Monday, October 4, 2010

Sample Feedback to the National Healthcare Quality Strategy and Plan

Below, you will find my humble attempt to provide feedback to the HHS regarding the National Healthcare Quality Strategy and Plan (see red text for responses).  My hope is that the comments below will serve as a starting point as you think about your response.  Please comment to this post with suggestions.  How would you respond differently?  I did not answer the state-specific questions because I ran out of gas completing the first part and wasn't sure how to respond, so if you have ideas, let us know.

Don't worry about perfection of responses or whether you agree with what I've said.  It's the passion for the work that counts. While I'm certain that higher quality responses garner attention, let's aim for a high volume of responses that succinctly mention areas of concern to our field.   

Once you have decided on your answers, go to the HHS website to send feedback.

What follows are some of the initial principles to guide the National Health Care Quality Strategy and Plan that build on many other strategic planning efforts.  These principles, in turn, are intended to guide the broad framework of our effort to engage state and diverse private-sector stakeholders in shaping this National Strategy.  Our hope is that a guiding framework will provide a vision that focuses the work of major strategic efforts and initiatives on a small set of core principles and goals that represent our highest priorities and are aspirational, actionable, and aligned across the nation.
Principles Guiding the National Quality Strategy
The initial set of potential “core principles” are intended to serve as the underpinning of the National Quality Strategy and should be reflected not only in the framework, but in how goals, targets, and plans are developed. They include:

  • Person-centeredness and family engagement will guide all strategies, goals, and improvement efforts
  • The strategy and goals will address all ages, populations, service locations, and sources of coverage
  • Eliminating disparities in care – including but not limited to those based on race, ethnicity, gender, age, disability, socioeconomic status and geography – will be integral to all strategies and goals
  • The design and implementation of the strategy will consistently seek to align the efforts of public and private sectors

Feedback Question:
1.      Are the proposed Principles for the National Strategy appropriate?  What is missing or how could the principles be better guides for the Framework, Priorities and Goals?

Appropriate and comprehensive.

Framework for the National Quality Strategy
In addition to being guided by a set of core principles, the initial thinking of the Department of Health and Human Services is that the National Quality Strategy should be organized around a simple framework that should resonate broadly, be clear, be easily understood and be attainable with concerted effort.  The proposed framework consists of three components that are intended to be consistent over-time, while allowing for both the initial identification of priorities and associated goals and measures, as well as regular updating to accommodate new directions and emerging issues. The proposed framework components are:
  • Better Care: Person-centered care that works for patients and providers. Better care should expressly address the quality, safety, access, and reliability of how care is delivered,  as well as the experience of individuals in receiving that care;  active engagement of patients and families; and the best possible care at all stages of health and disease;
  • Affordable Care: Care that reins in unsustainable costs for families, government, and the private sector to make it more affordable; and
  • Healthy People/Healthy Communities: Improving health and wellness at all levels through strong partnerships between health care providers, individuals, and community resources.
The framework components serve as the three pillars of the National Quality Strategy and are intended to frame its underlying priorities and goals.

Feedback Question:
2.      Is the proposed Framework for the National Strategy sound and easily understood?  Does the Framework set the right initial direction for the National Health Care Quality Strategy and Plan? How can it be improved?
Under better care where it is stated, "and the best possible care at all stages of health and disease" I would modify to say “the care that best meets the person’s goals at all stages of health and disease, whether that goal is prevention, remission, restoration of function, or palliation.”  

Priorities of the National Quality Strategy
Within each of the major components of the framework, the National Quality Strategy needs to identify specific priorities that represent the primary objectives for the initial period.   HHS is seeking broad public input to help identify priorities, while it conducts a review of leading private sector initiatives and current Federal and State programs.  The Affordable Care Act details some of the criteria that should guide priority selection, including:
Table 2.  Criteria Guiding Selection of Priorities

  • Demonstrates the greatest potential for improving health outcomes, efficiency, and patient-centeredness of health care for all populations, including children and vulnerable populations
  • Shows potential for rapid improvement in quality and efficiency
  • Addresses gaps in quality, efficiency, comparative effectiveness information, health outcomes measures, and data aggregation techniques
  • Improves payment policies to emphasize quality and efficiency
  • Enhances the use of health care data to improve quality, efficiency, transparency, and outcomes
  • Addresses the health care provided to patients with high-cost chronic diseases
  • Improves research and dissemination of strategies and best practices to improve patient safety and reduce medical errors, preventable admissions and readmissions, and health-care- associated infections
  • Reduces health disparities across populations and geographic areas

Feedback Question:
3.      Using the legislative criteria for establishing national priorities, what national priorities do you think should be addressed in the initial National Health Care Quality Strategy and Plan in each of the following areas:

a.      Better Care: Person-centered care that works for patients and providers. Better care should expressly address the quality, safety, access, and reliability of how care is delivered and how patients rate their experience in receiving such care;

The relatively new medical specialty of palliative care aims to provide high quality, accessible, and reliable care to patients with serious illness.  In reviewing the criteria for selection of priorities, palliative care addresses several of the criteria.  Importantly, palliative care aims to improve patient centered health care provided to patients with high-cost chronic diseases across the age spectrum.  Palliative care can help prevent hospital admissions, especially unwanted admissions/readmissions that are unlikely to meet the patient’s goals of care.  Because of the communication expertise of palliative care clinicians, it is more likely that patients’ goals will be understood and aimed for, which helps to reduce disparities.  Often times, palliative care teams employ simple strategies that can rapidly improve quality. More research is needed to learn which specific palliative care strategies are most effective. Such research would lead to opportunities to develop best practices that are patient centered and reduce costs.  

