AQA-HQA Steering Committee Meeting
August 4, 2006
Key Highlights
The meeting was called to order by Carolyn Clancy at 1 p.m. EDT at the Kaiser Family Foundation Barbara Jordan Conference Center located in Washington, DC. Dr. Clancy welcomed the members of the AQA-HQA Steering Committee and their staff.
Dr. Clancy indicated that Secretary Leavitt is very interested and supportive of the efforts of both Alliances. Working together is central to developing a road map that will align performance measurement efforts across hospital and ambulatory care settings which will ultimately advance the quality improvement agenda in health care. Dr. Clancy spoke of the extensive good work that has been completed thus far, and noted the opportunity to leverage what we have learned and to take advantage of opportunities to collaborate and build on other initiatives.
The AQA pilots are one such opportunity that can showcase what others have learned and also to promote local leadership. The importance of open communication with HQA and AQA members was also emphasized, and transparency with regard to deliberations of the Steering Committee with the health care community. Minutes and documents would be posted on the AQA website (www. aqaalliance.org). Dr. Clancy closed by thanking those in attendance either in person or by phone for making the time for this meeting and conveyed the urgency of the project as expressed by the Secretary.
Dr. Mark McClellan spoke to the members about building on current progress; while progress has been made, more needs to be done. The intent is to work together to develop an approach to get better information to the consumer, to get better value, and better quality of care throughout the health care system. To brief the Secretary, Dr. McClellan suggested that a report describing the collaborative work of AQA and HQA and what we hoped to accomplish would be helpful. . Possible topics included the significance of the project, a summary of the pilot activities to date, the criteria for selecting the initial pilots, options for expanding the number and scope of current pilots, and infrastructure support.
In order to expand the pilot program, there needs to be broad stakeholder participation to ensure that measure development reflects what consumers want to know about quality and that the provider community is confident in what is being reported. AQA and HQA efforts are very complementary and coordinating and aligning these initiatives will be vitally important, particularly in the areas of performance measurement and data reporting and aggregation, especially as the pilot projects expand both the type and number of measures. Technical support for expansion of the pilots as well as other infrastructure support may come from the QIOs, and other sources.
The general feeling of the group was that there are a number of activities taking place at the state level, and that there should be some way to draw on what states have experience with and what we collectively know. The group also agreed that it was important to solicit stakeholders’ feedback in this effort and that it would be extraordinarily helpful to develop and use a common terminology.
To accomplish our goals, Dr. McClellan highlighted the need for the steering committee to move ahead with the agenda of making information available to the public. He suggested four main topic areas: 1) expanding the scope and number of pilot sites; 2) developing an infrastructure/support for the pilots; 3) harmonization of measures across the ambulatory and hospital settings; 4) price transparency and efficiency/episodes of care. This agenda stimulated a broad discussion from the members of the committee. Important issues are noted below.
Expanding the pilots: How do we expand the pilot sites and what criteria will be used to do this? The group realized that the charter for new pilot sites might be different as compared to the original six.
An important intersection of the AQA-HQA concerns efficiency and episodes of care. The pilots are testing different ways of reporting the information to consumers. It was felt that working together we can get more concrete in terms of what works, and what doesn’t and how measures can be harmonized and made actionable. Striking the right balance between consistencies across pilot sites while encouraging local innovation is a recognized challenge.
Expanding the scope of the current pilots to include both ambulatory and hospital care can facilitate a focus on assessing quality across episodes of care. It was noted that both AQA and HQA have adopted a general principle that only NQF measures will be implemented nationally. The pilots’ experiences with implementing various measures will be critically important to inform the group’s discussion as they will be able to provide key insights. Peter Lee, PBGH, agreed to chair this work group.
Harmonizing measures: The group noted that looking across measurement sets there are areas where measure specifications are different. To identify these areas and begin to address how best to reconcile measurement specifications/definitions, the group felt that the NQF should act as a convener and facilitate bringing together all the involved players.
It was noted that as the pilots wrestle with how best to adapt measures for their circumstances specific to their local market, there would be an ongoing need to harmonize. In addition, harmonization needs to occur across ambulatory care and hospitals settings. According to NQF, there are approximately 20 measures that are different between hospital and physician measures, and it is preferable to make appropriate modifications up front rather than through the consensus development process.
