Since being named CEO of the National Quality Forum in December 2012, Dr. Christine Cassel's organization has come under increasing pressure to improve the measures used to judge the quality of the nation's hospitals, physician practices and other healthcare organizations. Modern Healthcare reporter Sabriya Rice recently spoke with the former head of the American Board of Internal Medicine and perennial member of Modern Healthcare's 100 Most Influential list about the organization's response to that pressure. This is an edited transcript.
Q&A: Cassel discusses NQF's search for better quality metrics
Modern Healthcare: Last July, the NQF said it would examine factors that boost hospital admissions. When can we expect the results?
Dr. Christine Cassel: There is a science to measurement and it is an evolving science—always responding to new evidence. In this instance, what the NQF did was to bring together a group of experts to look at this question of whether factors that aren't medical factors can influence the outcomes of patients in ways that are measurable.
We know that there are many things that affect people's health and their risk of illness—socio-economic and demographic factors such as poverty, literacy and homelessness. This committee made recommendations about the ways in which measures can be risk-adjusted for these factors and the ways in which they shouldn't be.
The CMS agreed to a trial period of using risk-adjusted measures when they are appropriate. We are in the early stages of what will be a two-year trial period of testing these risk-adjusted measures and evaluating their performance against measures that aren't risk-adjusted.
MH: What pressure is coming from stakeholders to address those problems, especially as hospitals face penalties for failure to meet the metrics?
Cassel: The NQF is constantly evaluating measures. There is a process called maintenance that brings new information. We have standing committees that are in place when there is new medical evidence. For example, we had a sepsis measure where a new study came out just less than a year ago that showed that one part of how the endorsed sepsis measure was used was no longer recognized as actually being helpful, and within six weeks we got the committee together and changed that measure.
We're constantly on the watch for new evidence of the impact of measures. People will be hearing more from us in other areas of measurement science.
MH: As more measures enter the healthcare environment, there has also been criticism that people are sometimes so busy collecting data that they are not doing the other things that really matter to patient care.
Cassel: As a physician, I am very sympathetic with the burden of data collection and reporting that many physicians and others face. It is part of the complexity of our healthcare system because every different insurance company has its own measures and then the government programs have their own measures. We have to align these measures wherever possible. We are actively involved in helping the federal government dramatically reduce and align the measures they are using across all of their 22 different clinical programs.
While people are complaining that there are too many and we heard the IOM report that just came out a couple months ago calling for a core set, there are a lot of specialties where patients can't get the information that they need. If you suffer from a condition like multiple sclerosis and there aren't good measures, those doctors don't have a way of evaluating their performance in a way that consumers can understand.
Some people say there are too many measures; other people say there are not enough. I call that the Goldilocks problem. We have to get the measures right and get the measures that matter. The NQF is doing a lot of work with measure developers to try to get more rapidly to the measures that really matter.
MH: Why are some measures used by the federal government while others are not?
Cassel: We are a contractor (that) provides services to help them align the measurements that they use and evaluate the quality of the measures in their programs. But as both the government and the private sector find the need for more and more measures, sometimes they will go ahead and put in use a measure that isn't yet endorsed (by the NQF) or that is in the process. Oftentimes, there are ways in which the standards that the NQF sets are useful in the broader framework of what CMS is doing and sometimes CMS is advancing new measures that aren't yet ready for the endorsement process. So, it is a very complex environment.
MH: When various providers disagree with the measures that the CMS is using, they will note that they are not yet endorsed or are still under review by the NQF. What do you say to them so they can feel certain that the measures that are out there are the best ones for their organizations?
Cassel: We have a process that is called consensus development where all those stakeholders come together around our table and work through these issues with our colleagues in the federal agencies. It would be great if the process was simpler, but the fact is that healthcare and human health is a complicated business. And measurement is a science that has to encompass all the complexity of that complicated business.
There is a sort of a crowd-sourcing that is going on as people are experimenting with using different measures for different purposes. That is one of the functions that the NQF brings. We uniquely bring all those stakeholders together in a transparent and public process so that people can raise those concerns.
MH: Last year, conflict-of-interest concerns were raised about NQF decisions affecting stakeholders, which led you to step down from two boards (Kaiser Permanente and Premier). What lessons have you learned from those experiences and what changes has the NQF made to ensure those kinds of conflicts don't happen again?
Cassel: We addressed all of those issues on our website and in documents around that time. I think that has been adequately addressed.
MH: The NQF has issued some safe practice guidelines on nursing workforce safety. Several states have moved to require health facilities to meet certain standards. Is that something the NQF would like to see more of?
Cassel: We have a number of health professional organizations that are members of the NQF and that are part of our process. Nursing is one of those, and a very important one. That safe practices document from 2010 does represent the state of the art of the group that came together around that time. (But) the NQF did not endorse a measure of nursing staffing because of concerns about the evidence.
There are a number of other patient outcome measures and other measures that are much more representative of nursing effectiveness and nurse safety. For example, new delivery systems are being generated by the ACA and by what the private payers are doing try to make care more comprehensive and more organized around the patient-centered approach. Many of these are using different kinds of teams in their approach to care. My personal view is that nurse-staff ratios are not the only indicator and not the best indicator of what really is the best outcome for how a healthcare team works.
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