Appendix B

TABLE B-1 National Organizations Involved in Performance Measurement

Name

Primary Role

Governance and Major Participants

Agency for Healthcare Research and Quality (AHRQ)

AHRQ sponsors and conducts research that provides evidence-based information on health care outcomes; quality; and cost, use, and access. The information helps health care decision makers—patients and clinicians, health system leaders, purchasers, and policymakers—make more informed decisions and improve the quality of health care services.

A Public Health Service agency in the U.S. Department of Health and Human Services (DHHS). Reporting to the DHHS Secretary, the Agency was authorized in 1989 as the Agency for Health Care Policy and Research and reauthorized in 1999 as AHRQ.



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Performance Measurement: Accelerating Improvement Appendix B TABLE B-1 National Organizations Involved in Performance Measurement Name Primary Role Governance and Major Participants Agency for Healthcare Research and Quality (AHRQ) AHRQ sponsors and conducts research that provides evidence-based information on health care outcomes; quality; and cost, use, and access. The information helps health care decision makers—patients and clinicians, health system leaders, purchasers, and policymakers—make more informed decisions and improve the quality of health care services. A Public Health Service agency in the U.S. Department of Health and Human Services (DHHS). Reporting to the DHHS Secretary, the Agency was authorized in 1989 as the Agency for Health Care Policy and Research and reauthorized in 1999 as AHRQ.

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Performance Measurement: Accelerating Improvement Major Quality Measurement Activities Source of Core Funding The National Healthcare Quality Report (NHQR) is the first comprehensive national effort to measure the quality of health care in America. It includes a broad set of performance measures that can serve as baseline views of the quality of health care and presents data on services for seven clinical conditions: cancer, diabetes, end-stage renal disease, heart disease, HIV/AIDS, mental health, and respiratory disease. Also included are data on maternal and child health, nursing home and home health care, and patient safety. The National Healthcare Disparities Report (NHDR), companion to the NHQR, provides measures of differences in access and use of health care services by various populations (cut by race/ethnicity, income, education, and insurance status where applicable) for all areas covered in the NHQR. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) family of surveys is used by many public and private purchasers, including the National Committee for Quality Assurance (NCQA), to (1) develop and test questionnaires assessing health plans and services, (2) produce easily understandable reports communicate survey information to consumers, and (3) evaluate the usefulness of these reports for consumers in selecting health care plans and services. The National Quality Measures Clearinghouse™ houses the most current evidence-based quality measures and measure sets to evaluate and improve the quality of health care. The National Guidelines Clearinghouse™ contains evidence-based clinical practice guidelines that are often linked to measures. QualityTools (www.qualitytools.ahrq.gov) house the NHQR and the NHDR. The Prevention Quality Indicators* are a set of 16 measures that can be used with hospital inpatient discharge data to identify “ambulatory care sensitive conditions” for which good outpatient care can potentially prevent the need for hospitalization, or for which early intervention can prevent complications or more severe disease. They measure the outcomes of preventive and outpatient care through analysis of inpatient discharge data. The Inpatient Quality Indicators* consist of a set of 30 measures that reflect the quality of care inside hospitals and include inpatient mortality; utilization of procedures for which there are questions of overuse, underuse, or misuse; and volume of procedures for which there is evidence that a higher volume of procedures is associated with lower mortality. Federal.

