National Priorities Partnership Research Articles

Interview With Richard J. Umbdenstock, FACHE, President and CEO of the American Hospital Association

Richard J. Umbdenstock has served as president and CEO of the American Hospital Association (AHA) since January 1, 2007, and is stepping down from this role at the end of 2015. In 2006, he was elected AHA board chair. Mr. Umbdenstock's career includes experience in hospital administration; health system governance, management, and integration; association governance and management; health maintenance organization (HMO) governance; and healthcare governance consulting. He has written several books and articles for the healthcare board audience and national survey reports for AHA, Health Research & Educational Trust, and ACHE. Mr. Umbdenstock has served as vice chair of the National Quality IH'orum, on the board of Enroll America, and on the National Priorities Partnership. Mr. Umbdenstock recently received ACHE's 2015 Gold Medal Award, the American Organization of Nurse Executives 2015 Honorary Member Award, and the Federation of American Hospitals Inaugural Health Care leadership Award.Dr. Kash: As a servant leader, what do you see as your legacy? How can emerging healthcare leaders, such as students and early careerists, learn from your experience?Mr. Umbdenstock: I am proud of having played a role in extending coverage to about 17 million Americans who did not have it before the Affordable Care Act (ACA)-to be part of something that has provided better access to care for millions of Americans. I am proud that it has happened without increased utilization busting the banks. Dire predictions that physicians' offices and emergency departments would be swamped because of the new coverage haven't happened. 1 think this shows that major change is possible without completely upsetting the existing system. We are, of course, in only the second year of this extended coverage, so we can't declare total victory-but so far, so good.I also hope I have left some mark on the system, and something for early careerists to be thinking about is in the area of performance improvement. As a trade association, AHA has become much more focused on helping members improve their performance. We embraced public reporting a long time ago, and when you do that, you hope that your members will look as good as possible. At the same time, I believe that our public policy credibility hinges on the height of the bar that AHA set for quality and safety. In a more transparent advocacy world, you want to eliminate your vulnerabilities, which means you have to get better faster and address any performance issues you may have.Performance improvement is the right thing for patients. None of us wants to see anybody harmed. There was a time in my career when people thought that they were doing extremely well if they achieved a 90% safety rate in some areas. Our thinking has changed. Many organizations reach a 100% rate-orzero harm-on certain measures because nothing less than that is satisfactory. I feel good about having promoted performance improvement, quality, and transparency.Finally, I hope I have helped our field see the value of moving on the path toward a more integrated system of care. 1 have spent time in such systems as both a board member and a patient, and those experiences have helped me chart a course for members interested in moving in this direction. Thirty years ago, many believed that HMOs were evil-they seemed so counter-cultural! Today, people want to see that kind of integration in healthcare.Dr. Kash: Tell us about the most challenging aspect of your term as CEO of AHA.Mr. Umbdenstock: The greatest challenge is how to reform the healthcare system in the long term. The AHA does three big things. First, we advocate for our members in the public policy realm. Second, we try to shape the long-term direction of the health system, which means creating a shared vision of where it should go, determining where forces are taking it, and then helping our members get from here to there. Third, we support our members in performance improvement. …

Orthopaedic Quality Reporting: A Comprehensive Review of the Current Landscape and a Roadmap for Progress.

Passage of the Patient Protection and Affordable Care Act in 2010 mandated sweeping changes to the United States health-care system1. The Patient Protection and Affordable Care Act has vastly expanded the government’s involvement in tracking and reporting quality measures for physicians and hospitals, creating a dizzying array of stakeholders in this complex policy arena (Fig. 1). Quality measures are now increasingly tied to reimbursement, potentially redefining payment models for physicians and hospitals across the country. Medicare alone will base 9% of hospital payments on performance by 20172. Fig. 1 Roadmap and relationships of major quality stakeholders. ACS = American College of Surgeons, AHRQ = Agency for Healthcare Research and Quality, AAOS = American Academy of Orthopaedic Surgeons, CDC = Centers for Disease Control and Prevention, CMS = Centers for Medicare & Medicaid Services, HACs = hospital-acquired conditions, HHS = U.S. Dept. of Health & Human Services, MAP = Measure Applications Partnership, NIH = National Institutes of Health, NPP = National Priorities Partnership, NSQIP = National Surgical Quality Improvement Project, NQF = National Quality Forum, PQRS = Physician Quality Reporting System, PROMIS = Patient-Reported Outcomes Measurement Information System, and SCIP = Surgical Care Improvement Project. Quality measurement has …

