Law and Standards Peer Review

Chapter 10 Performance Standards and Measures

This chapter examines public and private organizations and processes that establish standards for ensuring that health records are maintained accurately and completely and that they contain the data and information needed to define and report a wide range of measures to determine the quality and efficiency of health care. These activities are very important and have a significant influence on providers and HIT capabilities, significant enough for us to devote an entire chapter to them.

Health care organizations and health plans use data and information to measure performance against internal and external standards; to compare performance to other like organizations; to demonstrate performance to licensing, certifying, and accrediting bodies; and to demonstrate performance for reimbursement purposes. This chapter begins with an examination of the licensure, certification, and accreditation of health care facilities and health plans, followed by an overview of key comparative data sets often used by health care organizations in benchmarking performance. The chapter concludes with a description of the national initiatives using performance measures to improve the quality and safety of health care, including those affecting provider reimbursement.

In the section titled “Licensure, Certification, and Accreditation,” we define these processes, list the accrediting organizations recognized by CMS, and examine the missions and general functions of the Joint Commission and the National Committee for Quality Assurance (NCQA). These discussions focus on how the licensure, certification, and accreditation processes not only use health information to measure performance but also how they influence the health care information that is collected.

“Measuring the Quality of Care” begins with a historical perspective of major milestones in the national agenda for health care quality improvement, followed by a discussion of the current efforts to improve health care quality and patient safety, focusing on the efforts that involve using health care data and information to measure performance. Quality measures are created and validated by a range of organizations, private and public. However, in the recent years significant progress has been made in aligning these measures across organizations. Another significant movement related to quality measurement in the United States is implementation of value-based reimbursement programs, which are based on established performance criteria. The government plans for significant growth in these programs over the next decade.

Licensure, Certification, and Accreditation Health care organizations, such as hospitals, nursing homes, home health agencies, and the like, must be licensed to operate. If they wish to file Medicare or Medicaid claims, they must also be certified, and if they wish to demonstrate quality performance, they will undergo an accreditation process. What are these processes, and how are they related? If a health care organization is licensed, certified, and accredited, how will this affect the health care information

that it creates, uses, and maintains? In this section we will examine each of these processes, their impact on the health care organizations, and their relationships with one another.

Licensure Licensure is the process that gives a facility legal approval to operate. As a rule, state governments oversee the licensure of health care facilities, and each state sets its own licensure laws and regulations. All facilities must have a license to operate, and it is generally the state department of health or a similar agency that carries out the licensure function. Licensure regulations tend to emphasize areas such as physical plant standards, fire safety, space allocations, and sanitation. They may also contain minimum standards for equipment and personnel. A few states tie licensure to professional standards and quality of care, but not all. In their licensure regulations, states generally set minimum standards for the content, retention, and authentication of patient medical records. Exhibit 10.1 is an excerpt from the South Carolina licensure regulations for hospitals. This excerpt governs patient medical record content (with the exception of newborn patient records, which are addressed in a separate section of the regulations). Although each state has its own set of medical record content standards, these are fairly typical in scope and content.

Exhibit 10.1 Medical Record Content: Excerpt from South Carolina Standards for Licensing Hospitals and Institutional General Infirmaries 601.5 Contents:

A. Adequate and complete medical records shall be written for all patients admitted to the hospital and newborns delivered in the hospital. All notes shall be legibly written or typed and signed. Although use of initials in lieu of licensed nurses' signatures is not encouraged, initials will be accepted provided such initials can be readily identified within the medical record. A minimum medical record shall include the following information:

Admission Record: An admission record must be prepared for each patient and must contain the following information, when obtainable: Name; address, including county; occupation; age; date of birth; sex; marital status; religion; county of birth; father's name; mother's maiden name; husband's or wife's name; dates of military service; health insurance number; provisional diagnosis; case number; days of care; social security number; the name of the person providing information; name, address and telephone number of person or persons to be notified in the event of emergency; name and address of referring physician; name, address and telephone number of attending physician; date and hour of admission; History and physical within 48 hours after admission; Provisional or working diagnosis; Pre-operative diagnosis; Medical treatment; Complete surgical record, if any, including technique of operation and findings, statement of tissue and organs removed and post-operative diagnosis; Report of anesthesia; Nurses' notes;

Progress notes; Gross pathological findings and microscopic; Temperature chart, including pulse and respiration; Medication Administration Record or similar document for recording of medications, treatments and other pertinent data. Nurses shall sign this record after each medication administered or treatment rendered; Final diagnosis and discharge summary; Date and hour of discharge summary; In case of death, cause and autopsy findings, if autopsy is performed; Special examinations, if any, e.g., consultations, clinical laboratory, x-ray and other examinations. Source: South Carolina Department of Health and Environmental Control, Standards for Licensing Hospitals and Institutional General Infirmaries, Regulation 61–16 § 601.5 (2010). An initial license is required before a facility opens its doors, and this license to operate must generally be renewed annually. Some states allow organizations with the Joint Commission or other accreditation to forgo a formal licensure survey conducted by the state; others require the state survey regardless of accreditation status. As we will see in the section on accreditation, the accrediting bodies' standards are more detailed and more stringent than the typical state licensure regulations. Also, most accreditation standards are updated annually; most licensure standards are not.

