NQF Founder: Quality Measure Science Still 'Immature'

Kenneth Kizer has been around the quality block more than a few times.

He directed the VA Health Care System during its metamorphosis; led the California health department during the early years of HIV, spearheaded a blunt anti-tobacco campaign that politicians tried to quash, and coined the term "never events."

Perhaps most significant, in 1999 this former emergency room physician founded and directed the National Quality Forum, an independent group of stakeholders who develop reliable, accurate ways for hospitals and other providers to measure, report, and improve quality. That's a tough set of issues from which to draw consensus.

Last Friday, the NQF became an even more significant player in healthcare reform.  That's when the Obama Administration released the final rules for Value-Based Purchasing.

Set to take effect July 1, the rules establish specific measurements—nearly all of them researched and endorsed by the NQF—that will financially reward or penalize hospitals on the basis of care quality. With 1% or 2% of a hospital's entire Medicare DRG payments at stake in the coming years, quality now makes a business case for itself.

Moreover, next year there will be many more measures added, and more still the year after that.

Just before the VBP release, Kizer found some time for a telephone interview with me about where the quality field has been, and more importantly where it's headed.

"Now everyone is talking about measuring quality," he said, "But that wasn't how it was 11 or 12 years ago when I started NQF. No one really wanted to engage in measurement. Now, it's in a different place, but it clearly is not being used as much as it should be. There are many areas of medicine where there simply are no measures—or there are, but they aren't as good as they should be."

He added, "This is a very young and immature science, and that statement's probably more significantly true for outcome measures than for process measures."

Kizer says that for all of the work being done to link such process measures with improved survival, mobility and function, like giving patients serum glucose at 6 a.m. after their cardiac surgery, quality metrics today overlook one enormous ingredient that makes what doctors and hospitals and nurses provide pale in comparison.

"We have to remember that the healthcare that hospitals and doctors provide is only a small piece of what makes people healthy, perhaps only 10%," he says.  The rest has to do with family, food, diet, environment, education, lifestyle, and so forth.

And to focus on that, without looking at the other 90%, "creates misperceptions about a lot of other things that we should be looking at," Kizer says.

But unfortunately, we're only at the beginning of our search to find quality measures to improve that other 90%, he says.

Take, for example, let's look at veterans and smoking, two of his favorite topics.

The military tries to reduce smoking among its personnel, and does a good job offering nicotine replacement therapy to active duty members or veterans. But, Kizer says, "They don't offer it—it has been expressly forbidden—to give it to their families.

"So here you have veterans who got off the smoking habit, and we send them back to their families where everyone else is smoking. What's the likelihood they're going to continue to not smoke?  Here's a huge cause of morbidity in this country, and a great example of why we cannot treat patients in isolation."

The physician takes care of the hospitalized CHF patient, prescribes medications and sends him home. "But the patient doesn't take the medications, goes out and eats French fries and loads up on salt, and ends up back in the ER within 30 days. Whose responsibility is that?" Kizer asks.

What can be done, then, to change the situation? "I take the perspective that there's much more that healthcare could do to prevent these kinds of things than some people would agree with," Kizer explains. "Did they [the care provider(s)] try to have contact with the patient every day to measure their weight?"

The way to manage this increased intensity on quality, Kizer says, requires providers to adopt "a team activity."

  • Does the health provider have teams in place to support the patient at home so he doesn't end up back in the hospital?
  • Is anyone calling the patient to see if they took their medications? And ask if they are okay?
  • Is anyone asking how the patients are doing on their diets?

"It's unrealistic that the doctor should be doing that, as nice as that might be," he says.

Back in February, Kizer, 59, was tapped to direct the new Institute for Population Health Improvement at University of California at Davis Health System, an entity that will tackle pressing issues dealing with how we find strategies to improve health in the community, including how to measure them.  That's a whole new field of science.

Kizer says he's happy that hospital care is finally being measured in a meaningful way, though he realizes that many providers think the science isn't quite there yet. Still, he believes the most important revelations about quality of care are still to come.

"One way of keeping measurements from being good is to not use them, which some people would like to see," he acknowledges. "But we have a saying: 'Nothing makes a performance measure better than when it starts being used.'

"Because once it is used in the real world, you find out all the little nuances;  the real world situations that may not have been thought about when it was being designed.

Kizer believes that for those who think value based purchasing is a bad idea that can't last, and have the attitude that "this too shall pass,' are very mistaken. "It may not make some people very happy, but a few years from now, we'll be talking about amounts of money that are much higher than 1% to 2%."

I think he's absolutely correct.

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