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© National Comprehensive Cancer Network, Inc. 2019, All rights reserved.
The Role of Standardized Performance Measures in Ensuring
Quality in Cancer Care
Shantanu Agrawal, MD, MPhilChief Executive Officer
National Quality Forum (NQF)
#NCCNPolicy
Getting to the Results that Matter: Supporting the Transition to Value
Shantanu AgrawalSeptember 2019
2
What is the National Quality Forum?
Established in 1999
Multi-Stakeholder Member Organization
Driving Measurable Improvements
10+ Years Health Equity Experience
400+ Members covering all health care constituents
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Our Mission, Vision, and ValuesMISSIONThe trusted voice driving measurable health improvements
VISIONEvery person experiences high value care and optimal health outcomes
VALUESLeadership Passion Excellence Collaboration
Integrity
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Support the Transition To Value
Drive National Priorities
Health Equity
Strategic Priorities
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NQF Measure Endorsement
• Standards for quality measures
• Measures reviewed and approved by committees of hospitals, physicians, health plans, purchasers, and consumers
• Over 600 endorsed measures
NQF Endorsed Measures
Structure Process OutcomeComposite Cost/Efficiency
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NQF Endorsement Areas
7%
10%
5%
7%
2%5%
3%9%12%
4%3%
7%
10%
4%
12%
Percent of Total Endorsed Measures
All-Cause Admissions and Readmissions
Behavioral Health and Substance Use
Cancer
Cardiovascular
Cost and Efficiency
Geriatric and Palliative Care
Neurology
Patient Experience and Function
Patient Safety
Pediatrics
Perinatal
Prevention and Population Health
Primary Care and Chronic Illness
Renal
Surgery
NQF Portfolio of Cancer Measures
• Contains 28 measures: 26 process/structure measures and two outcome measures• 26 process/structure measure focus mostly on
documentation
• New outcome measure endorsed June 2019: Admission and Emergency Department (ED) Visits for Patients Receiving Outpatient Chemotherapy
• Outcome measures - significant gap area
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NQF Cancer Portfolio-Process/Structure Measures
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0
2
4
6
8
10
12
14
16
18
Screening Diagnosis Treatment/Early Disease Follow-up Care
10
NQF Endorsed Cancer Measures
0 2 4 6 8 10 12
General
Colon
Hematology
Cervical
Prostate
Breast
Number of Measures
Medical Oncology Measure Gaps & Future Development Areas
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Cancer- and stage-specific
survival
Surgical site infections
Patient reported outcomes
Quality of lifeSocial and emotional
health
Risk-stratified process/
outcomes
Patient experience
Expected clinical benefit
vs. risk
Total cost and Under-and
overuseAccess
Clinical trialsShared
decision making
Communication among
providers
Medication reconciliation
Public outreach and
education
Immuno-oncology
Precision medicine
Pediatric hematologic
cancer
Pediatric cancer – Transitions to
adult care
Prevalent cancers
Less prevalent cancers
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Measure Innovation:NQF Measure Incubator®
All NQF Measure Incubator® projects include patients - key contributors to understanding gaps and
priorities 22
Measure Incubator Projects to Address Cancer Measure Gaps
Diagnostic Accuracy and Evidence-Based Treatment•Biomarker screening and appropriate treatment for non-small cell
lung cancer (NSCLC)
Survival Rates•NSCLC and small-cell lung cancer (SCLC) overall survival rates,
stratified by stage•Overall survival rate for melanoma, stratified by stage
Patient-Reported Measures• NSCLC patient-reported outcome – Symptom burden among
patients receiving chemotherapy • Advanced prostate cancer patient-reported outcomes
Transitioning to Value Faster –Measurement Challenges
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Measure Alignment and Harmonization
Ease of Collection
Context of Use
0097 MedRec Post-Discharge
0419e Documentation of Current Medications in the Medical Record
0553 Care for Older Adults (COA) – Medication Review
2456 MedRec: Number of Unintentional Medication Discrepancies per Patient
3317 MedRec on Admission
2988 MedRec for Patients Receiving Care at Dialysis Facilities
Steward NCQA CMS NCQA Brigham and Women´s Hospital
CMS / HSAG Kidney Quality Care Alliance
Measure Focus
Reconciliation of discharge medication list with current outpatient medical record medication list
Eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter
Medication review of all a patient’s medications, including prescription medications, OTC medications by a prescribing practitioner or clinical pharmacist
Total number of unintentional medication discrepancies in admission orders + total number of unintentional medication discrepancies in discharge orders
Reconciliation of Prior to Admission medication list (referencing external sources) by end of Day 2 of hospitalization.
Patients receive medication reconciliation upon visit to dialysis facility.
.
