Executive Summary

The past decade has seen an unprecedented level of concern and action focused on improving the quality of American health care. Catalyzed in part by two Institute of Medicine (IOM) reports—To Err Is Human: Building a Safer Health System (IOM, 2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001)—organizations, professional associations, payers, regulators, accrediting bodies, and consumer groups have begun to make significant changes in their respective agendas and investments, all designed to achieve better safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity—the six aims for quality improvement specified in the Quality Chasm report. Initiatives undertaken include quality improvement collaboratives and other change programs; explorations of pay for performance; the development of early formats for public reporting on performance; and, most important, efforts to devise better ways to measure quality in nearly all of its dimensions.

Despite these investments, however, progress continues to be slow, lessons learned are fragmented, and little effort is being devoted to evaluating the impact of these improvement initiatives so future efforts can be guided more by evidence than by anecdote (Jencks et al., 2000; Leatherman and McCarthy, 2002, 2004, 2005). In short, the quality chasm in health care remains wide. On average, adults in the United States fail to receive almost half of the clinical services from which they would likely benefit (McGlynn et al., 2003). And while per capita health care spending in the United States greatly exceeds that in other industrialized countries, cross-national comparisons of health care quality reveal that other countries achieve better performance on many measures (Hussey et al., 2004; Reinhardt et al.,



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Performance Measurement: Accelerating Improvement Executive Summary The past decade has seen an unprecedented level of concern and action focused on improving the quality of American health care. Catalyzed in part by two Institute of Medicine (IOM) reports—To Err Is Human: Building a Safer Health System (IOM, 2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001)—organizations, professional associations, payers, regulators, accrediting bodies, and consumer groups have begun to make significant changes in their respective agendas and investments, all designed to achieve better safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity—the six aims for quality improvement specified in the Quality Chasm report. Initiatives undertaken include quality improvement collaboratives and other change programs; explorations of pay for performance; the development of early formats for public reporting on performance; and, most important, efforts to devise better ways to measure quality in nearly all of its dimensions. Despite these investments, however, progress continues to be slow, lessons learned are fragmented, and little effort is being devoted to evaluating the impact of these improvement initiatives so future efforts can be guided more by evidence than by anecdote (Jencks et al., 2000; Leatherman and McCarthy, 2002, 2004, 2005). In short, the quality chasm in health care remains wide. On average, adults in the United States fail to receive almost half of the clinical services from which they would likely benefit (McGlynn et al., 2003). And while per capita health care spending in the United States greatly exceeds that in other industrialized countries, cross-national comparisons of health care quality reveal that other countries achieve better performance on many measures (Hussey et al., 2004; Reinhardt et al.,

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Performance Measurement: Accelerating Improvement 2004). Similarly, spending levels vary widely among U.S. regions, yet there is no evidence that more expensive regions have either better quality or improved health outcomes (Baicker and Chandra, 2004; Fisher et al., 2003a,b). Racial, ethnic, and class disparities are pervasive; moreover, the numbers of uninsured are rising, currently making up more than 15 percent of the population (IOM, 2002, 2004). For the sizable investments being made in health care services, Americans should be getting much greater value from the care they receive. There are many obstacles to rapid progress in improving the quality of health care, but none exceeds the fact that the nation still lacks a coherent, goal-oriented, consistent, and efficient system for assessing and reporting on the performance of the health care system. Thus if quality improvement initiatives are to achieve their full potential, a concerted national effort to consolidate health care performance measurement and reporting activities will be essential. THE REDESIGNING HEALTH INSURANCE PROJECT In September 2004, the IOM launched the Redesigning Health Insurance Performance Measures, Payment, and Performance Improvement Project in response to two congressional mandates in the Medicare Prescription Drug, Improvement, and Modernization Improvement Act of 2003 (Public Law 108-173, Section 109). The committee empaneled by the IOM to carry out this project is producing three reports for Congress, the Centers for Medicare and Medicaid Services (CMS), and other public and private purchasers on strategies for accelerating the diffusion and pace of quality improvement efforts in the United States (see Table ES-1). Each of these reports, known collectively as the Pathways to Quality Health Care series, is focused on a specific policy approach to improving the quality of health care: (1) measurement and reporting of performance data, (2) payment incentives, and (3) quality improvement initiatives. All three approaches depend upon the availability of accurate, reliable, and valid performance measures. Performance measures can serve as the foundation for public reporting programs intended to promote accountability among providers and to aid consumers in making informed choices, serve as the basis for payment incentives that reward providers who deliver more effective and efficient care, and guide and inform clinicians and organizations in their quality improvement initiatives. This first report in the Pathways series focuses on the selection of measures to support the quality improvement efforts of a diverse set of stakeholders, and on the creation of a common infrastructure for guiding and managing a consistent set of such measures nationally and regionally. Future reports, to be released in 2006, will address payment incentive strate-