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Performance Measurement: Accelerating Improvement Name Primary Role Governance and Major Participants AHRQ     Ambulatory care Quality Alliance (AQA) AQA is a collaborative effort initially convened by AHRQ, the American Academy of Family Physicians, the American College of Physicians, and America’s Health Insurance Plans. The steering group has been expanded to include the American Medical Association, the American Osteopathic Association, the American College of Surgeons, the Society of Thoracic Surgeons, AARP, the National Partnership for Women and Families, and the Pacific Business Group on Health. Their mission is to improve health care quality and patient safety through a collaborative process in which key stakeholders agree on a strategy for measuring performance at the physician level; collecting and aggregating data in the least burdensome way; and reporting meaningful information to consumers, physicians and other stakeholders to inform choices and improve outcomes. Public–private partnership. The AQA consists of a large body of stakeholders that represents clinicians, consumers, purchasers, health plans, and others. Major participants: Health care organizations: ACP, AAFP, AMA, AMA Consortium, American Board of Internal Medicine, American Board of Medical Specialties, ACC, AAP, AAAAI, AOA, ACS, STS, MGMA, AHA, AAMC and state medical societies. Private participants: AARP, AFL-CIO, Consumer/Purchaser Disclosure Project, Employer Health Care Alliance Corp., Leapfrog Group, General Motors, National Business Group on Health, National Business Coalition on Health, Pacific Business Group on Health, Medstat, Motorola, UPS, BellSouth, Xerox, and Marriott. Public purchasers and other government agencies: CMS, OPM, AHRQ, and Department of Treasury. Health insurance plans: Aetna, Anthem, Cigna, Health Net, Health Partners, Humana, Independence BCBS, Kaiser Permanente, Pacificare, Presbyterian Health Plan, Regence BCBS, UnitedHealth Group, Wellchoice, Harvard Pilgrim HealthCare, AHIP, Blue Cross Blue Shield Association. Accrediting organizations: NCQA, JCAHO, and URAC.

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Performance Measurement: Accelerating Improvement Major Quality Measurement Activities Source of Core Funding The Patient Safety Indicators* are a set of 29 measures that provide a perspective on patient safety by screening for problems that patients experience as a result of exposure to the health care system and that are likely amenable to prevention by changes at the system or provider level. www.qualityindicators.ahrq.gov Combination of federal and private. *The AHRQ Quality Indicators initially were developed as metrics for quality improvement, however their use has evolved over time to include public reporting, and pay for performance. Endorsed key parameters (criteria) for selecting performance measures. For example: evidence-based, clinical importance, scientific validity, feasibility, relevance to physician performance, consumers, and purchasers. Endorsed a standardized set of 26 measures for physician practices that draws heavily on the 2004 ambulatory care clinical performance measure set released by the AMA Consortium, CMS, and NCQA. Expanding the initial “starter” set of measures to include specialty and subspecialty care measures, efficiency measures and patient experience measures. Working with CMS and AHRQ to finalize pilot projects that would utilize the endorsed measurement set and combine public and private payer data.

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Performance Measurement: Accelerating Improvement Name Primary Role Governance and Major Participants Centers for Medicare and Medicaid Services (CMS) The federal agency responsible for administering the Medicare, Medicaid, SCHIP (State Children’s Health Insurance Program), HIPAA (Health Insurance Portability and Accountability Act), CLIA (Clinical Laboratory Improvement Amendments), and several other health-related programs. Their mission is to ensure health care security for beneficiaries. An agency of U.S. DHHS. On July 1, 2001, the Health Care Financing Administration (HCFA) became CMS. Hospital Quality Alliance (HQA) The purpose of the HQA initiative is to make information about hospital performance accessible to the public and to inform and invigorate efforts to improve quality. Voluntary reporting is essential to the success of this initiative. Public–private partnership of hospitals, government agencies, quality experts, purchasers, consumer groups and other health care organizations. These organizations have joined together to develop a shared national strategy for hospital quality measurement and are committed to advancing quality of care. Major participants: American Hospital Association Association of American Medical Colleges Federation of American Hospitals AARP AFL-CIO CMS AHRQ JCAHO AMA NQF Consumer-Purchaser Disclosure Project