It may take as little as 30 days to identify the areas where harmonizing measures is needed and to outline a process by which the measure developers can work to align. A concern surfaced with regard to a potential conflict of interest in that NQF was aligning the measures and then putting them through their own consensus process. The general consensus of the group was that NQF was an appropriate convener for these activities because of their ability to engage all the involved stakeholders in an open and transparent manner. Members of the group cautioned that as harmonization of measures occurs, there may be downstream implications for accreditors, regulators, and other organizations that may have to be addressed. It was also noted that while “retrofitting” measures does consume resources, the cost of not aligning measures is higher in the long run, and that it would be counter-productive if hospital and physician measures go in different directions. As new measures are developed, the group noted that this was an opportunity to ensure measures were aligned from the beginning as opposed to retrospectively adjusting their specifications and definitions. Janet Corrigan, NQF, agreed to chair the harmonization work group.
The members indicated that it was necessary to develop a plan on how the project will proceed. Some of the members needed to describe and explain the project to their Board of Directors, and that an overall strategy/plan would be helpful and would allay confusion or any miscommunication. It was noted that the opportunity costs are so high and that if the group does not respond to the needs of purchasers and consumers, the purchaser community will develop and implement their own systems, which would lead to large challenges for providers. In the end, physicians and hospitals need to be comfortable with harmonization because we want to build something that is enduring. According to members of the committee, physicians favor harmonization; though some measures may remain specified at the group/system level and not be attributed to an individual physician.
Efficiency/Episodes of Care: In response to strong interest in improving efficiency, it was noted that a comprehensive approach will include examination of overall system, group, and individual physician performance. Episodes of care need to be evaluated in order to get at the issue of efficiency. The AQA performance measure work group has included a specific focus on cost of care. Concerns surfaced regarding the challenges of identifying what a hospital is responsible for and what the individual physician is responsible for during an episode of care. However, it was suggested that joint ownership of responsibility between hospital and physician may be needed. Dr. Kevin Weiss, the chair of the AQA performance measures work group was suggested as the co-chair of this work group. An additional co-chair from the hospital industry will be sought and recommended at a later date. It was suggested that the cost/pricing issue be separate from this work group and that an additional work group be convened to address this important issue. There was general agreement that there should be a separate work group for cost/pricing issues, but that the efficiency work group should also be involved in the discussions since the issues dovetail with one another. In addition, follow up is required with regard to infrastructure and support of the pilots, which may require its own work group.
Dr. Nancy Wilson, of AHRQ/CMS will follow up with those who volunteered to serve as chairs or co-chairs in the next week. She will arrange the logistics with the contractors for the work group meetings and conference calls.
In closing, the members reiterated that it was very important to elicit and incorporate feedback from multiple stakeholders throughout this process. Dr. Clancy asked if there were others that should or needed to be included in the discussions of the work groups, and asked the group to send those names and their contact information as soon as possible. Drs. Clancy and McClellan closed the discussion by thanking all the participants for their time and their willingness to take on this project and adjourned the meeting at 3 p.m. EDT.
Meeting Participants
Rich Umbdenstock, AHA*
Nancy Foster, AHA
Chip Kahn, FAH
Susan Van Gelder, FAH
Bob Dickler, AAMC
Jennifer Faerberg, AAMC
Gerry Shea, AFL-CIO
Karen Ignani, AHIP
John Tooker, American College of Physicians*
Jeff Rich, American College of Thoracic Surgeons
Nancy Nielsen, AMA
Anders Gilberg, AMA
Peter Lee, PBGH*
Debra Ness, National Partnership for Women & Families
Janet Corrigan, NQF
Greg Pawlson, NCQA
Dennis O’Leary, JCAHO*
Margaret VanAmringe, JCAHO
Jerod Loeb, JCAHO
Bruce Bradley, GM
Clarion Johnson, Exxon-Mobil
Pam French, Boeing*
Carmella Bocchino, AHIP
Mark McClellan, CMS
Barry Straube, CMS
Mary-Lacey Reuther, CMS
Carolyn Clancy, AHRQ
Nancy Wilson, AHRQ/CMS
Marybeth Farquhar, AHRQ
Douglas Kamerow, RTI
Shula Bernard, RTI
Judy George, DelMarva
*participated by phone.
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