Overuse of Health Care Services

There is widespread agreement that ‘more’ is not always better in health care. Doing ‘more’ can harm patients, generate excess costs, and defy patient preferences. All are major threats to the delivery of high quality health care. Reflecting this notion, the Institute of Medicine (IOM) National Roundtable on Health Care Quality coined the term ‘overuse’ in 1998,1 adapting the definition of an ‘inappropriate’ service developed for the RAND Appropriateness Method in the 1980s.2 Overuse was defined as “a health care service [that] is provided under circumstances in which its potential for harm exceeds the possible benefit.”1 Initiatives to address overuse of medical services3 will be crucial in reducing total health care spending and iatrogenic harms.4 But recent initiatives also illustrate a potential obstacle – what is meant by overuse may be conceptually vague. In 2008, the National Priorities Partnership identified eliminating overuse as a national priority, describing it as “unscientific,” “redundant,” and “excessive” care.3 The American College of Physicians identified examples of overused screening and diagnostic tests that “clinicians often use in a manner that does not reflect high-value, cost-conscious care and does not adhere to currently available clinical guidelines.”5 The American Board of Internal Medicine Foundation’s Choosing Wisely campaign provides yet another description of overuse and helps to demonstrate the potential consequences of this ambiguity. The campaign is intended to help physicians and patients choose care that is “supported by evidence, not duplicative of other tests or procedures already received, free from harm [to patients], [and] truly necessary.”6 But the diversity of scenarios identified is substantially broader than this description. Three scenarios in Choosing Wisely differ strikingly in their underlying premise of what constitutes overuse: ‘do not repeat colorectal cancer screening for 10 years after a high-quality colonoscopy is negative in average-risk individuals,’ ‘don’t use DEXA screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors,’ and ‘don’t initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians.’6 For too frequent colorectal cancer screening, potential for harm (e.g., perforation of the colon) outweighs the benefit. Although in theory any health care intervention can cause ‘harm,’ DEXA screening for low-risk groups would not have a measureable effect on quality of life or mortality. Rather, the low likelihood of meaningful benefit is associated with the high costs of DEXA screening (estimated $70 per scan, totaling $527 million per year in the United States for women under age 657). The reasons not to initiate chronic dialysis without shared decision-making are more complex than merely avoiding the initiation of a service expected to do more harm than good. Rather, integrating individual preferences and goals into clinical decisions can help to avoid the provision of undesired care.8 Among these and other examples, no clear conceptual pattern emerges. Rather, the lists are a loose collection of services joined only by the broad notion that they should not be delivered, at least in some contexts. In our view, this lack of conceptual backbone will impede the acceptance of these initiatives by physicians. Absent a clearer conceptual framework, it will be difficult to answer key questions. For example, what types of services should next be included on a list? How should a potential area of overuse be identified a priori? How should a culture that encourages overuse or fails to discourage it be mended? A conceptual framework contemplating different dimensions of overuse might help. The framework we propose has three categories: the tradeoff between benefits and harms, the tradeoff between benefits and costs, and consideration of patient preferences. Examples of overuse can be found in each category. Making the categories explicit can help clarify the reasons to diminish a service’s use, and help those who develop and use the recommendations to make sense of seemingly disjointed issues within and across initiatives.

Current Resources for Evidence‐Based Practice, May/June 2013

Current Evidence Reviews Related to Cesarean Birth With the current cesarean rate in the United States at nearly 33%, calls to reduce the number of cesarean births are increasing. The National Priorities Partnership (NPP), convened by the National Quality Forum (NQF), has as one of its aims to work toward reducing the cesarean rate for low-risk women to 15% (National Quality Forum, n.d.). The Joint Commission recently announced a new requirement for hospitals with more than 1,100 births per year to report on perinatal outcomes including elective delivery (vaginal and cesarean ≥37 and <39 weeks) and cesarean births (nulliparas with a term, singleton, vertex birth) beginning January 2014 (The Joint Commission, 2012). Although the cesarean rate may have stabilized recently after a steady increase of 60% over a 13-year period (Hamilton, Martin, & Ventura, 2012; Martin et al., 2012) it remains higher than recommended in the Healthy People 2020 goals (U.S. Department of Health and Human Services, 2012).

Use of palliative care measures to support improved patient outcomes and quality of life.

