2012 Annual Progress Report to Congress National Strategy for Quality Improvement in Health Care
Submitted by the U.S. Department of Health and Human Services
Collaboration with Stakeholders
A National Approach to Measuring Quality
Aligning Federal & State Efforts to the National Quality Strategy
Focus on Priorities: Key Measures and Long Term Goals
Appendix A: Key Measures for National Quality Strategy Priorities
The National Strategy for Quality Improvement in Health Care (the National Quality Strategy) sets a course for improving the quality of health and health care for all Americans. It serves as a blue print for health care stakeholders across the country – patients, providers, employers, health insurance companies, academic researchers, and local, State, and Federal governments – that helps prioritize quality improvement efforts, share lessons, and measure our collective success.
The initial National Quality Strategy, published in March 2011, established three aims and six priorities for quality improvement (see Exhibit 1). This report details some of the work conducted in public and private sectors over the past year to advance and further refine those aims and priorities.
Exhibit 1. National Quality Strategy Aims and Priorities
|National Quality Strategy's three aims:
National Quality Strategy's six priorities:
Collaboration with Stakeholders
The National Quality Strategy represents a collaborative effort across all sectors of the health care community. One of our key partners has been the National Quality Forum (NQF), which the U.S. Department of Health and Human Services (HHS) enlisted to recommend goals and key measures for each of the six National Quality Strategy priorities. The NQF is an independent nonprofit organization that refines and endorses standards and measures of health care quality through a national consensus based approach. The NQF convened the National Priorities Partnership, a collaborative of major health care stakeholders established to set national priorities and goals for improving health care quality throughout the country. The National Priorities Partnership collected input, and in September 2011, delivered its recommendations entitled Input to the Secretary of Health and Human Services on Priorities for the National Quality Strategy. This feedback, discussed in detail in this report, has guided HHS efforts to implement the National Quality Strategy.
The National Quality Strategy has also led to new collaborations across agencies in the Federal government, most notably through the Interagency Working Group on Health Care Quality, which convened for the first time in March 2011. Through the Interagency Working Group on Health Care Quality, Federal agencies are identifying ways to maximize resources to improve quality, align measures, and reduce duplication of efforts.
A National Approach to Measuring Quality
One of the primary objectives of the National Quality Strategy is to build a national consensus on how to measure quality so that stakeholders can align their efforts for maximum results. The strategy itself serves as a framework for quality measurement, measure development, and analysis of where everyone can do more, including across HHS agencies and programs as well as in the private sector. This alignment of measurement creates shared accountability across health systems and stakeholders around the country for improving patient-centered outcomes.
In the past year, HHS has also adopted a more transparent process for selecting quality measures for new and existing programs, incorporating an opportunity for public feedback prior to their formal adoption in rulemaking. To reduce the burden on health care providers and promote comparability of measurement data, the Department is working to align measures across CMS reporting initiatives, such as the EHR Incentive Program's Meaningful Use requirements.
Aligning Federal & State Efforts to the National Quality Strategy
There are quality improvement initiatives underway throughout the Federal government and in each of the States. The National Quality Strategy seeks to reduce duplication and create efficiencies – not just in measurement but in quality improvement efforts as well. For example, activities are well underway to assure that the National Quality Strategy supports and reinforces improvements in population health consistent with the Strategic Directions, Priorities and Recommendations of the National Prevention Strategy: America's Plan for Better Health and Wellness. HHS is also ensuring that new initiatives proposed by the Department align with the National Quality Strategy.
Further, divisions within HHS have developed initial agency-specific strategic quality plans to align their mission and programs with the National Quality Strategy aims and priorities. A pioneer in this effort, the Substance Abuse and Mental Health Services Administration (SAMHSA), developed the National Behavioral Health Quality Framework to reflect a SAMHSA-specific approach to implementing the National Quality Strategy. This process has prompted additional stakeholder engagement in SAMHSA's efforts to develop a core set of behavioral health quality and performance measures for its use and for other major behavioral health services purchasers. This work serves as a model for other agencies as they implement their strategic quality plans.
