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August 8, 2013

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National Quality Strategy: 2013 Annual Progress Report Update [Slide 1]

Ann Gordon: Welcome everyone. My name is Ann Gordon and I'll be facilitating today's webinar on the National Quality Strategy. We'll look at this year's Annual Progress Report, hearing from some of our friends in California about their efforts to create a Quality Strategy for that State

Agenda [Slide 2]

We'll hear from Dr. Nancy Wilson, who serves as the lead for the National Quality Strategy on behalf of the ´óÏóÊÓƵ at the U.S. Department of Health and Human Services. Dr. Wilson will provide us with an overview of the National Quality Strategy and an update on this year's Annual Progress Report. Then the California Department of Health Care Services will present on their Strategy for Quality Improvement in Health Care. We'll conclude today's webinar with some questions and answers.

Question and Answer [Slide 3)

The Question and Answer box is the best way to submit questions to us, whether they're technical in nature or related to the subject matter. We'll tackle the subject matter questions at the end of the presentation and will address technical issues as they arise. If you have a thought for the full audience, we do have the chat feature enabled and ask you to use your discretion regarding the topics you choose to chat about.

And with that note, I'd like to turn the floor over to Dr. Nancy Wilson. Dr. Wilson, take it away!

National Quality Strategy: 2013 Annual Progress Report. [Slide 4)

Dr. Wilson: Thank you, Ann. Welcome everyone, it's really great to see how many folks are on the call. I'll spend a few minutes on the background of the National Quality Strategy.

Background on the National Quality Strategy [Slide 5]

The National Quality Strategy was established to improve the delivery of health care services, patient health outcomes, and population health. So it really goes beyond our traditional way of thinking about the delivery system, and really is meant to be a catalyst and provide an opportunity for nationwide focus. It's not a Department of Health and Human Services Strategy or a government strategy. It's for the nation as a whole.

One thing I would flag is our Working for Quality Web site, with lots of content for you to explore including our award-winning Stakeholder Tool Kit.

But let's focus on what the Strategy is.

National Quality Strategy Three Aims [Slide 6]

The Strategy pursues three concurrent aims: better care, healthy people / healthy communities, and affordable care.

The Triple Aim and the Three Aims [Slide 7]

If you're familiar with the Institute for Healthcare Improvement you might think that sounds familiar, like the Triple Aim. Yes, it should. The three aims were purposefully created to build off of the Triple Aim and elaborate on the areas of healthy communities, moving beyond health of populations to emphasize community interventions that can also occur. This involves thinking about the health of neighborhoods and areas across the country.

The other elaboration is really about affordability. In addition to working to lower the per capita cost to society, the National Quality Strategy endeavors to lower the cost of care for individuals and families in particular.

National Quality Strategy Priorities and Improvement Initiatives [Slide 8]

This slide provides an overview of the six priorities of the National Quality Strategy. The table on this slide conveys that right out of the box at HHS we tried to identify nationwide initiatives that would support and address each of the six priorities that were identified. Many of you on the webinar today are involved in the Partnership for Patients initiative with the Hospital Engagement Networks and Action Teams. That's fabulous, and that fits in to the context of the larger framework of the first priority, patient safety.

We viewed the use of CAHPS as 30 percent of Value-Based Purchasing as the lever that drives patient experience, and gets person-centered care on everybody's radar screen even more than it has been in the past. The additional improvement initiatives we've listed are our way to support and push interventions that improve health and health care under each of the priorities.

New in the 2013 Annual Progress Report [Slide 9]

This year we focused on measure alignment across public and private payers, national tracking measures and aspirational targets, private sector success stories in moving the needle on the NQS aims and priorities, and updates on the cross-cutting strategic opportunities that had been identified the year before.

Patient and Private Sector Measure Alignment [Slide 10]

I'll flag a few things for your attention. One initiative with great promise is the Buying Value initiative, where 19 private health care purchasers and their representatives came together with CMS and other Federal partners to identify a common set of performance measures that they would use for value-based purchasing. Where CMS has been trying to get to value-based purchasing, now we've got the private sector trying to align with each other and with CMS so that the measurements that are used will meet the needs of whoever is buying health care from providers.

We've been working over the past year within HHS to try to align measures across agencies and within agencies. Our motto for this work in the Measurement Policy Council is "measures that matter and minimize burden." We've got a long way to go, but we've been working hard to try and identify places where we have the same measures across different programs and then get rid of measures that are slightly different but require a lot of effort to then calculate and submit. CMS has been doing terrific work in defining the requirements for the various programs that they have so that if you report once it can meet the needs and requirements of multiple programs.

