The 1st Annual Crossing the Quality Chasm Summit: A Focus on Communities: Report of a Summit (2004)

The aim of the cross-cutting session on measurement was to identify strategies communities might pursue for using performance measures to assess and improve quality of care, further the accountability of health care organizations, and inform payer and consumer purchasing and decision making. All of the communities participating in the summit had been involved in measuring the effectiveness of their efforts, although their objectives—whether for quality improvement purposes or public reporting—may have differed. Measurement was also an underlying assumption for all the condition-specific action plans.

The following definition of measurement served as the springboard for discussion during this session and had the general approval of the session’s participants (IOM, 2002):

Overall, the participants view measurement as crucial to accelerating performance improvement in health care. Four key strategies emerged from this session: (1) integrate measurement into the delivery of care to benefit the patient whose care is measured, (2) improve information and communications technology (ICT) infrastructure to reduce the burden of data collection, (3) focus on longitudinal change in performance and patient-centered outcomes in addition to point-in-time measures, and (4) improve public reporting by effectively disseminating results to diverse audiences.

The underlying principle behind this strategy is that measurement should be integrated into routine clinical practice, so that the process of providing care also enables measurement to occur. Decreasing the burden of measurement and increasing the likelihood of data collection makes it possible to determine more accurately the quality of care being delivered. Once the necessary data are available, health care delivery systems can develop creative solutions to address suboptimal performance—thus continually improving the process of care.

In addition to posing a minimal data collection burden, performance measurement and reporting cannot be overly time-consuming or perceived as punitive. Moreover, as noted throughout the condition-specific working group sessions, national consensus on a core set of performance measures should simplify and bolster compliance with data collection by eliminating the collection of multiple conflicting measures collected against competing or conflicting standards. It was suggested that this common set of measures would include assessment of success in meeting the Quality Chasm’s six aims for care—safe, effective, patient-centered, timely, efficient, and equitable—and do so in the most parsimonious manner possible so as to not be overwhelming (IOM, 2001). These key measures should be reviewed by professional societies and made readily available to purchasers and consumers.

The Washington State Diabetes Collaborative—one of the 15 community participants at the summit—candidly shared with the participants in the measurement session some lessons learned from that initiative regarding the need for standardized data collection of a discrete set of measures. See Box 2-1 for a brief overview of this ground-breaking state-level project.

The asthma working group suggested that national organizations such as the American Board of Internal Medicine (ABIM), the Centers for Medicare and Medicaid Services (CMS), the Leapfrog Group, the National Quality Forum (NQF), accrediting agencies, and appropriate subspecialty providers agree on a defined, well-validated set of quality performance measurement tools for chronic diseases—including patient self-management indicators—within 3 years. The depression and pain control working groups called on the NQF to serve as a convening body to bring together the appropriate experts to establish metrics for effective and efficient care in these areas. Many of the national champions at the summit weighed in on this issue and offered their support. Box 2-2 provides a snapshot of some of the commitments they made.

Improving ICT infrastructure was identified as a key strategy to ease the burden of incorporating data collection, performance measurement, and results reporting into everyday clinical practice. Physician offices, hospitals, nursing homes, and health centers will require incentives to encourage the adoption of interoperable clinical information systems. A strategy suggested during this session was to reward practices that have clinical information systems in place—such as patient registries or partial/full electronic health records—that are used to collect data on their patient populations for quality measurement and improvement purposes. To this end, structural measures of ICT adoption by individual providers would have to be collected and reported.

Once this structural change occurs, measuring performance for multiple conditions can readily be achieved. Box 2-3 describes the Bridges to Excellence initiative, which recently launched a program to incentivize structural change in clinical ICT capability in physician offices.

Although incentives to build ICT capacity are certainly important, they are only a piece of a complex puzzle. Unresolved issues related to interoperability standards (addressed in detail in Chapter 3) and consensus on measures also figure prominently. There is a critical need for investment in this area, and participants called for the federal government to provide the necessary leadership. The federal government has provided grants to state mental health and substance abuse agencies to embark upon this effort, but limited resources impede the ability to reach all providers at the local level.

Participants generally believe that widespread adoption of ICT to assist measurement collection at the physician office level will necessitate partnering by public- and private-sector purchasers.

The condition-specific working groups also touched on the essential role of ICT in supporting measurement efforts. For example, recognized measurement experts in the asthma group affirmed that metrics for processes of care for asthma are well established. The major challenge now is moving these measures closer toward implementation. One hurdle is that these measures are based on patient reports and chart reviews, rather than on more easily accessible administrative data. Therefore, the asthma group suggested that the focus needs to be on (1) mandating/pressuring providers to collect these data and (2) creating the necessary

ICT infrastructure so the data can be collected more easily.

The depression working group identified ICT as the basis for all transformation and for all of their proposed solutions. They acknowledged that, given concerns about privacy and stigma, it will be challenging to incorporate behavioral health information into electronic health records. The working group suggested that behavioral health data should be treated in the same way as all other health information, consistent with the Health Insurance Portability and Accountability Act of 1996 (U.S. DHHS, 2004). The group presented a strategy with the initial 1-year goal of convening a group of 15 communities that would include all of the key stakeholders and defining a shared dataset for behavioral health in primary care. This first year would see pilot collection of these data and conclude with the formulation of recommendations for a national behavioral health data policy. Over the course of 3 years, this effort would be expanded to include a broader base of community agencies and stakeholders. The process for the 3-year goals would mirror that for the 1-year pilot, with an expanded group of participants.