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Performance Measurement: Accelerating Improvement gies that incorporate these measures and offer an evaluation of the Quality Improvement Organizations that work under contracts with Medicare. NEED FOR A NATIONAL SYSTEM FOR PERFORMANCE MEASUREMENT AND REPORTING Congress, the public, and numerous other stakeholders concerned about the persistent quality gaps and rapidly rising costs of health care in the United States have high expectations that public reporting, pay for performance, and quality improvement initiatives can help realize the transformational change envisioned in the Quality Chasm report. As noted above, however, the full potential of these initiatives cannot be realized without a coherent, robust, integrated performance measurement system that is purposeful, comprehensive, efficient, and transparent. Such a system should link performance measures directly to explicit national goals for improvement. The performance measurement process should include audits to ensure the measures themselves are sufficiently accurate and reliable to yield credible data. The measurement process should also be streamlined to improve its value while reducing its costs. Its results should be open and available to all stakeholders. The committee fully recognizes that many public- and private-sector initiatives have made substantial progress in developing, implementing, and reporting on measures of provider performance. These efforts have yielded a laudable array of assets for performance measurement. However, the committee believes a well-functioning national system that can meet the need for performance measurement and reporting is unlikely to emerge from current voluntary, consensus-based efforts, which are often fragmented and lack a consistent connection to explicit, overarching national goals for health care improvement. In short, while recent efforts offer some promise, the committee believes a bolder national initiative is required. The current approach to quality measurement in the United States is unlikely to evolve on its own into an effective national system for performance measurement and reporting for the following reasons, among others: National goals are unlikely to be set and translated into measures, since existing entities have neither the authority nor the overarching leadership required to formulate such goals. Gaps in performance measurement, such as the capacity to measure equity and access, are unlikely to be filled because of the lack of clear ownership of these aspects of the nation’s quality improvement agenda. Wasteful duplication and inconsistencies among measures will continue, since no single stakeholder group has the standing to require others to use specific, standardized definitions and measurements.

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Performance Measurement: Accelerating Improvement TABLE ES-1 Mapping of IOM Reports of the Committee on Redesigning Health Insurance to Congressional Mandates P.L. 108-173 Section 238   EVALUATION-     (1) IN GENERAL-Not later than the date that is 2 months after the date of the enactment of this Act, the Secretary shall enter into an arrangement under which the Institute of Medicine of the National Academy of Sciences (in this section referred to as the ‘Institute’) shall conduct an evaluation of leading health care performance measures in the public and private sectors and options to implement policies that align performance with payment under the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.). (2) SPECIFIC MATTERS EVALUATED-In conducting the evaluation under paragraph (1), the Institute shall—       (A) catalogue, review, and evaluate the validity of leading health care performance measures; (B) catalogue and evaluate the success and utility of alternative performance incentive programs in public or private sector settings; and (C) identify and prioritize options to implement policies that align performance with payment under the medicare program that indicate—         (i) the performance measurement set to be used and how that measurement set will be updated; (ii) the payment policy that will reward performance; and (iii) the key implementation issues (such as data and information technology requirements) that must be addressed.     (3) SCOPE OF HEALTH CARE PERFORMANCE MEASURES-The health care performance measures described in paragraph (2)(A) shall encompass a variety of perspectives, including physicians, hospitals, other health care providers, health plans, purchasers, and patients. P.L. 108-173 Section 109   IOM STUDY OF QIOs-     (1) IN GENERAL-The Secretary shall request the Institute of Medicine of the National Academy of Sciences to conduct an evaluation of the program under part B of title XI of the Social Security Act. The study shall include a review of the following:       (A) An overview of the program under such part. (B) The duties of organizations with contracts with the Secretary under such part. (C) The extent to which quality improvement organizations improve the quality of care for Medicare beneficiaries. (D) The extent to which other entities could perform such quality improvement functions as well as, or better than, quality improvement organizations. (E) The effectiveness of reviews and other actions conducted by such organizations in carrying out those duties. (F) The source and amount of funding for such organizations. (G) The conduct of oversight of such organizations.

