Quality Framework: Community Stakeholder Input MDH Draft 8/8/18

Transcription

1 Quality Framewrk: Cmmunity Stakehlder Input MDH Draft 8/8/18 Prcess Frm June 15 thrugh August 3, MDH cnducted interviews with representatives f cmmunities that are disprprtinately impacted by health disparities. Deatrick LaPinte facilitated three small grup discussins and MDH staff fllwed-up with cmmunity representatives wh were unable t attend thse meetings and wanted t prvide input. In cnducting these interviews, Deatrick and MDH staff used the interview guide, and values and principles develped in cllabratin with the Steering Team. Key findings Values and principles Existing values and principles Values shuld be defined. Wrds have different meaning t different peple. Cnnectin and cllabratin There shuld be tw-way cmmunicatin between cmmunities and health care system, nt just ne way frm the health care system t patients and cmmunities. The health care system shuld leverage the assets f the cmmunity t advance health, and nt slely fcus n deficits. Dn t turn t the cmmunity nly when smething is needed frm them; this feels transactinal, nt authentic. Actinable infrmatin It is imprtant t prvide Infrmatin and educatin t cmmunities. Infrmatin can empwer patients and their families, and advance health literacy. Principle #3 It is imprtant that the quality measurement system is actinable fr different stakehlders. New values Access t care Health care is affrdable, culturally respnsive, nn-discriminatry. Accuntability The health care system is accuntable t patients. Thse wh use quality measure data are als accuntable t patients. Balance the pwer dynamic between patients and cmmunities, and the health care system. Cultural respnsiveness Health care staff shuld have a baseline f training in prviding culturally respnsive care (this includes care fr LGBTQ and HIV+ patients). Patients shuld be able t find such qualified health care prfessinals thrugh a directry. The health care system shuld espuse cultural humility. Inclusivity The current health care system was created by sme peple fr sme peple and is ne-size-fits-all; the framewrk shuld prmte a health care system that is nt ppressive and views a persn as a whle which includes the scial determinants f health. Racial and cultural equity Be intentinal abut advancing racial and cultural equity thrugh the quality measurement framewrk. Framewrk scpe The quality measurement framewrk and measurement system shuld: 1

2 Include mre than health care quality measurement, and within health care quality measurement, it shuld measure mre than clinic and hspital quality. Be living, flexible, and fluid, and adaptive t changing needs. Take a whle persn apprach and the cntext in which they live. This includes preventin, wellness, mental health, spiritual well-being, cnnectedness, belnging, and the scial determinants f health. Fcus n systemic barriers that keep cmmunities frm being healthy. Health equity A shared statement r definitin f health equity is needed fr the framewrk t enable the achievement f health equity gains. If the system culd identify where cmmunities are and are nt ding well n quality measures, it culd better identify significant health disparities and inequities. The system culd then ask if the right types f measures are being used t assess cmmunity health and if the measurements need t be adjusted. Data Data shuld be aggregated r segmented using infrmatin abut the scial determinants f health. It is imprtant fr patients and cmmunities t knw hw quality measure data is used, results shuld be shared with cmmunities, and data must be available fr use by cmmunities. The measurement system shuld include qualitative infrmatin that can be used alng with quantitative data as an input int measuring cmmunity health and fr cmmunities and partners t develp interventins. Track qualitative data within cmmunities t understand narratives f health equity and assess gaps in services, existing health disparities, understand hw scial determinants f health impact verall health f Minnestans. Equal access t health educatin and resurces thrugh cmmunity-based care crdinatrs and mbile applicatins that culd be develped, dwnladed n data phnes, and utilized with cmmunity members/patients. Ideas were generated fr an app that culd help with mental health cncerns and link patients with health resurces in their respective cmmunities. Sme cmmunity members expressed interest in giving patient experience feedback thrugh an app that culd be linked with their primary health care clinics and hspitals. Measures Preventive care Patient experience Patient trust in prvider r health care system Implementatin, maintenance, evlutin Implementatin, maintenance, and evlutin f hw data infrms strategic advancement f health care is critical fr innvatin and sustainability. The framewrk shuld be implemented and experimented with iteratively r as a pilt befre rlling it ut statewide this apprach will lead t evaluatin and evlutin. 2

