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Health Reform Panel Addresses Remaining Questions from Conference
 At the NAHQ 36th Annual Educational Conference, panelists Barbara Crawford, RN MS, and Cathy E. Duquette, PhD RN CPHQ NEA-BC, spoke on the topic of healthcare reform. The panel addressed the question, “What do we do next week, next month, and next year to prepare for the healthcare reform changes?” and discussed strategic and practical steps organizations should take in the short and long term to be successful in the new healthcare environment.
Panelists were unable to address all questions asked, so NAHQ e-news invited Crawford (BC), Duquette (CD), and Raj Behal (RB), MD MPH, to respond to these remaining member questions.
Question: Who should decide which measures are used to evaluate quality for value-based purchasing (VBP)? How? What is the role of the NAHQ member?
CD: In 2006, Congress passed a law that authorized the Centers for Medicare and Medicaid Services (CMS) to create a plan for VBP. This plan was expected to apply to Medicare hospital services by FY2009 and take into consideration feedback from affected parties as well as consider the experience from certain pay-for-performance demonstration projects. CMS followed a collaborative consensus process involving key hospital measurement entities such as the Hospital Quality Alliance, the National Quality Forum, and The Joint Commission. Through the formation of work groups and other mechanisms, CMS solicited input from key stakeholder groups and the public. NAHQ members interested in the VBP measurement selection process should get involved with local and national stakeholder groups involved in this process. While NAHQ members can provide feedback directly to CMS, feedback through key stakeholder groups may be more effective. Hospital representatives may consider reaching out to their state hospital association to stay current with the status of current measurement development efforts and provide feedback to support the public comment and the VBP measure selection process.
BC: I agree with Cathy’s response. I would also add that VBP applies to Medicare Fee for Service (FFS), not Medicare Advantage patients, so depending upon the hospital’s mix, the impact differs. I also suggest that hospital representatives reach out to the health plans with whom they contract and other organizations that they may participate in (such as patient safety organizations).
 RB: Ideally, healthcare providers and patients should determine measures of quality. Practicing clinicians should participate in evaluation of evidence base in the context of patients they treat, and patients should be able to provide their perspective on what they value. Traditionally, professional societies have served as clinicians’ proxies, but I think clinicians need to take a more active role. Developing robust measures is a science—and an opportunity for quality professionals to participate and lead the charge.
Question: What is NAHQ doing to help quality professionals across the continuum of care be best prepared to do our work under reform expectations?
CD: NAHQ membership provides quality professionals with access to timely, relevant information to ensure we are best prepared to respond to reform expectations as they evolve. Through local and national networking opportunities, conferences, website information, and the Journal for Healthcare Quality, NAHQ members have relevant information available at their fingertips to assist in the individual reflection and decision making necessary to ensure that the quality professional is ready.
Question: How do we prevent punishment of those who identify poor quality within the organization, especially when it will have public and financial consequences?
CD: The only way to prevent punishment of those who identify poor quality is through leadership vision, and support for a culture of safety and reporting. Once the highest levels of leadership support a culture of reporting, the organization then needs to ensure that the appropriate structures and tools (e.g., Patient Safety Committee, policies, procedures, and algorithms) are in place to support this culture. Many organizations are implementing strategies to promote a “just culture,” which sets the expectation for proactive risk identification and event reporting, and takes an algorithmic approach to guide the manager’s response to error based on the circumstances. Finally, leaders and staff at all levels need to be held to the expectations set by the organization around reporting and accountability.
BC: Quality and safety need to be first and foremost in any organization’s strategic priorities; if they are not, then I would submit that this is not an organization at which I would choose to work. That said, once leadership has established quality and safety as top priorities, there are tools and organizations that can be used to support leadership’s journey to a culture of safety, starting with assessing current culture via such instruments as the Agency for Healthcare Research and Quality (AHRQ) safety culture questionnaire, or the Safety Attitudes Questionnaire from Pascal Metrics (which is founded on Brian Sexton’s work in the aviation industry). The Institute for Healthcare Improvement (IHI) is an organization that is great at providing opportunities for executives to learn about themselves and how they need to change to support a just culture.
RB: This is, in part, a systems issue and, in part, organizational culture—we need both. Systems for measurement, feedback, and organizational structures for communication of data are all necessary. A culture that expects transparency in discussion of good and poor quality is very important. The right tone for transparency has to be set by the leaders in the organization. The best reason to identify problems with quality is to improve quality. Whether there are public or financial consequences is a secondary reason.
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