Secretarial Review and Publication of the Annual Report to Congress Submitted by the Contracted Consensus-Based Entity Regarding Performance Measurement, 56919-56984 [2012-22379]

Download as PDF Vol. 77 Friday, No. 179 September 14, 2012 Part II Department of Health and Human Services srobinson on DSK4SPTVN1PROD with NOTICES2 Secretarial Review and Publication of the Annual Report to Congress Submitted by the Contracted Consensus-Based Entity Regarding Performance Measurement; Notice VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00001 Fmt 4717 Sfmt 4717 E:\FR\FM\14SEN2.SGM 14SEN2 56920 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices DEPARTMENT OF HEALTH AND HUMAN SERVICES Secretarial Review and Publication of the Annual Report to Congress Submitted by the Contracted Consensus-Based Entity Regarding Performance Measurement AGENCY: Office of the Secretary of Health and Human Services, HHS. ACTION: Notice. SUMMARY: This notice acknowledges the Secretary of the Department of Health and Human Services’ (HHS) receipt and review of the annual report submitted to the Secretary and Congress by the contracted consensus-based entity as mandated by section 1890(b)(5) of the Social Security Act, as added by section 183 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) and section 3014 of the Affordable Care Act of 2010. The statute requires the Secretary to publish the report in the Federal Register together with any comments of the Secretary on the report not later than six months after receiving the report. This notice fulfills those requirements. FOR FURTHER INFORMATION CONTACT: Stephanie Mika (202) 260–6366. srobinson on DSK4SPTVN1PROD with NOTICES2 I. Background Rising health care costs coupled with the growing concern over the level and variation in quality and efficiency in the provision of health care raise important challenges for the United States. Section 183 of MIPPA also required the Secretary of the Department of Health and Human Services (HHS) to contract with a consensus-based entity to perform various duties with respect to health care performance measurement. These activities support HHS’s efforts to achieve value as a purchaser of highquality, patient-centered, and financially sustainable health care. The statute mandates that the contract be competitively awarded for a period of four years and may be renewed under a subsequent competitive contracting process. In January, 2009, a competitive contract was awarded by HHS to the National Quality Forum (NQF) for a four-year period. The contract specified that NQF should conduct its business in an open and transparent manner, provide the opportunity for public comment and ensure that membership fees do not pose a barrier to participation in the scope of HHS’s contract activities, if applicable. The HHS four-year contract with NQF includes the following major tasks: VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 Formulation of a National Strategy and Priorities for Health Care Performance—NQF shall synthesize evidence and convene key stakeholders on the formulation of an integrated national strategy and priorities for health care performance measurement in all applicable settings. NQF shall give priority to measures that: Address the health care provided to patients with prevalent, high-cost chronic diseases; provide the greatest potential for improving quality, efficiency and patient-centered health care and may be implemented rapidly due to existing evidence, standards of care or other reasons. NQF shall consider measures that assist consumers and patients in making informed health care decision; address health disparities across groups and areas; and address the continuum of care across multiple providers, practitioners and settings. Implementation of a Consensus Process for Endorsement of Health Care Quality Measures—NQF shall implement a consensus process for endorsement of standardized health care performance measures which shall consider whether measures are evidence-based, reliable, valid, verifiable, relevant to enhanced health outcomes, actionable at the caregiver level, feasible to collect and report, and responsive to variations in patient characteristics such as health status, language capabilities, race or ethnicity, and income level and is consistent across types of providers including hospitals and physicians. Maintenance of Consensus Endorsed Measures—NQF shall establish and implement a maintenance process to ensure that endorsed measures are updated (or retired if obsolete) as new evidence is developed. Promotion of Electronic Health Records—NQF shall promote the development and use of electronic health records that contain the functionality for automated collection, aggregation, and transmission of performance measurement information. Focused Measure Development, Harmonization and Endorsement Efforts to Fill Critical Gaps in Performance Measurement—NQF shall complete targeted tasks to support performance measurement development, harmonization, endorsement and/or gap analysis. Development of a Public Web site for Project Documents—NQF shall develop a public Web site to provide access to project documents and processes. The HHS contract work is found at: http:// www.qualityforum.org/projects/ ongoing/hhs/. PO 00000 Frm 00002 Fmt 4701 Sfmt 4703 Annual Report to Congress and the Secretary—Under section 1890(b)(5)(A) of the Act, by not later than March 1 of each year (beginning with 2009, NQF shall submit to Congress and the Secretary of HHS an annual report. The report shall contain a description of the implementation of quality measurement initiatives under the Act and the coordination of such initiatives with quality initiatives implemented by other payers; a summary of activities and recommendations from the national strategy and priorities for health care performance measurement task; and a discussion of performance by NQF of the duties required under the HHS contract. Section 1890(b)(5)(B) of the Social Security Act requires the Secretarial review of the annual report to Congress upon receipt and the publication of the report in the Federal Register together with any Secretarial comments not later than 6 months after receiving the report. The first annual report covered the performance period of January 14, 2009 to February 28, 2009 or the first six weeks post contract award. Given the short timeframe between award and the statutory requirement for the submission of the first annual report, this first report provided a brief summary of future plans. In March 2009, NQF submitted the first annual report to Congress and the Secretary of HHS. The Secretary published a notice in the Federal Register in compliance with the statutory mandate for review and publication of the annual report on September 10, 2009 (74 FR 46594). In March 2010, NQF submitted to Congress and the Secretary the second annual report covering the period of performance of March 1, 2009 through February 28, 2010. The second annual report was published in the Federal Register on October 22, 2010 (75 FR 65340) to comply with the statutorily required Secretarial review and publication. In March 2011, NQF submitted the third annual report to Congress and Secretary of HHS. This notice complies with the statutory requirement for Secretarial review and publication of the third annual report covering the period of performance of January 14, 2010 through January 13, 2011. The third annual report was published in the Federal Register on September 7, 2011 (76 FR 55474). Affordable Care Act was signed into law on March 23, 2010. Section 3014 of this Act included a time-sensitive requirement for NQF to provide input into the national priorities for consideration under for the National Strategy for Quality for Improvement in E:\FR\FM\14SEN2.SGM 14SEN2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices Healthcare. The NQF convened the National Priorities Partnership and developed a consensus report on input to HHS on the development of the National Quality Strategy. Section 3014 of the Affordable Care Act also required NQF to: convene multi-stakeholder groups to provide input on the selection of quality measures, such as for use in reporting performance information to the public; and transmit multi-stakeholder input to the Secretary. It also amended the requirements for the Annual Report to include identifying gaps in quality measures, including measures in the priority areas identified by the Secretary under the national strategy and areas in which evidence is insufficient to support evidence of quality measures in priority areas. Activities required by the Affordable Care Act will be carried out from 2010 throughout 2014. In March 2012, NQF submitted its fourth annual report to the Congress and the Secretary. The report covers the period of performance of January 14, 2011 through January 13, 2012. This notice complies with the statutory requirement for Secretarial review and publication of the fourth NQF annual report. II. March 2012—NQF Report to Congress and the HHS Secretary Submitted in March 2012, the fourth annual report to Congress and the Secretary spans the period of January 14, 2011 through January 13, 2012. A copy of NQF’s submission of the March 2012 annual report to Congress and the Secretary of HHS can be found at: http://www.qualityforum.org/ Publications/2012/03/ 2012_NQF_Report_to_Congress.aspx. The 2012 NQF annual report is reproduced in section III of this notice. This year’s annual report has two sections. The first is entitled 2012 NQF Report to Congress Changing Healthcare by the Numbers. The second section is entitled NQF Report on Measure Gaps and Inadequacies. Both sections were reviewed by the Secretary. III. NQF March 2012 Annual Report srobinson on DSK4SPTVN1PROD with NOTICES2 2012 NQF Report to Congress Changing Healthcare by the Numbers Report to the Congress and the Secretary of the U.S. Department of Health and Human Services, Covering the Period of January 14, 2011, to January 13, 2012 Pursuant to Public Law 110–275 and Contract #HHSM–500–2009–00010C Contents Letter From William Roper and Janet Corrigan Executive Summary VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 Building Consensus About What and How To Improve Endorsing Measures for Use in Accountability and Performance Improvement Aligning Payment and Public Reporting Programs That Reward Value National Quality Forum: Background Bridging Consensus About Improvement Priorities and Approaches National Priorities Partnership NQF’s Focus on Safety Endorsing Measures and Developing Related Tools NQF Endorsement in 2011 Culling the NQF Portfolio Enhancing NQF Endorsement The Information Technology Accelerant Aligning Accountability Programs To Enhance Value Growing Use of NQF-Endorsed Measures Measure Application and Alignment Achieving Results Looking Forward Endnotes Appendix A: 2011 Accomplishments: January 14, 2011 to January 13, 2012 Appendix B: NQF Board and Leadership Staff Appendix C: Overview of Consensus Development Process Appendix D: Map Measure-Selection Criteria Appendix E: NQF Membership Appendix F: 2011 NQF Volunteer Leaders Letter From William Roper and Janet Corrigan Over the last decade, Members of Congress from both parties, as well as federal and private-sector leaders, have increasingly supported the use of standardized quality measures as part and parcel of a larger healthcare value agenda. Agreed-upon strategies for improving value—healthier individuals and communities, as well as better, lower-cost care—include public reporting of standardized performance measures and linking measures to payment. Evidence of support for this agenda includes the fact that approximately 85 percent of measures currently used in public programs are endorsed by the National Quality Forum (NQF),1 as well as the significant use of NQF-endorsed measures by private health plans and employers. In addition, recent statutes— the 2008 Medicare Improvements for Patients and Providers Act (MIPPA) and the 2010 Affordable Care Act (ACA)— reinforce preferential use of NQFendorsed measures on federal healthcare Compare Web sites, and linkage of endorsed measures to payment for clinicians, hospitals, nursing homes, health plans, and other entities. In 2011, this commitment to a value agenda was significantly accelerated. Under the auspices of NQF, and in a historic first, private-sector PO 00000 Frm 00003 Fmt 4701 Sfmt 4703 56921 organizations voluntarily worked in a more coordinated and collaborative fashion with each other and with the public sector to forge consensus about how to further this accountability environment. Specifically, innovations in convening and rulemaking facilitated the private sector bringing its real-world experience to inform guidance to the Department of Health and Human Services (HHS) on implementing the first-ever National Quality Strategy (NQS), and provided advice on selecting the best measures for use across an array of federal health programs. Forwardthinking leaders—including those on Capitol Hill and within HHS— understand that the public and private sectors working independently will not yield improvements quickly or comprehensively enough in our unorganized and complex healthcare system. We are grateful to Congress, HHS, and private-sector leaders for their vision and tenacity in designing and advancing this ambitious value agenda, and for the progress we collectively are making against it each and every day. These advancements are made possible because of the ever-expanding number of organizations and individuals who are committing themselves to work in partnership, including our colleagues at HHS; the more than 450 institutional members of NQF; the hundreds of experts who volunteer to serve on NQF committees; the NQF staff; and the many, many organizations that constitute the quality movement. We are privileged to work at the intersection of so many committed and diverse organizations that are increasingly rowing in the same direction to improve both our nation’s health and healthcare for the benefit of the American public. We are changing healthcare by the numbers. William L. Roper, MD, MPH Chair, Board of Directors National Quality Forum Janet M. Corrigan, Ph.D., MBA President and Chief Executive Officer National Quality Forum Executive Summary The U.S. healthcare system is among the most innovative in the world and patients with very serious and/or unusual conditions are particularly appreciative of the range of therapies, interventions, and clinical talent it offers to treat them and restore them to health. That said, it is also one of the most fragmented, unorganized, and uncoordinated systems as compared to its counterparts in the industrialized world—which contributes to less-than- E:\FR\FM\14SEN2.SGM 14SEN2 srobinson on DSK4SPTVN1PROD with NOTICES2 56922 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices optimal quality outcomes, serious patient safety problems, and very high per-capita costs.2, 3, 4 Consequently, Members of Congress, business leaders from small and large companies, patients, physicians, nurses, and many others have come to the conclusion that Americans are not deriving enough value for the substantial dollars they spend. Important strides have been made toward improving this value proposition over the last decade, starting with the sine qua non of using standardized performance measures to assess ‘‘how we are doing’’ on an array of healthcare quality and cost dimensions, making the measure results public, and then linking those results to provider payment. And while establishing this accountability environment is critical foundational work, it is not sufficient for achieving the kind of substantial improvements that the National Quality Strategy (NQS) envisions. Released by the Department of Health and Human Services (HHS) in March 2011 and supported by publicand private-sector healthcare leaders, the NQS is built around three compelling aims focused on healthy people and communities, better care, and more affordable care. To achieve these ambitious aims also will take fundamental reform of care delivery and payment, which, while underway, will still require time, effort, and perseverance to realize. That said, the accountability environment’s basic infrastructure is moving into place. A key lesson learned in constructing it is that neither the public nor private sectors, nor any single stakeholder, can meaningfully shape it on their own. Healthcare is too large and complex, with too many interrelated parts, for a go-it-alone strategy to be fully effective. Recent actions of healthcare leaders demonstrate that they understand that sustainable solutions to our nation’s healthcare challenges are ones that all stakeholders embrace. Over the last year, significant progress has been made toward forging a shared sense of priorities for improvement; an agreedupon way to set, continuously enhance, and implement strategies to achieve these priorities; and standardized methods for measuring progress along the way. Without such agreements, competing strategies and a plethora of near-identical measures run the risk of whipsawing providers and overburdening them with redundant and sometimes conflicting reporting requirements. In addition, such an environment can confuse consumers who increasingly seek to better inform VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 themselves as they play a more active role in healthcare decision-making. Congress, wisely understanding this need for a quality infrastructure and more public-private collaboration, passed two statutes that included this notion, and directed HHS to work with a consensus-based entity to act as a key convener and measurement standard setter. These statutes include the 2008 Medicare Improvements for Patients and Providers Act (MIPPA) (Pub. L. 110– 275) and the 2010 Patient Protection and Affordable Care Act (ACA) (Pub. L. 111–148). HHS awarded contracts related to the consensus-based entity to the National Quality Forum (NQF). NQF has prepared this third Annual Report to Congress which covers highlights of work related to these statutes conducted under federal contract between January 14, 2011 and January 13, 2012. See appendix A for a complete listing of deliverables worked on and completed during the contract year. Building Consensus About What and How To Improve In the fall of 2010, as HHS was developing the first-ever NQS, the National Priorities Partnership (NPP), convened by NQF, was asked to provide initial input on the overarching aims and priority areas and published a report. Subsequently, in response to a second request from HHS, NPP identified three goals for each of the NQS six priorities in a second report, along with appropriate performance measures, and ‘‘strategic opportunities’’ to accelerate progress. These opportunities require leveraging the reach of the many public and private stakeholder groups participating in NPP, which balances the interests of consumers, purchasers, health plans, clinicians, providers, federal agency leaders, community alliances, states, quality organizations, and suppliers. In 2011, NPP focused further on enhancing patient safety, one of the six NQS priorities and a very important focus for HHS. More specifically, NPP worked collaboratively with HHS on its Partnership for Patients initiative, through hosting quarterly meetings and an interactive webinar series, which brought tools and ideas for reducing patient harm to nearly 10,000 front-line clinicians, hospitals, and other stakeholders across the country. Moving forward in 2012, NPP will draw on the real-world experience of its partners to develop implementation strategies, likely targeting patient safety in maternity care and readmissions. PO 00000 Frm 00004 Fmt 4701 Sfmt 4703 Endorsing Measures for Use in Accountability and Performance Improvement NQF completed 11 endorsement projects during the course of the contract year—using both the NQS priorities that cross conditions and leading health conditions with respect to prevalence and cost as a way to prioritize its efforts. In total, NQF committees evaluated 353 submitted measures and endorsed 170 new measures—or 48 percent of those submitted. While the number of measures endorsed is considerably higher than in previous years, the endorsement rate is lower due to the enhanced rigor of the review criteria. At the same time, NQF placed emphasis on reducing providers’ reporting burden by harmonizing specifications related to similar measures. Currently, the portfolio of NQFendorsed measures includes more than 700 measures, of which 30 percent assess patient outcomes and experience with care. Considerable progress also has been made in specifying measures for use with electronic health records. NQF worked with 18 measure developers to create eMeasure specifications for 113 existing endorsed measures, and released an initial and updated Measure Authoring Tool (MAT). The re-tooled measures and MAT are innovations that enable the field to get substantially closer to having electronic health records with the capacity to capture and report performance information during routine care. Aligning Payment and Public Reporting Programs That Reward Value A significant proportion—about 85 percent—of the measures used in federal programs are NQF-endorsed. Further, NQF-endorsed measures are used extensively by private health plans, state governments, and others. Such alignment can simultaneously reduce reporting burdens for providers and accelerate improvement because of the common signals that payers send. The NQF-convened Measure Applications Partnership (MAP), launched in the spring of 2011, fostered further alignment with its series of three performance measurement coordination strategy reports: Clinician Performance Measurement, Dual-Eligible Beneficiaries, and Healthcare-Acquired Conditions and Readmissions Across Public and Private Payers. As a part of these reports, MAP also developed a framework and criteria to guide the selection of the best measures for use in numerous payment and public reporting E:\FR\FM\14SEN2.SGM 14SEN2 srobinson on DSK4SPTVN1PROD with NOTICES2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices programs. Building on these reports, MAP then provided pre-rulemaking guidance to HHS, including input on measure sets pertaining to 17 HHS programs, as well as strategies for enhancing consistency and minimizing reporting burden across federal programs and between public- and private-sector efforts. Leaders from nine different HHS agencies are actively participating in MAP. This advice from MAP—provided many months in advance of relevant rules—represents a true innovation in rulemaking, with the public and private sectors now having forums for substantive back-and-forth dialogue that cuts across program silos, and a unique opportunity to build a shared perspective and consensus about measure selection. Measures related to care coordination—essential to making care more patient centered—are an object lesson for what is possible with pre-rulemaking convening and endorsement. More specifically, MAP recommended that an existing care transitions measure focused on hospitals also be used in other settings, and suggested a broadening of a readmission measure to include all ages and applicability to additional kinds of providers. MAP also advised the Center for Medicare & Medicaid Services (CMS) to require reporting of medication reconciliation measures at the time of transition between settings. As it turns out, NQF has already endorsed measures for medication reconciliation, readmission, and care transitions that apply to additional settings and populations so these measures can move right into other federal programs. Taken together, the reports are important stepping stones for MAP as the Partnership works on a comprehensive measurement strategy it will recommend to guide HHS measure selection for federal programs in the coming years. This strategy will be informed by the Partnership’s in-depth understanding of current measures and their use in relevant programs, opportunities for potential coordination and integration, growing collaboration across the public and private sectors, and a vision for the future. Numbers are an essential guidepost for gauging healthcare performance, and measures may be a powerful motivator of change when paired with public reporting and payment. But alone, they cannot drive achievement of the value agenda. Rather, implementation of innovative measures needs to go handin-glove with fundamental redesign of delivery and payment systems to achieve the NQS’ three, interconnected aims. And while local communities are VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 changing the way care is organized and paid for to break down existing silos, facilitate integration and coordination of care, and connect healthcare to other sectors (e.g., employment, education), such innovations have not yet swept the country. When they do, and are coupled with accountability strategies embraced by the public and private sectors, we will be able to achieve our goals of healthier people and communities, and better, less-costly patient care. We will have then changed healthcare by design and by the numbers. 1 National Quality Forum: Background More than a decade after their publication, the Institute of Medicine’s (IOM’s) landmark Quality Chasm and To Err is Human reports still resonate: Our healthcare system continues to fall short on quality, safety, and affordability. That said, recent years have seen a re-energized commitment to improving care and constraining healthcare costs. HHS, NQF, and the increasing number of private-sector organizations that constitute the quality movement are at the center of that resurgence. Established in 1999 as the standardsetting organization for healthcare performance measures, NQF today has a much-broadened mission to: • Build consensus on national priorities and goals for performance improvement, and work in partnership with the public and private sectors to achieve them. • Endorse and maintain best-in-class standards for measuring and publicly reporting on healthcare performance quality. • Promote the attainment of national goals and the use of standardized measures through education and outreach programs. NQF is governed by a 27-member Board of Directors (see Appendix B) from a diverse array of public- and private-sector organizations. A majority of seats on the board is held by consumers, employers, and other organizations that purchase healthcare services on consumers’ behalf. In 2011, NQF convened hundreds of experts across every stakeholder group on its priority-setting, measure-review, and measure-selection committees— individuals who volunteered their time, talents, experience, and insights (see Appendix F). NQF also directly reached some 10,000 frontline clinicians, hospitals, and others with educational programming via webinars. And its endorsed performance standards touched the care delivered to millions of patients every day. PO 00000 Frm 00005 Fmt 4701 Sfmt 4703 56923 In recent years, the number and variety of NQF-endorsed measures has greatly expanded. More than 700 NQFendorsed measures now address most settings of care, conditions, and types of providers. The measures portfolio includes clinical process measures, patient experience of care, the actual outcomes of care, the costs and resources that go into providing care, as well as select structural measures. The portfolio is being enhanced with advanced measures, such as functional outcome and crosscutting carecoordination measures. At the same time, the NQF portfolio is being carefully culled to retire measures that no longer meet the more rigorous criteria. In the last year alone, 353 measures were submitted to NQF and 170, or nearly half, were endorsed. This endorsement rate—or ratio of submittedto-endorsed measures—reflects NQF’s efforts to systematically raise the bar on performance measurement, even as it seeks to reduce the burden on providers by eliminating duplicative measures. To be NQF endorsed, a measure must be a process or outcome that is important to measure and report, be scientifically acceptable, be feasible to collect, and provide useful results. NQF conducts an eight-step, consensus-based process that has been continually improved over a decade (see Appendix C). Review committees are comprised of multiple stakeholders; consumer organizations are equal partners with clinicians and other stakeholders throughout the process. There is a strong commitment to transparency and NQF invites public participation at every step, ranging from nominations for committees, to decisions on specific measures. Endorsed measures are reevaluated every three years to ensure their actual use and usefulness in the field and their continuing relevance with current science, and to determine whether they continue to represent the best in class. Measures included in the NQF portfolio are developed and maintained by about 65 different organizations. The following gives a sense of the range of organizations NQF works with: CMS, the National Committee on Quality Assurance (NCQA), the American Medical Association-Physician Consortium for Performance Improvement (AMA PCPI), Ingenix, the Joint Commission, American College of Surgeons (ACS), Bridges to Excellence, Cleveland Clinic, Minnesota Community Measurement, and Pharmacy Quality Alliance. In recognition of its skill in building consensus across multiple stakeholders in the measure-endorsement realm, NQF E:\FR\FM\14SEN2.SGM 14SEN2 srobinson on DSK4SPTVN1PROD with NOTICES2 56924 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices has been asked to convene diverse committees to advise the public and private sectors on priorities for improvement, related implementation strategies, and selection of measures to both drive these strategies and gauge results. The NQF-convened NPP and MAP and their published reports are tangible outcomes of this work. An equally important outcome of these partnerships is the ongoing alignment across stakeholder groups and across public- and private-sector leaders about what levers to use to both improve healthcare performance and move the delivery system to be more patient centered. NQF has been fortunate to have received support from the federal government for over 10 years, with more substantial support starting in 2008 when federal leaders strongly committed themselves to designing and implementing a value agenda. More specifically: • MIPPA has provided NQF with $10 million annually over a four-year period starting in 2009. These funds—awarded to NQF through a competitive process— are supporting the organization’s efforts to identify priority areas for improvement, endorse and update related performance measures, foster the transition to an electronic environment, and report annually to Congress on the status and progress to date of this effort. • ACA has provided NQF with support of about $10 million, starting in 2011. Under section 3014, Congress directed HHS to contract with ‘‘the consensus-based entity under contract’’ to provide multi-stakeholder input into the NQS, as well as advice to the Secretary of HHS on the selection of measures for use in various quality programs that utilize the federal rulemaking process for measure selection. With federal leadership and support, as well as the support of foundations and over 450 NQF member organizations, much has been collectively accomplished since NQF’s founding in 1999. With more substantial and predictable support from the federal government over the last three years, and an enhanced commitment on the part of the public and private sectors to work together, the basic infrastructure for performance measurement is moving into place and our ability to shape and further an environment of accountability has grown. NQF’s accomplishments during 2011 will be described against that backdrop. VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 Sidebar 1—Working With NQF Helped Spur Rapid Evolution of Ophthalmology Measures There are many intangible benefits from the endorsement activities supported under the HHS contract. One of these is that it provides valuable input to measure developers which helps focus measure development resources on important gap areas. The efforts of the American Academy of Ophthalmology (AAO) are a case in point. As early as the 1980s, and before many other specialty societies, AAO developed ‘‘preferred practice patterns’’ to provide practice guidance for ophthalmologists. These guidelines proved to be a solid foundation to draw from when, in 2006, AAO began developing related quality measures for quality improvement feedback and public reporting purposes. Over the last five years, AAO has developed ever more sophisticated performance measures—evolving from process, to outcome, to functional status—and credits involvement with the NQF review process as an important catalyst in this evolution. More specifically: • AAO—in collaboration with the AMA–PCPI—first worked to develop process measures focused on eye-care issues such as diabetic retinopathy (damage to the eye’s retina as a result of long-term diabetes), and performance of optic nerve exams in primary openangle glaucoma (chronic, progressive optic-nerve damage) patients. • Recognizing that measures that evaluate actual results of care are more critical to improving quality, NQF encouraged AAO to shift its focus to developing clinical outcome measures. As a result, NQF later endorsed a measure focused on reducing glaucoma patients’ eye pressure (which can lead to optic-nerve damage or blindness) by 15 percent. • More outcome measures were later developed and endorsed under the HHS-funded outcomes project, focusing on issues such as complications within 30 days following cataract surgery, as well as 20/40 or better visual acuity within 90 days of cataract surgery. • Recently, the NQF board has approved measures related to patient functional status, attempting to measure improvement in patients’ visual functional status and their overall satisfaction within 90 days following cataract surgery. These measures are currently under NQF review, and have been included in the 2012 Physician Quality Reporting System (PQRS) measure set. PO 00000 Frm 00006 Fmt 4701 Sfmt 4703 Dr. Flora Lum, executive director of AAO’s H. Dunbar Hoskins Jr., MD Center for Quality Eye Care, noted that NQF’s ability to bring patient and consumer perspectives to the Steering Committee responsible for evaluating measures has been invaluable over the years. AAO’s efforts to advance healthcare quality continue, with the organization now striving to develop appropriateness-of-care measures. The evolution of AAO’s measures over a short time period is noteworthy and the information that results from the measures provides physicians with multi-faceted feedback about the care they deliver. Ideally, such information is available in rapid-response reports, with educational interventions to help facilitate improvements at the practice level, and over time, so that ophthalmologists and patients can gauge progress. As AAO has gone on this journey to develop ever-increasingly sophisticated and meaningful measures, NQF has been pleased to be a part of it. [End of Sidebar 1] Sidebar 2—Resource-Use Measures: Critical to the Value Agenda U.S. healthcare per-capita spending is greater than that in any other country, yet it has not resulted in better health for Americans. With costs increasing beyond annual inflation, spending is largely focused on treating acute and chronic illnesses rather than prevention and health promotion. Deriving more value from health spending is predicated on having both quality and cost (or resource use) information. To date, limited information about resource use exists. CMS and many measure developers are working to change that, and in 2009, NQF was tasked with further defining resource-use measures and identifying important attributes to consider when evaluating them. NQF also endorsed its first-ever resource-use measures during the 2011 contract year. As defined by NQF, resource-use measures are comparable measures of actual dollars or standardized units of resources applied to the care given to a specific population or event—such as a specific diagnosis, procedure, or type of medical encounter. The endorsed measures: • Relative Resource Use for People with Diabetes • Relative Resource Use for People with Cardiovascular Conditions • Total Resource Use Population-Based Per-Member Per-Month (PMPM) Index • Total Cost of Care Population-Based PMPM Index E:\FR\FM\14SEN2.SGM 14SEN2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices of stakeholders needed to improve the nation’s healthcare system. As the NQS was being formulated, HHS sought multi-stakeholder input from NPP on its aims and priorities. After publication of the NQS in March 2011, HHS again reached out to NQF to convene NPP to provide input on further specifying goals, measures, and implementation pathways to move the national strategy and related priorities forward, drawing upon the real-world experience of its stakeholder participants. The NPP recommendations are captured in a follow-up report to the HHS Secretary, Priorities for the National Quality Strategy, published in September 2011. This second report identifies goals and measure concepts that address the three NQS aims and six priorities simultaneously. For example, there are suggestions for goals and measurement areas related to care coordination that cut across clinical conditions. This would encourage National Priorities Partnership Development of the landmark NQS was informed by the collective input of the NQF-convened National Priorities Partnership (NPP), a collaboration of 51 public- and private-sector organizations uniquely qualified to represent the array VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 2 Bridging Consensus About Improvement Priorities and Approaches Released by HHS in March 2011, the country’s NQS focuses the public and PO 00000 Frm 00007 Fmt 4701 Sfmt 4703 private sectors on an inspiring set of three, interconnected aims—better care, more affordable care, and healthier people and communities—as well as six related priority areas (see Figure 1). While the field has long targeted improving clinical care, the NQS gives significant, equal heft to the notion of health/wellbeing and affordability. better, more integrated care delivery, enhanced health outcomes, and fewer wasted resources. The NPP report also acknowledges that successful implementation of NQS-related goals and measures are predicated on strategic and technical measure alignment—or agreement—across various levels of accountability in our healthcare system. This starts at the most granular level— the patient and physician—and moves in a linked chain across a family of measures and levels of increasing aggregation. Without agreement about strategic direction and concordance on measure selection, a predictable cacophony results, frustrating clinicians and confusing consumers. The cholesterol-control example (Figure 2) provides an illustration of a family of measures with linkages across levels and illustrates this crucial strategy of alignment. Further, these NQF-endorsed measures are included in HHS’s newly launched and broad-based Million E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.000</GPH> from an accountability standpoint. The measures recommended for endorsement give us a broader picture of healthcare—overall and related to specific conditions.’’ [End of Sidebar 2] The NQS provides a critical framework for the efforts of the multiple-stakeholder committees convened by NQF. These efforts range from discussions at the highest, most conceptual levels about a three-to-fiveyear measurement strategy to undergird the evolving value agenda; to committees working in a new measurement area and developing consensus about what and how to measure; to those simultaneously enhancing and culling a set of measures in an established area, while considering their larger context within the NQF-endorsed measurement portfolio. srobinson on DSK4SPTVN1PROD with NOTICES2 ‘‘The endorsement of standardized measures of healthcare resource use and cost fills a huge void that has kept the nation from measuring the value of healthcare in a consistent way,’’ said Steering Committee member Dolores Yanagihara, director, pay for performance, at the Integrated Healthcare Association. ‘‘That said, it is a complex process, both technically and 56925 56926 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices that decreasing healthcare-associated infections (HAIs), complications, and unnecessary readmissions by 10 to 20 percent could result in $2.4 billion to $4.9 billion annual savings for the U.S. healthcare system.5 implement something new in their institutions as a result of this novel public-private programming. Moving forward in 2012, NPP is developing two action pathways, which its multiple partners can implement and spread. These pathways are focused on the health of mothers and babies by reducing elective deliveries before 39 weeks, and reducing avoidable admissions and re-admissions across all settings of care. These represent 2 of the 10 areas Partnership for Patients is pursuing to achieve its global safety and harm-reduction goals. Reaching these goals also will substantially reduce costs. In addition, MAP released a report, Coordination Strategy for HealthcareAcquired Conditions and Readmissions Across Public and Private Payers, in October 2011, detailing the ways in which public and private healthcare providers can align performance measurement to enhance patient safety. Specifically, the report makes three recommendations: (1) There needs to be a national set of core safety measures applicable to all patients; (2) Data need to be collected on all patients to inform these national core safety measures; and (3) Public and private entities need to coordinate their efforts to make care safer. MAP’s recent pre-rulemaking report further emphasizes the importance of safety measures by supporting their inclusion in federal public reporting and performance-based payment programs, and MAP will focus on alignment of core safety measures across programs in 2012. With respect to measure review, NQF endorsed numerous patient-safety measures, including healthcare-associated infections (HAIs), which now address long-term, acute-care and rehabilitation hospitals, and radiation-safety measures, to name a few. NQF also updated its list of SREs, a compilation of serious, harmful, and largely—if not entirely—preventable patient-safety events, designed to help the healthcare field assess, measure, and report performance in providing safe care. In the 2011 update, the events were broadened in focus to explicitly include hospitals, office-based practices, ambulatory surgery centers, and skilled nursing facilities to reflect the various settings in which patients receive care and could experience harm. Based on input from users, the implementation guidance for each event was expanded, and a glossary was added to facilitate In 2011, NQF’s work in the safety realm spanned updating of measures and serious reportable events (SREs), a recommended approach for further aligning public- and private-sector patient-safety measurement strategies, and development of implementation strategies in support of HHS’s Partnership for Patients Initiative. Partnership for Patients is engaging stakeholders from the private and public sectors to reduce all-cause harm (i.e., all forms of harm that can affect patients) and hospital readmissions. More specifically, NPP partnered with the Partnership for Patients to host 11 webinars that attracted about 10,000 frontline clinicians, hospitals, and others across the country and provided education, tools, resources, and insight on key safety issues. These webinars ranged from big-picture interventions (e.g., how to get your Board on board when it comes to improving patient safety), to those with a more laser focus on clinical teams (e.g., reducing surgical-site infections [SSIs]). Nearly 90 percent of webinar participants, who came from every region of the country, reported that they would be able to VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00008 Fmt 4701 Sfmt 4703 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.001</GPH> implementation strategies—working across diverse stakeholder groups to spur collective action—focused on improving patient safety and reducing patient harm. Such a focus also can reduce costs, with the IOM estimating NQF’s Focus on Safety srobinson on DSK4SPTVN1PROD with NOTICES2 Hearts Campaign—a public-private initiative that aims to prevent one million heart attacks and strokes in five years. In addition to NPP’s consultative role as it relates to the NQS, NPP has served as a catalyst in developing Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices uniformity in reporting of the events. The list includes wrong-site surgery; death or serious injury associated with medication errors or unsafe blood products; and failure to follow up on lab, pathology, or radiology test results. Public and private purchasers have drawn heavily from the SRE list in identifying healthcare-associated conditions for use in payment and reporting programs. (See Sidebar 3.) Sidebar 3—NQF and Patient Safety srobinson on DSK4SPTVN1PROD with NOTICES2 Patient-Safety Measures NQF’s inventory of endorsed measures includes more than 100 patient-safety measures, with several focused specifically on healthcareassociated infections or HAIs. Preventing HAIs has become a national priority for public health and patient safety. To date, 27 states are requiring public reporting of certain HAIs. Further, the NQS has identified safer care as one of its primary aims and, in 2013, hospitals’ annual Medicare payment updates will be tied to submission of infection data, including central line-associated bloodstream infections and surgical-site infections (SSIs). In this past year, NQF endorsed four additional patient-safety measures focused on HAIs, including a successfully harmonized measure from the American College of Surgeons and the Centers for Disease Control and Prevention focused on SSIs, and updates of existing HAIs addressing urinary tract infections and bloodstream infections. These efforts were completed under federal contract. Serious Reportable Events Preventing adverse events in healthcare is also central to NQF’s patient-safety efforts. To ensure that all patients are protected from injury while receiving care, NQF has developed and endorsed a set of serious reportable events (SREs). This set is a compilation of serious, harmful, and largely—if not entirely preventable—patient safety events, designed to help the healthcare field assess, measure, and report performance in providing safe care. The SREs focus on the following areas: • Surgical or invasive-procedure events • Product or device events • Patient-protection events • Care-management events • Environmental events • Radiologic events • Potential criminal events Originally envisioned as a set of events that would form the basis for a national state-based reporting system, the SREs continue to serve that purpose. VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 To date, 26 states and the District of Columbia have enacted reporting systems to help stakeholders identify and learn from SREs. The majority of those states incorporate at least some portion of NQF’s list to help align reporting efforts and encourage learning across healthcare systems. [End of Sidebar 3] Finally, NQF launched a project in 2011 that will leverage health IT data to address patient safety and quality concerns associated with medical devices, such as pumps used to deliver intravenous medications at home. This project, which continues in 2012, will determine what data needs to be collected and shared to improve quality and safety related to devices. It also will focus on ways to identify and report adverse events associated with the use of such devices. 3 Endorsing Measures and Developing Related Tools With its extensive evaluation (see Sidebar 4) and multi-stakeholder input, NQF is recognized as a voluntary consensus standards-setting organization under the National Technology Transfer and Advancement Act of 1995. In addition, NQF adheres to the Office of Management and Budget’s formal definition of consensus.6 Consequently, NQFendorsed measures have special legal standing allowing federal agencies to readily adopt them into their programs, which they have done at a striking rate. About 85 percent of measures in federal health programs are currently NQFendorsed, including those that apply to hospitals, clinicians, nursing homes, patient-centered medical homes, and many other settings. In 2011, NQF completed 11 endorsement projects—reviewing 353 submitted measures and endorsing 170, or 48 percent. Enhancements to the endorsement process over the last year included strengthening its rigor by requiring testing of measures prior to measure review, initiation of a project to reduce endorsement cycle time, integration of review of existing measures with new measures to ensure harmonization and best-in-class assessment, and creation of an expedited review process to respond to important regulatory or legislative requests. In addition, NQF worked with 18 measure developers to update 113 electronic measures, or eMeasures, so they could be more readily collected through EHRs, and introduced and updated tools to respectively facilitate development and collection of eMeasures. PO 00000 Frm 00009 Fmt 4701 Sfmt 4703 56927 Sidebar 4—What does it take for a measure to get endorsed? With the enhanced rigor of NQF’s endorsement criteria, only about 50 percent of submitted measures were endorsed this past year. The leading reason that measures do not pass the grade is failure to meet the ‘‘must pass’’ importance-to-measureand-report criterion. This includes being able to demonstrate that the proposed measure or related data is focused on a high-impact health goal or priority; there is less-than-optimal performance; and there is strong scientific evidence for the measure, with respect to quality, quantity, and consistency. NQF expert committees rate the evidence based on specific guidance. The second ‘‘must pass’’ criterion is scientific acceptability of measure properties. In other words, do the data from testing the measure show that it is reliable and valid and precisely specified? Expert committees look for moderate-to-high ratings so they are confident the measure results are reliably consistent and can be compared across providers and analyzed longitudinally. Other important criteria include usability and feasibility— assessing whether intended audiences can understand the results and find them helpful for decision-making and quality improvement. The criteria also consider whether providers can collect data without undue burden. See Appendix C for more detail. [End of Sidebar 4] NQF Endorsement in 2011 The overall framework used to guide the NQF measures portfolio is multidimensional. It includes the NQS crosscutting priorities, as well as leading health conditions with respect to prevalence and cost that affect an array of populations. Figure 3 provides a snapshot of how the current NQFendorsed measures portfolio stacks up against the NQS, with the percentages reflecting the proportion of NQFendorsed measures against the six priorities. Some measures are counted in multiple priority areas. The chart shows gaps in emerging measurement areas, including patient-family centered care, measures related to community health and wellbeing, and affordability. These gaps require significant foundational work to understand what to focus on for measurement and how to best overcome technical barriers. NQF has undertaken this foundational work over the last year, and has started to bring in measures in all of these areas for endorsement review. E:\FR\FM\14SEN2.SGM 14SEN2 56928 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices New and Existing Measurement Areas Long a focus of NQF, these new patient-safety measures span settings and types of conditions. They include measures focused on HAIs (urinary tract, central-line-associated bloodstream, and SSIs), and measures focused on issues such as standardized data collection and reporting of radiation doses. These populations have been underrepresented in performance measurement. NQF has worked to fill these gaps through two endorsement projects over the past year—child health, and perinatal and reproductive health. Child-health measures focus on important screenings and access to care, including immunizations, hearing assessments, and well-child visits. Other measures address population health outcomes, including the number of school days missed due to illness and birth outcomes. Proposed perinatal measures (this project is still underway) address procedures such as cesarean sections and elective delivery prior to 39 weeks. NQF reviewed measures related to resource use, both those related to conditions (e.g., diabetes and cardiovascular disease), and those related more to global resource use. Endorsement projects in 2011 also focused on reviewing existing measurement areas for high-prevalence conditions or areas (palliative care and end-of-life care, cardiovascular disease and kidney disease), adding new measures, and retiring others as the expert committees saw fit. More specifically, NQF endorsed or maintained measures focused on optimal vascular care, complications or death for specific surgical procedures, and assessment of post-dialysis weight by nephrologists for kidney disease patients. Although NQF has made considerable progress in endorsing outcome measures—which constitute about 30 percent of the portfolio— differences exist with respect to outcome and process measures across conditions, which is illustrated in Figure 4. For example, there are more outcome measures for surgery and perinatal care than for mental health and cancer care. Also, HAIs are reflected under surgery, not infectious disease. NQF has made great strides over the past year to endorse measures that evaluate results of care, particularly in the patient-safety, nursing-home, and surgical-care areas. Outcome measures are considered most relevant to patients and providers looking for improved quality and patient experience, as opposed to measures that assess process or structure. Examples of outcome measures endorsed in 2011 include potentially avoidable complications for select conditions (i.e., stroke, pneumonia), remission of symptoms in patients with depression, and patient experience in nursing homes and dialysis facilities. VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 Maternal and Child-Health Measures PO 00000 Frm 00010 Fmt 4701 Sfmt 4703 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.002</GPH> Patient-Safety Measures Outcome Measures srobinson on DSK4SPTVN1PROD with NOTICES2 The 170 measures newly endorsed by NQF in 2011 include many outcome measures; measures that focus on populations previously underrepresented, including pregnant women and children; a number of patient-safety measures—given the importance of reducing patient harm; measures in new areas that fill important gaps, such as cost (resource use); as well as the updating of measures related to highly prevalent conditions, (e.g., cardiac and surgical care). More specifically: Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices 56929 patient-centric measurement framework for assessing the efficiency of care provided to individuals with multiple chronic conditions. This report will inform NQF’s future efforts to endorse measures that apply respectively to population health and care for people who have more than one chronic condition. and competing surgical-site infection (SSI) measures from the Centers for Disease Control and Prevention (CDC) and the American College of Surgeons (ACS) were reviewed. The CDC SSI measure has been in use since 2005; the ACS measure since 2004. As a result of NQF member and public comments, and requests by the Steering Committee, the developers worked with NQF support to harmonize these two competing approaches to measurement. The result is a newly harmonized SSI measure, which is currently focused on abdominal hysterectomies and colon surgeries. CDC and ACS will jointly maintain the measure. The two organizations have also committed to developing harmonized measures for other procedures and will incorporate them into the combined SSI measure. Notably, CMS has selected this harmonized measure for inclusion in the 2012 final rule of the Inpatient Prospective Payment System (IPPS). Dr. Clifford Ko, director of ACS’s National Surgical Quality Improvement Program, was directly involved in this effort. Dr. Ko noted that the resulting measure—Harmonized ProcedureSpecific Surgical-Site Infection Outcome Measure—will now be available to literally thousands of hospitals that want to measure and improve their surgical-site infection rates. Dr. Daniel Pollock, surveillance branch chief in CDC’s Division of Healthcare Quality Promotion, says CMS’ decision to include this measure will significantly increase SSI reporting rates in hospitals throughout the country. With increased reporting, providers will have more opportunities to identify areas for improvement. In addition, patients and payers will have SSI rate information when they are choosing between hospitals in a community. While both Drs. Ko and Clifford noted that some characteristics of the original measures may be diminished or lost, A key part of NQF’s review process is focusing on endorsing best-in-class measures and eliminating similar or even identical measures that create confusion and burden across clinical settings and providers. This alignment of very similar measures—or measure harmonization—can reduce reporting burden for providers and enhance comparability of results for patients and payers, thereby reducing confusion and enabling decision-making. The harmonization of the surgical site infection measures from the Centers for Disease Control and Prevention and the ACS is a case in point (see Sidebar 5). Further, NQF’s maintenance process retires existing measures that no longer meet the higher endorsement bar, thereby further culling the portfolio. Sidebar 5—Harmonizing Surgical-Site Infection Measures As part of NQF’s federally funded Patient-Safety Measures project, similar VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00011 Fmt 4701 Sfmt 4703 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.003</GPH> barriers. For example, NQF is developing a population healthmeasurement framework aimed at aligning delivery system, public health, and community stakeholder efforts to improve health outcomes and the social determinants of health. Historically, there has been little coordination across these sectors. NQF is also developing a Culling the NQF Portfolio srobinson on DSK4SPTVN1PROD with NOTICES2 When NQF begins to address a new measurement area, the relevant expert committee will often start by developing a framework report to guide its future measurement review. These reports may include a scan of existing measures, a discussion about where there are key opportunities for improvement, and consideration of potential technical 56930 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices measure evaluation criteria and guidance on evaluating related and competing measures, the Cardiovascular Committee reviewed proposed new measures and those undergoing maintenance, focusing on measures that address the broadest patient population or settings, while avoiding duplication whenever possible. Based on this rigorous vetting, 39 out of 65 measures (7 new and 32 undergoing maintenance) were endorsed (see Figure 5). When all is said and done, between 2010 and 2011 this represents approximately 13 percent fewer NQF-endorsed cardiovascular measures in this project. Enhancing NQF Endorsement redundancy, waste, and ultimately costs for measure developers, NQF, and HHS. allows for the collection of more clinically relevant and actionable performance-measurement data. These HIT-enabled environments hold out the promise of reducing reporting burden for clinicians and other providers, and enhancing the precision and comparability of results. In the past year, NQF has worked with measure developers to re-specify paper-based measures for EHRs, and developed tools that allow measure developers to marshal the building blocks necessary for their successful implementation. In both cases, these efforts broke new ground. To the best of NQF’s knowledge, they have never been attempted—or accomplished—before. More specifically: As NQF’s measures portfolio evolves, so too does its endorsement process. In 2011, NQF enhanced the rigor of its process by requiring that measures be tested before they are reviewed. This requirement now ensures that expert committees have crucial information about measure reliability and validity as they consider endorsement. In addition, NQF also established an approach that added greater consistency to review of the underlying evidence for measures, and created an expedited endorsement pathway to be responsive to key regulatory or legislative requests. Finally, NQF embarked upon a number of efforts to enhance effectiveness of the review process, including a lean effort to further reduce endorsement cycle time. This effort, which got underway in late 2011, maps each of the steps of the endorsement process to drive out VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 The Information Technology Accelerant A future healthcare system that fully embraces health information technology (HIT) will allow for performance data to be collected in real time across settings, integrated, and regularly fed back to providers to inform practice and decision-making. It also will allow performance information to be made accessible in aggregated, de-identified, and timely public reports for payers and patients. Recent federal efforts—to simultaneously wire ambulatory practices and hospitals and assess providers’ ‘‘meaningful use’’ of electronic health records (EHRs)—have been important steps on the path to a future HIT-enabled system. Such milestones have been augmented by a number of NQF efforts that are helping the field move to a common electronic data platform that PO 00000 Frm 00012 Fmt 4701 Sfmt 4703 E-Measures In 2010, at the request of HHS, NQF worked with 18 measure developers to re-tool 113 existing, endorsed measures for the electronic environment—that is, E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.004</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 they agreed that harmonized measures help eliminate the confusion noncomparable measures create and that, ultimately, providers, payers, and the public benefit. [End of Sidebar 5] The recent Cardiovascular Project illustrates how NQF expert committees now consider new measures against existing endorsed measures. Using the Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices share best practices related to implementation of eMeasures, and a project that will leverage health IT data to address patient safety and quality concerns associated with medical devices, which was described previously. More specifically, with respect to the first two projects: Quality Data Model (QDM) This information model provides measure developers with a first-ever ‘‘grammar,’’ which defines data elements. These data elements can then be efficiently assembled and reassembled into performance measures to be read by EHRs. Work on the QDM began in 2007, with funding from the Agency for Healthcare Research and Quality (AHRQ). In 2011, the third version of the QDM was released, which includes data elements to enable development of measures in gap areas, including patient/consumer engagement and disparities, as well as new methods of data capture and use. In summary, this effort makes a substantial contribution toward being able to more readily leverage existing electronic health-record data to produce clinically relevant, advanced measures. This project is analyzing the current process for identifying and sharing data on significant patient factors, planned interventions, and expected outcomes (care goals) to support quality measurement related to transitions of care. It will recommend a critical path forward with specific action steps that the government can take to enable electronic measurement around care plans. Measure Authoring Tool (MAT) This non-proprietary, web-based tool makes it easier and more efficient for measure developers to specify, submit, and maintain electronic measures, or eMeasures. Introduced in 2011, there are now more than 35 organizations using this tool for eMeasure development. Work that began in 2011 and carries over into 2012 includes a project focused on sharing data across settings, convening a forum for stakeholders to srobinson on DSK4SPTVN1PROD with NOTICES2 to develop electronic specifications that allow an EHR to calculate the measure— so they could be included in the Meaningful Use program. These eMeasures were further updated and enhanced in 2011. The measure stewards and NQF found that re-tooling measures for a new (electronic) platform was not a simple, straightforward matter; rather it involved the stewards re-conceptualizing each of the measures, with the support of NQF. 4 Aligning Accountability Programs To Enhance Value VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 HIT Systems To Support Care Coordination Measurement: Data Sources and Readiness E-Measure Collaborative The eMeasure Collaborative, a public forum convened by NQF, is bringing together stakeholders from across the quality enterprise. The eMeasure Collaborative’s goal is to promote shared learning and advance knowledge and best practices related to the development and implementation of eMeasures. At the request of HHS, NQF commissioned RAND Health to conduct an initial evaluation to better understand who is using NQF-endorsed measures and for what purposes. The RAND studies—coupled with NQF’s own internal tracking efforts to understand measure use—have helped to provide some important context for HHS, NQF, and the NQF-convened MAP discussions. PO 00000 Frm 00013 Fmt 4701 Sfmt 4703 56931 Growing Use of NQF-Endorsed Measures RAND interviews of key stakeholders using NQF-endorsed measures and online research across approximately 75 varied organizations found that nearly all used NQF-endorsed measures, although the extent varied as did the particular measures selected for use. Further, the study showed that most organizations used endorsed measures in quality-improvement efforts, followed closely by public reporting, then payment programs. The 2011 study also found that there is a strong preference to use NQF-endorsed measures where they exist because they are vetted, evidence-based, and seen as more credible within the provider community NQF’s additional research outside of the HHS contract indicates that about 90 percent of the portfolio of NQFendorsed measures is being used in varied programs across the public and private sectors. Figure 6 is an estimation of the use of NQF-endorsed measures by: federal programs; private payers such as health plans and employers; states; and an amalgamation of other key stakeholders such as national registries, accrediting and specialty board certifying organizations, and community alliances. The gold-colored, hatched, and dotted areas on the chart represent alignment in use of the same measures by key sectors—specifically the overlap between private payers (health plans and employers) and federal programs, and the overlap between state and federal efforts. Alignment holds out the promise of reducing data-collection burden for providers and associated costs, while simultaneously accelerating improvement by sending the same message about where providers should be focusing improvement resources. E:\FR\FM\14SEN2.SGM 14SEN2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices srobinson on DSK4SPTVN1PROD with NOTICES2 Overall use of NQF-endorsed measures by the federal government is high—about 85 percent of measures used in federal programs are NQFendorsed. Yet the proportion of NQFendorsed measures in use by various federal programs does differ. Sometimes it is a matter of timing. For example, the federal government has recently moved some non-endorsed measures into the Physician Quality Reporting System (PQRS) to better address the range of physician specialties. NQF is poised to quickly review such measures. States also are heavy users of NQFendorsed measures, in part due to federal programs that encourage or require standardized reporting at the state level, such as AHRQ’s Health Care Utilization Project (HCUP), CDC VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 measures and surveys, CHIPRA, and Medicaid. For example, 81 percent of CHIPRA measures and 88 percent of core adult Medicaid measures are NQFendorsed. In the safety realm, more than half of states and the District of Columbia have implemented reporting systems for SREs, as well as reporting of key patient-safety indicators such as bloodstream and SSI measures. Sidebar 7—AF4Q: Alignment at the Community Level At the community level it is more challenging to get a comprehensive picture of use of NQF-endorsed measures. That said, leading multistakeholder alliances in communities across the country use NQF-endorsed measures, including the Robert Wood PO 00000 Frm 00014 Fmt 4701 Sfmt 4703 Johnson Foundation’s Aligning Forces for Quality (AF4Q) alliances. To support community interest in aligning the measures they are using, a recent analysis conducted by NQF outside of the HHS contract has shown that at least 170 NQF-endorsed measures are being used in one or more of the 16 AF4Q alliances. In addition, NQF endorsed measures are being used by many of the Chartered Value Exchange (CVE) collaboratives, the federally-funded Beacon communities, other communities and a number of states. Given that there is no national requirement to use standardized measures at this level, communities/ states have shown leadership in adopting such measures into their local programs. E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.005</GPH> 56932 The Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative seeks to increase the quality of healthcare and reduce racial and ethnic disparities in 16 diverse communities—with the involvement and collaborative efforts of physicians, patients, consumer groups, hospitals, health plans, and others. The U.S. Agency for Healthcare Research and Quality (AHRQ) supports 24 Learning Network Chartered Value Exchanges. The CVEs are experimenting with new ways to bring healthcare stakeholders together to collect data and improve the quality of care. The federal Beacon Community Cooperative Agreement program provides 17 communities with funding to improve quality, cost-efficiency, and population health using electronic health records and other health information technology tools to collect and analyze clinical data. The program’s goal is to demonstrate the ability of health IT to transform local healthcare systems. i Geographic reach of these efforts varies, e.g., state-wide, county-specific [End of Sidebar 7] Measure Application and Alignment Convened by NQF in the spring of 2011, the Measure Applications Partnership (MAP) is a public-private VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 partnership made up of 60 organizations representing major stakeholder groups, 9 federal agencies, and 40 subject-matter experts. It was established to provide HHS with thoughtful, pre-rulemaking input about which performance measures to use in public reporting and payment within and across 17 federal programs. Simultaneously, MAP is informing the thinking and decisions of private-sector leaders with respect to their measure-selection strategies. Federal Agencies Participating in Map • Agency for Healthcare Research and Quality • Centers for Disease Control and Prevention • Centers for Medicare & Medicaid Services • Health and Human Services’ Office on Disability • Health Resources and Services Administration • Office of the National Coordinator for Health Information Technology • Office of Personnel Management • Substance Abuse and Mental Health Services Administration • Veterans Health Administration MAP represents an important innovation in the regulatory process made possible by ACA statute. In contrast to traditional federal rulemaking—where there are limited, unidirectional forums for input before PO 00000 Frm 00015 Fmt 4701 Sfmt 4703 56933 draft rules are issued and no forums that cross programmatic areas—MAP enables public- and private-sector leaders to work together on creating a measurement strategy and implementation plan that is crosscutting and coordinated across settings of care; federal, state, and private programs; levels of measurement analysis; payer type; and points in time. This is not an overnight prospect, but important, unprecedented steps in the direction of strategic alignment were taken. In 2011, MAP consisted of four programmatic-oriented workgroups— clinician, hospital, LTC/PAC, and dualeligible beneficiaries—and an ad-hoc safety workgroup, each of which makes recommendations to the MAP Coordinating Committee. This independent committee then integrates and aligns these recommendations across the four programmatic areas— which represent 17 different federal programs—and advises HHS directly. (See Sidebar 8) Sidebar 8—Measure Applications Partnership Workgroup Leadership MAP Coordinating Committee Co-Chairs George Isham, MD, MS, Chief Health Officer, Health Partners Elizabeth McGlynn, Ph.D., MPP, Director Center of Effectiveness and E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.006</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices 56934 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices srobinson on DSK4SPTVN1PROD with NOTICES2 Safety Research (CESR), Kaiser Permanente MAP Advisory Workgroups Ad-Hoc Safety Workgroup: Frank G. Opelka, MD FACS, Chair, Vice Chancellor for Clinical Affairs and Professor of Surgery, Louisiana State University Clinician Workgroup: Mark McClellan, MD, Ph.D., Chair, Director, Engelberg Center for Health Care Reform, Senior Fellow, Economic Studies, Brookings Institution, Leonard D. Schaeffer Chair in Health Policy Studies Dual-Eligible Beneficiaries Workgroup: Alice R. Lind, MPH, BSN, Chair, Senior Clinical Officer, Center for Health Care Strategies Hospital Workgroup: Frank G. Opelka, MD FACS, Chair, Vice Chancellor for Clinical Affairs and Professor of Surgery, Louisiana State University Post-Acute/Long-Term Care (PAC/ LTC) Workgroup: Carol Raphael, MPA, Chair, President and Chief Executive Officer, Visiting Nurse Service of New York [End of Sidebar 8] In the fall of 2011, and in advance of future measure-selection recommendations, MAP issued reports offering advice to HHS about how the agency might better coordinate its measure strategies as it relates to efforts focused on improving safety and clinician performance. Its reports include MAP Coordination Strategy for Clinician Performance Measurement and MAP Coordination Strategy for Healthcare-Acquired Conditions and Readmissions Across Public and Private Payers. In 2011, MAP also released the first of two reports focusing on dualeligible beneficiaries who are enrolled in both Medicare and Medicaid programs: MAP Strategic Approach to Performance Measurement for DualEligible Beneficiaries. Despite many of these individuals being the sickest and poorest patients enrolled in any federal program, not to mention among the most expensive, there has been little effort to date to use measurement as a tool to improve their care. For more detail about NQF’s efforts to address vulnerable populations, see sidebar 6. Sidebar 6—NQF Focuses on Vulnerable Populations Vulnerable populations—from the disabled, to veterans, to special needs kids, to low-income individuals and racial/ethnic minorities, among others— VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 often require a different and frequently higher level of care. Over the past year, NQF has taken on two major projects with a prime focus on such vulnerable individuals—The Measure Applications Partnership (MAP) Strategic Report: Performance Measurement for Dual Eligible Beneficiaries Interim Report to HHS, and measurement work focused on disparities in healthcare. The interim MAP report provides multi-stakeholder input on performance measures to assess and improve the quality of care delivered to individuals who are eligible for both Medicare and Medicaid (dual-eligible). An estimated 8.9 million individuals are classified as dual-eligible, a population that includes many of the poorest and sickest individuals in our communities. This particular population frequently experiences fragmented care and accounts for a disproportionate share of total healthcare costs. In its initial phase of work, MAP has developed a strategic approach to performance measurement and identified opportunities to promote significant improvement in the quality of care provided to these vulnerable populations. The core of the strategic approach is composed of: A vision for high-quality care. Centered on the needs and preferences of an individual and his or her loved ones, this relies on holistic supports to maximize function and quality of life. Guiding principles. These include desired effects, measurement design, and data. A discussion of high-need subgroups. MAP deliberations suggested that there is not yet an established taxonomy for classifying subgroups of the dualeligible population. MAP members observed that combinations of particular risk factors lead to high levels of need in an additive or synergistic manner. High-leverage opportunities for improvement through measurement. MAP reached consensus on five areas where measurement could drive significant positive change, including quality of life, care coordination, screening and assessment, mental health and substance use, and structural measures of coordination between Medicare and Medicaid benefits. In addition to the four primary elements, MAP also considered issues related to data sources and program alignment as inputs to the strategic approach. MAP will next consider gaps in currently available measures and may propose new measure concepts for development. A final report with MAP’s input on improving the quality of care delivered to dual-eligible beneficiaries, including recommendations related to PO 00000 Frm 00016 Fmt 4701 Sfmt 4703 measures, is due to HHS on June 1, 2012. NQF’s healthcare disparities measurement efforts are multi-faceted. For example, measure developers are required to submit measure results stratified by race and ethnicity at the time of measure evaluation. NQF has also worked to endorse measures that address vulnerable populations, including measures used for the Children’s Health Insurance and Reauthorization Act (CHIPRA) and Medicaid, as well as measures that fulfill important needs for vulnerable populations, including frail elders, pregnant women, children, and those who suffer from mental illness. With respect to already endorsed measures, NQF is working to identify measures across all settings that should be routinely stratified by race and ethnicity in order to identify conditions and populations that require targeted improvement efforts to improve quality and eliminate disparities. [End of Sidebar 6] MAP’s initial pre-rulemaking report published on February 1, 2012, and based on the consensus of 60 organizations: • Recommends that 40 percent of the measures CMS was considering move into federal programs targeting clinicians, hospitals, dual-eligible beneficiaries, and PAC/LTC settings via rules issued in 2012, with another 15 percent targeted for future consideration after further development, testing, and feasibility issues are worked out. MAP did not support inclusion of about 45 percent of other measures proposed by CMS. CMS submitted a large number of measures and measure concepts to get early, detailed feedback about them from key stakeholders. Consequently, many of the measures submitted did not have enough information to guide MAP measure evaluation and selection. See Appendix D for the criteria MAP used to guide measure selection. • Expresses clear preference for use of NQF-endorsed measures and feedback loops Nearly 87 percent of measures MAP supported for inclusion are currently endorsed by NQF, and many more are likely eligible for expedited review. That said, assessing the qualitative and quantitative impact of NQF-endorsed measures in the field would provide new and important information for future MAP analyses and decision-making. • Considers how to further align measures across programs and with the private sector with the goal of more targeted, interrelated sets of measures that are reported by different kinds of providers, in different settings and E:\FR\FM\14SEN2.SGM 14SEN2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices sectors, and across time. A good example is care-coordination measures contained within existing programs— care transitions, readmissions, and medication reconciliation—which MAP recommends be applied to additional kinds of providers, types of settings, and, consequently, to span and be integrated across federal programs. See Figure 7 to get a more detailed sense for MAP’s crosscutting recommendations for care coordination. • Lays out guiding principles for a future three-to-five-year measurement strategy that supports movement towards a healthcare system that enhances value for patients, communities, and those that pay the bills on their behalf. In this future 21st century system, priority is placed on measures that drive the system toward meeting the NQS; measurement is person- rather than clinician- or settingfocused; and measures span settings, time, and types of clinicians. Personcentered measurement provides information about what matters to patients (e.g., ‘‘Will I be able to run after 56935 I recover from knee surgery?’’) and measures that are specific to patient populations or care over time, (e.g., ‘‘Did I get the care and support needed to manage my diabetes so that I did not lose my vision or my mobility?’’). This kind of measurement is predicated on a redesigned delivery and payment system, and an HIT-enabled environment that facilitates both coordination and integration of care for a range of patients across the continuum. FIGURE 7—ALIGNING CARE COORDINATION MEASURES ACROSS PROGRAMS Clinician Care Transitions .... Hospital Post-acute care/long-term care Support CTM–3 (NQF #0228) if successfully developed, tested, and endorsed at the clinician level. Support immediate inclusion of CTM–3 measure and urge for it to be included in the existing HCAHPS survey. Support several discharge planning measures (i.e., NQF #0338, 0557, 0558). Support the inclusion of both a readmission measure that crosses conditions and readmission measures that are condition-specific. Recognize the importance of medication reconciliation upon both admission and discharge, particularly with the dual eligible beneficiaries and psychiatric populations. Support CTM–3 if successfully developed, tested, and endorsed in PAC– LTC settings. Readmissions ........ Readmission measures are a priority measure gap and serve as a proxy for care coordination. Medication Reconciliation. Support inclusion of measures that can be utilized in a health IT environment including medication reconciliation measure (NQF #0097). srobinson on DSK4SPTVN1PROD with NOTICES2 The MAP proposed guiding principles support the direction of many publicand private-sector leaders who are innovating to move the nation’s care delivery system towards more organization and shared accountability for patient welfare, community health, and stewardship of scarce resources. Where appropriate, they are encouraging transitioning from solophysician practices to actual and virtual patient-centered medical homes, from stand-alone hospitals to those working collaboratively with an array of providers in an integrated delivery system or Accountable Care VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 Organization (ACOs), and from singlespecialty to multi-specialty physician groups working more closely with public health oriented organizations. Figure 8 details some key principles to guide measure selection, measurement tactics, the providers the measures are focused on, and the related federal programs. Implementation of more advanced measures will be possible once care is more organized and integrated, payment crosses settings and providers, and HIT infrastructure is widely in place. Advanced measures could include how well patient care is coordinated between PO 00000 Frm 00017 Fmt 4701 Sfmt 4703 Identify specific measure for further exploration for its use in PAC–LTC settings (i.e., NQF #0326, 0647). Identify avoidable admissions/readmissions (both hospital and ER) as priority measure gaps. Identify potential measures for further exploration for its use across all PAC–LTC settings (i.e., NQF #0097). primary and specialty care and across specialists; whether patients are free of pain and can return to work, school, and other daily obligations; the degree to which patient preferences are incorporated into care decisions; and whether recommended care was appropriate in the first place and delivered cost effectively. Progress is being made as it relates to the development and implementation of such advanced measures, but is predicated on more integrated payment and delivery systems, as well as robust, common electronic data platforms. E:\FR\FM\14SEN2.SGM 14SEN2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices srobinson on DSK4SPTVN1PROD with NOTICES2 Achieving Results Those working to improve performance of the healthcare system are impatient for results, which take time to demonstrate and are influenced by many factors beyond measurement. Nevertheless, there are promising examples, particularly for hospitals and health plans that have been collecting, reporting, and acting on performance measures for a number of years. The case studies included in this section of the report were selected to provide illustrative examples of different kinds of programs and providers using NQFendorsed measures (although they are efforts conducted outside of the federal contracts.) Taken together, and reflecting upon NQF’s accomplishments over the last year, the case studies provide a clear sense that there is forward momentum, as well as a growing commitment on the part of healthcare leaders to enhance healthcare value for patients, communities, and payers. Eight Years of Hospital Reporting Show Results In 2002, three hospital industry associations demonstrated leadership by joining with HHS, The Joint Commission, consumer organizations, and other stakeholders to create a more unified approach to reporting hospital performance information to the public. VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 They launched the Hospital Quality Initiative—later re-named the Hospital Quality Alliance (HQA)—and defined its role as: • Identifying measures for reporting that are meaningful, relevant and understood by consumers; • Rallying hospitals to participate in the initiative and act on the performance results; and • Aligning stakeholders to reduce redundant and wasteful data collection and reporting. From the beginning, HQA recommended NQF-endorsed measures because of the organization’s transparent, rigorous multi-stakeholder consensus process and strong evidencebased approach to endorsement. In 2003, performance results for over 400 hospitals were reported on the CMS Web site for the first time. A year later, CMS began penalizing hospitals financially if they did not report to CMS the same performance information they were required to send to The Joint Commission to maintain hospital accreditation. Between 2003 and 2004, the number of hospitals reporting their results to CMS tripled—from over 400 to more than 1,400 hospitals. In 2005, CMS launched Hospital Compare. Today, over 4,000 hospitals simultaneously report performance data to CMS and The Joint Commission, and the number of measures collected has steadily PO 00000 Frm 00018 Fmt 4701 Sfmt 4703 increased. In 2012, The Joint Commission will incorporate hospital performance into its accreditation determinations for the first time. Performance results improved steadily over the last eight years. A recent analysis of hospitals shows marked improvement based on NQFendorsed measures between 2002 and 2009.7 More specifically, in 2002, about 20 percent of hospitals exceeded 90 percent performance on 22 key measures; by 2009 that percentage had climbed significantly to 86 percent. Key NQF-endorsed measures include measures related to heart attack and heart failure care, surgical care, children’s asthma care, and pneumonia care, among others. This tight alignment between HQA, CMS and The Joint Commission regarding use and reporting of NQFendorsed measures is a likely contributor to hospitals improving their performance over time. At the end of 2011, HQA decided to close its doors— noting that it had accomplished what it had set out to do: establishing a unified approach to collection and public reporting of hospital performance information. HQA also acknowledged that recommendations for measure selection going forward would be best left to the NQF-convened MAP, which is constituted to look across all federal E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.007</GPH> 56936 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices programs to foster alignment and a clear strategic direction for measurement use. National Priorities Focus North Carolina Hospitals Linking Quality Measurement to Payment Reform The North Carolina Center for Hospital Quality and Patient Safety (NCQC) was established by the North Carolina Hospital Association (NCHA) in 2004. The two organizations worked in partnership to conduct quality improvement collaborative projects across the state for about four years, but progress had grown stagnant. With North Carolina ranking as only the 35th healthiest state, NCQC’s director embraced the NPP’s 2008 National Priorities and Goals report recommendations as a way to focus, spur action, and benchmark North Carolina hospitals against national goals. Subsequent NPP reports have built on this first report. The NCQC targeted much of its initial efforts on patient safety, made sure that frontline staff understood how their actions related to the hospital-wide improvement goals, and focused on both culture change and building up quality improvement skills. The Central LineAssociated Bloodstream Infection (CLABSI) Collaborative, which involved 40 ICUs, was particularly successful. Using a separate intervention program that sought to learn from mistakes and improve safety, the CLABSI Collaborative achieved a 46 percent reduction in central-line infections over the 18-month time period. These results translated into saving approximately 18 lives (using a 15 percent fatality rate) and saving $4.5 million (using $40,000 as the extra cost to a hospital for a CLABSI) across 40 hospitals.9 It is important to note that although many individual hospitals had success, not all hospitals in North Carolina participated, and the state rate of CLABSIs did not decrease as much as NCQC had hoped. To address this, NCQC launched a Phase 2 of the initiative to continue its focus on reducing central-line infections, using the NQF-endorsed CLABSIs measure as a way to guide progress and benchmark themselves nationally. The NCQC has stated that it is too early to tell if alignment with the NPP priorities will enable it to meet its own performance goals, but does acknowledge measureable and exciting progress against benchmarks it set. srobinson on DSK4SPTVN1PROD with NOTICES2 Blue Cross Blue Shield Massachusetts’ Alternative Quality Contract In January 2009, Blue Cross Blue Shield of Massachusetts (BCBS) piloted the Alternative Quality Contract, a payfor-performance model directly linking payment to meeting quality and cost benchmarks. The private-payer program provides financial bonuses to participating provider organizations such as multispecialty groups, independent practice associations, and physician-hospital organizations that stay within a specified annual budget and meet clinical quality targets. The budget takes into account the entire spectrum of care, ranging from inpatient and outpatient services to long-term care and prescription drug costs. Performance was evaluated on the quality of care delivered in several clinical settings based on NQF-endorsed measures. More specifically: Seven participating clinical groups were eligible for bonus payments as high as five percent based on 32 NQFendorsed ambulatory and office-based quality measures. Measures included and focused on conditions and procedures such as diabetes testing and controlled LDL–C levels; breast, cervical, and colorectal cancer screenings; and patient experience with accessing and understanding care options. Providers were eligible for another five percent bonus payment based on 32 NQF-endorsed hospital-based measures. These measures focused on surgical site and wound infections, in-hospital mortality rates, and patient satisfaction communicating with doctors and nurses. Initial performance evaluations showed that across the board, provider groups delivered care within the scope of their budgets and performed well on clinical quality measures, allowing them to receive financial rewards of up to 10 percent of the total per-member permonth payments.8 The results illustrate that programs like the Alternative Quality Contract can offer providers strong incentives to control healthcare spending across the continuum while continuing to provide high-quality care. This idea is in line with recent policy proposals to design payment systems that reward highquality, efficient, and integrated care. VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 Performance of Thoracic Surgeons Published in Consumer Reports More than two decades ago, The Society of Thoracic Surgeons (STS) launched the Adult Cardiac Surgery Database to track and improve surgical quality. It is the largest cardiothoracic surgery outcomes and quality PO 00000 Frm 00019 Fmt 4701 Sfmt 4703 56937 improvement program in the world, containing more than 4.5 million surgical records and representing approximately 94 percent of all adult cardiac surgery centers throughout the U.S. Twenty plus years after the launch of its database, STS made the bold decision to offer participating surgical groups the option of voluntarily reporting their performance data in Consumer Reports. More specifically, Consumer Reports began publicly reporting heart surgery ratings at the surgical group level starting in 2010— including survival rates, complication rates, and other key NQF-endorsed measures. These ratings are now available on a bi-yearly basis. A variety of factors influenced STS’s decision to begin publicly reporting surgical performance, including the organization’s vast experience with collecting and analyzing performance measures; a desire to leverage public reporting to further accelerate improvements in thoracic surgeon performance; and wanting to exhibit leadership in an environment of enhanced accountability. Doris Peter, manager, Consumer Reports’ Health Ratings Center, notes that reaction to the reports has been very positive from cardiac surgery groups and consumers alike. Peter noted that the first time STS’s data was published in Consumer Reports, there were 20 million web impressions on the ratings. Consumer Reports’ readership is 8 million. Due to this success, the subsequent September 2011 release made the cover of Consumer Reports print edition. To date, 36 percent of STS surgery groups are participating in the Consumer Reports ratings, a 65 percent increase from the first release. Looking Forward A dozen years in existence, NQF has been able to make particularly strong strides in the last three years with the support of federal funding stemming from MIPPA and ACA, building very much upon the strong collaborative relationship that has been established between NQF, its hundreds of private sector partners, and HHS. At a high level, results over these three years include: • The ability of NQF to now set and implement a multi-year plan for measure endorsement that is cognizant of addressing gaps and focused on implementing a vision for where advanced measurement is heading in a 21st century healthcare system. Over the three years, NQF endorsed 184 measures under the federal contracts, and completed maintenance of 136 E:\FR\FM\14SEN2.SGM 14SEN2 56938 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices previously endorsed measures. Currently, there are 233 measures under maintenance review, another 157 measures undergoing updates to specifications, and 43 measures having testing results reviewed. These efforts involved approximately 65 measure developers and hundreds of experts who volunteered their time on review committees. In addition, NQF has developed tools that allow measure developers to more readily create and implement eMeasures so that providers can collect more meaningful and actionable clinical data that is both comparable for public reporting and valid for payment purposes. • Broad recognition that NQF is an effective and trusted convener of publicand private-sector leaders—reflected in the organization’s multi-stakeholder membership, established processes for achieving consensus, and its commitment to scientific evidence and transparency. This recognition has translated into requests that NQFconvened committees advise HHS on the first-ever NQS and related measurement strategy, as well as detailed measure-selection recommendations. NQF deliverables to HHS have been in the form of reports. Less perceptible perhaps is the growing consensus between scores of public- and private-sector leaders about how to collaborate to improve performance, which is translating into alignment around quality-improvement priorities and measure use. Looking ahead, NQF and the broader quality movement are at an exciting juncture. A robust measurement infrastructure is moving into place, and increasingly there is a shared commitment about what to improve and what measures to use in the process of doing so. Over the next couple of years, NQF will be: • Putting the patient first by facilitating efforts that move the field toward a focus on patient-oriented as opposed to clinician-oriented measurement. Implementation of patient reported measures—including those that address experience of care, functional status, patient reported outcomes and care coordination—can help put the patient at the center of care. • Helping drive waste out of the system by focusing on bringing more cost/resource use measures through NQF endorsement and understanding in more detail how existing NQF endorsed quality/safety measures—including readmission, medication reconciliation and care coordination measures—can contribute to a more cost-efficient system. • Facilitating a future measurement vision by supporting efforts of the NPP and MAP Partnerships to develop a 3– 5 year comprehensive measurement strategy—with broad and strong backing from multiple stakeholders—to recommend to HHS. The intent is that this strategy will cross settings and levels of care, as well as types of clinicians, and will in essence drive a strategic plan for payers that moves the needle with respect to the NQS’s six priorities. • Bringing the public and private sectors closer together by further strengthening collaboration and deepening their commitment to the value agenda, further aligning their respective measurement strategies to reduce redundant data collection, and dramatically accelerate improvements in performance of the U.S. healthcare system. In the coming years, the country should be in the position of realizing many benefits from these efforts to change healthcare by the numbers. 2 Description 4 5 6 7 8 9 Endnotes 1 3 Federal use of NQF-endorsed measures is based on an initial analysis by NQF during the Fall of 2011. The Commonwealth Fund, Why Not the Best: Results from the National Scorecard on U.S. Health System Performance, 2008, New York, NY:Commonwealth Fund, 2008. Available at www.commonwealthfund.org/ Publications/Fund-Reports/2008/Jul/ Why-Not_the_Best—Results-from-theNational-Scorecard-on-U–S—HealthSystem-Performance—2008.aspx. Last accessed February 2012. Bodenheimer T, High and rising health care costs. Part 1: seeking an explanation, Ann Intern Med,2005;142(10):847–854. Bodenheimer T, Fernandez A, High and rising health care costs. Part 4: can costs be controlled while preserving quality? Ann Intern Med,2005;143(1): 26–31. Institute of Medicine (IOM), Roundtable on Value & Science-Driven Health Care—The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary, Washington, DC: National Academies Press; 2010. Available at www.iom.edu/ Activities/Quality/VSRT.aspx. Last accessed January 2012. The White House, U.S. Office of Management and Budget (OMB). Circular No. A–119, February 10, 1998, Washington, DC:OMB; 1998. Available at www.whitehouse.gov/omb/ circulars_a119/. Last accessed January 2012. Chassin MR, Loeb JM, Schmaltz SP et al., Accountability measures—using measurement to promote quality improvement, New Engl J Med, 2010;363(7):683–688. Available at www.nejm.org/doi/full/10.1056/ NEJMsb1002320. Last accessed February 2012. Song Z. Safran DG, Landon BE et al., Health care spending and quality in year 1 of the Alternative Quality Contract, New Engl J Med, 2011;365(10):909–918. Available at www.nejm.org/doi/full/ 10.1056/NEJMsa1101416. Last accessed February 2012. National Quality Forum (NQF), Evaluation of the National Priorities Partnership, Washington, DC:NQF, 2011. Available at www.qualityforum.org/ SettingPriorities/Evaluationofthe National_Priorities_Partnership.aspx. Last accessed February 2012. Appendix A: 2011 Accomplishments: January 14, 2011 to January 13, 2012 Status (as of 1/13/12) Output Notes/scheduled or actual completion date I. Priorities, Principles, and Coordination Strategies srobinson on DSK4SPTVN1PROD with NOTICES2 Provision of input on priorities for the NQS. MAP report recommending measures for use in the improvement of physician performance. VerDate Mar<15>2010 17:12 Sep 13, 2012 Input to the Secretary of Health and Human Services on Priorities for the National Quality Strategy; final written report of Partnership and Subcommittee meeting deliberations and recommendations. Measure Applications Partnership Coordination Strategy for Clinician Performance Measurement; final report including MAP Coordinating Committee recommendations. Jkt 226001 PO 00000 Frm 00020 Fmt 4701 Sfmt 4703 Completed ............................. September 1, 2011. Completed ............................. October 1, 2011. E:\FR\FM\14SEN2.SGM 14SEN2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices 56939 Description Output Status (as of 1/13/12) MAP report recommending measures that address the quality issues identified for dual-eligible beneficiaries. Measure Applications Partnership Strategic Approach to Performance Measurement for DualEligible Beneficiaries; interim report including MAP Coordinating Committee recommendations. Measure Applications Partnership Coordination Strategy for Healthcare-Acquired Conditions and Readmissions Across Public and Private Payers; final report including recommendations regarding the optimal approach for coordinating readmission and HAC measures. Measure Applications Partnership Pre-Rulemaking Report: Input on Measures Under Consideration by HHS for 2012 Rulemaking. Final report including potential new performance measures to fill gaps in measurement for dualeligible beneficiaries. Completed ............................. October 1, 2011. Completed ............................. October 1, 2011. In progress ............................ Completed February 2012 after close of reporting year. June 1, 2012. MAP report recommending measures to be used by private and public payers to reduce readmissions and healthcare-acquired conditions (HACs). Measures for use in quality reporting programs under Medicare. MAP report recommending measures that address the quality issues identified for dual-eligible beneficiaries. In progress ............................ Notes/scheduled or actual completion date II. Measure Endorsement Cardiovascular measures and maintenance review. Two-phase project to endorse new cardiovascular measures and conduct maintenance on existing NQF-endorsed measures. Environmental scan and white paper comparing how regions coordinate and perform on delivering emergency services. Reviewed existing list of NQF SREs for hospitals to identify ones appropriate for other settings; considered potential new SREs for all settings. Three-phase project endorsing measures specific to outcomes on Medicare high-impact conditions, child health, and mental health. Completed ............................. 39 measures endorsed in January 2012. Completed ............................. Framework endorsed in January 2012. Completed ............................. Updated list of 29 SREs endorsed in May 2011. Completed ............................. Patient-safety measures ........ Two-phase project endorsed new measures of patient safety (e.g., healthcare-associated infections, medication safety) and maintaining currently endorsed measures. Completed ............................. Nursing-home measures ....... Endorsed measures of nursing-home care quality. Endorsed measures specific to the care of children. Two-phase project to endorse new surgery measures and conduct maintenance on existing NQF-endorsed measures. Completed ............................. Endorsed measures of imaging efficiency; white paper drafted; endorsed measures of healthcare efficiency. Completed ............................. In progress; completed just after contract year 38 measures endorsed: —30 measures endorsed in January and March 2011. —8 measures endorsed during previous contract year (September 2010). Phase 1: 4 measures endorsed in January 2012. Phase 2: 2 measures endorsed in August and September 2011. 5 measures endorsed in February 2011. 44 measures endorsed in September 2011. Phase 1: 18 measures endorsed in December 2011. NQF Board endorsed Phase 2 measures after the close of the contract year. Phase 2 addendum report issued for public comment just after contract year closed. Imaging Efficiency (Complete) —6 imaging efficiency measures endorsed in February 2011. —1 imaging efficiency measure was recommended to be combined with an existing NQF measure and was endorsed in April 2011. Efficiency—Resource Use (In Progress). Cycle 1: 4 measures ratified by Board January 2012. Jkt 226001 E:\FR\FM\14SEN2.SGM Emergency regionalization medical care measurement framework. Patient safety: SREs .............. Patient outcomes measures .. Child-health measures ........... Surgery measures and maintenance review. srobinson on DSK4SPTVN1PROD with NOTICES2 Efficiency and resource-use measures. VerDate Mar<15>2010 17:12 Sep 13, 2012 PO 00000 Frm 00021 Fmt 4701 Sfmt 4703 Completed ............................. Phase 1 complete; Phase 2 in progress. 14SEN2 56940 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices Description Status (as of 1/13/12) Output Cancer measures and maintenance review. Project to endorse new cancer measures and conduct maintenance on existing NQF-endorsed measures. In progress ............................ Perinatal measures and maintenance review. Project to endorse new perinatal measures and conduct maintenance on existing NQF-endorsed measures. Project to endorse new renal measures and conduct maintenance on existing NQF-endorsed measures. In progress ............................ Pulmonary/critical-care measures and maintenance review. Project to endorse new pulmonary/critical-care measures, and conduct maintenance on existing NQF-endorsed measures. In progress ............................ Palliative and end-of-life care Project to endorse new palliative and end-of-life care measures and conduct maintenance on existing NQF-endorsed measures. Set of endorsed care-coordination measures ...... In progress ............................ Renal measures and maintenance review. In progress ............................ Notes/scheduled or actual completion date Cycle 2: 4 measures posted for public comment in December 2011; voting closed in February 2012. Call for nominations completed in November 2011; call-for-measures deadline was January 2012. Steering Committee reviewed 23 measures in December 2011. Steering Committee reviewed 33 measures by December 2011; member and public commenting to conclude after close of reporting year. Call for nominations closed in December 2011. Call-for-measures deadline was January 2012. NQF Board endorsed measures after close of reporting year. Call for measures closed January 9, 2012. Member and public commenting period concluded February 2012. Care-coordination measures and maintenance review. Population Health Phase 1: Set of endorsed measures for preventative servPrevention measures and ices. maintenance measures review. Population health Phase 2: Commissioned paper addressing population Population health measures. health measurement issues and set of endorsed population health measures. Behavioral health measures Set of endorsed measures for behavioral health and maintenance review. In progress ............................ All-cause readmissions (expedited Consensus Development Process [CDP] review). Multiple Chronic Conditions Measurement Framework report analyzing measures being used to gauge quality of care for people with multiple chronic conditions. Patient-reported outcomes (PROs) workshops addressing prerequisites for endorsed PRO measures. Set of endorsed all-cause readmission measures In progress ............................ Work plan completed; interim report available for public comment. In progress ............................ May 30, 2012. Two workshops discussing commissioned papers addressing methodological prerequisites for NQF consideration of PRO measures for endorsement (The Veterans Administration may fund the papers; proposal is pending their approval). Report that catalogs oral health measures, measure concepts, priorities and gaps in measurement. Summary of process improvement approach, events, and metrics used to enhance the quality and efficiency of CDP process. In progress ............................ June 30, 2012. In progress ............................ July 6, 2012. In progress ............................ Four rapid-cycle improvement events completed in November and December 2012; additional events planned during first quarter of 2012. Oral health ............................. Rapid-cycle CDP improvement (measure-endorsement process). In progress ............................ In progress ............................ In progress ............................ Draft paper completed January 2012 after close of reporting year. Call for nominations closed December 13, 2011. Call for measures closed February 14, 2012. Member and public commenting concluded January 2012. srobinson on DSK4SPTVN1PROD with NOTICES2 III. Health Information Technology Retooled eMeasures, eMeasures Format Review Panel, and eMeasure Updates. VerDate Mar<15>2010 17:12 Sep 13, 2012 Published 113 measures for an electronic environment eMeasure Format Review Panel reviewed retooled measures to ensure the electronic specifications or requirements of these measures are consistent with the original focus and intent of the measure. Held 10 webinars/conference calls to solicit comments and proposed resolutions.. Completed ............................. Jkt 226001 E:\FR\FM\14SEN2.SGM PO 00000 Frm 00022 Fmt 4701 Sfmt 4703 14SEN2 All updates and related activities completed by December 22, 2011. Completed first cycle of review in Fall 2010, following public comment period. Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices 56941 Description Output Status (as of 1/13/12) Notes/scheduled or actual completion date MAT ....................................... Non-proprietary, web-based tool that allows performance-measure developers to specify, submit, and maintain electronic measures in a more streamlined, efficient, and highly structured way. Total number of unique organizations using MAT: 32. QDM maintenance ................. Updated the QDM (Version 3, released in April 2011) to reflect additional types of data needed to support emerging measures (e.g., measures that include social determinants of health, patient/consumer engagement). Completed ............................. Contractor training; release of the MAT Basic Version on 9/2911; enhanced version on target for release. Review and updates to QDM are ongoing based on annual cycle. eMeasures process and technical assistance. Provided education, training, and ad-hoc support to HHS, HHS contractors, MAT users, QDM users, eMeasure developers, EHR vendors, providers implementing measures, and other relevant quality and health IT stakeholders. Ongoing ................................ Patient-safety-complications measures and maintenance review (Phase 1). Commissioned paper on data sources and readiness of HIT systems to support care coordination. Critical path ............................ Set of endorsed measures on complications-related areas. In progress ............................ Final report and commissioned paper ................. In progress ............................ Examine new measurement areas (e.g. care plans) to understand the feasibility of measuring such areas in an electronic environment. Examining issues related to implementation of eMeasures with a multi-stakeholder group in order to define best practices and recommendations to the Office of the National Coordinator’s Federal Advisory Committees. Ongoing ................................ End of September 2012. Ongoing ................................ End of September 2012. eMeasure Learning Collaborative. Each new version of the QDM will be published annually; NQF will post a draft of modifications for the next version; annual QDM updates and versions will be integrated into MAT and, moreover, enable incorporation of required data elements in electronic measures as new types and sources of data are recognized over time. Developed and posted MAT User Guide to provide manual for MAT and eMeasure development. Completed 5 technical-assistance trainings to CMS’ eMeasure contractors, focusing on topics such as QDM and in-depth MAT training. Completed 7 public webinars (with as many as 740 attendees per webinar), focusing on topics such as eMeasures training for measure developers and IT vendors. Steering Committee reviewed 27 measures in December 2011. Draft paper available for public comment in February 2012. IV. Measure Use and Application srobinson on DSK4SPTVN1PROD with NOTICES2 Patient safety: state-based reporting agencies initiative. Convened 27 state-based patient-safety reporting agencies to discuss safety reporting efforts and share ‘‘best practices’’. Completed ............................. RAND report analyzing uses An Evaluation of the Use of Performance Measof NQF-endorsed measures. ures in Health Care; work plan and list of research questions completed; report by independent researcher completed. Recommendations for measMeasure Applications Partnership Pre-Ruleures to be implemented making Report: Input on Measures Under through the federal ruleConsideration by HHS for 2012 Rulemaking. making process for public reporting and payment. Completed ............................. VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00023 Fmt 4701 Sfmt 4703 In progress ............................ E:\FR\FM\14SEN2.SGM 14SEN2 Majority of work completed during previous contract year; final HHS-funded call completed January 24, 2011. Completed in February 2012 after close of reporting year. 56942 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices Description Output Status (as of 1/13/12) MAP report recommending measures for use in quality reporting for Prospective Payment System-exempt cancer hospitals. MAP report recommending measures for use in quality reporting for hospice care. NPP support for Partnership for Patients’ HHS initiative focused on patient safety. Final report including MAP Coordinating Committee recommendations. In progress ............................ June 1, 2012. Final report including MAP Coordinating Committee recommendations. In progress ............................ June 1, 2012. First round of work included 2 quarterly convenings and 8 webinars. Content of meetings and webinars were captured in individual summaries. Next round of work includes creating affinity groups to implement specific patient-safety strategies and webinars. In progress. ........................... srobinson on DSK4SPTVN1PROD with NOTICES2 Appendix B: NQF Board and Leadership Staff Board of Directors William L. Roper, MD, MPH (Chair), Dean, School of Medicine, Vice Chancellor for Medical Affairs and Chief Executive Officer, UNC Health Care System, University of North Carolina at Chapel Hill Andrew Webber (Vice Chair), President and CEO, National Business Coalition on Health Gerald M. Shea (Treasurer), Assistant to the President for External Affairs, AFL–CIO Lawrence M. Becker, Director, HR Strategic Partnerships, Xerox Corporation Judy Ann Bigby, MD, Secretary, Executive Office of Health & Human Services, Commonwealth of Massachusetts Janet M. Corrigan, Ph.D., MBA, President and CEO, National Quality Forum Maureen Corry, Executive Director, Childbirth Connection Leonardo Cuello, Staff Attorney, National Health Law Program Helen Darling, MA, President, National Business Group on Health Robert Galvin, MD, MBA, Chief Executive Officer, Equity Healthcare, The Blackstone Group Ardis Dee Hoven, MD, Chair, American Medical Association Board of Trustees, Medical Director, Bluegrass Care Clinic, Affiliated with the University of Kentucky School of Medicine Karen Ignagni, MBA, President and CEO, America’s Health Insurance Plans Chris Jennings, President, Jennings Policy Strategies, Inc. Charles N. Kahn III, MPH, President, Federation of American Hospitals Donald Kemper, Chairman and CEO, Healthwise, Inc. Mark B. McClellan, MD, Ph.D., Senior Fellow and Director, Engelberg Center for Health Care Reform and Leonard D. Schaeffer Chair in Health Policy Studies, The Brookings Institution Sheri S. McCoy, Worldwide Chairman of the Pharmaceuticals Group, Johnson & Johnson Harold D. Miller, President and CEO, Network for Regional Healthcare Improvement Dolores L. Mitchell, Executive Director, Commonwealth of Massachusetts Group Insurance Commission VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 Mary Naylor, Ph.D., RN, FAAN, Director, New Courtland Center for Transitions & Health and Marian S. Ware Professor in Gerontology, University of Pennsylvania School of Nursing Debra L. Ness, President, National Partnership for Women & Families Samuel R. Nussbaum, MD, Executive Vice President and Chief Medical Officer, WellPoint, Inc. J. Marc Overhage, MD, Ph.D., Chief Medical Informatics Officer, Siemens Medical Solutions, Inc. Bernard M. Rosof, MD, Chair, Board of Directors, Huntington Hospital, Chair, Physician Consortium for Performance Improvement John C. Rother, JD, President and CEO, National Coalition on Health Care Joseph R. Swedish, FACHE, President and CEO, Trinity Health John Tooker, MD, MBA, MACP, Associate Executive Vice President, American College of Physicians Richard J. Umbdenstock, President and CEO, American Hospital Association CMS Don Berwick, MD, Administrator (until 12/2/ 11) Marilyn Tavenner, BSN, MPA, Acting Administrator and Chief Operating Officer (12/5/11–present), Centers for Medicare & Medicaid Services Designee: Patrick Conway, MD, Chief Medical Officer AHRQ Carolyn M. Clancy, MD, Director, Agency for Healthcare Research and Quality Designee: Nancy Wilson, MD, MPH, Senior Advisor to the Director HRSA Mary Wakefield, Ph.D., RN, Administrator, Health Resources and Services Administration Designee: Terry Adirim, MD, Director, Office of Special Health Affairs CDC Thomas R. Frieden, MD, MPH, Director, Centers for Disease Control and Prevention Designee: Peter A. Briss, MD, MPH, Captain, U.S. Public Health Service Medical Director PO 00000 Frm 00024 Fmt 4701 Sfmt 4703 Notes/scheduled or actual completion date Ex Officio (Non-Voting): Timothy Ferris, MD, (Chair, Consensus Standards Approval Committee), Associate Professor of Medicine, Massachusetts General Hospital Paul C. Tang, MD, MS, (Chair, Health Information Technology Advisory Committee), Vice President and Chief Medical Information Officer, Palo Alto Medical Foundation NQF Leadership Staff Janet M. Corrigan, President and Chief Executive Officer Karen Adams, Vice President, National Priorities Heidi Bossley, Vice President, Performance Measures Helen Burstin, Senior Vice President, Performance Measures Floyd Eisenberg, Senior Vice President, Health Information Technology Larry Gorban, Vice President, Operations Ann Greiner, Vice President, External Affairs Ann Hammersmith, General Counsel Lisa Hines, Vice President, Member Relations Connie Hwang, Vice President, Measure Applications Partnership Rosemary Kennedy, Vice President, Health Information Technology Laura Miller, Senior Vice President and Chief Operating Officer Nicole Silverman, Vice President, Federal Program Management Lindsey Spindle, Senior Vice President, Communications and External Affairs Diane Stollenwerk, Vice President, Community Alliances Jeffrey Tomitz, Chief Financial Officer, Accounting & Finance Thomas Valuck, Senior Vice President, Strategic Partnerships Kyle Vickers, Chief Information Officer Appendix C: Overview of Consensus Development Process For each Consensus Development Project (CDP), NQF follows a careful eight-step process that ensures transparency, public input, and discussion among representatives across the healthcare enterprise. 1. Call for Nominations allows anyone to suggest a candidate for the committee that will oversee the project. Committees are diverse, often encompassing experts in a E:\FR\FM\14SEN2.SGM 14SEN2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices srobinson on DSK4SPTVN1PROD with NOTICES2 particular field, providers, scientists, and consumers. After selection, NQF posts committee rosters on its Web site to solicit public comments on the composition of the panel and makes adjustments as needed to ensure balanced representation. 2. Call for Measures starts a 30-day period for developers to submit a measure or practice through NQF’s online submission forms. 3. Steering Committee Review puts submitted measures to a four-part test to ensure they reflect sound science, will be useful to providers and patients, and will make a difference in improving quality. The expert steering committee conducts this detailed review in open sessions, each of which starts a limited period for public comment. 4. Public Comment solicits input from anyone who wishes to respond to a draft report that outlines the steering committee’s assessment of measures for possible endorsement. The steering committee may request a revision to the proposed measures. 5. Member Vote asks NQF members to review the draft report and cast their votes on the endorsement of measures. 6. CSAC Review marks the point at which the NQF Consensus Standards Approval Committee (CSAC) deliberates on the merits of the measure and the issues raised during the review process, and makes a recommendation on endorsement to the Board of Directors. The CSAC includes consumers, purchasers, healthcare professionals, and others. It provides the big picture to ensure that standards are being consistently assessed from project to project. 7. Board Ratification asks for review and ratification by the NQF Board of Directors of measures recommended for endorsement. VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 8. Appeal opens a period when anyone can appeal the Board’s decision. Appendix D: MAP Measure-Selection Criteria The Measure Applications Partnership (MAP) has developed measure-selection criteria to guide its evaluations of program measure sets. The term ‘‘measure set’’ can refer to a collection of measures—for a program, condition, procedure, topic, or population. For the purposes of MAP’s prerulemaking analysis, we qualify the term measure set as a ‘‘program measure set’’ to indicate the collection of measures used in a given federal public reporting or performance-based payment program. The measure-selection criteria are intended to facilitate structured discussion and decision- making processes. The iterative approach employed in developing the criteria allowed MAP in its entirety, as well as the public, to provide input on the criteria. Each MAP workgroup deliberated on draft criteria and advised the Coordinating Committee. Comments were received on the draft criteria through the public comment period for the Coordination Strategy for Clinician Performance Measurement report. A Measure-Selection Criteria Interpretive Guide also was developed to provide additional descriptions and direction on the meaning and use of the measure-selection criteria. 1. MAP measure-selection criteria and the interpretive guide were finalized at the November 1, 2011, Coordinating Committee in-person meeting The following criteria were then used as a tool during the prerulemaking task: 2. Measures within the program measure set are NQF-endorsed or meet the requirements for expedited review. PO 00000 Frm 00025 Fmt 4701 Sfmt 4703 56943 3. The program measure set adequately addresses each of the NQS priorities. 4. The program measure set adequately addresses high-impact conditions relevant to the program’s intended populations (e.g., children, adult non-Medicare, older adults, or dual-eligible beneficiaries). 5. The program measure set promotes alignment with specific program attributes, as well as alignment across programs. 6. The program measure set includes an appropriate mix of measure types (e.g., process, outcome, structure, patient experience, and cost). 7. The program measure set enables measurement across the person-centered episode of care. 8. The program measure set includes considerations for healthcare disparities. 9. The program measure set promotes parsimony. Public commenters supported the MAP measure-selection criteria and noted that the tool served MAP well in its pre-rulemaking activities. Appendix E: NQF Membership NQF members represent more than 450 organizations from across the country committed to advancing healthcare quality. Members of NQF participate in one of eight Member Councils organized by stakeholder group—consumers; health plans; health professionals; provider organizations; publiccommunity health agencies; purchasers; quality measurement, research, and improvement; and supplier-industry—and are afforded a strong voice in crafting national solutions to quality concerns. Member organizations are from every region of the country as the map below indicates. E:\FR\FM\14SEN2.SGM 14SEN2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices NQF Member Organizations 3M Health Care AARP Abbott Laboratories ABIM Foundation Academy of Managed Care Pharmacy Academy of Medical-Surgical Nurses Accreditation Association for Ambulatory Health Care Institute for Quality Improvement ACS–MIDAS+ Ada County Paramedics Adventist Health System Advocate Physician Partners Aetna Affinity Health System AFL–CIO Agency for Healthcare Research and Quality Albuquerque Coalition for Healthcare Quality Aligning Forces for Quality-South Central Pennsylvania Alliance for Health Alliance of Community Health Plans Ambulatory Surgery Foundation Amedisys American Academy of Allergy, Asthma and Immunology American Academy of Dermatology American Academy of Family Physicians American Academy of Hospice and Palliative Medicine American Academy of Neurology American Academy of Nurse Practitioners American Academy of Nursing American Academy of Ophthalmology American Academy of Orthopaedic Surgeons American Academy of Otolaryngology-Head and Neck Surgery American Academy of Pediatrics American Academy of Physical Medicine and Rehabilitation American Association of Birth Centers VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 American Association of Cardiovascular and Pulmonary Rehabilitation American Association of Clinical Endocrinologists American Association of Colleges of Nursing American Association of Diabetes Educators American Association of Neurological Surgeons American Association of Nurse Anesthetists American Association of Nurse Assessment Coordination American Board of Medical Specialties American Board of Optometry American Case Management Association American Chiropractic Association American College of Cardiology American College of Cardiology/American Heart Association Task Force on Performance Measures American College of Emergency Physicians American College of Gastroenterology American College of Medical Quality American College of Nurse-Midwives American College of Obstetricians and Gynecologists American College of Physician Executives American College of Physicians American College of Radiology American College of Rheumatology American College of Surgeons American Data Network American Dietetic Association American Federation of Teachers Healthcare American Gastroenterological Association Institute American Geriatrics Society American Health Care Association American Health Information Management Association American Health Quality Association American Heart Association American Hospice Foundation PO 00000 Frm 00026 Fmt 4701 Sfmt 4703 American Hospital Association American Medical Association American Medical Association-Physician Consortium for Performance Improvement American Medical Directors Association American Medical Informatics Association American Nurses Association American Occupational Therapy Association American Optometric Association American Organization of Nurse Executives American Osteopathic Association American Pharmacists Association Foundation American Physical Therapy Association American Psychiatric Association for Research and Education American Psychiatric Nurses Association American Sleep Apnea Association American Society for Gastrointestinal Endoscopy American Society for Radiation Oncology American Society of Anesthesiologists American Society of Breast Surgeons American Society of Clinical Oncology American Society of Colon and Rectal Surgeons American Society of Health-System Pharmacists American Society of Hematology American Society of Nuclear Cardiology American Society of Pediatric Nephrology American Society of Plastic Surgeons American Urological Association America’s Health Insurance Plans AmeriHealth Mercy Family of Companies AMGEN Inc. AmSurg Corp. Anesthesia Quality Institute Arkansas Medicaid Ascension Health Association for Professionals in Infection Control and Epidemiology E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.008</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 56944 srobinson on DSK4SPTVN1PROD with NOTICES2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices Association for the Advancement of Wound Care Association of American Medical Colleges Association of periOperative Registered Nurses Association of Rehabilitation Nurses Association of Women’s Health, Obstetric and Neonatal Nurses AstraZeneca Atlantic Health Aultman Health Foundation Aurora Health Care Avalere Health LLC Baptist Health South Florida Baptist Memorial Health Care Corporation Baxter Healthcare BayCare Health System Baylor Health Care System Betsy Lehman Center for Patient Safety and Medical Error Reduction Better Health Greater Cleveland BJC HealthCare BlueCross BlueShield Association Boehringer Ingelheim Bon Secours St. Francis Health System Booz Allen Hamilton Bristol-Myers Squibb Company Bronson Healthcare Group, Inc. Buyers Health Care Action Group California HealthCare Foundation California Hospital Association California Hospital Patient Safety Organization California Maternal Quality Care Collaborative California Office of Statewide Health Planning and Development CareFirst BlueCross BlueShield CareFusion CaroMont Health Case Management Society of America Caterpillar Inc. Catholic Health Association of the United States Catholic Health Initiatives Catholic Healthcare Partners Cedars-Sinai Medical Center Center for Health Care Quality, Department of Health Policy, George Washington University Center to Advance Palliative Care Centers for Disease Control and Prevention Centers for Medicare & Medicaid Services Childbirth Connection Children’s Hospital Boston Children’s Hospitals and Clinics of Minnesota CHRISTUS Health CIGNA HealthCare Citizens for Patient Safety City of Hope Cleveland Clinic Colorado Business Group on Health Commission for Case Manager Certification Community Health Accreditation Program Community Health Alliance- Humboldt County Del-Norte Community Health Foundation of Western and Central New York Connecticut Center for Patient Safety Connecticut Hospital Association Consumer Coalition for Quality Health Care Consumers Advancing Patient Safety Consumers’ Checkbook Consumers Union Coral Initiative, LLC VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 Core Consulting, Inc. Council of Medical Specialty Societies Crozer-Keystone Health System Dallas-Fort Worth Hospital Council Education and Research Foundation Dana-Farber Cancer Institute Deloitte Consulting LLP, Health Sciences and Government Dental Quality Alliance Detroit Medical Center Dialog Medical Edwards Lifesciences eHealth Initiative Eisai, Inc. Eli Lilly and Company Elsevier Clinical Decision Support Emergency Nurses Association Employers’ Coalition on Health Englewood Hospital and Medical Center Epstein Becker & Green, P.C. Exeter Health Resources Federation of American Hospitals FirstWatch Solutions, Inc. Florida Health Care Coalition Florida Hospital Florida State University, Center for Medicine and Public Health Forest Laboratories, Inc. Foundation for Informed Medical Decision Making Fox Chase Cancer Center Franciscan Alliance GE Healthcare Genentech Genesis HealthCare System Gentiva Health Services GlaxoSmithKline Good Samaritan Hospital Greater Detroit Area Health Council Greenway Medical Technologies Group Health Cooperative H. Lee Moffitt Cancer Center and Research Institute Hospital, Inc. Hackensack University Medical Center Harborview Medical Center Health Action Council Ohio Health Level Seven, Inc. Health Management Associates, Inc. Health Resources and Services Administration Health Services Advisory Group Health Services Coalition Health Watch USA HealthCare 21 Business Coalition Healthcare Information and Management Systems Society Healthcare Leadership Council HealthGrades HealthPartners HealthSouth Corporation Healthy Memphis Common Table Heart Rhythm Society Henry Ford Health System Highmark, Inc. Hoag Hospital Horizon Blue Cross Blue Shield of New Jersey Hospice and Palliative Nurses Association Hospira Hospital Corporation of America Hospital for Special Surgery Hudson Health Plan Humana Inc. Huntington Memorial Hospital Illinois Hospital Association Infectious Diseases Society of America PO 00000 Frm 00027 Fmt 4701 Sfmt 4703 56945 Infusion Nurses Society Inland Northwest Health Services Institute for Clinical Systems Improvement Institute for Safe Medication Practices Integrated Healthcare Association Intelligent Healthcare Interim HealthCare, Inc. Intermountain Healthcare Iowa Healthcare Collaborative IPRO Jefferson School of Population Health Johns Hopkins Health System Kaiser Permanente Kansas City Quality Improvement Consortium Kidney Care Partners Lamaze International Lehigh Valley Business Coalition on Health Care LHC Group, Inc. Long-Term Quality Alliance Louisiana Health Care Quality Forum Maine Health Management Coalition Maine Quality Counts Maine Quality Forum Maryland Health Care Commission Maryland Patient Safety Center Massachusetts Health Quality Partners Mayo Clinic McKesson Corporation MedAssets MedeAnalytics, Inc. Medisolv, Inc. MedStar Health Memorial Hermann Healthcare System Memorial Sloan-Kettering Cancer Center Merck & Co., Inc. Mercy Medical Center Meridian Health System MHA Keystone Center for Patient Safety & Quality Middlesex Hospital Midwest Care Alliance Milliman Care Guidelines Minnesota Community Measurement Mothers Against Medical Error Mount Auburn Hospital National Academy for State Health Policy National Academy of Clinical Biochemistry National Alliance of Wound Care National Association for Behavioral Health National Association for Healthcare Quality National Association of Certified Professional Midwives National Association of Children’s Hospitals and Related Institutions National Association of Dental Plans National Association of EMS Physicians National Association of Health Data Organizations National Association of Pediatric Nurse Practitioners National Association of Psychiatric Health Systems National Association of Public Hospitals and Health Systems National Association of State Medicaid Directors National Breast Cancer Coalition National Business Coalition on Health National Business Group on Health National Center for Healthcare Leadership National Coalition for Cancer Survivorship National Committee for Quality Assurance National Consensus Project for Quality Palliative Care E:\FR\FM\14SEN2.SGM 14SEN2 srobinson on DSK4SPTVN1PROD with NOTICES2 56946 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices National Consortium of Breast Centers National Consumers League National Council of State Boards of Nursing National Council on Aging National Forum for Heart Disease and Stroke Prevention National Health Law Program National Hospice and Palliative Care Organization National Institute for Quality Improvement and Education National Nursing Staff Development Organization National Partnership for Women & Families National Patient Safety Foundation National Pressure Ulcer Advisory Panel National Rural Health Association National Sleep Foundation NCH Healthcare System Nemours Foundation Neocure Group New Jersey Health Care Quality Institute New Jersey Hospital Association New York Presbyterian Healthcare System New York University College of Nursing Next Wave Niagara Health Quality Coalition North Carolina Center for Hospital Quality and Patient Safety North Mississippi Medical Center North Shore-Long Island Jewish Health System North Texas Specialty Physicians Northeast Health Care Quality Foundation Northwestern Memorial HealthCare Norton Healthcare, Inc. Novartis Nursing Alliance for Quality Care Oakstone Medical Publishing Oncology Nursing Society Oregon Health Care Quality Corporation Ortho-McNeill-Janssen Pharmaceutical, Inc. OSUCCC-James Cancer Hospital P2 Collaborative of Western New York Pacific Business Group on Health Park Nicollet Health Services Partners HealthCare System, Inc. Partnership for Prevention Patient Centered Primary Care Collaborative Pennsylvania Health Care Association Pfizer Pharmacy Quality Alliance PhRMA Phytel, Inc. Planetree Premier, Inc. Press Ganey Associates Professional Research Consultants, Inc. Providence Health & Services Puget Sound Health Alliance PULSE of New York Quality Outcomes, LLC Quantros, Inc. Renal Physicians Association Resolution Health, Inc. Rhode Island Department of Health Robert Wood Johnson University HospitalHamilton Rockford Health System Roswell Park Cancer Institute Saint Barnabas Health Care System Saint Francis Hospital and Medical Center Sanofi Pasteur Sanofi-Aventis Scott & White Healthcare Seattle Cancer Care Alliance VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 Sharp HealthCare Siemens Healthcare, USA Sisters of Charity of Leavenworth Health System SNP Alliance Society for Academic Emergency Medicine Society for Cardiovascular Angiography and Interventions Society for Healthcare Epidemiology of America Society for Maternal-Fetal Medicine Society for the Advancement of Blood Management Society for Vascular Surgery Society of Behavioral Medicine Society of Critical Care Medicine Society of Gynecologic Oncology Society of Hospital Medicine Society of Thoracic Surgeons Southeast Texas Medical Associates, LLP St. Joseph Health System St. Louis Area Business Health Coalition Stamford Health System State Associations of Addiction Services Substance Abuse and Mental Health Services Administration Summa Health System Surgical Care Affiliates Sylvester Comprehensive Cancer Center, University of Miami Hospitals and Clinics Taconic IPA, Inc. Takeda Pharmaceuticals North