3 Evaluate the impact; see what, if any, change ccurred. Onging cmmunity cnversatins with intergeneratinal representatin will be imprtant. Cntinue t identify and fill-in gaps abut health quality thrugh cnversatins with cmmunities. The framewrk needs a prcess t keep it relevant. One ptin wuld be t cnvene an nging steering team with mre cmmunity member representatin allwing fr better cmmunity feedback. Cmmunities need a better idea f hw utcmes f measurement are being used and hw high quality health care services are incentivized verall and fr patients and prviders with the biggest barriers. When the framewrk is cmplete, MDH shuld share the stry f this prcess back with the cmmunity. Think f hw many drs this culd pen the interest in hw MDH cllects data can generate mre cmmunity interest and invlvement. Keep the cnversatin lp with cmmunities pen. Other cnsideratins Because f the anti-immigratin sentiment in the natin, peple frm immigrant cmmunities (as well as cmmunities f clr and ther ethnic cmmunities) are under a lt f stress and mental health cncerns are strng. Peple s sense f belnging t cmmunities is being diminished and exacerbating anxiety. There is high distrust f the health care system and peple are nt seeking services fr themselves r their families. There is a strng desire by cmmunities t avid the health care system altgether due t all f the barriers: it is cstly, there is a lack f prvisin f culturally respnsive care leading t distrust, there is a lack f services in rural Minnesta, and the system was nt designed by r fr cmmunities that are disprprtinately impacted by disparities. Therefre, a health quality framewrk that includes mre than health care is desirable. Frm the patient perspective, high quality health care is excellent custmer service: prviders cmmunicate at the patient s level (nt talking abve r arund the patient), shw respect fr the patient as a human being, and prvide cnnectins (i.e., specialist referrals) t resurces t help care fr the whle persn. There is a scarcity f services in rural Minnesta as cmpared t the metr area, e.g., resurces, specialized services, prviders, dental care, and mental health prviders. What weight is being applied t patient and cmmunity input t balance the pwer dynamic f stakehlder input int this framewrk (i.e., balancing the pwer that prviders and insurers hld in the health system and in the develpment f this framewrk)? Patients are the experts turn t them fr slutins in addressing health disparities, and identifying gaps and hw t clse them. Public events were recmmended t prmte health literacy t learn mre abut hw the health systems wrk and understand the imprtance f health care preventin and interventin services. 3

4 Allw patients t give feedback abut their experience in the health care system thrugh electrnic nline prtals t assess qualitative and quantitative data t cntinuusly imprve health care services. Health equity is nt defined and is lacking quantitative and qualitative data t supprt what it means frm a cmmunity and health systems stakehlder perspective. Metrics and strategic slutins t advance equality f health fr all Minnestans can be a cnsideratin fr the Quality Framewrk. Cnsider cllecting qualitative data as a hlistic apprach t understand scial determinants f health frm a patients perspective in regards t: preventin, interventin, wellness, mental health, spiritual well-being, cnnectedness, and sense f belnging within their experience f the health care system. Fcus n data that matters t the patient experience, quality and access t health care, standardizatin f health care. Identify systematic barriers that keep cmmunities frm being healthy and discver technlgical slutins fr health equity. It is imprtant fr the best interests f the State f Minnesta that this framewrk gets it right that means the framewrk will have pertinence, it will supprt the state s ecnmic interests, it will be patient-centered, and it will make use f cmmunity resurces. 4