Population Patients ages 18 + Patients ages 18 + Patients ages 66 + Random sample of adults admitted to the hospital
All inpatientpsychiatric admissions
Dialysis patients
Data Source Claims, Electronic Health Records, Paper Medical Records
Claims, Electronic Health Records, Registry Data
Claims, Electronic Health Records, Paper Medical Records
Electronic Health Data, Electronic Health Records, Instrument-Based Data, Other, Paper Medical Records
Paper Medical Records
Electronic Health Records, Other
Level of Analysis
Clinician: individualClinician: groupHealth PlanIntegrated Delivery System
Clinician: individualClinician: group
Health PlanIntegrated Delivery System
Facility Facility Facility
Setting Outpatient Outpatient Inpatient/Hospital, Outpatient Services, Post-Acute Care
Hospital Inpatient/ Hospital
Post-Acute Care
Example of NQF-Endorsed Medication Reconciliation Measures
15 15
Areas of Major Differences in Measure Attributes
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Medication Reconciliation/Review
Setting
Defining Medication Reconciliation/Review
Requirements
Documenting the Mediation
Reconciliation/Review Process
Individuals Eligible to Perform the Medication
Reconciliation/Review
Frequency of Medication
Reconciliation/Review
Information Source for Medication
Reconciliation/Review
Populations and Risk Factors
Measure Alignment Considerations
• Key first step: need for standardized definitions
• Measures targeting certain populations may require differences in specifications
• Measures use different data sources based on setting/population
• Outcome measures may be optimal but are challenging; there may be benefit in process measures focused on medication reconciliation/review
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Core Quality Measures Collaborative (CQMC)
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• Identify high-value, high-impact evidence-based measures
• Align measures across public and private payers
• Reduce burden of measurement
• Developed 8 core measure sets
CQMC Medical Oncology Core Set
• Currently 14 measure in the domains of Breast Cancer, Colorectal Cancer, Hospice/End of Life, and Prostate Cancer
• Updating the core set, evaluating measures for addition and removal
• Discussions on implementation and alignment opportunities
• Creating a framework for the composition of the ideal oncology measure set; guide gap identification and expansion opportunities
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Context of Use
Objective
Aggregation Methodology
Incentive
Attribution
Risk Adjustment Approach
Data
Testing
Measurement Systems
Ratings Systems
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• Overall rating from 1 to 5 stars
• 5 stars = best quality• Average is 3 stars• Posted publicly • Summarizes variety of
quality measures• Key issues Risk Adjustment Aggregation
Methodology
Hospital Star Ratings
Quality Improvement AreasDrawing on extensive experience in healthcare quality improvement and
measurement, we lead projects on a variety topics across our major focus areas
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NQF Serious Illness Initiative
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Advance Quality
Measurement
Develop recommendations and
concrete next steps
Provideopportunities
for engagement
Guide Quality Efforts
Use quality measuresto inform
the delivery of care
Prepare and launch Issue Brief for palliative
care programs
Engage & Activate
Stakeholders
Identify existing measures and address gaps
Disseminate broadly to spur action and
alignment
To improve our ability to assess the quality of care delivered to individuals with serious illness and their caregivers, NQF will:
NQF Issue Brief Coming 2020
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Quality Improvement Tools
Health Disparities in the U.S.
• Food Insecurity: forty million people struggle with hunger in the United States, including more than 12 million children.
• Homelessness: on any given night in the United States, more than half a million people experience homelessness.
• Maternal Mortality: the risk of pregnancy-related deaths for black women is 3 to 4 times higher than those of white women.
• Quality of Care: African-Americans, Hispanics, Native Americans, and Alaska Natives received worse care than whites for about 40 percent of quality measures.
• Rural Areas: residents more likely to be in poor health and have higher mortality rates for chronic conditions.
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NQF Health Equity Priorities
Better Outcomes, Better Value
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Enabling Data Integration
• To identify and stratify vulnerable populations to recommend and track interventions
Improving Quality Measurement
• To embed health equity in quality measurement to substantiate resource use, inform risk adjustment, and track improvements and outcomes
Fostering Innovative Practices
• To identify targeted practices that improve outcomes for specific communities, vulnerable populations, and individuals
NQF Social Determinants of Health Data Integration Action Team
Purpose: Accelerate the integration of data on social determinants of health (SDOH) into clinical practice
Goal: Share successful approaches to SDOH data integration to support providers and communities in their efforts to eliminate disparities
What We Did• 42 NQF Member organizations discussed actions to accelerate data integration to improve
health and eliminate disparities • Developed an Action Brief that recommends:
1. Standardizing and sharing data across sectors and settings2. Demonstrating collaboration and partnerships3. Evaluating effectiveness
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Social Determinants of Health Quality and Payment Innovation
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Purpose: Advance payment’s role in supporting successful innovations in social determinants of health (SDOH)
Goal: Prioritize a set of meaningful and actionable recommendations to advance the delivery of high-quality healthcare by identifying quality and payment innovations that address SDOH and reduce health disparities
What We Are Doing • Brought together over 50 leaders from across public and private sectors to discuss approaches
and recommendations to advance successful quality and payment innovations in SDOH
• Prioritize recommendations to address disparities through innovation in quality and payment
• Issue a National Call to Action in October 2019