America, Inc. Tampa General Hospital Telligen Tenet Healthcare Corporation Texas Health Resources Texas Medical Institute of Technology The Advanced Medical Technology Association The Alliance The Alliance for Home Health Quality and Innovation The Commonwealth Fund The Coordinating Center The Empowered Patient Coalition The Federation of State Medical Boards of the U.S., Inc. The Health Alliance of Mid-America, LLC The Health Collaborative The Joint Commission The Leapfrog Group The National Consumer Voice for Quality Long-Term Care The National Forum of ESRD Networks The Partnership for Healthcare Excellence Thomas Jefferson University Hospital Thomson Reuters Trauma Support Network Trinity Health Trust for America’s Health UCB, Inc. UMass Memorial Medical Group, Inc. United Surgical Partners International UnitedHealth Group Universal American Corp. University HealthSystem Consortium University of California-Davis Medical Group University of Kansas School of Nursing University of Michigan Hospitals & Health Centers University of North Carolina-Program on Health Outcomes University of Pennsylvania Health System University of Texas Southwestern Medical Center University of Texas-MD Anderson Cancer Center PO 00000 Frm 00028 Fmt 4701 Sfmt 4703 University of Virginia Health System URAC Urgent Care Association of America US Department of Defense-Health Affairs UW Health Vanderbilt University Medical Center Vanguard Health Management Verilogue, Inc Veterans Health Administration VHA, Inc. Virginia Business Coalition on Health Virginia Cardiac Surgery Quality Initiative Virginia Mason Medical Center Virtua Health WellPoint WellSpan Health WellStar Health System West Virginia Medical Institute Wisconsin Collaborative for Healthcare Quality Wisconsin Medical Society Wound, Ostomy and Continence Nurses Society Yale New Haven Health System Zynx Health Appendix F: 2011 NQF Volunteer Leaders Stancel M. Riley, Chair, Ambulatory and Office-Based Surgery Technical Advisory Panel Serious Reportable Events in Healthcare Project Chair, Patient Safety Serious Reportable Events Technical Advisory Panel, Massachusetts Board of Registration in Medicine Mary George, Co-chair, Cardiovascular Endorsement Maintenance Steering Committee, Centers for Disease Control and Prevention Raymond Gibbons, Co-chair, Cardiovascular Endorsement Maintenance Steering Committee, Mayo Clinic Donald Casey, Co-chair, Care Coordination Endorsement Maintenance Steering Committee, Atlantic Health Gerri Lamb, Co-chair, Care Coordination Endorsement Maintenance Steering Committee, Arizona State University Thomas McInerny, Co-chair, Child Health Quality Measures Steering Committee, University of Rochester Marina L. Weiss, Co-chair, Child Health Quality Measures Steering Committee Co-chair, National Voluntary Standards for Patient Outcomes Child Health Steering Committee, March of Dimes David Classen, Co-chair, Common Formats Expert Panel, University of Utah Henry Johnson, Co-chair, Common Formats Expert Panel, ACS–MIDAS+ Timothy Ferris, Chair, Consensus Standards Approval Committee, Massachusetts General Hospital/Institute for Health Policy Ann Monroe, Vice-chair, Consensus Standards Approval Committee, Community Health Foundation of Western and Central New York Doris Lotz, Co-chair, Efficiency Resource Use Steering Committee, New Hampshire Department of Health and Human Services Sally Tyler, Co-chair, Patient Safety SRE Steering Committee, AFSCME Gregg S. Meyer, Co-chair, Patient Safety SRE Steering Committee, Massachusetts General Hospital E:\FR\FM\14SEN2.SGM 14SEN2 srobinson on DSK4SPTVN1PROD with NOTICES2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices Paul C. Tang, Chair, Health Information Technology Advisory Committee, Palo Alto Medical Foundation and Stanford University Dennis Andrulis, Co-chair, Healthcare Disparities and Cultural Competency Consensus Standards Committee, Texas Health Institute Denice Cora-Bramble, Co-chair, Healthcare Disparities and Cultural Competency Consensus Standards Committee, Children’s National Medical Center Michael Doering, Co-chair, Improving Patient Safety through State-Based Reporting in Healthcare Workgroup, Pennsylvania Patient Safety Authority Diane Rydrych, Co-chair, Improving Patient Safety through State-Based Reporting in Healthcare Workgroup, Minnesota Department of Health Iona Thraen, Co-chair, Improving Patient Safety through State-Based Reporting in Healthcare Workgroup, Utah Department of Health William Corley, Chair, Leadership Network, Community Health Network George J. Isham, Co-chair, Measure Applications Partnership Coordinating Committee, HealthPartners, Inc. Elizabeth A. McGlynn, Co-chair, Measure Applications Partnership Coordinating Committee, Kaiser Permanente Center for Effectiveness and Safety Research Frank G. Opelka, Chair, Measure Applications Partnership Ad Hoc Safety Workgroup Chair, Measure Application Partnership Hospital Workgroup, Louisiana State University Health Sciences Center Mark McClellan, Chair, Measure Applications Partnership Clinician Workgroup, The Brookings Institution, Engelberg Center for Health Care Reform Alice Lind, Chair, Measure Applications Partnership Dual Eligible Beneficiaries Workgroup, Center for Health Care Strategies Carol Raphael, Chair, Measure Applications Partnership Post-Acute Care/Long-Term Care Workgroup, Visiting Nurse Service of New York Michael Lieberman, Chair, Measure Authoring Tool Oversight and Testing Workgroup, Oregon Health and Science University Caroline S. Blaum, Co-chair, Multiple Chronic Conditions Measurement Framework Steering Committee, University of Michigan Health System—Institute of Gerontology Barbara McCann, Co-chair, Multiple Chronic Conditions Measurement Framework Steering Committee, Interim HealthCare Helen Darling, Co-chair, National Priorities Partnership, National Business Group on Health Margaret O’Kane, Co-chair, National Priorities Partnership, National Committee for Quality Assurance Bernard Rosof, Co-chair, National Priorities Partnership, Physician Consortium for Performance Improvement convened by the American Medical Association Peter Crooks, Co-chair, National Voluntary Consensus Standards for End Stage Renal Disease VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 Co-chair, Renal Endorsement Maintenance Steering Committee, Southern California Permanente Medical Group Kristine Schonder, Co-chair, National Voluntary Consensus Standards for End Stage Renal Disease Co-chair, Renal Endorsement Maintenance Steering Committee, University of Pittsburgh School of Pharmacy Tom Rosenthal, Co-chair, National Voluntary Consensus Standards for Endorsing Performance Measures for Resource Use: Phase II, UCLA School of Medicine Bruce Steinwald, Co-chair, National Voluntary Consensus Standards for Endorsing Performance Measures for Resource Use: Phase II Co-chair, Efficiency Resource Use Steering Committee, Independent Consultant G. Scott Gazelle, Co-chair, National Voluntary Consensus Standards for Imaging Efficiency, Massachusetts General Hosital Eric D. Peterson, Co-chair, National Voluntary Consensus Standards for Imaging Efficiency, Duke University Medical Center David A. Johnson, Chair, National Voluntary Consensus Standards for Patient Outcomes Biliary and Gastrointestinal Technical Advisory Panel, American College of Gastroenterology Dianne Jewell, Chair, National Voluntary Consensus Standards for Patient Outcomes Bone/Joint Technical Advisory Panel, Virginia Commonwealth University Lee Newcomer, Chair, National Voluntary Consensus Standards for Patient Outcomes Cancer Technical Advisory Committee, United HealthCare Edward Gibbons, Chair, National Voluntary Consensus Standards for Patient Outcomes Cardiovascular Technical Advisory Panel, University of Washington School of Medicine David Herman, Chair, National Voluntary Consensus Standards for Patient Outcomes Eye Care Technical Advisory Panel, Mayo Clinic E. Patchen Dellinger, Chair, National Voluntary Consensus Standards for Patient Outcomes Infectious Disease Technical Advisory Panel, University of Washington School of Medicine Sheldon Greenfield, Chair, National Voluntary Consensus Standards for Patient Outcomes Metabolic Technical Advisory Panel, University of California, Irvine Barbara Yawn, Chair, National Voluntary Consensus Standards for Patient Outcomes Pulmonary Technical Advisory Panel, Olmstead Medical Center Tricia Leddy, Co-chair, National Voluntary Consensus Standards for Patient Outcomes Mental Health Steering Committee, Rhode Island Department of Health Jeffrey Sussman, Co-chair, National Voluntary Consensus Standards for Patient Outcomes Mental Health Steering Committee, University of Cincinnati Charles Homer, Co-chair, National Voluntary Standards for Patient Outcomes Child Health Steering Committee, NICHQ David Gifford, Co-chair, National Voluntary Standards for Nursing Homes, American Health Care Association and National Center for Assisted Living PO 00000 Frm 00029 Fmt 4701 Sfmt 4703 56947 Christine Mueller, Co-chair, National Voluntary Standards for Nursing Homes, University of Minnesota School of Nursing June Lunney, Co-chair, Palliative Care and End-of-Life Care Endorsement Maintenance Steering Committee, Hospice and Palliative Nurses Association Sean Morrison, Co-chair, Palliative Care and End-of-Life Care Endorsement Maintenance Steering Committee, Mount Sinai School of Medicine Sherrie Kaplan, Co-chair, Patient Outcomes: All-Cause Readmissions Expedited Review Steering Committee, UC Irvine School of Medicine Eliot Lazar, Co-chair, Patient Outcomes: AllCause Readmissions Expedited Review Steering Committee, New York Presbyterian Healthcare System Lisa J. Thiemann, Co-chair, Patient Safety Measures Steering Committee, Surgical Care Affiliates William A. Conway, Co-chair, Patient Safety Measures Steering Committee Co-chair, Patient Safety Measures: Complications Endorsement Maintenance Steering Committee, Henry Ford Health System Darrell A. Campbell, Jr., Chair, Patient Safety Measures HAI Technical Advisory Panel, University of Michigan Hospitals & Health Centers David Nau, Chair, Patient Safety Measures Medical Management Technical Advisory Panel, Pharmacy Quality Alliance Steven Clark, Chair, Patient Safety Measures Perinatal Technical Advisory Panel, Hospital Corporation of America Pamela Cipriano, Co-chair, Patient Safety Measures: Complications Endorsement Maintenance Steering Committee, University of Virginia Health System Tejal Gandhi, Chair, Patient Safety Serious Reportable Events Technical Advisory Panel Chair, Physician Office Technical Advisory Panel Serious Reportable Events in Heatlhcare, Partners Healthcare Eric Tangalos, Chair, Patient Safety Serious Reportable Events Technical Advisory Panel Chair, Skilled Nursing Facility Technical Advisory Panel Serious Reportable Events In Healthcare Project, Mayo Clinic Laura Riley, Co-chair, Perinatal and Reproductive Health Endorsement Maintenance Steering Committee, Massachusetts General Hospital Carol Sakala, Co-chair, Perinatal and Reproductive Health Endorsement Maintenance Steering Committee, Childbirth Connection Paul Jarris, Co-chair, Population Health: Prevention Endorsement Maintenance Steering Committee, Association of State and Territorial Health Officers Kurt Stange, Co-chair, Population Health: Prevention Endorsement Maintenance Steering Committee, Case Western Reserve University David Bates, Co-chair, Quality Data Model Sub-committee, Partners Healthcare Caterina Lasome, Co-chair, Quality Data Model Sub-committee, Ion Informatics Arthur Kellermann, Co-chair, Regionalized Emergency Medical Care Services Steering Committee, The RAND Corporation E:\FR\FM\14SEN2.SGM 14SEN2 56948 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices Andrew Roszak, Co-chair, Regionalized Emergency Medical Care Services Steering Committee, Department of Health and Human Services James Weinstein, Chair, Resource Use Project: Phase II Bone/Joint Technical Advisory Panel, The Dartmouth Institute for Health Policy; Dartmouth-Hitchcock Clinic David Penson, Chair, Resource Use Project: Phase II Cancer Technical Advisory Panel, Vanderbilt University Medical Center Jeptha Curtis, Co-chair, Resource Use Project: Phase II Cardiovascular/Diabetes Technical Advisory Panel, Yale University School of Medicine James Rosenzweig, Co-chair, Resource Use Project: Phase II Cardiovascular/Diabetes Technical Advisory Panel, Boston Medical Center and Boston University School of Medicine Kurtis Elward, Co-chair, Resource Use Project: Phase II Pulmonary Technical Advisory Panel, Family Medicine of Albermarle Janet Maurer, Co-chair, Resource Use Project: Phase II Pulmonary Technical Advisory Panel, American College of Chest Physicians Arden Morris, Co-chair, Surgery Endorsement Maintenance Steering Committee, Ann Arbor Veterans Affairs Medical Center David Torchiana, Co-chair, Surgery Endorsement Maintenance Steering Committee, Massachusetts General Physicians Organization NATIONAL QUALITY FORUM 1030 15th Street NW., Suite 800 Washington, DC 20005 www.qualityforum.org Overview Methods In order to prepare this report on measure gaps, NQF staff consulted numerous data sources to identify endorsed measure and evidence gaps. Staff reviewed approximately 750 endorsed measures within the NQF portfolio and identified the measures that address one or more of the National Quality Strategy (NQS) priority areas and areas where gaps remain. Staff also reviewed NQF-related efforts that address many of the priority areas, including NQF project consensus development project reports. NQF endorsement committees routinely identify gaps as part of the work of the consensus development process. The NQF report ‘‘Prioritization of HighImpact Medicare Conditions and Measure Gaps’’ developed by the Measure Prioritization Advisory Committee and published in May, 2010 was also used as a data source for gaps. NQF has captured this information in a high-level matrix organized by priority area and the high impact clinical conditions which highlights where endorsed measures exist and gaps remain. Given the volume of clinical conditions and cross-cutting areas addressed within the NQF portfolio, a targeted list of clinical conditions is included. It is anticipated that this analysis will continue to evolve over the coming years through the NQF National Priorities Partnership, the Measures Applications Partnership, endorsement maintenance projects, and other activities. The Affordable Care Act (ACA) (Pub. L. 111–148, sec. 3011), requires the Secretary of Health and Human Services to establish a National Strategy for Quality Improvement in Health Care, which serves as a strategic plan for improving the delivery of health care services, achieving better patient outcomes, and improving the health of the U.S. population. The strategy will be continually updated as the Affordable Care Act is implemented. Section 3014 of ACA requires a report from the National Quality Forum (NQF) regarding the identification of gaps in endorsed quality measures—to include measures within the National Quality Strategy priority areas—to be provided to the Secretary by February 1, 2012 and annually thereafter. The report was also intended to identify areas where evidence was insufficient to support endorsement of quality measures in priority areas. National Quality Strategy Overview The NQF-convened National Priorities Partnership (NPP) proposed goals and measure concepts in its September 1, 2011 report ‘‘Input to the Secretary of Health and Human Services on Priorities for the National Quality Strategy’’ regarding the six national priorities: 1. Making Care Safer 2. Ensuring Person- and FamilyCentered Care 3. Promoting Effective Communication and Coordination of Care 4. Promoting the Most Effective Prevention and Treatment of the Leading Causes of Mortality, Starting with Cardiovascular Disease 5. Working with Communities to Promote Wide Use of Best Practices to Enable Healthy Living 6. Making Quality Care More Affordable The proposed goals and measure concepts are intended to ‘‘provide a set srobinson on DSK4SPTVN1PROD with NOTICES2 NQF Report on Measure Gaps and Inadequacies VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00030 Fmt 4701 Sfmt 4703 of clear aims with which the NQS can guide the nation to achieve safe, timely, effective, efficient, and equitable care,’’ and are discussed in more detail below. Some of the measure concepts identify important measurement gaps, while measure development may be limited by evidence gaps. The Secretary’s National Quality Strategy requires a wide array of quality and efficiency measures for implementation. While some of the strategy’s priority areas may be wellsupported by NQF-endorsed measures, others may have fewer, or in some cases, no endorsed measures aligned with them. For the purposes of this report, we have expanded the applicability of the fourth priority area, related to prevention and treatment, beyond cardiovascular disease to the other conditions listed below. While there are numerous condition-specific clinical process measures, there are major gaps for some conditions (e.g., Alzheimer’s). There are also important gaps in condition-specific measures that address critical national priorities (e.g., cost measures for high-cost conditions). • Alzheimer’s Disease • Cancer • Cardiovascular • Cataract • Child Health • Depression • Diabetes • Glaucoma • Hip/Pelvic Fracture • Maternal Health • Osteoporosis • Pulmonary • Renal Disease • Rheumatoid Arthritis/Osteoarthritis • Serious Mental Illness • Stroke Since there is a strong desire to move toward patient-focused outcomes of care, the report also identifies potential outcome gaps for clinical and crosscutting areas. For example, while there are numerous cancer-related process measures, there are no endorsed cancer outcome measures. Recent work by NQF’s Evidence Task Force identified a hierarchical preference for outcomes linked to evidence-based processes and structures (Figure 1). While there is still a need for process and structural measures, especially for quality improvement, they should be closely linked to outcomes. In the tables that follow, gaps for outcome measures in some high impact clinical areas are identified. E:\FR\FM\14SEN2.SGM 14SEN2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 measures in many clinical areas. For example, an endorsed cardiovascular care composite encompasses the key secondary prevention elements critical for prevention of cardiac events (e.g., use of aspirin, non-smoking status, lipid control, and blood pressure control). Given the interest in these measures, gaps for composite measures are also noted in the tables that follow. Gaps Across Cross-Cutting Areas While many measures within the NQF portfolio relate to specific conditions or clinical areas, others address or are applicable to cross-cutting areas such as safety and care coordination. Currently NQF-endorsed measures are categorized by these cross-cutting areas when applicable, overlapping with many of the cross-cutting national priorities outlined within the NQS. Figure 2 provides a graphic representation of the more than 750 measures across these areas. This figure provides information on NQF-endorsed measures by cross-cutting area, as well PO 00000 Frm 00031 Fmt 4701 Sfmt 4703 as the type of measure (structure, process, outcome, and composite). As demonstrated in the figure below, population health/prevention and safety represent the cross-cutting areas with the largest number of measures, while there are clear measure gaps in crosscutting areas such as care coordination and patient experience and engagement. In addition, for areas with a range of measures, many focus on processes of care. However, there has been an increased focus on outcome measures with outcome measures now representing approximately 30 percent of the NQF portfolio. Measure development is also evolving to new areas such as resource use/cost (an area for which NQF is now endorsing measures) and patient-reported outcomes. Planned NQF endorsement projects in the coming year in these high priority areas, such as patient engagement and population health, should help to fill some of these important gaps. E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.009</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 The NQF Evidence Task Force also emphasized the importance of assessing the quality, quantity and consistency of evidence underlying the measure focus. While endorsement of some clinical measures has been limited by empirical evidence, NQF provides an exception in cases for which expert opinion can be systematically assessed with agreement that the benefits to patients greatly outweigh potential harms. In some cross-cutting priority areas, such as pain management and patient engagement, Committee expert opinion has been used to satisfy the evidence requirement. There has also been a strong interest from numerous stakeholders, including consumers and purchasers, in moving to composite measures. Composite measures are defined as one or more measures that are combined into a single score. Because composite measures provide a more comprehensive view of care and may be more understandable to end users, there has been a shift toward composite 56949 56950 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices The following sections address measures and gaps related to each of the cross-cutting areas. Making Care Safer EN14SE12.011</GPH> The NPP provided guidance on proposed goals and measure concepts related to the National Quality Strategy. The following table provides the NPPrecommended goals and measure concepts on Priority Area #1, Making Care Safer. Under the identified measure concepts, there are gaps related to inappropriate medication use and polypharmacy. There are also continued efforts to expand all-cause safety measures. VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00032 Fmt 4701 Sfmt 4725 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.010</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 NQF has endorsed a robust set of patient safety measures. However, gaps remain. For example, there is a need for measures that assess broader, more cross-cutting issues of medication safety, rather than measures that apply to separate medications. There is also interest in ‘‘templates’’ for medication management and safety that could be applied to different medications or conditions. In addition, more research on standard medication monitoring and its effect on outcomes or complications are needed. There is also a recognized need to expand available patient safety measures beyond the hospital setting and harmonize safety measures across sites and settings of care. There have also been recognized patient safety gaps in potentially high leverage areas, such as healthcare associated infections (e.g., MRSA) and measures that assess the culture of safety. Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices 56951 Ensuring Person- and Family-Centered Care There have been a growing number of standardized measures that assess patient experience in multiple care settings. However, as noted in the NPP measure concepts related to this priority area, there is a significant gap in measures that assess patient and family involvement in decisions about healthcare. There is a growing evidence base on decision quality and there is an expectation that these measures will be submitted to NQF in the coming year. The measurement of care planning and joint development of treatment goals has not been limited by available evidence. It has been difficult to construct meaningful measures that move beyond ‘‘checkbox’’ measures that assess whether a plan exists. Promoting Effective Communication and Coordination of Care Some limited development is underway, but much work remains. The table below from the National Priorities Partnership’s September report shows the NPP-recommended goals and measure concepts for Promoting Effective Communication and Coordination of Care, the third priority area in HHS’ National Quality Strategy. Several of the measure concepts have associated endorsed measures, such as transition records and advanced care planning. These endorsed measures tend to be limited to certain populations and settings and there is a need for a measure development and testing that would move these measures to broader populations. The NPP goals also specifically note the need for measures that assess symptom management and functional status. While there have been measures that assess patient function and wellbeing in certain settings, such as home health and nursing homes, measures that assess a change (or ‘‘delta’’) in function have been limited. In addition, while there are many patient-level instruments/measures of health status and function, there are few performance measures that utilize these tools to assess the care provided by healthcare entities. In 2012, NQF will work with experts to address some of methodological challenges that have limited use of patient-reported outcomes across data platforms as performance measures. EN14SE12.013</GPH> VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00033 Fmt 4701 Sfmt 4725 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.012</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 In the area of care coordination, measures that focus on communication and transitions across setting (e.g., medication reconciliation and transitions from inpatient facilities to other settings) and healthcare home have been endorsed, leaving many areas outlined in the NQF care coordination framework (i.e., proactive plan of care and follow-up, information systems) without current endorsed measures. NQF is aware of some work to begin to leverage information systems to facilitate care coordination, but in a recent call for measures related to Care Coordination, NQF did not receive any new measures to address this area. 56952 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices Health project may bring some of these measures forward for evaluation for endorsement. Condition-specific measures and the gaps related to effective prevention and treatment of high impact conditions, including cardiovascular care, are discussed in the condition-specific section of this report. Working With Communities To Promote Wide Use of Best Practices To Enable Healthy Living concepts for this priority area are noted below. The NPP recommended a threetiered approach to population health to address the national priority of working with communities to promote the wide use of best practices to enable healthy living and well-being. While there have been endorsed measures that relate to the receipt of clinical preventive services and immunization measures across the lifespan, most, but not all, of these measures focused on clinical rather than community settings. There are measurement gaps in many of the population-level concepts below, including social support, unhealthy drinking, obesity, and dental health. In the current Population Health Project, NQF will evaluate submitted population-level measures that include a focus on healthy lifestyle behaviors and community interventions that improve health and well-being. A new oral health project will also help to prioritize dental concepts and identify gaps in both dental measures and evidence. are under NQF review, examining some specific clinical conditions as well as the total cost of care for patients who interact with the healthcare system in a given year. While private payers have captured and reported the associated costs and resources used for patients within their systems, these measures had not yet been publicly vetted; the current NQF work can pave the way for srobinson on DSK4SPTVN1PROD with NOTICES2 Measures that can assess the health of populations are a growing area of interest in the measurement enterprise. Population health focuses not only on disease across multiple sectors, but also on prevention and health promotion. Identifying valid and reliable measures of performance across these multiple sectors can be challenging. The NPPrecommended goals and measure Making Quality Care More Affordable A new area for NQF endorsement is related to cost and resource use. Currently, a small number of measures VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00034 Fmt 4701 Sfmt 4703 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.015</GPH> Mortality, Starting with Cardiovascular Disease. While most of the identified cardiovascular prevention concepts relate to currently endorsed measures, there are some measurement gaps related to access to healthy foods and nutrition. Evidence will likely be strong for these cardiovascular prevention measures. The current NQF Population EN14SE12.014</GPH> Promoting the Most Effective Prevention and Treatment of the Leading Causes of Mortality, Starting With Cardiovascular Disease The following table provides the NPPrecommended goals and measure concepts on Priority Area #4, Promoting the Most Effective Prevention and Treatment of the Leading Causes of Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices 56953 increased transparency as well as the possibility of tracking costs in a consistent manner by multiple payers and other interested parties. Many challenges remain within this area, specifically enabling measurement and reporting of costs/resources at the individual provider level, and in the future, pairing these measures with those of quality to begin to capture efficiency. The NPP’s guidance on proposed goals and measure concepts related to this priority area appears in the table below. There are important measure gaps related to access, per capita expenditures and affordability. In addition, development of measures around potential overuse of specific procedures may be limited by the available evidence in clinical guidelines. However, the overuse measures that have failed endorsement to date primarily relate to the lack of availability of the detailed clinical information in claims data. Similarly, the ability to construct a measure of preventable emergency department use has been limited by the availability of data to assess the concept of preventability. Identification of Gap Areas Based on Federal Programs’ Measure Usage important measurement gaps. The MAP Pre-Rulemaking Report provides input on over 350 measures under consideration by HHS for nearly twenty clinician, hospital, and post-acute care/ long-term care performance measurement programs, using the six NQS priorities to guide its recommendations. The findings of the MAP related to gaps in the federal programs reinforce the gap analysis presented in this report. For example, MAP found that most federal reporting programs lacked measures in the areas of person and family-centered care, and cost and appropriateness. Looking specifically at clinical areas, MAP also noted a lack of measures in the area of mental health. All these findings echo the lack of NQF-endorsed measures in these areas as described. In part due to MAP’s required focus on the federal programs, which to date have often been defined by setting of care, the MAP work identified gaps by setting or provider type for the clinician, hospital and Post-Acute Care/Long Term Care (PAC/LTC) federal reporting programs. The high-level measure development and implementation gaps in federal programs are included in the table below: The Measure Applications Partnership (MAP) is a public-private partnership convened by the National Quality Forum (NQF) for the primary purpose of providing input to the Department of Health and Human Services (HHS) on selecting performance measures for public reporting, performance-based payment programs, and other purposes. In its first year, the MAP focused on the availability of measures for federal programs and provided input on • • • • • • • Patient-reported outcomes, health-related quality of life. Shared decision-making, patient activation, care planning. Care coordination. Multiple chronic conditions. Palliative and end-of-life care. Cost including total cost, cost transparency, efficiency, and resource use. Appropriateness. Hospital Programs • Cost—total cost of care, episode, transparency, efficiency. • Appropriateness—admissions, treatment. • Care coordination—transitions of care, readmissions, hand-off communication, follow-up. VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00035 Fmt 4701 Sfmt 4703 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.016</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 Clinician Programs 56954 • • • • • • • Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices Patient-reported outcomes—patient and family experience of care and engagement, patient and family preferences, shared decision-making. Disparities in care. Special populations—behavioral health, child health, maternal health. Quality of life/well-being. Pain. Malnutrition. Palliative Care—comfort, integration of patient values in care planning. PAC/LTC Programs • Functional status is a high-priority gap across all programs because assessing function and change in function over time is a baseline for tailoring care for individuals and population subsets. • A second prominent gap is measures that incorporate the patient, family, and caregiver experience and their involvement in shared decisionmaking. • Measures that assess if care goals are established using a shared decision making process and if those goals are attained. • Measures understanding how providers use assessment information to tailor goals. • Establishing and attaining care goals. • Care coordination, including transitions. • Cost. • Mental health. • Nutritional status. srobinson on DSK4SPTVN1PROD with NOTICES2 Gaps Across National Priority Areas by Condition-Specific Areas To better highlight gaps areas, NQF further grouped its endorsed measures by the following high impact conditions, and reported gaps by each condition, mapped to the NQS priority areas. The condition-specific areas map to the Prioritization of High-Impact Medicare Conditions and Measure Gaps report prepared for HHS in 2011, with additional high impact areas added to address younger populations (e.g., child health, maternal health, and serious mental illness). For example, NQF broadened the high-impact condition VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 COPD to include other pulmonary conditions (such as asthma.) Finally, related conditions, such as acute myocardial infarction and congestive heart failure, have been grouped together under the broader term of cardiovascular. • Alzheimer’s Disease • Cancer • Cardiovascular • Cataract • Child Health • Depression • Diabetes • Glaucoma • Hip/Pelvic Fracture PO 00000 Frm 00036 Fmt 4701 Sfmt 4703 • • • • • • • Maternal Health Osteoporosis Pulmonary Renal Disease Rheumatoid Arthritis/Osteoarthritis Serious Mental Illness Stroke In addition to categorizing the measures by NQS priority area, the measure type (i.e., structure, process, outcome, and composite) have been included in these tables. Figure 3 offers a high level analysis of measures by clinical system. As evident in the table, there are many clinical areas that need further outcome measure development. E:\FR\FM\14SEN2.SGM 14SEN2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 aggregation of patient-reported outcomes into measures appropriate for accountability and quality improvement). Gaps Across National Priority Areas by Condition-Specific Areas For each condition, the shaded spaces in the tables below represent areas where there are NQF-endorsed measures addressing NQS priority areas, by measure type. The blank spaces represent areas where there are gaps in NQF-endorsed measures. PO 00000 Frm 00037 Fmt 4701 Sfmt 4703 Alzheimer’s Disease While Alzheimer’s is recognized as a critical area for measurement, there is a gap in endorsed measures for this condition. There has been limited measure development in this area, which was evidenced through a request for measures by NQF that resulted in no submissions in 2010. Through recent discussions with several developers, NQF has learned that some development has begun. Future NQF measure endorsement projects will include an opportunity for submission of newly developed measures related to Alzheimer’s disease. E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.017</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 As a result, high-level information is presented below regarding gaps in endorsed quality measures within the priority areas identified in the NQS. While there are many reasons for the persistent gaps in performance measurement described below, many developers who submit measures to NQF report that the lack of adequate financial support for measure development is a major driver. In addition, measure gaps persist due to insufficient evidence (e.g., management and treatment of Alzheimer’s disease) and methodological challenges related to emerging measurement areas (e.g., 56955 cancer survival. There are a small number of overuse measures related to affordable care. Gaps related to the quality of life and other critical outcomes of care related to patients diagnosed with cancer remain. No measures were brought forward to address these gap areas in the recent call for measures for the current NQF Cancer Endorsement Project. Cardiovascular Care NQF has a very large set of endorsed cardiovascular measures addressing conditions such as acute myocardial infarction, coronary artery disease, and congestive heart failure. There are also endorsed process, outcome, and composite measures related to healthy living and prevention, including measures that align with the CDC goals in its national initiative ‘‘Million Hearts’’ to prevent one million heart attacks and strokes. While each of the clinical conditions within the larger topic area of cardiovascular care has a robust set of measures of process and outcome measures, gaps remain in the area of person- and family-centered care. As a result of the NQF Patient Outcomes project completed in 2011, several composite measures that examine care transitions for cardiovascular care are now included in the NQF portfolio. In addition, measures that assess coordination of care, such as the recently endorsed measure that assesses referral to cardiac rehabilitation after a heart attack, are in development. Measures that begin to address affordable care are slowly increasing in numbers. For example, NQF recently endorsed measures of appropriate use of cardiac stress testing as well as measures that capture resources or costs associated with specific cardiovascular conditions, but many gap areas remain. VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00038 Fmt 4701 Sfmt 4703 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.018</GPH> The set of endorsed cancer measures is primarily oriented to cancer screening and effectiveness of treatment for specific cancers. For the priority area of prevention, there are process measures addressing breast, cervical, and colorectal cancer screening. For this topic, there are gaps across all measure types in the healthy living priority area. In the person and family centered care priority area, there are several process measures and there are measures that specifically address the quality of care received at the end of life through caregiver surveys. For safer care, there are several process measures and a small number of outcome measures. There is a gap in outcomes related to EN14SE12.019</GPH> Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices Cancer srobinson on DSK4SPTVN1PROD with NOTICES2 56956 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices While only a handful of measures have been endorsed in the area of cataracts, these measures address the outcomes of cataract surgery. Complications following surgery and improvement in patients’ visual srobinson on DSK4SPTVN1PROD with NOTICES2 Child Health The number of endorsed measures focused on child health has grown in the last year—in part due to a targeted NQF Child Health project that was completed in 2011. The portfolio has also expanded to accommodate core measures for the CHIPRA program. Similar to Maternal Health discussed below, Child Health has many measures focused on screening, immunizations, well-child visits, and treatment for specific clinical conditions. While there are endorsed outcome measures for children, such as those that examine VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 also a need for measures that address cataract outcomes for patients with multiple co-morbid comorbidities, including diabetes. These may be examples where the evidence base may limit applicability of these measures to more complex patients. infection, mortality, and readmission in the intensive care units, they are primarily hospital focused rather than ambulatory. In terms of affordable care, there is a measure focused on length of stay in pediatric intensive care units and a measure of emergency department visits for children with asthma, both of which address use of resources. An opportunity exists to increase the number of measures that apply to children by adapting adult-focused measures to apply to younger ages. This gap is very dependent on measure developers’ willingness to apply measures to younger populations, but age-based population limits and this limitation should only occur when the evidence does not support the expansion to those under 18 years of age. In January 2011, NQF released a report from the Measure Prioritization Advisory Committee focused on measure development and endorsement agenda that identified child health gaps in the areas of care coordination (transitions, referrals, medical homes); acute and chronic management (health promotion, community resources, timely and appropriate follow-up of screening tests); and population health outcomes. PO 00000 Frm 00039 Fmt 4701 Sfmt 4703 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.021</GPH> function have been targeted. Currently, the measures focus on those patients who have had surgery. Future measures should address the appropriate selection of treatment of patients with cataracts, ensuring that only those patients whose visual function and quality of life is compromised receive surgery. There is EN14SE12.020</GPH> Cataract 56957 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices Diabetes While NQF has endorsed multiple diabetes measures, they are primarily oriented to prevention and healthy living, including two composite VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 However, gaps remain specific to other priorities. There is an endorsed patient experience of care measure for inpatient psychiatric care and a set of measures that assess transition from inpatient to outpatient care. Measure gaps relate to affordability, such as potential measures that assess overuse of multiple antipsychotic medications. There are also important population health gaps for serious mental illness, including measures that would address issue of social support and homelessness. NQF anticipates that additional measures related to serious mental illness will be submitted in the upcoming Behavioral Health project. admissions for diabetic complications. While there are measures that address the treatment of patients with the disease, measures have not yet been developed or endorsed that adequately PO 00000 Frm 00040 Fmt 4701 Sfmt 4703 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.023</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 There is a growing set of endorsed outcome and process measures that address depression. There are some endorsed measures that address Healthy Living and Prevention (e.g., maternal depression screening, suicide risk assessment). In NQF’s Patient Outcomes project, measures looking at whether remission of symptoms was achieved at 6 and 12 months were recently endorsed—a step toward assessing patient outcomes related to depression. Many gaps remain specific to personand family-centered care. There are also a small number of endorsed process measures related to safer care in the areas of medication management and evaluation and assessment for major depressive disorder. There are a limited number of measures that assess coordination of care, such as persistent use of needed antidepressants, as well as follow-up care after hospitalization. There are many measurement gaps for patients with serious mental illness. Currently, only measures specific to schizophrenia and bipolar disease are endorsed, leaving many other mental health conditions unaddressed. There are endorsed process measures that address prevention and safer care (e.g., screening for potential comorbidities for patients with bipolar disorder, use of multiple antipsychotic medications). measures that address both processes and intermediate outcomes for patients with diabetes. In healthy living, there are also population-level measures that assess potentially preventable Depression and Serious Mental Illness EN14SE12.022</GPH> 56958 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices 56959 address the pediatric population or primary screening and prevention of diabetes for high-risk individuals. Many of these gaps are due to the lack of consistent, strong evidence on appropriate screening and treatment. In the current NQF Resource Use project, a recently endorsed measure captures the relative resource use for patients with diabetes. This measure should allow implementers including payers to identify the costs and resources associated with this chronic illness. Glaucoma appropriate evaluations and the reduction of intraocular pressures. Many gaps remain, including addressing patients’ quality of life, experience with care, care coordination, and education related to treatments. measure that examines the mortality rate related to these fractures. Beyond these three outcomes measures, the NQF portfolio includes measures that address osteoporosis screening and treatment with several specifically targeting those patients who have had a hip or pelvic fracture. Those measures are captured within the discussion and analysis of osteoporosis and are not reflected in the table below. Many gaps remain related to the coordination of care and person/ family centered care. For affordable care, resource use measures related to hip fracture are under consideration in the current NQF Resource Use Project. Two measures have been endorsed in the area of glaucoma that address EN14SE12.025</GPH> There is a limited set of endorsed measures that address hip and pelvic fracture. Two outcome measures were recently endorsed that target the rate of complications and readmissions after hip surgery. There is also an endorsed VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00041 Fmt 4701 Sfmt 4703 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.024</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 Hip/Pelvic Fracture 56960 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices relate to affordable care, such as the rate of Cesarean sections for first-time mothers and elective deliveries prior to 39 weeks. One significant area for which measures may be in development but have not yet been submitted to NQF is related to reproductive health. endorsed measures that target appropriate screening or treatment following a fracture, or general screening of women at risk. Significant gaps remain in areas that assess patients’ quality of life and functional status and care coordination, in addition to the dearth of outcomes measures and the lack of applicability of the current measures to men. VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00042 Fmt 4701 Sfmt 4703 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.026</GPH> EN14SE12.027</GPH> delivery. Several measures related to appropriate processes or intermediate outcomes during labor and delivery (e.g., use of prophylactic antibiotics and health-care acquired infections in the newborn) are linked to the priority area of Safer Care. There are measures that Osteoporosis Few measures have been endorsed in the area of osteoporosis. To date, those measures have focused on appropriate screening and treatment, such as srobinson on DSK4SPTVN1PROD with NOTICES2 Maternal Health NQF has a growing set of endorsed measures that relate to maternal health. There are several important process measures, such as ensuring adequate screening, prenatal and postpartum visits, and appropriate treatment during Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices Pulmonary For the purpose of this report, pulmonary conditions include asthma, chronic obstructive pulmonary disease (COPD), and pneumonia. There are many process measures that examine care for adults and children with asthma, measures of appropriate use of life for patients with COPD in pulmonary rehabilitation programs. While some measures looking at safer care and person/family centered care have now been endorsed, measures related to other pulmonary conditions or applicable to broader settings are needed. recent End Stage Renal Disease (ESRD) endorsement project, a CAHPS measure was endorsed that assesses patient experience with in-center hemodialysis. There are also multiple outcome measures related to adequacy of dialysis and infection rates. Evidence continues to evolve regarding the appropriate target hemoglobin for patients with ESRD. Due to the black box warning issued by the FDA and continued changes to what hemoglobin levels are considered safe targets, NQF and its committees have been reluctant to endorse measures for which the evidence is not yet consistent to support a performance measure. Additional gaps remain related to care coordination and affordable care. EN14SE12.029</GPH> There is a broad set of measures related to End Stage Renal Disease (ESRD) and a small but emerging set of measures related to chronic renal disease. NQF has endorsed several process and outcome measures on this topic, in the priority area of Healthy Living and Prevention. As part of a medications to prevent and treat exacerbations of COPD, and outcome measures related to mortality and readmission for pneumonia. Several outcome measures for pulmonary conditions were recently endorsed through the NQF Patient Outcomes project, including care transitions for patients with pneumonia and quality of VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00043 Fmt 4701 Sfmt 4703 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.028</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 Renal Disease 56961 56962 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices Rheumatoid Arthritis/Osteoarthritis Few measures have been endorsed in the areas of rheumatoid arthritis and osteoarthritis. To date, those measures have focused on appropriate screening Stroke measures, such as anticoagulation for patients with atrial fibrillation and secondary prevention related measures, such as use of statins. There are multiple measures that assess the appropriate care and screening for patients after stroke, including issues related to anticoagulation and ongoing need for speech therapy. There is a single endorsed measure related to stroke education, but no endorsed measures that assess person and family centered care. There are also gaps in measures in the healthy living and affordable care priority areas. While NQF has not previously endorsed measures related to affordable care, there are stroke-related resource use measures currently in the NQF endorsement process. EN14SE12.031</GPH> toxicity. Significant gaps remain in areas that assess patients’ quality of life and functional status and care coordination. There is also an absence of outcomes measures such as functional status. VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00044 Fmt 4701 Sfmt 4703 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.030</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 Within stroke, there are endorsed process and outcome measures related to prevention, safer care and care coordination. Within safer care, there are outcome measures related to potentially avoidable complications and mortality after stroke. NQF has also endorsed primary prevention related and treatment. For example, NQF has endorsed measures related to medication safety for patients with rheumatoid arthritis as well as measures that focus on ensuring appropriate follow-up and testing to prevent Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices srobinson on DSK4SPTVN1PROD with NOTICES2 While the NQF portfolio of endorsed measures can address many important priority area and high priority clinical conditions, there are many gaps that remain. While many measure gaps could be filled with measure development, there would be a small sub-set where development would be limited by available evidence. Another VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 important impediment to measure development in many high priority areas relates to the lack high quality data for measurement. The move toward an electronic data platform should help increase capacity to measure some of these important concepts. Collectively, the NPP, MAP and endorsement-related work provide a roadmap to where measures are needed to fill many important gaps. This report can be used PO 00000 Frm 00045 Fmt 4701 Sfmt 4703 to target measure development resources to areas where there are critical development gaps. Appendix of Measures Included Within the Condition-Specific Areas Alzheimer’s Disease * There are no measures in the portfolio for this condition. BILLING CODE P E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.032</GPH> Conclusion 56963 VerDate Mar<15>2010 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00046 Fmt 4701 Sfmt 4725 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.033</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 56964 VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00047 Fmt 4701 Sfmt 4725 E:\FR\FM\14SEN2.SGM 14SEN2 56965 EN14SE12.034</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices VerDate Mar<15>2010 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00048 Fmt 4701 Sfmt 4725 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.035</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 56966 VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00049 Fmt 4701 Sfmt 4725 E:\FR\FM\14SEN2.SGM 14SEN2 56967 EN14SE12.036</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices VerDate Mar<15>2010 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00050 Fmt 4701 Sfmt 4725 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.037</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 56968 VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00051 Fmt 4701 Sfmt 4725 E:\FR\FM\14SEN2.SGM 14SEN2 56969 EN14SE12.038</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices VerDate Mar<15>2010 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00052 Fmt 4701 Sfmt 4725 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.039</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 56970 VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00053 Fmt 4701 Sfmt 4725 E:\FR\FM\14SEN2.SGM 14SEN2 56971 EN14SE12.040</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices VerDate Mar<15>2010 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00054 Fmt 4701 Sfmt 4725 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.041</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 56972 VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00055 Fmt 4701 Sfmt 4725 E:\FR\FM\14SEN2.SGM 14SEN2 56973 EN14SE12.042</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices VerDate Mar<15>2010 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00056 Fmt 4701 Sfmt 4725 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.043</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 56974 VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00057 Fmt 4701 Sfmt 4725 E:\FR\FM\14SEN2.SGM 14SEN2 56975 EN14SE12.044</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices VerDate Mar<15>2010 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00058 Fmt 4701 Sfmt 4725 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.045</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 56976 VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00059 Fmt 4701 Sfmt 4725 E:\FR\FM\14SEN2.SGM 14SEN2 56977 EN14SE12.046</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices VerDate Mar<15>2010 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00060 Fmt 4701 Sfmt 4725 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.047</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 56978 VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00061 Fmt 4701 Sfmt 4725 E:\FR\FM\14SEN2.SGM 14SEN2 56979 EN14SE12.048</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices VerDate Mar<15>2010 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00062 Fmt 4701 Sfmt 4725 E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.049</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 56980 VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 PO 00000 Frm 00063 Fmt 4701 Sfmt 4725 E:\FR\FM\14SEN2.SGM 14SEN2 56981 EN14SE12.050</GPH> srobinson on DSK4SPTVN1PROD with NOTICES2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices BILLING CODE C srobinson on DSK4SPTVN1PROD with NOTICES2 IV. Secretarial Comments on the Annual Report to Congress The Secretary is pleased with the scope and vision of NQF’s March 2012 annual report to Congress (the ‘‘annual report’’). An internal multidisciplinary cross-component HHS team is working collaboratively with NQF to provide for a clear multi-year vision to ensure the most efficient and effective utilization of the HHS contract. The contract with NQF provides an important opportunity to further enhance HHS’ efforts to foster a collaborative, multi-stakeholder VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 approach to increase the availability of national voluntary consensus standards for quality and efficiency measures. Over the past year NQF continued work on tasks outlined in the Statement of Work, including: Providing additional input on the development of a national strategy for performance measurement and prioritization of measures for development and endorsement; conducting measure endorsement projects focused on measure gap areas such as outcomes measures and patient safety measures; maintaining current NQF-endorsed measures; promoting Electronic Health PO 00000 Frm 00064 Fmt 4701 Sfmt 4703 Records through activities that include developing a measure authoring software tool; and retooling of a subset of existing NQF-endorsed measures into electronic measure format. NQF provided input on the implementation of the national priorities of the National Strategy for Quality Improvement in Healthcare (NQS). The NQF convened the National Priorities Partnership (NPP) and delivered a report that focused further on enhancing patient safety, one of the six NQS priorities. The NPP worked with HHS on the Partnership for Patients initiative. The E:\FR\FM\14SEN2.SGM 14SEN2 EN14SE12.051</GPH> 56982 srobinson on DSK4SPTVN1PROD with NOTICES2 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices NQF continued its endorsement of quality measures for use in accountability and performance improvement with a focus on crosscutting measures and measures addressing costly and prevalent health conditions. NQF convened the Measure Applications Partnership (MAP) to foster alignment of measures in order to reduce reporting burden and accelerate improvement in reporting. The MAP provided pre-rulemaking guidance to HHS, including input on the selection of quality and efficiency measures. The Secretary has reviewed the annual report and has the following comments. First, the Secretary notes an inadvertent statement in the annual report. The statement appears in the third sentence of the first paragraph on page 16 of the Report to Congress under the section entitled ‘‘3. Endorsing Measures and Developing Related Tools’’. It refers to NQF-endorsed measures and states they have ‘‘special legal standing’’. The suggestion that NQF-endorsed measures enjoy ‘‘special legal standing’’ is ambiguous and could be misinterpreted. Numerous statutory provisions in the Social Security Act (the ‘‘Act’’) require the Secretary to specify measures for quality programs that have been endorsed by the consensus-based entity with a contract under section 1890(a) of the Act. NQF currently holds this contract and the Secretary often selects NQF-endorsed measures for quality programs. Nonetheless, the suggestion that these measures ‘‘have special legal standing’’ does not describe the significance of NQF endorsement for measures the Secretary selects. In addition, this statement oversimplifies the complex intellectual property concerns that frequently attend federal agency use, adoption, and dissemination of NQFendorsed measures. Second, the Secretary wishes to clarify a statement that has the potential to be misleading. This statement appears in the final sentence of the first full paragraph on page 7 of the Report to Congress and states: ‘‘As it turns out, NQF has already endorsed measures for medication reconciliation, readmission, and care transitions that apply to additional settings and populations so these measures can move right into other federal programs.’’ This sentence is vague and the reference to measures moving ‘right into other federal programs’ does not accurately describe the process by which measures are selected for use in quality programs. Third, the Secretary also wishes to clarify a statement in the sentence in the middle of the second column in ‘‘Sidebar 5: Harmonizing Surgical-Site VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 Infection Measures’’ on page 20 of the Report to Congress. The sentence states: ‘‘Notably, CMS has selected this harmonized measure for inclusion in the 2012 final rule of the Inpatient Prospective Payment System (IPPS).’’ This sentence suggests that the referenced measure—Surgical Site Infection—was included in Fiscal Year 2012 Inpatient Prospective Payment System (IPPS)/Long term Care Hospital Prospective Payment System final rule as part of the payment for the IPPS program, when in fact this measure was finalized in that rule for use in the Hospital Inpatient Quality Reporting (‘‘Hospital IQR’’) program. Fourth, the section entitled ‘‘Eight Years of Hospital Reporting Show Results’’ on page 31 of the Report to Congress discusses simultaneous reporting on measures by hospitals to the Centers for Medicare & Medicaid Services (‘‘CMS’’), presumably for the Hospital IQR program, and to the Joint Commission for hospital accreditation. Although there may be some overlap in the measures on which hospitals report to CMS and the Joint Commission, this section suggests that CMS and the Joint Commission run the Hospital IQR program together, which is not the case. Fifth, the Secretary notes some ambiguity with respect to the description of funding that NQF receives from the MIPPA and the Affordable Care Act. Specifically the language in the Report to Congress implies that the two laws directly appropriated funds to the NQF, which is not accurate. The NQF receives MIPPA and Affordable Care Act funding through a contract from HHS. In addition, regarding the first bullet point before the text box entitled ‘Working with NQF Helped Spur Rapid Evolution of Ophthalmology Measures,’ the Secretary clarifies that section 3014 of the Affordable Care Act amended section 1890(b) of the Social Security Act by adding paragraphs (7) and (8), which require NQF to convene multistakeholder groups to provide input on the selection of quality and efficiency measures and national priorities for improvement in population health and the delivery of healthcare services for consideration under the national strategy, and to transmit the multistakeholder group input to the Secretary. Sixth, the Secretary also wishes to note that section 3014 of the Affordable Care Act added additional items that must be included in the report that the consensus-based entity submits to Congress and the Secretary that are not included in the last bullet in the narrative prior to the next section, ‘2 PO 00000 Frm 00065 Fmt 4701 Sfmt 4703 56983 Bridging Consensus About Improvement Priorities and Approaches,’ of the Report to Congress. Section 3014 of the Affordable Care Act amended section 1890(b)(5)(A) of the Social Security Act to require that the report submitted to Congress and the Secretary identify gaps in endorsed quality and efficiency measures, including gaps in priority areas identified in the national strategy, instances where quality and efficiency measures are unavailable or inadequate to address such gaps, areas in which evidence is insufficient to support endorsement of quality and efficiency measures, including priority areas, as well as the input provided by multistakeholder groups on the selection of quality and efficiency measures and the national priorities. Finally, the Secretary wishes to clarify the first sentence in the second paragraph on page 1 of the Overview section of the NQF Report on Measure Gaps and Inadequacies. Section 3014 of the Affordable Care Act amended section 1890(b)(5)(A) of the Act to add additional topics to the items that must be described in the Report to Congress, but these amendments did not change the date by which the entity with a contract is required to submit the Report to Congress and the Secretary. That date is March 1 of each year (beginning in 2009), not February 1, 2012 and annually thereafter, as the addendum states. The Secretary is pleased with the progress and timeliness of the work outlined in the Annual Report. V. Future Steps HHS provided a four-year contract to NQF. During this performance year of the contract, NQF completed deliverables for each task required by section 183 in MIPPA and by section 3014 in Affordable Care Act. In the final year of the contract, HHS will continue to task NQF with projects than can be completed wholly or partially by the expiration of the current contract. In addition, HHS will develop a contract mechanism to support the Affordable Care Act-required work needed through FY2014. Maintenance of Consensus-Based Endorsed Measures During January 14, 2012 to January 13, 2013, NQF will maintain endorsed measures relevant to HHS-wide programs and will continue to maintain consensus-based endorsed measures as developed under the priority process. Maintenance of NQF-endorsed measures encompasses five areas: (1) Review of time-limited measure results, (2) annual updates, (3) endorsement maintenance E:\FR\FM\14SEN2.SGM 14SEN2 56984 Federal Register / Vol. 77, No. 179 / Friday, September 14, 2012 / Notices projects, (4) ad hoc reviews, and (5) education to measure developers on endorsement maintenance activities. In 2012, 42 time-limited endorsed measures are expected to undergo NQF review while 276 measures will require annual updates. Measures in these topical areas are undergoing endorsement maintenance: Cardiovascular, surgery, palliative/endof-life-care, renal, perinatal, cancer, and pulmonary/critical care measures. In addition, NQF will begin endorsement maintenance projects for the following four topics: Gastrointestinal/ genitourinary; infectious diseases; neurology; head, ears, eyes, nose and throat (HEENT). Finally, NQF is prepared to undertake ad hoc endorsement reviews as needed and will be hosting web-based educational events on its endorsement maintenance activities. srobinson on DSK4SPTVN1PROD with NOTICES2 Promotion of Electronic Health Records In 2012, NQF will continue to support the promotion of electronic health records as part of HHS-wide efforts. NQF’s contributions will include enhancements of the Quality Data Model, which specify the necessary data for electronic and personal health records. NQF will continue hosting and enhancing the Measure Authoring Tool, and will provide technical assistance and support to tool users. NQF will also maintain an online Knowledge Base of VerDate Mar<15>2010 17:12 Sep 13, 2012 Jkt 226001 information gleaned during the eMeasure retooling process of 2011, the subsequent comment and updating process, and the ongoing consulting activities that began in 2011. The Knowledge Base will be available on the NQF Web site for public use and updated at a minimum on a monthly basis to highlight new critical issues that are identified. The content of the Knowledge Base will support educational requirements for measure developers, measure implementers, EHR vendors, clinician, health care organizations, health information exchanges, and others as new stakeholders are identified. In addition, NQF will help HHS transition the Measure Authoring Tool to HHS for continued hosting and enhancements. Focused Measure Development, Harmonization, and Endorsement Efforts To Fill Critical Gaps in Performance Measurement In 2012, NQF will finish endorsement efforts focused on efficiency/resource use measures and regionalized emergency care services. In addition, NQF will perform an assessment of need among key stakeholders for a measure registry, a system capturing the lifecycle of a measure with capability to track versions of measures as they proceed through their lifecycle. Such a registry could assist measure developers and users to better identify measures in PO 00000 Frm 00066 Fmt 4701 Sfmt 9990 development, especially those identified as filling critical gaps, and how measures are similar and different version to version. General issues/ concerns regarding establishing, using, and maintaining a registry (e.g., intellectual property, data quality, incentives for use) will be explored specific to health care performance and cost measures. Convening Multi-Stakeholder Groups NQF will continue work to provide further input into the National Quality Strategy and annual selection of quality measures for use in public and private reporting programs and value-based purchasing programs. V. Collection of Information Requirements This document does not impose information collection and recordkeeping requirements. Consequently, it need not be reviewed by the Office of Management and Budget under the authority of the paperwork Reduction Act of 1995 (44 U.S.C. 35) Dated: August 27, 2012. Kathleen Sebelius, Secretary, Department of Health and Human Services. [FR Doc. 2012–22379 Filed 9–13–12; 8:45 am] BILLING CODE P E:\FR\FM\14SEN2.SGM 14SEN2