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Performance Measurement: Accelerating Improvement Performance Measurement Report This report will address issues related to the promulgation and use of standardized performance measures for payment, public reporting, and performance improvement. Specifically, it will do the following:     Catalogue, review, and evaluate the validity of leading health care performance measures. Recommend a process for the ongoing promulgation and maintenance of performance measures, the submission of data by providers, and public reporting of performance information. Payment Incentives Report This report will identify and analyze options for aligning Medicare payment policies with provider performance in the original fee-for-service program (under parts A and B of Title XVIII of the Social Security Act), the new Medicare Advantage program (under Part C), and other programs (under Title XVIII). Specifically, it will do the following:     Select and weight of health care performance measures for use in payment programs. Catalogue and evaluate the success and utility of alternative performance incentive programs in public- and private-sector settings. Identify and prioritize options for implementing policies that align performance with payment under the Medicare program, indicating:       The performance measurement set to be used and how that measurement set will be updated. The payment policy that will reward performance. The key implementation issues (such as data and information technology requirements) that must be addressed. Performance Improvement Report This report will provide an evaluation of Medicare’s quality improvement program (under Part B of Title XI of the Social Security Act). Specifically, it will provide the following:     An overview of the quality improvement program, including a description of the duties of private-sector organizations (known as quality improvement organizations, or QIOs) that have contracts with the Secretary under this program, and the source and amount of funding for QIOs. An assessment of the effectiveness of reviews and other actions conducted by QIOs, and the extent to which QIOs improve the quality of care for Medicare beneficiaries. An assessment of the extent to which other entities could perform such quality improvement functions as well as, or better than, QIOs. An assessment of the conduct of CMS oversight of QIOs.

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Performance Measurement: Accelerating Improvement Measures may not be viewed as authoritative, credible, or objective since the measures developed by most stakeholders are more apt to reflect the interests of their constituencies than those of others. Public goods, such as investments in better risk adjustment methodologies and data aggregation methods, are unlikely to be addressed adequately in a competitive market among current developers of measures. Making all information fully transparent and available to the public is unlikely, since much of the technology and data on performance measurement is currently held as proprietary. Creating a coherent national system that strengthens current performance measurement efforts by enabling those involved to work more effectively toward a common, clearly articulated set of goals is a major challenge. Strong, independent leadership is needed to coordinate and guide existing efforts and to broaden the scope of measurement to overcome existing gaps. Moreover, sustained, adequate funding is needed for a structure capable of encouraging multiple initiatives, withstanding pressures from narrow stakeholder interests, and sustaining patients’ interests as the primary objective. And a social investment in learning is necessary to understand, as a matter of public good, how measurement can best accelerate improvement. The factors cited above, along with the long history of multiple, sometimes competing efforts to promulgate and report on performance measures, convinced the committee that current initiatives are unlikely to evolve into the well-functioning national system required to achieve the six quality aims set forth in the Quality Chasm report. The committee believes federal leadership is necessary to overcome these limitations, to ensure that a viable national system does emerge, and to incorporate the public-good dimensions of performance measurement in the American health care enterprise. Such leadership should ensure the creation and maintenance of a robust system for performance measurement and reporting with at least the following functions: (1) establishing national health care improvement goals and priorities, (2) setting standards for measurement, and (3) ensuring a level playing field through oversight and public reporting. RECOMMENDATIONS FOR ACHIEVING A NATIONAL PERFORMANCE MEASUREMENT AND REPORTING SYSTEM Based on its careful analysis of alternatives for achieving a national performance measurement and reporting system, the committee recommends the establishment of a new independent board, the National Quality Coordination Board (NQCB), which would be recognized by all public and private stakeholders as the lead agency responsible for ensuring the creation