The Strategy serves also as an opportunity to spread best practices seamlessly between State and Federal governments. States have also taken the initiative to align quality improvement priorities in their public health plans and Medicaid programs with the National Quality Strategy. This report highlights two States, Colorado and Ohio, that have been particularly forward thinking in this regard. Ohio has identified performance measures aligned with the six National Quality Strategy priorities and will provide incentives to privately operated Medicaid health plans that excel in these areas and will penalize plans that fail to meet the standards. Colorado has brought together State departments and agencies to share data around key National Quality Strategy measures to improve access to Colorado's publicly funded health care system.
Focus on Priorities: Key Measures & Long Term Goals
This edition of the National Quality Strategy indicates how it will pursue – and measure—improvement in the six priority areas identified in last year's report. The National Priorities Partnership's recommendations of measures to monitor National Quality Strategy priorities contributed to the selection of the key measures for each priority described in this report. These selected key measures provide population-based, nationally representative information. In two National Quality Strategy priority areas, HHS has launched major improvement initiatives in the past year: the Partnership for Patients and the Million Hearts Campaign. In this report, we have formally adopted the measures and aspirational targets set by those initiatives into the National Quality Strategy to drive improvement. During this implementation year, HHS will identify aspirational targets for the key measures selected for each of the four remaining priority areas. This report also details long-term goals for each of the six priority areas, established in consultation with the National Priorities Partnership.
The National Quality Strategy is an evolving guide for the Nation. As its implementation continues, the National Quality Strategy will be refined, based on lessons learned in the public and private sectors, emerging best practices, new research findings, and the changing needs of the American people. Subsequent annual reports to Congress and the public will include updates on the Strategy and the Nation's progress in meeting the three aims of better care, improved health for people and communities, and making quality care more affordable.
The National Strategy for Quality Improvement in Health Care (National Quality Strategy) is an important element of the Affordable Care Act and a roadmap for improving the delivery of health care services, patient health outcomes, and population health. The National Quality Strategy is intended to align the priorities and efforts of governmental and private sector stakeholders in improving the quality and reducing the cost of health care.
The U.S. Department of Health and Human Services (HHS) has collaborated with stakeholders across the entire health care system, including Federal and State agencies, local communities, provider organizations, clinicians, consumers, businesses, employers, and payers. HHS observed overwhelming consensus among stakeholders that everyone can play a role in improving the quality and reducing the cost of health care. This shared ownership, and support of the aims and priorities guiding the National Quality Strategy, establishes a strong foundation for collaboration and improvement in the coming years.
This report provides an update on the National Quality Strategy work that has occurred over the past year, and the activities currently underway. Further, this report focuses attention on the aims and priorities first described in the National Quality Strategy's report to Congress in March of 2011 by including key measures that HHS will use to evaluate the Nation's progress towards the quality improvement aims of the National Quality Strategy. Finally, it gives concrete examples of new initiatives at HHS, and among other public and private stakeholders, that are directly working to advance the National Quality Strategy's ambitious goals.
Background on the National Quality Strategy
The Affordable Care Act calls on the Secretary of HHS to “establish a national strategy to improve the delivery of health care services, patient health outcomes, and population health.” In March 2011, HHS released the inaugural report to Congress establishing the National Quality Strategy's three aims:
- Better Care: Improve the overall quality of care, by making health care more patient-centered, reliable, accessible, and safe.
- Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care.
- Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.
To advance these aims, we focus on 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 the most 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.
A core set of consensus-based principles guide the National Quality Strategy and all efforts to improve health and health care delivery. The 2011 National Quality Strategy Report and these principles are available at www.ahrq.gov/workingforquality.
The National Quality Strategy aims to align new and existing health care improvement efforts around these priorities and to measure progress.
First Year Progress
During the first full year of the National Quality Strategy, HHS successfully engaged many sectors of the health care community and has made strides toward a unified approach to quality measurement and harmonized quality-improvement efforts.
With the help of key stakeholders, including the National Priorities Partnership, HHS identified the following four short-term goals for implementing the aims and priorities of the National Quality Strategy. In each of these areas, the National Quality Strategy has led to significant achievements and HHS has accomplished all of its short-term implementation goals:
- Collaboration with Stakeholders: The National Quality Strategy set a short-term goal to request and receive feedback from the private sector on long-term goals, quality measures, and strategic opportunities. This was accomplished, primarily through a report from the National Priorities Partnership entitled Input to the Secretary of Health and Human Services on Priorities for the National Quality Strategy.1 The National Quality Strategy has also resulted in important strides in collaboration with other Federal and State governmental partners, including launching the Interagency Working Group for Healthcare Quality, as required by the Affordable Care Act.