5 Key Findings frm Health Industry Stakehlder Input MAD Draft 7/26/18 Methds Frm May 15 t June 27, 2018, Management Analysis and Develpment (MAD) cnducted 14 small grup and key infrmant interviews using the interview guide develped in cllabratin with the Minnesta Department f Health and the Steering Team. Analysis invlved the develpment f a qualitative cding structure based n legislative requirements and MDH assessment f what shuld be accmplished thrugh stakehlder input. The fllwing stakehlder grups were represented in interviews: Prviders, including thse f sciecnmically cmplex patient ppulatins Assciatins and patient advcacy grups Public health Health plans Purchasers Quality imprvement rganizatins Quality measurement rganizatins Key findings Values and principles Mst grups said the draft values and principles were gd at a high level but were very general and wuld benefit frm further definitin arund wnership r perspective (e.g., t whm? fr whm?). Prviders, assciatins and patient advcacy grups, public health, health plans, purchasers, and quality imprvement rganizatins said values and principles were gd at a high level. Prviders, assciatins and patient advcacy grups, public health, health plans, purchasers, and quality measurement rganizatins said values and principles were very general. Prviders, public health, purchasers, and quality measurement rganizatins said values and principles need mre definitin arund wnership r perspective. 1

6 Specific feedback abut values and principles acrss stakehlders included: Values: Expand n cst and affrdability fr peple nt currently seeking care. Principles: 1: Unclear whether it is referring t the system f health r the health care system; shuld include examples f health utside the health care system. 2: The principle is gd but very brad. It assumes measurement fsters imprvement. Include prvider experience (e.g., retentin) with health equity and patient experience. 3: Lts f general supprt. Unclear whether it is referring t the system f health r the health care system. Perhaps there culd be a strnger stance r guidelines n hw measures shuld be used. 4: Unclear whether it is referring t the system f health r the health care system. Duplicating effrts may need t be further defined t clarify whether alignment is cnsidered duplicatin. Als, t whm quality measurement shuld be actinable needs further definitin. 5: The term imprtant has different meanings fr different peple. 6: Will need t keep in mind cst and affrdability as value is assessed. Add smething abut cmmunity engagement. Inclusive shuld mean inclusive f peple beynd the typical data users. Measurement shuld include things that the public thinks reflect quality. Items identified as missing r understated in current values and principles (in rder f the number f interviews frm mst t least): Purpse r gal f the framewrk (identified by prviders, assciatins and patient advcacy grups, quality imprvement rganizatins, quality measurement rganizatins) Equity and fairness, specifically measuring the scial determinants f health (SDOH) (identified by prviders, assciatins and patient advcacy grups, public health, quality imprvement rganizatins) Cst, affrdability, and burden cntainment (identified by prviders, public health) Access t health care (identified by prviders, assciatins and patient advcacy grups, and public health) Onging maintenance and hw measures will be added, mdified, and remved (identified by prviders, quality imprvement rganizatins) 2

7 Principles f framewrk stewardship One cnversatin mentined the need fr nging gvernance. Nearly all grups mentined the need t invlve stakehlders n an nging basis. Framewrk cmpnents/actins Many respndents, generally prvider grups, health plans, and quality imprvement rganizatins, nted that SQRMS has tried t be all things t all peple, and a framewrk shuld prvide a mre fcused apprach. Assciatins and patient advcacy grups and sme prvider grups mentined that sme grups, namely patients r cnsumers, are nt included in the reference, all things t all peple. Mst respndent grups were in favr f alignment with ther health care quality measures and measurement systems (generally unspecified) t reduce measurement burden and increase cnsistency in reprting. N ne viced ppsitin except t cautin that it might cause backslide in patient impact r that full alignment alne may reduce the visibility and impact f SQRMS n advancing medical care. Prviders, assciatins and patient advcacy grups, health plans, purchasers, quality imprvement rganizatins, and quality measurement rganizatins talked abut aligning with ther measurement systems. Prviders, assciatins and patient advcacy grups, quality imprvement rganizatins, and quality measurement rganizatins talked abut measurement burden. Prviders, health plans, and quality imprvement rganizatins expressed cautin that full alignment might cause Minnesta t backslide n sme measures and n lnger be setting the natinal standard. Framewrk pririties Respndent grups identified characteristics they thught aligned with a high quality health care system, and they thught measurement culd cntribute t these characteristics. At a high level, pssible statewide gals r pririties respndents cited mst ften were: Caring fr the whle persn, incrprating SDOH and ther cntext, patient-centered (mentined in discussins acrss all stakehlder grups) Prviding care that is effective; achieves intended results (mentined acrss all stakehlder grups) Care that is affrdable, thugh nt specific t whm (mentined acrss all stakehlder grups) Imprving access t care (prviders, assciatins and patient advcacy grups, public health, purchasers, and quality measurement rganizatins) Creating a system that is fair and equitable (prviders, assciatins and patient advcacy grups, public health, health plans, quality imprvement rganizatins, and quality measurement rganizatins) 3

