Progress on the AAP Quality Measures Task Force Town Hall Dialogue! John A. F. Zupancic MD Associate Professor of Pediatrics, Harvard Medical School Neonatologist Beth Israel Deaconess Medical Center Boston, MA Dr. Zupancic is an Associate Professor of Pediatrics at Harvard Medical School and Associate Chief of Neonatology at Beth Israel Deaconess Medical Center in Boston. Following medical and pediatrics training at McMaster University, he completed a fellowship in Neonatal-Perinatal Medicine at Harvard Medical School and received his Doctorate in Health Policy from the Harvard School of Public Health. Dr. Zupancic s research seeks to improve the efficiency with which scarce resources are used in improving the health of children, and in particular, newborns. His work has focused on performing and improving the validity of economic evaluations alongside neonatal clinical trials, and on the use of computer modeling to determine best practice when evidence is currently lacking or where empirical studies are infeasible. In addition to his research work, Dr. Zupancic is the Chair-elect of the American Academy of Pediatrics Section on Perinatal Pediatrics and served as leader of the Value Initiative for Vermont Oxford Network s Neonatal Intensive Care Quality Improvement Collaborative. Dr. Zupancic is a recipient of the Merton R. Bernfield Award for Excellence in Mentoring from the Harvard Medical School Division of Newborn Medicine and the John M. Eisenberg Award for Excellence in Mentorship from the Agency for Healthcare Research and Quality. Heather Kaplan MD, MSCE Assistant Professor of Pediatrics Perinatal Institute and The James M. Anderson Center for Health Systems Excellence Cincinnati Children s Hospital Medical Center Cincinnati, OH Heather Kaplan MD, MSCE is an Assistant Professor of Pediatrics in the Perinatal Institute and the James M. Anderson Center for Health Systems Excellence at Cincinnati Children s Hospital Medical Center (CCHMC). Heather is a neonatologist and health services researcher interested in enhancing care delivery and studying how systems of care can be improved using innovative approaches. She completed her neonatal-perinatal fellowship training, including earning a Master s degree of science in clinical epidemiology, at The Children s Hospital of Philadelphia/University of Pennsylvania. She joined the faculty at CCHMC in August 2007. Heather s early research focused on understanding variation in adoption of evidence-based practices in neonatal care and quality improvement as a strategy for implementing evidence in practice. With funding from the Robert Wood Johnson Foundation, she studied the role of context in the success of quality improvement initiatives and developed a model, the Model for Understanding Success in Quality (MUSIQ). MUSIQ is a tool for developing theories about which aspects of context help or hinder a
specific project, and designing and implementing tests of changes to modify those aspects of context. Her current work examines the way research and improvement networks ( learning networks ) can be used to improve care delivery and outcomes. She is specifically interested in scaling improvement to reach entire populations of patients and the ways technology, quality improvement methods, and N-of- 1 trial methods can be combined to create a personalized learning healthcare system for the individual. Heather also has extensive experience with front-line quality improvement in perinatal care. Dr. Kaplan serves as the Improvement Advisor for the Ohio Perinatal Quality Collaborative (OPQC) neonatal improvement work. She also serves as a faculty expert for Vermont Oxford Network quality collaboratives and has been working with teams to improve their system of improvement by using MUSIQ to identify and modify key aspects of context that are affecting the success of the quality improvement projects and to help them engage with senior leadership around their improvement work. Renate D. Savich MD Professor of Pediatrics Chief, Division of Neonatology and Newborn Services at the University of Mississippi Medical Center Jackson, MS Dr. Renate Savich, Professor of Pediatrics, is the Chief, Division of Neonatology and Newborn Services at the University of Mississippi Medical Center in Jackson, Mississippi. She is the Division Chief of the state s only Level IV NICU with over 100 patients and a 15-bed Level II nursery. Her Division has 12 neonatologists, 3 neonatal hospitalists and 4 PhD research faculty. She is also on the Steering Committee of the newly organized Mississippi Perinatal Quality Collaborative, a joint effort of neonatologists and obstetricians in Mississippi to improve perinatal and neonatal morbidity and mortality. She was previously at the University of New Mexico School of Medicine, Albuquerque, NM. She received an M.D. degree at the Northwestern University School of Medicine in 1982 and completed pediatrics residency at Children s Memorial Hospital (Northwestern University) before her fellowship training in neonatal/perinatal medicine from 1985-88 at the University of California, San Francisco. A fellow in the American Academy of Pediatrics, Savich is currently the Chair of the American Academy of Pediatrics Section on Perinatal Pediatrics, representing over 6000 neonatologists in the US. She is also a member of the editorial board of NeoReviews. She has extensive involvement in neonatal Global Health and is on the AAP Steering Committee for Helping Babies Breathe. She has recently been appointed as the AAP Liaison to Ethiopia for the Saving 100,000 Newborns Initiative. Annual Quality Congress Breakout Session, Sunday, October 4, 2015 Progress on the AAP Quality Measures Task Force Town Hall Dialogue! Objective: Review and critique evolving drafts for the AAP quality measures.
