Health Care Quality Measurement and Reporting: Experiences from the NQF

Health care quality measurement has become an integral part of the health care system. Curtis Collins, PharmD, MS, BCPS (AQ-ID), FASHP, told attendees that the National Quality Forum (NQF) is at the forefront of organizations endorsing quality measures. Dr. Collins described the history of health care quality and safety organizations, which began with the American College of Surgeons setting minimum standards for hospitals in 1917. Quality organizations to follow include the Joint Commission for the accreditation of hospitals, the National Committee for Quality Assurance, the Agency for Healthcare Research and Quality, Leapfrog, several Centers for Medicare & Medicaid Services (CMS) programs, and most recently, the Pharmacy Quality Alliance (PQA).

Hospital value-based purchasing is one area affected by quality measures. According to Dr. Collins, more quality indicators are being added each year and the financial penalties are continuing to grow. The 1% reduction in payments to hospitals that do not meet the quality measure requirements will increase to a 2% reduction in 2017.

By virtue of his experiences serving on an NQF committee, Dr. Collins offered a unique perspective on the development of quality measures. NQF was established in 1999 as a result of the recommendation of the Advisory Commission on Consumer Protection and Quality in the Health Care Industry, a Bill Clinton initiative. The department of Health and Human Services relies on NQF-endorsed measures through programs such as the CMS Physician Quality Reporting System and the Electronic Health Records (EHRs) Incentive Program. The board of directors consists of 31 voting members; however, in 2012, more than 800 experts across the country took part in measure review, measure selection, and priority setting committees. NQF’s vision includes being the primary go-to organization for quality and efficiency initiatives, and being an important motivating force for and facilitator of continuous quality improvement.

According to NQF, a performance measure is a way to calculate whether and how often the healthcare system is doing what it should. The performance measures developed by NQF fall into 3 categories—structural, process, and outcomes. Most measures are either process or outcomes measures. Dr. Collins provided examples of measures that were submitted to the NQF. To illustrate the lifecycle of a performance measure, Dr. Collins discussed a measure developed in Minnesota that evaluates depression remission at 6 months. First, depression prevalence was determined. Then, an assessment tool was developed, a local initiative was performed, and the results from that initiative encouraged changes in practice. Results were made public, and NQF endorsed the measure as a national consensus standard. The tool was tweaked for use in an EHR, and the measure was suggested for inclusion in CMS’ Meaningful Use health information technology payment program by an NQF-convened group. Another example provided was a measure related to the number of babies electively delivered prior to 39 weeks. The measure was developed by Hospital Corporation of America, endorsed by NQF, and then adopted by the Joint Commission, which led to $1 billion in savings and 500,000 fewer neonatal intensive care unit days.

In 2011, there were 917 endorsed quality measures. Of those, cardiovascular-related measures make up the majority. NQF has a call for measures, and various organizations submit quality measures for review. Each measure is broken down into a therapeutic area for review. NQF approached ASHP and various pharmacy organizations requesting pharmacist involvement on NQF committees. There is an appeal process if a measure is not approved. Approved measures are subject to annual maintenance updates and endorsement reviews on a 3-year cycle.

Measures are evaluated based on 4 major and 5 minor criteria. Each criterion is voted on separately and can be categorized via a rating scale as met completely, partially, minimally, not at all, or as not applicable. One criterion that requires a yes vote assesses the importance of the measure. In other words, is there an underserved population this measure will help, and are there gaps in care? Additional criteria include assessments of:

• Reliability and validity
• Usability—Would the public understand the results of the measure and find it useful?
• Feasibility—Can the data be retrieved with minimal resources and implemented for performance measurement?
• Superiority—Is the measure superior to competing measures?

The PQA is working on pharmacy measurement development, and ASHP’s current president serves on the PQA board. An ASHP staff member convened 20 to 30 pharmacists to identify therapeutic areas that pharmacy could endorse. This group identified 4 areas (anticoagulants, pain management, glycemic control, and antibiotic stewardship). With ASHP’s sponsorship of the Pharmacy Practice Model Initiative, Dr. Collins noted that pharmacists are in a good position to respond to quality measures and play an integral role in the development of these measures.