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Performance Measurement: Accelerating Improvement Major Quality Measurement Activities Source of Core Funding Technical Assistance: Under the Quality Improvement Organization (QIO) program, CMS contracts with independent medical organizations to ensure the quality of medical care paid under the Medicare program to Medicare Advantage and fee-for-service beneficiaries. Measure Development: CMS has collaborated with many organizations such as JCAHO, AQA, and HQA to develop measures in nursing homes, home health agencies, hospitals, dialysis facilities, and physician offices. Public Reporting: Web-based tools, such as the Nursing Home Compare, Home Health Compare, and Hospital Compare, allow the public to compare data on the quality of providers were developed by CMS in collaboration with others. Financial Incentives Linked to Quality: CMS is conducting quality incentive demonstrations by awarding bonus payments to providers for high performance, most notably through the Premier Hospital Quality Incentive Demonstration and Physician Group Practice Demonstration. The Medicare Health Support Program is a pilot program under way addressing chronic care disease management for fee-for-service beneficiaries. In addition, hospitals are provided with financial incentive to report on performance measures through MMA 501(b). Federal. Currently has 20 hospital quality measures. Hospital Compare is a tool patients can use in making care decisions by providing the public with useful information on hospital quality of care in an easily accessible way. HCAHPS—measuring patient perspectives on hospital care—and anticipated for public reporting in 2007. Combination of federal and private.

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Performance Measurement: Accelerating Improvement Name Primary Role Governance and Major Participants Joint Commission on Accreditation of Healthcare Organizations (JCAHO) JCAHO evaluates and accredits more than 15,000 health care organizations and programs in the United States. Its mission is to continuously improve the safety and quality of care provided to the public. Private, nonprofit. Governed by a 29-member Board of Commissioners that includes nurses, physicians, consumers, health care executives, purchasers, labor representatives, quality experts, ethicists, and educators. Major participants: Commonwealth Fund, California Endowment, Robert Wood Johnson Foundation, and AHRQ. Leapfrog Group The Leapfrog Group is a voluntary initiative to mobilize employer purchasing power to improve the safety, quality, and affordability of health care for Americans. Their mission is to trigger leaps forward by supporting informed health care decisions by those who use and pay for and promote high-value health care through incentives. Private. The Leapfrog Group includes over 170 members from a growing consortium of Fortune 500 companies and other large private and public healthcare purchasers that provide health benefits to more than 34 million Americans in all 50 states. Major participants: Business Roundtable Robert Wood Johnson Foundation National Committee for Quality Assurance (NCQA) NCQA is dedicated to improving health care quality through evaluation of health care at various levels of the system from health plans to medical groups and individual doctors. NCQA’s mission is to transform health care through measurement, transparency, and accountability. Private, nonprofit. Advised by a board of directors. NCQA frequently works with the federal and state governments to advance shared goals. Major participants: AHRQ American Diabetes Association American Heart Association/American Stroke Association Bridges to Excellence California Endowment Foundation California HealthCare Foundation Integrated Healthcare Association Commonwealth Fund Robert Wood Johnson Foundation Bristol-Myers Squib Pfizer

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Performance Measurement: Accelerating Improvement Major Quality Measurement Activities Source of Core Funding In February 1997, the Joint Commission launched its ORYX® initiative, to develop evidence-based performance measures and integrate outcomes and other performance measurement data into the accreditation process. In July 2002, hospitals began collecting core measure data on four initial core measurement areas: acute myocardial infarction; heart failure; community-acquired pneumonia; and pregnancy and related conditions. In January 2003, hospitals began transmitting their measurement results to the Joint Commission. In 2004, surgical infection prevention measures were added as a data collection and submission option. Combination of federal and private. The Leapfrog Group identified and has since refined four hospital quality and safety practices that are the focus of its health care provider performance comparisons and hospital recognition and reward. All of the practices are endorsed by the National Quality Forum. Based on independent scientific evidence, the quality practices are: computer physician order; entry evidence-based hospital referral; intensive care unit (ICU) staffing by physicians experienced in critical care medicine; and the Leapfrog Safe Practices Score. Private. The Research group engages in collaborative research that explores new approaches to measuring and reporting on the quality and efficiency of health care. The Analysis group provides both day-to-day analysis of NCQA Accreditation, Health Plan Employer Data and Information Set (HEDIS) and CAHPS databases, and design and analysis of statistical processes used in research projects and measure development and maintenance. The Measures Development (or Quality Measurement) group is devoted to the development and maintenance of measures in HEDIS. Working with the American Diabetes Association and the American Heart Association/American Stroke Association, established the Diabetes Physician Recognition Program and the Heart/Stroke Physician Recognition program to identify physicians who demonstrate high quality care in these areas. Developed Physician Practice Connections, a recognition program based on an evaluation of the presence and use of systems in office practice. All three recognition programs have been adopted for use in pay for performance programs. Combination of public and private.