Agencies

[Federal Register Volume 77, Number 179 (Friday, September 14, 2012)]
[Notices]
[Pages 56919-56984]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2012-22379]



[[Page 56919]]

Vol. 77

Friday,

No. 179

September 14, 2012

Part II





 Department of Health and Human Services





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Secretarial Review and Publication of the Annual Report to Congress 
Submitted by the Contracted Consensus-Based Entity Regarding 
Performance Measurement; Notice

Federal Register / Vol. 77 , No. 179 / Friday, September 14, 2012 / 
Notices

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DEPARTMENT OF HEALTH AND HUMAN SERVICES


Secretarial Review and Publication of the Annual Report to 
Congress Submitted by the Contracted Consensus-Based Entity Regarding 
Performance Measurement

    AGENCY: Office of the Secretary of Health and Human Services, HHS.

ACTION: Notice.

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    SUMMARY: This notice acknowledges the Secretary of the Department 
of Health and Human Services' (HHS) receipt and review of the annual 
report submitted to the Secretary and Congress by the contracted 
consensus-based entity as mandated by section 1890(b)(5) of the Social 
Security Act, as added by section 183 of the Medicare Improvements for 
Patients and Providers Act of 2008 (MIPPA) and section 3014 of the 
Affordable Care Act of 2010. The statute requires the Secretary to 
publish the report in the Federal Register together with any comments 
of the Secretary on the report not later than six months after 
receiving the report. This notice fulfills those requirements.
    FOR FURTHER INFORMATION CONTACT: Stephanie Mika (202) 260-6366.

I. Background

    Rising health care costs coupled with the growing concern over the 
level and variation in quality and efficiency in the provision of 
health care raise important challenges for the United States. Section 
183 of MIPPA also required the Secretary of the Department of Health 
and Human Services (HHS) to contract with a consensus-based entity to 
perform various duties with respect to health care performance 
measurement. These activities support HHS's efforts to achieve value as 
a purchaser of high-quality, patient-centered, and financially 
sustainable health care. The statute mandates that the contract be 
competitively awarded for a period of four years and may be renewed 
under a subsequent competitive contracting process.
    In January, 2009, a competitive contract was awarded by HHS to the 
National Quality Forum (NQF) for a four-year period. The contract 
specified that NQF should conduct its business in an open and 
transparent manner, provide the opportunity for public comment and 
ensure that membership fees do not pose a barrier to participation in 
the scope of HHS's contract activities, if applicable.
    The HHS four-year contract with NQF includes the following major 
tasks:
    Formulation of a National Strategy and Priorities for Health Care 
Performance--NQF shall synthesize evidence and convene key stakeholders 
on the formulation of an integrated national strategy and priorities 
for health care performance measurement in all applicable settings. NQF 
shall give priority to measures that: Address the health care provided 
to patients with prevalent, high-cost chronic diseases; provide the 
greatest potential for improving quality, efficiency and patient-
centered health care and may be implemented rapidly due to existing 
evidence, standards of care or other reasons. NQF shall consider 
measures that assist consumers and patients in making informed health 
care decision; address health disparities across groups and areas; and 
address the continuum of care across multiple providers, practitioners 
and settings.
    Implementation of a Consensus Process for Endorsement of Health 
Care Quality Measures--NQF shall implement a consensus process for 
endorsement of standardized health care performance measures which 
shall consider whether measures are evidence-based, reliable, valid, 
verifiable, relevant to enhanced health outcomes, actionable at the 
caregiver level, feasible to collect and report, and responsive to 
variations in patient characteristics such as health status, language 
capabilities, race or ethnicity, and income level and is consistent 
across types of providers including hospitals and physicians.
    Maintenance of Consensus Endorsed Measures--NQF shall establish and 
implement a maintenance process to ensure that endorsed measures are 
updated (or retired if obsolete) as new evidence is developed.
    Promotion of Electronic Health Records--NQF shall promote the 
development and use of electronic health records that contain the 
functionality for automated collection, aggregation, and transmission 
of performance measurement information.
    Focused Measure Development, Harmonization and Endorsement Efforts 
to Fill Critical Gaps in Performance Measurement--NQF shall complete 
targeted tasks to support performance measurement development, 
harmonization, endorsement and/or gap analysis.
    Development of a Public Web site for Project Documents--NQF shall 
develop a public Web site to provide access to project documents and 
processes. The HHS contract work is found at: http://www.qualityforum.org/projects/ongoing/hhs/.
    Annual Report to Congress and the Secretary--Under section 
1890(b)(5)(A) of the Act, by not later than March 1 of each year 
(beginning with 2009, NQF shall submit to Congress and the Secretary of 
HHS an annual report. The report shall contain a description of the 
implementation of quality measurement initiatives under the Act and the 
coordination of such initiatives with quality initiatives implemented 
by other payers; a summary of activities and recommendations from the 
national strategy and priorities for health care performance 
measurement task; and a discussion of performance by NQF of the duties 
required under the HHS contract. Section 1890(b)(5)(B) of the Social 
Security Act requires the Secretarial review of the annual report to 
Congress upon receipt and the publication of the report in the Federal 
Register together with any Secretarial comments not later than 6 months 
after receiving the report.
    The first annual report covered the performance period of January 
14, 2009 to February 28, 2009 or the first six weeks post contract 
award. Given the short timeframe between award and the statutory 
requirement for the submission of the first annual report, this first 
report provided a brief summary of future plans. In March 2009, NQF 
submitted the first annual report to Congress and the Secretary of HHS. 
The Secretary published a notice in the Federal Register in compliance 
with the statutory mandate for review and publication of the annual 
report on September 10, 2009 (74 FR 46594).
    In March 2010, NQF submitted to Congress and the Secretary the 
second annual report covering the period of performance of March 1, 
2009 through February 28, 2010. The second annual report was published 
in the Federal Register on October 22, 2010 (75 FR 65340) to comply 
with the statutorily required Secretarial review and publication.
    In March 2011, NQF submitted the third annual report to Congress 
and Secretary of HHS. This notice complies with the statutory 
requirement for Secretarial review and publication of the third annual 
report covering the period of performance of January 14, 2010 through 
January 13, 2011. The third annual report was published in the Federal 
Register on September 7, 2011 (76 FR 55474).
    Affordable Care Act was signed into law on March 23, 2010. Section 
3014 of this Act included a time-sensitive requirement for NQF to 
provide input into the national priorities for consideration under for 
the National Strategy for Quality for Improvement in

[[Page 56921]]

Healthcare. The NQF convened the National Priorities Partnership and 
developed a consensus report on input to HHS on the development of the 
National Quality Strategy.
    Section 3014 of the Affordable Care Act also required NQF to: 
convene multi-stakeholder groups to provide input on the selection of 
quality measures, such as for use in reporting performance information 
to the public; and transmit multi-stakeholder input to the Secretary. 
It also amended the requirements for the Annual Report to include 
identifying gaps in quality measures, including measures in the 
priority areas identified by the Secretary under the national strategy 
and areas in which evidence is insufficient to support evidence of 
quality measures in priority areas. Activities required by the 
Affordable Care Act will be carried out from 2010 throughout 2014.
    In March 2012, NQF submitted its fourth annual report to the 
Congress and the Secretary. The report covers the period of performance 
of January 14, 2011 through January 13, 2012. This notice complies with 
the statutory requirement for Secretarial review and publication of the 
fourth NQF annual report.