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Performance Measurement: Accelerating Improvement of a national system for performance measurement and reporting. In addition to carrying out general management and coordinating functions, the board would provide leadership and policy guidance that would support existing efforts, and seek to align those efforts with national health goals through contractual agreements, educational programs, and consensus-building initiatives. Recommendation 1: Congress should establish a National Quality Coordination Board (NQCB) with seven key functions: Specify the purpose and aims for American health care. Establish short- and long-term national goals for improving the health care system. Designate, or if necessary develop, standardized performance measures for evaluating the performance of current providers, and monitor the nation’s progress toward these goals. Ensure the creation of data collection, validation, and aggregation processes. Establish public reporting methods responsive to the needs of all stakeholders. Identify and fund a research agenda for the development of new measures to address gaps in performance measurement. Evaluate the impact of performance measurement on pay for performance, quality improvement, public reporting, and other policy levers. The NQCB should produce useful information for three purposes that address different audiences: Accountability—Information should be available to assist stakeholders in making choices about providers. These stakeholders include patients identifying a clinician, hospital, or other provider from which to seek services; purchasers and health plans selecting providers to include in their health insurance networks; and quality oversight organizations making accreditation and certification decisions. Quality improvement—The information provided should be of value to stakeholders responsible for improving the quality of care, including clinicians, and administrators and governing board members of health care organizations. Population health—The information should be useful for stakeholders making decisions about access to services (e.g., public insurance benefits and coverage); those involved in communitywide programs and efforts to address racial and ethnic disparities and promote healthy behav-

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Performance Measurement: Accelerating Improvement iors; and public officials responsible for disease surveillance and health protection. Recommendation 2: The NQCB’s membership and procedures should be designed to ensure that the board has structural independence, protection from undue special interests, substantive expertise drawn from the public and private sectors (including not-for-profit entities), contract authority, standards-setting authority, financial strength, and external accountability. The committee believes that an NQCB without adequate authority and protection cannot succeed in this endeavor. Therefore, the committee proposes that the NQCB be armed with at least the following attributes: Structural independence. The NQCB should have the capacity to move the health care system beyond the status quo. The committee recommends that the board be housed within the U.S. Department of Health and Human Services (DHHS) and report directly to the Secretary. Protection from undue influence. The membership of the NQCB should be appointed by the President, with terms that are staggered and long enough to protect the board against short-term political influence and major stakeholder interests. Substantive expertise. The committee’s intention is not to supplant or duplicate the often outstanding work of the many organizations currently involved in developing, evaluating, vetting, and implementing performance measures in health care. Rather, the goal is to accelerate progress through coordination and direct financial support for these current activities. Thus the membership of the NQCB should encompass the technical competence needed to assess and guide that work. Contract authority. In the event that the major organizations currently engaged in measurement development, implementation, and reporting prove unwilling or unable to undertake the activities outlined by the NQCB or to deliver under contract the required levels of standardization, analysis, and reporting, the board should have the backup authority and sufficient funding to broaden the array of contractors through which it can execute its key functions. Standards-setting authority. The Secretary of DHHS should direct CMS (including Medicare, Medicaid, and the State Children’s Health Insurance Program), the Health Resources and Services Administration, and the Agency for Healthcare Research and Quality (AHRQ) to focus on the achievement of all applicable national goals established by the NQCB through public reporting, payment reform, and other incentives such as health care improvement programs, benefit design, health professions edu-