281 Background: Key public-private quality improvement entities, such as the National Quality Forum (NQF) and the National Priorities Partnership, have identified palliative care measures as being critical for the care of cancer patients. In this study, Avalere sought to understand whether current palliative care measures are adequate to support desired patient outcomes, including quality of life. Methods: Avalere conducted searches of large, national quality measure databases—including the Agency for Healthcare Research and Quality’s National Quality Measure Clearinghouse and NQF—as well as public quality measurement programs to better understand the range of existing palliative care measures and the use thereof. In addition, Avalere augmented this research through a review of the white and grey literature to determine how such measures may be better used to support desired outcomes. Results: Several organizations—most notably the American Society of Clinical Oncology (ASCO); the American Medical Association–convened Physician Consortium for Performance Improvement, with the National Comprehensive Cancer Network and ASCO; and the RAND Corporation—have developed measures addressing palliative care for cancer patients. Several of these measures have been subsequently endorsed by NQF. Despite this, few palliative care measures have been incorporated into national quality measurement programs, outside of ASCO’s proprietary Quality Oncology Practice Initiative (QOPI). Conclusions: While it is widely acknowledged that palliative care measures are critical for the care of cancer patients, particularly as it relates to supporting quality of life, little has been done to ensure such measures are incorporated into national public quality improvement initiatives, such as the Centers for Medicare &amp; Medicaid Services’ Physician Quality Reporting System. As calls for increased use of patient-reported outcomes and other palliative care measures continue to rise, policymakers may need to consider incorporating existing, NQF–endorsed measures, such as those used in QOPI, into public programs.

Millennial Health Care: Change You Can Believe in

Millennial Health Care: Change You Can Believe in

The Road Ahead

The Road Ahead

The Impact of Palliative Medicine on Franciscan St. Francis Health

Franciscan St. Francis Health of Indiana implemented a palliative medicine pilot program in 2004 that introduced palliative care to 13 patients and their families during Day 3 of their intensive care unit stay to help resolve life-limiting and end-of-life issues. As a result, the hospital saved $29,240 per patient (based on Center to Advance Palliative Care formula) that year. These savings allowed the hospital to hire one full-time palliative medicine employee. The criteria to implement the program met the National Quality Forum requirements set by the National Priorities Partnership in 2008. Because of its success, the palliative medicine team (physicians, nurses, nurse practitioners, social workers, chaplains, and pain control specialists) consulted on more than 1200 cases in 2010.

Choosing Wisely

WHILE THE UNITED STATES GRAPPLES WITH THE challenge of health care costs that contribute to high rates of poor-quality care, burdens to business competitiveness, and looming government deficits, clearly there are areas in which health care spending does not add to the health of individuals and communities. The polarizing political environment makes it difficult to conduct rational public discussions about this issue, but clinicians and consumers can change the nature of this debate to the potential benefit of patients, the medical profession, and the nation. The initial focus should be on overuse of medical resources, which not only is a leading factor in the high level of spending on health care but also places patients at risk of harm. In fact, some estimates suggest that as much as 30% of all health care spending is wasted. To reduce unnecessary tests and procedures, physicians will need to play a leading role—their decisions account for about 80% of health care expenditures. Yet physicians do not always have the most current effectiveness data, and despite acting in good faith, they can recommend diagnostic or therapeutic interventions that are no longer considered essential. Also, research shows that physicians may need help communicating these matters to their patients. This may be especially difficult when clinicians and consumers are deluged with advertising and promotion. Clinicians often report feeling compelled to accommodate patients’ requests for interventions they know are unnecessary. At the same time, patients need trustworthy information to help them better understand that more care is not always better care, and in some cases can actually cause more harm than good. A major goal of health care reform is enhancing “patientcentered care.” Patients, and consumer groups representing them, express increasing interest in forging true partnerships with their clinicians, with real-time access to their own medical records, to science-based comparative effectiveness information, and to health care delivery environments built to enhance both comfort and personalization of medical care. Patient engagement, as 1 of the 6 major initiatives of the National Priorities Partnership of the National Quality Forum, promises more informed and involved patients as decision makers. To make good on this promise requires transparent and credible information about the relative value and risk of various medical diagnostic and therapeutic interventions. To help reduce waste in the US health care system and promote physician and patient conversations about making wise choices about treatments, 9 medical specialty societies have joined the ABIM (American Board of Internal Medicine) Foundation and Consumer Reports in the first phase of the Choosing Wisely campaign, including the following: American Academy of Allergy, Asthma & Immunology; American Academy of Family Physicians; American College of Cardiology; American College of Physicians; American College of Radiology; American Gastroenterological Association; American Society of Clinical Oncology; American Society of Nephrology; and the American Society of Nuclear Cardiology. As part of Choosing Wisely, each society has developed a list of 5 tests, treatments, or services that are commonly used in that specialty and for which the use should be reevaluated by patients and clinicians. Those lists were released on April 4, 2012, at a national event in Washington, DC. Additionally, other societies, consumer organizations, and physician organizations have asked how they can become part of this effort to engage physicians and patients in conversations about tests and procedures that should rarely be used. The early origins of this campaign can be found in “Medical Professionalism in the New Millennium: A Physician Charter.” Authored in 2002 by the ABIM Foundation, American College of Physicians Foundation, and European Federation of Internal Medicine, the charter has as its fundamental principles the primacy of patient welfare, pa-