8 Prviding preventive care (prviders, assciatins and patient advcacy grups, public health, health plans, quality imprvement rganizatins, and quality measurement rganizatins) Health equity There was universal interest in knwing mre abut SDOH. Specifically, respndent grups nted the need t measure SDOH and use them t set the cntext fr measurement and disaggregate measure data. Grups prvided the fllwing suggestins regarding health equity and quality measurement: Use the Natinal Quality Frum Radmap t Health Equity fr examples f equity measures (prviders, assciatins and patient advcacy grups) Use measures t identify disparities and target resurces t address disparities (prviders, assciatins and patient advcacy grups, public health) Payer data culd prvide additinal infrmatin n access and affrdability (prviders) Include peple with disabilities; be intentinal abut hw varius disabilities are defined (assciatins and patient advcacy grups) A few grups (prviders and quality imprvement rganizatins) cautined that health equity may be t big t achieve thrugh measurement alne and that negativity arund measurement burden culd impact health equity effrts if they were tied t measurement. A few grups (prviders and public health) als cautined that nt measuring the right things r disprprtinately targeting slutins t the least disadvantaged grups culd have the unintentinal effect f making disparities wrse. Measurement areas Mst grups als expressed interest in ppulatin health, thugh sme (prviders, health plans, and quality imprvement rganizatins) were cautius that prviders wuld be held accuntable fr aspects f health that are ut f their cntrl and were interested in measuring ppulatin health acrss settings. Suggestins fr which settings t measure varied widely and included behaviral health, dental, ambulatry care (e.g., primary care), aspects f bth ambulatry and in-patient care (e.g., care integratin and crdinatin), pst-acute and lng-term care, public health, and pharmacies. Implementatin, maintenance, and evaluatin In terms f nging maintenance and evaluatin f the framewrk, several grups cited a tensin between needing a framewrk that is nimble and can quickly adapt t innvatin r research and the need fr cnsistent measurement t develp histric data and reduce measurement burden. A few cautined that there shuld be mnitring t ensure measures are used fr their intended purpse and avid unintended cnsequences. Prviders and public health said sme things shuld be kept cnstant t develp histric data and reduce burden. 4

9 Prviders, purchasers, and quality imprvement rganizatins said the framewrk and measurement system shuld be mnitred t ensure their relevance and identify pprtunities t advance. Prviders, public health, and quality imprvement rganizatins said the framewrk and measurement system needs t be agile, nimble, and fluid. Prviders and quality measurement rganizatins said the framewrk shuld underg peridic review, perhaps annual r every three years. Prviders, purchasers, quality imprvement rganizatins, and quality measurement rganizatins said stakehlder feedback shuld be included in the evaluatin f the framewrk. Keys t success r barriers/challenges t implementatin Nearly all stakehlder grups (prviders, assciatins and patient advcacy grups, public health, purchasers, quality imprvement rganizatins, and quality measurement rganizatins) said it wuld be imprtant t cntinue gathering input frm stakehlders, including thse nt invlved in health care, such as patients and the public. Nearly all stakehlder grups (prviders, public health, health plans, purchasers, quality imprvement rganizatins, and quality measurement rganizatins) cited the need fr innvatin and advancement in technlgy resurces in rder t create an efficient system f measurement. Such a system culd allw fr mre streamlined data entry, extractin, reprting, and sharing. Prviders, public health, purchasers, quality imprvement rganizatins, and quality measurement rganizatins cited r described challenges with electrnic medical recrds, including limited fields t enter data and that they vary widely acrss health systems. Prviders, public health, health plans, purchasers, quality imprvement rganizatins, and quality measurement rganizatins cited and described challenges with the current measurement and reprting infrastructure. Prviders, public health, and quality imprvement rganizatins mentined desire t increase the ability t share data and challenges assciated with data sharing. Public health and quality measurement rganizatins cited challenges specific t certain types f data, such as units f measure (e.g., the patient, the prvider, the clinic, etc.) and peple that d nt access health care. Other cnsideratins Grups generally favred a brader scpe f health versus fcusing n health care alne fr the framewrk. Purchasers said they liked the current fcus n health care, thugh they als suggested expansins beynd current settings. 5