Certification Certification gives a health care organization the authority to participate in the federal Medicare and Medicaid programs. Legislation passed in 1972 mandated that hospitals had to be reviewed and certified to receive reimbursement from Medicare and Medicaid programs (CMS, n.d.a). At that time the Health Care Financing Administration, now the Centers for Medicare and Medicaid Services (CMS), developed a set of minimum standards known as the conditions of participation (CoPs). CMS contracts with state agencies to inspect facilities to make sure they meet these minimum standards, organized by facility functions and services. See Exhibit 10.2 for the CoP standards section governing medical record content.

Exhibit 10.2 Medical Record Content: Excerpt from the Conditions of Participation for Hospitals Sec. 482.24 Condition of participation: Medical record services.

(c) Standard: Content of record. The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient's progress and response to medications and services. (1) All entries must be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished. (i) The author of each entry must be identified and must authenticate his or her entry. (ii) Authentication may include signatures, written initials or computer entry. (2) All records must document the following, as appropriate:

(i) Evidence of a physical examination, including a health history, performed no more than 7 days prior to admission or within 48 hours after admission. (ii) Admitting diagnosis. (iii) Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. (iv) Documentation of complications, hospital acquired infections, and unfavorable reactions to drugs and anesthesia. (v) Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. (vi) All practitioners' orders, nursing notes, reports of treatment, medication records, radiology, and laboratory reports, and vital signs and other information necessary to monitor the patient's condition. (vii) Discharge summary with outcome of hospitalization, disposition of case, and provisions for follow-up care. (viii) Final diagnosis with completion of medical records within 30 days following discharge. Source: Conditions of Participation: Medical Record Services, 42 C.F.R. §§ 482.24c et seq. (2007).

Accreditation Accreditation is an external review process that an organization elects to undergo; it is voluntary and has fees associated with it. The accrediting agency grants recognition to organizations that meet its predetermined performance standards. The review process and standards are devised and regulated by the accrediting agency. By far the best-known health care accrediting agency in the United States is the Joint Commission, but there are others. The National Committee for Quality Assurance (NCQA) is a leading accrediting agency for health plans.

Although accreditation is voluntary, there are financial and legal incentives for health care organizations to seek accreditation. In order to eliminate duplicative processes, Section 1865 of the Social Security Act “permits providers and suppliers ‘accredited’ by an approved national accreditation organization (AO) to be exempt from routine surveys by State survey agencies to determine compliance with Medicare conditions” (CMS, 2015). This is often referred to as deemed status. Table 10.1 lists the 2015 approved AOs with corresponding program types and websites. Table 10.1 2015 approved CMS accrediting organizations

Accrediting Organization Program Types Website Accreditation Association for Ambulatory Health Care (AAAHC) ASC (ambulatory surgery center) www.aaahc.org Accreditation Commission for Health Care, Inc. (ACHC) HHA (home health agency) Hospice www.achc.org American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) ASC OPT (outpatient physical therapy) RHC (rural health clinics) www.aaaasf.org American Osteopathic Association/Healthcare Facilities Accreditation Program (HFAP) ASC

CAH (critical access hospital) Hospital www.hfap.org Center for Improvement in Healthcare Quality (CIHQ) Hospital www.cihq.org Community Health Accreditation Program (CHAP) HHA Hospice www.chapinc.org DNV GL—Healthcare (DNV GL) CAH Hospital www.dnvglhealthcare.com The Compliance Team (TCT) RHC www.thecomplianceteam.org The Joint Commission (TJC) ASC CAH HHA Hospice Hospital Psychiatric hospital www.jointcommission.org Similar to CMS, many states also recognize accreditation in lieu of their own licensure surveys. Other benefits for an organization are that accreditation

May be required for reimbursement from payers (including CMS) Validates the quality of care within the organization May favorably influence liability insurance premiums May enhance access to managed care contracts Gives the organization a competitive edge over nonaccredited organizations The Joint Commission The Joint Commission's stated mission is “to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value” (The Joint Commission, n.d.). The Joint Commission on Accreditation of Hospitals (as the Joint Commission was first called) was formed as an independent, not-for-profit organization in 1951, as a joint effort of the American College of Surgeons, American College of Physicians, American Medical Association, and American Hospital Association. The Joint Commission has grown and evolved to set standards for and accredit nearly twenty-one thousand health care organizations and programs in the United States. In addition to hospitals, the Joint Commission has accreditation programs for health care organizations that offer ambulatory care, behavioral health care, home care, long-term care, and office-based surgery. They also provide an accreditation program for organizations that offer laboratory services (The Joint Commission, 2016, n.d.).

In order to maintain accreditation, a health care organization must undergo an on-site survey by a Joint Commission survey team every three years. Laboratories must be surveyed every two years. This survey is conducted to ensure that the organization continues to meet the established standards. The standards themselves are the result of an ongoing, dynamic process that incorporates the experience and perspectives of health care professionals and others throughout the country. New standards manuals are published annually and health care organizations are responsible for knowing and incorporating any changes as they occur.