Incorporating National Priorities Into the Curriculum

There are many aspects of care that need an overhaul to function safely, efficiently, and effectively. There needs to be a new culture in health care that focuses on safety and quality, and it will take many shareholders working together to make this possible. The National Priorities Partnership is a group of 28 national organizations from across the health care spectrum collaborating to change the health care delivery system. The Partners acknowledged four challenges individuals face in the current U.S. system: harm, disparity, disease burden, and waste. To meet these challenges and improve performance, the Partners identified six priorities: patient and family engagement, population health, safety, care coordination, palliative and end-of-life care, and overuse (National Priorities Partnership). It is hopeful that when put into practice, these essentials will have a significant impact on improving health care. It comes down to creating a culture of safety and quality. This culture should start during entry-level education for health care providers, such as nursing schools. The priorities and goals provide a framework that can be incorporated into the curriculum so future nurses are aware of the issues and challenges in health care today. Each challenge needs evidence-based strategies for achieving the desired results. It is time to create a culture of safety and quality in health care.

Long-term elimination of ICU infections requires specific steps

A few simple ideas differentiate hospitals that completely eliminate central-line-associated bloodstream infections (CLABSIs) from facilities that simply seek to put a dent in the problem, says Peter Pronovost, director of the Quality and Safety Research Group at the Johns Hopkins University School of Medicine in Baltimore. About a decade ago, Pronovost spearheaded the development of a checklist based on a 200-page infection-control guideline from the Centers for Disease Control and Prevention (CDC). During an August 3 webinar hosted by the National Quality Forum’s National Priorities Partnership, Pronovost said the checklist supports five “mission-critical things” that were distilled from the CDC guidelines: “Wash your hands, clean the skin with chlorhexidine, avoid the femoral site, use full barrier precautions, and ask every day, ‘Do I still need the catheter?’” When the checklist was used in Michigan hospitals, CLABSI rates in ICUs fell dramatically. According to recently published data, 60% of the units went at least one year without an infection, and 17% went two years or more.

National Priorities Partnership Focus on Eliminating Overuse

As one of several initiatives to transform health care delivery across the United States, the National Priorities Partnership has identified "eliminating overuse while ensuring the delivery of appropriate care" as a top priority. Cardiac revascularization procedures, including coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), constitute one area of focus for reduction of overuse. Despite the multiyear development of clinical guidelines to define appropriate use of cardiac revascularization, substantial variability in the application of these procedures is observed. Concurrent data collection tools to support real-time clinical decision making regarding appropriateness are needed and can be used, along with financial incentives such as pay-for-performance programs and public reporting of performance information, to support more appropriate use of cardiac revascularization. Efforts to achieve more rational use of CABG and PCI should be made carefully and with the goal that patients receive the most appropriate and effective care.

Nurse Executives and the National Priorities Partnership

Nurse Executives and the National Priorities Partnership

National Priorities Partnership: Eliminating Overuse

THIS EDITORIAL PRESENTS the last in a series examining the challenges and goals established by the National Priorities Partnership (NPP), which is charged with developing a vision for world-class, affordable health care. 1 NPP National priorities and goals: Aligning our efforts to transform American’s healthcare. National Priorities Partnership, Washington, DC2008 Google Scholar The NPP’s final priority concerns the elimination of overuse while ensuring the delivery of appropriate care. Vallire D. Hooper, PhD, RN, CPAN, FAAN, is a Perianesthesia Consultant and Assistant Professor, School of Nursing, Medical College of Georgia, Augusta, GA.

