measures that support the priorities, and attempting to achieve parsimony in designating measures (e.g., a single rather than multiple care coordination measures or a palliative care measure applicable for multiple diseases). No one organization or single initiative can bring about the degree of change necessary to address the substantial gaps in the quality of U.S. health care, but collaborative efforts are expected to have greater reach (NPP, 2009a,b).
Although the NPP plans to conduct an evaluation of the uptake of its recommended priority areas and goals in the activities of various entities, neither the NPP nor NQF have plans to be a central repository of data for national tracking related to the priorities.11 It is quite conceivable, therefore, that AHRQ's future NHQRs and NHDRs could play important roles by relaying these national priorities to audiences, and providing a means for reporting on the progress made toward achieving priorities and goals. Moreover, just as the NPP and the nation can benefit from having the priorities tracked in the AHRQ reports, AHRQ can benefit from the ongoing work of the NPP and its expanding networks of actors.
Other Entities' Recommended Priority Areas
Numerous entities in the United States, apart from the NPP and previous IOM committees, have sought to identify priority areas for health care quality improvement, develop scorecards on performance, or focus resources on health care quality improvement. The committee scanned articulated priority areas for health care quality improvement across a variety of these entities and has summarized them, along with priority areas identified by the previous IOM committees and the NPP, in Table 2-1.
The IOM Future Directions Committee's Eight Priority Areas
The eight national priority areas recommended after considerable deliberation by the Future Directions committee are shown in Box 2-3. The committee thought that the NPP's six priorities captured most of the key priorities for health care quality improvement. Thus, six of the committee's eight recommended priorities for health care quality improvement are the priorities recommended by the NPP (NPP, 2008). In addition, the committee added two priority areas not included in the NPP's recommended priorities—access to care and health systems infrastructure capabilities.
The NPP's priorities presuppose access to care. Yet access to health care remains a challenge for a large segment of the U.S. population and is a fundamental dimension of health care quality for all populations. Consequently, the committee believes that it is vital to single out access to care, especially in light of upcoming changes to health insurance coverage.12 Lack of coverage is a well-documented barrier to care, but it is not the only one (others include transportation, ability to take time off from work to seek care, lack of a regular source of care, unwillingness of providers to accept specific types of insurance, and affordability of coverage, co-payments, and deductibles) (Ahmed et al., 2001; Cummingham et al., 2008; Goins et al., 2005; Goldman and McGlynn, 2005; Grumbach and Mold, 2009; Hall et al., 2008; Lofland and Frick, 2006; RWJF, 2002; Wang et al., 2009).
The development of health systems infrastructure, also not included in the NPP's national priorities, is similarly considered by the committee to be an area demanding national attention. With the health care data sources that are available today, AHRQ has been stymied in its ability to obtain data that are more directly related to care processes and outcomes. The adoption of electronic health records and establishment of health information exchanges spurred through the American Recovery and Reinvestment Act of 200913 will eventually open up new possibilities for obtaining clinical data across areas and payers (Arrow et al., 2009; Blumenthal, 2009; Kern et al., 2009) (go to Chapter 5). These investments in data development and "meaningful use" of that data for quality improvement could eventually support national-level reporting in the NHQR and NHDR. Strengthening standardized collection of race, ethnicity, and language need data will assist in identifying the nature and scope of disparities in health care related to these factors. Furthermore, the development of organizational capacity to coordinate care (e.g., e-prescribing, patient-centered medical homes) and provision of a sufficient workforce are important areas of infra-structure that are relevant to health care quality and disparities (these components of infrastructure are examined further in Chapter 3 and Appendix D). Thus, the committee makes the following recommendation:
Recommendation 1: AHRQ should ensure that both the NHQR and NHDR report on the progress made on the priority areas for health care quality improvement and disparities elimination, and should align selection of measures with priority areas. Until a national set of priority areas is established, AHRQ should be guided by the Future Directions committee's recommended priority areas.
While the committee has recommended eight national priority areas that are crosscutting in nature, that does not mean that tracking disease-specific measures of health care quality will no longer be necessary. There will still be audiences for whom that level of detail is important, but the print versions of the AHRQ reports do not always have to feature each disease-specific element; some elements can be included in expanded data featured online via an appendix to the report or other Web-based product.
Focusing Resources and Attention on National Priority Areas
Priority setting is a systematic approach to distributing available resources among multiple demands in the effort to create the best health care system possible given economic constraints. Priority setting is also a first step toward actionability by focusing attention on areas that are considered most important (McGlynn, 2004; McMahon and Heisler, 2008; Ranson and Bennett, 2009; Sabik and Lie, 2008; Whitlock et al., 2010). Priorities matter because resources of all of kinds (e.g., labor/time, funding for research on measures, data development and analysis) are limited. The setting of national priority areas for the measurement of health care quality improvement can be viewed as having the potential for influencing the "allocation of limited resources among many desirable but competing programs or people;" thus, "it is highly political and can be controversial" (AHRQ, 2009a; McKneally et al., 1997; Whitlock et al., 2010, p. 493).