II. March 2012--NQF Report to Congress and the HHS Secretary

    Submitted in March 2012, the fourth annual report to Congress and 
the Secretary spans the period of January 14, 2011 through January 13, 
2012.
    A copy of NQF's submission of the March 2012 annual report to 
Congress and the Secretary of HHS can be found at: http://www.qualityforum.org/Publications/2012/03/2012_NQF_Report_to_Congress.aspx.
    The 2012 NQF annual report is reproduced in section III of this 
notice. This year's annual report has two sections. The first is 
entitled 2012 NQF Report to Congress Changing Healthcare by the 
Numbers. The second section is entitled NQF Report on Measure Gaps and 
Inadequacies. Both sections were reviewed by the Secretary.

III. NQF March 2012 Annual Report

2012 NQF Report to Congress Changing Healthcare by the Numbers

Report to the Congress and the Secretary of the U.S. Department of 
Health and Human Services, Covering the Period of January 14, 2011, to 
January 13, 2012 Pursuant to Public Law 110-275 and Contract 
HHSM-500-2009-00010C

Contents

Letter From William Roper and Janet Corrigan
Executive Summary
    Building Consensus About What and How To Improve
    Endorsing Measures for Use in Accountability and Performance 
Improvement
    Aligning Payment and Public Reporting Programs That Reward Value
National Quality Forum: Background
Bridging Consensus About Improvement Priorities and Approaches
    National Priorities Partnership
    NQF's Focus on Safety
Endorsing Measures and Developing Related Tools
    NQF Endorsement in 2011
    Culling the NQF Portfolio
    Enhancing NQF Endorsement
    The Information Technology Accelerant
Aligning Accountability Programs To Enhance Value
    Growing Use of NQF-Endorsed Measures
    Measure Application and Alignment
Achieving Results
Looking Forward
Endnotes
Appendix A: 2011 Accomplishments: January 14, 2011 to January 13, 
2012
Appendix B: NQF Board and Leadership Staff
Appendix C: Overview of Consensus Development Process
Appendix D: Map Measure-Selection Criteria
Appendix E: NQF Membership
Appendix F: 2011 NQF Volunteer Leaders

Letter From William Roper and Janet Corrigan

    Over the last decade, Members of Congress from both parties, as 
well as federal and private-sector leaders, have increasingly supported 
the use of standardized quality measures as part and parcel of a larger 
healthcare value agenda. Agreed-upon strategies for improving value--
healthier individuals and communities, as well as better, lower-cost 
care--include public reporting of standardized performance measures and 
linking measures to payment.
    Evidence of support for this agenda includes the fact that 
approximately 85 percent of measures currently used in public programs 
are endorsed by the National Quality Forum (NQF),\1\ as well as the 
significant use of NQF-endorsed measures by private health plans and 
employers. In addition, recent statutes--the 2008 Medicare Improvements 
for Patients and Providers Act (MIPPA) and the 2010 Affordable Care Act 
(ACA)--reinforce preferential use of NQF-endorsed measures on federal 
healthcare Compare Web sites, and linkage of endorsed measures to 
payment for clinicians, hospitals, nursing homes, health plans, and 
other entities.
    In 2011, this commitment to a value agenda was significantly 
accelerated. Under the auspices of NQF, and in a historic first, 
private-sector organizations voluntarily worked in a more coordinated 
and collaborative fashion with each other and with the public sector to 
forge consensus about how to further this accountability environment. 
Specifically, innovations in convening and rulemaking facilitated the 
private sector bringing its real-world experience to inform guidance to 
the Department of Health and Human Services (HHS) on implementing the 
first-ever National Quality Strategy (NQS), and provided advice on 
selecting the best measures for use across an array of federal health 
programs. Forward-thinking leaders--including those on Capitol Hill and 
within HHS--understand that the public and private sectors working 
independently will not yield improvements quickly or comprehensively 
enough in our unorganized and complex healthcare system.
    We are grateful to Congress, HHS, and private-sector leaders for 
their vision and tenacity in designing and advancing this ambitious 
value agenda, and for the progress we collectively are making against 
it each and every day. These advancements are made possible because of 
the ever-expanding number of organizations and individuals who are 
committing themselves to work in partnership, including our colleagues 
at HHS; the more than 450 institutional members of NQF; the hundreds of 
experts who volunteer to serve on NQF committees; the NQF staff; and 
the many, many organizations that constitute the quality movement. We 
are privileged to work at the intersection of so many committed and 
diverse organizations that are increasingly rowing in the same 
direction to improve both our nation's health and healthcare for the 
benefit of the American public.
    We are changing healthcare by the numbers.

William L. Roper, MD, MPH

Chair, Board of Directors
National Quality Forum

Janet M. Corrigan, Ph.D., MBA

President and Chief Executive Officer
National Quality Forum

Executive Summary

    The U.S. healthcare system is among the most innovative in the 
world and patients with very serious and/or unusual conditions are 
particularly appreciative of the range of therapies, interventions, and 
clinical talent it offers to treat them and restore them to health. 
That said, it is also one of the most fragmented, unorganized, and 
uncoordinated systems as compared to its counterparts in the 
industrialized world--which contributes to less-than-

[[Page 56922]]

optimal quality outcomes, serious patient safety problems, and very 
high per-capita costs.2, 3, 4 Consequently, Members of 
Congress, business leaders from small and large companies, patients, 
physicians, nurses, and many others have come to the conclusion that 
Americans are not deriving enough value for the substantial dollars 
they spend.
    Important strides have been made toward improving this value 
proposition over the last decade, starting with the sine qua non of 
using standardized performance measures to assess ``how we are doing'' 
on an array of healthcare quality and cost dimensions, making the 
measure results public, and then linking those results to provider 
payment. And while establishing this accountability environment is 
critical foundational work, it is not sufficient for achieving the kind 
of substantial improvements that the National Quality Strategy (NQS) 
envisions. Released by the Department of Health and Human Services 
(HHS) in March 2011 and supported by public- and private-sector 
healthcare leaders, the NQS is built around three compelling aims 
focused on healthy people and communities, better care, and more 
affordable care. To achieve these ambitious aims also will take 
fundamental reform of care delivery and payment, which, while underway, 
will still require time, effort, and perseverance to realize.
    That said, the accountability environment's basic infrastructure is 
moving into place. A key lesson learned in constructing it is that 
neither the public nor private sectors, nor any single stakeholder, can 
meaningfully shape it on their own. Healthcare is too large and 
complex, with too many interrelated parts, for a go-it-alone strategy 
to be fully effective. Recent actions of healthcare leaders demonstrate 
that they understand that sustainable solutions to our nation's 
healthcare challenges are ones that all stakeholders embrace. Over the 
last year, significant progress has been made toward forging a shared 
sense of priorities for improvement; an agreed-upon way to set, 
continuously enhance, and implement strategies to achieve these 
priorities; and standardized methods for measuring progress along the 
way. Without such agreements, competing strategies and a plethora of 
near-identical measures run the risk of whipsawing providers and 
overburdening them with redundant and sometimes conflicting reporting 
requirements. In addition, such an environment can confuse consumers 
who increasingly seek to better inform themselves as they play a more 
active role in healthcare decision-making.
    Congress, wisely understanding this need for a quality 
infrastructure and more public-private collaboration, passed two 
statutes that included this notion, and directed HHS to work with a 
consensus-based entity to act as a key convener and measurement 
standard setter. These statutes include the 2008 Medicare Improvements 
for Patients and Providers Act (MIPPA) (Pub. L. 110-275) and the 2010 
Patient Protection and Affordable Care Act (ACA) (Pub. L. 111-148). HHS 
awarded contracts related to the consensus-based entity to the National 
Quality Forum (NQF).
    NQF has prepared this third Annual Report to Congress which covers 
highlights of work related to these statutes conducted under federal 
contract between January 14, 2011 and January 13, 2012. See appendix A 
for a complete listing of deliverables worked on and completed during 
the contract year.

Building Consensus About What and How To Improve

    In the fall of 2010, as HHS was developing the first-ever NQS, the 
National Priorities Partnership (NPP), convened by NQF, was asked to 
provide initial input on the overarching aims and priority areas and 
published a report. Subsequently, in response to a second request from 
HHS, NPP identified three goals for each of the NQS six priorities in a 
second report, along with appropriate performance measures, and 
``strategic opportunities'' to accelerate progress. These opportunities 
require leveraging the reach of the many public and private stakeholder 
groups participating in NPP, which balances the interests of consumers, 
purchasers, health plans, clinicians, providers, federal agency 
leaders, community alliances, states, quality organizations, and 
suppliers. In 2011, NPP focused further on enhancing patient safety, 
one of the six NQS priorities and a very important focus for HHS. More 
specifically, NPP worked collaboratively with HHS on its Partnership 
for Patients initiative, through hosting quarterly meetings and an 
interactive webinar series, which brought tools and ideas for reducing 
patient harm to nearly 10,000 front-line clinicians, hospitals, and 
other stakeholders across the country. Moving forward in 2012, NPP will 
draw on the real-world experience of its partners to develop 
implementation strategies, likely targeting patient safety in maternity 
care and readmissions.

Endorsing Measures for Use in Accountability and Performance 
Improvement

    NQF completed 11 endorsement projects during the course of the 
contract year--using both the NQS priorities that cross conditions and 
leading health conditions with respect to prevalence and cost as a way 
to prioritize its efforts. In total, NQF committees evaluated 353 
submitted measures and endorsed 170 new measures--or 48 percent of 
those submitted. While the number of measures endorsed is considerably 
higher than in previous years, the endorsement rate is lower due to the 
enhanced rigor of the review criteria. At the same time, NQF placed 
emphasis on reducing providers' reporting burden by harmonizing 
specifications related to similar measures.
    Currently, the portfolio of NQF-endorsed measures includes more 
than 700 measures, of which 30 percent assess patient outcomes and 
experience with care. Considerable progress also has been made in 
specifying measures for use with electronic health records. NQF worked 
with 18 measure developers to create eMeasure specifications for 113 
existing endorsed measures, and released an initial and updated Measure 
Authoring Tool (MAT). The re-tooled measures and MAT are innovations 
that enable the field to get substantially closer to having electronic 
health records with the capacity to capture and report performance 
information during routine care.

Aligning Payment and Public Reporting Programs That Reward Value

    A significant proportion--about 85 percent--of the measures used in 
federal programs are NQF-endorsed. Further, NQF-endorsed measures are 
used extensively by private health plans, state governments, and 
others. Such alignment can simultaneously reduce reporting burdens for 
providers and accelerate improvement because of the common signals that 
payers send. The NQF-convened Measure Applications Partnership (MAP), 
launched in the spring of 2011, fostered further alignment with its 
series of three performance measurement coordination strategy reports: 
Clinician Performance Measurement, Dual-Eligible Beneficiaries, and 
Healthcare-Acquired Conditions and Readmissions Across Public and 
Private Payers. As a part of these reports, MAP also developed a 
framework and criteria to guide the selection of the best measures for 
use in numerous payment and public reporting

[[Page 56923]]

programs. Building on these reports, MAP then provided pre-rulemaking 
guidance to HHS, including input on measure sets pertaining to 17 HHS 
programs, as well as strategies for enhancing consistency and 
minimizing reporting burden across federal programs and between public- 
and private-sector efforts. Leaders from nine different HHS agencies 
are actively participating in MAP.
    This advice from MAP--provided many months in advance of relevant 
rules--represents a true innovation in rulemaking, with the public and 
private sectors now having forums for substantive back-and-forth 
dialogue that cuts across program silos, and a unique opportunity to 
build a shared perspective and consensus about measure selection. 
Measures related to care coordination--essential to making care more 
patient centered--are an object lesson for what is possible with pre-
rulemaking convening and endorsement. More specifically, MAP 
recommended that an existing care transitions measure focused on 
hospitals also be used in other settings, and suggested a broadening of 
a readmission measure to include all ages and applicability to 
additional kinds of providers. MAP also advised the Center for Medicare 
& Medicaid Services (CMS) to require reporting of medication 
reconciliation measures at the time of transition between settings. As 
it turns out, NQF has already endorsed measures for medication 
reconciliation, readmission, and care transitions that apply to 
additional settings and populations so these measures can move right 
into other federal programs.
    Taken together, the reports are important stepping stones for MAP 
as the Partnership works on a comprehensive measurement strategy it 
will recommend to guide HHS measure selection for federal programs in 
the coming years. This strategy will be informed by the Partnership's 
in-depth understanding of current measures and their use in relevant 
programs, opportunities for potential coordination and integration, 
growing collaboration across the public and private sectors, and a 
vision for the future.
    Numbers are an essential guidepost for gauging healthcare 
performance, and measures may be a powerful motivator of change when 
paired with public reporting and payment. But alone, they cannot drive 
achievement of the value agenda. Rather, implementation of innovative 
measures needs to go hand-in-glove with fundamental redesign of 
delivery and payment systems to achieve the NQS' three, interconnected 
aims. And while local communities are changing the way care is 
organized and paid for to break down existing silos, facilitate 
integration and coordination of care, and connect healthcare to other 
sectors (e.g., employment, education), such innovations have not yet 
swept the country. When they do, and are coupled with accountability 
strategies embraced by the public and private sectors, we will be able 
to achieve our goals of healthier people and communities, and better, 
less-costly patient care. We will have then changed healthcare by 
design and by the numbers.

1 National Quality Forum: Background

    More than a decade after their publication, the Institute of 
Medicine's (IOM's) landmark Quality Chasm and To Err is Human reports 
still resonate: Our healthcare system continues to fall short on 
quality, safety, and affordability. That said, recent years have seen a 
re-energized commitment to improving care and constraining healthcare 
costs. HHS, NQF, and the increasing number of private-sector 
organizations that constitute the quality movement are at the center of 
that resurgence.
    Established in 1999 as the standard-setting organization for 
healthcare performance measures, NQF today has a much-broadened mission 
to:
     Build consensus on national priorities and goals for 
performance improvement, and work in partnership with the public and 
private sectors to achieve them.
     Endorse and maintain best-in-class standards for measuring 
and publicly reporting on healthcare performance quality.
     Promote the attainment of national goals and the use of 
standardized measures through education and outreach programs.
    NQF is governed by a 27-member Board of Directors (see Appendix B) 
from a diverse array of public- and private-sector organizations. A 
majority of seats on the board is held by consumers, employers, and 
other organizations that purchase healthcare services on consumers' 
behalf. In 2011, NQF convened hundreds of experts across every 
stakeholder group on its priority-setting, measure-review, and measure-
selection committees--individuals who volunteered their time, talents, 
experience, and insights (see Appendix F). NQF also directly reached 
some 10,000 frontline clinicians, hospitals, and others with 
educational programming via webinars. And its endorsed performance 
standards touched the care delivered to millions of patients every day.
    In recent years, the number and variety of NQF-endorsed measures 
has greatly expanded. More than 700 NQF-endorsed measures now address 
most settings of care, conditions, and types of providers. The measures 
portfolio includes clinical process measures, patient experience of 
care, the actual outcomes of care, the costs and resources that go into 
providing care, as well as select structural measures. The portfolio is 
being enhanced with advanced measures, such as functional outcome and 
crosscutting care-coordination measures. At the same time, the NQF 
portfolio is being carefully culled to retire measures that no longer 
meet the more rigorous criteria. In the last year alone, 353 measures 
were submitted to NQF and 170, or nearly half, were endorsed. This 
endorsement rate--or ratio of submitted-to-endorsed measures--reflects 
NQF's efforts to systematically raise the bar on performance 
measurement, even as it seeks to reduce the burden on providers by 
eliminating duplicative measures.
    To be NQF endorsed, a measure must be a process or outcome that is 
important to measure and report, be scientifically acceptable, be 
feasible to collect, and provide useful results. NQF conducts an eight-
step, consensus-based process that has been continually improved over a 
decade (see Appendix C). Review committees are comprised of multiple 
stakeholders; consumer organizations are equal partners with clinicians 
and other stakeholders throughout the process. There is a strong 
commitment to transparency and NQF invites public participation at 
every step, ranging from nominations for committees, to decisions on 
specific measures. Endorsed measures are re-evaluated every three years 
to ensure their actual use and usefulness in the field and their 
continuing relevance with current science, and to determine whether 
they continue to represent the best in class.
    Measures included in the NQF portfolio are developed and maintained 
by about 65 different organizations. The following gives a sense of the 
range of organizations NQF works with: CMS, the National Committee on 
Quality Assurance (NCQA), the American Medical Association-Physician 
Consortium for Performance Improvement (AMA PCPI), Ingenix, the Joint 
Commission, American College of Surgeons (ACS), Bridges to Excellence, 
Cleveland Clinic, Minnesota Community Measurement, and Pharmacy Quality 
Alliance.
    In recognition of its skill in building consensus across multiple 
stakeholders in the measure-endorsement realm, NQF

[[Page 56924]]

has been asked to convene diverse committees to advise the public and 
private sectors on priorities for improvement, related implementation 
strategies, and selection of measures to both drive these strategies 
and gauge results. The NQF-convened NPP and MAP and their published 
reports are tangible outcomes of this work. An equally important 
outcome of these partnerships is the ongoing alignment across 
stakeholder groups and across public- and private-sector leaders about 
what levers to use to both improve healthcare performance and move the 
delivery system to be more patient centered.
    NQF has been fortunate to have received support from the federal 
government for over 10 years, with more substantial support starting in 
2008 when federal leaders strongly committed themselves to designing 
and implementing a value agenda. More specifically:
     MIPPA has provided NQF with $10 million annually over a 
four-year period starting in 2009. These funds--awarded to NQF through 
a competitive process--are supporting the organization's efforts to 
identify priority areas for improvement, endorse and update related 
performance measures, foster the transition to an electronic 
environment, and report annually to Congress on the status and progress 
to date of this effort.
     ACA has provided NQF with support of about $10 million, 
starting in 2011. Under section 3014, Congress directed HHS to contract 
with ``the consensus-based entity under contract'' to provide multi-
stakeholder input into the NQS, as well as advice to the Secretary of 
HHS on the selection of measures for use in various quality programs 
that utilize the federal rulemaking process for measure selection. With 
federal leadership and support, as well as the support of foundations 
and over 450 NQF member organizations, much has been collectively 
accomplished since NQF's founding in 1999. With more substantial and 
predictable support from the federal government over the last three 
years, and an enhanced commitment on the part of the public and private 
sectors to work together, the basic infrastructure for performance 
measurement is moving into place and our ability to shape and further 
an environment of accountability has grown. NQF's accomplishments 
during 2011 will be described against that backdrop.
Sidebar 1--Working With NQF Helped Spur Rapid Evolution of 
Ophthalmology Measures
    There are many intangible benefits from the endorsement activities 
supported under the HHS contract. One of these is that it provides 
valuable input to measure developers which helps focus measure 
development resources on important gap areas. The efforts of the 
American Academy of Ophthalmology (AAO) are a case in point.
    As early as the 1980s, and before many other specialty societies, 
AAO developed ``preferred practice patterns'' to provide practice 
guidance for ophthalmologists. These guidelines proved to be a solid 
foundation to draw from when, in 2006, AAO began developing related 
quality measures for quality improvement feedback and public reporting 
purposes. Over the last five years, AAO has developed ever more 
sophisticated performance measures--evolving from process, to outcome, 
to functional status--and credits involvement with the NQF review 
process as an important catalyst in this evolution.
    More specifically:
     AAO--in collaboration with the AMA-PCPI--first worked to 
develop process measures focused on eye-care issues such as diabetic 
retinopathy (damage to the eye's retina as a result of long-term 
diabetes), and performance of optic nerve exams in primary open-angle 
glaucoma (chronic, progressive optic-nerve damage) patients.
     Recognizing that measures that evaluate actual results of 
care are more critical to improving quality, NQF encouraged AAO to 
shift its focus to developing clinical outcome measures. As a result, 
NQF later endorsed a measure focused on reducing glaucoma patients' eye 
pressure (which can lead to optic-nerve damage or blindness) by 15 
percent.
     More outcome measures were later developed and endorsed 
under the HHS-funded outcomes project, focusing on issues such as 
complications within 30 days following cataract surgery, as well as 20/
40 or better visual acuity within 90 days of cataract surgery.
     Recently, the NQF board has approved measures related to 
patient functional status, attempting to measure improvement in 
patients' visual functional status and their overall satisfaction 
within 90 days following cataract surgery. These measures are currently 
under NQF review, and have been included in the 2012 Physician Quality 
Reporting System (PQRS) measure set.
Dr. Flora Lum, executive director of AAO's H. Dunbar Hoskins Jr., MD 
Center for Quality Eye Care, noted that NQF's ability to bring patient 
and consumer perspectives to the Steering Committee responsible for 
evaluating measures has been invaluable over the years. AAO's efforts 
to advance healthcare quality continue, with the organization now 
striving to develop appropriateness-of-care measures.
    The evolution of AAO's measures over a short time period is 
noteworthy and the information that results from the measures provides 
physicians with multi-faceted feedback about the care they deliver. 
Ideally, such information is available in rapid-response reports, with 
educational interventions to help facilitate improvements at the 
practice level, and over time, so that ophthalmologists and patients 
can gauge progress. As AAO has gone on this journey to develop ever-
increasingly sophisticated and meaningful measures, NQF has been 
pleased to be a part of it. [End of Sidebar 1]
Sidebar 2--Resource-Use Measures: Critical to the Value Agenda
    U.S. healthcare per-capita spending is greater than that in any 
other country, yet it has not resulted in better health for Americans. 
With costs increasing beyond annual inflation, spending is largely 
focused on treating acute and chronic illnesses rather than prevention 
and health promotion.
    Deriving more value from health spending is predicated on having 
both quality and cost (or resource use) information. To date, limited 
information about resource use exists. CMS and many measure developers 
are working to change that, and in 2009, NQF was tasked with further 
defining resource-use measures and identifying important attributes to 
consider when evaluating them. NQF also endorsed its first-ever 
resource-use measures during the 2011 contract year.
    As defined by NQF, resource-use measures are comparable measures of 
actual dollars or standardized units of resources applied to the care 
given to a specific population or event--such as a specific diagnosis, 
procedure, or type of medical encounter. The endorsed measures:

 Relative Resource Use for People with Diabetes
 Relative Resource Use for People with Cardiovascular 
Conditions
 Total Resource Use Population-Based Per-Member Per-Month 
(PMPM) Index
 Total Cost of Care Population-Based PMPM Index


[[Page 56925]]


``The endorsement of standardized measures of healthcare resource use 
and cost fills a huge void that has kept the nation from measuring the 
value of healthcare in a consistent way,'' said Steering Committee 
member Dolores Yanagihara, director, pay for performance, at the 
Integrated Healthcare Association. ``That said, it is a complex 
process, both technically and from an accountability standpoint. The 
measures recommended for endorsement give us a broader picture of 
healthcare--overall and related to specific conditions.'' [End of 
Sidebar 2]

2 Bridging Consensus About Improvement Priorities and Approaches

    Released by HHS in March 2011, the country's NQS focuses the public 
and private sectors on an inspiring set of three, interconnected aims--
better care, more affordable care, and healthier people and 
communities--as well as six related priority areas (see Figure 1). 
While the field has long targeted improving clinical care, the NQS 
gives significant, equal heft to the notion of health/wellbeing and 
affordability.
[GRAPHIC] [TIFF OMITTED] TN14SE12.000

    The NQS provides a critical framework for the efforts of the 
multiple-stakeholder committees convened by NQF. These efforts range 
from discussions at the highest, most conceptual levels about a three-
to-five-year measurement strategy to undergird the evolving value 
agenda; to committees working in a new measurement area and developing 
consensus about what and how to measure; to those simultaneously 
enhancing and culling a set of measures in an established area, while 
considering their larger context within the NQF-endorsed measurement 
portfolio.

National Priorities Partnership

    Development of the landmark NQS was informed by the collective 
input of the NQF-convened National Priorities Partnership (NPP), a 
collaboration of 51 public- and private-sector organizations uniquely 
qualified to represent the array of stakeholders needed to improve the 
nation's healthcare system. As the NQS was being formulated, HHS sought 
multi-stakeholder input from NPP on its aims and priorities. After 
publication of the NQS in March 2011, HHS again reached out to NQF to 
convene NPP to provide input on further specifying goals, measures, and 
implementation pathways to move the national strategy and related 
priorities forward, drawing upon the real-world experience of its 
stakeholder participants.
    The NPP recommendations are captured in a follow-up report to the 
HHS Secretary, Priorities for the National Quality Strategy, published 
in September 2011. This second report identifies goals and measure 
concepts that address the three NQS aims and six priorities 
simultaneously. For example, there are suggestions for goals and 
measurement areas related to care coordination that cut across clinical 
conditions. This would encourage better, more integrated care delivery, 
enhanced health outcomes, and fewer wasted resources. The NPP report 
also acknowledges that successful implementation of NQS-related goals 
and measures are predicated on strategic and technical measure 
alignment--or agreement--across various levels of accountability in our 
healthcare system. This starts at the most granular level--the patient 
and physician--and moves in a linked chain across a family of measures 
and levels of increasing aggregation. Without agreement about strategic 
direction and concordance on measure selection, a predictable cacophony 
results, frustrating clinicians and confusing consumers. The 
cholesterol-control example (Figure 2) provides an illustration of a 
family of measures with linkages across levels and illustrates this 
crucial strategy of alignment. Further, these NQF-endorsed measures are 
included in HHS's newly launched and broad-based Million

[[Page 56926]]

Hearts Campaign--a public-private initiative that aims to prevent one 
million heart attacks and strokes in five years.
    In addition to NPP's consultative role as it relates to the NQS, 
NPP has served as a catalyst in developing implementation strategies--
working across diverse stakeholder groups to spur collective action--
focused on improving patient safety and reducing patient harm. Such a 
focus also can reduce costs, with the IOM estimating that decreasing 
healthcare-associated infections (HAIs), complications, and unnecessary 
readmissions by 10 to 20 percent could result in $2.4 billion to $4.9 
billion annual savings for the U.S. healthcare system.\5\
[GRAPHIC] [TIFF OMITTED] TN14SE12.001

NQF's Focus on Safety

    In 2011, NQF's work in the safety realm spanned updating of 
measures and serious reportable events (SREs), a recommended approach 
for further aligning public- and private-sector patient-safety 
measurement strategies, and development of implementation strategies in 
support of HHS's Partnership for Patients Initiative.
    Partnership for Patients is engaging stakeholders from the private 
and public sectors to reduce all-cause harm (i.e., all forms of harm 
that can affect patients) and hospital readmissions. More specifically, 
NPP partnered with the Partnership for Patients to host 11 webinars 
that attracted about 10,000 frontline clinicians, hospitals, and others 
across the country and provided education, tools, resources, and 
insight on key safety issues. These webinars ranged from big-picture 
interventions (e.g., how to get your Board on board when it comes to 
improving patient safety), to those with a more laser focus on clinical 
teams (e.g., reducing surgical-site infections [SSIs]). Nearly 90 
percent of webinar participants, who came from every region of the 
country, reported that they would be able to implement something new in 
their institutions as a result of this novel public-private 
programming. Moving forward in 2012, NPP is developing two action 
pathways, which its multiple partners can implement and spread. These 
pathways are focused on the health of mothers and babies by reducing 
elective deliveries before 39 weeks, and reducing avoidable admissions 
and re-admissions across all settings of care. These represent 2 of the 
10 areas Partnership for Patients is pursuing to achieve its global 
safety and harm-reduction goals. Reaching these goals also will 
substantially reduce costs.
    In addition, MAP released a report, Coordination Strategy for 
Healthcare-Acquired Conditions and Readmissions Across Public and 
Private Payers, in October 2011, detailing the ways in which public and 
private healthcare providers can align performance measurement to 
enhance patient safety. Specifically, the report makes three 
recommendations: (1) There needs to be a national set of core safety 
measures applicable to all patients; (2) Data need to be collected on 
all patients to inform these national core safety measures; and (3) 
Public and private entities need to coordinate their efforts to make 
care safer. MAP's recent pre-rulemaking report further emphasizes the 
importance of safety measures by supporting their inclusion in federal 
public reporting and performance-based payment programs, and MAP will 
focus on alignment of core safety measures across programs in 2012. 
With respect to measure review, NQF endorsed numerous patient-safety 
measures, including healthcare-associated infections (HAIs), which now 
address long-term, acute-care and rehabilitation hospitals, and 
radiation-safety measures, to name a few.
    NQF also updated its list of SREs, a compilation of serious, 
harmful, and largely--if not entirely--preventable patient-safety 
events, designed to help the healthcare field assess, measure, and 
report performance in providing safe care. In the 2011 update, the 
events were broadened in focus to explicitly include hospitals, office-
based practices, ambulatory surgery centers, and skilled nursing 
facilities to reflect the various settings in which patients receive 
care and could experience harm. Based on input from users, the 
implementation guidance for each event was expanded, and a glossary was 
added to facilitate

[[Page 56927]]

uniformity in reporting of the events. The list includes wrong-site 
surgery; death or serious injury associated with medication errors or 
unsafe blood products; and failure to follow up on lab, pathology, or 
radiology test results. Public and private purchasers have drawn 
heavily from the SRE list in identifying healthcare-associated 
conditions for use in payment and reporting programs. (See Sidebar 3.)
Sidebar 3--NQF and Patient Safety
Patient-Safety Measures
    NQF's inventory of endorsed measures includes more than 100 
patient-safety measures, with several focused specifically on 
healthcare-associated infections or HAIs. Preventing HAIs has become a 
national priority for public health and patient safety. To date, 27 
states are requiring public reporting of certain HAIs. Further, the NQS 
has identified safer care as one of its primary aims and, in 2013, 
hospitals' annual Medicare payment updates will be tied to submission 
of infection data, including central line-associated bloodstream 
infections and surgical-site infections (SSIs).
    In this past year, NQF endorsed four additional patient-safety 
measures focused on HAIs, including a successfully harmonized measure 
from the American College of Surgeons and the Centers for Disease 
Control and Prevention focused on SSIs, and updates of existing HAIs 
addressing urinary tract infections and bloodstream infections. These 
efforts were completed under federal contract.

Serious Reportable Events

    Preventing adverse events in healthcare is also central to NQF's 
patient-safety efforts. To ensure that all patients are protected from 
injury while receiving care, NQF has developed and endorsed a set of 
serious reportable events (SREs). This set is a compilation of serious, 
harmful, and largely--if not entirely preventable--patient safety 
events, designed to help the healthcare field assess, measure, and 
report performance in providing safe care. The SREs focus on the 
following areas:

 Surgical or invasive-procedure events
 Product or device events
 Patient-protection events
 Care-management events
 Environmental events
 Radiologic events
 Potential criminal events

    Originally envisioned as a set of events that would form the basis 
for a national state-based reporting system, the SREs continue to serve 
that purpose. To date, 26 states and the District of Columbia have 
enacted reporting systems to help stakeholders identify and learn from 
SREs. The majority of those states incorporate at least some portion of 
NQF's list to help align reporting efforts and encourage learning 
across healthcare systems. [End of Sidebar 3]
    Finally, NQF launched a project in 2011 that will leverage health 
IT data to address patient safety and quality concerns associated with 
medical devices, such as pumps used to deliver intravenous medications 
at home. This project, which continues in 2012, will determine what 
data needs to be collected and shared to improve quality and safety 
related to devices. It also will focus on ways to identify and report 
adverse events associated with the use of such devices.

3 Endorsing Measures and Developing Related Tools

    With its extensive evaluation (see Sidebar 4) and multi-stakeholder 
input, NQF is recognized as a voluntary consensus standards-setting 
organization under the National Technology Transfer and Advancement Act 
of 1995. In addition, NQF adheres to the Office of Management and 
Budget's formal definition of consensus.\6\ Consequently, NQF-endorsed 
measures have special legal standing allowing federal agencies to 
readily adopt them into their programs, which they have done at a 
striking rate. About 85 percent of measures in federal health programs 
are currently NQF-endorsed, including those that apply to hospitals, 
clinicians, nursing homes, patient-centered medical homes, and many 
other settings.
    In 2011, NQF completed 11 endorsement projects--reviewing 353 
submitted measures and endorsing 170, or 48 percent. Enhancements to 
the endorsement process over the last year included strengthening its 
rigor by requiring testing of measures prior to measure review, 
initiation of a project to reduce endorsement cycle time, integration 
of review of existing measures with new measures to ensure 
harmonization and best-in-class assessment, and creation of an 
expedited review process to respond to important regulatory or 
legislative requests. In addition, NQF worked with 18 measure 
developers to update 113 electronic measures, or eMeasures, so they 
could be more readily collected through EHRs, and introduced and 
updated tools to respectively facilitate development and collection of 
eMeasures.
Sidebar 4--What does it take for a measure to get endorsed?
    With the enhanced rigor of NQF's endorsement criteria, only about 
50 percent of submitted measures were endorsed this past year.
    The leading reason that measures do not pass the grade is failure 
to meet the ``must pass'' importance-to-measure-and-report criterion. 
This includes being able to demonstrate that the proposed measure or 
related data is focused on a high-impact health goal or priority; there 
is less-than-optimal performance; and there is strong scientific 
evidence for the measure, with respect to quality, quantity, and 
consistency. NQF expert committees rate the evidence based on specific 
guidance.
    The second ``must pass'' criterion is scientific acceptability of 
measure properties. In other words, do the data from testing the 
measure show that it is reliable and valid and precisely specified? 
Expert committees look for moderate-to-high ratings so they are 
confident the measure results are reliably consistent and can be 
compared across providers and analyzed longitudinally. Other important 
criteria include usability and feasibility--assessing whether intended 
audiences can understand the results and find them helpful for 
decision-making and quality improvement. The criteria also consider 
whether providers can collect data without undue burden. See Appendix C 
for more detail. [End of Sidebar 4]

NQF Endorsement in 2011

    The overall framework used to guide the NQF measures portfolio is 
multi-dimensional. It includes the NQS crosscutting priorities, as well 
as leading health conditions with respect to prevalence and cost that 
affect an array of populations. Figure 3 provides a snapshot of how the 
current NQF-endorsed measures portfolio stacks up against the NQS, with 
the percentages reflecting the proportion of NQF-endorsed measures 
against the six priorities. Some measures are counted in multiple 
priority areas. The chart shows gaps in emerging measurement areas, 
including patient-family centered care, measures related to community 
health and wellbeing, and affordability. These gaps require significant 
foundational work to understand what to focus on for measurement and 
how to best overcome technical barriers. NQF has undertaken this 
foundational work over the last year, and has started to bring in 
measures in all of these areas for endorsement review.

[[Page 56928]]

[GRAPHIC] [TIFF OMITTED] TN14SE12.002

    The 170 measures newly endorsed by NQF in 2011 include many outcome 
measures; measures that focus on populations previously under-
represented, including pregnant women and children; a number of 
patient-safety measures--given the importance of reducing patient harm; 
measures in new areas that fill important gaps, such as cost (resource 
use); as well as the updating of measures related to highly prevalent 
conditions, (e.g., cardiac and surgical care). More specifically:

Outcome Measures

    NQF has made great strides over the past year to endorse measures 
that evaluate results of care, particularly in the patient-safety, 
nursing-home, and surgical-care areas. Outcome measures are considered 
most relevant to patients and providers looking for improved quality 
and patient experience, as opposed to measures that assess process or 
structure. Examples of outcome measures endorsed in 2011 include 
potentially avoidable complications for select conditions (i.e., 
stroke, pneumonia), remission of symptoms in patients with depression, 
and patient experience in nursing homes and dialysis facilities.

Patient-Safety Measures

    Long a focus of NQF, these new patient-safety measures span 
settings and types of conditions. They include measures focused on HAIs 
(urinary tract, central-line-associated bloodstream, and SSIs), and 
measures focused on issues such as standardized data collection and 
reporting of radiation doses.

Maternal and Child-Health Measures

    These populations have been underrepresented in performance 
measurement. NQF has worked to fill these gaps through two endorsement 
projects over the past year--child health, and perinatal and 
reproductive health. Child-health measures focus on important 
screenings and access to care, including immunizations, hearing 
assessments, and well-child visits. Other measures address population 
health outcomes, including the number of school days missed due to 
illness and birth outcomes. Proposed perinatal measures (this project 
is still underway) address procedures such as cesarean sections and 
elective delivery prior to 39 weeks.

New and Existing Measurement Areas

    NQF reviewed measures related to resource use, both those related 
to conditions (e.g., diabetes and cardiovascular disease), and those 
related more to global resource use. Endorsement projects in 2011 also 
focused on reviewing existing measurement areas for high-prevalence 
conditions or areas (palliative care and end-of-life care, 
cardiovascular disease and kidney disease), adding new measures, and 
retiring others as the expert committees saw fit. More specifically, 
NQF endorsed or maintained measures focused on optimal vascular care, 
complications or death for specific surgical procedures, and assessment 
of post-dialysis weight by nephrologists for kidney disease patients. 
Although NQF has made considerable progress in endorsing outcome 
measures--which constitute about 30 percent of the portfolio--
differences exist with respect to outcome and process measures across 
conditions, which is illustrated in Figure 4. For example, there are 
more outcome measures for surgery and perinatal care than for mental 
health and cancer care. Also, HAIs are reflected under surgery, not 
infectious disease.

[[Page 56929]]

    When NQF begins to address a new measurement area, the relevant 
expert committee will often start by developing a framework report to 
guide its future measurement review. These reports may include a scan 
of existing measures, a discussion about where there are key 
opportunities for improvement, and consideration of potential technical 
barriers. For example, NQF is developing a population health-
measurement framework aimed at aligning delivery system, public health, 
and community stakeholder efforts to improve health outcomes and the 
social determinants of health. Historically, there has been little 
coordination across these sectors. NQF is also developing a patient-
centric measurement framework for assessing the efficiency of care 
provided to individuals with multiple chronic conditions. This report 
will inform NQF's future efforts to endorse measures that apply 
respectively to population health and care for people who have more 
than one chronic condition.
[GRAPHIC] [TIFF OMITTED] TN14SE12.003

Culling the NQF Portfolio

    A key part of NQF's review process is focusing on endorsing best-
in-class measures and eliminating similar or even identical measures 
that create confusion and burden across clinical settings and 
providers. This alignment of very similar measures--or measure 
harmonization--can reduce reporting burden for providers and enhance 
comparability of results for patients and payers, thereby reducing 
confusion and enabling decision-making. The harmonization of the 
surgical site infection measures from the Centers for Disease Control 
and Prevention and the ACS is a case in point (see Sidebar 5). Further, 
NQF's maintenance process retires existing measures that no longer meet 
the higher endorsement bar, thereby further culling the portfolio.
Sidebar 5--Harmonizing Surgical-Site Infection Measures
    As part of NQF's federally funded Patient-Safety Measures project, 
similar and competing surgical-site infection (SSI) measures from the 
Centers for Disease Control and Prevention (CDC) and the American 
College of Surgeons (ACS) were reviewed. The CDC SSI measure has been 
in use since 2005; the ACS measure since 2004.
    As a result of NQF member and public comments, and requests by the 
Steering Committee, the developers worked with NQF support to harmonize 
these two competing approaches to measurement. The result is a newly 
harmonized SSI measure, which is currently focused on abdominal 
hysterectomies and colon surgeries. CDC and ACS will jointly maintain 
the measure. The two organizations have also committed to developing 
harmonized measures for other procedures and will incorporate them into 
the combined SSI measure.
    Notably, CMS has selected this harmonized measure for inclusion in 
the 2012 final rule of the Inpatient Prospective Payment System (IPPS).
    Dr. Clifford Ko, director of ACS's National Surgical Quality 
Improvement Program, was directly involved in this effort. Dr. Ko noted 
that the resulting measure--Harmonized Procedure-Specific Surgical-Site 
Infection Outcome Measure--will now be available to literally thousands 
of hospitals that want to measure and improve their surgical-site 
infection rates.
    Dr. Daniel Pollock, surveillance branch chief in CDC's Division of 
Healthcare Quality Promotion, says CMS' decision to include this 
measure will significantly increase SSI reporting rates in hospitals 
throughout the country. With increased reporting, providers will have 
more opportunities to identify areas for improvement. In addition, 
patients and payers will have SSI rate information when they are 
choosing between hospitals in a community.
    While both Drs. Ko and Clifford noted that some characteristics of 
the original measures may be diminished or lost,

[[Page 56930]]

they agreed that harmonized measures help eliminate the confusion non-
comparable measures create and that, ultimately, providers, payers, and 
the public benefit. [End of Sidebar 5]
    The recent Cardiovascular Project illustrates how NQF expert 
committees now consider new measures against existing endorsed 
measures. Using the measure evaluation criteria and guidance on 
evaluating related and competing measures, the Cardiovascular Committee 
reviewed proposed new measures and those undergoing maintenance, 
focusing on measures that address the broadest patient population or 
settings, while avoiding duplication whenever possible. Based on this 
rigorous vetting, 39 out of 65 measures (7 new and 32 undergoing 
maintenance) were endorsed (see Figure 5). When all is said and done, 
between 2010 and 2011 this represents approximately 13 percent fewer 
NQF-endorsed cardiovascular measures in this project.
[GRAPHIC] [TIFF OMITTED] TN14SE12.004

Enhancing NQF Endorsement

    As NQF's measures portfolio evolves, so too does its endorsement 
process. In 2011, NQF enhanced the rigor of its process by requiring 
that measures be tested before they are reviewed. This requirement now 
ensures that expert committees have crucial information about measure 
reliability and validity as they consider endorsement. In addition, NQF 
also established an approach that added greater consistency to review 
of the underlying evidence for measures, and created an expedited 
endorsement pathway to be responsive to key regulatory or legislative 
requests. Finally, NQF embarked upon a number of efforts to enhance 
effectiveness of the review process, including a lean effort to further 
reduce endorsement cycle time. This effort, which got underway in late 
2011, maps each of the steps of the endorsement process to drive out 
redundancy, waste, and ultimately costs for measure developers, NQF, 
and HHS.