Categories of accreditation (The Joint Commission, 2016) that an organization can achieve are the following:

Preliminary accreditation: for organizations that demonstrate compliance with selected standards under the Early Survey Policy, which allows organizations to undergo a survey prior to having the ability to demonstrate full compliance. Organizations that receive preliminary accreditation will be required to undergo a second on-site survey. Accreditation: for organizations that demonstrate compliance with all standards. Accreditation with follow-up survey: for organizations that are not in compliance with specific standards and require a follow-up survey within thirty days to six months. Contingent accreditation: for organizations that fail to address all requirements in an accreditation with follow-up survey decision or for organizations that do not have the proper license or other similar issue at the time of the initial survey. A follow-up survey is generally required within thirty days. Preliminary denial of accreditation: for organizations for which there is justification for denying accreditation. This decision is subject to appeal. Denial of accreditation: for organizations that fail to meet standards and that have exhausted all appeals. The Joint Commission focus on quality of care provided in health care facilities dates back to the early 1900s, when the American College of Surgeons began surveying hospitals and established a hospital standardization program. With the program came the question, how is quality of care measured? One of the early concerns of the standardization program was the lack of documentation in patient records. The early surveyors found that documentation was so poor that they had no way to judge the quality of care provided. The Joint Commission's emphasis on health care information and the documentation of care has continued to the present. Not only do the Joint Commission reporting requirements rely heavily on patient information but also the current survey process uses “tracer methodology,” through which the surveyors analyze the organization's systems by tracing the care provided to individual patients. Patient records provide the road maps for the tracer methodology. The absence of quality health records would have a direct impact on the accreditation process. The following sections discuss Joint Commission standards that directly influence the creation, maintenance, and use of health care information. These sections further illustrate how the overall accreditation process relies on the availability of high-quality health care information (The Joint Commission, 2016).

The Joint Commission Record of Care (RC), Treatment, and Services Standards The Joint Commission Record of Care (RC), Treatment, and Services standards provide information about the requirements for the content of a complete health record, regardless of its format. The RC standards for an ambulatory care program dictate that the organization will do the following:

Maintain complete and accurate clinical record. Ensure clinical record entries are authenticated appropriately by authorized persons. Ensure documentation in clinical records is timely.

Audit their clinical records. Retain their clinical records according to relevant laws and regulations. Ensure clinical records contain specific information that reflects the patient's care, treatment, or services. Ensure clinical records accurately reflect operative and high-risk procedures and use of sedation and anesthesia. Ensure documentation of proper use of restraints and seclusion. Ensure ambulatory care records contain a summary list. Ensure qualified staff members receive and record verbal orders. (The Joint Commission, 2014b) Each RC standard has specific elements that must be addressed. For more information, refer to the most recent edition of the appropriate Comprehensive Accreditation Manual. All Joint Commission–accredited organizations have access to the complete manual.

The Joint Commission Information Management Standards The Joint Commission Information Management (IM) standards reflect the Joint Commission's belief that quality information management influences quality care. In the overview of the IM standards, the Joint Commission states, “Every episode of care generates health information that must be managed systematically” (emphasis is the authors'). Information is a resource that must be managed similar to any other resource within the organization. Whether the information management systems employed by the organization are basic or sophisticated, the functions should include features that allow for the following:

Categorizing, filing, and maintaining all data and information used by the organization Accurately capturing health information generated by delivery of care, treatment, and services Accessing information by those authorized users who need the information to provide safe, quality care (The Joint Commission, 2014a) The IM standards apply to noncomputerized systems and systems employing the latest technologies. The first standard within the IM chapter focuses on information planning. The organization's plan for IM should consider the full spectrum of data generated and used by the organization as well as the flow of information within and to and from external organizations. Identifying and understanding the flow of information is critical to meeting the organization's needs for data collection and distribution while maintaining the appropriate level of security (The Joint Commission, 2014a). The remaining IM standards address the requirements for health care organizations:

Provide continuity of the information management process, including managing system interruptions and maintaining backup systems. Ensure the privacy, security, and integrity of health information. Manage data collection, including use of standardized data sets and terminology and limiting the use of abbreviations. Manage health information retrieval, dissemination, and transmission. Provide knowledge-based information resources twenty-four hours a day, seven days a week. Ensure the accuracy of the health information. (The Joint Commission, 2011, 2014a)

National Committee for Quality Assurance The National Committee for Quality Assurance (NCQA) is the leading accrediting body for health plans, including health maintenance organizations (HMOs), Preferred Provider Organizations (PPOs), and Point of Service (POS) plans in the United States. In addition, the NCQA also accredits the following programs:

Disease management Case management Wellness and health promotion Accountable care organizations Wellness and health promotion Managed behavioral health care organizations (NCQA, n.d.a) The full list of NCQA accreditation requirements are published on its website at www.ncqa.org. The 2015 Health Plan Accreditation Program requirements include specific criteria divided into the following sections:

Quality management and improvement (QI) Utilization management (UM) Credentialing and recredentialing (CR) Members' rights and responsibilities (RR) Member connections (MEM) Medicaid benefits and services (MED) Health Effectiveness Data and Information Set (HEDIS) performance measures (see the “Measuring the Quality of Care” section for more information about HEDIS) (NCQA, 2015). Measuring the Quality of Care Two landmark Institute of Medicine (IOM) reports, To Err Is Human: Building a Safer Health System, published in 2000 (Kohn, Corrigan, & Donaldson), and Crossing the Quality Chasm: A New Health System for the 21st Century, published in 2001, are often cited as marking the beginning of the modern era of national health care quality and patient safety initiatives. The two reports led to increased awareness of the severity of patient safety and quality issues and helped frame the national landscape of improvement efforts. To Err Is Human estimated that as many as ninety-eight thousand people died in hospitals each year as a result of preventable medical errors. The report found that most errors could be traced to poor processes and systems and recommended development and implementation of improved performance standards, including those associated with licensure, certification, and accreditation. Crossing the Quality Chasm specifically outlined six aims for establishing quality health care, stating that health care in the United States should be (CMSS, 2014; Kohn, Corrigan, & Donaldson, 2000; IOM, 2001):

Safe Effective Patient-centered Timely Efficient

Equitable One of the challenges to meeting these aims was determining how to measure success in each area. What are the standards and performance measures associated with these important aims?

