The Quality Improvement Committee of the National Association of EMS Physicians (NAEMSP), which I chair, is leading a new project to develop a set of nationally standardized EMS performance measures that may be used by communities and payers to assess the overall performance of their EMS systems.
The need for standardized performance measures is being catalyzed by anticipated changes in rules for payment to EMS provider organizations (EMSPOs) by the Centers for Medicare and Medicaid Services (CMS) and the establishment of contracts between EMSPOs and accountable care organizations (ACOs).
CMS has stated its intent to extend the core measures program to all sectors of healthcare that receive CMS reimbursement for services–including EMSPOs. The core measures program now includes review of acute care hospital, mental health and home health services. When the CMS core measures program is brought to EMS, it is likely to follow the same rules that have been applied to other sectors of healthcare. This means that failure of EMSPOs to report their core measures to CMS will likely result in reductions in CMS payments. Increases in CMS payments are likely to be provided to EMSPOs that are top performers in their core measures.
The establishment of contracts between ACOs and EMSPOs will also create a need for performance measures by which ACOs can potentially hold EMSPOs accountable and make adjustments in payments similar to what has taken place with CMS.
The purpose of the core measures program at the CMS and ACO levels is straightforward: to catalyze improvements in the quality of care by encouraging and supporting healthcare provider organizations to continuously monitor and improve the performance of key healthcare processes.
Hospital core measures are also used by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to continuously assess the performance of accredited hospitals. As stated on jointcommission.org:
“Performance measurement is used internally by healthcare organizations to support performance improvement and externally, to demonstrate accountability to the public and other interested stakeholders. Performance measurement benefits the healthcare organization by providing statistically valid, data-driven mechanisms that generate a continuous stream of performance information. This enables a healthcare organization to understand how well their organization is doing over time and have continuous access to objective data to support claims of quality. The organization can verify the effectiveness of corrective actions; identify areas of excellence within the organization; and compare their performance with that of peer organizations using the same measures. Similarly, performance data can be used by external stakeholders to make value-based decisions on where to seek quality healthcare.”
NQF template
Given the significant clinical and financial implications that the core measures program has, CMS and JCAHO have spent significant time and funds with stakeholders and leading performance measurement experts from across the county to create a template for submission, review and approval of healthcare performance measures. The template and review process is managed by the National Quality Forum (NQF). The NQF template and review process is worthwhile for the EMS community to use for several reasons:
“¢ Their methodology has the benefit of input and refinement from a host of technical experts, complemented by refinements through the collective experience of thousands of hospitals and millions of patient episodes of care.
“¢ Benchmarking their methodology could significantly reduce the research and development costs for developing performance measures for EMS from scratch.
“¢ Development of like systems and processes for performance measurement in EMS can help facilitate data system interoperability and exchange across the continuum of care and possibly lead to some alleviation in the difficulties that EMS providers have in linking their data to other healthcare provider organizations.
NAEMSP and the collaborating organizations are conducting this project in hopes that when CMS begins to develop core measures metrics for EMSPOs, the performance metrics we develop will have EMS community consensus support and be technically suitable for adoption by CMS.
The following list shows the criteria that should be met by a proposed performance metric in order to be considered for inclusion as a core measure.
“¢ Targets improvement in the health of populations: Measures should address areas where performance improvement is likely to have a significant, positive impact on the health of specified populations.
“¢ Precisely defined & specified: Measures should be standardized with explicit pre-defined requirements for data collection and for calculation of the measure value or score.
“¢ Reliable: Measures should consistently identify the events they were designed to identify across multiple participating healthcare organizations over time.
“¢ Valid: Measures should capture what they were intended to measure.
“¢ Can be interpreted: Measures should have rationale and results that are easily understood by users of the data including accreditors, providers and consumers.
“¢ Risk-adjusted or stratified: Measures should incorporate the influences of factors that differ among the groups being compared that can be controlled or taken into account.
“¢ Data collection effort is assessed: Measures should use information that is available and accessible. There is practicality in the effort and cost of abstracting and collecting data.
“¢ Useful in the accreditation process: Measures should supplement or enhance the current accreditation processes and support healthcare organization quality improvement efforts.
“¢ Under provider control: Measures should be within the ability of providers to influence the processes and/or outcomes being measured.
“¢ Public access: The constructs and calculation algorithms used for the measures should be publicly accessible.
It is important to note that NAEMSP plans to seek the input and collaboration of other national EMS organizations on this project.
The technical formats required by the NQF for healthcare performance measures are quite detailed. More information can be found at http://www.qualityforum.org/Measuring_Performance/Submitting_Standards.aspx. The general strategy will be to start with a review of some of the existing EMS performance measures. They will be evaluated against the criteria listed above. Those that fare well in review will be used to help get the team started on putting them into the detailed NQF format.
A project timeline has not yet been established, but the NAEMSP QI Committee is hoping to have a small set of measures fully developed and ready to submit to the NQF by the end of the year.