The Information Technology Accelerant

    A future healthcare system that fully embraces health information 
technology (HIT) will allow for performance data to be collected in 
real time across settings, integrated, and regularly fed back to 
providers to inform practice and decision-making. It also will allow 
performance information to be made accessible in aggregated, de-
identified, and timely public reports for payers and patients. Recent 
federal efforts--to simultaneously wire ambulatory practices and 
hospitals and assess providers' ``meaningful use'' of electronic health 
records (EHRs)--have been important steps on the path to a future HIT-
enabled system.
    Such milestones have been augmented by a number of NQF efforts that 
are helping the field move to a common electronic data platform that 
allows for the collection of more clinically relevant and actionable 
performance-measurement data. These HIT-enabled environments hold out 
the promise of reducing reporting burden for clinicians and other 
providers, and enhancing the precision and comparability of results.
    In the past year, NQF has worked with measure developers to re-
specify paper-based measures for EHRs, and developed tools that allow 
measure developers to marshal the building blocks necessary for their 
successful implementation. In both cases, these efforts broke new 
ground. To the best of NQF's knowledge, they have never been 
attempted--or accomplished--before. More specifically:

E-Measures

    In 2010, at the request of HHS, NQF worked with 18 measure 
developers to re-tool 113 existing, endorsed measures for the 
electronic environment--that is,

[[Page 56931]]

to develop electronic specifications that allow an EHR to calculate the 
measure--so they could be included in the Meaningful Use program. These 
eMeasures were further updated and enhanced in 2011. The measure 
stewards and NQF found that re-tooling measures for a new (electronic) 
platform was not a simple, straightforward matter; rather it involved 
the stewards re-conceptualizing each of the measures, with the support 
of NQF.

Quality Data Model (QDM)

    This information model provides measure developers with a first-
ever ``grammar,'' which defines data elements. These data elements can 
then be efficiently assembled and re-assembled into performance 
measures to be read by EHRs. Work on the QDM began in 2007, with 
funding from the Agency for Healthcare Research and Quality (AHRQ). In 
2011, the third version of the QDM was released, which includes data 
elements to enable development of measures in gap areas, including 
patient/consumer engagement and disparities, as well as new methods of 
data capture and use. In summary, this effort makes a substantial 
contribution toward being able to more readily leverage existing 
electronic health-record data to produce clinically relevant, advanced 
measures.

Measure Authoring Tool (MAT)

    This non-proprietary, web-based tool makes it easier and more 
efficient for measure developers to specify, submit, and maintain 
electronic measures, or eMeasures. Introduced in 2011, there are now 
more than 35 organizations using this tool for eMeasure development.
    Work that began in 2011 and carries over into 2012 includes a 
project focused on sharing data across settings, convening a forum for 
stakeholders to share best practices related to implementation of 
eMeasures, and a project that will leverage health IT data to address 
patient safety and quality concerns associated with medical devices, 
which was described previously. More specifically, with respect to the 
first two projects:

HIT Systems To Support Care Coordination Measurement: Data Sources and 
Readiness

    This project is analyzing the current process for identifying and 
sharing data on significant patient factors, planned interventions, and 
expected outcomes (care goals) to support quality measurement related 
to transitions of care. It will recommend a critical path forward with 
specific action steps that the government can take to enable electronic 
measurement around care plans.

E-Measure Collaborative

    The eMeasure Collaborative, a public forum convened by NQF, is 
bringing together stakeholders from across the quality enterprise. The 
eMeasure Collaborative's goal is to promote shared learning and advance 
knowledge and best practices related to the development and 
implementation of eMeasures.

4 Aligning Accountability Programs To Enhance Value

    At the request of HHS, NQF commissioned RAND Health to conduct an 
initial evaluation to better understand who is using NQF-endorsed 
measures and for what purposes. The RAND studies--coupled with NQF's 
own internal tracking efforts to understand measure use--have helped to 
provide some important context for HHS, NQF, and the NQF-convened MAP 
discussions.

Growing Use of NQF-Endorsed Measures

    RAND interviews of key stakeholders using NQF-endorsed measures and 
online research across approximately 75 varied organizations found that 
nearly all used NQF-endorsed measures, although the extent varied as 
did the particular measures selected for use. Further, the study showed 
that most organizations used endorsed measures in quality-improvement 
efforts, followed closely by public reporting, then payment programs. 
The 2011 study also found that there is a strong preference to use NQF-
endorsed measures where they exist because they are vetted, evidence-
based, and seen as more credible within the provider community
    NQF's additional research outside of the HHS contract indicates 
that about 90 percent of the portfolio of NQF-endorsed measures is 
being used in varied programs across the public and private sectors. 
Figure 6 is an estimation of the use of NQF-endorsed measures by: 
federal programs; private payers such as health plans and employers; 
states; and an amalgamation of other key stakeholders such as national 
registries, accrediting and specialty board certifying organizations, 
and community alliances. The gold-colored, hatched, and dotted areas on 
the chart represent alignment in use of the same measures by key 
sectors--specifically the overlap between private payers (health plans 
and employers) and federal programs, and the overlap between state and 
federal efforts. Alignment holds out the promise of reducing data-
collection burden for providers and associated costs, while 
simultaneously accelerating improvement by sending the same message 
about where providers should be focusing improvement resources.

[[Page 56932]]

[GRAPHIC] [TIFF OMITTED] TN14SE12.005

    Overall use of NQF-endorsed measures by the federal government is 
high--about 85 percent of measures used in federal programs are NQF-
endorsed. Yet the proportion of NQF-endorsed measures in use by various 
federal programs does differ. Sometimes it is a matter of timing. For 
example, the federal government has recently moved some non-endorsed 
measures into the Physician Quality Reporting System (PQRS) to better 
address the range of physician specialties. NQF is poised to quickly 
review such measures.
    States also are heavy users of NQF-endorsed measures, in part due 
to federal programs that encourage or require standardized reporting at 
the state level, such as AHRQ's Health Care Utilization Project (HCUP), 
CDC measures and surveys, CHIPRA, and Medicaid. For example, 81 percent 
of CHIPRA measures and 88 percent of core adult Medicaid measures are 
NQF-endorsed. In the safety realm, more than half of states and the 
District of Columbia have implemented reporting systems for SREs, as 
well as reporting of key patient-safety indicators such as bloodstream 
and SSI measures.
Sidebar 7--AF4Q: Alignment at the Community Level
    At the community level it is more challenging to get a 
comprehensive picture of use of NQF-endorsed measures. That said, 
leading multi-stakeholder alliances in communities across the country 
use NQF-endorsed measures, including the Robert Wood Johnson 
Foundation's Aligning Forces for Quality (AF4Q) alliances. To support 
community interest in aligning the measures they are using, a recent 
analysis conducted by NQF outside of the HHS contract has shown that at 
least 170 NQF-endorsed measures are being used in one or more of the 16 
AF4Q alliances. In addition, NQF endorsed measures are being used by 
many of the Chartered Value Exchange (CVE) collaboratives, the 
federally-funded Beacon communities, other communities and a number of 
states. Given that there is no national requirement to use standardized 
measures at this level, communities/states have shown leadership in 
adopting such measures into their local programs.

[[Page 56933]]

[GRAPHIC] [TIFF OMITTED] TN14SE12.006

    The Robert Wood Johnson Foundation's Aligning Forces for Quality 
initiative seeks to increase the quality of healthcare and reduce 
racial and ethnic disparities in 16 diverse communities--with the 
involvement and collaborative efforts of physicians, patients, consumer 
groups, hospitals, health plans, and others.
    The U.S. Agency for Healthcare Research and Quality (AHRQ) supports 
24 Learning Network Chartered Value Exchanges. The CVEs are 
experimenting with new ways to bring healthcare stakeholders together 
to collect data and improve the quality of care.
    The federal Beacon Community Cooperative Agreement program provides 
17 communities with funding to improve quality, cost-efficiency, and 
population health using electronic health records and other health 
information technology tools to collect and analyze clinical data. The 
program's goal is to demonstrate the ability of health IT to transform 
local healthcare systems.

i Geographic reach of these efforts varies, e.g., state-wide, county-
specific [End of Sidebar 7]

Measure Application and Alignment

    Convened by NQF in the spring of 2011, the Measure Applications 
Partnership (MAP) is a public-private partnership made up of 60 
organizations representing major stakeholder groups, 9 federal 
agencies, and 40 subject-matter experts. It was established to provide 
HHS with thoughtful, pre-rulemaking input about which performance 
measures to use in public reporting and payment within and across 17 
federal programs. Simultaneously, MAP is informing the thinking and 
decisions of private-sector leaders with respect to their measure-
selection strategies.
Federal Agencies Participating in Map
 Agency for Healthcare Research and Quality
 Centers for Disease Control and Prevention
 Centers for Medicare & Medicaid Services
 Health and Human Services' Office on Disability
 Health Resources and Services Administration
 Office of the National Coordinator for Health Information 
Technology
 Office of Personnel Management
 Substance Abuse and Mental Health Services Administration
 Veterans Health Administration

    MAP represents an important innovation in the regulatory process 
made possible by ACA statute. In contrast to traditional federal 
rulemaking--where there are limited, unidirectional forums for input 
before draft rules are issued and no forums that cross programmatic 
areas--MAP enables public- and private-sector leaders to work together 
on creating a measurement strategy and implementation plan that is 
crosscutting and coordinated across settings of care; federal, state, 
and private programs; levels of measurement analysis; payer type; and 
points in time. This is not an overnight prospect, but important, 
unprecedented steps in the direction of strategic alignment were taken.
    In 2011, MAP consisted of four programmatic-oriented workgroups--
clinician, hospital, LTC/PAC, and dual-eligible beneficiaries--and an 
ad-hoc safety workgroup, each of which makes recommendations to the MAP 
Coordinating Committee. This independent committee then integrates and 
aligns these recommendations across the four programmatic areas--which 
represent 17 different federal programs--and advises HHS directly. (See 
Sidebar 8)
Sidebar 8--Measure Applications Partnership Workgroup Leadership
MAP Coordinating Committee Co-Chairs
George Isham, MD, MS, Chief Health Officer, Health Partners
Elizabeth McGlynn, Ph.D., MPP, Director Center of Effectiveness and

[[Page 56934]]

Safety Research (CESR), Kaiser Permanente
MAP Advisory Workgroups
    Ad-Hoc Safety Workgroup:

Frank G. Opelka, MD FACS, Chair, Vice Chancellor for Clinical Affairs 
and Professor of Surgery, Louisiana State University

    Clinician Workgroup:

Mark McClellan, MD, Ph.D., Chair, Director, Engelberg Center for Health 
Care Reform, Senior Fellow, Economic Studies, Brookings Institution, 
Leonard D. Schaeffer Chair in Health Policy Studies

    Dual-Eligible Beneficiaries Workgroup:

Alice R. Lind, MPH, BSN, Chair, Senior Clinical Officer, Center for 
Health Care Strategies

    Hospital Workgroup:

Frank G. Opelka, MD FACS, Chair, Vice Chancellor for Clinical Affairs 
and Professor of Surgery, Louisiana State University

    Post-Acute/Long-Term Care (PAC/LTC) Workgroup:

Carol Raphael, MPA, Chair, President and Chief Executive Officer, 
Visiting Nurse Service of New York [End of Sidebar 8]

    In the fall of 2011, and in advance of future measure-selection 
recommendations, MAP issued reports offering advice to HHS about how 
the agency might better coordinate its measure strategies as it relates 
to efforts focused on improving safety and clinician performance. Its 
reports include MAP Coordination Strategy for Clinician Performance 
Measurement and MAP Coordination Strategy for Healthcare-Acquired 
Conditions and Readmissions Across Public and Private Payers. In 2011, 
MAP also released the first of two reports focusing on dual-eligible 
beneficiaries who are enrolled in both Medicare and Medicaid programs: 
MAP Strategic Approach to Performance Measurement for Dual-Eligible 
Beneficiaries. Despite many of these individuals being the sickest and 
poorest patients enrolled in any federal program, not to mention among 
the most expensive, there has been little effort to date to use 
measurement as a tool to improve their care. For more detail about 
NQF's efforts to address vulnerable populations, see sidebar 6.
Sidebar 6--NQF Focuses on Vulnerable Populations
    Vulnerable populations--from the disabled, to veterans, to special 
needs kids, to low-income individuals and racial/ethnic minorities, 
among others--often require a different and frequently higher level of 
care. Over the past year, NQF has taken on two major projects with a 
prime focus on such vulnerable individuals--The Measure Applications 
Partnership (MAP) Strategic Report: Performance Measurement for Dual 
Eligible Beneficiaries Interim Report to HHS, and measurement work 
focused on disparities in healthcare.
    The interim MAP report provides multi-stakeholder input on 
performance measures to assess and improve the quality of care 
delivered to individuals who are eligible for both Medicare and 
Medicaid (dual-eligible). An estimated 8.9 million individuals are 
classified as dual-eligible, a population that includes many of the 
poorest and sickest individuals in our communities. This particular 
population frequently experiences fragmented care and accounts for a 
disproportionate share of total healthcare costs.
    In its initial phase of work, MAP has developed a strategic 
approach to performance measurement and identified opportunities to 
promote significant improvement in the quality of care provided to 
these vulnerable populations. The core of the strategic approach is 
composed of:
    A vision for high-quality care. Centered on the needs and 
preferences of an individual and his or her loved ones, this relies on 
holistic supports to maximize function and quality of life.
    Guiding principles. These include desired effects, measurement 
design, and data.
    A discussion of high-need subgroups. MAP deliberations suggested 
that there is not yet an established taxonomy for classifying subgroups 
of the dual-eligible population. MAP members observed that combinations 
of particular risk factors lead to high levels of need in an additive 
or synergistic manner.
    High-leverage opportunities for improvement through measurement. 
MAP reached consensus on five areas where measurement could drive 
significant positive change, including quality of life, care 
coordination, screening and assessment, mental health and substance 
use, and structural measures of coordination between Medicare and 
Medicaid benefits.
    In addition to the four primary elements, MAP also considered 
issues related to data sources and program alignment as inputs to the 
strategic approach. MAP will next consider gaps in currently available 
measures and may propose new measure concepts for development. A final 
report with MAP's input on improving the quality of care delivered to 
dual-eligible beneficiaries, including recommendations related to 
measures, is due to HHS on June 1, 2012.
    NQF's healthcare disparities measurement efforts are multi-faceted. 
For example, measure developers are required to submit measure results 
stratified by race and ethnicity at the time of measure evaluation. NQF 
has also worked to endorse measures that address vulnerable 
populations, including measures used for the Children's Health 
Insurance and Reauthorization Act (CHIPRA) and Medicaid, as well as 
measures that fulfill important needs for vulnerable populations, 
including frail elders, pregnant women, children, and those who suffer 
from mental illness. With respect to already endorsed measures, NQF is 
working to identify measures across all settings that should be 
routinely stratified by race and ethnicity in order to identify 
conditions and populations that require targeted improvement efforts to 
improve quality and eliminate disparities. [End of Sidebar 6]
    MAP's initial pre-rulemaking report published on February 1, 2012, 
and based on the consensus of 60 organizations:
     Recommends that 40 percent of the measures CMS was 
considering move into federal programs targeting clinicians, hospitals, 
dual-eligible beneficiaries, and PAC/LTC settings via rules issued in 
2012, with another 15 percent targeted for future consideration after 
further development, testing, and feasibility issues are worked out. 
MAP did not support inclusion of about 45 percent of other measures 
proposed by CMS. CMS submitted a large number of measures and measure 
concepts to get early, detailed feedback about them from key 
stakeholders. Consequently, many of the measures submitted did not have 
enough information to guide MAP measure evaluation and selection. See 
Appendix D for the criteria MAP used to guide measure selection.
     Expresses clear preference for use of NQF-endorsed 
measures and feedback loops Nearly 87 percent of measures MAP supported 
for inclusion are currently endorsed by NQF, and many more are likely 
eligible for expedited review. That said, assessing the qualitative and 
quantitative impact of NQF-endorsed measures in the field would provide 
new and important information for future MAP analyses and decision-
making.
     Considers how to further align measures across programs 
and with the private sector with the goal of more targeted, 
interrelated sets of measures that are reported by different kinds of 
providers, in different settings and

[[Page 56935]]

sectors, and across time. A good example is care-coordination measures 
contained within existing programs--care transitions, readmissions, and 
medication reconciliation--which MAP recommends be applied to 
additional kinds of providers, types of settings, and, consequently, to 
span and be integrated across federal programs. See Figure 7 to get a 
more detailed sense for MAP's crosscutting recommendations for care 
coordination.
     Lays out guiding principles for a future three-to-five-
year measurement strategy that supports movement towards a healthcare 
system that enhances value for patients, communities, and those that 
pay the bills on their behalf. In this future 21st century system, 
priority is placed on measures that drive the system toward meeting the 
NQS; measurement is person- rather than clinician- or setting-focused; 
and measures span settings, time, and types of clinicians. Person-
centered measurement provides information about what matters to 
patients (e.g., ``Will I be able to run after I recover from knee 
surgery?'') and measures that are specific to patient populations or 
care over time, (e.g., ``Did I get the care and support needed to 
manage my diabetes so that I did not lose my vision or my mobility?''). 
This kind of measurement is predicated on a redesigned delivery and 
payment system, and an HIT-enabled environment that facilitates both 
coordination and integration of care for a range of patients across the 
continuum.

                          Figure 7--Aligning Care Coordination Measures Across Programs
----------------------------------------------------------------------------------------------------------------
                                                                                          Post-acute care/long-
                                              Clinician                 Hospital                term care
----------------------------------------------------------------------------------------------------------------
Care Transitions.....................  Support CTM-3 (NQF       Support immediate        Support CTM-3 if
                                        0228) if        inclusion of CTM-3       successfully
                                        successfully             measure and urge for     developed, tested, and
                                        developed, tested, and   it to be included in     endorsed in PAC-LTC
                                        endorsed at the          the existing HCAHPS      settings.
                                        clinician level.         survey.
                                                                Support several          Identify specific
                                                                 discharge planning       measure for further
                                                                 measures (i.e., NQF      exploration for its
                                                                 0338, 0557,     use in PAC-LTC
                                                                 0558).                   settings (i.e., NQF
                                                                                          0326, 0647).
Readmissions.........................  Readmission measures     Support the inclusion    Identify avoidable
                                        are a priority measure   of both a readmission    admissions/
                                        gap and serve as a       measure that crosses     readmissions (both
                                        proxy for care           conditions and           hospital and ER) as
                                        coordination.            readmission measures     priority measure gaps.
                                                                 that are condition-
                                                                 specific.
Medication Reconciliation............  Support inclusion of     Recognize the            Identify potential
                                        measures that can be     importance of            measures for further
                                        utilized in a health     medication               exploration for its
                                        IT environment           reconciliation upon      use across all PAC-LTC
                                        including medication     both admission and       settings (i.e., NQF
                                        reconciliation measure   discharge,               0097).
                                        (NQF 0097).     particularly with the
                                                                 dual eligible
                                                                 beneficiaries and
                                                                 psychiatric
                                                                 populations.
----------------------------------------------------------------------------------------------------------------

    The MAP proposed guiding principles support the direction of many 
public- and private-sector leaders who are innovating to move the 
nation's care delivery system towards more organization and shared 
accountability for patient welfare, community health, and stewardship 
of scarce resources. Where appropriate, they are encouraging 
transitioning from solo-physician practices to actual and virtual 
patient-centered medical homes, from stand-alone hospitals to those 
working collaboratively with an array of providers in an integrated 
delivery system or Accountable Care Organization (ACOs), and from 
single-specialty to multi-specialty physician groups working more 
closely with public health oriented organizations. Figure 8 details 
some key principles to guide measure selection, measurement tactics, 
the providers the measures are focused on, and the related federal 
programs.
    Implementation of more advanced measures will be possible once care 
is more organized and integrated, payment crosses settings and 
providers, and HIT infrastructure is widely in place. Advanced measures 
could include how well patient care is coordinated between primary and 
specialty care and across specialists; whether patients are free of 
pain and can return to work, school, and other daily obligations; the 
degree to which patient preferences are incorporated into care 
decisions; and whether recommended care was appropriate in the first 
place and delivered cost effectively. Progress is being made as it 
relates to the development and implementation of such advanced 
measures, but is predicated on more integrated payment and delivery 
systems, as well as robust, common electronic data platforms.

[[Page 56936]]

[GRAPHIC] [TIFF OMITTED] TN14SE12.007

Achieving Results

    Those working to improve performance of the healthcare system are 
impatient for results, which take time to demonstrate and are 
influenced by many factors beyond measurement. Nevertheless, there are 
promising examples, particularly for hospitals and health plans that 
have been collecting, reporting, and acting on performance measures for 
a number of years. The case studies included in this section of the 
report were selected to provide illustrative examples of different 
kinds of programs and providers using NQF-endorsed measures (although 
they are efforts conducted outside of the federal contracts.) Taken 
together, and reflecting upon NQF's accomplishments over the last year, 
the case studies provide a clear sense that there is forward momentum, 
as well as a growing commitment on the part of healthcare leaders to 
enhance healthcare value for patients, communities, and payers.

Eight Years of Hospital Reporting Show Results

    In 2002, three hospital industry associations demonstrated 
leadership by joining with HHS, The Joint Commission, consumer 
organizations, and other stakeholders to create a more unified approach 
to reporting hospital performance information to the public. They 
launched the Hospital Quality Initiative--later re-named the Hospital 
Quality Alliance (HQA)--and defined its role as:
     Identifying measures for reporting that are meaningful, 
relevant and understood by consumers;
     Rallying hospitals to participate in the initiative and 
act on the performance results; and
     Aligning stakeholders to reduce redundant and wasteful 
data collection and reporting.
    From the beginning, HQA recommended NQF-endorsed measures because 
of the organization's transparent, rigorous multi-stakeholder consensus 
process and strong evidence-based approach to endorsement.
    In 2003, performance results for over 400 hospitals were reported 
on the CMS Web site for the first time. A year later, CMS began 
penalizing hospitals financially if they did not report to CMS the same 
performance information they were required to send to The Joint 
Commission to maintain hospital accreditation. Between 2003 and 2004, 
the number of hospitals reporting their results to CMS tripled--from 
over 400 to more than 1,400 hospitals. In 2005, CMS launched Hospital 
Compare. Today, over 4,000 hospitals simultaneously report performance 
data to CMS and The Joint Commission, and the number of measures 
collected has steadily increased. In 2012, The Joint Commission will 
incorporate hospital performance into its accreditation determinations 
for the first time.
    Performance results improved steadily over the last eight years. A 
recent analysis of hospitals shows marked improvement based on NQF-
endorsed measures between 2002 and 2009.\7\ More specifically, in 2002, 
about 20 percent of hospitals exceeded 90 percent performance on 22 key 
measures; by 2009 that percentage had climbed significantly to 86 
percent. Key NQF-endorsed measures include measures related to heart 
attack and heart failure care, surgical care, children's asthma care, 
and pneumonia care, among others.
    This tight alignment between HQA, CMS and The Joint Commission 
regarding use and reporting of NQF-endorsed measures is a likely 
contributor to hospitals improving their performance over time. At the 
end of 2011, HQA decided to close its doors--noting that it had 
accomplished what it had set out to do: establishing a unified approach 
to collection and public reporting of hospital performance information. 
HQA also acknowledged that recommendations for measure selection going 
forward would be best left to the NQF-convened MAP, which is 
constituted to look across all federal

[[Page 56937]]

programs to foster alignment and a clear strategic direction for 
measurement use.

Linking Quality Measurement to Payment Reform

Blue Cross Blue Shield Massachusetts' Alternative Quality Contract
    In January 2009, Blue Cross Blue Shield of Massachusetts (BCBS) 
piloted the Alternative Quality Contract, a pay-for-performance model 
directly linking payment to meeting quality and cost benchmarks. The 
private-payer program provides financial bonuses to participating 
provider organizations such as multispecialty groups, independent 
practice associations, and physician-hospital organizations that stay 
within a specified annual budget and meet clinical quality targets. The 
budget takes into account the entire spectrum of care, ranging from 
inpatient and outpatient services to long-term care and prescription 
drug costs.
    Performance was evaluated on the quality of care delivered in 
several clinical settings based on NQF-endorsed measures. More 
specifically:
    Seven participating clinical groups were eligible for bonus 
payments as high as five percent based on 32 NQF-endorsed ambulatory 
and office-based quality measures. Measures included and focused on 
conditions and procedures such as diabetes testing and controlled LDL-C 
levels; breast, cervical, and colorectal cancer screenings; and patient 
experience with accessing and understanding care options.
    Providers were eligible for another five percent bonus payment 
based on 32 NQF-endorsed hospital-based measures. These measures 
focused on surgical site and wound infections, in-hospital mortality 
rates, and patient satisfaction communicating with doctors and nurses.
    Initial performance evaluations showed that across the board, 
provider groups delivered care within the scope of their budgets and 
performed well on clinical quality measures, allowing them to receive 
financial rewards of up to 10 percent of the total per-member per-month 
payments.\8\
    The results illustrate that programs like the Alternative Quality 
Contract can offer providers strong incentives to control healthcare 
spending across the continuum while continuing to provide high-quality 
care. This idea is in line with recent policy proposals to design 
payment systems that reward high-quality, efficient, and integrated 
care.

National Priorities Focus North Carolina Hospitals

    The North Carolina Center for Hospital Quality and Patient Safety 
(NCQC) was established by the North Carolina Hospital Association 
(NCHA) in 2004. The two organizations worked in partnership to conduct 
quality improvement collaborative projects across the state for about 
four years, but progress had grown stagnant. With North Carolina 
ranking as only the 35th healthiest state, NCQC's director embraced the 
NPP's 2008 National Priorities and Goals report recommendations as a 
way to focus, spur action, and benchmark North Carolina hospitals 
against national goals. Subsequent NPP reports have built on this first 
report.
    The NCQC targeted much of its initial efforts on patient safety, 
made sure that frontline staff understood how their actions related to 
the hospital-wide improvement goals, and focused on both culture change 
and building up quality improvement skills. The Central Line-Associated 
Bloodstream Infection (CLABSI) Collaborative, which involved 40 ICUs, 
was particularly successful. Using a separate intervention program that 
sought to learn from mistakes and improve safety, the CLABSI 
Collaborative achieved a 46 percent reduction in central-line 
infections over the 18-month time period. These results translated into 
saving approximately 18 lives (using a 15 percent fatality rate) and 
saving $4.5 million (using $40,000 as the extra cost to a hospital for 
a CLABSI) across 40 hospitals.\9\
    It is important to note that although many individual hospitals had 
success, not all hospitals in North Carolina participated, and the 
state rate of CLABSIs did not decrease as much as NCQC had hoped. To 
address this, NCQC launched a Phase 2 of the initiative to continue its 
focus on reducing central-line infections, using the NQF-endorsed 
CLABSIs measure as a way to guide progress and benchmark themselves 
nationally. The NCQC has stated that it is too early to tell if 
alignment with the NPP priorities will enable it to meet its own 
performance goals, but does acknowledge measureable and exciting 
progress against benchmarks it set.

Performance of Thoracic Surgeons Published in Consumer Reports

    More than two decades ago, The Society of Thoracic Surgeons (STS) 
launched the Adult Cardiac Surgery Database to track and improve 
surgical quality. It is the largest cardiothoracic surgery outcomes and 
quality improvement program in the world, containing more than 4.5 
million surgical records and representing approximately 94 percent of 
all adult cardiac surgery centers throughout the U.S.
    Twenty plus years after the launch of its database, STS made the 
bold decision to offer participating surgical groups the option of 
voluntarily reporting their performance data in Consumer Reports. More 
specifically, Consumer Reports began publicly reporting heart surgery 
ratings at the surgical group level starting in 2010--including 
survival rates, complication rates, and other key NQF-endorsed 
measures. These ratings are now available on a bi-yearly basis.
    A variety of factors influenced STS's decision to begin publicly 
reporting surgical performance, including the organization's vast 
experience with collecting and analyzing performance measures; a desire 
to leverage public reporting to further accelerate improvements in 
thoracic surgeon performance; and wanting to exhibit leadership in an 
environment of enhanced accountability.
    Doris Peter, manager, Consumer Reports' Health Ratings Center, 
notes that reaction to the reports has been very positive from cardiac 
surgery groups and consumers alike. Peter noted that the first time 
STS's data was published in Consumer Reports, there were 20 million web 
impressions on the ratings. Consumer Reports' readership is 8 million. 
Due to this success, the subsequent September 2011 release made the 
cover of Consumer Reports print edition. To date, 36 percent of STS 
surgery groups are participating in the Consumer Reports ratings, a 65 
percent increase from the first release.

Looking Forward

    A dozen years in existence, NQF has been able to make particularly 
strong strides in the last three years with the support of federal 
funding stemming from MIPPA and ACA, building very much upon the strong 
collaborative relationship that has been established between NQF, its 
hundreds of private sector partners, and HHS. At a high level, results 
over these three years include:
     The ability of NQF to now set and implement a multi-year 
plan for measure endorsement that is cognizant of addressing gaps and 
focused on implementing a vision for where advanced measurement is 
heading in a 21st century healthcare system. Over the three years, NQF 
endorsed 184 measures under the federal contracts, and completed 
maintenance of 136

[[Page 56938]]

previously endorsed measures. Currently, there are 233 measures under 
maintenance review, another 157 measures undergoing updates to 
specifications, and 43 measures having testing results reviewed. These 
efforts involved approximately 65 measure developers and hundreds of 
experts who volunteered their time on review committees. In addition, 
NQF has developed tools that allow measure developers to more readily 
create and implement eMeasures so that providers can collect more 
meaningful and actionable clinical data that is both comparable for 
public reporting and valid for payment purposes.
     Broad recognition that NQF is an effective and trusted 
convener of public- and private-sector leaders--reflected in the 
organization's multi-stakeholder membership, established processes for 
achieving consensus, and its commitment to scientific evidence and 
transparency. This recognition has translated into requests that NQF-
convened committees advise HHS on the first-ever NQS and related 
measurement strategy, as well as detailed measure-selection 
recommendations. NQF deliverables to HHS have been in the form of 
reports. Less perceptible perhaps is the growing consensus between 
scores of public- and private-sector leaders about how to collaborate 
to improve performance, which is translating into alignment around 
quality-improvement priorities and measure use.
    Looking ahead, NQF and the broader quality movement are at an 
exciting juncture. A robust measurement infrastructure is moving into 
place, and increasingly there is a shared commitment about what to 
improve and what measures to use in the process of doing so. Over the 
next couple of years, NQF will be:
     Putting the patient first by facilitating efforts that 
move the field toward a focus on patient-oriented as opposed to 
clinician-oriented measurement. Implementation of patient reported 
measures--including those that address experience of care, functional 
status, patient reported outcomes and care coordination--can help put 
the patient at the center of care.
     Helping drive waste out of the system by focusing on 
bringing more cost/resource use measures through NQF endorsement and 
understanding in more detail how existing NQF endorsed quality/safety 
measures--including readmission, medication reconciliation and care 
coordination measures--can contribute to a more cost-efficient system.
     Facilitating a future measurement vision by supporting 
efforts of the NPP and MAP Partnerships to develop a 3-5 year 
comprehensive measurement strategy--with broad and strong backing from 
multiple stakeholders--to recommend to HHS. The intent is that this 
strategy will cross settings and levels of care, as well as types of 
clinicians, and will in essence drive a strategic plan for payers that 
moves the needle with respect to the NQS's six priorities.
     Bringing the public and private sectors closer together by 
further strengthening collaboration and deepening their commitment to 
the value agenda, further aligning their respective measurement 
strategies to reduce redundant data collection, and dramatically 
accelerate improvements in performance of the U.S. healthcare system.
    In the coming years, the country should be in the position of 
realizing many benefits from these efforts to change healthcare by the 
numbers.

Endnotes

1 Federal use of NQF-endorsed measures is based on an initial 
analysis by NQF during the Fall of 2011.
2 The Commonwealth Fund, Why Not the Best: Results from the National 
Scorecard on U.S. Health System Performance, 2008, New York, 
NY:Commonwealth Fund, 2008. Available at www.commonwealthfund.org/
Publications/Fund-Reports/2008/Jul/Why-Not_the_Best_Results-from-
the-National-Scorecard-on-U-S_Health-System-Performance_2008.aspx. 
Last accessed February 2012.
3 Bodenheimer T, High and rising health care costs. Part 1: seeking 
an explanation, Ann Intern Med,2005;142(10):847-854.
4 Bodenheimer T, Fernandez A, High and rising health care costs. 
Part 4: can costs be controlled while preserving quality? Ann Intern 
Med,2005;143(1): 26-31.
5 Institute of Medicine (IOM), Roundtable on Value & Science-Driven 
Health Care--The Healthcare Imperative: Lowering Costs and Improving 
Outcomes: Workshop Series Summary, Washington, DC: National 
Academies Press; 2010. Available at www.iom.edu/Activities/Quality/VSRT.aspx. Last accessed January 2012.
6 The White House, U.S. Office of Management and Budget (OMB). 
Circular No. A-119, February 10, 1998, Washington, DC:OMB; 1998. 
Available at www.whitehouse.gov/omb/circulars_a119/. Last accessed 
January 2012.
7 Chassin MR, Loeb JM, Schmaltz SP et al., Accountability measures--
using measurement to promote quality improvement, New Engl J Med, 
2010;363(7):683-688. Available at www.nejm.org/doi/full/10.1056/NEJMsb1002320. Last accessed February 2012.
8 Song Z. Safran DG, Landon BE et al., Health care spending and 
quality in year 1 of the Alternative Quality Contract, New Engl J 
Med, 2011;365(10):909-918. Available at www.nejm.org/doi/full/10.1056/NEJMsa1101416. Last accessed February 2012.
9 National Quality Forum (NQF), Evaluation of the National 
Priorities Partnership, Washington, DC:NQF, 2011. Available at 
www.qualityforum.org/SettingPriorities/EvaluationoftheNational_Priorities_Partnership.aspx. Last accessed February 2012.

Appendix A: 2011 Accomplishments: January 14, 2011 to January 13, 2012

----------------------------------------------------------------------------------------------------------------
                                                                   Status  (as of 1/13/     Notes/scheduled or
            Description                         Output                      12)           actual completion date
----------------------------------------------------------------------------------------------------------------
                             I. Priorities, Principles, and Coordination Strategies
----------------------------------------------------------------------------------------------------------------
Provision of input on priorities     Input to the Secretary of    Completed.............  September 1, 2011.
 for the NQS.                         Health and Human Services
                                      on Priorities for the
                                      National Quality Strategy;
                                      final written report of
                                      Partnership and
                                      Subcommittee meeting
                                      deliberations and
                                      recommendations.
MAP report recommending measures     Measure Applications         Completed.............  October 1, 2011.
 for use in the improvement of        Partnership Coordination
 physician performance.               Strategy for Clinician
                                      Performance Measurement;
                                      final report including MAP
                                      Coordinating Committee
                                      recommendations.

[[Page 56939]]

 
MAP report recommending measures     Measure Applications         Completed.............  October 1, 2011.
 that address the quality issues      Partnership Strategic
 identified for dual-eligible         Approach to Performance
 beneficiaries.                       Measurement for Dual-
                                      Eligible Beneficiaries;
                                      interim report including
                                      MAP Coordinating Committee
                                      recommendations.
MAP report recommending measures to  Measure Applications         Completed.............  October 1, 2011.
 be used by private and public        Partnership Coordination
 payers to reduce readmissions and    Strategy for Healthcare-
 healthcare-acquired conditions       Acquired Conditions and
 (HACs).                              Readmissions Across Public
                                      and Private Payers; final
                                      report including
                                      recommendations regarding
                                      the optimal approach for
                                      coordinating readmission
                                      and HAC measures.
Measures for use in quality          Measure Applications         In progress...........  Completed February
 reporting programs under Medicare.   Partnership Pre-Rulemaking                           2012 after close of
                                      Report: Input on Measures                            reporting year.
                                      Under Consideration by HHS
                                      for 2012 Rulemaking.
MAP report recommending measures     Final report including       In progress...........  June 1, 2012.
 that address the quality issues      potential new performance
 identified for dual-eligible         measures to fill gaps in
 beneficiaries.                       measurement for dual-
                                      eligible beneficiaries.
----------------------------------------------------------------------------------------------------------------
                                             II. Measure Endorsement
----------------------------------------------------------------------------------------------------------------
Cardiovascular measures and          Two-phase project to         Completed.............  39 measures endorsed
 maintenance review.                  endorse new cardiovascular                           in January 2012.
                                      measures and conduct
                                      maintenance on existing
                                      NQF-endorsed measures.
Emergency regionalization medical    Environmental scan and       Completed.............  Framework endorsed in
 care measurement framework.          white paper comparing how                            January 2012.
                                      regions coordinate and
                                      perform on delivering
                                      emergency services.
Patient safety: SREs...............  Reviewed existing list of    Completed.............  Updated list of 29
                                      NQF SREs for hospitals to                            SREs endorsed in May
                                      identify ones appropriate                            2011.
                                      for other settings;
                                      considered potential new
                                      SREs for all settings.
Patient outcomes measures..........  Three-phase project          Completed.............  38 measures endorsed:
                                      endorsing measures                                  --30 measures endorsed
                                      specific to outcomes on                              in January and March
                                      Medicare high-impact                                 2011.
                                      conditions, child health,                           --8 measures endorsed
                                      and mental health.                                   during previous
                                                                                           contract year
                                                                                           (September 2010).
Patient-safety measures............  Two-phase project endorsed   Completed.............  Phase 1: 4 measures
                                      new measures of patient                              endorsed in January
                                      safety (e.g., healthcare-                            2012.
                                      associated infections,                              Phase 2: 2 measures
                                      medication safety) and                               endorsed in August
                                      maintaining currently                                and September 2011.
                                      endorsed measures.
Nursing-home measures..............  Endorsed measures of         Completed.............  5 measures endorsed in
                                      nursing-home care quality.                           February 2011.
Child-health measures..............  Endorsed measures specific   Completed.............  44 measures endorsed
                                      to the care of children.                             in September 2011.
Surgery measures and maintenance     Two-phase project to         Phase 1 complete;       Phase 1: 18 measures
 review.                              endorse new surgery          Phase 2 in progress.    endorsed in December
                                      measures and conduct                                 2011.
                                      maintenance on existing                             NQF Board endorsed
                                      NQF-endorsed measures.                               Phase 2 measures
                                                                                           after the close of
                                                                                           the contract year.
                                                                                          Phase 2 addendum
                                                                                           report issued for
                                                                                           public comment just
                                                                                           after contract year
                                                                                           closed.
Efficiency and resource-use          Endorsed measures of         Completed.............  Imaging Efficiency
 measures.                            imaging efficiency; white   In progress; completed   (Complete)
                                      paper drafted; endorsed      just after contract    --6 imaging efficiency
                                      measures of healthcare       year.                   measures endorsed in
                                      efficiency.                                          February 2011.
                                                                                          --1 imaging efficiency
                                                                                           measure was
                                                                                           recommended to be
                                                                                           combined with an
                                                                                           existing NQF measure
                                                                                           and was endorsed in
                                                                                           April 2011.
                                                                                          Efficiency--Resource
                                                                                           Use (In Progress).
                                                                                          Cycle 1: 4 measures
                                                                                           ratified by Board
                                                                                           January 2012.