Private Sector Successes [Slide 11]

I'd like to spend a minute or two talking about some of the private sector successes that we've seen over the past year. The first one is Kaiser Permanente. They've been doing some great work in California with their shared decision-making initiative. They saw a 50 percent reduction in the number of elective hip replacement surgeries over an eight month program. That doesn't mean that people weren't getting care that they wanted. It was about people understanding the risks and benefits and being able to make appropriate choices for themselves.

Another example that comes to mind that some of you may have seen recently is the CareFirst lueCross BlueShield Initiative, where their Patient Centered Medical Homes have reduced cost by 8 million dollars and documented improvement in the quality of care. These are examples that directly address the aims of better care and making quality care more affordable.

Strategic Opportunities [Slide 12]

Strategic opportunities were identified in conjunction with our private sector colleagues at the National Priorities Partnership, and these opportunities span all the priorities. The first was to establish a national strategy for data collection, measurement, and reporting. The second was to create organizational infrastructure at the community level so that geopolitical communities could drive improvement. The last was to continue ongoing alignment around payment and delivery system reforms.

The examples on this slide focus on the things we've seen happening that support these strategic opportunities. In addition to the work that we've been doing to align measurement around data collection and reporting for the first opportunity – the national strategy for data collection, measurement, and reporting – the Office of the National Coordinator for Health Information Technology is almost ready to release a Quality Improvement Strategy that will guide our efforts in developing electronic clinical quality measures.

For the strategic opportunity of organizational infrastructure at the community level, we've highlighted the work of the Health Information Technology Regional Extension Centers. They're working with 45 percent of primary care providers to adopt and meaningfully use electronic health records. Part of this is getting to the point where we have interoperability in the health care delivery system and also across delivery systems and public health systems. There's a lot of work we have to do but interoperability is on top of the list in terms of getting to the point where those who are caring for people have the information they need regardless of the source in order to be able to maximize value in care.

As far as payment and delivery system reforms go, at this point the Center for Medicare & Medicaid Innovation has sponsored 500 hospitals, 30,000 physicians, and 2,500 other clinicians in a new delivery model such as accountable care organizations. I think we've got a lot that's rolling along and we still have to learn what the effects are and monitor for consequences, but we've begun to get some traction.

I want to encourage you to all peruse our website and read the 2013 Annual Progress Report if you haven't done so already. With that I'll turn it back to Ann.

California Department of Health Care Services, Strategy for Quality Improvement in Health Care [Slide 13]

Ann Gordon: Thank you, Nancy. As you heard, many different groups are important in telling this year's story about the National Quality Strategy. I think one of the points that's really important to emphasize here is that this is in fact a national strategy; it's not a Federal strategy or government strategy. That's why we invited the California Department of Health Care Services to present to you today. Representing that group is Dr. Neal Kohatsu who serves as Medical Director and Dr. Desiree Backman who serves as the Chief Prevention Officer. They're going to share their story about quality improvement within the State of California.

Dr. Kohatsu: Thank you so much. We really appreciate the opportunity to share our work. We've certainly been inspired by Dr. Wilson's work, and I'll touch upon that on the next slide.

Drivers of the DHCS Quality Strategy [Slide 14]

I'd like to present the background of some of the drivers behind why our Department of Health Care Services, which oversees the Medicare program in California, Medi-Cal, decided to put time and effort into developing a Quality Strategy.

We were certainly inspired by the work of Dr. Wilson, her team, and all the collaborators around the country that have created the wonderful blueprint that is the National Quality Strategy. It was a great framework for us, and as Dr. Wilson alluded to, it was important for us to take the Strategy and make it practical, putting the Strategy in perspective of our own work. We think that in developing a culture and emphasis on quality, moving from a focus on volume to value, it is critically important that there be a blueprint. That's why we elected to create our Quality Strategy.

We've just gone through a strategic planning process in the department and we've really taken seriously our ethical obligation to members, patients, and families, as well as the public at large. The core set of values we drive within the department include integrity, service, accountability, and innovation. We've tried to weave those four values throughout the DHCS Quality Strategy.

We're lucky to have one of the large Federal 1115 waivers. It's a waiver that focuses on quality, access, improving patient safety, and is a means of gaining flexibility in working with our local partners at the local level to enable some novel approaches to system design.