- A National Approach to Measuring Quality: The National Quality Strategy set a short-term goal to conduct a review and comparison of recommended quality measures and measures currently in use and tracked by HHS. This review has been accomplished, and the findings are now driving ongoing work in developing a unified approach to quality measurement. This National Quality Strategy-driven effort has also led to new transparency policies around measure selection for HHS programs, and is supporting the retirement of measures that are no longer aligned with National Quality Strategy priorities.
- Alignment across Federal & State Governments: The National Quality Strategy set a short-term goal to have each HHS agency involved in health care quality-improvement work develop an Agency-Specific Quality Strategic Plan for alignment with the National Quality Strategy (as required by the legislation). HHS created a template for these plans for use by individual agencies, and all agencies have now completed initial versions of these quality strategic plans. The National Quality Strategy also set a short-term goal to assess current HHS initiatives and their alignment to the National Quality Strategy. This assessment has been completed, and as a result, HHS has developed a checklist for use in the review of proposed activities to ensure that all new initiatives align with National Quality Strategy priorities. The National Quality Strategy has led to collaboration with State partners and has spurred State efforts to redesign their quality improvement efforts in line with National Quality Strategy priorities.
- Focus on Priorities: Key Measures & Long Term Goals: As promised in the 2011 National Quality Strategy report, key measures, and long-term goals have now been established for each of the six National Quality Strategy priorities. In addition to identifying these key measures and long-term goals, this report also lists the current status of each of the measures and sets aspirational targets for improvement. The long-term goals for each priority area take a broader view, beyond the key measures, of what the National Quality Strategy hopes to achieve with respect to better care, healthy people/healthy communities, and affordable care.
The remainder of this report is divided into four sections, detailing the achievement of goals and ongoing progress in each of these four areas of work.
Additionally, HHS has launched many new initiatives aimed at improving health care quality, all of which align with the National Quality Strategy. These include the Partnership for Patients, a national campaign to reduce preventable hospital-acquired conditions and 30-day hospital readmissions; the Million Hearts Campaign, a national effort to prevent 1 million heart attacks and strokes over the next 5 years; and the Multi-Payer Advance Primary Care Practice Demonstration, a multi-payer collaboration to transform primary care practices around quality outcomes. Descriptions of these initiatives and others and the ways in which they support National Quality Strategy aims and priorities can be found throughout this report.
Collaboration with Stakeholders
The importance of stakeholder involvement in the National Quality Strategy cannot be overstated. Achieving the aims of improving the quality of care, the health outcomes of patients, and lowering the costs of care will only be possible through true collaboration between the private and public sectors. If successful, the National Quality Strategy will facilitate health care improvement efforts at the point of care delivery, among researchers, private payers, within State and local governments, and in all Federal agencies. Widespread reliance on the National Quality Strategy can only occur with the full involvement of all parts of the health care community at every stage.
The hard work of improving health care quality did not begin with the creation of the National Quality Strategy. The strategy has benefited from building on the work of well-established organizations that have convened stakeholders and advised the National Quality Strategy development process. How all of these organizations relate to each other and their various roles in the development of National Quality Strategy can seem complex. Below are descriptions of some of the key organizations involved.
The National Quality Forum (NQF) is an independent nonprofit organization that, for more than a decade, has been refining and endorsing standards and measures of health care quality. NQF-endorsed measures have become an industry standard for providers,payers, and others to measure progress toward quality-improvement goals.
The National Priorities Partnership is a collaborative of major health care stakeholders, convened by the NQF, to set national priorities and goals for improving health care quality throughout the country, in all settings. Its membership includes a wide variety of stakeholders, including consumer organizations, public and private purchasers, physicians, nurses, hospitals, and health research organizations.
The Measures Application Partnership, also convened by NQF, is a multi-stakeholder group that provides ongoing detailed analysis of measures being considered for use in Federal public reporting and performance-based payment programs. The Measures Application Partnership assures alignment of these measures with the National Quality Strategy aims and priorities and fosters their alignment and use across the private sector.
The Interagency Working Group on Health Care Quality, which includes leaders from 24 Federal departments and agencies that have missions' related to health care and quality improvement, provides an ongoing opportunity for collaboration across Federal programs. This group facilitates shared learning and avoidance of duplicative efforts.