b.      Affordable Care: Care that reins in unsustainable costs for families, government, and the private sector to make it more affordable; and

Research to date has shown that palliative care services help to reduce costs while improving outcomes such as palliation of symptoms and concordance of care with patient preferences.  

c.       Healthy People/Healthy Communities: The promotion of health and wellness at all levels.
Palliative care is also family centered.  A patient’s serious illness poses a tremendous burden on loved ones, leading to symptoms of depression, post traumatic stress disorder, and physical illness.  Palliative care interventions reduce psychological morbidity of family members, which may have positive impact on physical health as well.  More research is needed to understand the longterm impact of palliative care on the perspective of health/disease/death in survivors.  (For instance, does prior exposure to patient/family centered palliative care change attitudes towards the experience of serious illness and death?  What about attitudes towards preventative care and trust of the healthcare system?  What about healthcare utilization?)

Goals of the National Quality Strategy
The goals refer to targeted performance levels that the National Quality Strategy seeks to attain. Goals are broad, long-term objectives that define a desired outcome. HHS believes that to provide for national focus during the initial period of the National Quality Strategy, there should only be a few goals for each component of the framework, and the goals should be aspirational, actionable, attainable with concerted action and aligned across the nation. Examples of the sorts of areas around which the National Quality Strategy could articulate goals include:
  • Make health care safer, by eliminating adverse preventable events that injure patients through the delivery of care;
  • Increase the degree to which care is coordinated for patients, leading to demonstrably improved patient outcomes such as reduced  preventable hospital readmissions and fewer medication errors due to poorly managed care transitions;
  • Dramatically reduce the occurrence of and improve management of chronic illnesses through strong partnerships and clear accountability across health care providers, patients, and communities.
The goals should align to the proposed priorities. Together, the priorities and goals should engage multiple stakeholders, inspire the nation, and provide a public and private roadmap for accelerating our common path towards better quality care, improved health outcomes for people and communities, and an affordable system of care for all Americans.

Feedback Question:
4.      What aspirational goals should be set for the next 5 years, and to what extent should achievable goals be identified for a shorter timeframe? 
Increase the extent to which patients with serious illnesses receive care across settings that is concordant with their goals, values, and preferences.

Measures of Progress to Priorities and Goals
Appropriately aligned measures are needed to ensure that progress is made against the identified priorities and goals. Just as we believe that the goals and priorities should build on existing work that has been done, for measures of our progress we aspire to use or build on existing, established, and widely-used measures or measure sets that have been reviewed and endorsed by multiple stakeholders. Future new measure development should be prioritized and aligned to the national priorities and strategic framework.
Feedback Question:
5.      Are there existing, well-established, and widely used measures that can be used or adapted to assess progress towards these goals? What measures would best guide public and private sector action, as well as support assessing the nation’s progress to meeting the goals in the National Quality Strategy?

A chart audit  that examines the frequency that hospitalized patients’ goals of care and preferences are documented and then examines the frequency that those preferences are followed.  This has been used in research recently Detering K, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ 2010;340:c1345 doi:10.1136/bmj.c1345.  This research showed that an advance care planning intervention increased concordance between patient’s preferences and the treatment actually received, improved family satisfaction, reduced stress, while reducing ICU admissions.

Given the critical importance of this initiative, HHS is committed to an open and transparent process designed to engage multiple stakeholders and obtain direct input into the National Quality Strategy’s development and all of its components.  Input is being gathered through multiple stakeholder venues and through posting of this document on  In addition to this posting, HHS will use a wide range of other public forums to garner input and suggestions in the coming months.
Additional Feedback Issues
In addition to the questions identified above, HHS welcomes comments and suggestions on all aspects of the proposed structure, principles, conceptualization, and specific details of the National Quality Strategy.  HHS looks forward to getting specific feedback on the following:
6.      The success of the National Health Care Quality Strategy and Plan is, in large part, dependent on the ability of diverse stakeholders across both the public and private sectors to work together. Do you have recommendations on how key entities, sectors, or stakeholders can best be engaged to drive progress based on the National Health Care Quality Strategy and Plan?

Health care providers on the front line need an improved mechanism for rapid feedback to CMS.  Once the framework is established, a website should be developed that allows providers to make comments on an ongoing basis regarding their experience with progress in reform.

The greatest changes typically occur on a local level in the form of small, rapid quality improvement projects.  A national database for quality improvement needs to be established so that providers can share experiences, learn from each other, and more efficiently effect change at a local level.

Multi-stakeholder/State Questions
Health care is local and much of the effort to organize, support and foster improvements in health care and prevention occur at the level of States.  The questions that follow are relevant to all audiences, but are particularly relevant to States:

7.      Given the role that States can play in organizing health care delivery for vulnerable populations, do the Principles and Framework address the needs and issues of these populations?

8.      Are there priorities and goals that should be considered to specifically address State needs?

9.      What measures or measure sets should be considered to reflect States’ activities, priorities, and concerns?

10.    What are some key recommendations on how to engage with States and ensure continued alignment with the National Quality Strategy?

11.   Additional comments:

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