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Performance Measurement: Accelerating Improvement cation, and organizational and systems capacity building. The Secretary should also direct CMS to require that providers submit to the NQCB (or its designee) performance data that can be used by Medicare for public reporting and quality improvement activities or as a basis for payment. In addition, Congress should activate an interagency task force to explore mechanisms for aligning other government health care programs with these efforts—including the Department of Defense (DoD) TRICARE program and DoD-operated clinical facilities, the Federal Employees Health Benefits Program, and the programs of the Veterans Health Administration and the Indian Health Service. Financial strength. The NQCB should have sufficient, stable funding to contract for services with outside groups and organizations so it can perform its designated functions effectively. The board should be funded directly from the Medicare Trust Fund and have bypass authority to request an appropriation directly from Congress. This bypass authority would free the NQCB from the unpredictable budgetary cycles commonly associated with preparing discretionary budgets that are subject to review and modification on the basis of other departmental, executive, and legislative priorities. Congress should authorize and appropriate funds to support the work of the NQCB and to implement its recommendations in Medicare and other government programs by the end of fiscal year 2007. More specifically, Congress should authorize an annual allocation from the Medicare Trust Fund, initially in the range of $100–200 million. This level of investment is based on an analysis of resources that currently support related but more limited activities within the National Quality Forum, the National Committee for Quality Assurance, and the Joint Commission on Accreditation of Healthcare Organizations. This figure constitutes approximately 0.1 percent of the Medicare annual budget,1 a relatively small investment with great potential to enhance value and improve efficiency throughout the health care delivery system. The committee envisions substantial staff requirements to support the functions of the board delineated in Recommendation 1 and substantial costs related to contracts with existing entities to carry out tasks pursuant to the mission of the board. Although the federal government should provide up front the funding needed for the NQCB to become fully operational, particularly with regard to its public-good functions, public–private partnerships could be formed over time to support this ongoing work. External accountability. The NQCB should be required to provide an annual report to Congress on its progress toward implementing an effective quality measurement and reporting system. In addition, the board 1   $278 billion in 2003 (CMS, 2004).

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Performance Measurement: Accelerating Improvement should undergo periodic independent assessments performed by an external organization such as the Medicare Payment Advisory Commission, the IOM, or the Government Accountability Office. The health care system in the United States is fundamentally a local enterprise. The operations of the NQCB should therefore be sensitive and responsive to local goals and improvement priorities and create mechanisms for broad input from national and local stakeholders into the agenda-setting process. The national goals to be established by the NQCB should build upon earlier statements of purpose and aims of the health care system, as articulated by both the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry (1998) and the IOM (IOM, 1990, 2001). The national goals and performance measures articulated by the NQCB should provide a benchmark for an acceptable, minimum set of performance measures and an agenda for improvement on the part of each community, but these leadership activities should in no way preclude communities or states from establishing additional, locally relevant goals. Indeed, the NQCB should encourage widespread local innovation to improve health care, and standards setting by government should both build upon measures that are widely accepted in many sectors and promote local experimentation with innovative measures, from which all can learn. Recommendation 3: Local innovation in pursuit of national goals for improving health care quality should be encouraged. Performance measurement, improvement, and reporting activities—including those of public and private purchasers; accreditation and certification entities; and federal, state, and local government programs—should be substantially aligned with the national goals and standardized measures established by the NQCB, but local communities should also be encouraged to identify and pursue local priorities, in addition to helping to achieve national goals. A RECOMMENDED STARTER SET OF PERFORMANCE MEASURES The committee recommends that the NQCB build upon the substantial scientifically grounded gains that have already been made by various stakeholder groups committed to the development and promulgation of performance measures by immediately upon its inception endorsing the leading measure sets listed in Table ES-2 as national standards. The NQCB should ensure the reliable collection and national reporting of these measures through a data repository system that includes auditing functions and public reporting methods. During the first phase of implementation, providers

