NATIONAL CONSENSUS NATIONAL CONSENSUS STANDARDS FOR STANDARDS FOR

PHYSICIAN PHYSICIAN PERFORMANCE: ROUND 1PERFORMANCE: ROUND 1

Kenneth W. Kizer, M.D., M.P.H.President and CEO

National Quality Forum

August 22, 2005

Presentation Overview

Provide some context for physician performance standards

Provide an overview of the NQF Ambulatory Care PM Project:

What has occurred to date?What is forthcoming?

THE IDEA OF HAVING

STANDARDS FOR PHYSICIAN

PERFORMANCE IS NOT NEW

“If a physician make a large incision with the operating knife and cure it,…, he shall receive ten shekels in money.

If a physician make a large incision with the operating knife, and kill him,…, his hands shall be cut off.”

Code of Hammurabi, 1870 BC

The Quest for Healthcare The Quest for Healthcare QualityQuality

TODAY’S INCREASED ATTENTION TO

HEALTHCARE QUALITY IS BEING

DRIVEN BY AN UNPRECEDENTED

CONFLUENCE OF FORCES

Healthcare Quality Healthcare Quality Improvement Driving Improvement Driving

ForcesForces

1. Knowledge of deficiencies2. Rising healthcare

expenditures3. Purchaser activism 4. Consumerism5. Regulation and accreditation

A CROWDED FIELD

Who are the “players” Who are the “players”

in the performance in the performance

measurement and measurement and

quality improvement quality improvement

game?game?

A partial list of the Alphabet Soup of

PM/QI-Related OrganizationsJCAHO NCQA CMSIOM AHRQ FDA NQF CDC QIOsHQA GAO PCPIOPM NBCH ACQALeapfrog MedPAC ACMQ IHI WBGH PBGHQUIC UHC ABMS

Lots of Signals…..

BUT

Little Direction

Lots of Signals…..

BUT

Little Direction

There is need for a single There is need for a single national entity to be the national entity to be the steward for healthcare steward for healthcare

performance measurement and performance measurement and quality improvement.quality improvement.

The The

NATIONAL QUALITY FORUMNATIONAL QUALITY FORUM

(NQF)(NQF)

NQF-ENDORSED NQF-ENDORSED

CONSENSUS STANDARDSCONSENSUS STANDARDS

Appoint Steering CommitteeAppoint Steering Committeeand Technical Advisory Panels and Technical Advisory Panels

Identify (open call) and Evaluate measures, etc.;

Propose candidate voluntaryconsensus standard (VCS)

Review and Revise

Board of Directors,NQF Staff & Management

Member Councils,Non-member External Entities

Vote by Member Councils

Member Councils,Member Organizations,

Public

Steering Committee with NQF Staff

(any entity can proposemeasures, etc., for

consideration

NQF ( nominations from membership and public)

Member Organizations

Approved by AllMember Councils

Review and Revisionof unapproved

VCS

Member Councils,Member Organizations,

Public

Repeat Vote

Approved by 0 or 1 Council(no further action)

Approved by at least 2 Councils

Board of Directors Vote

Members and Nonmembersdirectly and materially affected

by VCS

Appeals of Board-endorsed VCS

NQF-Endorsed Voluntary Consensus Standard

Board of Directors

Conceptualize and Plan Project

Review and Revisionof unapproved

VCS

NQFNQF Consensus Development Process

NQF National Consensus Standards:

Patient Safety Patient Safety Strategic Priorities (2001)

Serious Reportable Adverse Events (2002)

Safe Practices (2003)

Standardized Patient Safety Taxonomy (2005)

Improved Medication Use Recommendations (2005)

Improved Informed Consent Process (2005)

NQF National Consensus Standards: Institutions/Settings

of CareAcute Care Hospital National

Performance Measures Initial Set (2003) Nursing Care PMs (2004) Cardiac Surgery PMs (2004) Coordination of Care PMs (2005) Mortality for AMI, CHF and CAP (2005) HCAPHS (2005)

NQF National Consensus Standards: Institutions/Settings

of Care Nursing Home Care Performance

Measures (2002, 2004)

Home Care PMs (2005)

Palliative and Hospice Care Framework (2005)

Ambulatory Care (2004-2008)

Dialysis Centers/ESRD (2006)

NQF National Consensus Standards:

Conditions/Populations Diabetes (2002, 2005)

Cancer Care Quality Measures (2004-2007)

Deep Venous Thrombosis (2005-2007)

Child Healthcare PMs (?2006)

Behavioral Healthcare PMs (2005-2006)

