Posts tagged National Quality Forum

The Devil Is in the Denominator

To improve quality, whom we measure is as important as what.

by Joe Rotella, MD, MBA, FAAHPM

The growing awareness in America that our healthcare system is unaffordable and fails to deliver consistent quality has led us to healthcare reform, mandatory quality reporting, pay-for-performance, and Accountable Care Organizations (ACOs). We need good measures of quality healthcare so we can direct our limited resources where they provide the most value. We would do well to pay particular attention to the quality of care near the end of life. As Ellen Goodman noted in her recent Harvard Business Review article “Die the Way You Want To”, 25% of Medicare expenditures are incurred by the 5% who are in their last year of life. Surely we can deliver more value by increasing quality of life and decreasing futile medical interventions for these patients.

It makes sense that we should measure quality in order to improve it, but figuring out exactly how can be a real devil. We often focus on what we should measure—the numerator, but whom—the denominator—is just as important. Working on the AAHPM Quality and Practice Standards Task Force this past year has been an eye-opening experience for me. Wading through ponderous technical documents describing a host of proposed national quality measures, I was struck with how hard it is to design a really good one. The National Quality Forum (NQF) recently recommended a set of quality measures for hospice and palliative care. The NQF only recommends measures with well-defined methodologies validated for the specific populations under consideration. Many employ a narrow denominator, e.g. hospice patients rather than dying patients. It’s a good start, but I hope policymakers and payers will be careful in how they incorporate them into mandatory quality reporting systems. Measuring only hospice patients in order to improve the quality of end-of-life care is like searching for a lost dollar bill only where the light is good. The real payoff may be lurking in that dark corner.

For example, the best set of quality measures we have for end-of-life care so far, the Family Evaluation of Hospice Care (FEHC), has only been validated for hospice patients. When we apply the FEHC to hospices, we can compare the quality of Hospice A with that of Hospice B. That might be good enough if most dying patients received hospice care, but the National Hospice and Palliative Care Organization reports in its 2011 Facts and Figures that only 42% of those who died in 2010 were enrolled in hospice. So what about the quality of end-of-life care for the majority of patients who die in hospitals, skilled nursing facilities and homes without the benefit of hospice care? How can we measure that?

Current and proposed mandatory quality reporting programs perpetuate the silos in our healthcare delivery system. Since hospitals are designed for treating acute, potentially-reversible problems, they report post-discharge, patient-rated satisfaction surveys that totally miss the experience of the many patients who die during their stay. Likewise, we see skilled nursing facilities as places for rehabilitation, so we require a Minimum Data Set that focuses on restoration of function, even though many patients languish and die there. Since hospice is the place for dying, that’s where we’ll mandate reporting of end-of-life quality measures, but that’s not going to improve the quality of dying where most of it happens.

The Medicare final rule creating ACOs requires them to report on 33 quality measures linked to how much they can share in any savings. Despite the striking disproportion of Medicare dollars spent in the last year of life, none of these measures has anything to do with comfortable dying or the appropriate utilization of hospice or palliative care. In the original 127-page proposed ACO rule, the word “hospice” appeared once and “palliative” not at all. Comments from the AAHPM and others must have been heard, because the terms appear about a dozen times in the final rule. It’s a step in the right direction, but we have a long way to go. We need researchers to develop and validate quality of life and quality of dying measures for all relevant care settings. Once available, we should push for their inclusion in all mandatory quality reporting and pay-for-performance systems. We’ll never get the maximum value for the Medicare dollar without it.

JPSM Call for QI Papers Closes April 15

The Journal of Pain and Symptom Management is pleased to announce a call for papers that report the results of Quality Improvement initiatives in palliative care.

This publication of brief reports is a joint project of the American Academy of Hospice and Palliative Medicine and the National Hospice and Palliative Care Organization. Papers focusing on hospice and palliative care settings are encouraged.

The Journal offers this professional forum to encourage dialogue, peer review, and dissemination in response to a growing international concern about quality care, patient safety, and the role of evidence-based medicine. Submissions should describe specific Quality Improvement projects, such as efforts to increase pain screening, encourage goals discussions, promote palliative care consults, encourage earlier hospice referrals, or support staff well-being. Submissions must describe the impact of the intervention, either in terms of change over time or relative to a comparator.

Papers will be considered Brief Reports and must include the following:

1) A structured abstract of <150 words with five headings: Background, Measures, Intervention, Outcomes, Conclusions/Lessons Learned.

2) Five sections—Background, Measures, Intervention, Outcomes, Conclusions/Lessons learned—requiring no more than 1,250 words

3) No more than 10 references and two graphs or tables. (References/tables/ graphs are not included in the word count.)