Types of Measures Whether at the local organizational level or at a national level, quality improvement requires the identification of standards that define quality care and measurement of performance to determine whether or not the identified standards are met. Quality measures are used across the full continuum of care, from individual physicians to health plans. As we will examine in this chapter, there are literally hundreds of different health care quality measures in use today. These existing quality measures can generally be categorized into four types: structure, process, outcome, and patient experience. Table 10.2 summarizes the types of measures, descriptions, and examples of each.

Table 10.2 Major types of quality measures

Source: Morris (2014).

Type Description Example Structure Assesses the characteristics of a care setting, including facilities, personnel, and policies related to care delivery Does an intensive care unit (ICU) have a critical care specialist on staff at all times? Process Determines if the services provided to patients are consistent with routine clinical care Does a doctor ensure that his or her patients receive recommended cancer screenings? Outcome Evaluates patient health as a result of the care received What is the survival rate for patients who experience a heart attack? Patient Experience Provides feedback on patients' experiences of care Do patients report that their provider explains their treatment options in ways that are easy to understand? Data Sources for Measures Whether quality measures are applied by an individual physician or by a federal agency, they rely on valid and reliable data. A few of the common sources of health care data used in performance measurement are listed in the following sections.

Administrative Data Administrative data submitted to private and government payers have the advantage of being easy to obtain. Private and public payers have very large claims databases.

Disease Registries Public health agencies, including state and federal agencies collect data on patients with specific conditions. These disease registries often go beyond administrative claims data. Health Records The EHR is recognized as a rich source of detailed patient information. However, the full potential of the EHR as an easy-to-use source of reliable data has not been reached. More work

on standardization and tools for data extraction is needed. Data extraction from paper records is labor intensive and, therefore, expensive to implement. As you have seen in previous chapters, Meaningful Use criteria address the need for EHR data extraction and sharing.

Qualitative Data Qualitative data from patient surveys or interviews are often used for patient experience measures (Morris, 2014).

Measurement Development Regardless of the data source, the resulting measures must not only be reliable and valid but also feasible to collect (CMSS, 2015). There are dozens of public and private organizations that develop health care–related performance measures. The following paragraphs identify a few of the key players and their respective role in the development of recognized measures.

The NCQA is responsible for the HEDIS measures, one of the oldest and most widely used sets of health care performance measures in the United States. More than 90 percent of health plans in the United States collect and report HEDIS data. HEDIS data is not only used for accreditation of health plans but also for the basis of health plan comparison and quality improvement.

The Joint Commission also has a long history of developing and using performance measures as a component of accreditation. In 1987, the Joint Commission revamped its accreditation process with the goal of incorporating standardized performance measures. This initiative led to the development of ORYX program. The current ORYX program is closely aligned with CMS quality initiatives, using many of the same measures. Hospitals seeking Joint Commission Accreditation in 2016 were required to report on six of nine sets of chart (paper)-abstracted clinical quality measures (CQMs) or six of eight electronic clinical quality measures (eCQMs) (The Joint Commission, 2015b).

CQMs are identified and updated by CMS each year. Selected CQMs are used in the EHR Incentive Programs for eligible professionals and other CMS quality initiatives (discussed following in this chapter). The CMS does not develop all of the CQMs but rather relies on private organizations, such as NCQA, the Joint Commission, the American Medical Association Physician Consortium for Performance Improvement (AMA-PCPI), and a host of other health care societies, collaboratives, and alliances, as well as government agencies, such as AHRQ, Centers for Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA) for most of them. Table 10.3 is an excerpt from the CQMs for the 2014 EHR Incentive Programs. Note that each measure is defined by a unique identifier, National Quality Forum (NQF) number, a measure description, numerator and denominator statements, measure steward, and Physicians Quality Reporting System (PQRS) number. Note: The PQRS role in quality improvement and performance measurement is discussed in more detail following in this chapter.

Table 10.3 Excerpt of CQMs for 2014 EHR Incentive Programs

Source: CMS (n.d.f).

CMS eMeasure ID NQF No. Measure Title and NQS Domain Measure Description Numerator Statement Denominator Statement Measure Steward PQRS No. CMS69v5 0421 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan Domain: Population/Public Health Percentage of patients aged eighteen years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter Normal Parameters: Age eighteen years and older BMI = > 18.5 and < 25 kg/m2 Patients with a documented BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter All patients eighteen and older on the date of the encounter with at least one eligible encounter during the measurement period Centers for Medicare & Medicaid Services 128 GPRO PREV-9 CMS132v5 0564 Cataracts: Complications within Thirty Days Following Cataract Surgery Requiring Additional Surgical Procedures Domain: Patient Safety Percentage of patients aged eighteen years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the thirty days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence Patients who had one or more specified operative procedures for any of the following major complications within thirty days following cataract surgery: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence All patients aged eighteen years and older who had cataract surgery and no significant ocular conditions impacting the surgical complication rate PCPI(R) Foundation (PCPI[R]) 192 CMS133v5 0565 Cataracts: 20/40 or Better Visual Acuity within Ninety Days Following Cataract Surgery Domain: Clinical Process/Effectiveness Percentage of patients aged eighteen years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery Patients who had best-corrected visual acuity of 20/40 or better (distance or near) achieved within ninety days following cataract surgery All patients aged eighteen years and older who had cataract surgery PCPI(R)