10 Mst grups, including prviders, health plans, purchasers, quality imprvement rganizatins, and quality measurement rganizatins prvided input n hw measurement is cnnected t imprvement. Cllectively, they said measurement alne des nt necessarily lead t quality imprvement. Stakehlders (prviders, quality imprvement rganizatins, and quality measurement rganizatins) cited additinal resurces, such as payment mdels, dedicatin f internal resurces, r prviders dedicating time and effrt t imprvement as ways that measures can infrm and drive quality imprvement. Prviders, health plans, and quality imprvement rganizatins suggested t the extent that measures influence payment structures, measures shuld be aligned with intended areas f quality imprvement. 6

11 Quality Framewrk: Internal Wrkgrup Input MDH Draft 7/3/18 Prcess Frm March 26 thrugh June 18, MDH cnvened three meetings f its internal wrkgrup that includes representatin frm the Minnesta Department f Health, Minnesta Department f Human Services, and Minnesta Management and Budget. Key findings Values and principles Values shuld be defined. Add a value f Respnsiveness. The framewrk shuld respnd t the needs identified by the cmmunity, and ther external and internal stakehlders. Engaging in nging cnversatins with external and internal stakehlders is ne way t implement the value f respnsiveness. Equity is nt clearly reflected in the principles. Cnsider including a principle t reflect the accuracy and rigr value, e.g., A measurement system shuld accurately assess the quality f services by health care prviders It can be assumed that the current system prbably strives tward these values. Nw that federal measurement has made advances, are there places where certain areas r values are nt cvered? Are there gaps r areas we can wrk n as a state? Framewrk characteristics Include mre than health care quality measurement in the framewrk. Within health care quality measurement, the framewrk shuld measure mre than clinic and hspital quality, and it can measure clinic and hspital quality differently than it des nw. There shuld be a way fr the state t signal the new things that need attentin withut lsing what already exists. With respect t the diagram, a visin statement is needed and there shuld be an act/use element (measurement ccurs, then the data are used which helps infrm measurement system and framewrk evaluatin and evlutin). Visualize the framewrk as a multi-dimensinal web s that the framewrk can be actinable fr different stakehlders. Build-in stakehlder feedback lps at multiple pints, wherever data is invlved. Health equity Quality measurement can help advance health equity by: Measuring disparities (e.g. health literacy); Translating data mre effectively t bth patients and prviders; Advancing ppulatin health by translating data t cmmunity health; 1

