Quality experts call for HHS to revive the National Quality Strategy 10 years after ACA

Stakeholders from across the industry have been working together over the last 10 months on a national strategy to improve quality of care over the next decade.

If that sounds familiar, it may be because the Patient Protection and Affordable Care Act in 2010 mandated that such a strategy be created; but after it was produced, it withered rather quickly.

“It’s now a decade later, and it’s incumbent on all of us to get together and set a new strategy looking forward. We took that upon ourselves,” National Quality Forum CEO Dr. Shantanu Agrawal said.

The NQF, which endorses quality measures with funding from Medicare, plans to release its own strategy later this spring with broad goals for the industry. Nearly 100 stakeholders are involved in the NQF’s effort including leaders at federal agencies who acted as advisers.

Agrawal declined to offer details on the strategy ahead of its publication, but he said the industry is still not where it should be on quality 10 years since the National Quality Strategy was created. He mentioned healthcare disparities, interoperability, risk adjustment and payment as problems that continue to afflict the industry.

“I don’t want to suggest there hasn’t been an evolution over the years but there are some basic, fundamental structural issues that need to be addressed and resolved if we are going to move the enterprise forward as much as we want to,” he said.

And while Agrawal is hoping the NQF’s new strategy will have an impact, he admits the federal government has more leverage leading the effort since it’s the largest payer. “I don’t think there is anything replacing the public sector taking a broad and proactive stance on quality improvement and what its goals should be,” he said.

Others in the quality sector agree there is value in reviving the National Quality Strategy considering what still needs to be done on quality improvement, yet there aren’t any signals the federal government intends to.

The federal government has stopped discussing the strategy, and ACA-mandated annual progress reports have stopped being produced. The last report was published in 2016 by the Agency for Healthcare Research and Quality, and the webpage was last updated in March 2017.

AHRQ spokeswoman Farah Englert said while the progress reports are no longer published, both AHRQ and the CMS use the strategy “as a framework for our quality improvement activities.”

There is even more doubt among some that the Trump administration will take it on as a priority considering their efforts to undercut the ACA. “I see a loss of focus on quality and a loss of focus on universal coverage,” said Dr. Don Berwick, who led the CMS at the time the strategy was implemented. “In order to have quality healthcare, you have to have healthcare.”

However, founders of the strategy say its irrelevance now isn’t a bad thing because the priorities are baked into the industry’s daily operations.

The National Quality Strategy’s main objective was to achieve the Triple Aim: better care, healthier communities and lower costs.

Developed by the Institute for Healthcare Improvement in the early 2000s, the Triple Aim is now part of healthcare vernacular, said Peter Lee, who led the execution of the strategy in his role as director of delivery reform for HHS’ Office of Health Reform.

The strategy’s six complementary priorities include reducing patient harm, engaging patients and family as partners in their care and promoting care coordination.

“I don’t lose sleep over the fact that people aren’t wearing National Quality Strategy T-shirts,” Lee said, who is now executive director of Covered California. “That wasn’t the goal. I take great comfort in knowing that those core principles have become really truly industry standards.”

But there is still work to be done on the National Quality Strategy’s priorities. For instance, while there has been improvement on hospital-acquired conditions, there are still disparities in access to care, affordability concerns for patients, problems with quality measures and challenges with care coordination.

In its final report on the national strategy, AHRQ showed black, Hispanic, American Indians and Alaska Natives received worse care than white Americans for about 40% of quality measures.

Critics argue the strategy began with a strong foundation on how to improve quality but lacked specific goals and revisions that would keep it relevant.

“I think what the National Quality Strategy ultimately became in its final product was less of a strategy and more of a taxonomy,” said Akin Demehin, director of policy at the American Hospital Association. “It’s a solid articulation of the building blocks of improving quality and safety … but in my mind a strategy is one that does have specific steps and some measurable goals to it—I’m not sure the National Quality Strategy did that.”

In 2012, the first report to Congress on progress toward realizing the strategy’s aims did list long-term goals, although they were broad and didn’t quantify how much metrics should improve over a certain time period.

For example, in regards to the priority about reducing harm, the goals listed are to reduce preventable hospital admissions and readmissions; reduce the incidence of adverse healthcare-associated conditions and reduce harm from inappropriate or unnecessary care. The report then identifies the hospital-acquired condition measures and the hospital 30-day readmission measures as how to track progress.

Lee said the broad goals and priorities were intentional. “It was never intended to be” specific, he said. “A road map is generally not a specific (route) to get to the granular level.”

The strategy was meant to get both the private and public sector on the same page about what quality healthcare looks like, Lee said.