Foundation (PCPI[R]) 191 CMS158v5 N/A Pregnant Women That Had HBsAg Testing Domain: Clinical Process/Effectiveness This measure identifies pregnant women who had a HBsAg (hepatitis B) test during their pregnancy Patients who were tested for hepatitis B surface antigen (HBsAg) during pregnancy within 280 days prior to delivery All female patients aged twelve and older who had a live birth or delivery during the measurement period Optum 369 CMS159v5 0710 Depression Remission at Twelve Months Domain: Clinical Process/Effectiveness Patients age eighteen and older with major depression or dysthymia and an initial Patient Health Questionnaire (PHQ-9) score greater than nine who demonstrate remission at twelve months (+/- 30 days after an index visit) defined as a PHQ-9 score less than five. This measure applies to both patients with newly diagnoses and existing depression whose current PHQ-9 score indicates a need for treatment. Patients who achieved remission at twelve months as demonstrated by a twelve month (+/- 30 days grace period) PHQ-9 score of less than five Patients age eighteen and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine during the index visit MN Community Measurement The NQF is a nonprofit, member organization whose mission is “to lead national collaboration to improve health and healthcare quality through measurement” (NQF, n.d.). It was created in 1999 and includes board members from private and public sectors, including providers, purchasers, and representatives from AHRQ, CDC, CMS, and HRSA. The NQF maintains a large, searchable database of performance measures. Measures can be searched on the NQF website (www.qualityforum.org) by any combination of the following dimensions:

Endorsement Status (e.g. Endorsed, Not Endorsed) Measure Status (Time Limited, Reserved) Measure Format (eMeasure, Measure) Measure Steward (e.g., NCQA, CMS, The Joint Commission) Use in Federal Program (e.g., Meaningful Use, Medicare Shared Savings Program) Clinical Condition/Topic Area (e.g., Cancer, Infectious Disease) Cross-Cutting Area (e.g., Overuse, Safety, Disparities) Care Setting (e.g., Ambulatory Care, Home Health, Hospital) National Quality Strategy Priorities (e.g., Affordable Care, Patient Safety) Actual/Planned Use (e.g., Public Reporting, Payment Program) Data Source (e.g., Administrative Data, Electronic Clinical Data, Healthcare Provider Survey) Level of Analysis (e.g., Clinician, Facility, Health Plan) Target Population (Children's Health) Comparative Health Care Data Sets Comparative health care data sets and information are often aligned with organizations' quality improvement efforts. An organization might collect data on one or more of the specific performance measures, such as those previously identified, and then use this information to compare its performance to other similar organizations or state average results, for example. The process of comparing one or more performance measures against a standard is called

benchmarking. Benchmarking may be limited to internally set standards; however, frequently it employs one or more externally generated benchmark or standard.

Providers may select from many publicly and privately available health care data sets for benchmarking purposes. Many of the organizations identified in the previous section not only develop standards but also provide searchable websites that enable consumers and providers to compare results of their measures across multiple organizations. Although each comparative data set is unique, they can be loosely categorized by purpose: patient satisfaction, practice patterns, or clinical data. The following paragraphs identify some of the more well-known and frequently used comparative data sets and list their associated searchable website when applicable.

Patient Satisfaction Data Sets Patient satisfaction data generally come from survey data. Several private organizations, such as NRC+Picker, Press Ganey, and the health care division of Gallup, provide extensive consulting services to health care organizations across the country. One of these services is to conduct patient satisfaction surveys. Some health care organizations undertake patient satisfaction surveys on their own. The advantage of using a national organization is the comparative database it offers, which organizations can use for benchmarking purposes.

Some of the most widely used groups of patient experience surveys in the public arena were developed under the Agency for Healthcare Research and Quality (AHRQ) Consumer Assessment of Healthcare Providers and Systems (CAHPS) program. CAHPS originated in 1995 to assess participants' perspectives on their health plans. Since that time the program has evolved to include the following surveys:

Health Plan Clinician & Group Hospital Home Health Care In-Center Hemodialysis Nursing Home Surgical Care American Indian Dental Plan Experience of Care and Health Outcomes (for mental health and substance abuse services) CAHPS surveys are available to any organization. Federal agencies, such as CMS, use the CAHPS survey results, but the results are also used by health systems, physician practices, hospitals, and other health care providers in their quality improvement efforts (AHRQ, 2016). The Hospital CAHPS (HCAHPS) results are available to consumers as a part of CMS Hospital Compare (discussed under “Clinical Data Sets”) and from the AHRQ website. Information about the CAHPS comparative data and access to the database and chart books is located at http://www.ahrq.gov/cahps/cahps-database/comparative-data/index.html (AHRQ, 2016).

Practice Patterns Data Set The Dartmouth Atlas is a widely used, interactive, online tool that enables health care organizations to compare data across a wide variety of parameters. The project is a privately funded program through the Dartmouth Institute for Health Policy and Clinical Practice, which primarily uses Medicare data to document variations in the use of medical resources across the United States. To access the Dartmouth Atlas, go to http://www.dartmouthatlas.org (The Dartmouth Institute, n.d.). Clinical Data Sets The Joint Commission and CMS are committed to the improvement of clinical outcomes, and as a part of that commitment they provide consumers with comparative data that encompasses clinical measures. The Joint Commission's Quality Check has evolved since its introduction in 1994 to become a comprehensive guide to health care organizations in the United States. Visitors to www.Qualitycheck.org can search for health care organizations by a variety of parameters, identify accreditation status, and compare hospital performance measures in terms of the Joint Commission's (2015a) National Patient Safety Goals. The 2016 National Patient Safety Goals for Hospitals describes sixteen specific goals, including these:

Identifying patients correctly Improving staff member communication Using medicines safely Using alarms safely Preventing infection Identifying patient safety risks Preventing mistakes in surgery (The Joint Commission, 2016) Hospital Compare is the CMS-sponsored interactive, online comparative data set. Located at www.medicare.gov/hospitalcompare, this data set contains information about the quality of care at over four thousand Medicare-certified hospitals. The interactive tool enables consumers to compare clinical and patient satisfaction data. The purpose of the tool is to promote informed decision making by consumers of hospital care and to encourage hospitals to improve the quality of care they provide (CMS, n.d.b). In addition to Hospital Compare, CMS sponsors public reporting of other health care organizations, such as nursing homes, home health agencies, and kidney dialysis facilities (CMS, n.d.d).

Comparative Data for Health Plans In addition to data sets used by providers, the NCQA website enables consumers to have access to comparative data for health plans through a variety of report cards. The majority of the comparative data is derived from HEDIS and CAHPS. NCQA health care report cards are found at http://reportcard.ncqa.org. NCQA also offers a subscription service for a more detailed interactive tool, Quality Compass (NCQA, n.d.b, n.d.c).

Federal Quality Improvement Initiatives As stated at the beginning of the chapter, the publication of the IOM reports addressing serious quality concerns marked a new era of government initiatives to improve the quality of patient care. Multiple new programs were established and new efforts to link Medicare and Medicaid

reimbursement to quality care were undertaken. In this section we will examine the Patient Safety Act, the National Quality Strategy, and a selection of related government programs aimed at improving the quality of health care through performance measurement including the related aspects of the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA).

The Patient Safety Act The IOM To Err Is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 2000) outlined serious concerns about and the need to improve the safety and quality of health care in the United States. Despite the ongoing efforts by voluntary accrediting bodies to ensure high-quality care, this report identified a critical need for reporting and analyzing individual facility and aggregate data related to adverse events. To address the need to capture information to improve health care quality and prevent harm to patients, the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) was passed by Congress “to promote shared learning to enhance quality and safety nationally.” To implement the act, the Department of Health and Human Services issued the Patient Safety Rule (effective January 2009), which authorized the identification of Patient Safety Organizations (PSOs). As of August 2016, there were eighty-two PSOs in twenty-eight states. PSOs are responsible for the collection and analysis of health information that is referred to in the Final Rule as patient safety work product (PSWP). The PSWP contains identifiable patient information that is covered by specific privilege and confidentiality protections (AHRQ, n.d.a). The types of patient safety events that are reported under these protections include the following:

Incidents: patient safety events that reached the patient, whether or not there was harm involved Near misses (or close calls): patient safety events that did not reach the patient Unsafe conditions: circumstances that increase the probability of a patient safety event occurring To facilitate these activities, AHRQ has created Common Formats, which are “common definitions and reporting formats to help providers uniformly report patient safety events” (AHRQ, n.d.b).

National Quality Strategy The requirement for a National Strategy for Quality Improvement in Health Care (National Quality Strategy) was established by the Affordable Care Act and subsequently published in 2011. More than three hundred groups and individuals representing all aspects of the health care industry and public provided input. It has subsequently been updated on an annual basis, but the three broad aims and six priorities have remained consistent. The three broad aims used to “guide and assess national efforts to improve health and the quality of health care” (AHRQ, 2011) are as follows:

Better care: Improve the overall quality by making health care more patient-centered, reliable, accessible, and safe.

Healthy people/healthy communities: Improve the health of the US population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care. Affordable care: Reduce the cost of quality health care for individuals, families, employers, and government To achieve these aims, the National Quality Strategy identifies the following six priorities:

Making care safer by reducing harm caused in the delivery of care Ensuring that each person and family are engaged as partners in their care Promoting effective communication and coordination of care Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease Working with communities to promote wide use of best practices to enable healthy living Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models The strategy goes further by recommending that all sectors of the health care system (individuals, families, payers, providers, employers, and communities) employ one or more of the following “levers” to “align” with the National Quality Strategy (NQS)(AHRQ, 2011): Measurement and feedback: Provide performance feedback to plans and providers to improve care. Public reporting: Compare treatment results, costs, and patient experience for consumers. Learning and technical assistance: Foster learning environments that offer training, resources, tools, and guidance to help organizations achieve quality improvement goals. Certification, accreditation, and regulation: Adopt or adhere to approaches to meet safety and quality standards. Consumer incentives and benefit designs: Help consumers adopt healthy behaviors and make informed decisions. Payment: Reward and incentivize providers to deliver high-quality, patient-centered care. Health information technology: Improve communication, transparency, and efficiency for better coordinated health and health care. Innovation and diffusion: Foster innovation in health care quality improvement, and facilitate rapid adoption within and across organizations and communities. Workforce development: Invest in people to prepare the next generation of health care professionals and support lifelong learning for providers. CMS Quality Programs The Centers for Medicare and Medicaid (CMS) released its specific Quality Strategy in 2016, which is based on the NQS. Adhering to the same broad aims in the NQS, CMS developed a strategy to improve health care delivery by the following means:

Using incentives to improve care Tying payment to value through new payment models Changing how care is given through Better teamwork Better coordination across health care settings

More attention to population health Putting the power of health care information to work (CMS, 2016) Since 2001, CMS has engaged in a variety of Quality Initiatives, including initiatives that result in public reporting of performance measures as previously discussed. The Physician Quality Reporting System (PQRS) encourages individual “eligible professionals” (EPs) (e.g., physicians) and group practices to assess and report the quality of care provided to their patients. EPs and group practices that do not report on quality measures as outlined for Medicare Part B covered services risk a negative payment adjustment. There are several mechanisms for reporting PQRS data, including EHRs (CMS, n.d.g).