12 Prviding data analytics and technical assistance t cmmunities; and Increasing respnsiveness and utility t cmmunities and stakehlders. The framewrk shuld include a clear statement f hw it can serve individual cmmunities. The framewrk and/r measurement system shuld prvide infrmatin t health care prviders abut the value f the demgraphic infrmatin that is in a patient s medical recrd which prviders can use t advance health equity. Measures Ppulatin health Preventin Patient experience Stakehlder rles The framewrk is a multi-dimensinal web that is actinable fr different stakehlders. Nt all stakehlders necessarily need t be invlved in each part, and MDH culd be the minder f the web t keep track f the big picture, and identify and cmmunicate gaps. MDH shuld prvide technical assistance and capacity building t data users (e.g., cmmunity grups, patient advcacy rganizatins, researchers, prviders). Cmmunicating data in ways patients and prviders can understand is such a huge challenge; we get hung-up n using technical crrect language instead f plain language. Prgrams within MDH shuld figure ut hw t plug int the framewrk in terms f where prgrams are interacting with cmmunities and prviders. Implementatin, maintenance, evlutin In rder t evlve, we need t be respnsive, knw that the data is used and is meaningful, and have a methd fr gap recgnitin. We need t think mre abut the methds f data cllectin, extractin, and aggregatin advancements that allw us t be mre respnsive and actinable in areas that need imprvement. Engage in nging stakehlder cnversatins. Keep an pen less-structured prcess s everyne can participate. This apprach fsters implementatin f the values innvatin and respnsiveness. 2

13 Quality Framewrk Stakehlder Panel Summary Date: July 31, 2018 Mderatr: Stefan Gildemeister, State Health Ecnmist, Minnesta Department f Health (MDH) Panelists: Debra Burns, Directr f the Centers fr Health Equity and Cmmunity Health, MDH Dr. Rdney Christensen, Vice President fr Medical Operatins in the Netwrk Divisin, Allina Health; Representative f the Minnesta Medical Assciatin s (MMA) Physician-Cnsensus Measures f Perfrmance t Advance Quality and Safety Wrk Grup Dr. Kevin Larsen, Enterprise Lean and Health IT Advisr, Centers fr Medicare & Medicaid Services Maiyia Yang, PhD, Researcher at SLaHm Partnership fr Health and Wellness Welcme Mr. Gildemeister welcmed everyne t the call, intrduced panelists, and explained that the sessin s intent was t: Prvide space fr additinal discussin n input frm varius stakehlders in the develpment f the framewrk, and Allw panelists t share their wn perspectives mre bradly n the tpic f health quality measurement. Discussin 1. What is yur cnnectin t health quality measurement, what related initiatives have yu been a part f, and what are the areas f alignment and difference with the quality measurement framewrk we are cllectively develping fr Minnesta? Ms. Burns: Public health prfessinal withut explicit expertise in health care quality measurement, but invlved in related cnversatins regarding hw t align quality initiatives acrss public health, ppulatin health and the health care system t develp cmmn directin and gals. Invlved with Natinal Quality Frum ppulatin health framewrk that develped a guide fr health care rganizatins. Wrked with Institute fr Clinical Systems Imprvement n glbal health measures. There is a need fr alignment acrss all sectrs that seek t imprve health. This framewrk effrt can help us mve tward that. Dr. Christensen: Family physician with experience in clinics t fster imprved perfrmance n quality measures (state, natinal, internal pririty measures). 1

14 In Minnesta we deliver better care because we have pushed urselves as a state and system t measure, benchmark, and be transparent. There is als tremendus waste in hw we d quality measurement which diverts us frm delivering imprvements. As a state, we need t mve tward measuring quality imprvement tpics that lead t better utcmes (i.e. functinal utcmes, efficient care, equitable care) and matter t the ppulatin at the clinic, state r cmmunity level. We shuld use benchmarking t help urselves imprve and give peple, patients, and buyers the ability t cmpare the quality f care we deliver. In terms f the MMA wrkgrup, we want t ensure that chsen measures have been prven valuable. There is tensin with parsimny, because every measure has supprt. Additinally, there is lts f enthusiasm abut ppulatin level measures, thugh they need clear purpse and accuntability. Ms. Yang: Researcher with the Quality Measurement Enhancement Prject; brings cmmunity perspective t the table. As part f the Quality Measurement Enhancement Prject, we held cmmunity listening sessins and asked cmmunity members t priritize what quality primary care lks like. Quality health care is a cncept that everyne wants, but there are different cultural definitins and scial justice cmpnents. We shuld engage cmmunities thrughut the framewrk prcess. Dr. Larsen: Federal perspective frm wrk with Centers fr Medicare & Medicaid; experience helping t run the quality prgram fr Meaningful Use. Fr Meaningful Use, we had lts f the same cnversatins yu are having nw fr the framewrk. Measurement is difficult and expensive; we want it t be cheap and easy. Hw des cheap and easy lk in cmparisn t difficult and expensive? Hw d we think abut quality measurement at different levels (e.g., state, clinics, teams, cnsumers, etc.)? The challenge that Minnesta, ther states and federal agencies are experiencing is t build a system fr all levels at the same time, where perspectives are different. The Natinal Cmmittee fr Quality Assurance is wrking n hw t cllect data, in a tech-enabled wrld, that makes sense fr varius levels f the system (physicians t health plans). In this framewrk cnversatin, figuring ut hw t priritize and cnnect different levels and purpses f measurement is key and imprtant. 2. What excites yu abut a statewide health quality measurement framewrk? What pprtunities are there fr yu and yur clleagues r cmmunities? Hw might yu/yur rganizatin/yur members/yur cmmunity use this framewrk? Hw culd it be mre useful t yu? Dr. Christensen: (1) Opprtunity t measure in a way that causes us t think differently abut the care we prvide. A fcus n larger, glbal functinal utcme measures fr peple and ppulatins that wuld frce us t think mre creatively abut where we re nt prviding care. (2) Better aligning measures with utcmes that are useful t the intended audience. 2