The Affordable Care Act has been a huge driver for the DHCS Quality Strategy. It's enabled new models of care delivery to put an emphasis on value and patients.

Three Linked Goals and Three Aims [Slide 15]

We certainly looked very carefully at the three aims of the National Quality Strategy, which really resonate with the work that we do within the department. Just as Dr. Wilson described, the National Quality Strategy's three aims evolved from the Institute of Healthcare Improvement's Triple Aim. We in turn said we need to make this relevant to our work in the department and at the State level in the Medi-Cal program. So, you can see that there's alignment if you look across the bullets in terms of improving the quality of patient experience of care, improving health, and addressing cost. We'd like to emphasize the alignment but in our own version, which we call the Three Linked Goals, we put "Improving the health of all Californians" at the top because we think it's fundamental to look upstream at the ultimate drivers of health.

Seven Quality Strategy Priorities and Related Initiatives [Slide 16]

On the next slide, we'll focus on the priorities and related initiatives in California. There are six priorities in the National Quality Strategy, and you will see the alignment that we have with those six priorities. We chose to highlight a seventh priority in eliminating health disparities. Now, that's very prominent in the National Quality Strategy as well, in fact it's one of the ten basic principles. Because we have specific targets and goals, we decided to put it as one of the priorities.

I'll talk about three of the priorities, and my colleague Dr. Backman will cover the rest. I'll give an example or two of a related initiative for each priority, and there's more detail in the full Quality Strategy.

The priorities are equal in importance, but I'll begin with the one that's listed first, "Improve Patient Safety." What we've highlighted there on the slide is an inpatient safety initiative across children's hospitals that has actually been going on for a number of years and has seen some dramatic improvements i patient safety, particularly in things like central-line associated infections.

I want to highlight another initiative that is not shown in the slide. I mentioned the 1115 waiver, and this is a 3.3 billion dollar piece of that waiver which is emphasizing quality, improved access, and patient safety in several domains, including reducing central line and surgical site infections.

The second priority is delivering effective, efficient, and affordable care. At DHCS, you could think of that as developing and deploying new methods of care such as accountable care organizations and patient-centered medical homes. What is highlighted there on the slide is the dual-eligible program for those who are both on Medicare and Medicaid. In California and several other States, there is a demonstration program to serve the dual-eligibles with a focus on improving quality, prevention, and coordinating care across the spectrum. With that, I'd like to turn the virtual podium over to my colleague Dr. Desiree Backman and she will highlight several more of our priorities.

Dr. Backman: Hello, everyone. The next priority is to engage persons and families in their health. Here we see a great opportunity to leverage social media and other community outreach tools to engage our members. DHCS has traditionally engaged our Medi-Cal members on topics such as insurance enrollment, recertification, and related administrative matters. But, with the explosion of social media we see that there is a huge opportunity to engage our members in their health and to form a stronger health communication link with our contracted health plans. As an example, we recently launched a prevention-focused Facebook paged called "Welltopia by the California Department of Health Care Services." It provides information, free applications, and videos on nutrition, physical activity, quitting smoking, and stress management. Plus, it links our members to job placement, education, food assistance, housing resources, and much more. It also creates a powerful space for our Medi-Cal members in the broader community to share their ideas and great tips about healthy living. So it really allows for two-way communication. Our Facebook page will be reinforced by regular prevention tweets and a new prevention Web page that is currently under development. We're also exploring Pinterest, text messaging, and other social media platforms to essentially form a social network on health among our Medi-Cal members and broader community in our State.

The next priority area is to enhance communication and coordination of care. One of our hallmark efforts in this area is to increase adoption of electronic health records and Meaningful Use compliance. Our goal is that by 2015, 90 percent of the Medi-Cal providers who are eligible for incentive payments will have adopted electronic health records for Meaningful Use in their practices. As a result, we expect to see improved care coordination, greater member engagement, and population health improvements.

Now a topic that is very near and dear to my heart is the next priority, which is to advance prevention. One of the cornerstone projects in this space is our Medi-Cal Incentives to Quit Smoking program, which is a 10 million dollar project funded by the Center for Medicare & Medicaid Innovation to test the use of small incentives to encourage Medi-Cal members to quit smoking. We're currently conducting a randomized control trial with California Smoker's Help Line, who is also providing counseling services and incentive delivery for this program. We're also looking at tobacco cessation from a broader policy perspective with our managed care plans, and setting forward some best standards of care for tobacco cessation, including the availability of Food and Drug Administration drugs to treat tobacco use, barriers for tobacco treatment benefits, ready access to counseling, and system-wide use of "Ask. Advise. Refer." We're also investigating the feasibility of smoke-free campus policies in long-term care facilities to round-out our portfolio to help our Medi-Cal members who are smoking and attempting to quit.