[[Page 56940]]

 
                                                                                          Cycle 2: 4 measures
                                                                                           posted for public
                                                                                           comment in December
                                                                                           2011; voting closed
                                                                                           in February 2012.
Cancer measures and maintenance      Project to endorse new       In progress...........  Call for nominations
 review.                              cancer measures and                                  completed in November
                                      conduct maintenance on                               2011; call-for-
                                      existing NQF-endorsed                                measures deadline was
                                      measures.                                            January 2012.
Perinatal measures and maintenance   Project to endorse new       In progress...........  Steering Committee
 review.                              perinatal measures and                               reviewed 23 measures
                                      conduct maintenance on                               in December 2011.
                                      existing NQF-endorsed
                                      measures.
Renal measures and maintenance       Project to endorse new       In progress...........  Steering Committee
 review.                              renal measures and conduct                           reviewed 33 measures
                                      maintenance on existing                              by December 2011;
                                      NQF-endorsed measures.                               member and public
                                                                                           commenting to
                                                                                           conclude after close
                                                                                           of reporting year.
Pulmonary/critical-care measures     Project to endorse new       In progress...........  Call for nominations
 and maintenance review.              pulmonary/critical-care                              closed in December
                                      measures, and conduct                                2011.
                                      maintenance on existing                             Call-for-measures
                                      NQF-endorsed measures.                               deadline was January
                                                                                           2012.
Palliative and end-of-life care....  Project to endorse new       In progress...........  NQF Board endorsed
                                      palliative and end-of-life                           measures after close
                                      care measures and conduct                            of reporting year.
                                      maintenance on existing
                                      NQF-endorsed measures.
Care-coordination measures and       Set of endorsed care-        In progress...........  Call for measures
 maintenance review.                  coordination measures.                               closed January 9,
                                                                                           2012.
Population Health Phase 1:           Set of endorsed measures     In progress...........  Member and public
 Prevention measures and              for preventative services.                           commenting period
 maintenance measures review.                                                              concluded February
                                                                                           2012.
Population health Phase 2:           Commissioned paper           In progress...........  Draft paper completed
 Population health measures.          addressing population                                January 2012 after
                                      health measurement issues                            close of reporting
                                      and set of endorsed                                  year.
                                      population health measures.
Behavioral health measures and       Set of endorsed measures     In progress...........  Call for nominations
 maintenance review.                  for behavioral health.                               closed December 13,
                                                                                           2011.
                                                                                          Call for measures
                                                                                           closed February 14,
                                                                                           2012.
All-cause readmissions (expedited    Set of endorsed all-cause    In progress...........  Member and public
 Consensus Development Process        readmission measures.                                commenting concluded
 [CDP] review).                                                                            January 2012.
Multiple Chronic Conditions          Work plan completed;         In progress...........  May 30, 2012.
 Measurement Framework report         interim report available
 analyzing measures being used to     for public comment.
 gauge quality of care for people
 with multiple chronic conditions.
Patient-reported outcomes (PROs)     Two workshops discussing     In progress...........  June 30, 2012.
 workshops addressing prerequisites   commissioned papers
 for endorsed PRO measures.           addressing methodological
                                      prerequisites for NQF
                                      consideration of PRO
                                      measures for endorsement
                                      (The Veterans
                                      Administration may fund
                                      the papers; proposal is
                                      pending their approval).
Oral health........................  Report that catalogs oral    In progress...........  July 6, 2012.
                                      health measures, measure
                                      concepts, priorities and
                                      gaps in measurement.
Rapid-cycle CDP improvement          Summary of process           In progress...........  Four rapid-cycle
 (measure-endorsement process).       improvement approach,                                improvement events
                                      events, and metrics used                             completed in November
                                      to enhance the quality and                           and December 2012;
                                      efficiency of CDP process.                           additional events
                                                                                           planned during first
                                                                                           quarter of 2012.
----------------------------------------------------------------------------------------------------------------
                                       III. Health Information Technology
----------------------------------------------------------------------------------------------------------------
Retooled eMeasures, eMeasures        Published 113 measures for   Completed.............  All updates and
 Format Review Panel, and eMeasure    an electronic environment                            related activities
 Updates.                             eMeasure Format Review                               completed by December
                                      Panel reviewed retooled                              22, 2011.
                                      measures to ensure the                              Completed first cycle
                                      electronic specifications                            of review in Fall
                                      or requirements of these                             2010, following
                                      measures are consistent                              public comment
                                      with the original focus                              period.
                                      and intent of the measure.
                                     Held 10 webinars/conference
                                      calls to solicit comments
                                      and proposed resolutions..

[[Page 56941]]

 
MAT................................  Non-proprietary, web-based   Completed.............  Total number of unique
                                      tool that allows            Contractor training;     organizations using
                                      performance-measure          release of the MAT      MAT: 32.
                                      developers to specify,       Basic Version on 9/
                                      submit, and maintain         2911; enhanced
                                      electronic measures in a     version on target for
                                      more streamlined,            release.
                                      efficient, and highly
                                      structured way.
QDM maintenance....................  Updated the QDM (Version 3,  Review and updates to   Each new version of
                                      released in April 2011) to   QDM are ongoing based   the QDM will be
                                      reflect additional types     on annual cycle.        published annually;
                                      of data needed to support                            NQF will post a draft
                                      emerging measures (e.g.,                             of modifications for
                                      measures that include                                the next version;
                                      social determinants of                               annual QDM updates
                                      health, patient/consumer                             and versions will be
                                      engagement).                                         integrated into MAT
                                                                                           and, moreover, enable
                                                                                           incorporation of
                                                                                           required data
                                                                                           elements in
                                                                                           electronic measures
                                                                                           as new types and
                                                                                           sources of data are
                                                                                           recognized over time.
eMeasures process and technical      Provided education,          Ongoing...............  Developed and posted
 assistance.                          training, and ad-hoc                                 MAT User Guide to
                                      support to HHS, HHS                                  provide manual for
                                      contractors, MAT users,                              MAT and eMeasure
                                      QDM users, eMeasure                                  development.
                                      developers, EHR vendors,                            Completed 5 technical-
                                      providers implementing                               assistance trainings
                                      measures, and other                                  to CMS' eMeasure
                                      relevant quality and                                 contractors, focusing
                                      health IT stakeholders.                              on topics such as QDM
                                                                                           and in-depth MAT
                                                                                           training.
                                                                                          Completed 7 public
                                                                                           webinars (with as
                                                                                           many as 740 attendees
                                                                                           per webinar),
                                                                                           focusing on topics
                                                                                           such as eMeasures
                                                                                           training for measure
                                                                                           developers and IT
                                                                                           vendors.
Patient-safety-complications         Set of endorsed measures on  In progress...........  Steering Committee
 measures and maintenance review      complications-related                                reviewed 27 measures
 (Phase 1).                           areas.                                               in December 2011.
Commissioned paper on data sources   Final report and             In progress...........  Draft paper available
 and readiness of HIT systems to      commissioned paper.                                  for public comment in
 support care coordination.                                                                February 2012.
Critical path......................  Examine new measurement      Ongoing...............  End of September 2012.
                                      areas (e.g. care plans) to
                                      understand the feasibility
                                      of measuring such areas in
                                      an electronic environment.
eMeasure Learning Collaborative....  Examining issues related to  Ongoing...............  End of September 2012.
                                      implementation of
                                      eMeasures with a multi-
                                      stakeholder group in order
                                      to define best practices
                                      and recommendations to the
                                      Office of the National
                                      Coordinator's Federal
                                      Advisory Committees.
----------------------------------------------------------------------------------------------------------------
                                         IV. Measure Use and Application
----------------------------------------------------------------------------------------------------------------
Patient safety: state-based          Convened 27 state-based      Completed.............  Majority of work
 reporting agencies initiative.       patient-safety reporting                             completed during
                                      agencies to discuss safety                           previous contract
                                      reporting efforts and                                year; final HHS-
                                      share ``best practices''.                            funded call completed
                                                                                           January 24, 2011.
RAND report analyzing uses of NQF-   An Evaluation of the Use of  Completed.............  ......................
 endorsed measures.                   Performance Measures in
                                      Health Care; work plan and
                                      list of research questions
                                      completed; report by
                                      independent researcher
                                      completed.
Recommendations for measures to be   Measure Applications         In progress...........  Completed in February
 implemented through the federal      Partnership Pre-Rulemaking                           2012 after close of
 rulemaking process for public        Report: Input on Measures                            reporting year.
 reporting and payment.               Under Consideration by HHS
                                      for 2012 Rulemaking.

[[Page 56942]]

 
MAP report recommending measures     Final report including MAP   In progress...........  June 1, 2012.
 for use in quality reporting for     Coordinating Committee
 Prospective Payment System-exempt    recommendations.
 cancer hospitals.
MAP report recommending measures     Final report including MAP   In progress...........  June 1, 2012.
 for use in quality reporting for     Coordinating Committee
 hospice care.                        recommendations.
NPP support for Partnership for      First round of work          In progress...........  ......................
 Patients' HHS initiative focused     included 2 quarterly
 on patient safety.                   convenings and 8 webinars.
                                     Content of meetings and
                                      webinars were captured in
                                      individual summaries.
                                     Next round of work includes
                                      creating affinity groups
                                      to implement specific
                                      patient-safety strategies
                                      and webinars.
----------------------------------------------------------------------------------------------------------------

Appendix B: NQF Board and Leadership Staff

Board of Directors

William L. Roper, MD, MPH (Chair), Dean, School of Medicine, Vice 
Chancellor for Medical Affairs and Chief Executive Officer, UNC 
Health Care System, University of North Carolina at Chapel Hill
Andrew Webber (Vice Chair), President and CEO, National Business 
Coalition on Health
Gerald M. Shea (Treasurer), Assistant to the President for External 
Affairs, AFL-CIO
Lawrence M. Becker, Director, HR Strategic Partnerships, Xerox 
Corporation
Judy Ann Bigby, MD, Secretary, Executive Office of Health & Human 
Services, Commonwealth of Massachusetts
Janet M. Corrigan, Ph.D., MBA, President and CEO, National Quality 
Forum
Maureen Corry, Executive Director, Childbirth Connection
Leonardo Cuello, Staff Attorney, National Health Law Program
Helen Darling, MA, President, National Business Group on Health
Robert Galvin, MD, MBA, Chief Executive Officer, Equity Healthcare, 
The Blackstone Group
Ardis Dee Hoven, MD, Chair, American Medical Association Board of 
Trustees, Medical Director, Bluegrass Care Clinic, Affiliated with 
the University of Kentucky School of Medicine
Karen Ignagni, MBA, President and CEO, America's Health Insurance 
Plans
Chris Jennings, President, Jennings Policy Strategies, Inc.
Charles N. Kahn III, MPH, President, Federation of American 
Hospitals
Donald Kemper, Chairman and CEO, Healthwise, Inc.
Mark B. McClellan, MD, Ph.D., Senior Fellow and Director, Engelberg 
Center for Health Care Reform and Leonard D. Schaeffer Chair in 
Health Policy Studies, The Brookings Institution
Sheri S. McCoy, Worldwide Chairman of the Pharmaceuticals Group, 
Johnson & Johnson
Harold D. Miller, President and CEO, Network for Regional Healthcare 
Improvement
Dolores L. Mitchell, Executive Director, Commonwealth of 
Massachusetts Group Insurance Commission
Mary Naylor, Ph.D., RN, FAAN, Director, New Courtland Center for 
Transitions & Health and Marian S. Ware Professor in Gerontology, 
University of Pennsylvania School of Nursing
Debra L. Ness, President, National Partnership for Women & Families
Samuel R. Nussbaum, MD, Executive Vice President and Chief Medical 
Officer, WellPoint, Inc.
J. Marc Overhage, MD, Ph.D., Chief Medical Informatics Officer, 
Siemens Medical Solutions, Inc.
Bernard M. Rosof, MD, Chair, Board of Directors, Huntington 
Hospital, Chair, Physician Consortium for Performance Improvement
John C. Rother, JD, President and CEO, National Coalition on Health 
Care
Joseph R. Swedish, FACHE, President and CEO, Trinity Health
John Tooker, MD, MBA, MACP, Associate Executive Vice President, 
American College of Physicians
Richard J. Umbdenstock, President and CEO, American Hospital 
Association

CMS

Don Berwick, MD, Administrator (until 12/2/11)
Marilyn Tavenner, BSN, MPA, Acting Administrator and Chief Operating 
Officer (12/5/11-present), Centers for Medicare & Medicaid Services
Designee: Patrick Conway, MD, Chief Medical Officer

AHRQ

Carolyn M. Clancy, MD, Director, Agency for Healthcare Research and 
Quality
Designee: Nancy Wilson, MD, MPH, Senior Advisor to the Director

HRSA

Mary Wakefield, Ph.D., RN, Administrator, Health Resources and 
Services Administration
Designee: Terry Adirim, MD, Director, Office of Special Health 
Affairs

CDC

Thomas R. Frieden, MD, MPH, Director, Centers for Disease Control 
and Prevention
Designee: Peter A. Briss, MD, MPH, Captain, U.S. Public Health 
Service Medical Director

Ex Officio (Non-Voting):

Timothy Ferris, MD, (Chair, Consensus Standards Approval Committee), 
Associate Professor of Medicine, Massachusetts General Hospital
Paul C. Tang, MD, MS, (Chair, Health Information Technology Advisory 
Committee), Vice President and Chief Medical Information Officer, 
Palo Alto Medical Foundation

NQF Leadership Staff

Janet M. Corrigan, President and Chief Executive Officer
Karen Adams, Vice President, National Priorities
Heidi Bossley, Vice President, Performance Measures
Helen Burstin, Senior Vice President, Performance Measures
Floyd Eisenberg, Senior Vice President, Health Information 
Technology
Larry Gorban, Vice President, Operations
Ann Greiner, Vice President, External Affairs
Ann Hammersmith, General Counsel
Lisa Hines, Vice President, Member Relations
Connie Hwang, Vice President, Measure Applications Partnership
Rosemary Kennedy, Vice President, Health Information Technology
Laura Miller, Senior Vice President and Chief Operating Officer
Nicole Silverman, Vice President, Federal Program Management
Lindsey Spindle, Senior Vice President, Communications and External 
Affairs
Diane Stollenwerk, Vice President, Community Alliances
Jeffrey Tomitz, Chief Financial Officer, Accounting & Finance
Thomas Valuck, Senior Vice President, Strategic Partnerships
Kyle Vickers, Chief Information Officer

Appendix C: Overview of Consensus Development Process

    For each Consensus Development Project (CDP), NQF follows a 
careful eight-step process that ensures transparency, public input, 
and discussion among representatives across the healthcare 
enterprise.
    1. Call for Nominations allows anyone to suggest a candidate for 
the committee that will oversee the project. Committees are diverse, 
often encompassing experts in a

[[Page 56943]]

particular field, providers, scientists, and consumers. After 
selection, NQF posts committee rosters on its Web site to solicit 
public comments on the composition of the panel and makes 
adjustments as needed to ensure balanced representation.
    2. Call for Measures starts a 30-day period for developers to 
submit a measure or practice through NQF's online submission forms.
    3. Steering Committee Review puts submitted measures to a four-
part test to ensure they reflect sound science, will be useful to 
providers and patients, and will make a difference in improving 
quality. The expert steering committee conducts this detailed review 
in open sessions, each of which starts a limited period for public 
comment.
    4. Public Comment solicits input from anyone who wishes to 
respond to a draft report that outlines the steering committee's 
assessment of measures for possible endorsement. The steering 
committee may request a revision to the proposed measures.
    5. Member Vote asks NQF members to review the draft report and 
cast their votes on the endorsement of measures.
    6. CSAC Review marks the point at which the NQF Consensus 
Standards Approval Committee (CSAC) deliberates on the merits of the 
measure and the issues raised during the review process, and makes a 
recommendation on endorsement to the Board of Directors. The CSAC 
includes consumers, purchasers, healthcare professionals, and 
others. It provides the big picture to ensure that standards are 
being consistently assessed from project to project.
    7. Board Ratification asks for review and ratification by the 
NQF Board of Directors of measures recommended for endorsement.
    8. Appeal opens a period when anyone can appeal the Board's 
decision.

Appendix D: MAP Measure-Selection Criteria

    The Measure Applications Partnership (MAP) has developed 
measure-selection criteria to guide its evaluations of program 
measure sets. The term ``measure set'' can refer to a collection of 
measures--for a program, condition, procedure, topic, or population. 
For the purposes of MAP's pre-rulemaking analysis, we qualify the 
term measure set as a ``program measure set'' to indicate the 
collection of measures used in a given federal public reporting or 
performance-based payment program.
    The measure-selection criteria are intended to facilitate 
structured discussion and decision- making processes. The iterative 
approach employed in developing the criteria allowed MAP in its 
entirety, as well as the public, to provide input on the criteria. 
Each MAP workgroup deliberated on draft criteria and advised the 
Coordinating Committee. Comments were received on the draft criteria 
through the public comment period for the Coordination Strategy for 
Clinician Performance Measurement report. A Measure-Selection 
Criteria Interpretive Guide also was developed to provide additional 
descriptions and direction on the meaning and use of the measure-
selection criteria.
    1. MAP measure-selection criteria and the interpretive guide 
were finalized at the November 1, 2011, Coordinating Committee in-
person meeting The following criteria were then used as a tool 
during the pre-rulemaking task:
    2. Measures within the program measure set are NQF-endorsed or 
meet the requirements for expedited review.
    3. The program measure set adequately addresses each of the NQS 
priorities.
    4. The program measure set adequately addresses high-impact 
conditions relevant to the program's intended populations (e.g., 
children, adult non-Medicare, older adults, or dual-eligible 
beneficiaries).
    5. The program measure set promotes alignment with specific 
program attributes, as well as alignment across programs.
    6. The program measure set includes an appropriate mix of 
measure types (e.g., process, outcome, structure, patient 
experience, and cost).
    7. The program measure set enables measurement across the 
person-centered episode of care.
    8. The program measure set includes considerations for 
healthcare disparities.
    9. The program measure set promotes parsimony.
    Public commenters supported the MAP measure-selection criteria 
and noted that the tool served MAP well in its pre-rulemaking 
activities.

Appendix E: NQF Membership

    NQF members represent more than 450 organizations from across 
the country committed to advancing healthcare quality. Members of 
NQF participate in one of eight Member Councils organized by 
stakeholder group--consumers; health plans; health professionals; 
provider organizations; public-community health agencies; 
purchasers; quality measurement, research, and improvement; and 
supplier-industry--and are afforded a strong voice in crafting 
national solutions to quality concerns. Member organizations are 
from every region of the country as the map below indicates.

[[Page 56944]]

[GRAPHIC] [TIFF OMITTED] TN14SE12.008

NQF Member Organizations

3M Health Care
AARP
Abbott Laboratories
ABIM Foundation
Academy of Managed Care Pharmacy
Academy of Medical-Surgical Nurses
Accreditation Association for Ambulatory Health Care Institute for 
Quality Improvement
ACS-MIDAS+
Ada County Paramedics
Adventist Health System
Advocate Physician Partners
Aetna
Affinity Health System
AFL-CIO
Agency for Healthcare Research and Quality
Albuquerque Coalition for Healthcare Quality
Aligning Forces for Quality-South Central Pennsylvania
Alliance for Health
Alliance of Community Health Plans
Ambulatory Surgery Foundation
Amedisys
American Academy of Allergy, Asthma and Immunology
American Academy of Dermatology
American Academy of Family Physicians
American Academy of Hospice and Palliative Medicine
American Academy of Neurology
American Academy of Nurse Practitioners
American Academy of Nursing
American Academy of Ophthalmology
American Academy of Orthopaedic Surgeons
American Academy of Otolaryngology-Head and Neck Surgery
American Academy of Pediatrics
American Academy of Physical Medicine and Rehabilitation
American Association of Birth Centers
American Association of Cardiovascular and Pulmonary Rehabilitation
American Association of Clinical Endocrinologists
American Association of Colleges of Nursing
American Association of Diabetes Educators
American Association of Neurological Surgeons
American Association of Nurse Anesthetists
American Association of Nurse Assessment Coordination
American Board of Medical Specialties
American Board of Optometry
American Case Management Association
American Chiropractic Association
American College of Cardiology
American College of Cardiology/American Heart Association Task Force 
on Performance Measures
American College of Emergency Physicians
American College of Gastroenterology
American College of Medical Quality
American College of Nurse-Midwives
American College of Obstetricians and Gynecologists
American College of Physician Executives
American College of Physicians
American College of Radiology
American College of Rheumatology
American College of Surgeons
American Data Network
American Dietetic Association
American Federation of Teachers Healthcare
American Gastroenterological Association Institute
American Geriatrics Society
American Health Care Association
American Health Information Management Association
American Health Quality Association
American Heart Association
American Hospice Foundation
American Hospital Association
American Medical Association
American Medical Association-Physician Consortium for Performance 
Improvement
American Medical Directors Association
American Medical Informatics Association
American Nurses Association
American Occupational Therapy Association
American Optometric Association
American Organization of Nurse Executives
American Osteopathic Association
American Pharmacists Association Foundation
American Physical Therapy Association
American Psychiatric Association for Research and Education
American Psychiatric Nurses Association
American Sleep Apnea Association
American Society for Gastrointestinal Endoscopy
American Society for Radiation Oncology
American Society of Anesthesiologists
American Society of Breast Surgeons
American Society of Clinical Oncology
American Society of Colon and Rectal Surgeons
American Society of Health-System Pharmacists
American Society of Hematology
American Society of Nuclear Cardiology
American Society of Pediatric Nephrology
American Society of Plastic Surgeons
American Urological Association
America's Health Insurance Plans
AmeriHealth Mercy Family of Companies
AMGEN Inc.
AmSurg Corp.
Anesthesia Quality Institute
Arkansas Medicaid
Ascension Health
Association for Professionals in Infection Control and Epidemiology

[[Page 56945]]

Association for the Advancement of Wound Care
Association of American Medical Colleges
Association of periOperative Registered Nurses
Association of Rehabilitation Nurses
Association of Women's Health, Obstetric and Neonatal Nurses
AstraZeneca
Atlantic Health
Aultman Health Foundation
Aurora Health Care
Avalere Health LLC
Baptist Health South Florida
Baptist Memorial Health Care Corporation
Baxter Healthcare
BayCare Health System
Baylor Health Care System
Betsy Lehman Center for Patient Safety and Medical Error Reduction
Better Health Greater Cleveland
BJC HealthCare
BlueCross BlueShield Association
Boehringer Ingelheim
Bon Secours St. Francis Health System
Booz Allen Hamilton
Bristol-Myers Squibb Company
Bronson Healthcare Group, Inc.
Buyers Health Care Action Group
California HealthCare Foundation
California Hospital Association
California Hospital Patient Safety Organization
California Maternal Quality Care Collaborative
California Office of Statewide Health Planning and Development
CareFirst BlueCross BlueShield
CareFusion
CaroMont Health
Case Management Society of America
Caterpillar Inc.
Catholic Health Association of the United States
Catholic Health Initiatives
Catholic Healthcare Partners
Cedars-Sinai Medical Center
Center for Health Care Quality, Department of Health Policy, George 
Washington University
Center to Advance Palliative Care
Centers for Disease Control and Prevention
Centers for Medicare & Medicaid Services
Childbirth Connection
Children's Hospital Boston
Children's Hospitals and Clinics of Minnesota
CHRISTUS Health
CIGNA HealthCare
Citizens for Patient Safety
City of Hope
Cleveland Clinic
Colorado Business Group on Health
Commission for Case Manager Certification
Community Health Accreditation Program
Community Health Alliance- Humboldt County Del-Norte
Community Health Foundation of Western and Central New York
Connecticut Center for Patient Safety
Connecticut Hospital Association
Consumer Coalition for Quality Health Care
Consumers Advancing Patient Safety
Consumers' Checkbook
Consumers Union
Coral Initiative, LLC
Core Consulting, Inc.
Council of Medical Specialty Societies
Crozer-Keystone Health System
Dallas-Fort Worth Hospital Council Education and Research Foundation
Dana-Farber Cancer Institute
Deloitte Consulting LLP, Health Sciences and Government
Dental Quality Alliance
Detroit Medical Center
Dialog Medical
Edwards Lifesciences
eHealth Initiative
Eisai, Inc.
Eli Lilly and Company
Elsevier Clinical Decision Support
Emergency Nurses Association
Employers' Coalition on Health
Englewood Hospital and Medical Center
Epstein Becker & Green, P.C.
Exeter Health Resources
Federation of American Hospitals
FirstWatch Solutions, Inc.
Florida Health Care Coalition
Florida Hospital
Florida State University, Center for Medicine and Public Health
Forest Laboratories, Inc.
Foundation for Informed Medical Decision Making
Fox Chase Cancer Center
Franciscan Alliance
GE Healthcare
Genentech
Genesis HealthCare System
Gentiva Health Services
GlaxoSmithKline
Good Samaritan Hospital
Greater Detroit Area Health Council
Greenway Medical Technologies
Group Health Cooperative
H. Lee Moffitt Cancer Center and Research Institute Hospital, Inc.
Hackensack University Medical Center
Harborview Medical Center
Health Action Council Ohio
Health Level Seven, Inc.
Health Management Associates, Inc.
Health Resources and Services Administration
Health Services Advisory Group
Health Services Coalition
Health Watch USA
HealthCare 21 Business Coalition
Healthcare Information and Management Systems Society
Healthcare Leadership Council
HealthGrades
HealthPartners
HealthSouth Corporation
Healthy Memphis Common Table
Heart Rhythm Society
Henry Ford Health System
Highmark, Inc.
Hoag Hospital
Horizon Blue Cross Blue Shield of New Jersey
Hospice and Palliative Nurses Association
Hospira
Hospital Corporation of America
Hospital for Special Surgery
Hudson Health Plan
Humana Inc.
Huntington Memorial Hospital
Illinois Hospital Association
Infectious Diseases Society of America
Infusion Nurses Society
Inland Northwest Health Services
Institute for Clinical Systems Improvement
Institute for Safe Medication Practices
Integrated Healthcare Association
Intelligent Healthcare
Interim HealthCare, Inc.
Intermountain Healthcare
Iowa Healthcare Collaborative
IPRO
Jefferson School of Population Health
Johns Hopkins Health System
Kaiser Permanente
Kansas City Quality Improvement Consortium
Kidney Care Partners
Lamaze International
Lehigh Valley Business Coalition on Health Care
LHC Group, Inc.
Long-Term Quality Alliance
Louisiana Health Care Quality Forum
Maine Health Management Coalition
Maine Quality Counts
Maine Quality Forum
Maryland Health Care Commission
Maryland Patient Safety Center
Massachusetts Health Quality Partners
Mayo Clinic
McKesson Corporation
MedAssets
MedeAnalytics, Inc.
Medisolv, Inc.
MedStar Health
Memorial Hermann Healthcare System
Memorial Sloan-Kettering Cancer Center
Merck & Co., Inc.
Mercy Medical Center
Meridian Health System
MHA Keystone Center for Patient Safety & Quality
Middlesex Hospital
Midwest Care Alliance
Milliman Care Guidelines
Minnesota Community Measurement
Mothers Against Medical Error
Mount Auburn Hospital
National Academy for State Health Policy
National Academy of Clinical Biochemistry
National Alliance of Wound Care
National Association for Behavioral Health
National Association for Healthcare Quality
National Association of Certified Professional Midwives
National Association of Children's Hospitals and Related 
Institutions
National Association of Dental Plans
National Association of EMS Physicians
National Association of Health Data Organizations
National Association of Pediatric Nurse Practitioners
National Association of Psychiatric Health Systems
National Association of Public Hospitals and Health Systems
National Association of State Medicaid Directors
National Breast Cancer Coalition
National Business Coalition on Health
National Business Group on Health
National Center for Healthcare Leadership
National Coalition for Cancer Survivorship
National Committee for Quality Assurance
National Consensus Project for Quality Palliative Care

[[Page 56946]]

National Consortium of Breast Centers
National Consumers League
National Council of State Boards of Nursing
National Council on Aging
National Forum for Heart Disease and Stroke Prevention
National Health Law Program
National Hospice and Palliative Care Organization
National Institute for Quality Improvement and Education
National Nursing Staff Development Organization
National Partnership for Women & Families
National Patient Safety Foundation
National Pressure Ulcer Advisory Panel
National Rural Health Association
National Sleep Foundation
NCH Healthcare System
Nemours Foundation
Neocure Group
New Jersey Health Care Quality Institute
New Jersey Hospital Association
New York Presbyterian Healthcare System
New York University College of Nursing
Next Wave
Niagara Health Quality Coalition
North Carolina Center for Hospital Quality and Patient Safety
North Mississippi Medical Center
North Shore-Long Island Jewish Health System
North Texas Specialty Physicians
Northeast Health Care Quality Foundation
Northwestern Memorial HealthCare
Norton Healthcare, Inc.
Novartis
Nursing Alliance for Quality Care
Oakstone Medical Publishing
Oncology Nursing Society
Oregon Health Care Quality Corporation
Ortho-McNeill-Janssen Pharmaceutical, Inc.
OSUCCC-James Cancer Hospital
P2 Collaborative of Western New York
Pacific Business Group on Health
Park Nicollet Health Services
Partners HealthCare System, Inc.
Partnership for Prevention
Patient Centered Primary Care Collaborative
Pennsylvania Health Care Association
Pfizer
Pharmacy Quality Alliance
PhRMA
Phytel, Inc.
Planetree
Premier, Inc.
Press Ganey Associates
Professional Research Consultants, Inc.
Providence Health & Services
Puget Sound Health Alliance
PULSE of New York
Quality Outcomes, LLC
Quantros, Inc.
Renal Physicians Association
Resolution Health, Inc.
Rhode Island Department of Health
Robert Wood Johnson University Hospital-Hamilton
Rockford Health System
Roswell Park Cancer Institute
Saint Barnabas Health Care System
Saint Francis Hospital and Medical Center
Sanofi Pasteur
Sanofi-Aventis
Scott & White Healthcare
Seattle Cancer Care Alliance
Sharp HealthCare
Siemens Healthcare, USA
Sisters of Charity of Leavenworth Health System
SNP Alliance
Society for Academic Emergency Medicine
Society for Cardiovascular Angiography and Interventions
Society for Healthcare Epidemiology of America
Society for Maternal-Fetal Medicine
Society for the Advancement of Blood Management
Society for Vascular Surgery
Society of Behavioral Medicine
Society of Critical Care Medicine
Society of Gynecologic Oncology
Society of Hospital Medicine
Society of Thoracic Surgeons
Southeast Texas Medical Associates, LLP
St. Joseph Health System
St. Louis Area Business Health Coalition
Stamford Health System
State Associations of Addiction Services
Substance Abuse and Mental Health Services Administration
Summa Health System
Surgical Care Affiliates
Sylvester Comprehensive Cancer Center, University of Miami Hospitals 
and Clinics
Taconic IPA, Inc.
Takeda Pharmaceuticals North America, Inc.
Tampa General Hospital
Telligen
Tenet Healthcare Corporation
Texas Health Resources
Texas Medical Institute of Technology
The Advanced Medical Technology Association
The Alliance
The Alliance for Home Health Quality and Innovation
The Commonwealth Fund
The Coordinating Center
The Empowered Patient Coalition
The Federation of State Medical Boards of the U.S., Inc.
The Health Alliance of Mid-America, LLC
The Health Collaborative
The Joint Commission
The Leapfrog Group
The National Consumer Voice for Quality Long-Term Care
The National Forum of ESRD Networks
The Partnership for Healthcare Excellence
Thomas Jefferson University Hospital
Thomson Reuters
Trauma Support Network
Trinity Health
Trust for America's Health
UCB, Inc.
UMass Memorial Medical Group, Inc.
United Surgical Partners International
UnitedHealth Group
Universal American Corp.
University HealthSystem Consortium
University of California-Davis Medical Group
University of Kansas School of Nursing
University of Michigan Hospitals & Health Centers
University of North Carolina-Program on Health Outcomes
University of Pennsylvania Health System
University of Texas Southwestern Medical Center
University of Texas-MD Anderson Cancer Center
University of Virginia Health System
URAC
Urgent Care Association of America
US Department of Defense-Health Affairs
UW Health
Vanderbilt University Medical Center
Vanguard Health Management
Verilogue, Inc
Veterans Health Administration
VHA, Inc.
Virginia Business Coalition on Health
Virginia Cardiac Surgery Quality Initiative
Virginia Mason Medical Center
Virtua Health
WellPoint
WellSpan Health
WellStar Health System
West Virginia Medical Institute
Wisconsin Collaborative for Healthcare Quality
Wisconsin Medical Society
Wound, Ostomy and Continence Nurses Society
Yale New Haven Health System
Zynx Health

Appendix F: 2011 NQF Volunteer Leaders

Stancel M. Riley, Chair, Ambulatory and Office-Based Surgery 
Technical Advisory Panel Serious Reportable Events in Healthcare 
Project
Chair, Patient Safety Serious Reportable Events Technical Advisory 
Panel, Massachusetts Board of Registration in Medicine
Mary George, Co-chair, Cardiovascular Endorsement Maintenance 
Steering Committee, Centers for Disease Control and Prevention
Raymond Gibbons, Co-chair, Cardiovascular Endorsement Maintenance 
Steering Committee, Mayo Clinic
Donald Casey, Co-chair, Care Coordination Endorsement Maintenance 
Steering Committee, Atlantic Health
Gerri Lamb, Co-chair, Care Coordination Endorsement Maintenance 
Steering Committee, Arizona State University
Thomas McInerny, Co-chair, Child Health Quality Measures Steering 
Committee, University of Rochester
Marina L. Weiss, Co-chair, Child Health Quality Measures Steering 
Committee
Co-chair, National Voluntary Standards for Patient Outcomes Child 
Health Steering Committee, March of Dimes
David Classen, Co-chair, Common Formats Expert Panel, University of 
Utah
Henry Johnson, Co-chair, Common Formats Expert Panel, ACS-MIDAS+
Timothy Ferris, Chair, Consensus Standards Approval Committee, 
Massachusetts General Hospital/Institute for Health Policy
Ann Monroe, Vice-chair, Consensus Standards Approval Committee, 
Community Health Foundation of Western and Central New York
Doris Lotz, Co-chair, Efficiency Resource Use Steering Committee, 
New Hampshire Department of Health and Human Services
Sally Tyler, Co-chair, Patient Safety SRE Steering Committee, AFSCME
Gregg S. Meyer, Co-chair, Patient Safety SRE Steering Committee, 
Massachusetts General Hospital

[[Page 56947]]

Paul C. Tang, Chair, Health Information Technology Advisory 
Committee, Palo Alto Medical Foundation and Stanford University
Dennis Andrulis, Co-chair, Healthcare Disparities and Cultural 
Competency Consensus Standards Committee, Texas Health Institute
Denice Cora-Bramble, Co-chair, Healthcare Disparities and Cultural 
Competency Consensus Standards Committee, Children's National 
Medical Center
Michael Doering, Co-chair, Improving Patient Safety through State-
Based Reporting in Healthcare Workgroup, Pennsylvania Patient Safety 
Authority
Diane Rydrych, Co-chair, Improving Patient Safety through State-
Based Reporting in Healthcare Workgroup, Minnesota Department of 
Health
Iona Thraen, Co-chair, Improving Patient Safety through State-Based 
Reporting in Healthcare Workgroup, Utah Department of Health
William Corley, Chair, Leadership Network, Community Health Network
George J. Isham, Co-chair, Measure Applications Partnership 
Coordinating Committee, HealthPartners, Inc.
Elizabeth A. McGlynn, Co-chair, Measure Applications Partnership 
Coordinating Committee, Kaiser Permanente Center for Effectiveness 
and Safety Research
Frank G. Opelka, Chair, Measure Applications Partnership Ad Hoc 
Safety Workgroup
Chair, Measure Application Partnership Hospital Workgroup, Louisiana 
State University Health Sciences Center
Mark McClellan, Chair, Measure Applications Partnership Clinician 
Workgroup, The Brookings Institution, Engelberg Center for Health 
Care Reform
Alice Lind, Chair, Measure Applications Partnership Dual Eligible 
Beneficiaries Workgroup, Center for Health Care Strategies
Carol Raphael, Chair, Measure Applications Partnership Post-Acute 
Care/Long-Term Care Workgroup, Visiting Nurse Service of New York
Michael Lieberman, Chair, Measure Authoring Tool Oversight and 
Testing Workgroup, Oregon Health and Science University
Caroline S. Blaum, Co-chair, Multiple Chronic Conditions Measurement 
Framework Steering Committee, University of Michigan Health System--
Institute of Gerontology
Barbara McCann, Co-chair, Multiple Chronic Conditions Measurement 
Framework Steering Committee, Interim HealthCare
Helen Darling, Co-chair, National Priorities Partnership, National 
Business Group on Health
Margaret O'Kane, Co-chair, National Priorities Partnership, National 
Committee for Quality Assurance
Bernard Rosof, Co-chair, National Priorities Partnership, Physician 
Consortium for Performance Improvement convened by the American 
Medical Association
Peter Crooks, Co-chair, National Voluntary Consensus Standards for 
End Stage Renal Disease
Co-chair, Renal Endorsement Maintenance Steering Committee, Southern 
California Permanente Medical Group
Kristine Schonder, Co-chair, National Voluntary Consensus Standards 
for End Stage Renal Disease
Co-chair, Renal Endorsement Maintenance Steering Committee, 
University of Pittsburgh School of Pharmacy
Tom Rosenthal, Co-chair, National Voluntary Consensus Standards for 
Endorsing Performance Measures for Resource Use: Phase II, UCLA 
School of Medicine
Bruce Steinwald, Co-chair, National Voluntary Consensus Standards 
for Endorsing Performance Measures for Resource Use: Phase II
Co-chair, Efficiency Resource Use Steering Committee, Independent 
Consultant
G. Scott Gazelle, Co-chair, National Voluntary Consensus Standards 
for Imaging Efficiency, Massachusetts General Hosital
Eric D. Peterson, Co-chair, National Voluntary Consensus Standards 
for Imaging Efficiency, Duke University Medical Center
David A. Johnson, Chair, National Voluntary Consensus Standards for 
Patient Outcomes Biliary and Gastrointestinal Technical Advisory 
Panel, American College of Gastroenterology
Dianne Jewell, Chair, National Voluntary Consensus Standards for 
Patient Outcomes Bone/Joint Technical Advisory Panel, Virginia 
Commonwealth University
Lee Newcomer, Chair, National Voluntary Consensus Standards for 
Patient Outcomes Cancer Technical Advisory Committee, United 
HealthCare
Edward Gibbons, Chair, National Voluntary Consensus Standards for 
Patient Outcomes Cardiovascular Technical Advisory Panel, University 
of Washington School of Medicine
David Herman, Chair, National Voluntary Consensus Standards for 
Patient Outcomes Eye Care Technical Advisory Panel, Mayo Clinic
E. Patchen Dellinger, Chair, National Voluntary Consensus Standards 
for Patient Outcomes Infectious Disease Technical Advisory Panel, 
University of Washington School of Medicine
Sheldon Greenfield, Chair, National Voluntary Consensus Standards 
for Patient Outcomes Metabolic Technical Advisory Panel, University 
of California, Irvine
Barbara Yawn, Chair, National Voluntary Consensus Standards for 
Patient Outcomes Pulmonary Technical Advisory Panel, Olmstead 
Medical Center
Tricia Leddy, Co-chair, National Voluntary Consensus Standards for 
Patient Outcomes Mental Health Steering Committee, Rhode Island 
Department of Health
Jeffrey Sussman, Co-chair, National Voluntary Consensus Standards 
for Patient Outcomes Mental Health Steering Committee, University of 
Cincinnati
Charles Homer, Co-chair, National Voluntary Standards for Patient 
Outcomes Child Health Steering Committee, NICHQ
David Gifford, Co-chair, National Voluntary Standards for Nursing 
Homes, American Health Care Association and National Center for 
Assisted Living
Christine Mueller, Co-chair, National Voluntary Standards for 
Nursing Homes, University of Minnesota School of Nursing
June Lunney, Co-chair, Palliative Care and End-of-Life Care 
Endorsement Maintenance Steering Committee, Hospice and Palliative 
Nurses Association
Sean Morrison, Co-chair, Palliative Care and End-of-Life Care 
Endorsement Maintenance Steering Committee, Mount Sinai School of 
Medicine
Sherrie Kaplan, Co-chair, Patient Outcomes: All-Cause Readmissions 
Expedited Review Steering Committee, UC Irvine School of Medicine
Eliot Lazar, Co-chair, Patient Outcomes: All-Cause Readmissions 
Expedited Review Steering Committee, New York Presbyterian 
Healthcare System
Lisa J. Thiemann, Co-chair, Patient Safety Measures Steering 
Committee, Surgical Care Affiliates
William A. Conway, Co-chair, Patient Safety Measures Steering 
Committee
Co-chair, Patient Safety Measures: Complications Endorsement 
Maintenance Steering Committee, Henry Ford Health System
Darrell A. Campbell, Jr., Chair, Patient Safety Measures HAI 
Technical Advisory Panel, University of Michigan Hospitals & Health 
Centers
David Nau, Chair, Patient Safety Measures Medical Management 
Technical Advisory Panel, Pharmacy Quality Alliance
Steven Clark, Chair, Patient Safety Measures Perinatal Technical 
Advisory Panel, Hospital Corporation of America
Pamela Cipriano, Co-chair, Patient Safety Measures: Complications 
Endorsement Maintenance Steering Committee, University of Virginia 
Health System
Tejal Gandhi, Chair, Patient Safety Serious Reportable Events 
Technical Advisory Panel
Chair, Physician Office Technical Advisory Panel Serious Reportable 
Events in Heatlhcare, Partners Healthcare
Eric Tangalos, Chair, Patient Safety Serious Reportable Events 
Technical Advisory Panel
Chair, Skilled Nursing Facility Technical Advisory Panel Serious 
Reportable Events In Healthcare Project, Mayo Clinic
Laura Riley, Co-chair, Perinatal and Reproductive Health Endorsement 
Maintenance Steering Committee, Massachusetts General Hospital
Carol Sakala, Co-chair, Perinatal and Reproductive Health 
Endorsement Maintenance Steering Committee, Childbirth Connection
Paul Jarris, Co-chair, Population Health: Prevention Endorsement 
Maintenance Steering Committee, Association of State and Territorial 
Health Officers
Kurt Stange, Co-chair, Population Health: Prevention Endorsement 
Maintenance Steering Committee, Case Western Reserve University
David Bates, Co-chair, Quality Data Model Sub-committee, Partners 
Healthcare
Caterina Lasome, Co-chair, Quality Data Model Sub-committee, Ion 
Informatics
Arthur Kellermann, Co-chair, Regionalized Emergency Medical Care 
Services Steering Committee, The RAND Corporation

[[Page 56948]]

Andrew Roszak, Co-chair, Regionalized Emergency Medical Care 
Services Steering Committee, Department of Health and Human Services
James Weinstein, Chair, Resource Use Project: Phase II Bone/Joint 
Technical Advisory Panel, The Dartmouth Institute for Health Policy; 
Dartmouth-Hitchcock Clinic
David Penson, Chair, Resource Use Project: Phase II Cancer Technical 
Advisory Panel, Vanderbilt University Medical Center
Jeptha Curtis, Co-chair, Resource Use Project: Phase II 
Cardiovascular/Diabetes Technical Advisory Panel, Yale University 
School of Medicine
James Rosenzweig, Co-chair, Resource Use Project: Phase II 
Cardiovascular/Diabetes Technical Advisory Panel, Boston Medical 
Center and Boston University School of Medicine
Kurtis Elward, Co-chair, Resource Use Project: Phase II Pulmonary 
Technical Advisory Panel, Family Medicine of Albermarle
Janet Maurer, Co-chair, Resource Use Project: Phase II Pulmonary 
Technical Advisory Panel, American College of Chest Physicians
Arden Morris, Co-chair, Surgery Endorsement Maintenance Steering 
Committee, Ann Arbor Veterans Affairs Medical Center
David Torchiana, Co-chair, Surgery Endorsement Maintenance Steering 
Committee, Massachusetts General Physicians Organization
NATIONAL QUALITY FORUM
1030 15th Street NW., Suite 800
Washington, DC 20005
www.qualityforum.org

NQF Report on Measure Gaps and Inadequacies

Overview

    The Affordable Care Act (ACA) (Pub. L. 111-148, sec. 3011), 
requires the Secretary of Health and Human Services to establish a 
National Strategy for Quality Improvement in Health Care, which serves 
as a strategic plan for improving the delivery of health care services, 
achieving better patient outcomes, and improving the health of the U.S. 
population. The strategy will be continually updated as the Affordable 
Care Act is implemented.
    Section 3014 of ACA requires a report from the National Quality 
Forum (NQF) regarding the identification of gaps in endorsed quality 
measures--to include measures within the National Quality Strategy 
priority areas--to be provided to the Secretary by February 1, 2012 and 
annually thereafter. The report was also intended to identify areas 
where evidence was insufficient to support endorsement of quality 
measures in priority areas.