Town Hall Meeting: The AAP Section on Neonatal-Perinatal Medicine I have nothing to disclose. Disclosure Measurement Quality IOM. Vital signs: Core metrics. 2015 October 4, 2015 1
Why Measure? Audit Governance Banchmarking Efficiency IOM. Vital signs: Core metrics. 2015 Why the AAP Perinatal Section? Commitment to facilitate quality improvement Ensure membership is well-prepared to participate in discussions with payers, regulators, government Enormous resources to Convene Consider Convince Steering Committee Leslie Allen (OHSU) David Burchfield (Past Chair, SoNPM) Bill Edwards (Dartmouth) Dan Ellsbury (Pediatrix) Jeff Gould (CPQCC) Jeffrey Horbar (VON) Heather Kaplan (OPQC) Scott Lorch (CHOP) Jochen Profit (CPQCC) John Zupancic (Chair Elect, SoNPM) Link to Outcome Structure Process Outcomes October 4, 2015 2
Bias Referral bias (in utero transfers) Inclusion bias Resuscitation decisions Case Mix Illness acuity of admitted patients Risk Adjustment Sociodemographic Illness acuity Regionalization Raleigh et al. http://www.kingsfund.org.uk/publications/gettingmeasure-quality Unintended Consequences Fixation Emphasis on one measure because it is measured, leading to neglect of other aspects of quality Gaming consciously [finding] ways to achieve a required level of performance against a given measure, or appear to achieve it, without actually achieving the changes that the measure was designed to achieve Target Fatigue Decreasing effectiveness of improvement initiatives due to focus on a select number of metrics Raleigh et al. http://www.kingsfund.org.uk/publications/gettingmeasure-quality Miscellaneous How should outliers be identified? Clinically relevant threshold Statistical threshold (VON implicitly uses p=0.05) How will attribution of outcome be assigned in highly regionalized systems? Should composite outcome scores be employed? Need for iterative approach Revisit previous (selected and unselected) measures eg newly feasible with EHR Evaluate new measures eg time to therapeutic hypothermia Previous Work Individuals Profit et al. Kaempf et al. IOM NQF VON Consensus example Antenatal corticosteroid Hypothermia in first hour of life Pneumothorax Nosocomial infection Oxygen or mechanical ventilation at 36 wkspma Discharge on any human breast milk Mortality in NICU during birth hospitalization Growth velocity Profit et al. J Perinatol 2011 October 4, 2015 3
AAP Task Force Process 1. Determine criteria for screening measures 2. Determine criteria for comparing measures 3. Generate comprehensive list of measures 4. Generate list of high priority candidate measures 5. Assess high priority candidate measures 6. Convene consensus conference 7. Generate white paper/publications 1. Recommended list of measures for adoption 2. Alternate measures and requirements for adoption 3. Exploration of neonatology-specific issues AAP Task Force Process Brain Storm Session & Discussion Selection Criteria Relevance Evidence of a care gap Level of evidence (eg appears in national guidelines) Economic impact Quality of life impact Scientific Soundness Reliability Variability Risk adjustment Implementation Barriers to data entry Barriers to data collection Unintended consequences Barker and Fields. ADC Fetal and Neonatal 2014 October 4, 2015 4
Task Force Criteria: Screening Barker and Fields. ADC Fetal and Neonatal 2014 Task Force Criteria: Comprehensive Task Force Candidate Measures Brain Storm Session & Discussion October 4, 2015 5
Discussion October 4, 2015 6