To prevent councils with fewer members, such as consumers, from being at a disadvantage when voting, NQF calculates the total vote from each council and then determines the percentage of councils that approve the measure. In other words, each council, no matter how big or how small, gets one vote.
In this case, four of the seven councils that participated in the voting process supported the CMS/Yale readmissions measure, leading to an approval rating of 57% among the councils. But only 49% of the 64 NQF-member organizations that voted actually supported the measure and the provider organizations' council voted overwhelmingly against it.
“We don't view this as a consensus and that's our primary point,” Casey said during a June 11 conference call held by NQF's Consensus Standards Approval Committee to discuss the appeal. “We think there ought to be a different approach.”
Casey said during the call that providers have been discouraged from participating in the NQF's endorsement process for a long time, and he argued that the controversy surrounding the split vote on the readmissions measure could even “run the risk of putting NQF's viability at risk.”
But Dr. Helen Burstin, NQF's senior vice president of performance measures, instead characterized the organization's process as deliberate and thorough, with numerous opportunities to seek clarification and voice concerns.
In this instance, she said, a 21-member expert steering committee reviewed the readmissions measure in mid-February and after an initial “straw vote,” which resulted in a vote of “no,” the committee sought additional information and analysis from the developers at Yale. After reviewing that data and member comments, the committee voted again, reversing its earlier decision, and the measure was recommended for endorsement by a vote of 14-5.
At that point, the measure was put out for membership vote.
Despite the issues stated in the appeal, Burstin contends other NQF members haven't raised many concerns up until this point regarding the council voting process.
“It's very rare that we don't have overwhelming support for measures when they're endorsed because there are so many opportunities to have issues raised and resolved along the way that by the time we get to that point, issues have already been addressed,” Burstin said. “This is an unusual case.”
Especially unusual, she added, because it's one of only two times there has ever been a split vote, or a vote where the popular vote was different than the council vote.
Burstin says she views the hospitals' appeal as less of an overall indictment of NQF's processes and more of a reflection of the contentiousness of this particular measure and of readmissions in general as a hospital quality indicator.
Providers' unease about linking preventable readmissions and quality is not surprising, said Dr. Ashish Jha, associate professor of health policy and management at the Harvard School of Public Health, Boston. Jha co-authored an April article in the New England Journal of Medicine in which he called policymakers' focus on 30-day readmissions misguided. He argues that not all readmissions are preventable, particularly when so many determining factors are out of hospitals' control. Jha said hospitals may be investing their limited time, energy and resources on strategies to prevent readmissions, at the expense of other quality-improvement priorities.