NQF National Consensus Projects

National Priorities for Healthcare Quality Measurement and Reporting

15 Healthcare conditions priorities

5 Process of care priorities

2 Infrastructure priorities

NATIONAL CONSENSUS NATIONAL CONSENSUS

STANDARDS FOR STANDARDS FOR

AMBULATORY CAREAMBULATORY CARE

NQF National Consensus Standards: Ambulatory Care

Project Phase I (2004) – Identify priority areas

Phase II (2005) – Expedited consensus of existing ambulatory care PMs

Phase III (2005-2008) – Flesh out all 12 priority areas; four cycles

National Consensus Standards for Ambulatory Care: Phase I -

Priority Areas Patient experience with care Coordination of care Asthma

Prevention, including immunization Medication management Ischemic heart diseaseDiabetesHypertensionDepressionObesity

National Consensus Standards for Ambulatory Care: Additional

Priority Areas

Prenatal care

Bone conditions

National Consensus Standards for Ambulatory Care: Phase II

36 physician-focused PMs endorsed in seven priority areas (8/3/05)

6 measures will undergo a second round of voting

2 measures not endorsed will be re-considered in Phase 3

NQF-EndorsedTM

Ambulatory Care Consensus Standards

Asthma/Respiratory Illness (4) Behavioral Health/Depression (3) Bone Conditions (2) Heart Disease—CAD(10), CHF (7) Hypertension (2) Prenatal Care (2) Prevention, Immunization, and Screening

(6)

NQF-EndorsedTM

Ambulatory Care Consensus Standards

• Asthma/Respiratory Illness

– Asthma assessment

– Asthma: pharmacologic therapy

– Appropriate treatment for children with upper respiratory infection

– Appropriate testing for children with pharyngitis

NQF-EndorsedTM

Ambulatory Care Consensus Standards

• Behavioral Health/Depression– Optimal practitioner contacts for

medication management– Effective acute phase treatment– Effective continuation phase treatment

• Bone Conditions– Osteoarthritis: assessment for use of

anti-inflammatory or analgesic over-the-counter medications

– Osteoarthritis: functional and pain assessment

NQF-EndorsedTM

Ambulatory Care Consensus Standards

• Heart Disease—Coronary artery disease– Symptoms and activity– Cholesterol screen– Lipid profile– Drug therapy for lowering low-density

lipoprotein (LDL) cholesterol– Cholesterol control– LDL cholesterol level– Anti-platelet therapy– Beta blocker therapy–prior myocardial

infarction– ACEI/ARB therapy– Smoking cessation and smoking cessation

intervention      

NQF-EndorsedTM

Ambulatory Care Consensus Standards

• Heart Disease—Congestive heart failure

– Left ventricular function (LVF) assessment

– Weight measurement– Assessment of clinical symptoms of

volume overload– Assessment of activity level– Beta blocker therapy– ACEI/ARB therapy– Warfarin therapy for patients with

atrial fibrillation

NQF-EndorsedTM

Ambulatory Care Consensus Standards

• Hypertension

– Plan of care– Controlling high blood pressure

• Prenatal Care– Anti D immune globulin– Screening for human

immunodeficiency virus (HIV)

NQF-EndorsedTM

Ambulatory Care Consensus Standards

• Prevention, Immunization, and Screening– Tobacco use and tobacco cessation – Advising smokers to quit, discussing

smoking cessation medication, and discussing smoking cessation strategies

– Discussing urinary incontinence and receiving urinary incontinence treatment

– Flu shot for older adults and flu shot for adults ages 50-64 years

– Influenza vaccination– Pneumonia vaccination   

Phase II Measures in 2nd Round of Voting

Use of appropriate medications for people with asthma

Coronary artery disease: Beta-blocker treatment after a heart attack

Childhood immunization Breast cancer screening Colorectal cancer screening Cervical cancer screening

National Consensus Standards for Ambulatory Care: Phase III

Cycle 1 (Fall 2005): care coordination, medication management, obesity, asthma, hypertension, prevention

Cycle 2 (Spring 2006): patient experience with care, heart disease, bone conditions, prenatal care, behavioral health, diabetes

National Consensus Standards for Ambulatory Care: Phase III

Cycle 3 (2006-2007): special ambulatory settings of care (i.e., ambulatory surgical centers)

Cycle 4 (2007-2008): development of index/composite measures

National Consensus Standards for Ambulatory Care: Project

DeliverablesSets of endorsed consensus standards

Recommendations for implementation and research issues for each set.

Commissioned background paper on barriers to small group (< 5), provider-level implementation

Index(es)/composite(s) for ambulatory care measurement and reporting.

Workshop to guide ambulatory care measurement research, development, and testing