15 Ms. Burns: (1) The prcess being used in this framewrk develpment is a gd, deliberate and stakehlder-fcused apprach. There are a lt f exciting pprtunities presented in the values and principles; e.g., equity, cnnectin and cllabratin, actinable infrmatin, health is mre than health care. Opprtunity t think abut measures (ppulatin health, scial determinants f health, preventin) that have a brader impact n peple s health. (2) There is an pprtunity t think abut aligning effrts n the part f many different kinds f sectrs that are brader than health care measurements that wuld be in the quality measurement framewrk. Ms. Yang: (1) Opprtunity t change hw cmmunities are engaged in the prcess. The cmmunity can prvide input n defining and measuring quality, and evaluatin and implementatin plicies that cme ut f the framewrk. (2) Opprtunity t acknwledge and address scial determinants f health and histrical trauma, and t pay fr services in thse cntexts. Space fr psitive change t help cmmunities acrss Minnesta. 3. What cncerns yu abut this new framewrk? What barriers d yu anticipate? Ms. Burns: Cst and cmplexity. We want t keep a reasnable number f measures but als include thse that relate t scial determinants f health, preventin and ther activities. We dn t have an verall umbrella f measures r gals tied t measures that multiple grups have agreed upn t track quality and prgress. It s impssible t d everything, s priritizatin is key. We need t create a high level agreement under which measures can fall ut. Dr. Christensen: We need t be held t a high level f evidence befre endrsing a measure (i.e., it needs t be wrth it). It s a cntinual learning prcess and it s hard t get cnsensus n what the evidence shws. In rder t mve t brader, mre imprtant measures, we need t have the guts t stp measuring what isn t wrking. We ve experienced tremendus resistance t stpping measures. Ms. Yang: (1) Aligning and synchrnizing perspectives f stakehlders and cmmunities is a ptential challenge. If the framewrk truly wants authentic cmmunity engagement, a ptential barrier is nt having cmmunity buy-in if cmmunity members d nt see r experience the prpsed change. (2) Cncern abut hw individual physicians are being reimbursed based n quality measurements. (3) Cncern that plicies created frm the framewrk may be misinterpreted t perpetuate structural inequities. It will be imprtant t create a place in the prcess t reflect and imprve n thse ptential negative cnsequences and als include the patient vice. 4. Dr. Larsen, yu have seen a number f statewide quality measurement systems in varius states f develpment and implementatin. What lessns can we learn frm ther states as we develp ur quality measurement framewrk in Minnesta, and what pitfalls shuld we avid? Minnesta has been a leader, s the risk is t align with natinal measurement effrts that wuld lead t regressin. Wrk n things like PHQ-9 and D5 have been grundbreaking and lead the cuntry. Even thugh they re imperfect, we can learn frm them. Minnesta als lead the charge fr patient reprted utcmes. Few states have 3