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Performance Measurement: Accelerating Improvement TABLE ES-2 Recommended Starter Set of Performance Measures Ambulatory Care Ambulatory care Quality Alliance (26) Prevention measuresa (7), coronary artery diseasea (3), heart failurea (2), diabetesa (6), asthmaa (2), depressiona (2), prenatal carea (2), quality measures addressing overuse or misuse (2)   Ambulatory Care Survey CAHPS Clinician and Group Survey: getting care quickly, getting needed care, how well providers communicate, health promotion and education, shared decision making, knowledge of medical history, how well office staff communicate Acute Care Hospital Quality Alliance (20) Acute coronary syndromea (7), heart failurea (3), pneumoniaa (5), smoking cessationa (3), surgical infection preventiona (from the Surgical Care Improvement Project) (2)   Structural Measures (computerized provider order entry, intensive care unit intensivists, evidence-based hospital referrals)   Hospital CAHPS Patient communication with physicians, patient communication with nurses, responsiveness of hospital staff, cleanliness/noise level of physical environment, pain control, communications about medicines, discharge information Health Plans and Accountable Health Organizations Health Plan Employer Data and Information Set (HEDIS) (61) Integrated delivery systems (health maintenance organizations): effectiveness (26), access/availability of care (8), satisfaction with the experience of care (4), health plan stability (2), use of service (15), cost of care, informed health care choices, health plan descriptive information (6) Preferred provider organizations within Medicare Advantage: selected administrative data and hybrid measures   Ambulatory Care Survey CAHPS Health Plan Survey: getting care quickly, getting needed care, how well providers communicate, health plan paperwork, health plan customer service Long-Term Care Minimum Data Set (15) Long-term care (12), short-stay care (3)   Outcome and Assessment Information Set (11) Ambulation/locomotion (1), transferring (1), toileting (1), pain (1), bathing (2), management of oral medications (1), acute care hospitalization (1), emergent care (1), confusion (1) End-Stage Renal Disease National Healthcare Quality Report (5) Transplant registry and results (2), dialysis effectiveness (2), mortality (1) Longitudinal Measures of Outcomes and Efficiency 1-year mortality, resource use, and functional status (SF-12) after acute myocardial infarction aThe committee recommends the aggregation of individual measures to patient-level composites for these areas.

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Performance Measurement: Accelerating Improvement should also be encouraged to invest in electronic health records if they have not already done so. Although most providers will be able to meet data reporting requirements during this first phase by abstracting samples of medical records and culling information from administrative files, this practice will be economically unsustainable as the NQCB moves toward more comprehensive measurement. Providers who have made concerted efforts to modernize information and communications technologies in their practice settings should be encouraged in these investments, and should be given additional latitude to customize their measurement systems in accordance with general guidelines from the NQCB. Recommendation 4: The NQCB should promulgate measure sets that build on the work of key public- and private-sector organizations. Specifically, the NQCB should: As a starting point, endorse as national standards performance measures currently approved through ongoing consensus processes led by major stakeholder groups. Ensure that a data repository system2 and public reporting program capable of data collection at the individual patient level are established and open to participation by all payers and providers. Ensure that technical and financial assistance is available to all providers who need help in establishing performance measurement and improvement capabilities. The committee also believes that while the leading measure sets provide an excellent springboard, they are inadequate to drive the health sector toward the transformational changes envisioned in the Quality Chasm. The committee identified several serious limitations of currently available performance measures, and proposes complementary approaches to overcome these shortfalls: Lack of comprehensive measures. The committee recommends broadening the limited scope of current measures to address important domains of quality, most notably the IOM aims of efficiency, equity, and patient-centeredness. 2   The data repository system would collect, validate, and aggregate provider performance data (see Recommendation 1).

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Performance Measurement: Accelerating Improvement Narrow time window. In general, most performance measures assess care at only one point in time. The committee recommends measuring the quality, costs, and outcomes of care over a longer time frame. Doing so will necessitate further development of longitudinal measures that can capture the performance of multiple providers caring for a patient; examine how well care is provided across transitions to different settings (e.g., hospital to nursing home); and, most important, evaluate patient outcomes over time. The committee believes that focusing on chronic illness, care across time and locations, and clinical and functional outcomes will move performance measurement much closer to a patient-centered perspective. Provider-centric focus. Current measures tend to focus on specific settings of care, so that measure specifications are applicable to only one setting, such as a physician office or hospital. The committee recommends moving toward individual patient-level measurement, even for the starter set of measures, because of the markedly increased value and flexibility offered by this approach. This approach to data collection would allow for aggregation along three important dimensions: (1) composite measures that can document whether a patient received all recommended services for a given condition within a specified time window; (2) population-based measures, whose aggregation for defined strata of the population on the basis of socioeconomic status, race, and ethnicity would allow for assessment of disparities in treatment at the provider, system, or community level; and (3) systems-level measures that can characterize the overall performance of an organization or entity across conditions and service lines, and can better identify gaps in performance and foster accountability at each level of care, from the individual clinician to the community. The committee strongly recommends that data collection protocols be planned and implemented to support such reporting. Narrow focus of accountability. The committee endorses the principle of shared accountability among all providers involved in a patient’s care. This strategy represents perhaps the most significant explicit departure from a traditional guideline for selecting performance measures—that a responsible entity or person be known at the outset. The committee believes that shared accountability can be achieved both by reporting specific measures that are not uniquely the responsibility of a single provider (e.g., care transitions) and by aggregating patient-level measures. In short, the committee recommends that certain important aspects of care be measured even when no single entity can be held accountable for the results. Qualities such as population mortality rates, efficiency through time, chronic disease complication rates, and measures of oversupply of services may be among the most important of these aspects from the viewpoint of patients and society. Left unmeasured, they are certain to be left unaddressed.