Using PQRS reporting to determine reimbursement for Medicare Part B is one of many mechanisms through which CMS incentivizes improved quality of care. CMS has multiple value-based or pay-for-performance programs aimed at tying reimbursements to demonstration of quality. CMS's original value-based programs were an attempt to link performance on endorsed quality measures to reimbursement. These programs included the following:

Hospital Value-Based Purchasing (HVBP) program rewards acute care hospitals for quality care using incentives. Hospital Readmissions Reduction (HRR) program rewards acute care hospitals that reduce unnecessary hospital readmissions for certain conditions, such as acute myocardial infarction, health failure, pneumonia, chronic obstructive pulmonary disease, elective hip or knee replacement, and coronary artery bypass surgery. Hospital-Acquired Conditions (HAC) program determines whether or not an acute care hospital should be paid a reduced amount based on performance across health-acquired infections and unacceptable adverse events. Value Modifier (VM) program (also known as Physician Value-Based Modifier or PVBM) rewards physicians (and, beginning in 2018, other primary care professionals, for example, physician assistants and nurse practitioners) for high-quality, lower-cost performance using an adjustment (modifier) for each claim. Three other value-based programs are applied to end-stage renal disease programs, skilled nursing facilities, and home health programs.

Beyond these traditional value-based programs, CMS encourages innovative, alternative models of care through the CMS Innovation Center. These models are designed to promote lower-cost, higher-quality care. All depend on appropriate reporting of performance measures (CMS, n.d.h). The Medicare Access and CHIP Reauthorization Act (MACRA) The Medicare Access and CHIP Reauthorization Act (MACRA) was enacted in 2015. MACRA is one aspect of CMS's push toward improving quality and value. In January 2015, the Department of Health and Human Services announced two goals for value-based payments and alternative payment models (APMs):

Goal 1: 30 percent of Medicare payments are tied to quality or value through APMs by the end of 2016; 50 percent by the end of 2018.

Goal 2: 85 percent of Medicare fee-for-service payments are tied to quality or value by the end of 2016; 90 percent by the end of 2018. They also invited private sector payers to match or exceed these same goals.

MACRA affects physician providers, moving HHS closer to meeting these goals. Key elements to MACRA are the following:

Changes the way Medicare rewards physicians and practitioners for value over volume Streamlines multiple quality programs directed at physicians and practitioners under the new Merit-based Incentive Payment System (MIPS) Provides bonus payments for physician and practitioners participation in eligible APMs (see Chapter One for examples of APMs) MIPS will incorporate aspects of three existing quality and value programs: PQRS, Value-based Modifier, and the Medicare EHR Incentive Program. The resulting set of performance measures will be divided into the following categories to calculate a score (between 0 and 100) for eligible professionals. Each category of performance will be weighted as shown in Table 10.4. Table 10.4 MIPS performance categories

Category Weight (%) Quality 50 Advancing care information 25 Clinical practice improvement activities 15 Resource use 10 Health care providers meeting the established threshold score will receive no adjustment to payment; those scoring below will receive a negative adjustment and those above, a positive adjustment. Exceptional performers may receive bonus payments (CMS, n.d.c, n.d.e).

The exact implementation dates for MACRA were not set by the publication date for this textbook; however, the projected timetable for implementation of the various aspects of the law is shown in Figure 10.2 (CMS, n.d.c).

Figure 10.2 Projected timetable for implementation of MACRA

Source: CMS (n.d.e).

Summary In this chapter we examined how health care organizations and health plans use data and information to demonstrate performance to licensing, certifying, and accrediting bodies; to measure performance against internal and external standards; to compare performance to other similar organizations; and to demonstrate performance for reimbursement purposes. This chapter began with an examination of the licensure, certification, and accreditation of health care facilities and health plans, followed by an overview of key comparative data sets often used by health care organizations in benchmarking performance. The chapter further explored major

milestones in the national agenda for health care quality improvement, followed by a discussion of the current efforts to improve health care quality and patient safety, focusing on the efforts that involve using health care data and information to measure performance. The private and public organizations responsible for developing and endorsing national quality measures were introduced, and the progress that has been made in aligning these measures across these organizations was discussed. The chapter concluded with an overview of the significant movement toward value-based reimbursement programs and plans for significant growth in these programs over the next decade.

Clearly, there is a bewildering and complex set of measures with many organizations involved. Consequently, many measures being collected are inconsistent across the organizations requiring them. There are differences of opinion about which measures to be collected and the specific definitions of these measures. Efforts are under way, largely driven by CMS, to align measures to ease the collection burden for health care providers. However, today's reality remains an overwhelmingly complex web of standards and measurement requirements.

EHRs have been cited as the solution for easing the collection burden for health care organizations and providers. However, the most current EHR systems are limited in their ability to collect the required measures. The result is that organizations and providers must resort to manual data collection. In other chapters in this text we have explored reasons for the current limitations of EHRs in this area, including provider resistance because of the time burden. There is a largely unresolved tension in the health care community and HIT industry between the desire to collect accurate and timely measures and the provider resistance to entering the data into the EHR in a standard, retrievable format.