The Agency for Healthcare Research and Quality (AHRQ) at HHS provides ongoing oversight of the National Quality Strategy. AHRQ already reports annually on progress and opportunities for improving health care quality and reducing disparities through two Congressionally-mandated reports: the National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report (NHDR), often referred to jointly as the NHQR-DR.
Private Sector Stakeholder Input on National Quality Strategy Goals and Measures
The private sector is an integral part of the development of a comprehensive set of quality measures and metrics for a national, quality strategy. The private sector is essential to the development and refinement of the National Quality Strategy because of the expertise it can provide, and its role in first-hand experience in quality improvement efforts. The private sector also provides a unique perspective on the barriers and constraints to certain measurement approaches. This input is invaluable in developing a strategy and measure set that is applicable to a wide range of stakeholders.
Following the release of the National Quality Strategy in March 2011, HHS enlisted the expertise of the National Quality Forum (NQF) and its members to recommend goals and key measures for each of the six National Quality Strategy priorities. NQF then worked with the National Priorities Partnership and the Measures Application Partnership to bring the stakeholder community to consensus.
In September 2011, the National Priorities Partnership delivered its recommendations entitled Input to the Secretary of Health and Human Services on Priorities for the National Quality Strategy. That report made specific recommendations of long-term goals and “measure concepts” for each of the six National Quality Strategy priorities. HHS's adoption of the recommended long-term goals and identification of key measures is discussed in the Focus on Priorities: Key Measures and Long Term Goals section of this report.
Particularly important for the National Quality Strategy, the National Priorities Partnership also outlined three strategic opportunities to accelerate improvement across all the National Quality Strategy aims and priorities. These strategic opportunities to accelerate system-wide improvement are:
- Develop a national strategy for data collection, measurement, and reporting that supports performance measurement and improvement efforts of public and private sector stakeholders at the national and community level.
- Develop an infrastructure at the community level that assumes responsibility for improvement efforts, resources for communities to benchmark and compare performance, and mechanisms to identify, share, and evaluate progress.
- Develop payment and delivery system reforms—emphasizing primary care—that reward value over volume; promote patient-centered outcomes, efficiency, and appropriate care; and seek to improve quality while reducing or eliminating waste from the system.
In addition to embracing the current recommendations of the National Priorities Partnership, we intend to obtain further input specifically regarding how to make progress on these three strategic opportunities. HHS will also conduct outreach activities including Web site updates and public comment opportunities such as conference calls and open door forums to obtain additional feedback and promote widespread stakeholder engagement.
Collaborating Across the Federal Government
To streamline efforts and foster collaboration across Federal agencies, the Affordable Care Act required the creation of the Interagency Working Group on Health Care Quality. HHS convened the Interagency Working Group on Health Care Quality for its inaugural meeting in March 2011. Comprised of representatives from 24 Federal agencies2 with quality-related missions, the Interagency Working Group on Health Care Quality is responsible for aligning Federal and State efforts to eliminate duplication of quality-related initiatives. HHS delivered the first report to Congress on the Interagency Working Group on Health Care Quality's activities in October 2011, available at the Working for Quality site.
The Interagency Working Group on Health Care Quality met again in December 2011 to discuss the National Quality Strategy and identify opportunities for alignment and synergy. The group identified four areas to explore this year: lessons learned from expanding Federally Qualified Health Centers (FQHC); the U.S. Department of Veterans Affairs' ASPIRE reporting initiative; disseminating better information to consumers; and potential new applications of the Baldrige Framework – the nation's public-private partnership dedicated to performance excellence. The Interagency Working Group on Health Care Quality will meet next in May 2012.
2 Interagency Working Group on Health Care Quality Member Agencies: Department of Health and Human Services (Chair), Administration for Children and Families, Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, Centers for Medicare & Medicaid Services, Consumer Products Safety Commission, Department of Commerce, Department of Defense, Department of Education, Department of Labor, Department of Veterans Affairs, Federal Bureau of Prisons, Federal Trade Commission, Food and Drug Administration, Health Resources and Services Administration, National Highway Traffic Safety Administration, National Institutes of Health, Office of Management and Budget, Office of the National Coordinator for Health Information Technology, Social Security Administration, Substance Abuse and Mental Health Services Administration, United States Coast Guard, United States Office of Personnel Management, Veterans Health Administration