“The strategy was never about folks signing on the dotted line saying I’m going to do every one of these things,” he said. “It was to reinforce core principles.”

For the federal agencies, the strategy helped guide their work, according to Berwick. For instance, when putting together contracts for the CMS’ Quality Improvement Organizations Program, Berwick said he used the strategy to help focus priorities. “I saw it as an important document to help us all come together across the departments of HHS to advance quality of care.”

The priorities of the strategy were heavily influenced by the National Priorities Partnership, a collaborative of 48 public and private stakeholders formed by the National Quality Forum to offer feedback to HHS on what the goals of the National Quality Strategy should be. The ACA required HHS to get stakeholder engagement before creating the strategy.

Recommendations from the collaborative, which were submitted to HHS in late 2010, were inspired strongly by the Institute of Medicine’s 2001 report Crossing the Quality Chasm, said Dr. Bernard Rosof, CEO of the Quality HealthCare Advisory Group consultancy who co-chaired the partnership.

While the IOM report brought national attention to quality of care issues, “not a heck of a lot was done,” Rosof said. “They were really important concepts that needed to be mentioned and followed through for a long period of time.”

Signs the National Quality Strategy was fading away were apparent in its final progress report published in 2016. The report was combined with AHRQ’s annual disparities report instead of being its own document. And AHRQ no longer listed any long-term goals. Rather, it was a collection of measures related to the National Quality Strategy’s priorities and how performance changed over time.

The reports weren’t “very meaningful” to the industry because of their design, argues Margaret VanAmringe, executive vice president of government policy and government relations at the Joint Commission.

“There are so many interventions going on in terms of safety and quality, and you really couldn’t attribute change or lack of change to the National Quality Strategy … because you couldn’t get the data to be specific enough,” she said.

Another criticism is that the strategy’s priorities stayed the same even as more was learned about quality improvement and focuses shifted. “This is a great framework, but it needs to be further developed. That’s the issue,” said Dr. Allen Kachalia, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine.

For instance, physician burnout, the opioid epidemic and teen vaping aren’t mentioned in the National Quality Strategy because they weren’t in the limelight a decade ago but they are real problems today for the industry. “We could’ve taken all of the horsepower in the private sector with the federal government and put us into synergy,” VanAmringe said. “We can make a difference (together).”

Revising the National Quality Strategy more frequently also would’ve been a way to review the quality programs the CMS has implemented since the ACA, said Dr. Peter Pronovost, a patient safety expert and chief clinical transformation officer at University Hospitals in Cleveland.

All the different activities from the agency feel more like a game of whack-a-mole rather than an aligned strategy, he said. “It’s hard to keep up with all the different interventions and payment reforms. … It would be great if every three or five years we review what we learned, what works and, importantly, how do we integrate some of these pieces. We are pulling at all of these different levers,” Pronovost added.

The CMS is trying to achieve more synergy at least for its quality measures. HHS is currently seeking feedback from leaders across the industry on how to better align and revise measures across its federal programs, which the 2012 report mentioned should be a focus of the National Quality Strategy. Pronovost is co-leading the effort along with HHS Deputy Secretary Eric Hargan, but he declined to discuss the efforts.

A potential reason the National Quality Strategy never underwent substantial modifications may be because there wasn’t enough funding for it. From 2011 to 2017, AHRQ spent $4.2 million on producing the National Quality Strategy, according to Englert at AHRQ.

AHRQ, which released the final report, also has a smaller budget than its other HHS agency counterparts. For fiscal 2020, AHRQ’s budget is $338 million compared with the National Institutes of Health, which has a $41.7 billion budget.

The directors who led AHRQ after the National Quality Strategy was implemented, and prior to this administration, either didn’t respond to requests for comment or declined to comment on the record for this story.

But some doubt funding was much of an issue; while AHRQ took over the final report, the ACA intended this to be a priority for HHS overall. “It was very much an HHS activity,” Demehin said. Perhaps the reports stopped and more work wasn’t done on the strategy because of shifting priorities and resources at the agency, he added.

Even with its flaws, there is value in reviving the National Quality Strategy, according to provider stakeholders and patient safety experts.

“We have learned a lot in the last 10 years (in terms of safety and quality), and now it’s time to take a step back and say, ‘What is the next phase of quality improvement and patient safety we should be undertaking?’ ” said Dr. Janis Orlowski, chief healthcare officer at the Association of American Medical Colleges.

Other countries have adopted national strategies on healthcare quality, and Berwick said it’s useful to bring both the private and public sectors together to influence change.

“We need very strong public-private partnerships. Healthcare delivery is largely a private-sector enterprise. I sense an enormous possibility here. … We could do it, but at the moment I don’t see that momentum underway,” Berwick said.

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