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Performance Measurement: Accelerating Improvement Name Primary Role Governance and Major Participants National Quality Forum (NQF) Established consequent to a Presidential Commission, the NQF was created primarily to standardize national performance measures, quality indicators, and similar metrics for health care. It was envisioned to be the singular body performing this function. Other functions envisioned for the NQF were to develop and implement a national strategy for health care quality measurement and reporting and to be an “honest-broker” convener for health care quality matters. The mission of the NQF is to improve American health care through endorsement of consensus-based national standards for measurement and public reporting of health care performance data that provide meaningful information about whether care is safe, timely, beneficial, patient-centered, equitable, and efficient. Not-for-profit membership organization. Unique public–private partnership. About 300 member organizations. NQF is governed by a 29-member Board of Directors representing health care providers, health plans, consumers, purchasers, accreditors, researchers, and quality improvement organizations. Government members of the Board include CMS, AHRQ, VHA, ONCHIT, and NIH. Board also includes JCAHO, NCQA, IOM, AARP, GM, Physician Consortium for Performance Improvement, and elected representatives of the 4 Member Councils. Major participants: AARP Leapfrog Group, GM, Ford 20 largest hospital organizations CMS AHRQ VA AMA, AAFP, medical specialty societies National Partnership for Women and Children Kaiser Permanente Robert Wood Johnson Foundation The Physician Consortium for Performance Improvement convened by the American Medical Association (AMA) The Physician Consortium for Performance Improvement’s (the Consortium) mission is to improve patient health and safety by (1) identifying and developing evidence-based clinical performance measures; (2) promoting implementation of effective and relevant clinical performance improvement activities; and (3) advancing the science of clinical performance measurement and improvement. Professional societies. The Consortium is currently formalizing its governance and structure. The Consortium includes physicians and experts in methodology convened by the AMA. The Consortium includes representatives from more than 70 national medical specialty and state medical societies, the AHRQ, CMS, and others. Representatives from employers, health plans, and consumer groups participate in measure development work groups.

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Performance Measurement: Accelerating Improvement Major Quality Measurement Activities Source of Core Funding Over 200 national consensus standards have been endorsed so far for care settings across the continuum of care (e.g., acute care hospitals, ambulatory care, nursing homes, home care, palliative and hospice care, other) as well as for conditions (e.g., cancer, asthma, acute coronary syndrome, diabetes, and deep vein thrombosis) and issues (e.g., patient safety, reportable events, medication use). A variety of workshops have been conducted to address specific issues related to quality. Membership dues, contracts and grants; combination of federal and private. The Consortium selects topics for performance measures development that are actionable, for which established clinical recommendations are available, and for which feasible data sources exist. Work groups review the levels of evidence provided in clinical practice guidelines that demonstrate potential positive impact on health outcomes and propose feasible measures for inclusion in a physician performance measurement set. All specifications for Consortium measures are available at www.physicianconsortium.org, including specifications for electronic health record systems. As of October 2005, 24 Consortium measures have been NQF-endorsed, and several are included in the AQA starter set. AMA. In-kind funding, national medical specialty societies. Additional funding for measure development from contracts with CMS.