Another solution put forward by the strategy session participants was for measurement efforts to focus on longitudinal change in patient health status over time. Implementing this solution would require evolving from the customary collection of process and outcome measures—which tend to focus on provider inputs—to a more multidimensional approach that includes assessing patients’ self-reports on their capabilities for self-management and their functional status. Using patient-reported health status to inform the medical encounter, essentially making it part of the “vital signs” taken at any visit, would improve individual patient care, as well as enhance the ability to gauge on a population basis how well care is being delivered for specific conditions and patient subgroups with each condition. A case in point provided during the session was the use of a standardized questionnaire to evaluate heart failure status. This type of feedback could quite easily be obtained from patients while they are sitting in the waiting room, and providers could use this information to customize and improve care. Additionally, data could be plotted over time to track patient-reported progress and/or aggregated to support population-based comparisons.

The heart failure working group also suggested collecting patient-reported health status as a routine part of care. They emphasized the need for adopting multiple approaches to make the collection of information from patients more convenient—such as a computer in the waiting room and web-based entry from home—as well as for organizing the data for clinicians in an easily interpretable format. Such information should be made readily available to the physician/nurse at first contact during the office visit and be automatically incorporated into the patient’s electronic health record if entered at home—coupled with an alarm to the health provider if there is a negative change in status. Additionally, patients should be provided with

their “scores,” and these results should be graphed over time to assist patients in self-management of their condition and allow the provider to examine trends. The group proposed that measures of mental health status also be included and that comorbidities be considered in interpreting quality-of-life scores, as heart failure patients often have multiple chronic illnesses, such as depression and diabetes.

The pain control working group proposed making assessment of pain the “fifth vital sign” and suggested that measures be developed to track and monitor the following: (1) percent of patients being evaluated for pain, (2) interventions conducted, and (3) effectiveness of the interventions (rate of overall decline in pain). These measures would then be incorporated into the Agency for Healthcare Research and Quality’s (AHRQ) annual National Health Care Quality Report (AHRQ, 2003) and the National Committee for Quality Assurance’s Health Plan Employer Data and Information Set (HEDIS^®) report (NCQA, 2004).

The group also proposed taking a patient-centered approach to measuring pain control. Strategies to achieve this goal include (1) providing cancer patients with multiple ways to record their pain outside the clinician encounter, such as over the Internet or by phone, so that results can be reviewed regularly and acted on in a timely way; and (2) establishing measures of family/caregiver experience as part of a performance measures set, for example, adding a question to the death certificate—which is often completed by a caregiver/family member—asking how effective the care team was in treating end-of-life pain.

Agreeing with the strategy session participants, the pain working group recognized the need to evaluate data on the prevalence of pain over time for individual patients. Doing so is particularly important during transitions between settings, such as from hospital to nursing home, when breakdowns in care are most likely to occur. The group suggested that providers adopt a standardized patient flow chart that would be recorded electronically for purposes of quality improvement, performance measurement, and patient education.

This strategy had two prongs: first, to improve public reporting of performance measures by including the patient experience; and second, to package and disseminate this information in a way that is useful and meaningful to different audiences. Underlying assumptions brought forth by the working groups included the need for transparent public reporting and the use of this information to foster quality improvement at multiple levels of the health care delivery system. For example, patients could compare their diabetes outcomes against those of a similar cohort as a stimulus to their self-management, individual clinicians could judge their performance among their peers, and communities could correlate local outcomes with regional and/or national benchmarks.

In response to the first part of this strategy, the condition-specific working groups echoed the need for patient/consumer input in the development and selection of quality measures. The depression working group suggested several strategies to this end: obtaining feedback from objective patient advocates and consumers; conducting focus groups among patients with depression to identify key quality characteristics and outcomes of care; and rallying a collaborative group of stakeholders—patients, physicians, purchasers, and payers—to achieve consensus on performance and satisfaction measures.

The second part of this strategy—reporting measures at different levels of granularity and in a variety of formats to divergent groups—is critical to stimulating consumer demand for quality services and accelerating the uptake of best practices by providers. The asthma

working group called for identifying methods to increase consumer use of report cards and for determining how various population subgroups prefer to receive these materials. Intermountain Health Care’s Depression in Primary Care Initiative illustrates how performance data can be used and marketed to address the needs of a variety of stakeholder groups (see Box 2-4).

SOURCE: Reprinted with permission from Brenda Reiss-Brennan (2004). Copyright 2004 by Brenda Reiss-Brennan.

At the summit, measurement was repeatedly identified as the backbone of quality improvement efforts. From the need to measure outcomes to make a business case and link rewards to quality care (see Chapter 6) to the importance of community-based measures and outcomes (see Chapter 7), documenting performance is critical to substantiate the positive effect of interventions—such as care coordination and self-management—and to better direct resources to problem areas.

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Daniel DM, Norman J, Davis C, Lee H, Hindmarsh MF, McCulloch DK, Wagner EH, Sugarman JR. 2004b. A state-level application of the chronic illness breakthrough series: Results from two collaboratives on diabetes in Washington state. Joint Commission Journal on Quality and Safety 30(2):69–79.

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