4) A cover letter specifying that the Brief Report is being submitted in response to this Call for Papers.

Papers that fulfill the length and formatting requirements will undergo preliminary review by the Editors, and some will undergo external peer review. Acceptance for publication will depend on evaluation of the problem addressed, innovation, quality of the description, and clinical relevance of the intervention and outcomes.

Manuscripts submitted in response to this announcement should be submitted online to the Journal of Pain and Symptom Management (http://ees.elsevier.com/jps/) by April 15, 2011.

For questions regarding format or content of potential manuscripts, please contact Dr. David Casarett (Casarett@mail.med.upenn.edu).

Academy Voices Vital Role of Palliative and Hospice Care in Improving Quality of Health Care

Many health care initiatives launched by the Affordable Care Act focus on improving the quality of health care. The Academy and its members have been participating in these efforts, trying to bring wider visibility to the role that palliative care and hospice care can play in improving the quality of health care for patients with serious, advanced illness. Here’s a brief recap of some of the recent activity:

  • The Palliative Care and End-of-life Care workgroup of the National Priority Partners, (convened by the National Quality Forum), held an all day workshop on November 2 to come up with priorities to promote the diffusion of palliative care throughout the health care system. Numerous AAHPM members either presented or participated, including Sean Morrison, Sarah Friebert, Javier Kane, Karl Lorenz, Christine Ritchie, and Joan Teno. Diane Meier presented the opening overview, examining the current state of palliative and hospice care services and opportunities to improve access and close performance gaps. The speakers’ slides are posted on the NPP website.
  • AAHPM submitted comments to the Secretary of HHS on the National Health Care Quality Strategy and Plan. AAHPM’s public policy advisors see this plan as a critical document that will likely guide how federal energy and resources are spent over the next several years. AAHPM’s comments (which other Hospice and Palliative Care Coalition member organizations also submitted) made two main recommendations:
    • Add focus on patient-centered care guided by palliative care principles to measurement and accountability for all providers serving seriously ill patients.
    • Assure that specialty level palliative care and hospice services are broadly available and of demonstrably high quality.

Specific actions needed to achieve the above goals were also specified.

  • AAHPM also submitted comments (as part of the Hospice and Palliative Care Coalition) on the National Quality Forum measure gap agenda. Incredulously, the committee that ranked priorities for measures needed over the next few years ranked palliative care LAST. It received ZERO votes! The Coalition said in its comments: “the Coalition urges the NQF to recognize the urgency of making palliative care measures a high priority on the national measure development agenda.”

AAHPM’s Quality Task Force, chaired by Sydney Dy, would appreciate hearing from you about how we are articulating the need for quality palliative and hospice care. Please leave a comment and let us know whether you think we are succeeding in making the case.


Heads up!! Calling all measure geeks!! Save the date: NQF call for measures planned for November 2010

This post was co-authored by Dale Lupu, PhD and Sydney Dy, MD

The National Quality Forum (NQF) is planning to issue a call for measures relevant to hospice and palliative care some time late in 2010, probably November. This is a critical opportunity to advance quality measurement for our field. (Hopefully, quality improvement follows on the heels of measurement.) Any of you who have submitted measures to NQF in the past know that quite a bit of effort goes into filling out the measure submission form, so we wanted to give you some advance notice as you think about the workload for yourself and your team going into the fall. Once NQF issues the call for measures, you will have 30 days to submit the forms. Here are links to general information on the NQF measure submission and endorsement process:

Every measure endorsed by NQF has to have a measure steward. The measure steward is responsible for making the necessary updates to the measure, and for informing NQF about any changes that are made to the measure on an annual basis. The measure steward is also responsible for providing the required measure information for the measure maintenance process that occurs approximately every three years.

If your organization has developed quality measures that you are finding useful in guiding quality improvement within hospice and palliative care, please consider submitting the measure(s) to NQF in the fall. It is very important that NQF receive a strong and robust set of measures to consider for endorsement. NQF endorsed measures form the backbone of pay for performance and value-based purchasing efforts that will likely impact more and more on hospice and palliative care in the coming years. The field needs a strong set of endorsed measures to move quality improvement efforts forward.

For those of you who fit the category of “measure user” more than “measure developer” – take heart. When it is finished, the results of this NQF project will be an important resource for you. A clear set of NQF endorsed measures in palliative and hospice care will make it easier for you to select and promote measures in your own setting. Begin laying the groundwork now for eventual implementation by spreading the word to the quality gurus in your organization that NQF endorsed palliative care measures are on the way for 2011.