The next priority area is to foster healthy communities. We see this priority as an opportunity to create a stronger bridge between health care and public health and to transform our disease management, sick-care system into a true health care system that proactively addresses population health, much akin to the work that is going on in the National Quality Strategy. As a tangible example of this priority area in California, we've highlighted a partnership with the California Department of Social Services and Public Health. We're working to increase Cal-Fresh enrollment, otherwise known as the Supplemental Nutrition Assistance Program, among the 1.2 million Medi-Cal members who are eligible but not currently enrolled in this program. All of the partners have our hands in the ring because we all agree fundamentally that having enough money to purchase food is a basic foundation for health. We've joined forces to use our Medi-Cal communication, enrollment, and recertification process to better promote the Cal-Fresh program so that more members can purchase adequate food for their families.

Now I'll turn the conversation back over to Neal, who will talk about the elimination of health disparities.

Dr. Kohatsu: The last priority we will discuss is eliminating health disparities. I want to take us back to the end of 2012 when a large report was released in California by a taskforce created by the Governor, "Let's Get Healthy California." The goal was to make California the healthiest State in the nation, no offense to any other States on the line. Dr. Berwick was the co-chair along with our California HHS Secretary, Diane Dooley. The report they produced emphasized the need to eliminate health disparities. To quote Dr. Berwick, "We must be aspirational when we set goals."

We have a lot of partners, and obviously this is not a single department's mission. It is something that as a society in California we must take on, because the disparities are many, serious, and will require broad involvement to address. One of our partners is the Department of Public Health Office of Health Equity, which was recently created by legislation and with full support of Governor Brown. That office will serve as a clearinghouse, as a point-of-focus to push this goal of eliminating health disparities within California. Members have continued the "Let's Get Healthy California" work and are now collaborating to apply for a State Innovation Model grant from the Center for Medicare & Medicaid Innovation.

Similar to the National Quality Strategy, we see eliminating health disparities as cutting across each of the efforts in the blueprint. But as we said before, getting down to the average patient and family is really critical. To speak about how we're moving from principles to practice, I'll turn the podium back to Dr. Backman.

Dr. Backman: Thank you, Neal. Now I'll provide you all with an overview of how we're advancing the DHCS Quality Strategy and building a culture of quality.

Advancing the DHCS Quality Strategy: Building a Culture of Quality [Slide 17)

There's been a lot of work in this area to not only build the Strategy but also a system-wide culture of quality, not only in our organization but in our partnerships as well.

The Strategy was developed in the summer of 2012 with extensive stakeholder input. In particular, we did a complete internal review so that we gave all of our staff within the department an opportunity to weigh in on the Quality Strategy, its guiding principles, the three linked goals, and the priority areas. We also held a Statewide webinar on the strategy and invited nearly five thousand stakeholders in the State. We conducted a Statewide stakeholder survey to gather additional input.

Then we took all of this very rich input that we received from throughout the State, analyzed it, and revised our summer version of the Quality Strategy to form the Strategy that you'll see in the link at the end of this presentation.

Simultaneously, we also conducted a Baseline Assessment of Quality Improvement for several reasons. The first was to establish a department-wide inventory of quality improvement activities within all functional areas of our organization, including clinical care, health promotion and disease prevention, and administration. We were also looking to identify quality metrics that were being collected by our department but were not necessarily linked to quality improvement activities.

Additionally, we were looking for gaps in the department's quality improvement work. We wanted to obtain recommendations from all of our staff about where quality improvement should move forward and what kind of initiatives we should be embracing in the future. We had wonderful cooperation in our department: all of the operational units within our organization responded to the assessment and half of the units contributed robust quality improvement while the remaining half had no quality improvement to report at that time. In total, we gathered a broad range of twenty clinical care, four health promotion and disease prevention, and twenty administrative quality improvement activities. Some of these Neal and I represented in the previous slide, and there is a link provided at the end of the slide presentation where you can find a complete report of how we did the assessment and what we learned.

