QUERI Quality Forum: Advancing Quality Measurement in VA

On October 29th and 30th, HSR&D and QUERI hosted an invitational workshop of 21 experts on quality measures. Participants included researchers, policy experts, and clinical decision-makers from within and outside VA, with the goal of identifying highpriority areas for research on the development, validation, and implementation of quality measures for the VA healthcare system. In order for VA to maintain its position of national leadership and continue to serve as a model for other systems, QUERI Director David Atkins, MD, MPH, and HSR&D Scientific Program Manager Andrew Guccione, PhD, DPT, convened the forum to review what we know and what we still need to learn about quality measurement within VA, and to identify what research is most important for improving the use of quality measurement within VA.

Day 1: Paper Presentations

On the first day of this conference, five papers (commissioned by HSR&D and QUERI) were presented and discussed. These papers were designed to summarize current evidence regarding the development and application of quality measurement, identify current controversies, and target future directions in quality measure development and implementation that also would supplement the scientific basis for policy.

Day 2: Identifying Research Questions

On the second day of the meeting, participants identified what they felt were the most important research questions related to developing valid measures of quality and performance, with the aim of creating measures that are responsive to the needs of patients, providers, and administrators, that improve healthcare at a reasonable cost, and that ensure optimal patient outcomes from individualized care.

The output of this meeting will help target HSR&D research to the most important areas, especially components of quality measurement development that are unique to VA. It also will provide a scientific foundation to help inform VA policy regarding the application of quality measures within VA to improve health care for Veterans.

Presentation Overview

Karen Adams, PhD, Vice President for National Priorities, National Quality Forum (NQF), set VA quality measurement in the larger perspective of the NQF experience. NQF has learned that organizational priorities should drive measure development and implementation, but also that some measures may not be worth the cost or have a sufficiently large enough impact on quality to be worthwhile.

Tim Hofer, MD, MSc, Diabetes Mellitus QUERI, and Steve Asch, MD, MPH, HIV/Hepatitis QUERI, challenged the group to reconsider the very concept of quality and how it was defined. They noted that quality is a multidimensional concept that should be reflected in the measures researchers use, but is often narrowly understood to represent only what has been measured.

Rod Hayward, MD, and Eve Kerr, MD, MPH, both part of Diabetes Mellitus QUERI, collaborated on a paper that explored the relationship between quality measurement and its ultimate value to patients. Dr. Hayward indicated that optimal measurement systems reward care with a high net value and encourage providers to share decision-making with patients.

Steve Fihn, MD, MPH, Ischemic Heart Disease QUERI, and Chief Officer, Office of Quality and Performance (OQP), and his OQP colleague and Director of Performance Management, Tammy Czarnecki, MSOL, MSN, RN, analyzed the value as well as the shortcomings of electronic information in evaluating quality of care and measuring performance. As a national leader in the use of the electronic patient record, VA is in a position to lead the move towards measuring quality on a more complete sample of patients and encounters through the use of routinely captured data.

Laura Petersen, MD, Ischemic Heart Disease QUERI, described the literature on the impact of applying performance measures as a tool to improve care, including data on potential downsides of performance measurement that may inadvertently diminish patient preferences and restrict clinicians from providing the best individualized care.

Toward a Research Agenda

The forum provided participants with considerable material from which to develop a preliminary research agenda. Many of the agenda questions require further development, but include questions such as:

• What is an optimal combination of structure, process and outcome measures to ensure quality?
• What sets of measures best correspond to our notion of quality at system, provider, and patient levels?
• What factors influence the perceived value of a measure for administrators, providers, and patients?

Preliminary work and deliberations at the workshop/meeting gave rise to several near-term goals including: dissemination to a considerably broader audience within HSR&D via the 2009 HSR&D National Meeting; disseminating papers presented at the meeting in a peer-reviewed publication; refining the research questions into an HSR&D solicitation; and conducting a panel presentation at the 2009 AcademyHealth Meeting to alert a non-VA audience to some of the lessons learned through VA’s pursuit of quality and experience in performance measurement.

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