Methods

    In order to prepare this report on measure gaps, NQF staff 
consulted numerous data sources to identify endorsed measure and 
evidence gaps. Staff reviewed approximately 750 endorsed measures 
within the NQF portfolio and identified the measures that address one 
or more of the National Quality Strategy (NQS) priority areas and areas 
where gaps remain. Staff also reviewed NQF-related efforts that address 
many of the priority areas, including NQF project consensus development 
project reports. NQF endorsement committees routinely identify gaps as 
part of the work of the consensus development process. The NQF report 
``Prioritization of High-Impact Medicare Conditions and Measure Gaps'' 
developed by the Measure Prioritization Advisory Committee and 
published in May, 2010 was also used as a data source for gaps.
    NQF has captured this information in a high-level matrix organized 
by priority area and the high impact clinical conditions which 
highlights where endorsed measures exist and gaps remain. Given the 
volume of clinical conditions and cross-cutting areas addressed within 
the NQF portfolio, a targeted list of clinical conditions is included.
    It is anticipated that this analysis will continue to evolve over 
the coming years through the NQF National Priorities Partnership, the 
Measures Applications Partnership, endorsement maintenance projects, 
and other activities.

National Quality Strategy Overview

    The NQF-convened National Priorities Partnership (NPP) proposed 
goals and measure concepts in its September 1, 2011 report ``Input to 
the Secretary of Health and Human Services on Priorities for the 
National Quality Strategy'' regarding the six national priorities:

1. Making Care Safer
2. Ensuring Person- and Family-Centered Care
3. Promoting Effective Communication and Coordination of Care
4. Promoting the Most Effective Prevention and Treatment of the Leading 
Causes of Mortality, Starting with Cardiovascular Disease
5. Working with Communities to Promote Wide Use of Best Practices to 
Enable Healthy Living
6. Making Quality Care More Affordable

    The proposed goals and measure concepts are intended to ``provide a 
set of clear aims with which the NQS can guide the nation to achieve 
safe, timely, effective, efficient, and equitable care,'' and are 
discussed in more detail below. Some of the measure concepts identify 
important measurement gaps, while measure development may be limited by 
evidence gaps.
    The Secretary's National Quality Strategy requires a wide array of 
quality and efficiency measures for implementation. While some of the 
strategy's priority areas may be well-supported by NQF-endorsed 
measures, others may have fewer, or in some cases, no endorsed measures 
aligned with them.
    For the purposes of this report, we have expanded the applicability 
of the fourth priority area, related to prevention and treatment, 
beyond cardiovascular disease to the other conditions listed below. 
While there are numerous condition-specific clinical process measures, 
there are major gaps for some conditions (e.g., Alzheimer's). There are 
also important gaps in condition-specific measures that address 
critical national priorities (e.g., cost measures for high-cost 
conditions).

 Alzheimer's Disease
 Cancer
 Cardiovascular
 Cataract
 Child Health
 Depression
 Diabetes
 Glaucoma
 Hip/Pelvic Fracture
 Maternal Health
 Osteoporosis
 Pulmonary
 Renal Disease
 Rheumatoid Arthritis/Osteoarthritis
 Serious Mental Illness
 Stroke

    Since there is a strong desire to move toward patient-focused 
outcomes of care, the report also identifies potential outcome gaps for 
clinical and cross-cutting areas. For example, while there are numerous 
cancer-related process measures, there are no endorsed cancer outcome 
measures. Recent work by NQF's Evidence Task Force identified a 
hierarchical preference for outcomes linked to evidence-based processes 
and structures (Figure 1). While there is still a need for process and 
structural measures, especially for quality improvement, they should be 
closely linked to outcomes. In the tables that follow, gaps for outcome 
measures in some high impact clinical areas are identified.

[[Page 56949]]

[GRAPHIC] [TIFF OMITTED] TN14SE12.009

    The NQF Evidence Task Force also emphasized the importance of 
assessing the quality, quantity and consistency of evidence underlying 
the measure focus. While endorsement of some clinical measures has been 
limited by empirical evidence, NQF provides an exception in cases for 
which expert opinion can be systematically assessed with agreement that 
the benefits to patients greatly outweigh potential harms. In some 
cross-cutting priority areas, such as pain management and patient 
engagement, Committee expert opinion has been used to satisfy the 
evidence requirement.
    There has also been a strong interest from numerous stakeholders, 
including consumers and purchasers, in moving to composite measures. 
Composite measures are defined as one or more measures that are 
combined into a single score. Because composite measures provide a more 
comprehensive view of care and may be more understandable to end users, 
there has been a shift toward composite measures in many clinical 
areas. For example, an endorsed cardiovascular care composite 
encompasses the key secondary prevention elements critical for 
prevention of cardiac events (e.g., use of aspirin, non-smoking status, 
lipid control, and blood pressure control). Given the interest in these 
measures, gaps for composite measures are also noted in the tables that 
follow.

Gaps Across Cross-Cutting Areas

    While many measures within the NQF portfolio relate to specific 
conditions or clinical areas, others address or are applicable to 
cross-cutting areas such as safety and care coordination. Currently 
NQF-endorsed measures are categorized by these cross-cutting areas when 
applicable, overlapping with many of the cross-cutting national 
priorities outlined within the NQS.
    Figure 2 provides a graphic representation of the more than 750 
measures across these areas. This figure provides information on NQF-
endorsed measures by cross-cutting area, as well as the type of measure 
(structure, process, outcome, and composite).
    As demonstrated in the figure below, population health/prevention 
and safety represent the cross-cutting areas with the largest number of 
measures, while there are clear measure gaps in cross-cutting areas 
such as care coordination and patient experience and engagement. In 
addition, for areas with a range of measures, many focus on processes 
of care. However, there has been an increased focus on outcome measures 
with outcome measures now representing approximately 30 percent of the 
NQF portfolio. Measure development is also evolving to new areas such 
as resource use/cost (an area for which NQF is now endorsing measures) 
and patient-reported outcomes. Planned NQF endorsement projects in the 
coming year in these high priority areas, such as patient engagement 
and population health, should help to fill some of these important 
gaps.

[[Page 56950]]

[GRAPHIC] [TIFF OMITTED] TN14SE12.010

    The following sections address measures and gaps related to each of 
the cross-cutting areas.

Making Care Safer

    NQF has endorsed a robust set of patient safety measures. However, 
gaps remain. For example, there is a need for measures that assess 
broader, more cross-cutting issues of medication safety, rather than 
measures that apply to separate medications. There is also interest in 
``templates'' for medication management and safety that could be 
applied to different medications or conditions. In addition, more 
research on standard medication monitoring and its effect on outcomes 
or complications are needed. There is also a recognized need to expand 
available patient safety measures beyond the hospital setting and 
harmonize safety measures across sites and settings of care. There have 
also been recognized patient safety gaps in potentially high leverage 
areas, such as healthcare associated infections (e.g., MRSA) and 
measures that assess the culture of safety.
    The NPP provided guidance on proposed goals and measure concepts 
related to the National Quality Strategy. The following table provides 
the NPP-recommended goals and measure concepts on Priority Area 
1, Making Care Safer. Under the identified measure concepts, 
there are gaps related to inappropriate medication use and 
polypharmacy. There are also continued efforts to expand all-cause 
safety measures.
[GRAPHIC] [TIFF OMITTED] TN14SE12.011


[[Page 56951]]



Ensuring Person- and Family-Centered Care

    There have been a growing number of standardized measures that 
assess patient experience in multiple care settings. However, as noted 
in the NPP measure concepts related to this priority area, there is a 
significant gap in measures that assess patient and family involvement 
in decisions about healthcare. There is a growing evidence base on 
decision quality and there is an expectation that these measures will 
be submitted to NQF in the coming year. The measurement of care 
planning and joint development of treatment goals has not been limited 
by available evidence. It has been difficult to construct meaningful 
measures that move beyond ``checkbox'' measures that assess whether a 
plan exists.
[GRAPHIC] [TIFF OMITTED] TN14SE12.012

Promoting Effective Communication and Coordination of Care

    In the area of care coordination, measures that focus on 
communication and transitions across setting (e.g., medication 
reconciliation and transitions from inpatient facilities to other 
settings) and healthcare home have been endorsed, leaving many areas 
outlined in the NQF care coordination framework (i.e., proactive plan 
of care and follow-up, information systems) without current endorsed 
measures. NQF is aware of some work to begin to leverage information 
systems to facilitate care coordination, but in a recent call for 
measures related to Care Coordination, NQF did not receive any new 
measures to address this area. Some limited development is underway, 
but much work remains.
    The table below from the National Priorities Partnership's 
September report shows the NPP-recommended goals and measure concepts 
for Promoting Effective Communication and Coordination of Care, the 
third priority area in HHS' National Quality Strategy. Several of the 
measure concepts have associated endorsed measures, such as transition 
records and advanced care planning. These endorsed measures tend to be 
limited to certain populations and settings and there is a need for a 
measure development and testing that would move these measures to 
broader populations.
    The NPP goals also specifically note the need for measures that 
assess symptom management and functional status. While there have been 
measures that assess patient function and well-being in certain 
settings, such as home health and nursing homes, measures that assess a 
change (or ``delta'') in function have been limited. In addition, while 
there are many patient-level instruments/measures of health status and 
function, there are few performance measures that utilize these tools 
to assess the care provided by healthcare entities. In 2012, NQF will 
work with experts to address some of methodological challenges that 
have limited use of patient-reported outcomes across data platforms as 
performance measures.
[GRAPHIC] [TIFF OMITTED] TN14SE12.013


[[Page 56952]]



Promoting the Most Effective Prevention and Treatment of the Leading 
Causes of Mortality, Starting With Cardiovascular Disease

    The following table provides the NPP-recommended goals and measure 
concepts on Priority Area 4, Promoting the Most Effective 
Prevention and Treatment of the Leading Causes of Mortality, Starting 
with Cardiovascular Disease. While most of the identified 
cardiovascular prevention concepts relate to currently endorsed 
measures, there are some measurement gaps related to access to healthy 
foods and nutrition. Evidence will likely be strong for these 
cardiovascular prevention measures. The current NQF Population Health 
project may bring some of these measures forward for evaluation for 
endorsement.
    Condition-specific measures and the gaps related to effective 
prevention and treatment of high impact conditions, including 
cardiovascular care, are discussed in the condition-specific section of 
this report.
[GRAPHIC] [TIFF OMITTED] TN14SE12.014

Working With Communities To Promote Wide Use of Best Practices To 
Enable Healthy Living

    Measures that can assess the health of populations are a growing 
area of interest in the measurement enterprise. Population health 
focuses not only on disease across multiple sectors, but also on 
prevention and health promotion. Identifying valid and reliable 
measures of performance across these multiple sectors can be 
challenging. The NPP-recommended goals and measure concepts for this 
priority area are noted below. The NPP recommended a three-tiered 
approach to population health to address the national priority of 
working with communities to promote the wide use of best practices to 
enable healthy living and well-being. While there have been endorsed 
measures that relate to the receipt of clinical preventive services and 
immunization measures across the lifespan, most, but not all, of these 
measures focused on clinical rather than community settings. There are 
measurement gaps in many of the population-level concepts below, 
including social support, unhealthy drinking, obesity, and dental 
health. In the current Population Health Project, NQF will evaluate 
submitted population-level measures that include a focus on healthy 
lifestyle behaviors and community interventions that improve health and 
well-being. A new oral health project will also help to prioritize 
dental concepts and identify gaps in both dental measures and evidence.
[GRAPHIC] [TIFF OMITTED] TN14SE12.015

Making Quality Care More Affordable

    A new area for NQF endorsement is related to cost and resource use. 
Currently, a small number of measures are under NQF review, examining 
some specific clinical conditions as well as the total cost of care for 
patients who interact with the healthcare system in a given year. While 
private payers have captured and reported the associated costs and 
resources used for patients within their systems, these measures had 
not yet been publicly vetted; the current NQF work can pave the way for

[[Page 56953]]

increased transparency as well as the possibility of tracking costs in 
a consistent manner by multiple payers and other interested parties. 
Many challenges remain within this area, specifically enabling 
measurement and reporting of costs/resources at the individual provider 
level, and in the future, pairing these measures with those of quality 
to begin to capture efficiency.
    The NPP's guidance on proposed goals and measure concepts related 
to this priority area appears in the table below. There are important 
measure gaps related to access, per capita expenditures and 
affordability. In addition, development of measures around potential 
overuse of specific procedures may be limited by the available evidence 
in clinical guidelines. However, the overuse measures that have failed 
endorsement to date primarily relate to the lack of availability of the 
detailed clinical information in claims data. Similarly, the ability to 
construct a measure of preventable emergency department use has been 
limited by the availability of data to assess the concept of 
preventability.
[GRAPHIC] [TIFF OMITTED] TN14SE12.016

Identification of Gap Areas Based on Federal Programs' Measure Usage

    The Measure Applications Partnership (MAP) is a public-private 
partnership convened by the National Quality Forum (NQF) for the 
primary purpose of providing input to the Department of Health and 
Human Services (HHS) on selecting performance measures for public 
reporting, performance-based payment programs, and other purposes. In 
its first year, the MAP focused on the availability of measures for 
federal programs and provided input on important measurement gaps. The 
MAP Pre-Rulemaking Report provides input on over 350 measures under 
consideration by HHS for nearly twenty clinician, hospital, and post-
acute care/long-term care performance measurement programs, using the 
six NQS priorities to guide its recommendations. The findings of the 
MAP related to gaps in the federal programs reinforce the gap analysis 
presented in this report. For example, MAP found that most federal 
reporting programs lacked measures in the areas of person and family-
centered care, and cost and appropriateness. Looking specifically at 
clinical areas, MAP also noted a lack of measures in the area of mental 
health. All these findings echo the lack of NQF-endorsed measures in 
these areas as described.
    In part due to MAP's required focus on the federal programs, which 
to date have often been defined by setting of care, the MAP work 
identified gaps by setting or provider type for the clinician, hospital 
and Post-Acute Care/Long Term Care (PAC/LTC) federal reporting 
programs. The high-level measure development and implementation gaps in 
federal programs are included in the table below:

------------------------------------------------------------------------
 
---------------------------------------------------------------------------
                           Clinician Programs
------------------------------------------------------------------------
 Patient-reported outcomes, health-related quality of life.
 Shared decision-making, patient activation, care planning.
 Care coordination.
 Multiple chronic conditions.
 Palliative and end-of-life care.
 Cost including total cost, cost transparency, efficiency, and
 resource use.
 Appropriateness.
------------------------------------------------------------------------
                            Hospital Programs
------------------------------------------------------------------------
 Cost--total cost of care, episode, transparency, efficiency.
 Appropriateness--admissions, treatment.
 Care coordination--transitions of care, readmissions, hand-off
 communication, follow-up.

[[Page 56954]]

 
 Patient-reported outcomes--patient and family experience of
 care and engagement, patient and family preferences, shared decision-
 making.
 Disparities in care.
 Special populations--behavioral health, child health, maternal
 health.
 Quality of life/well-being.
 Pain.
 Malnutrition.
 Palliative Care--comfort, integration of patient values in care
 planning.
------------------------------------------------------------------------
                            PAC/LTC Programs
------------------------------------------------------------------------
 Functional status is a high-priority gap across all programs
 because assessing function and change in function over time is a
 baseline for tailoring care for individuals and population subsets.
 A second prominent gap is measures that incorporate the
 patient, family, and caregiver experience and their involvement in
 shared decision-making.
 Measures that assess if care goals are established using a
 shared decision making process and if those goals are attained.
 Measures understanding how providers use assessment information
 to tailor goals.
 Establishing and attaining care goals.
 Care coordination, including transitions.
 Cost.
 Mental health.
 Nutritional status.
------------------------------------------------------------------------

Gaps Across National Priority Areas by Condition-Specific Areas

    To better highlight gaps areas, NQF further grouped its endorsed 
measures by the following high impact conditions, and reported gaps by 
each condition, mapped to the NQS priority areas. The condition-
specific areas map to the Prioritization of High-Impact Medicare 
Conditions and Measure Gaps report prepared for HHS in 2011, with 
additional high impact areas added to address younger populations 
(e.g., child health, maternal health, and serious mental illness). For 
example, NQF broadened the high-impact condition COPD to include other 
pulmonary conditions (such as asthma.) Finally, related conditions, 
such as acute myocardial infarction and congestive heart failure, have 
been grouped together under the broader term of cardiovascular.

 Alzheimer's Disease
 Cancer
 Cardiovascular
 Cataract
 Child Health
 Depression
 Diabetes
 Glaucoma
 Hip/Pelvic Fracture
 Maternal Health
 Osteoporosis
 Pulmonary
 Renal Disease
 Rheumatoid Arthritis/Osteoarthritis
 Serious Mental Illness
 Stroke

    In addition to categorizing the measures by NQS priority area, the 
measure type (i.e., structure, process, outcome, and composite) have 
been included in these tables. Figure 3 offers a high level analysis of 
measures by clinical system. As evident in the table, there are many 
clinical areas that need further outcome measure development.

[[Page 56955]]

[GRAPHIC] [TIFF OMITTED] TN14SE12.017

    As a result, high-level information is presented below regarding 
gaps in endorsed quality measures within the priority areas identified 
in the NQS. While there are many reasons for the persistent gaps in 
performance measurement described below, many developers who submit 
measures to NQF report that the lack of adequate financial support for 
measure development is a major driver. In addition, measure gaps 
persist due to insufficient evidence (e.g., management and treatment of 
Alzheimer's disease) and methodological challenges related to emerging 
measurement areas (e.g., aggregation of patient-reported outcomes into 
measures appropriate for accountability and quality improvement).

Gaps Across National Priority Areas by Condition-Specific Areas

    For each condition, the shaded spaces in the tables below represent 
areas where there are NQF-endorsed measures addressing NQS priority 
areas, by measure type. The blank spaces represent areas where there 
are gaps in NQF-endorsed measures.

Alzheimer's Disease

    While Alzheimer's is recognized as a critical area for measurement, 
there is a gap in endorsed measures for this condition. There has been 
limited measure development in this area, which was evidenced through a 
request for measures by NQF that resulted in no submissions in 2010. 
Through recent discussions with several developers, NQF has learned 
that some development has begun. Future NQF measure endorsement 
projects will include an opportunity for submission of newly developed 
measures related to Alzheimer's disease.

[[Page 56956]]

[GRAPHIC] [TIFF OMITTED] TN14SE12.018

Cancer

    The set of endorsed cancer measures is primarily oriented to cancer 
screening and effectiveness of treatment for specific cancers. For the 
priority area of prevention, there are process measures addressing 
breast, cervical, and colorectal cancer screening. For this topic, 
there are gaps across all measure types in the healthy living priority 
area. In the person and family centered care priority area, there are 
several process measures and there are measures that specifically 
address the quality of care received at the end of life through 
caregiver surveys. For safer care, there are several process measures 
and a small number of outcome measures. There is a gap in outcomes 
related to cancer survival. There are a small number of overuse 
measures related to affordable care. Gaps related to the quality of 
life and other critical outcomes of care related to patients diagnosed 
with cancer remain. No measures were brought forward to address these 
gap areas in the recent call for measures for the current NQF Cancer 
Endorsement Project.
[GRAPHIC] [TIFF OMITTED] TN14SE12.019

Cardiovascular Care

    NQF has a very large set of endorsed cardiovascular measures 
addressing conditions such as acute myocardial infarction, coronary 
artery disease, and congestive heart failure. There are also endorsed 
process, outcome, and composite measures related to healthy living and 
prevention, including measures that align with the CDC goals in its 
national initiative ``Million Hearts'' to prevent one million heart 
attacks and strokes. While each of the clinical conditions within the 
larger topic area of cardiovascular care has a robust set of measures 
of process and outcome measures, gaps remain in the area of person- and 
family-centered care. As a result of the NQF Patient Outcomes project 
completed in 2011, several composite measures that examine care 
transitions for cardiovascular care are now included in the NQF 
portfolio. In addition, measures that assess coordination of care, such 
as the recently endorsed measure that assesses referral to cardiac 
rehabilitation after a heart attack, are in development. Measures that 
begin to address affordable care are slowly increasing in numbers. For 
example, NQF recently endorsed measures of appropriate use of cardiac 
stress testing as well as measures that capture resources or costs 
associated with specific cardiovascular conditions, but many gap areas 
remain.

[[Page 56957]]

[GRAPHIC] [TIFF OMITTED] TN14SE12.020

Cataract

    While only a handful of measures have been endorsed in the area of 
cataracts, these measures address the outcomes of cataract surgery. 
Complications following surgery and improvement in patients' visual 
function have been targeted. Currently, the measures focus on those 
patients who have had surgery. Future measures should address the 
appropriate selection of treatment of patients with cataracts, ensuring 
that only those patients whose visual function and quality of life is 
compromised receive surgery. There is also a need for measures that 
address cataract outcomes for patients with multiple co-morbid 
comorbidities, including diabetes. These may be examples where the 
evidence base may limit applicability of these measures to more complex 
patients.
[GRAPHIC] [TIFF OMITTED] TN14SE12.021

Child Health

    The number of endorsed measures focused on child health has grown 
in the last year--in part due to a targeted NQF Child Health project 
that was completed in 2011. The portfolio has also expanded to 
accommodate core measures for the CHIPRA program. Similar to Maternal 
Health discussed below, Child Health has many measures focused on 
screening, immunizations, well-child visits, and treatment for specific 
clinical conditions. While there are endorsed outcome measures for 
children, such as those that examine infection, mortality, and 
readmission in the intensive care units, they are primarily hospital 
focused rather than ambulatory. In terms of affordable care, there is a 
measure focused on length of stay in pediatric intensive care units and 
a measure of emergency department visits for children with asthma, both 
of which address use of resources.
    An opportunity exists to increase the number of measures that apply 
to children by adapting adult-focused measures to apply to younger 
ages. This gap is very dependent on measure developers' willingness to 
apply measures to younger populations, but age-based population limits 
and this limitation should only occur when the evidence does not 
support the expansion to those under 18 years of age. In January 2011, 
NQF released a report from the Measure Prioritization Advisory 
Committee focused on measure development and endorsement agenda that 
identified child health gaps in the areas of care coordination 
(transitions, referrals, medical homes); acute and chronic management 
(health promotion, community resources, timely and appropriate follow-
up of screening tests); and population health outcomes.

[[Page 56958]]

[GRAPHIC] [TIFF OMITTED] TN14SE12.022

Depression and Serious Mental Illness

    There is a growing set of endorsed outcome and process measures 
that address depression. There are some endorsed measures that address 
Healthy Living and Prevention (e.g., maternal depression screening, 
suicide risk assessment). In NQF's Patient Outcomes project, measures 
looking at whether remission of symptoms was achieved at 6 and 12 
months were recently endorsed--a step toward assessing patient outcomes 
related to depression. Many gaps remain specific to person- and family-
centered care. There are also a small number of endorsed process 
measures related to safer care in the areas of medication management 
and evaluation and assessment for major depressive disorder. There are 
a limited number of measures that assess coordination of care, such as 
persistent use of needed antidepressants, as well as follow-up care 
after hospitalization.
    There are many measurement gaps for patients with serious mental 
illness. Currently, only measures specific to schizophrenia and bipolar 
disease are endorsed, leaving many other mental health conditions 
unaddressed. There are endorsed process measures that address 
prevention and safer care (e.g., screening for potential comorbidities 
for patients with bipolar disorder, use of multiple antipsychotic 
medications). However, gaps remain specific to other priorities. There 
is an endorsed patient experience of care measure for inpatient 
psychiatric care and a set of measures that assess transition from 
inpatient to outpatient care. Measure gaps relate to affordability, 
such as potential measures that assess overuse of multiple 
antipsychotic medications. There are also important population health 
gaps for serious mental illness, including measures that would address 
issue of social support and homelessness. NQF anticipates that 
additional measures related to serious mental illness will be submitted 
in the upcoming Behavioral Health project.
[GRAPHIC] [TIFF OMITTED] TN14SE12.023

Diabetes

    While NQF has endorsed multiple diabetes measures, they are 
primarily oriented to prevention and healthy living, including two 
composite measures that address both processes and intermediate 
outcomes for patients with diabetes. In healthy living, there are also 
population-level measures that assess potentially preventable 
admissions for diabetic complications. While there are measures that 
address the treatment of patients with the disease, measures have not 
yet been developed or endorsed that adequately

[[Page 56959]]

address the pediatric population or primary screening and prevention of 
diabetes for high-risk individuals. Many of these gaps are due to the 
lack of consistent, strong evidence on appropriate screening and 
treatment. In the current NQF Resource Use project, a recently endorsed 
measure captures the relative resource use for patients with diabetes. 
This measure should allow implementers including payers to identify the 
costs and resources associated with this chronic illness.
[GRAPHIC] [TIFF OMITTED] TN14SE12.024

Glaucoma

    Two measures have been endorsed in the area of glaucoma that 
address appropriate evaluations and the reduction of intraocular 
pressures. Many gaps remain, including addressing patients' quality of 
life, experience with care, care coordination, and education related to 
treatments.
[GRAPHIC] [TIFF OMITTED] TN14SE12.025

Hip/Pelvic Fracture

    There is a limited set of endorsed measures that address hip and 
pelvic fracture. Two outcome measures were recently endorsed that 
target the rate of complications and readmissions after hip surgery. 
There is also an endorsed measure that examines the mortality rate 
related to these fractures. Beyond these three outcomes measures, the 
NQF portfolio includes measures that address osteoporosis screening and 
treatment with several specifically targeting those patients who have 
had a hip or pelvic fracture. Those measures are captured within the 
discussion and analysis of osteoporosis and are not reflected in the 
table below. Many gaps remain related to the coordination of care and 
person/family centered care. For affordable care, resource use measures 
related to hip fracture are under consideration in the current NQF 
Resource Use Project.

[[Page 56960]]

[GRAPHIC] [TIFF OMITTED] TN14SE12.026

Maternal Health

    NQF has a growing set of endorsed measures that relate to maternal 
health. There are several important process measures, such as ensuring 
adequate screening, prenatal and postpartum visits, and appropriate 
treatment during delivery. Several measures related to appropriate 
processes or intermediate outcomes during labor and delivery (e.g., use 
of prophylactic antibiotics and health-care acquired infections in the 
newborn) are linked to the priority area of Safer Care. There are 
measures that relate to affordable care, such as the rate of Cesarean 
sections for first-time mothers and elective deliveries prior to 39 
weeks. One significant area for which measures may be in development 
but have not yet been submitted to NQF is related to reproductive 
health.
[GRAPHIC] [TIFF OMITTED] TN14SE12.027

Osteoporosis

    Few measures have been endorsed in the area of osteoporosis. To 
date, those measures have focused on appropriate screening and 
treatment, such as endorsed measures that target appropriate screening 
or treatment following a fracture, or general screening of women at 
risk. Significant gaps remain in areas that assess patients' quality of 
life and functional status and care coordination, in addition to the 
dearth of outcomes measures and the lack of applicability of the 
current measures to men.

[[Page 56961]]

[GRAPHIC] [TIFF OMITTED] TN14SE12.028

Pulmonary

    For the purpose of this report, pulmonary conditions include 
asthma, chronic obstructive pulmonary disease (COPD), and pneumonia. 
There are many process measures that examine care for adults and 
children with asthma, measures of appropriate use of medications to 
prevent and treat exacerbations of COPD, and outcome measures related 
to mortality and readmission for pneumonia. Several outcome measures 
for pulmonary conditions were recently endorsed through the NQF Patient 
Outcomes project, including care transitions for patients with 
pneumonia and quality of life for patients with COPD in pulmonary 
rehabilitation programs. While some measures looking at safer care and 
person/family centered care have now been endorsed, measures related to 
other pulmonary conditions or applicable to broader settings are 
needed.
[GRAPHIC] [TIFF OMITTED] TN14SE12.029

Renal Disease

    There is a broad set of measures related to End Stage Renal Disease 
(ESRD) and a small but emerging set of measures related to chronic 
renal disease. NQF has endorsed several process and outcome measures on 
this topic, in the priority area of Healthy Living and Prevention. As 
part of a recent End Stage Renal Disease (ESRD) endorsement project, a 
CAHPS measure was endorsed that assesses patient experience with in-
center hemodialysis. There are also multiple outcome measures related 
to adequacy of dialysis and infection rates. Evidence continues to 
evolve regarding the appropriate target hemoglobin for patients with 
ESRD. Due to the black box warning issued by the FDA and continued 
changes to what hemoglobin levels are considered safe targets, NQF and 
its committees have been reluctant to endorse measures for which the 
evidence is not yet consistent to support a performance measure. 
Additional gaps remain related to care coordination and affordable 
care.

[[Page 56962]]

[GRAPHIC] [TIFF OMITTED] TN14SE12.030

Rheumatoid Arthritis/Osteoarthritis

    Few measures have been endorsed in the areas of rheumatoid 
arthritis and osteoarthritis. To date, those measures have focused on 
appropriate screening and treatment. For example, NQF has endorsed 
measures related to medication safety for patients with rheumatoid 
arthritis as well as measures that focus on ensuring appropriate 
follow-up and testing to prevent toxicity. Significant gaps remain in 
areas that assess patients' quality of life and functional status and 
care coordination. There is also an absence of outcomes measures such 
as functional status.
[GRAPHIC] [TIFF OMITTED] TN14SE12.031

Stroke

    Within stroke, there are endorsed process and outcome measures 
related to prevention, safer care and care coordination. Within safer 
care, there are outcome measures related to potentially avoidable 
complications and mortality after stroke. NQF has also endorsed primary 
prevention related measures, such as anticoagulation for patients with 
atrial fibrillation and secondary prevention related measures, such as 
use of statins. There are multiple measures that assess the appropriate 
care and screening for patients after stroke, including issues related 
to anticoagulation and ongoing need for speech therapy. There is a 
single endorsed measure related to stroke education, but no endorsed 
measures that assess person and family centered care. There are also 
gaps in measures in the healthy living and affordable care priority 
areas. While NQF has not previously endorsed measures related to 
affordable care, there are stroke-related resource use measures 
currently in the NQF endorsement process.

[[Page 56963]]

[GRAPHIC] [TIFF OMITTED] TN14SE12.032

Conclusion

    While the NQF portfolio of endorsed measures can address many 
important priority area and high priority clinical conditions, there 
are many gaps that remain. While many measure gaps could be filled with 
measure development, there would be a small sub-set where development 
would be limited by available evidence. Another important impediment to 
measure development in many high priority areas relates to the lack 
high quality data for measurement. The move toward an electronic data 
platform should help increase capacity to measure some of these 
important concepts. Collectively, the NPP, MAP and endorsement-related 
work provide a roadmap to where measures are needed to fill many 
important gaps. This report can be used to target measure development 
resources to areas where there are critical development gaps.

Appendix of Measures Included Within the Condition-Specific Areas

Alzheimer's Disease

    * There are no measures in the portfolio for this condition.
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IV. Secretarial Comments on the Annual Report to Congress

    The Secretary is pleased with the scope and vision of NQF's March 
2012 annual report to Congress (the ``annual report''). An internal 
multidisciplinary cross-component HHS team is working collaboratively 
with NQF to provide for a clear multi-year vision to ensure the most 
efficient and effective utilization of the HHS contract. The contract 
with NQF provides an important opportunity to further enhance HHS' 
efforts to foster a collaborative, multi-stakeholder approach to 
increase the availability of national voluntary consensus standards for 
quality and efficiency measures.
    Over the past year NQF continued work on tasks outlined in the 
Statement of Work, including: Providing additional input on the 
development of a national strategy for performance measurement and 
prioritization of measures for development and endorsement; conducting 
measure endorsement projects focused on measure gap areas such as 
outcomes measures and patient safety measures; maintaining current NQF-
endorsed measures; promoting Electronic Health Records through 
activities that include developing a measure authoring software tool; 
and retooling of a subset of existing NQF-endorsed measures into 
electronic measure format. NQF provided input on the implementation of 
the national priorities of the National Strategy for Quality 
Improvement in Healthcare (NQS). The NQF convened the National 
Priorities Partnership (NPP) and delivered a report that focused 
further on enhancing patient safety, one of the six NQS priorities. The 
NPP worked with HHS on the Partnership for Patients initiative. The

[[Page 56983]]

NQF continued its endorsement of quality measures for use in 
accountability and performance improvement with a focus on crosscutting 
measures and measures addressing costly and prevalent health 
conditions. NQF convened the Measure Applications Partnership (MAP) to 
foster alignment of measures in order to reduce reporting burden and 
accelerate improvement in reporting. The MAP provided pre-rulemaking 
guidance to HHS, including input on the selection of quality and 
efficiency measures.
    The Secretary has reviewed the annual report and has the following 
comments. First, the Secretary notes an inadvertent statement in the 
annual report. The statement appears in the third sentence of the first 
paragraph on page 16 of the Report to Congress under the section 
entitled ``3. Endorsing Measures and Developing Related Tools''. It 
refers to NQF-endorsed measures and states they have ``special legal 
standing''. The suggestion that NQF-endorsed measures enjoy ``special 
legal standing'' is ambiguous and could be misinterpreted. Numerous 
statutory provisions in the Social Security Act (the ``Act'') require 
the Secretary to specify measures for quality programs that have been 
endorsed by the consensus-based entity with a contract under section 
1890(a) of the Act. NQF currently holds this contract and the Secretary 
often selects NQF-endorsed measures for quality programs. Nonetheless, 
the suggestion that these measures ``have special legal standing'' does 
not describe the significance of NQF endorsement for measures the 
Secretary selects. In addition, this statement oversimplifies the 
complex intellectual property concerns that frequently attend federal 
agency use, adoption, and dissemination of NQF-endorsed measures.
    Second, the Secretary wishes to clarify a statement that has the 
potential to be misleading. This statement appears in the final 
sentence of the first full paragraph on page 7 of the Report to 
Congress and states: ``As it turns out, NQF has already endorsed 
measures for medication reconciliation, readmission, and care 
transitions that apply to additional settings and populations so these 
measures can move right into other federal programs.'' This sentence is 
vague and the reference to measures moving `right into other federal 
programs' does not accurately describe the process by which measures 
are selected for use in quality programs.
    Third, the Secretary also wishes to clarify a statement in the 
sentence in the middle of the second column in ``Sidebar 5: Harmonizing 
Surgical-Site Infection Measures'' on page 20 of the Report to 
Congress. The sentence states: ``Notably, CMS has selected this 
harmonized measure for inclusion in the 2012 final rule of the 
Inpatient Prospective Payment System (IPPS).'' This sentence suggests 
that the referenced measure--Surgical Site Infection--was included in 
Fiscal Year 2012 Inpatient Prospective Payment System (IPPS)/Long term 
Care Hospital Prospective Payment System final rule as part of the 
payment for the IPPS program, when in fact this measure was finalized 
in that rule for use in the Hospital Inpatient Quality Reporting 
(``Hospital IQR'') program.
    Fourth, the section entitled ``Eight Years of Hospital Reporting 
Show Results'' on page 31 of the Report to Congress discusses 
simultaneous reporting on measures by hospitals to the Centers for 
Medicare & Medicaid Services (``CMS''), presumably for the Hospital IQR 
program, and to the Joint Commission for hospital accreditation. 
Although there may be some overlap in the measures on which hospitals 
report to CMS and the Joint Commission, this section suggests that CMS 
and the Joint Commission run the Hospital IQR program together, which 
is not the case.
    Fifth, the Secretary notes some ambiguity with respect to the 
description of funding that NQF receives from the MIPPA and the 
Affordable Care Act. Specifically the language in the Report to 
Congress implies that the two laws directly appropriated funds to the 
NQF, which is not accurate. The NQF receives MIPPA and Affordable Care 
Act funding through a contract from HHS. In addition, regarding the 
first bullet point before the text box entitled `Working with NQF 
Helped Spur Rapid Evolution of Ophthalmology Measures,' the Secretary 
clarifies that section 3014 of the Affordable Care Act amended section 
1890(b) of the Social Security Act by adding paragraphs (7) and (8), 
which require NQF to convene multi-stakeholder groups to provide input 
on the selection of quality and efficiency measures and national 
priorities for improvement in population health and the delivery of 
healthcare services for consideration under the national strategy, and 
to transmit the multi-stakeholder group input to the Secretary.
    Sixth, the Secretary also wishes to note that section 3014 of the 
Affordable Care Act added additional items that must be included in the 
report that the consensus-based entity submits to Congress and the 
Secretary that are not included in the last bullet in the narrative 
prior to the next section, `2 Bridging Consensus About Improvement 
Priorities and Approaches,' of the Report to Congress. Section 3014 of 
the Affordable Care Act amended section 1890(b)(5)(A) of the Social 
Security Act to require that the report submitted to Congress and the 
Secretary identify gaps in endorsed quality and efficiency measures, 
including gaps in priority areas identified in the national strategy, 
instances where quality and efficiency measures are unavailable or 
inadequate to address such gaps, areas in which evidence is 
insufficient to support endorsement of quality and efficiency measures, 
including priority areas, as well as the input provided by multi-
stakeholder groups on the selection of quality and efficiency measures 
and the national priorities.
    Finally, the Secretary wishes to clarify the first sentence in the 
second paragraph on page 1 of the Overview section of the NQF Report on 
Measure Gaps and Inadequacies. Section 3014 of the Affordable Care Act 
amended section 1890(b)(5)(A) of the Act to add additional topics to 
the items that must be described in the Report to Congress, but these 
amendments did not change the date by which the entity with a contract 
is required to submit the Report to Congress and the Secretary. That 
date is March 1 of each year (beginning in 2009), not February 1, 2012 
and annually thereafter, as the addendum states.
    The Secretary is pleased with the progress and timeliness of the 
work outlined in the Annual Report.

V. Future Steps

    HHS provided a four-year contract to NQF. During this performance 
year of the contract, NQF completed deliverables for each task required 
by section 183 in MIPPA and by section 3014 in Affordable Care Act. In 
the final year of the contract, HHS will continue to task NQF with 
projects than can be completed wholly or partially by the expiration of 
the current contract. In addition, HHS will develop a contract 
mechanism to support the Affordable Care Act-required work needed 
through FY2014.

Maintenance of Consensus-Based Endorsed Measures

    During January 14, 2012 to January 13, 2013, NQF will maintain 
endorsed measures relevant to HHS-wide programs and will continue to 
maintain consensus-based endorsed measures as developed under the 
priority process. Maintenance of NQF-endorsed measures encompasses five 
areas: (1) Review of time-limited measure results, (2) annual updates, 
(3) endorsement maintenance

[[Page 56984]]

projects, (4) ad hoc reviews, and (5) education to measure developers 
on endorsement maintenance activities. In 2012, 42 time-limited 
endorsed measures are expected to undergo NQF review while 276 measures 
will require annual updates. Measures in these topical areas are 
undergoing endorsement maintenance: Cardiovascular, surgery, 
palliative/end-of-life-care, renal, perinatal, cancer, and pulmonary/
critical care measures. In addition, NQF will begin endorsement 
maintenance projects for the following four topics: Gastrointestinal/
genitourinary; infectious diseases; neurology; head, ears, eyes, nose 
and throat (HEENT). Finally, NQF is prepared to undertake ad hoc 
endorsement reviews as needed and will be hosting web-based educational 
events on its endorsement maintenance activities.

Promotion of Electronic Health Records

    In 2012, NQF will continue to support the promotion of electronic 
health records as part of HHS-wide efforts. NQF's contributions will 
include enhancements of the Quality Data Model, which specify the 
necessary data for electronic and personal health records. NQF will 
continue hosting and enhancing the Measure Authoring Tool, and will 
provide technical assistance and support to tool users. NQF will also 
maintain an online Knowledge Base of information gleaned during the 
eMeasure retooling process of 2011, the subsequent comment and updating 
process, and the ongoing consulting activities that began in 2011. The 
Knowledge Base will be available on the NQF Web site for public use and 
updated at a minimum on a monthly basis to highlight new critical 
issues that are identified. The content of the Knowledge Base will 
support educational requirements for measure developers, measure 
implementers, EHR vendors, clinician, health care organizations, health 
information exchanges, and others as new stakeholders are identified. 
In addition, NQF will help HHS transition the Measure Authoring Tool to 
HHS for continued hosting and enhancements.

Focused Measure Development, Harmonization, and Endorsement Efforts To 
Fill Critical Gaps in Performance Measurement

    In 2012, NQF will finish endorsement efforts focused on efficiency/
resource use measures and regionalized emergency care services. In 
addition, NQF will perform an assessment of need among key stakeholders 
for a measure registry, a system capturing the lifecycle of a measure 
with capability to track versions of measures as they proceed through 
their lifecycle. Such a registry could assist measure developers and 
users to better identify measures in development, especially those 
identified as filling critical gaps, and how measures are similar and 
different version to version. General issues/concerns regarding 
establishing, using, and maintaining a registry (e.g., intellectual 
property, data quality, incentives for use) will be explored specific 
to health care performance and cost measures.

Convening Multi-Stakeholder Groups

    NQF will continue work to provide further input into the National 
Quality Strategy and annual selection of quality measures for use in 
public and private reporting programs and value-based purchasing 
programs.

V. Collection of Information Requirements

    This document does not impose information collection and 
recordkeeping requirements. Consequently, it need not be reviewed by 
the Office of Management and Budget under the authority of the 
paperwork Reduction Act of 1995 (44 U.S.C. 35)

    Dated: August 27, 2012.
Kathleen Sebelius,
Secretary, Department of Health and Human Services.
[FR Doc. 2012-22379 Filed 9-13-12; 8:45 am]
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