One of the interesting outcroppings of this process was not just the data that we got; this Baseline Assessment gave us a rich opportunity to educate our staff about quality improvement and to work with them directly to think through how their day-to-day work advances quality. From these conversations, we found that there was a wide range of understanding of quality improvement from those with a sophisticated understanding to those unfamiliar with the topic. Needless to say, the assessment ignited a department-wide conversation about quality and this conversation led to a culture shift around quality that is continuing to gain momentum.

Speaking of gaining momentum, once we had all of these great Baseline Assessment findings, we looked at each of the priorities within the DHCS Quality Strategy and we matched the quality improvement activities in the department to those priorities. That resulted in the Quality Improvement Map. What this allowed us to do was to see which priorities in our strategy were well represented with quality improvement activities and which ones needed further development. In particular, the priority areas of patient and family engagement, prevention and healthy communities, and elimination of health disparities were wide open for the development of new initiatives and collaboration. We didn't find a lot of quality improvement activities going on in those priorities, but it turns our attention to the opportunities that we can pursue to fill those gaps.

Where is all this leading us? We intend to update our Quality Strategy annually to reflect new initiatives and developments in quality improvement happening not only in California but nationwide. In fact, we've just completed our 2013 DHCS Quality Strategy, which has many more initiatives than the 2012 Quality Strategy in large part because of the Baseline Assessment and the Statewide conversation around quality improvement. Our plan is to have the 2013 Quality Strategy released this Fall. Please take a look when it's available.

I'll now turn the conversation over to Neal to discuss some lessons learned over this past year.

DHCS Quality Strategy Lessons Learned [Slide 18]

Dr. Kohatsu: Thank you, Desiree. Let me start with one of the points we think is so key. Without the leadership support we had, we would never have been able to launch the DHCS Quality Strategy or make the progress with our colleagues across the department of some three thousand employees. I want to acknowledge the enthusiasm of my boss, Director of DHCS Toby Douglas, and his boss, Secretary Diana Dooley, who we have had the privilege to work with on the Let's Get Healthy California Task Force as well as on the State Innovations Model grant planning. Both of these individuals as chief executives of their respective areas within government have been supportive not only of the Quality Strategy but also the underlying principles of improving health, improving care, and reducing cost.

To continue our discussion of our lessons learned, I'll turn it back over to Dr. Backman.

Dr. Backman: A foundational principle that I think we know and appreciate was very evident during this process. We learned that involvement leads to commitment. As mentioned, we've involved our staff and stakeholders throughout every step in the process, and at the national level that was certainly the case as well. That can reap very large benefits. Our staff and stakeholders have also seen their feedback in large part reflected in all of the products that we have produced. It's not just about the process it's about honoring and reflecting that input in this work.

We've also been open to all types of feedback. You know when you go through a stakeholder input process you're going to receive criticism as well as compliments, and we were wholeheartedly open to that full spectrum. At the end of the day, our process has demonstrated that it's all about relationships, and we want to build those relationships on the core values of integrity, trust, and a shared commitment to delivering the best health care possible. We're really quite fortunate in our State that we have strong, committed partners in all sectors of the health care and public health community. We are engaging our Medi-Cal members in getting their opinions about where we're headed. For instance, we just conducted community conversations here at our local food banks with Medi-Cal members to get their input on our social media work.

We've also realized that in order to build this culture of quality that we keep talking about that we need to do more to foster a learning organization that is focused on quality improvement principles. We learned along the way that we have a widespread spectrum of those who understand quality improvement and those who have yet to understand what this is all about. We're planning to conduct basic quality improvement trainings for our staff as well as more in-depth training and technical assistance for a variety of multi-disciplinary teams in our organization that are beginning new quality improvement projects or want to enhance some of their current quality improvement work. The idea here is the culture of quality improvement to touch every major functional area within our department and to be applied as standard practice in our day-to-day work.

Another lesson learned along the way is that we need to do more to establish meaningful quality standards. We have our Baseline Assessment findings and that provides us with a robust set of quality improvement activities that are very specific, with particular aims, baseline and target metrics, start and end dates. But our next step in this is to refine the set of activities to fill those gaps and design an evaluation system that demonstrates the individual and the collective impact of efforts in accomplishing the three linked goals. With that in mind, I'll turn the conversation back over to Dr. Kohatsu to discuss the topic of evaluation.

Dr. Kohatsu: It is well known that quality improvement is key and Desiree has pointed out that not only do we need to look at our current activities at the individual project level, but also from the perspective of the entire Quality Strategy: how is the blueprint working? I want to thank her very much for her leadership. I emphasize that leadership is key, but it's not just for those at the top of the organizational pyramid. We work across the Director's office at all levels of a very large organization, and leadership throughout has really been key.