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Performance Measurement: Accelerating Improvement A RECOMMENDED RESEARCH AGENDA A key function of the NQCB would be to work collaboratively with stakeholder groups to develop, implement, and fund a research agenda that can support national goals and improve the measurement and reporting enterprise itself. The committee recommends four areas of focus for such a research agenda: (1) development, implementation, and evaluation of new measures to address current gaps; (2) applied research to address underlying methodological issues; (3) design and testing of reporting formats that will be helpful to different end-users; and (4) evaluation of the performance measurement and reporting system with regard to intended and unintended consequences for cost and care. Recommendation 5: The NQCB should formulate and promptly pursue a research agenda to support the development of a national system for performance measurement and reporting. The board should develop this agenda in collaboration with federal agencies and private-sector stakeholders. The agenda should address the following: Development, implementation, and evaluation of new measures to address current gaps in performance measurement. Applied research focused on underlying methodological issues, such as risk adjustment, sample size, weighting, and models of shared accountability. Design and testing of reporting formats for consumer usability. Evaluation of the performance measurement and reporting system. The NQCB should receive funding adequate to enable it to oversee and ensure the implementation of a robust research agenda. The committee recommends that the NQCB work closely with AHRQ, which has an established track record in funding evidence-based health services research, and other groups that can provide linkages at the local level between foundations and community collaborations, such as Grantmakers in Health, to align investment strategies for carrying out this agenda. Recommendation 6: Congress should provide the financial resources needed to carry out the research agenda developed by the NQCB. The Agency for Healthcare Research and Quality should collaborate with Grantmakers in Health and others that have ties to local foundations to convene public- and private-sector stakeholders currently investing in various aspects of this research agenda for the purpose of identifying complementary investment strategies.

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Performance Measurement: Accelerating Improvement The stakeholders convened should include private foundations, government research and development programs, and health systems with internal research capacity. CONSEQUENCES OF INACTION Failure to establish a well-functioning national performance measurement and reporting system would severely compromise our ability to achieve the essential quality improvements called for in the Quality Chasm report. Because payment incentives, public reporting, and quality improvement initiatives all require the existence of meaningful and valid performance measures, their potential impact would be limited by a constrained, fragmented, and ineffective measurement system. Yet without strong, central leadership, individual stakeholders will have great difficulty in acting together voluntarily to create the kind of system that is needed. Improving performance measurement will vastly improve the nation’s ability to provide better health care services, and will catalyze action to provide high-quality, patient-centered care consistently and efficiently to all Americans. Providers will face less frustration from having to respond to multiple requests for reports on often conflicting measures; performance measurement will become less of a burden and more of a resource for internal quality improvement to enhance care processes of care. Improved reporting formats will facilitate better access to information that is understandable, meaningful, and important to patients, families, and communities. Public trust will grow as a greater balance between the information available to health care system and its consumers is achieved. Current participants in measurement initiatives who are suspicious of national leadership may find themselves better off in the long run as a consistent national approach to measurement allows them to add greater value and compete more on execution in contributing to an industrywide endeavor. In sum, the committee believes that, in the absence of a centralized organizing structure such as the NQCB to set clear goals, coordinate measurement efforts, and ensure stable funding for organizations involved in performance measurement, a robust and well-functioning system to support fair comparisons of cost and quality is unlikely to emerge on its own. REFERENCES Baicker K, Chandra A. 2004. Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Affairs. Jan-June Suppl Web Exclusive: W4:184–197. CMS (Centers for Medicare and Medicaid Services). 2004. 2004 CMS Statistics. Washington, DC: CMS.

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