the evolution of quality and value - moqc · 6/23/2017 · helen burstin, md, mph. chief...
TRANSCRIPT
Helen Burstin, MD, MPHChief Scientific Officer, NQF
Michigan Oncology Quality Consortium Annual MeetingJune 23, 2017
The Evolution of Quality and Value
National Quality Strategy
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U.S. Policy Environment: From Volume to Value
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NQF Strategic Vision
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National Quality Strategy IOM Vital Signs NQF Prioritization Advisory
Committees Healthy People 2020 Indicators Kaiser Family Foundation Health
Tracker Consumer priorities for Hospital
QI and Implications for Public Reporting, 2011
IOM: Future Directions for National Healthcare Quality and Disparities Report, 2010
IHI Whole System Measures Commonwealth Fund
International Profiles of Healthcare Systems, 2015
Prioritization Criteria: Environmental Scan
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OECD Healthcare Quality Project OECD Improving Value in
Healthcare: Measuring Quality Conceptual Model for National
Healthcare Quality Indicator System in Norway
Denmark Quality Indicators UK NICE standards – Selecting and
Prioritizing Quality Standard Topics Australia's – Indicators used
Nationally to Report on Healthcare, 2013
European Commission Healthcare Quality Indicators
Consumer-Purchaser Disclosure Project – Ten criteria for meaningful and usable measures of performance
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NQF Prioritization CriteriaCriterion Description
Outcome-focused Preference for outcome measures and measures with strong link to improved outcomes and costs
Improvable and actionable Preference for actionable measures with demonstrated need for improvement and evidence-based strategies for doing so
Meaningful to patients and caregivers Preference for person-centered measures with meaningful and understandable results for patients and caregivers
Support systemic and integrated view of care
Preference for measures that reflect care that spans settings, providers, and time to ensure that care is improving within and across systems of care
Hierarchical Framework
Priority Measures
Driver Measures
High Impact Outcomes
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Improvement Measures
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High-Impact OutcomesHigh Impact Outcomes
Well-being (including survival)
Patient experience (including care coordination, shared decisionmaking)
Preventable harm/complications
Prevention/healthy behaviors
Total cost/high value care
Access to needed care
Equity of care
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Reduce Measurement Burden
• Measure only when and where it is appropriate• Prioritize measures that will drive improvement• Feedback on burden and benefits of measurement• Remove measures that do not add value
Reduce Measurement Reduction
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measures (of 242) recommended for removal from 7 federal programs
86 NQF’s Measure Applications Partnership urges federal programs to strive for limited sets of high-value measures to reduce provider burden and improve healthcare quality
M a k i n g O h i o B e t t e rO H I O D E P A R T M E N T O F M E D I C A I D
Mesosystem
Microsystem
Macrosystem
Plan or health system measuresCommunity measures
State or federal reported measures
Clinician/Practice/Individual measures
Collaboration, Cooperation & Coordination Are Difficult
Mary Applegate, MD
NQF Measure Feedback
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NQF Strategic Vision
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Mismatch: What health outcomes patients want clinicians to deliver vs. what can be delivered
Engagement: Unengaged patients served by providers making key decisions
Performance: High costs, variable quality, overlapping measures, fragmented care
Learning Health System: Every patient benefits from available science & contributes to new scientific knowledge
Coproduction: We together assess needs, make decisions, & delivery care
Integration: Person-centered, coordinated, high value system with core quality & cost metrics
Problems: Solutions:
Accelerating Innovation
Eugene Nelson, Dartmouth
PatientsLikeMe/NQF PRO Stakeholder Listening Sessions
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Assess value and costs in
more complete way.
Empower patients to engage in
decisions and choose according
to preferences.
Increase ability to connect what we pay for to health improvement.
Uncover problems only patients can
evaluate.
More meaningful
data.
Involvement
Values Concordance
Decision Quality
Knowledge
Did the patient know what he or she needed to know?
Did the decision reflect the patient’s goals and concerns?
• Did the patient know a decision was being made?• Did the patient know the pros and cons of the treatment options?
• Did the provider elicit the patient’s preferences?
Measurement of Decision Quality
Shared Decision Making Process (IMDF) (NQF # 2962)
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This measure assesses the extent to which health care providers actually involve patients in a decision-making process when there is more than one reasonable option.▫ Radical prostatectomy for prostate cancer▫ Mastectomy for early stage breast cancer Patient tool assess 3 things:▫ What matters most to you? ▫ How well are we doing our job of giving you information? ▫ What do you talk about with your health care providers?
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1. How much effort was made to understand your health issues?
2. How much effort was made to listen to the things that matter most to you about your health issues?
3. How much effort was made to include what matters most to you in choosing what to do next?
UR VOICE 20
PROMIS in Clinical Practice
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PROMIS: Item Bank Approach
UR VOICE
Overall Survival Results of a Trial Assessing Patient-Reported Outcomes for Symptom Monitoring During Routine Cancer Treatment (Basch et al)
Overall Survival Among Patients With Metastatic Cancer Assigned to Electronic Patient-Reported Symptom Monitoring During Routine Chemotherapy vs Usual
JAMA. Published online June 04, 2017. doi:10.1001/jama.2017.7156
Symptom Reporting and Survival
PRO (concept)
PROM(instrument, tool,
single-item measure)
PRO-PM(PRO-based
performance measure)
Symptom: depression
PROMs and PRO-PMs
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Target Population:Patients with clinical depression
Percentage of patients with diagnosis of major depression or dysthymia and initial PHQ-9 score >9 with a follow-up PHQ-9 score <5 at 6 months (NQF #0711) and at 12 months (NQF #0710)
PHQ-9 ©, a standardized tool to assess depression
The Swedish Rheumatology Quality Registry Approach
Registry Enabled Shared Information Environment:Facilitated networks, clinical collaboratives,
public reporting & research
Patient & Family
Clinician & Care TeamPartnership for
Co-production
Clinical Team Conversations:
Population management,Pre-visit planning
Registry/IndustryConversations: Post-approval
surveillance; population modeling
Benchmarking & TransparencyConversations: Variations
in outcomes, good value services
Research Conversations:New treatments,
comparative effectiveness
Community of Patients Conversations:
Helpful knowledge, support, resources
Patient-Clinician Conversations: Goals,treatment decisions,
outcomes tracking
Patient-FamilyConversations:
Self-care actions &outcomes tracking
See QJM Nov 2016Lindblad et. al.
SRQ Patient Module
Patient’s overview
Earlier Later
<<Previous part Print the whole summary
Your disease activity
High
Medium
Low
SRQ Clinician Module
2015 2016
RxPrescribed
Patient ReportedOutcomes
ClinicalOutcomes
Complexity of Care: PatientsLikeMe COPD Analysis
Social Determinants and Equity
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“Another important component of this strategy is to measure equity itself. Health equity measures or domains should be developed and introduced into existing payment programs to measure disparities and provide incentives for reducing them.”
Joynt et al, NEJM December 28, 2016
Accelerating Innovation: Success Factors
Reduce burden to focus on what matters to patients, clinicians, payers, others Get feedback on measures to drive reduction and
share lessons learned Collect and use patient-reported data alongside
clinical data Use data in real time to provide feedback to patients
and clinicians Consider complexity, social determinants of health
and measure equity Rapid cycle testing to scale toward learning health
system
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Why we measure?Improve healthcare quality*
The Quality Imperative
Not everything that counts can be counted, and not everything that can be counted counts
~William Bruce Cameron
But…..
You can’t improve what you don’t measure
~ W. Edwards Deming
Quality Imperative