Desiree will be leading a workgroup to develop an evaluation plan program specifically for the overall blueprint, not just the individual program. That reflects an ongoing commitment. We intend on having an annual update to the Quality Strategy as Desiree mentioned, but the process has been ongoing throughout the year in various iterations as the environment changes., and as we find value in new ways of being able to accomplish better care through new models and things of that sort.

I want to thank Dr. Wilson very much, not only for this opportunity to present on the webinar with my colleague Dr. Backman, but for her leadership at the ´óÏóÊÓƵ. The National Quality Strategy has been an important effort moving the nation towards better health, better outcomes, and a more efficient delivery system. With that, I'll turn it back over to our moderator, Ann.

Ann Gordon: Thank you very much Drs. Kotasu and Backman. This was a lot of really great information. Getting into the final stages of the presentation, I want to hand it back over to Dr. Wilson to talk about how your State or organization can fit into the National Quality Strategy.

How can other States or organizations align to the National Quality Strategy? [Slide 19]

Dr. Wilson: Thanks, Ann. There are many ways to align to the National Quality Strategy. It may be across all the priorities or it may be a focus on a particular priority. In general, what we see is that if you examine the three aims and the six priorities, you can see where you have initiatives that might relate. So it involves thinking about what are you doing in terms of person-centered care? How are you engaging people in their care? What is it that you're doing in patient safety? And so on.

I think there was a bit of questions that came up about this that had to with what to do if your program's activities don't match the priorities exactly. I think the priorities are broad enough that you can think through them to meet the needs of the population you're serving.

I think the slide speaks for itself and I'll turn it back over to Ann.

Ann Gordon: Thank you. To finish the presentation here, I'd like to make sure everyone knows where to get more information.

How to Find NQS Tools and Resources [Slide 20]

Where can you find National Quality Strategy tools and resources? The Working for Quality Web site is the best place to go. There you can find the 2013 Annual Progress Report along with the reports from years past. We also have a Stakeholder Toolkit and Briefing Slides if you're interested in promoting the National Quality Strategy at the local, State, or national level. We put the aims, priorities, icons, and all of the content around the National Quality Strategy in one place in the Briefing Slides. Also available are the Priorities in Action. Once a month we post a brief summary of examples of quality improvement programs from around the country that align to the priorities. If you have suggestions or questions, Dr. Wilson has been very generous to make her email available to everyone on the webinar, so you may reach out to her.

How to Find DHCS Tools and Resources [Slide 21]

Thanks again to our friends in California who did such a great job presenting their DHCS Quality Strategy. They wanted to provide some tools and resources for you as well. We did see a couple of questions from the audience about this content, so here are the links for that so you're able to do more research about what California is doing to improve health care.

Questions and Answers [Slide 22]

We've come to the time in the presentation to answer some questions that have come in through the Question and Answer box. Thank you for sending those questions in to us.

Question and Answer Session [Slide 23]

Question 1 (Ann Gordon): The first one is for Dr. Wilson, but I encourage our presenters to talk to each other and answer these collectively. This question has to do with the activities of the rest of the Department of Health and Human Services. What information is available around the Agency-Specific Plans, and can people find those online as well?

Dr. Wilson: Great question. One of the requirements of the Affordable Care Act along with the annual update to the National Quality Strategy is that each of the agencies inside the Department of Health and Human Services must identify what they are doing to support the National Quality Strategy each year. Those Agency-Specific Plans are all available on the Working for Quality Web site. So you can browse what the Substance Abuse and Mental Health Services Administration is doing, what the Centers for Medicare & Medicaid Services is doing, etc. I will say that each year the Agency-Specific Plans become more robust and I think this coming year in particular will be very exciting to see how agencies are addressing all of the priorities.

Question 2 (Ann Gordon): Thank you. Our next question is also for Dr. Wilson. One of the questions we received from an audience member is around provisions or focus placed on making identifiable health data available publicly to allow greater analysis to improve quality, reduce costs, and increase consumer empowerment.

Dr. Wilson: I think there is a lot of activity around the country in disseminating information through the use of registries to learn more about how to improve quality for particular populations of patients. That information has not been made public yet, although we've been working with folks running health registries to make more and more of that information public. The Centers for Medicare & Medicaid Services has access to health care data in an unprecedented way, and that was due to the authority granted through the Affordable Care Act. So qualifying entities that participate in the Medicare Data Sharing for Performance Measurement Program are now eligible to receive previously restricted Medicare data to measure provider performance.