As the Future Directions committee's charge read to "establish national priority areas," the committee considered its role to be to advise AHRQ on a set of priorities. At the same time, AHRQ asked for advice on making the national healthcare reports more actionable, and others who came before the Future Directions committee or whose reports the committee reviewed also stressed the need for greater progress. Many are frustrated with the slow progress toward improvement despite repeated documentation of the same quality shortcomings and persistent disparities. However, focusing the combined efforts of many actors and various intervention techniques on the same priorities could be expected to enhance progress, whether they are the priorities that are recommended in this report or a set that emerges as a result of developing the national quality improvement strategy pursuant to health reform legislation.14
While AHRQ can use the priority areas offered in this report to select measures and guide the content of the NHQR and NHDR, it is not AHRQ's role to set intervention-related policies for a national quality improvement agenda that can have implications for resource allocation across HHS and external sources. Since AHRQ falls under the direction of the Secretary of HHS, the Future Directions committee concludes that HHS leadership is needed to establish national priorities and set clear goals that can be featured in the national healthcare reports and thereby bring to bear the resources of the department.
Box 2-3. The Committee's Eight Recommended National Priority Areas for Health Care Quality Improvement
The IOM Committee on Future Directions for the National Healthcare Quality and Disparities Reports recommends a set of eight national priority areas for health care quality improvement for use in the NHQR and NHDR; it believes these priorities can guide the national healthcare reports. The recommended areas include six priority areas identified by the National Priorities Partnership (NPP, 2008), as well as two additional priorities that the committee believes are important to highlight.
The six NPP priority areas included in the committee's set of national priority areas are:
The two additional priority areas in the committee's set are:
Leadership in Establishing National Priorities and Goals
Although measures and reports such as the national healthcare reports cannot improve the quality of U.S. health care directly, they provide context and motivation for quality improvement (Moy, 2009). Reports can also present data in ways that better inform policy and practice. Complementary policies and practices that would help close priority area quality gaps and support more widespread implementation of programmatic initiatives are essential to drive progress. As noted in Chapter 1, the concept of a national quality measurement and reporting system outlined by the Strategic Framework Board depends not only on reporting, but also on the setting of goals, adoption of comparable measures, and interventions to change the state of quality and disparities (McGlynn, 2003). Thus, other incentives and collaborative efforts are needed to get to higher levels of performance (go to Box 2-4 for examples of mechanisms and actors).
Having AHRQ alone adopt priority areas for use in the national healthcare reports without support across HHS is less likely to advance quality than if these other actors become engaged. Having common priority areas can help drive concerted national and local action toward the same ends. Part of the Future Directions committee's logic in adopting the six NPP priority areas was the NPP's ability to draw consensus from a reputable group of private and public sector members and the NPP's continuing engagement in fostering progress on those priority areas. The NPP has recommended priority areas and goals; the Future Directions committee's charge only extended to the naming of priority areas for quality improvement, not goals, although it heartily endorses the setting of goals and/or targets by HHS.
Furthermore, the word "national" is part of the names of the NHQR and NHDR, and the Future Directions committee observes that no report could present a full picture of national health care delivery without considering how priorities and goals are integrated and implemented in the health systems under the auspices of the VA, DOD, the Federal Employees Benefit Program, and the federal Bureau of Prisons. Under the Patient Protection and Affordable Health Care Act, the President would convene an interagency working group to foster collaboration between departments and agencies with respect to developing and disseminating strategies and goals for national health care quality priorities. The working group would be comprised of representatives from various HHS agencies, the Department of Commerce, the Office of Management and Budget, the Social Security Administration, the Department of Labor, the U.S. Office of Personnel Management, DOD, the VA, and the Department of Education, among others.15
The IOM report Leadership by Example: Coordinating Government Roles in Improving Health Care Quality stressed that if the federal government could take collective action across programs for which it has accountability, it would lead the way to action elsewhere (IOM, 2002b). To make substantial progress on national priorities and associated goals, there needs to be unequivocal endorsement and commitment at least at the level of the HHS Secretary to make substantial change in performance levels. Such a commitment could be embodied through a range of regulations and policies, including systematic reporting on quality metrics by federally sponsored direct health care service programs. The HHS Secretary is positioned to direct HHS programs to focus on the achievement of national priorities and goals through policies that support a stronger quality improvement infrastructure (i.e., measure development and the collection and analysis of evidence-based performance information), health care interventions (e.g., changes in insurance coverage, support of preventive and care coordination services), public reporting, incentive payments, demonstration projects, benefit design, and health professions education, as well as refining performance measures through research and funding of data sources (IOM, 2009). These HHS-wide efforts would complement efforts by the NPP.