The Busy Emergency Department

“The office is closed at this time and will reopen at 9 am tomorrow morning. If this is an emergency, please call 911 or go to the nearest emergency room.” There has been an important evolution in the practice of medicine in the past decade. An article included in this issue, “Exploring New Intake Models for the Emergency Department,” clearly highlights the emergence of the emergency department (ED) as a primary portal of entry for many patients. Within the context of the issues raised by the authors we must answer the following questions: “Why does the percentage of nonurgent ED visits as a percentage of overall visits continue to rise (ie, 10% in 2002 and 13.9% in 2005)?” “Who uses the ED for nonurgent care?” “Where are the opportunities to reduce ED overuse?” The National Quality Forum’s National Priorities Partnership (NPP) has identified eliminating overuse while ensuring the delivery of appropriate care as one of 6 national priority areas. The NPP envisions health care that promotes better health and more affordable care by continually and safely reducing the burden of unscientific, inappropriate, and excessive care including tests, drugs, procedures, office and hospital visits, and hospital stays. Making overuse a national concern will reduce harm, disparities, disease burden, and waste. Assuring access to appropriate care on a timely basis will also reduce more serious chronic disease consequences downstream. Examples include hypertension, congestive heart failure, and early detection of malignant disease. Potentially preventable ED visits is one of the 9 areas targeted by the overuse committee of the NPP. The Commonwealth Fund 2008 National Scorecard on US performance noted that 26% of adults went to the ED in the previous 2 years for conditions that could have been treated by their regular doctor, if available. The United States fared the worst in a comparison with 6 other countries (Germany, Netherlands, New Zealand, the United Kingdom, Australia, and Canada). Nationally, 60 million, or half of the 120 million annual ED visits, are potentially avoidable. In 2006, there were 119.2 million visits to hospital EDs, 15.9 million of which were considered emergent or urgent. Emergency services are often the only alternative for the uninsured or underinsured as their access to primary care services is limited. However, the New England Healthcare Institute notes that lack of timely appointments and after-hours care also drives patients to the ED. Primary care practices often instruct patients to seek care in the ED. Patients can receive care in the ED anytime—regardless of the severity of their condition—and in view of the wide array of services available in the ED, patients can receive immediate feedback about their condition. These factors contribute to the fact that all payer groups and age groups contribute to the issue of nonurgent care in the ED. This trend applies to Medicare and Medicaid beneficiaries in particular. Insured patients with a primary care alternative also inappropriately use the ED; one third of ED visits are made during regular business hours when primary care offices are open. According to statistics from the Centers for Disease Control and Prevention and the Massachusetts Division of Health Care Financing and Policy, the estimated nonurgent, preventable/avoidable ED visits in Massachusetts in 2006 were made by 22 000 patients with private insurance, 15 000 with Medicaid, 10 000 uninsured, and 9000 Medicare patients. The average cost of an ED visit is $540 more than the cost of an office visit. If we can reduce ED overuse (ie, if all 60 million avoidable ED visits were redirected to a less costly setting), there is an opportunity to improve care and a potential savings of $32 billion. Overuse of nonurgent ED services results in potentially avoidable hospital admissions in 5.5% of cases as well as higher volumes of more expensive testing. The unintended consequences of harm inherent from inappropriate testing, procedures, and hospitalizations have been well documented and affect quality and patient safety. The frequent lack of follow-up on recommendations given to the patient in the ED and poor communication with the primary care physician (if indeed there is one) add to the concerns of poor coordination of care—particularly in the elderly and patients with chronic illnesses—and ED revisits. To ensure quality, safety, and patient satisfaction when the patient arrives in the ED, the recommendations inherent in the Welch and Davidson article in this journal should be carefully reviewed. Timely access to primary care services must be a focus of quality improvement efforts if we

National Priorities Partnership: Palliative and End-of-Life Care

National Priorities Partnership: Palliative and End-of-Life Care

National Priorities Partnership: Care Coordination

THIS EDITORIAL PRESENTS the sixth in a continuing series of editorials examining the challenges and goals established by the National Priorities Partnership (NPP), which is charged with developing a vision for world-class, affordable health care. 1 NPPNational priorities and goals: Aligning our efforts to transform American's healthcare. National Priorities Partnership, Washington, DC2008 Google Scholar The NPP has established six priority areas which they believe, if addressed, will significantly improve health care on the national level. The fourth of these priorities is focused on care coordination within and across all health care organizations, settings, and levels of care. Vallire D. Hooper, PhD, RN, CPAN, FAAN, is a Perianesthesia Consultant and Assistant Professor, School of Nursing, Medical College of Georgia, Augusta, GA.

National Priorities Partnership: Improving the Safety and Reliability of America's Health Care System

THIS EDITORIAL PRESENTS a return to the fifth in a continuing series of editorials examining the challenges and goals established by the National Priorities Partnership (NPP), which is charged with developing a vision for world-class, affordable health care.1 The NPP has identified six priorities that they believe, if addressed, will have a significant impact on improving health care at the national level. The third of these priorities is focused on improving the safety and reliability of the nation's health care system.

National Priorities Partnership: Improving the Health of the Population

National Priorities Partnership: Improving the Health of the Population

National Priorities Partnership: Engaging Patients and Family

National Priorities Partnership: Engaging Patients and Family