Many regional non-profit organizations are trying to create public websites to share information. Some examples are the Minnesota Measurement Community and the Wisconsin Collaborative for Healthcare Quality. Publicly available information has developed most robustly through the consensus driven by multi-stakeholder groups coming together and agreeing to share that kind of information. More needs to be done, of course, and there's a lot of interest in identifying the kinds of information that empower consumers and allow them to make better choices.

Question 3 (Ann Gordon): Thank you. The next couple of questions are for the California Department of Health Care Services. The first question we have from an audience member is, "How would you enhance physician's involvement in quality improvement and patient safety?"

Drs. Kohatsu and Backman: Great question. To provide some context, the Medi-Cal program is well on its way to becoming predominantly managed care delivered through health plans. In a year or two, we'll probably be about 90 percent capitated, managed care. We created a working group with our health plans' medical directors to engage them on that very subject, which is how to reduce costs all the way from the clinic level to the group plan level. In settings that are heavily capitated, there are all these layers to work with. So we have to think about the action points where we can impact things. So that's one area of engagement through our health plan medical directors.

Another way we're reaching out is through individual professional societies and primary care organizations. That's been a meaningful way of getting stakeholder input. For example, we sent this Quality Strategy out to thousands of stakeholders including professional societies, Federally Qualified Health Centers—the whole gamut in the health care delivery system. We received responses from quite a number of individual stakeholders. One thing we learned was that looking at different channels to engage stakeholders is critical due to time and resource constraints.

Dr. Wilson: I would just add that clearly within the delivery system that quality improvement driven by leadership supports that engagement and you need to free people up to be able to do it. There's a growing movement for integrating quality improvement so that it becomes part of the expectation of medical professions, and this increases clinician enjoyment of it. On a very practical basis, I know that for ambulatory physicians in private practices sometimes health care systems pay them a certain amount of money to participate because they are giving up a day's work.

Question 4 (Ann Gordon): The next question is also for California, and this question came from another State. It is a private, physician-owned pediatric clinic that is making efforts to achieve a certain level of recognition for the patient-centered medical home. While there is commitment to the National Quality Strategy within the organization, they are having a hard time getting the same level of commitment from the State. Any recommendations on ways to get the State on board?

Drs. Kohatsu and Backman: I'll assume by the State they mean the State's Medicaid program. We think input from stakeholders is very important, so we will meet by phone, in-person, or email to gather feedback from all our stakeholders. I don't know the backdrop to the situation, but I would encourage the organization to reach out to the Medicaid medical director or the director of quality, if there is one. If for some reason you have received a cold reception, Medicaid agencies are quite large so don't give up. Try some other areas within the agencies. If you haven't reached out yet, start with the medical director. If the agency is divided up into different domains, such as fee-for-service or managed care, you might try each in turn.

Dr. Wilson: You're welcome to email me offline and we can see if we can give you any more detailed advice.

Question 5 (Ann Gordon): We have another question that would be great for both Dr. Wilson and our California presenters to weigh in on. The question is, "When you talk about training health care workers on quality improvement, what would your recommended approach be? Could you provide related resources?"

Dr. Wilson: There are many approaches that are fitting for quality improvement training. There is a patient safety education group that has been developing curriculums where you can learn the basics of patient safety and how to reduce harm within your practice. In the hospital setting, some of the best practices are leadership institutes. I would actually look into the American Hospital Association Quest for Quality Award. This is an award we've been giving out for ten years, and I've happened to be one of the judges. There are descriptions of various awardees and what they've been doing to support and engage staff in quality improvement.

In general, the American Hospital Association could give you some pointers. When we talk about training, it can sometimes seem like you need to attend an all-day event, but I think even participation in improvement activities is experiential learning. Sometimes all it takes is finding a leader who has credibility with his or her peers who can start the process within the organization.

Drs. Kohatsu and Backman: That was great. We're working with a physician in the University of California Health Systems Institute for Population Health Improvement who is the director of quality improvement within the health system. She's brought a lot of teachings to our organization and also helped us think through how we can apply the principles of quality improvement with a strong emphasis on experiential, hands-on learning on the ground. She will not only help us with our broad-based quality improvement training so that we can build a foundation for a quality improvement movement, but also in designing specific quality improvement projects. She is forming multi-disciplinary teams representing multiple parts of the organization and forging them into quality circles where they examine projects in a hands-on way, setting the parameters of the quality improvement projects and developing an evaluation plan to monitor their progress.