References Agency for Healthcare Research and Quality (AHRQ). (2011). National quality strategy (NQS). Retrieved August 31, 2016, from http://www.ahrq.gov/workingforquality/nqs/nqs2011annlrpt.pdf Agency for Healthcare Research and Quality (AHRQ). (2016, July). Comparative data. Retrieved August 31, 2016, from http://www.ahrq.gov/cahps/cahps-database/comparative-data/index.html Agency for Healthcare Research and Quality (AHRQ). (n.d.a). About the PSO program. Retrieved August 31, 2016, from https://pso.ahrq.gov/about Agency for Healthcare Research and Quality (AHRQ). (n.d.b). Common formats. Retrieved August 31, 2016, from https://pso.ahrq.gov/common Centers for Medicare and Medicaid (CMS). (2015, Sept.). CMS-approved accrediting organizations contacts for prospective clients. Retrieved August 30, 2016, from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInf o/Downloads/Accrediting-Organization-Contacts-for-Prospective-Clients-.pdf Centers for Medicare and Medicaid (CMS). (2016). CMS quality strategy 2016. Retrieved August 31, 2016, from https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/qualityinitiativ esgeninfo/downloads/cms-quality-strategy.pdf

Centers for Medicare and Medicaid (CMS). (n.d.a). Accreditation of Medicare-certified providers & suppliers. Retrieved August 21, 2016, from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInf o/Accreditation-of-Medicare-Certified-Providers-and-Suppliers.html Centers for Medicare and Medicaid (CMS). (n.d.b). Hospital compare. Retrieved August 31, 2016, from https://www.medicare.gov/hospitalcompare Centers for Medicare and Medicaid (CMS). (n.d.c). MACRA. Retrieved August 31, 2016, from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Base d-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html Centers for Medicare and Medicaid (CMS). (n.d.d). Medicare. Retrieved August 31, 2016, from https://www.cms.gov/Medicare Centers for Medicare and Medicaid (CMS). (n.d.e). The Medicare Access & CHIP Reauthorization Act of 2015: Path to value. Retrieved August 31, 2016, from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Base d-Programs/MACRA-MIPS-and-APMs/MACRA-LAN-PPT.pdf Centers for Medicare & Medicaid Services (n.d.f). The merit-based incentive payment system: MIPS scoring methodology overview. Retrieved August 4, 2016, from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Base d-Programs/MACRA-MIPS-and-APMs/MIPS-Scoring-Methodology-slide-deck.pdf Centers for Medicare and Medicaid (CMS). (n.d.g). Physician quality reporting system. Retrieved August 31, 2016, from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/inde x.html?redirect=/pqri Centers for Medicare and Medicaid (CMS). (n.d.h). Value-based programs. Retrieved August 31, 2016, from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Base d-Programs/Value-Based-Programs.html Council of Medical Specialty Societies (CMSS). (2014, Nov.). The measurement of health care performance (3rd ed.). Retrieved August 21, 2016, from http://cmss.org/wp-content/uploads/2015/07/CMSS-Quality-Primer-layout.final.pdf The Dartmouth Institute (n.d.) Understanding of the efficiency and effectiveness of the health care system. Retrieved August 31, 2016, from http://www.dartmouthatlas.org/ Institute of Medicine Committee (IOM) on Quality in America. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. The Joint Commission. (2011). Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: Author. The Joint Commission. (2014a, Aug.). Program: Ambulatory. Chapter: information management (e-dition). Retrieved August 21, 2016, from http://foh.hhs.gov/tjc/im/standards.pdf The Joint Commission. (2014b, Aug.). Program: Ambulatory. Chapter: Record of care, treatment and services (e-dition). Retrieved August 21, 2016, from http://foh.hhs.gov/tjc/roc/standards.pdf The Joint Commission. (2015a, Nov. 5). Hospital: 2016 national patient safety goals. Retrieved August 31, 2016, from https://www.jointcommission.org/hap_2016_npsgs/

The Joint Commission. (2015b, Sept. 2). Joint Commission measure sets effective January 1, 2016. Retrieved August 21, 2016, from https://www.jointcommission.org/joint_commission_measure_sets_effective_january_1_2016/ The Joint Commission. (2016, April 27). Accreditation process overview. Retrieved August 21, 2016, from https://www.jointcommission.org/accreditation_process_overview/ The Joint Commission. (n.d.). About the Joint Commission. Retrieved August 21, 2016, from https://www.jointcommission.org/about_us/about_the_joint_commission_main.aspx Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press. Morris, C. (2014, May). Measuring health care quality: An overview of quality measures (Issue brief). FamiliesUSA. Retrieved August 21, 2016, from http://familiesusa.org/sites/default/files/product_documents/HIS_QualityMeasurement_Brief_fina l_web.pdf National Committee for Quality Assurance (NCQA). (2015). 2015 NCQA health plan accreditation standards. Retrieved August 21, 2016 from http://www.ncqa.org/programs/accreditation/health-plan-hp National Committee for Quality Assurance (NCQA). (n.d.a). About NCQA. Retrieved August 21, 2016, from http://www.ncqa.org/about-ncqa National Committee for Quality Assurance (NCQA). (n.d.b). Quality compass. Retrieved August 21, 2016, from http://www.ncqa.org/tabid/177/Default.aspx National Committee for Quality Assurance (NCQA). (n.d.c). Report cards. Retrieved August 21, 2016, from http://www.ncqa.org/report-cards National Quality Forum (NQF). (n.d.). About us. Retrieved August 31, 2016, from http://www.qualityforum.org/About_NQF/