Implementation by the HHS Secretary of initiatives for expanding health insurance coverage and reforming payment for services will require monitoring to ensure that the initiatives and existing programs will have the desired effect on quality of care, its costs, equitable treatment, and ultimately the health of the nation.16 Additionally, substantial federal funds are being invested in strengthening electronic health records and providing for their meaningful use in quality improvement.17 The NHQR and NHDR are natural vehicles for tracking the effect of these changes, utilizing the data that emerge for national reporting, and reporting on designated priority areas. The NHQR and NHDR should contain a strategic vision for U.S. health care quality improvement efforts by reporting on areas with the potential to achieve the best value and equity for the dollars invested while having the greatest impact on population health. This strategic vision is the basis for the measure selection process for the NHQR and NHDR outlined in Chapter 4. The results of quantitative assessments of quality improvement impact for measurement areas and the identification of benchmarks based on best-in-class performance (Chapter 6) would additionally inform realistic goal- and target-setting for priority areas.
Box 2-4. Health Care Quality Improvement: Illustrative Mechanisms of Influence and Actors
To meet the needs of Congress and various other users for information on health care quality and to articulate a vision for national health care quality improvement, the committee believes that the NHQR and NHDR should do more than reporting on what has already transpired. The NHQR and NHDR and related products have the potential to articulate a vision for health care quality improvement and engage others to achieve quality improvement goals. Because disparities in care are a health care quality issue, greater integration between the NHQR and NHDR is recommended.
As required by its charge, the committee recommends a set of eight priority areas for national health care improvement: (1) patient and family engagement, (2) population health, (3) safety, (4) care coordination, (5) palliative care, (6) overuse, (7) access, and (8) capabilities of health systems infrastructure. While the Future Directions committee believes AHRQ can incorporate the offered priority areas into the NHQR and NHDR, especially through its messaging and measure selection process, more progress will be made toward achieving priority area goals if there is more widespread adoption and integration of national priority areas into a common quality and disparities improvement strategy.
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6 The NPP consisted of 28 members when the initial priorities and goals were established in 2008 (http://www.nationalprioritiespartnership.org/Partners.aspx [accessed May 14, 2010]). The Partnership has since grown and now consists of 32 members. They represent multiple stakeholder groups in both the public and private sectors (e.g., health plans, providers, medical associations, workforce interest groups). Stakeholders include AARP, AFL-CIO, Agency for Healthcare Research and Quality, Aligning Forces for Quality, Alliance for Pediatric Quality, American Board of Medical Specialties, American Health Care Association, American Nurses Association, America's Health Insurance Plans, AQA, Centers for Disease Control and Prevention, Centers for Medicare and Medicaid Services, Certification Commission for Health Information Technology, Consumers Union, Hospital Quality Alliance, Institute for Healthcare Improvement, Institute of Medicine, Johnson & Johnson, The Joint Commission, The Leapfrog Group, National Association of Community Health Centers, National Business Group on Health, National Committee for Quality Assurance, National Governors Association, National Institutes of Health, National Partnership for Woman & Families, National Quality Forum, Pacific Business Group on Health, Physician Consortium for Performance Improvement convened by the American Medical Association, PQA, Quality Alliance Steering Committee, and the U.S. Chamber of Commerce.
7 The goals are aspirational because they typically set a high bar for achievement—for example, "All Americans will receive the most effective preventive services recommended by the U.S. Preventive Services Task Force"; or "Seek to eliminate all healthcare-associated infections and serious adverse events." (Note: Emphasis added.)
8 The NPP did not limit selection of national priority area goals to areas where proven interventions are available (e.g., obesity is a problem, but there is not a clear-cut intervention strategy).
9 The NPP's 2008 report is available online at http://www.nationalprioritiespartnership.org/AboutNPP.aspx (accessed May 13, 2010).
10 Personal communication, Karen Adams, National Priorities Partnership, National Quality Forum, November 15, 2009.
11 Personal communication, Janet Corrigan, National Quality Forum and Karen Adams, National Priorities Partnership, National Quality Forum, May 11, 2009.
12 Patient Protection and Affordable Care Act, Public Law 111-148, 111th Cong., 2d sess. (March 23, 2010).
13 American Recovery and Reinvestment Act of 2009, Public Law 111-5, 111th Cong., 1st sess. (February 17, 2009).
14 Patient Protection and Affordable Care Act, Public Law 111-148 � 3012, 111th Cong., 2d sess. (March 23, 2010).
15 Patient Protection and Affordable Care Act, Public Law 111-148 § 3012, 111th Cong., 2d sess. (March 23, 2010).
16 Patient Protection and Affordable Care Act, Public Law 111-148, 111th Cong., 2d sess. (March 23, 2010).
17 American Recovery and Reinvestment Act of 2009, Public Law 111-5, 111st Cong., 1st sess. (February 17, 2009).
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