This in turn allows that core group to spread more innovation throughout the organization in a real, tangible way. She is guiding us this way because she has extensive experience working with clinicians on the ground, and has had success in devising curricula and forming learning collaboratives. So clinicians on the ground are learning quality improvement as they engage with patients, and have support from other clinicians throughout the State as part of the collaborative to share lessons learned and solve problems as a group.

The Institute for Healthcare Improvement has a library of resources available, as well as Web-based or in-person training. The American College of Medical Quality also puts out materials and training and sponsors training. Most medical schools are also paying much more attention to medical quality.

Question 6 (Ann Gordon): Great. Our next question returns to the National Quality Strategy's aims. The question here is, "Can you explain the difference between the National Quality Strategy priorities compared to the National Quality Strategy domains as identified in the Centers for Medicare & Medicaid Services Final Rule?"

Dr. Wilson: Sure, thanks Ann. I don't think I'm mis-channeling my colleagues at the Centers for Medicare & Medicaid Services in saying that these two frameworks are aligned. They really are the same. I think that the one area that comes to mind is the priority on addressing the leading causes of mortality, starting with cardiovascular disease. Because the Centers for Medicare & Medicaid Services has the need to address many more clinical conditions, they broaden that priority to say that is the category for effective prevention and treatment for all medical conditions. It's connected to the other legislation that requires them to do things like the Physician Quality Rating System.

With every physician wanting measures relevant to their practice, and in thinking through how to address all the different populations they need to care for, they need a broader vision of prevention. Another area is the focus on lower cost within the CMS Final Rule, but we acknowledged that lower cost is part of the National Quality Strategy priority of making quality care affordable. We see total alignment.

Question 7 (Ann Gordon): Thank you. We received a question, Dr. Wilson, regarding the Office of the National Coordinator for Health Information Technology's plan to develop a health information technology quality strategy and where it might be found. Do you have any information on this?

Dr. Wilson: Getting through clearance is sometimes an unpredictable process, so I'm not sure when it's going to be released but we can definitely post it on the Working for Quality Web site when it is released.

Question 8 (Ann Gordon): Thank you. The next question comes back to the role of different stakeholders in the National Quality Strategy. The question here is around the role that pharmaceutical manufacturers play in the implementation of the National Quality Strategy.

Dr. Wilson: I absolutely think that everyone has a role to play. There is so much that pharmaceutical companies can do by way of medication safety and consumer understanding around medication. I think that there is a broad arena for pharmaceutical manufacturers to engage patients. It's important that one looks at one's core business and thinks about what you can relate to any or all of the priorities.

Question 9 (Ann Gordon): Our next question is, "How would the National Quality Strategy priorities impact physicians such as pathologists who may not be able to interact directly with patients very often?"

Dr. Wilson: I actually saw the question come in and sent off an email to my colleagues at the Centers for Medicare & Medicaid Services, so I'll be sure to follow-up with any information they provide around pathology measures. I don't know the answer to the measurement question, but I will say that one of the critical areas for patient safety is diagnostic accuracy and timely processing of biopsies and specimens. As far as national reporting goes, I don't know the answer. But pathology plays a vitally important role, and I think sometimes we underestimate the value our pathologists bring.

Ann Gordon: Great. That marks the end of today's presentation. Just as a reminder, we will be sending out an announcement when the webinar archive is available. You will be able to download the presentation slides as well as a written transcript of today's event.

If you are not already subscribed for updates from the National Quality Strategy, we encourage you to visit the Working for Quality website. On the homepage there is a link to register to receive updates from us, and you can browse all the content we have on the Web site including the 2013 Annual Progress Report. I'd like to turn it over to our presenters to provide final remarks from today's event.

Dr. Wilson: I want to thank everyone for participating. I love getting your questions so feel free to email me directly if you think of additional questions.

Dr. Backman: Thank you everyone for your active participation and good questions. Nancy, thank you for giving us an opportunity to talk about the work in California.

Dr. Wilson: Well, thank you because the national strategy comes alive as it gets translated and embraced at the State and local level. Thank you for the great work you're doing.

Ann Gordon: Thank you to everyone who participated in today's event. We hope to hear from you again soon, and stay tuned for more updates. Thanks very much.

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