16 the kind f deliberatin and brad stakehlder engagement and cmmitment t measurement that Minnesta has. Minnesta can learn frm Oregn and Michigan. Oregn has a standing cmmittee that cntinually reviews and thinks abut measurement. Michigan tk mre f a businessriented apprach health plans, payers, and thers say what they are willing t pay fr in a given year and this helps drive the measurement agenda. It s very expensive t create evidence fr measurement and then create measurement. If the bar fr evidence is high, the price tag will be high, and yu will get few measures. Evidence created using scientific research investment ften fcuses n the majrity and the middle. If what we care abut is the minrity and the edges (rare cnditin, ppulatin, age, etc.) we wn t have a lt f evidence r pre-existing measurement. Open questin d we believe if we mve the middle, everyne will mve with it, r, d we wrk in the middle and at the edges? Steering Team Questins Jennifer Lundblad: I was struck by a number f panelists speaking directly r indirectly abut a measurement system in Minnesta trying t be all things t all peple. Any advice r elabratin n hw t be inclusive and cmprehensive but als targeted and actinable, and hw t balance the tensin? Dr. Christensen: One apprach is t use patient-reprted utcme questins where anyne culd participate, and parse it by scial determinants f health (e.g., age, race). Dr. Larsen: Healthy Days measure. In the last 30 days, hw many days were healthy? The questin is defined by the persn and takes their cntext int accunt. Dr. Larsen: Articulate the tensin that yu have and build tests arund that tensin. Fr example, if yu want a measure that includes a lt f peple, meeting the needs f diverse vices, have that as a gal. Test and try. Dr. Christensen: Everyne wuld like t address equity issues and the scial determinants f health. A barrier is the reluctance t get that scial determinant f health data that s needed t address it. We need t persuade individuals and cmmunities t prvide that infrmatin n the basis that it will be used fr gd. 4

17 Framewrk Develpment: Prgress and Remaining Wrk Gal: A system f measurement that fsters imprvement in health utcmes, health care quality, health equity, patient experience, and ppulatin health, and reduces csts fr patients, prviders, and purchasers Phase 1 Prgress March August 2018 Phase 2 Remaining Wrk 6-12 mnths Framewrk Implementatin Steps 2020 and beynd We have articulated Stand-up framewrk stewardship structure values We have develped guiding principles We have decided that measurement is mre than clinical care We have decided that measurement must be subject t nging evaluatin We have determined that the stewardship prcess shuld be trusted, transparent, and able t include all perspectives Incrprate additinal recmmendatins frm stakehlders Identify fr whm measurement shuld matter Develp criteria fr making measurement actinable Articulate thughts n hw t reslve tensins between efficiency, simplicity and transparency Explre appraches fr identifying what measurement is mst imprtant Identify ptentials fr unintended cnsequences Name the clients f the framewrk and identify their needs Articulate the structure and cmpnents f an evaluatin plan Discuss a pssible structure fr framewrk stewardship and resurce needs Identify accuntability paths fr framewrk implementatin Articulate a draft radmap fr implementatin under plitical, peratinal, system pwer, and resurce realities Cnsider which rles shuld be utside stewardship, i.e. be independent f it (e.g., evaluatin?) Implement apprach t cmmunity and patient engagement at all levels f decisin-making Specify imprvement gals acrss clinical, ppulatin health, public health, and equity dimensins Identify measurement dmains, including by capturing verarching cncepts Select measures and specify the uses Explicitly cnsider the ptential fr winners/lsers with measurement Identify measurement frequency and methd Reprt ut measure results, after aligning with intended uses and making necessary adjustments Develp prcess fr acting n measurement results t advance quality imprvement (e.g., resurces, training, rles, etc.) Establish prcess fr assessing measurement impact (e.g., data, windw f measurement, criteria) and alignment with ur visin Evlve measures (e.g., criteria fr remving measures and new measurement)